Medical Univer sity
Prof. Dr. Paraskev Stoyanov
VARNA, Bul garia
Scripta
Scientifica
Medica
Vol. 43 (1), 2011
pp. 1 - 56

SCRIPTA SCIENTIFICA MEDICA
An of fi cial pub li ca tion of Med i cal Uni ver sity "Prof. Dr. Paraskev Stoyanov", Varna
Editor-in-Chief:
Prof. Anelia Klissarova, MD, PhD, DSc
Rector of Medical Univer sity of Varna
e-mail: klisarova@mu-varna.bg
Co-Editor-in-Chief:
Prof. Rossen Madjov, MD, PhD, DSc
Vice Rec tor of Med i cal Uni ver sity of Varna
e-mail: madjov@mu-varna.bg
Edito rial Board:
Assoc Prof. Pe ter Genev, MD, PhD Assoc. Prof. Boriana Varbanova, MD, PhD
Depart ment of Pathoanatomy Department of Pediatrics and Medical Genetics
E-mail: peterghenev@ya hoo.com e-mail: dr_boriana_varbanova@abv.bg
Assoc. Prof. Minko Minkov, MD, PhD Assoc. Prof. Zhaneta Georgieva, MD, PhD
Head, Depart ment of Anat omy, Histology and Vice Rector Univer sity Hospital Coordination and
Em bryol ogy Post graduate Educa tion
e-mail: anatomia@mu-varna.bg e-mail: zhana_georgieva@abv.bg
Prof. Krasimir Ivanov, MD, PhD, DSc Assoc. Prof. Svetoslav Georgiev, MD, PhD
Head, De part ment of Sur gery Department of Internal Medicine
e-mail: kivanov@gisurgery.com e-mail: georgievs@pro-lan.net
Prof. Iskren Kotsev, MD, PhD, DSc Assoc. Prof. Negrin Negrev, MD, PhD
De part ment of Hepato - Gastroenterology Vice Rec tor for Stu dents Af fair
e-mail: uni@mu-varna.bg e-mail: zam_rec tor_ud@mu-varna.bg
Assoc. Prof. Marinka Peneva, MD, PhD Assoc. Prof. Stoyanka Popova, MD, PhD
Dean, Fac ulty of Med i cine Dean, Fac ulty of Pub lic Health
e-mail: marinka_peneva@mail.bg e-mail: popova@mu-varna.bg
Assoc. Prof. Vasil Svechtarov, DMD, PhD Assoc. Prof. Violeta Tacheva, PhD
Dean, Fac ulty of Den tal Med i cine Head, De part ment of Lan guage Teach ing,
e-mail: svechtarov@ya hoo.co.uk Com munica tions and Sports
e-mail: tachevai@mu-varna.bg
Assoc. Prof. Di ana Ivanova, MD, PhD Assoc. Prof. Valentina Madjova, MD, PhD
Head, Department of biochemistry molecular medicine Department of Family Medicine
and nutragenomics e-mail: v_madjov@abv.bg
e-mail: divanova@mu-varna.bg
Assoc. Prof. Emanuela Mutafova, PhD Assoc. Prof. Radoslav Radev, MD, PhD
Head, Depart ment of Econom ics Head, De part ment of Sur gery
and Healthcare Man age ment e-mail: radev@hotmail.com
e-mail: emoutafova@ya hoo.com
Secretary:
Nikola Kolev, MD, PhD Emilia Jordanova
Depart ment of Surgery IT Cen ter
Univer sity Hospital "St. Marina" e-mail: cio_varna@ya hoo.com

CONTENTS
Petkova D., Y. Yotov, D. Paskalev, Y. Bocheva, S. Andonova, N. Usheva -
N-TER MI NAL B-TYPE NATRIURETIC PEP TIDE (NT-PROBNP) IN PA TIENTS WITH
OB STRUC TIVE SLEEP APNEA SYN DROME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Andonova S., D. Ganeva, V. Velinov - VASOSPASM IN THE INTRACRANIAL
ARTERIES AFTER SUBARACHNOID HAEMORRHAGE - CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . 11
Plachkov I., V. Bozhkov, Pl. Chernopolsky, T. Ivanov - SMALL INTESTINE ILEUS
IN ADULT PATIENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Terzieva M., I. Dimitrov, B. Ivanov, N. Deleva, A. Kaprelyan, D. Arabadzhieva,
S. Geneva - REFLEX THERAPY IN THE TREATMENT OF LOW BACK PAIN . . . . . . . . . . . . . . . . . . . . . 15
Ivanov S., E. Kovachev, A. Tsonev, A. Abbud - OUR AND FOREIGN EXPERIENCE IN
PREOPERATIVE CHEMOTHERAPY COMPARED WITH PRIMARY CYTOREDUCTIVE
SURGERY IN ADVANCED OVARIAN CANCER FOR 20 YEARS PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . 19
Kovachev E. - A CASE RE PORT OF AN ENOR MOUS PROLAPSED PEDUNCULATED
SUBMUCOUS MYOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Shtilionova S., P. Drumeva, M. Balabanova, I. Krasnaliev - THERAPEUTICAL
APPROACH IN PATIENTS WITH CUTANEOUS PSEUDOLYMPHOMAS . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Ivanov K., V. Ignatov, N. Kolev, A. Tonev - POSTOPERATIVE VOMITING IN
PATIENTS AFTER LAPAROSCOPIC SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Kerekovska A. - PUBLIC AWARENESS AND PERCEPTIONS OF ORGAN DONATION
IN BULGARIA AND ACROSS THE EUROPEAN UNION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Dobreva D., B. Galunska, M. Stancheva - LIQUID CHROMATOGRAPHY METHOD
FOR THE SIMULTANEOUS QUANTIFICATION OF FAT SOLUBLE VITAMINS IN FISH TISSUE . . . . . . . 35
Georgieva M., N. Alexandrov - EF FECT OF THE PROBIOTIC BIOSTIM LBS IN ACUTE
INTOXICATION AFTER INDUSTRIAL ACCIDENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Petrova G., R. Assenova, G. Foreva, V. Madjova - MANAGEMENT OF POSTGRADUATE
EDUCATION IN GENERAL MEDICINE AT THE MEDICAL UNIVERSITY OF PLOVDIV. . . . . . . . . . . . . . 43
Todorova K. - ALTERED QUALITY OF LIFE IN EPILEPSY: SIGNIFICANCE OF INTERICTAL
DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Romanova Hr., I. Marinova, N. Radeva, M. Marinov - EARTHQUAKE IN HAITI
AND DISASTER MEDICINE TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
AUTOR'S INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
PERMUTERM SUBJECT INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
INSTRUCTIONS TO AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

N-TER MI NAL B-TYPE NATRIURETIC PEP TIDE (NT-PROBNP) IN
PA TIENTS WITH OB STRUC TIVE SLEEP APNEA SYN DROME
Petkova D.1, Y. Yotov2, D. Paskalev3, Y. Bocheva4, S. Andonova5, N. Usheva6
1Clinic of Pulmonary Diseases,2Clinic of Cardiology,3Clinic of Nephrology,4Central Clinical
Laboratory, 5II Clinic of Neurology,6Dep of Social Medicine; University Hospital, "Sveta Marina"
Varna, Bulgaria; Medical University Varna, Bulgaria
Reviewed by: assoc. prof. M. Peneva
SUMMARY
The aim of the pres ent study is to eval u ate the plasma N-ter mi nal pro BNP in pa tients with ob struc tive sleep
apnea syn drome (OSAS). A pro spec tive study of 40 pa tients was car ried out. Thir teen of them were ac cepted
for di ag nos tic eval u a tion of a sus pected sleep apnea which was proved with polysomnography (PSG), 26 were
with doc u mented con ges tive heart fail ure (CHF). The val ues of NTpro-BNP are not dif fer ent be tween the pa -
tients with OSAS with out con com i tant dis eases. There is a sig nif i cant dif fer ence in the NT pro-BNP in OSAS
pa tients with and with out ar te rial hy per ten sion, as well as in pa tients with CHF. There is no as so ci a tion be -
tween the val ues of the natriuretic pep tide and the vari ables as sess ing the se ver ity of OSAS. In con clu sion: the
undiagnosed OSAS is not re lated with se vere im pair ment of the left ven tric u lar func tion. The anal y sis of the
NT-pro-BNP in pa tients with pos si ble OSAS may be used as a fast, eas ily ac ces si ble, and re li able di ag nos tic
marker as well as suit able im prov ing the treat ment and con trol of the con com i tant car dio vas cu lar mor bid ity
and mor tality.
Key words: obstructive sleep apnea syndrome, NT-proBNP, sleep disordered breathing
INTRODUCTION
The ob struc tive sleep apnea syn drome is char ac ter ized with
repetitive collapse of the pharynx and oxygen desaturation
dur ing sleep which leads to sleep frag men ta tion and ex ces -
sive sleep i ness dur ing day time. OSAS is a fre quent con di -
tion; its prev a lence is up to 4% of the mid dle-aged males
and 2% in fe males (20). The in ter mit tent night hypoxemia
and the continuous sym pathetic nervous sys tem activation
are con sid ered as stress fac tors for the car dio vas cu lar sys -
tem in un treated pa tients with OSAS (8). Through this
pathway OSAS is associated with arterial hypertension
(AH) (3,9,14,16), car diac arrhythmias (12), cor o nary ar tery
disease (12,16,17), pulmonary arterial hyper tension and
cerebrovascular in ci dents (4). In the Sleep Heart Health
Study was es tab lished that OSAS is an in de pend ent risk
fac tor for hy per ten sion and CHF (16). There is an in creas -
ing ev i dence that the ef fec tive treat ment of OSAS with
continuous positive air pressure (CPAP) lowers blood pres -
sure and im proves the LV func tion (2,7). Aminoterminal
pro-brain natriuretic pep tide (NT pro-BNP) is a car diac
neurohormone secreted predom inantly by the ventricular
myocytes in re sponse to in creased vol ume over load and the
in creas ing intraventricular pres sure. The level of BNP rises
quickly in re sponse to var i ous stim uli. Re cent stud ies found
that NT-pro-BNP is an im por tant prog nos tic fac tor in pa -
tients with hyper tension and LV hyper trophy, especially in
those without evident signs of a cardiovas cular disease
(18,19). Un cer tain data ex ist whether OSAS af fects BNP
and whether the ap pli ca tion of ven ti la tion with con stant
positive pressure influences the BNP excretion in patients
with OSAS. New re ports are con tro ver sial about the lev els
of BNP in pa tients with OSAS and the ef fects of the treat -
ment with CPAP on the BNP values.
The aim of the pres ent study is the eval u a tion of the plasma
con cen tra tion of NT-pro-BNP in pa tients with ob struc tive
sleep apnea.
PATIENTS AND METHODS
This is a pro spec tive study of NT-pro-BNP in pa tients with
OSAS and pa tients with doc u mented CHF in or der to as sess
the ef fect of OSAS on BNP. Over all, 40 pa tients were in -
cluded. Thir teen of them were ac cepted for di ag nos tic eval u -
a tion in the cen tre for sleep med i cine in the Pul mo nary Clinic
of MHAT "St. Ma rina" - Varna with the sus pi cion of sleep
apnea. The in clu sion cri te rion was clin i cal doubt for OSAS.
De mo graphic data: 10 males (76.9%) and 3 fe males (23.1%)
at a mean age 49.6±9.2 years and a mean BMI 38.2±9.9
7
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 7-10 Copyright © Medical Univer sity, Varna
Address for correspondence:
D. Petkova, Clinic of Pul mo nary Dis eases; Uni ver sity Hos pi tal
"Sveta Ma rina", 9000, 1 "H.Smirnenski" blv., Varna, Bul garia
e-mail: dipetkova@hotmail.com
kg/m2 were in cluded in the study. Their re sults were com -
pared to those of 27 pa tients with doc u mented CHF, 18
males (66.7%) and 9 fe males (33.3%), com pa ra ble for age
and BMI. All pa tients had a his tory of daily sleep i ness, life
style, the presence of concom itant diseases, the medication
for ba sic treat ment and were phys i cally ex am ined. The sleep
anal y sis in cluded over night PSG which doc u ment the sleep
dis tur bances and the se ver ity of the OSAS ac cord ing stan -
dard cri te ria (1). The in ves ti ga tion was per formed on a mon i -
tor ing sys tem MEPAL (MAP, Medizin-Technologie,
Martinsried, Germany). The minimal time of investigation
was 6 hours ac cord ing to the known di ag nos tic cri te ria. The
sleep was doc u mented by stan dard 16-18 chan nel
polysomnography including electroencephalogram (EEG:
C3-A2, C4-A1, O1-A2, O2-À1), electroocculograms (EOG)
electromyograms - Chin EMG, ex trem i ties EMG left/right,
EKG, heart rate, na sal and oral air flow, tho racic and ab dom -
inal movements, snoring regis tration, body position, SaO2,
monitoring of pulse oxymetry, video surveillance associ ated
with the PSG. The sleep phases and arous als were an a lyzed
in con for mity with Rechtschaffen's and Kales' cri te ria (15).
Apneas and hypopneas were eval u ated in ac cor dance with
the ac cepted in ter na tional cri te ria (1). Apnea in dex (AI) was
de fined as the num ber of apneas per hour sleep while
hypopnea in dex (HI) - the num ber of hypopneas per 1 hour
sleep. Apnea- hypopnea in dex (AHI) com bined the num ber
of apneas and hypopneas per 1 hour sleep. The se ver ity of
the seep apnea was graded as: mild, with AHI 5-15 ep i -
sodes/hour sleep; mod er ate, with 16-30 ep i sodes/hour sleep;
se vere, with more than 30 ep i sodes/hour sleep. Blood pres -
sure was mea sured three times in sit ting po si tion af ter 10 min
rest in stan dard con di tions. The pa tients with hy per ten sion
during the study continued their prescribed medication. The
sub jects in the group with doc u mented CHF had his tory
data, clin i cal signs and echocardiographic find ings to prove
the di ag no sis of CHF with out OSAS. In all pa tients rou tine
blood sam ples were drawn in clud ing the anal y sis of
NT-pro-BNP. The quan ti ta tive anal y sis of NT-pro-BNP was
done us ing heparinised plasma. The meth od ol ogy was
adapted for au to mated immunoanalyser IMMULITE 2000
/Siemens Healthcare Group/. The ex pected val ues of
NT-pro-BNP us ing this method in pa tients be low 75 years
were £ 110 pg/ml.
Sta tis ti cal anal y sis
The data anal y sis was per formed on a com mer cial sta tis ti -
cal pack age (SPSS 11 for Win dows). The re la tion ship be -
tween NT-pro-BNP and the vari ables from the
polysomnographic study and other lab o ra tory tests were
eval u ated by the means of Pearson's cor re la tion anal y sis,
variabil ity analysis for continuous variables - Student's
t-test. Statistical significance was accepted if p<0.05.
RESULTS
All pa tients with sus pected sleep dis tur bances mea sured by
PSG study had se vere OSAS (AHI=65.9±15.3/h). The
main variables characterizing sleep disturbance in the stud -
ied sub jects are pre sented on Fig. 1.
It is prom i nent that fe males are fewer which re flects the dis -
ease pro file and the smaller rel a tive share of women with
sleep breath ing dis tur bances. From the 13 pa tients with
OSAS, 4 (30.8%) have a his tory of ar te rial hy per ten sion.
One (7.8%) of the pa tients with OSAS has a his tory of cor -
onary artery disease. All hypertensive patients with OSAS
had ba sic antihypertensive treat ment. Two pa tients (50%)
received b-blockers and the other half - ACE/ATII in hib i -
tors with a di uretic. All pa tients with OSAS be came
normotensive. Fig. 2 dem on strates the NT-pro-BNP val ues
in pa tients with OSAS.
The re sults show that in 11 (84.6%) of the stud ied pa tients
with OSAS the NT-pro-BNP val ues are within nor mal
8
N-ter mi nal B-type natriuretic pep tide ...
Fig. 1. Variables characteristic of sleep and breathing
Fig. 2. NT-pro-BNP values in patients with OSAS.
Fig. 3. NT-pro-BNP in patients with OSAS and with
CHF
range. In only 2 pa tients (15.4%) which have ar te rial hy per -
tension the NT-pro-BNP are pathologically elevated. There
are no pa tients with NT-pro-BNP which may clas sify them
as hav ing heart fail ure. The mean val ues of NT-pro-BNP in
pa tients with OSAS and with CHF are pre sented on Fig. 3.
Our data show that the OSAS pa tients have sig nif i cantly
lower lev els of NT-pro-BNP (p<0.05) com pared to the
con trol group of pa tients with CHF.
The re sults for NT-pro-BNP in hy per ten sive OSAS pa -
tients (pa tients 2 and 9) are sig nif i cantly higher from those
in normotensive. The cor re la tion anal y sis re vealed lack of
statistically im portant correlation between NT-pro-BNP
and age, AHI, mean SaO2, minimal SaO2, desaturation in -
dex and AH. Sig nif i cant cor re la tion was found be tween
NT-pro-BNP, BMI, and Arousal in dex (Ta ble 1).
DISCUSSION
It is well known that there is a lin ear re la tion ship be tween
the sever ity of OSAS and the cardiovas cular morbidity and
mor tal ity (1). It I s sug gested that the ma jor fac tors af fect ing
the cardiovas cular sys tem in OSAS depend on sym pathetic
ner vous sys tem and its over ac tiv ity, on the vari a tion in tho -
racic pres sures and the in ter mit tent hypoxia, as well as on
the changes in the in flam ma tory patho genic path way due to
in ter mit tent dis or ders in the reoxigenation, the reperfusion
in jury and, thus, the in creased ox i da tive stress (7,8). This
patho logic mech a nism in duces arrhythmias, LV sys tolic
and di a stolic dys func tion, and CHF which leads to
polyorgan im pair ment (5). There are only a few data which
per tain to prog no sis whether OSAS is re lated to car diac im -
pairment before the objective occurrence of clinical and
echocardiographic signs. Maeder et al. de ter mined that the
high level of NT-pro-BNP is a use ful marker to de tect car -
dio vas cu lar in jury in pa tients with OSAS (11). An other
study of the ef fect of snor ing in chil dren finds out that in pa -
tients with def i nite apnoic pauses dur ing sleep there are
higher se rum lev els of BNP com pared to those with or di -
nary snor ing (6). The study of Lavie et al. shows re duc tion
in se rum pro-BNP lev els in pa tients with CHF and OSAS
af ter in tro duc ing treat ment with CPAP (9). As a re sult from
our study we may draw the fol low ing main con clu sions: in
normotensive pa tients with AH and OSAS there is no sig -
nif i cant in crease in NT-pro-BNP. NT-pro-BNP is sig nif i -
cantly el e vated in pa tients with OSAS and other co-mor -
bid i ties. Al though there is a trend for higher NT-pro-BNP
val ues, in pa tients with OSAS we did not find el e vated lev -
els of NT-pro-BNP un like these with CHF. In the study by
Kita et al. the BNP val ues in creased dur ing sleep be tween 2
and 6 o'clock a.m. in pa tients with OSAS and de crease sig -
nif i cantly af ter ef fec tive treat ment with CPAP (7). The
mean NT-pro-BNP in our group with OSAS is 149.7
(range 22-1024 pg/ml). All stud ied pa tients are with se vere
OSAS, AHI 65.9/h sleep, the NT-pro-BNP are not sig nif i -
cantly dif fer ent be tween the var i ous pa tients with the ex -
cep tion of those with ar te rial hy per ten sion (p<0.005). Our
results show no signif icant correlation with age (r=0.36,
p=0.23); AHI (r=0.05, p=0.28); the mean SaO2 (r=-0.45,
p=0.012); min i mal SaO2 (r=-0.54, p=0.06); desaturation
index (r=0.37, p=0.22); arterial hyper tension (r=0.32;
p=0.28). NT-pro-BNP do not differby gen der in pa tients
with OSAS. NT-pro-BNP showed a pos i tive cor re la tion
with BMI (r=0.65, p=0.02) and the Arousal in dex (ArI)
(r=0.44, p=0.03). They are in ac cor dance with Nil?fer et
al.(13) who did not find a cor re la tion be tween se rum
pro-BNP lev els and the se ver ity of OSAS, AHI, and the
vari ables of the ox y gen sat u ra tion. Data from the
Framingham Sudy (10) in 623 pa tients also did not find an
association between AHI and BNP. Several recent studies
showed a negative relationship between natriuretic pep -
tides and the BMI (Das, et al., Wang et al., Olsen et al.)
which sug gest that the natriuretic pep tide as an end point in
acute heart fail ure and as apredictor in CHF should be cor -
rected for BMI. We con sider that the low level of
NT-pro-BNP in pa tients with OSAS may be due to obe sity
and the al tered body stat ure in pa tients with OSAS. The
pres ent cor re la tion be tween NT-pro-BNP, ArI, and the
BMI and the miss ing re la tion be tween age, se ver ity of
OSAS and the vari ables of the sat u ra tion can be ex plained
with the im pact of the body stat ure on NT-pro-BNP. In our
sam ple, the pa tients with OSAS and hypertensionin pa -
tients with showed a trend of higher NT-pro-BNP com -
pared to non-hy per ten sive. The ap pli ca tion of CPAP treat -
ment in pa tients with AH and OSAS re sults in greater drop
of NT-pro-BNP as in the normotensive pa tients with
OSAS. The ef fec tive ap pli ca tion of CPAP in OSAS pa -
tients leads to nor mal iza tion of the intrathoracic pres sure
which goes down by 50 mm Hg dur ing the apnea ep i sodes
(Moller's manouvre) . This can be ex plained with the fact
that the treat ment with CPAP at a high base line
NT-pro-BNP generates normalization of the elevated sys -
tolic and transmural pres sures and LV afterload which re -
sults in low er ing the BNP. Whether this ef fect is due to in -
ter rup tion of the apnea and hypopnea ep i sodes or is a di rect
re sult of the treat ment with CPAP it is not well known. The
re sults of our study em pha size the need of ad di tional in ves -
ti ga tion to eval u ate the ef fect of CPAP treat ment on mor tal -
ity in pa tients with car dio vas cu lar diseases and SDB.
CONCLUSION
The pres ent study adds more ev i dence that OSAS is not re -
lated to sub stan tial ex pres sion of the B-natriuretic pep tide.
Undiagnosed OSAS is not con nected with se vere LF dys -
func tion. The test for NT-pro-BNP in pa tients with prob a -
9
Petkova D., Y. Yotov, D. Paskalev, Y. Bocheva, S. Andonova, N. Usheva
age Â̲ ÀH² Mean
SaO2
Min.
SaO2
Desat.
index ArI AP
Pearson's
Correlation (r) 0.36 0.65 0.05 -0.45 -0.54 0.37 0.44 0.32
p 0.23 0.02 0.88 0.12 0.06 0.22 0.03 0.28
Table 1. Correlation between BNP and different
variables for OSAS (n=13).
ble OSAS may be used as fast, eas ily ac ces si ble, and re li -
able di ag nos tic marker in the pres ence of dyspnea and heart
fail ure and also for the treat ment im prove ment and con trol
of the cardiovas cular co-morbidity and mortality in patients
with OSAS. The abil ity of CPAP to have a long-term ef fect
on NT-pro-BNP lev els and to be an end point of the treat -
ment of pa tients with OSAS and car dio vas cu lar dis eases
has to be con firmed in ad di tional stud ies.
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6. Kaditis AG, Alexopoulos EI, Hatzi F,
Kostadima E, Kiaffas M,Zakynthinos E; Over -
night change in brain natriuretic pep tide lev els in chil -
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Tsuboi T, Itoh H, Nakao K, Kuno K; The noc -
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ob struc tive sleep apnea and its re sponse to ther apy
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tor? Z Kardiol; 2003; 92:977-984
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apnea as a risk fac tor for hy per ten sion: pop u la tion
study.BMJ; 2000; 320:479-482
10. Levy D, Sav age DD, Gar ri son RJ et al;
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tro phy: the Framingham Heart Study. Am J Cardiol;
1987; 59:956-960
11. Maeder MT, Ammann P, Rickli H, Schoch
OD, Korte W, Hhrny C, Myers J, Mhnzer T;
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tional ca pac ity in pa tients with ob struc tive sleep
apnea. Sleep Breath; 2008;12:7-16
12. McNicholas WT, Bonsigore MR, Management
Com mit tee of EU COST ACTION B26; Sleep
apnoea as an in de pend ent risk fac tor for car dio vas cu -
lar disease: current evidence, basic mechanisms and
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13. Nilhfer G.,M. Uyar, O.Elbek,H.Shyhr,
E.Ekinci; Im pact of CPAP treat ment on car diac
biomarkers and pro-BNP in ob struc tive sleep apnea
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Pro spec tive study of the as so ci a tion be tween
sleep-dis or dered breath ing and hy per ten sion. N Engl J
Med; 2000; 342:1378-1384
15. Rechtschaffen A, Kales AA; A man ual of stan -
dard ized ter mi nol ogy, tech nique and scor ing sys tem
for sleep stages of hu man sub jects. Na tional In sti tutes
of Health, Wash ing ton, DC, Pub li ca tion;1968;No 204
16. Shahar E, Whit ney CW, Red line S, Lee ET,
Newman AB, Javier Nieto F,O'Connor GT,
Boland LL, Schwartz JE, Samet JM Sleep-dis -
or dered breath ing and car dio vas cu lar dis ease:
cross-sec tional re sults of the sleep heart health study.
Am J Respir Crit Care Med, (2001),163:19-25
17. Sch@fer H, Koehler U, Ploch T, Pe ter JH;
Sleep-re lated myo car dial ischemia and sleep struc ture
in pa tients with ob struc tive sleep apnea and cor o nary
heart dis ease. Chest;1997; 111:387-393
18. Svatikova A, Shamsuzzaman AS,Wolk R,
Phillips BG, Olson LJ, Somers VK; Plasma
brain natriuretic pep tide in ob struc tive sleep
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Bang LE, Hall C, Ib sen H,Rokkedal J,
Devereux RB, Hildebrandt P; N-ter mi nal
pro-brain natriuretic pep tide pre dicts car dio vas cu lar
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Weber S, Badr S; The oc cur rence of sleep-dis or -
dered breath ing among mid dle-aged adults. N Engl J
Med;1993; 328:1230-1235
10
N-ter mi nal B-type natriuretic pep tide ...
VASOSPASM IN THE INTRACRANIAL ARTERIES AFTER
SUBARACHNOID HAEMORRHAGE - CASE REPORT
Andonova S.1, D. Ganeva1, V. Velinov2
1Second Clinic of Neurology, 2Clinic of Radiology, University Hospital "St. Marina" - Varna
Reviewed by: assoc. prof. A. Kaprelian
Vasospasm and raised intracranial pres sure (ICP) are com mon com pli ca tions in subarachnoid haem or rhage
(SAH) due to rup tured intracranial an eu rysm. Vasospasm can be re li ably mon i tored by re peated
transcranial Dopp ler (TCD) ex am i na tions. The changes in flow ve loc i ties due to vasospasm are use ful for
early diag nosis, moni toring effec tive ness of treatment and deter mining prog nosis. Intracranial pressure can
also in crease to dan ger ous lev els and af fect blood flow in the intracranial cir cu la tion. These changes in ICP
may be eval u ated by the spec tral wave form pat terns ob tained dur ing TCD ex am i na tion. We de scribe the
dynamic TCD spectral changes in a patient with SAH. The changes ob served dur ing se rial TCD ex am i na -
tions, were well cor re lated with the neu ro log i cal sta tus. Transcranial Dopp ler is a re li able, non-in va sive and
re pro duc ible test that can be used to mon i tor vasospasm and sus pected of ICP in SAH. The use of TCD can be
ex tended to other intracranial dis eases that can po ten tially lead to an abnormally high ICP.
Key words: subarachnoid hemorrhage, Vasospasm, transcranial Doppler
Case re port
We de scribe a case of a 59-year old man, with his tory of
hyper tension, and hyper cholester olemia, who was admitted
in the in ten sive care unit of Sec ond Clinic of Neu rol ogy -
UMHAT "St. Ma rina" Varna with di ag no sis Subarachnoid
haem or rhage: Hunt-Hess grade ²V.
The angiography was not per formed be cause of the sever
sta tus of the pa tient, per haps due to rup ture of an intracranial
aneurysm. Daily transcranial Doppler (TCD) exam ination
was performed. Transcranial Doppler exam ination was sug -
ges tive of an early vasospasm in the right in ter nal ca rotid ar -
tery, how ever, the usual low re sis tance flow pat tern of the
intracranial cir cu la tion was still main tained (Fig. 1).
Despite ‘triple-H’ therapy (hy pertension, hypervolaemia
and hemodilution) a re peat TCD study, on the sec ond day
after the onset, showed persistently elevated flow velocities
in most of the ar ter ies of the intracranial cir cu la tion, in clud -
ing the vertebro-bas i lar sys tem. The Dopp ler spec trum
started to show a mild re sis tive pat tern. A day later,
transcranial Doppler exam ination revealed a highly abnor -
mal flow pat tern with di a stolic flow reversal in all the major
ar ter ies of the intracranial cir cu la tion. Brainstem re flexes
were still pre served. This TCD pat tern and in tact brainstem
re flexes were also noted dur ing the fol low ing day.
11
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 11-12 Copyright © Medical Univer sity, Varna
Fig. 1
Address for correspondence:
S. Andonova, Dept. of Neu rol ogy, Uni ver sity Hos pi tal “St. Ma rina”
1“Hristo Smirnenski”Str, 9010 Varna
e-mail: drsilva@abv.bg
The pa tient showed no any signs of im prove ment. Two days
later, no brainstem re flexes could be ob tained and
hemodynamic instability occurred, ultimately leading to death.
DISCUSSION
Vasospasm in the intracranial ar ter ies is seen in a large pro -
por tion of pa tients fol low ing a subarachnoid haem or rhage
due to rup ture of an intracranial an eu rysm. This is of ten re -
sponsible for delayed ischaemic neurological deficits.
Previously, vasospasm could be di ag nosed only by for mal
angiography, but the ad vent of TCD has rev o lu tion ized our
understanding this potentially harm ful process.
Transcranial Dopp ler is safe, re peat able and a re li able in -
ves ti ga tion and can be per formed. Vasospasm-re lated
ischaemic neu ro log i cal def i cits are the ma jor cause of mor -
tal ity and mor bid ity in sur vi vors of aneurysmal SAH. The
de gree of vasospasm in the intracranial ar ter ies can be in -
ferred from the ac cel er a tion of the blood flow ve loc i ties.
Transcranial Dopp ler can be used to mon i tor vasospasm, ef -
fects of the ‘tri ple H’ ther apy and pre dict out comes af ter
subarachnoid haem orrhage. The cerebral perfusion pressure
is de ter mined by the ar te rial pres sure and the ICP. The crit i -
cal closing pressure characterizes the pressure-flow velocity
relationship in the cerebral circula tion, which is the pressure
at which flow ceases. The crit i cal clos ing pres sure has been
re ported to be in creased by vasoconstriction de spite a de -
crease in intracranial pres sure. Intracranial pres sure is a
strong de ter mi nant of flow pat terns in the ar ter ies. The qual i -
ta tive changes in ICD wave forms that oc cur with pro gres -
sively rising ICP and eventual cerebral circulatory arrest (7).
Our re port dem on strates the use ful ness of TCD spec tral
pat terns in show ing the changes in the ce re bral blood flow
follow ing a subarachnoid haem orrhage. Initially the
changes were lim ited to vasospasm only in the right ICA
but later, a more wide spread vasospasm and a pro gres -
sively in creas ing ICP re sulted in the di a stolic flow re ver sal.
Se vere vasospasm could have lead to an el e vated crit i cal
closing pressure and early cerebral circulatory arrest that
was later ag gra vated by an in creased ICP. Di a stolic flow
re ver sal or a re ver ber at ing flow sig nal on TCD sug gests es -
tablished or im pending cerebral-cir culatory arrest and
signifies a grim prognosis.
REFERENCES
1. Sloan MA. Ce re bral vasoconstriction: phys i ol ogy,
pathophysiology, and oc cur rence in se lected
cerebrovascular dis or ders. In: Caplan LR, ed i tor.
Brain Ischemia: Ba sic Con cepts and their Clin i cal
Rel e vance. Lon don: Springer-Verlag; 1994. p.
151–172.
2. Lindegaard KF, Nornes H, Bakke SJ, et al.
Ce re bral vasospasm af ter subarachnoid hem or rhage
in ves ti gated by means of transcranial Dopp ler ul tra -
sound. Acta Neurochir 1988;42; :81–84.
3. Kassel NF, Torner J, Haley EC, et al. The in -
ter na tional co op er a tive study on the tim ing of
aneurismal sur gery, 1. Over all man age ment re sults. J
Neurosurg 1990;73:18–36.
4. Qureshi AI, Suarez JI, Bhardwaj A, et al.
Early pre dic tors of out come in pa tients re ceiv ing
hypervolemic and hy per ten sive ther apy for symp tom -
atic vasospasm af ter subarachnoid hem or rhage. Crit
Care Med 2000;28:824–829.
5. Weyland A, Buhre W, Grund S, et al.
Cerebrovascular tone rather than intracranial pres sure
determines the effective downstream pressure of the
ce re bral cir cu la tion in the ab sence of intracranial hy -
per ten sion. J Neurosurg Anesthesiol 2000;
12:210–216.
6. Asalid R, Lash SR, Bar dy GH, et al. Dynamic
pressure flow velocity relationships in the human ce -
rebral circulation. Stroke 2003;34: 1645–1649.
7. Sloan MA, Alexandrov AV, Tegeler CH, et
al. Assessment: transcranial Doppler
ultrasonography. Re port of the ther a peu tics and tech -
nol ogy as sess ment sub com mit tee of the Amer i can
Acad emy of Neu rol ogy. Neu rol ogy 2004;
62:1468–1481.
8. Hassler W, Steinmetz H, Gawlowski J.
Transcranial Dopp ler sonography in raised
intracranial pres sure and in intracranial cir cu la tory ar -
rest. J Neurosurg 1988;68:745–751.
9. Hassler W, Steinmetz H, Pirschel J.
Transcranial Dopp ler study of intracranial cir cu la tory
ar rest. J Neurosurg 1989;71:195–201.
10. Lopez-Navidad A, Ca bal lero F, Domingo P,
et al. Early di ag no sis of brain death in pa tients
treated with cen tral ner vous sys tem de pres sant drugs.
Trans plan ta tion 2000;70:131–135.
11. Zurynski Y, Dorsch N, Pearson I, et al.
Transcranial Dopp ler ul tra sound in brain death: ex pe -
ri ence in 140 pa tients. Neurol Res 1991;13:248–252.
12. Reinhard M, Petrick M, Steinfurth G, et al.
Acute in crease in intracranial pres sure re vealed by
transcranial Dopp ler sonography. J Clin Ul tra sound
2003;31:32
12
Vasospasm in the intracranial arteries after subarachnoid haemorrhage...
SMALL INTESTINE ILEUS IN ADULT PATIENTS
Plachkov I., V. Bozhkov, Pl. Chernopolsky, T. Ivanov
Sec ond De part ment of Sur gery, UMHAT “St. Ma rina” – Varna
Reviewed by: assoc. prof. V. Ignatov
SUMMARY
Small in tes tine in tus sus cep tions caused by ma lig nant tu mor is very rare dis ease, not ex pected from the sur -
geons. The course of the dis ease usu ally is acute and non spe cific. Treat ment is sur gi cal with jus ti fied risk of
one stage op er a tion be cause of the ad vanced years of the pa tients.
INTRODUCTION
Small in tes tine tu mors are very rare. Al though the con sid -
er able length of the small in tes tines (about 75% of whole
GIT length), their can cer rate is very lit tle - 1,75-6,5% of all
gastrointestinal malignancies (1). Small bowel intussuscep -
tions as a cause for in tes ti nal ob struc tion is mostly in chil -
dren, but very rare in adult pa tients - just about 5% of all in -
tus sus cep tions and 0,003-0,02% of all ad mit ted in hos pi tal
adults (2,3). The main dif fer ence is that in chil dren the in -
tus sus cep tions is id io pathic in 90%, but in adults usu ally
there is a patho log i cal ab nor mal ity (70-90% of cases).
CASE REPORT
We re port about an 83 years old pa tient ad mit ted in the Sec -
ond De part ment of sur gery as an emer gency case. The pa -
tient pres ents with signs and symp toms of small bowel ob -
struc tion with pre scrip tion about 24 hours - acute pain in
upper abdomen, nausea, vom iting; laboratory data of in -
flam mation; abdom inal X-rays data of obstructive small in -
tes tines dis ease with fluid lev els in the stom ach. CT scan
re veals a small in tes tine tu mor (fig. 1). An emer gent sur gi -
cal in ter ven tion was per formed - an intussusception of the
ini tial part of the je ju num at about 50 cm from lig. Treize
with dis tended small bowel loop be fore it was es tab lished
(fig. 2), a tu mor for ma tion in the intussusception part of the
bowel (fig. 3), in volved lymph nodes in the mesoradix, no
in volve ment of paraaortal lymph nodes and le sions in the
liver. A re sec tion of the je ju num was per formed with T-L
anas to mo sis. The pa tient was dis charged with nor mal post -
operative period. The histological findings present an
anaplastic malignant blastoma - undifferentiated carcinoma
of small in tes tine with a me tas ta sis in one lymph node.
DISCUSSION
Small intestine intussusceptions in adult patients are often
un ex pected for the sur geons. Type of di gested food and
peri stal tic ac tiv ity has a re la tion with this dis ease. The clin i -
cal pre sen ta tion usu ally is chronic with non spe cific symp -
toms (5,6). Ab dom i nal pain is the most typ i cal symp tom,
followed by nausea and vom iting. Palpable abdom inal
mass pres ents in 24-42% of cases. In about 30%, ma lig nant
le sions (pri mary or met a static) are the cause for in tus sus -
cep tions. There is no pro ce dure, which can be con sid ered
as golden stan dard in di ag no sis of small in tes tine in tus sus -
cep tions. Ab dom i nal X-rays re veal the level of ob struc tion.
Ul tra sound scan di ag no sis is an ac ci dent. CT scan is the
most effective diagnostic procedure, which can reveal to us
pres ence of tu mor for ma tion (4). Usu ally the dis ease is di -
agnosed intraoperative. The surgical intervention generally
involves resection of the affected intestine, sometimes
block re sec tion with res ti tu tion of the GIT at one stage. The
in creased risk of one stage op er a tion is jus ti fied, be cause of
the place of the even tual enterostomy at an ini tial part of
GIT, re spec tively loss of liq uids and nu tri tious sub stances
and the ad vanced years of the pa tients.
13
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 13-14 Copyright © Medical Univer sity, Varna
Fig. 1. CT scan reveals a small intestine tumor
Address for correspondence:
I. Plachkov, Sec ond dept. of sur gery, MHAT "Sv. Ma rina", Med i cal
university - Varna, BG-9002, Varna, 1, Hristo Smirnenski Str.
e-mail: iplachkov@mail.bg
REFERENCES
1. Azar T, Berger DL. Adult intussusception. Ann
Surg 1997;226: 134-138
2. Begos DG, Sandor A, Modlin IM. The di ag no -
sis and man age ment of adult intussusception. Am J
Surg 1997; 173: 88-94
3. Weilbaecher D, Bolin JA, Hearn D, Ogden W
2nd Intussusception in adults. Re view of 160 cases.
Am J Surg 1971; 121: 531-535
4. Fe lix EL, Co hen MH, Bernstein AD,
Schwartz JH. Adult intussusception; case re port of
re cur rent intussusception and re view of the lit er a ture.
Am J Surg 1976; 131: 758-761
5. Tan KY, Tan SM, Tan AG, Chen CY, Chng
HC, Hoe MN. Adult intussusception: ex pe ri ence in
Sin ga pore. ANZ J Surg 2003; 73: 1044-1047
6. Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu
CC, Jao SW. Clin i cal en tity and treat ment strat e -
gies for adult in tus sus cep tions: 20 years’ ex pe ri ence.
Dis Co lon Rec tum 2007; 50: 1941-1949
14
Small intestine ileus in adult patients
Fig. 2. Small bowel intussusceptions
Fig.3. Tumor formation in the intussusception part of
the bowel
REFLEX THERAPY IN THE TREATMENT OF LOW BACK PAIN
Terzieva M., I. Dimitrov, B. Ivanov, N. Deleva, A. Kaprelyan,
D. Arabadzhieva, S. Geneva
Department of Neurology, Varna Medical University,
First Clinic of Neurology, "Sveta Marina" University Hospital, Varna
Reviewed by: assoc. prof. Sv. Kalevski
SUMMARY
Lum bar disc dis ease is a lead ing cause of low back pain. It rep re sents a heavy bur den for the pa tients and for
the so ci ety, im pair ing work ing ca pac ity and qual ity of life. Acute at tacks of back pain are usu ally treated with
a com bination of anal gesics, muscle relaxants and NSAIDs, but acupunc ture is being applied increasingly as
well. The aim of our study was to eval u ate the ef fect of com bined re flex ther apy on low back pain. We as sessed
34 pa tients with lum bar disc herniations and ob tained pos i tive re sults for the ther a peu tic ef fec tive ness of com -
bined treat ment with acu punc ture: quicker im prove ment of pain and mus cle spasticity, lack of gas tro in tes ti -
nal ad verse effects, faster recovery of the impaired working capacity.
Key words: acupuncture, disc herniation, low back pain, reflex therapy
INTRODUCTION
Epidemiological studies have shown that lum bar disc dis -
ease, one of the lead ing causes of low back pain, is most
fre quent dur ing the third to fifth de cade. This is the age
when the bur den of im paired work ing ca pac ity is the heavi -
est for the pa tients and for the so ci ety. In this re gard, the
quick and ef fec tive treat ment of one of the fre quent causes
of pain and im paired lumbosacral biomechanics, namely
the lum bar disc herniation, with min i mal ad verse ef fects, is
a matter of increasing importance.
Acute at tacks of back pain are usu ally treated with a com bi -
nation of analgesics, muscle relaxants and nonsteroidal
anti-in flam ma tory drugs (NSAIDs) (2,3). Ac cord ing to lit -
erature data, classical and laser acupuncture is applied in -
creas ingly as well. This is a ther a peu ti cal method used for
an al ge sia, but also for trophic im prove ment. It is thought
that the treat ment in duces a re lease of endorphins, more
powerful than artificially synthesized ones. The correct se -
lec tion of bi o log i cal ac tive points (BAP) and the ap pli ca -
tion of com bined treat ment (clas si cal and la ser acu punc -
ture, mus cle re lax ants) have a particular effect on the
treatment outcome (1,6,7).
PURPOSE
To as sess the ef fect of com bined re flex ther apy on low back pain.
PATIENTS AND METHODS
Thirty-four pa tients with CT-ver i fied disc herniations, 28
men and 6 women, aged 23 to 52 years, were fol lowed-up
(Table 1).
Twenty-seven pa tients had a lat eral disc herniation with re -
laps ing lum bar pain and mono- or polyradicular ipsilateral
symp toms (L4, L5 and/or S1), while 7 had a me dian disc
herniation with al ter nat ing or bi lat eral radicular symp toms.
Neurological exam ination revealed positive extension phe -
nom ena, dermatomal hypaesthesia, de creased or ab sent
patellar or an kle re flexes. No mo tor weak ness or blad -
der/bowel dis tur bances were found. Neuroimaging was
per formed, in clud ing CT and X-ray of the lum bar spine.
Disc herniations were de scribed at L3-L4 level in 8 cases,
at L4- L5 in 14 cases, at L5- S1 in 12.
No sur gi cal treat ment was per formed in any pa tient.
Though it was rec om mended by a neu ro sur geon in 9 cases,
the pa tients re fused the operation.
EMG dem onstrated demyelination of different sever ity and
location.
After a precise evaluation of indications, treatment was car -
ried out in a hos pi tal set ting. All pa tients had his tory of pre -
15
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 15-17 Copyright © Medical Univer sity, Varna
Address for correspondence:
I. Dimitrov, First Clinic of Neu rol ogy, "Sveta Ma rina" Uni ver sity
Hos pi tal, 1 Hr. Smirnenski str., 9010 Varna, Bul garia
e-mail: indimitrov@mail.bg
Number Age
Men 28 41,2 ±7,2
Women 6 39,0 ±7,0
Total 34 40,9 ±7,1
Table 1. Distribution of patients according to age and sex
vious or current gastrointestinal com plaints. Contrast X-ray
and fibrogastroscopy re vealed gas tric or du o de nal ul cers,
acid re flux, and re flux esophagitis in 17 cases.
Re flex ther apy was per formed, up to 4 weeks from dis ease
onset, using the classical technique of needle introduction
in points with gen eral in flu ence, hav ing a re flex ac tion on
the func tional states of the cen tral ner vous sys tem. Seg -
men tal points were used, spi nal, from the paravertebral
lines, predom inantly from the bladder meridian (Fig.1):
Sanjiaoshu, Shenshu, Quihaishu, Dachangshu,
Guanyuanshu. Due to the dermatomal ir ra di a tion of pain,
we also used points on the an te rior, outer and/or pos te rior
line of the leg: Huantiao, Yinmen, Chengfu, Kunlun, etc.
The au ric u lar point of the "sci at ica" was used ipsi- or bi lat -
er ally, as well as the com mon au ric u lar point Shenmen
which was used bilaterally (1,4,6).
Tolperisone hy dro chlo ride 150-300 mg daily was added in
the pa tients with pain ful spasm of the paravertebral mus cles
as the lat ter dis turbs lo cal blood cir cu la tion and ox y gen
supply, thus intensifying pain (9).
Pain was self-as sessed by the pa tients us ing a vi sual an a -
logue scale (VAS) mod i fied by McGill (5,8), rang ing from 0
points (no pain at all) to 20 points (ex tremely se vere pain).
The test of Schober was also ap plied: ipsi- and contralateral
flexion, mea sur ing the dis tance from the fin gers to the floor.
RESULTS
Based on the anal y sis of the clin i cal course, the VAS pain
as sess ment, and the Schober test, fol lowed up to 20 days af -
ter the ini ti a tion of treat ment, we found al le vi a tion of pain
with 3 points, im prove ment of the ver te bral syn drome, and
re duc tion of the dis tance mea sured by about 23 cm af ter an
av er age of 7 days in pa tients treated with acu punc ture and
muscle relaxants (tolperisone hydrochloride). No gastroin -
tes ti nal adverse reactions were observed.
DISCUSSION
Our re sults sup port the opin ion that early com bined treat -
ment (up to 4 weeks from the on set of symp toms) could
lead to a de crease of the pain ful spasm of the paravertebral
muscles, thus increas ing mobility, im proving quality of life
and work ing ca pac ity. It should be un der lined that no sed a -
tive effect was observed. Local circula tion and oxygen sup -
ply were im proved. Acu punc ture also has an an al ge sic ef -
fect through its typ i cal neurochemical mech a nisms of ac -
tion, in clud ing enkephalin and en dor phin opioid sys tems,
as well as non-opioid neuropeptides of the hy po tha lamicpi
tuitary system.
CONCLUSION
The analysis of our findings dem onstrates the therapeutic
effectiveness of com bined treatment with acupuncture of
BAP in pa tients with lum bar disc dis ease: quick im prove -
ment of pain and mus cle spasticity, lack of gas tro in tes ti nal
ad verse ef fects, and there fore re cov ery of the im paired
working capacity.
REFERENCES
1. Èëèåâ, Å., Âúëêîâà, Ò. Àêóïóíêòóðà ïðè
ëå÷åíèåòî íà çàáîëÿâàíèÿ íà îïîðíî- äâèãàòåëíèÿ
àïàðàò â ëóìáî-ñàêðàëíàòà îáëàñò è òàçîáåäðåíèòå
ñòàâè. Àêóïóíêòóðà, 2004, 1, 3-19.
2. Êîñòàäèíîâ, Ä. Áîëêè â ãúðáà è êðúñòà. Ñ.,
2000, 34-45.
3. Ïåòðîâ, Ï. Ïîÿñíî- äèñêîâà áîëåñò. Ñ., 1980,
23-35.
4. Chen Jing, A. Anatomical atlas of Chinese acu -
punc ture points. 1982, 105, 165, 239.
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Reflex therapy in the treatment of low back pain
Fig. 1. Hu man body me rid i ans and seg men tal points
(BL = blad der me rid ian)
5. Cox, J. Low back pain. Bal ti more, 1990.
6. Huskisson, E. Vi sual an a logue scales. In: Melzack,
R., ed,. Pain mea sure ment and as sess ment. NY Ra ven
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punc ture con tra anti phlog is tics in acute lum bago.
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prop er ties and scor ing meth ods. Pain, 1974, 1,
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spasm. Pain, 1996, 67, 417-425.
17
Terzieva M., I. Dimitrov, B. Ivanov, N. Deleva, A. Kaprelyan, D. Arabadzhieva, S. Geneva

OUR AND FOREIGN EXPERIENCE IN PREOPERATIVE
CHEMOTHERAPY COMPARED WITH PRIMARY
CYTOREDUCTIVE SURGERY IN ADVANCED OVARIAN CANCER
FOR 20 YEARS PERIOD
Ivanov S., E. Kovachev, A. Tsonev, A. Abbud
Department of Obstetrics and Gynaecology, Medical University of Varna
Reviewed by: assoc. prof. D. Kalev
SUMMARY
AIM: In our coun try the ovar ian can cer be came very com mon in the last 20 years and is on the third place af -
ter the endometrial and cer vi cal can cer. It has a very bad prog no sis. Till now cytoreductive sur gery (debuking
sur gery) and taxol/carboplatin based che mo ther apy were the two main ways of treat ment of this very ma lig -
nant dis ease. In the last few years a new way of treat ment with pre op er a tive che mo ther apy fol lowed by in ter -
val debulking sur gery has been in vented into prac tice. Our re sults and the re sults of for eign clin ics with
pa tients stage IIIC and stage IV showed that the re sults con nected with sur vival for pa tients with pre op er a tive
che mo ther apy fol lowed by in ter val debulking were sim i lar to those with pri mary cytoreduction fol lowed by
sur gery. MATERIAL AND METHODS: We as sessed for 20 years pe riod 1000 pa tients with ad vanced ovar -
ian can cers (IIIC and IV stage). Neoadjuvant che mo ther apy was com pared with pri mary debulking sur gery
in these ad vanced ovar ian can cer cases. We com pared our re sults with the re sults of for eign clin ics and clin i -
cal tri als. RESULTS: The post sur gi cal com pli ca tions and mor tal ity lev els were lower af ter in ter val
debulking than af ter pri mary cytoreductive sur gery. Ac cord ing to our re sults and the re sults of for eign clin ics
and clinical trials- the most important independent prog nostic factor for survival was: no residual tumor after
pri mary cytoreductive sur gery or in ter val debulking sur gery. The sur vival rate was better when the
metastases were smaller than 4-6 cm in di am e ter. There were no dif fer ences in sur vival rates be tween the two
groups of pa tients. CONCLUSIONS: On the ba sis of our re sults com pared with the re sults of for eign re -
search ers we con clude that se lec tion of the cor rect pa tients stage IIIC and IV ovar ian can cers ei ther for pri -
mary cytoreductive sur gery or for pre op er a tive che mo ther apy fol lowed by in ter val debulking is very
im por tant. A very im por tant role plays the CT and PET scan im ag ing as well as lap a ros copy for the as sess -
ment of these pa tients. Our re sults are sim i lar to those of for eign clin ics work ing in this field.
Key words: preoperative chemotherapy, primary cytoreduction, advanced ovarian cancers, survival rate
INTRODUCTION
The most im por tant ways of treat ment for ovar ian can cers
is debulking sur gery and taxol /carboplatinum ther apy
(1,2,3,4,5,6). In our coun try as well as in other coun tries the
dis ease is di ag nosed at ad vanced stages and usu ally have
very poor prog no sis (3,4,5,6).
When we use pri mary cytoreductive sur gery or debulking sur -
gery our aim is to re move as much as pos si ble of the tu mor
and also metastases, be fore che mo ther apy is im ple mented.
The in ter val cytoreductive sur gery is an op er a tion that we
per form in se lected pa tients af ter a course of pre op er a tive
chemotherapy. We usually use 3 cycles of chemotherapy.
Ac cord ing to our re search work the amount of re sid ual tu -
mor af ter pri mary sur gery is an im por tant prog nos tic fac tor
in the treat ment of stage III C and stage IV ovar ian can cers.
That is why we de cided to as sess 20 years pe riod of treat -
ment mo dal i ties con nected with ovar ian can cers and to
com pare our re sults with the re sults of for eign stud ies in
this field.
MATHERIALS AND METODS
We as sessed for 20 years pe riod 1000 pa tients with ad -
vanced ovar ian can cers (IIIC and IV stage). Neoadjuvant
che mo ther apy was com pared with pri mary debulking sur -
gery in these ad vanced can cer cases. We com pared our re -
sults with the re sults of for eign clin ics and clin i cal tri als.
19
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 19-20 Copyright © Medical Univer sity, Varna
Address for correspondence:
St.Ivanov, Dept. of Ob stet rics and Gy ne col ogy, SBAGAL-Varna
150, Tsar Osvoboditel Blvd, 9000-Varna, Bul garia
e-mail: stephan66ivanov@abv.bg
RESULTS
When we com pared the pri mary cytoreductive sur gery
with in ter val debulking sur gery we came to the fol low ing
results:
· interval debulking significantly bettered the survival
rate (4,5,6) in patients, who didn't have successful
primary surgery(residual tumor £1 cm).
· addition of interval debulking surgery to post operative
chemotherapy didn't improve survival rate.
Ac cord ing to us the in ter val debulking sur gery per formed
only by ex pe ri enced oncogynaecologist im proved sur vival
in pa tients who did not have proper ini tial op ti mal
debulking sur gery, due to unexperienced oncogynaecological
sur geon or some poor med i cal con di tion.
Based on our re sults we con clude that in ter val debulking
did n't give ad van tage to pa tients that were pri mar ily rad i -
cally operated, removing maximally the disease from ab -
dom inal cavity (1,2,3,4,5,6).
When we used preoper ative chemotherapy and interval
debulking and com par ing to pri mary debulking sur gery we
had sim i lar re sults. We used this method when we had high
met a static dis ease, large and heavy tu mor masses or in pa -
tients with poor gen eral con di tions.
Ac cord ing to our re sults the FIGO stage IIIC pa tients were
80% and FIGO stage IV were 20% in our re searched
groups of pa tients. 80% of the pa tients had metastases
larger than 5-8 cm in di am e ter.
The pa tients with the larg est re sid ual tu mor £1 cm were
50% af ter pri mary cytoreductive sur gery and 90% af ter in -
ter val debulking sur gery.
Ac cord ing to our re sults for stage IIIC and stage IV ovar ian
cancers preoper ative chemotherapy followed by interval
debulking had sim i lar sur vival rates com pared to pri mary
cytoreductive sur gery.
The preoper ative chemotherapy followed by interval
debulking had less post op er a tive ad verse ef fects and com -
pli ca tions com pared to pri mary cytoreductive sur gery.
The qual ity of life were sim i lar also in both groups.
The op ti mal debulking sur gery was the most im por tant
prog nos tic fac tor for the sur vival rate. Ac cord ing to us and
the most for eign au thors (1,2,3,4,5,6) the pre op er a tive che -
mo ther apy fol lowed by in ter nal debulking sur gery can be
the method of choise for pa tients with ovar ian can cers stage
III and stage IV. Most of the pa tients in cluded in our study
had metastases 6-8 cm and more in di am e ter.
For the pri mary cytoreductive sur gery was very im por tant
not to leave any re sid ual tu mor, and ac cord ing to us it was
the most im por tant in de pend ent fac tor. We and the most
for eign re search ers con sider that no re sid ual tu mor is the
best definition of "optimal debulking surgery" (1,2,3,4,5,6).
CONCLUSIONS
Pre operative chemotherapy followed by interval debulking
sur gery for ad vanced ovar ian can cers had sim i lar over all
and pro gres sion free sur vival rate as pri mary cytoreductive
surgery followed by chemotherapy.
The op ti mal cytoreductive sur gery was the most im por tant
prog nos tic fac tor for the sur vival rate. The sur vival rate was
better also when the metastases were smaller than 5-6 cm,
af ter pri mary cytoreductive sur gery.
The se lec tion of the suit able pa tients with stage IIIC and
Stage IV ovar ian can cers ei ther for pri mary cytoreduction
or preoper ative chemotherapy followed by interval
debulking sur gery is very im por tant. At our in sti tu tion we
agree with most of the cri te ria for se lec tion used by other
au thors work ing in this field (4,5,6). The im ag ing with CT
and PET scan as well as lap a ros copy play also very im por -
tant role in this se lec tion of pa tients. In the last few years
there is a ten dency from some oncogynaecological clin ics
to use more cytoreductive sur gery fol lowed by che mo ther -
apy. Fu ture clin i cal tri als can give more light in this field.
REFERENCES
1. Berek Js, Bertelsen K, Du Bois A, Brady Mf,
Carmichael I, Eisenhauer Ea. Ad vanced ep i the -
lial ovar ian can cer: 1998 Concsensus state ments. An -
nals of on col ogy;1999;10:87-92.
2. Chi Ds, Eisenhauer El, Lang I et al. What is
the op ti mal goal of pri mary cytoreductive sur gery for
bulky stage IIIC ep i the lial ovar ian car ci noma (EOC)?
Gynecol Oncol 2006;103 :559-64.
3. Rose Rg, Nerenstone C, Brady M.F. et al.
Sec ond ary sur gi cal cytoreduction for ad vanced ovar -
ian carcinoma. N.Engl J Med, 2004: 351:2489-97.
4. Van Der Burg Mel, Van Zeut M, Buyse M, et
al. The ef fect of debulking sur gery af ter in duc tion
che mo ther apy on the prog no sis in ad vanced ep i the lial
ovarian cancer. Gynecological Cancer Cooperative
Group of the Eu ro pean Or gani sa tion for Re search and
treat ment of Can cer. New Engl J Med 1995;
332/10:629-34.
5. Vergote I, Van Gorp T., Amant F, Leunen K,
Neven P, Berteloot P. Tim ing of sur gery in ad -
vanced ovar ian can cer. Int J Gynecol can cer 2008;
Suppl 1;11-9.
6. Vergote I, De Wever I, Tjalma W, Van
Gramberen M; Decloedt J, Van Dam P.
Neoadjuvant che mo ther apy or pri mary debulking sur -
gery in advanced ovarian carcinoma: a retrospective
anal y sis of 285 pa tients. Gynecol Oncol 1998;
71:431-436.
20
Our and foreign experience in preoperative chemotherapy
A CASE RE PORT OF AN ENOR MOUS PROLAPSED
PEDUNCULATED SUBMUCOUS MYOMA
Kovachev E.
Department of Obstetrics and Gynecology,
Prof. Paraskev Stoyanov Medical University of Varna
Reviewed by: prof. St. Ivanov
ABSTRACT
We re port the case of a pa tient with a large spon ta ne ous pro lapse of a pedunculated uter ine submucosal
leiomyoma ex pelled from the introitus. Af ter the vag i nal myomectomy, we per formed a to tal ab dom i nal hys -
ter ec tomy, be cause of the enor mous size of the myomatous uterus. The fi nal histopathological re port re vealed
a be nign submucous leiomyoma and the post op er a tive re cov ery was quick with out any com pli ca tions.
Key words: submucous myoma, pedunculated, uterus
INTRODUCTION
Uter ine fibromyomas are the most com mon tu mours of the
fe male gen i tal tract and are clas si fied as submucosal, in tra -
mu ral, or subserosal. Myomas are usu ally as so ci ated with
abnormal vaginal bleeding, lower abdom inal pain, threat -
ened abortion, recur rent miscar riage, intrauterine growth
retardation, abruptio placentae, preterm labor, infertility (1).
Some of the submucous myomas may be pedunculated and
even tu ally can pro trude through the cer vi cal ca nal and into
the va gina (4,7). Even very large myomas can pro lapse into
the va gina and out side (8). Af ter that, the myoma usu ally
be comes ne crotic and some times in fected (2).
Myomectomy for submucous leiomyomas can be ac com -
plished by open, lap aro scopic, hysteroscopic, and vag i nal
approaches (5,9).
Case presentation
A 49-year-old nulliparous woman was hos pi tal ized in the
gynecological department with abnormal vaginal bleeding. Pel -
vic ex am i na tion re vealed the pres ence of a large tu mour mass
mea sur ing 38 cm in di am e ter and prolapsed from the va gina
(figure 1). The ultrasound exam ination dem onstrated several
fib roids as fo cal masses with a het er o ge neous tex ture and de ter -
mined one more submucosal and two in tra mu ral myomas. The
big gest in tra mu ral fib roids mea sured 85.4 x 84.7 mm and are
visualized on figure 2. Laboratory tests showed low haemoglo -
bin level of 72 g/l; hematocrit 0.26 L/L; MCV - 70.6 FL; MCH
- 20.6 pg; RDW - 30.2 %; WBC - 7.3 G/L.
With these clin i cal find ings, we inrpreted the mass as a
prolapsed pedunculated submucous myoma. Af ter the in -
tensive reanimation a vaginal myomectomy was planned.
21
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 21-22 Copyright © Medical Univer sity, Varna
Address for correspondence:
E. Kovachev, SBAGAL -Varna, Dept. of Ob stet rics and Gy ne col ogy;
Medical Centre of Assisted Reproduction "Varna" Ltd,
150, Tsar Osvoboditel Blvd, 9000 Varna - Bul garia
e-mail: kovachev_md@abv.bg
Fig. 1. A view of a prolapsed pedunculated submucous
myoma.
The fi broid was clamped and twisted around its pedicle and
the stump was li gated un der di rect vi sion. When bleed ing
from the pedicle stump per sisted, electrocoagulation was
per formed. A vag i nal myomectomy fol lowed by
laparotomy with Pfannenstiel in ci sion and to tal ab dom i nal
hysterectomy was performed (figure 3). The postoper ative
pe riod was un event ful and the pa tient was dis charged from
the hos pi tal six days af ter the sur gery.
The fi nal histopathological re port re vealed a be nign
submucous pedunculated leiomyoma and myomatous uterus.
Venous throm bosis and congestion with interstitial hem or -
rhage are re spon si ble for the color of a leiomyoma un der -
going red (carneous) degeneration.
DISCUSSION
On the first clin i cal step, af ter the gynecological and ul tra -
sound exam ination, we rejected uterine inversion, which is
pos si ble af ter sud den ex pul sion of the large tu mour (3).
The main symp toms of non-pu er peral uter ine in ver sions
are anaemia caused by irregular vaginal bleeding, vaginal
dis charge, lower ab dom i nal pain, a pro trud ing mass in the
va gina, and in some cases ob struc tion of the ure thra (3,6).
Our pa tient had not vis ited rou tine gynecological and ul tra -
sound ex am i na tions and the rea son was the enor mous tu -
mour size. She was hos pi tal ized af ter a sud den pro lapse of
the myoma following physical activities.
CONCLUSION
We re port a case of a prolapsed pedunculated submucous
myoma with enor mous size (1800 g), life-threat en ing vag i -
nal bleed ing and ane mia.
Im aging modalities cannot clearly distinguish between the
be nign uter ine leiomyoma and the ma lig nant
leiomyosarcoma and in some cases a bi opsy is re quired.
Vag i nal myomectomy can be cho sen as a method of treat -
ment for prolapsed pedunculated submucous myomas. In
other cases, when the myoma is not very large a
hysteroscopic re sec tion is planned.
REFERENCES
1. Decherney A, Na than L. Cur rent Ob stet ric&
Gynecologic Di ag no sis&Treat ment, Ninth Edi tion
2003, Lange Med i cal Books/McGraw-Hill, 693-699.
2. Demirci F, Somunkiran A, Safak A, Ozdemir
I, Demirci E. Vag i nal re moval of prolapsed
pedunculated submucosal myoma dur ing preg nancy.
Ad vances in Ther apy 2007 July/Au gust, vol 24 (4):
903-906.
3. De Vries M, Perquin D. Non-pu er peral uter ine in -
ver sion due to submucous myoma in a young woman:
a case re port. Jour nal of Med i cal Case Re ports 2010,
4-21.
4. Golan A, Zachalka N, Lurie S, Sagiv R,
Glezerman M. Vag i nal re moval of prolapsed
pedunculated submucous myoma: a short, sim ple, and
de fin i tive pro ce dure with min i mal mor bid ity. Arch
Gynecol Obstet. 2005 Jan; 271(1):11-3.
5. Hamid A, Balgobin S, Cherine A. Tech nique of
vag i nal myomectomy for intracavitary submucous
myomas. Jour nal of Pel vic Med i cine & Sur gery 2006
Nov / Dec, vol 12 (6): 339-341.
6. Hoffman M, Par sons A, Spellacy W. Expectant
man age ment of a prolapsing submucous uter ine
myoma. Jour nal of Gynecologic Sur gery 2009 Jan,
vol 16(2):29
7. Inab M, Hobeika E, Nassar A. A tale of 2
pedunculated myomas. Amer i can Jour nal of Obstet &
Gynec. 2005 Nov; vol 193(5): 1753-1755.
8. Jin K, Chang l, Kyeong K, Cheol P. Spon ta ne -
ous pro lapse of pedunculated uter ine submucosal
leiomyoma: use ful ness of broc coli sign on CT and
MR im ag ing. Clin i cal Im ag ing 2008 May, vol 32 (3):
233-235.
9. Riley P. Treat ment of prolapsed submucous fib -
roids. SA Med i cal Jour nal 1982 July, vol 62
(3):22-24.
22
A case re port of an enor mous prolapsed pedunculated submucous myoma
Fig. 2. Ultrasound image of an intramural fibroid of the
patient.
Fig. 3. Submucous pedunculated leiomyoma and
myomatous uterus with carneous (red) degeneration.
THERAPEUTICAL APPROACH IN PATIENTS WITH CUTANEOUS
PSEUDOLYMPHOMAS
Shtilionova S.1, P. Drumeva1, M. Balabanova3, I. Krasnaliev2
1Department of dermatology and venereology, Medical University - Varna
2Department of pathology, Medical University - Varna
3Department of dermatology and venereology, Medical University - Sofia
Reviewed by: assoc. prof. M. Peneva
SUMMARY
Cu ta ne ous pseudolymphomas are re ac tive lymphocytic pro lif er a tions that ap pear in the skin and re sem ble a
ma lig nant lym phoma. Most of the pseudolymphomas are caused by in fec tions with B. Burgdorferi, oth ers in -
clude tattoo reactions, immunizations or allergens desensibilization injec tions and infec tion with herpes sim -
plex and zoster. The most com mon clin i cal man i fes ta tions in clude a sin gle large nod ule or sol i tary and
mul ti ple le sions. They are sharply bor dered, soft, red dish, dome- shaped and cov ered by thinned skin. The
sites of pre di lec tion in clude the ear lobes, nape, nip ple and are ola, axillae, scro tum and the dor sum of the foot.
Key words: Cutaneous Pseudolymphomas
The cutaneous pseudolymphomas present a heterogeneous
group of be nign re ac tive lymphoproliferative pro cesses of
differ ent etiology which stim ulate clinically and
histologically the malignant cutaneous lym phomas. The
great va ri ety in the clin i cal pic ture of the cu ta ne ous
pseudolymphomas man i fested most com monly by
erythemic and infiltrating plaques, tumor lesions, papular
and nodular alterations, etc., create serious differential
diagnostic difficulties (1,2,3).
Lo cal med i ca tion and, in some clin i cal forms, gen eral med -
i ca tion, too, is used for the treat ment of cu ta ne ous
pseudolymphomas. The therapeutical approach is deter -
mined according to the predicted etiological factor.
A pos si ble choice for the lo cal treat ment of the
pseudolymphomas con sists in the po tent corticosteroid un -
guents such as Clobetazol pro pi o nate (Clobederm, Dermovete),
Betametason dipropionate or valerate (Diprosone, Betnovate)
and Flucinolon acetonid (Abricort, Flucinar).
In pa tients with nod u lar or plaque le sions ac com pa nied
with in ten sive itch ing (mainly post-sca bi ous and post-in -
sect pseudolymphomas) and an unsatis factory therapeuti -
cal re sult from the lo cal corticosteroid ther apy, intralesion
in jec tion of corticosteroids (Flosteron, Diprophos), is ad -
min is tered, di luted with Lidocaine 1% in a ra tio 1:1 - one,
two or three ap pli ca tions al to gether, in an in ter val 2 - 4
weeks, yield ing a very good therapeutical result.
In Lime's borreliosis, doxycyclin (Vibramycin, Doxat,
Dotur) is used twice daily x 100 mg p. o. for a pe riod of two
weeks. In case of gastrointestinal tract intolerance
Amoxycilln or another antibiotic is recom mended (3,4).
In sca bies, an anti-sca bies ther apy is ap plied (based mostly
on benzyl ben zo ate) and sub se quently a lo cal corticosteroid
therapy is administered and, possibly, intralesion injection
of corticosteroids.
In cutaneous pseudolymphomas resulting from insect bites,
sting ing by wasps, bees or oth ers, anti-pruritic, anti-in flam -
ma tory and anti-al ler gic drugs are pre scribed (lo cal
corticosteroids, general anti-histamine treatment) (5,6).
23
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 23-25 Copyright © Medical Univer sity, Varna
Address for correspondence:
S. Shtilionova, Dept. of der ma tol ogy and venereology
Medical University – Varna
e-mail: shtilionova@abv.bg
In ac tinic reticuloid, a pos si ble choice of treat ment is pre -
sented by lo cal photo pro tec tion means with high SPF and
corticosteroids. In gen eral, Resochin twice daily x 1 tab let
for a pe riod of 10 days, fol lowed by 1 tab let daily for a pe -
riod of at least an other 20 days. In case when there is no im -
provement, systemic corticosteroids are administered to -
gether with non-ste roid anti-in flam ma tory drugs (5). The
pa tients are in structed to avoid exposure to sunlight.
In idiopathic cutaneous pseudolymphomas, only patients
with sub jec tive com plaints are treated, start ing with lo cal
corticosteroids and in cases when there is no im prove ment,
their intra-lesion application is undertaken.
DISCUSSION
1. The choice of therapeutical approach should be made
following clarification of the etiological factor.
2. In the diagnosis of cutaneous pseudolymphoma, the
first drugs of choice should include the local
corticosteroids and photo protectors.
3. In cases of cutaneous pseudolymphomas resistant to
local corticosteroid therapy, a combination with
parenteral and intra-lesion corticosteroids should be
considered.
4. A parenteral antibiotic can also be included if necessary
and if indicated, for a period of 1 -2 weeks according to
the etiological agent.
5. Patients with cutaneous pseudolymphomas which are
resistant to the applied local and parenteral therapy
24
Therapeutical approach in patients with cutaneous pseudolymphomas
should be clinically monitored because of the risk of
evolution toward malignant lymphoma.
BIBLIOGRAPHY
1. Rijlaarsdam U, Scheffer E, Meijer CJLM, et
al. Mycosis fungoides-like le sions as so ci ated with
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3. Ploysangam T, Breneman DL, Mutasim DF.
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Dermatol 1991; 96: 569A.
5. Kerl H, Ackerman AB. Inflammatory diseases
that sim u late lym pho mas: cu ta ne ous
pseudolymphomas. In: Fitzpatrick TB, Eisen AZ,
Wolff K, Freedberg IM, Austen KF (ed i tors). Der ma -
tol ogy in gen eral med i cine, 4th ed. New York:
McGrew-Hill, 1993, 1315-1327.
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25
Shtilionova S., P. Drumeva, M. Balabanova, I. Krasnaliev

POSTOPERATIVE VOMITING IN PATIENTS AFTER
LAPAROSCOPIC SURGERY
Ivanov K., V. Ignatov, N. Kolev, A. Tonev
Department of General and Operative Surgery, St. Marina Varna University Hospital
Reviewed by: assoc. prof. R. Radev
ABSTRACT
BACKGROUND: Postopera tive nausea and vom iting (PONV) is com mon after anaesthesia and surgery. We
de cided to eval u ate metoclopramide, dexa meth a sone, and their com bi na tion in pre vent ing PONV in pa tients
un der go ing lap aro scopic sur gery. METHOD: 396 pa tients were stud ied. Four groups were cre ated: group 1
re ceived metoclopramide post op er a tively; group 2 re ceived dexa meth a sone fol low ing an aes the sia; and group
3 received dexa metha sone following anaesthesia and metoclopramide before end of anaesthesia. Results were
com pared to group with out anti-emetic. PONV in ci dence, basal and ac tive mean vi sual an a logue pain scores,
time to first an al ge sia re quest, side ef fects, and well-be ing score were re corded at first 24 h post op er a tively.
RESULTS: Lit er a ture to tal in ci dence of PONV was 60% in con trol group de void of anti-emetic but 45% of
PONV was seen in Group 1 with metoclopramide, Group 2 -23% with dexa meth a sone, and Group 3-12% with
the com bi na tion of dexa meth a sone and metoclopramide. Anti-emetic res cue was not re quired in dexa meth a -
sone plus metoclopramide group or group with only dexa meth a sone, com pared with four pa tients in the
metoclopramide group and six pa tients in the con trol group. CONCLUSION: Dexa meth a sone or dexa meth a -
sone + metoclopramide com bi na tion was more ef fec tive in pre vent ing PONV than metoclopramide or lack of
anti-emetic.
Key words: postoperative nausea, vomiting, laparoscopic surgery
INTRODUCTION
Post op er a tive nau sea and vom it ing (PONV) is one of the most
com mon com plaints follow ing anaesthesia and surgery (1)
Despite im provements in anaesthesia, 20-30% of patients still
experience nausea and vom iting after surgery (2,3,4,5). A
large clinical trial of postoper ative nausea and vom iting
showed that 4 mg ondansetron, 4 mg dexa meth a sone, or 1.25
mg droperidol were ef fec tive, and that com bi na tions of these
drugs had an ad di tive ef fect (2). Dexa meth a sone was rec om -
mended as the first line drug, as it is safe and cheap. Data on
metoclopramide as an anti-emetic af ter sur gery are con tra dic -
tory. A meta-anal y sis found that an in tra ve nous dose of 10 mg
had only a mar ginal ef fect, (6) but be cause of its com plex
mode of ac tion (it binds to do pa mine, se ro to nin, and his ta mine
receptors), metoclopramide remains an interesting drug for
preventing postoper ative nausea and vom iting (7). Studies
have con cluded that metoclopramide is in ef fec tive in this con -
text, but the tim ing of ad min is tra tion and use of larger doses
were not in ves ti gated fully (8,9,10,11). We in ves ti gated the ef -
fi cacy of metoclopramide, dexa meth a sone, and their com bi -
nation in preventing PONV in patients undergoing laparo -
scopic sur gery.
MATERIAL AND METH ODS
We screened 460 pa tients hos pi ta lised in the clinic of in ten sive
care and clinic of gen eral and op er a tive sur gery in St. Ma rina
Uni ver sity hos pi tal Varna, Bul garia, from 2001 to 2006 op er -
ated laparoscopically. We in cluded 396 in the study and ana -
lysed all of them (Ta ble 1) and sum ma rises de mo graphic data
and pu ta tive risk fac tors. A data for non-treated pa tients with
anti-emetic ther apy was ob served by an Internet lit er a ture sur -
vey us ing the fol low ing keywords: post op er a tive nau sea and
vom it ing (PONV) (12,13). These re sults formed a group of pa -
tients as signed as con trol group. The me dian in ci dence of
PONV re ported in the ob served lit er a ture was 62%. They were
sur gi cally treated and no anti-emetic ther apy was ad min is tered.
Our Group 1 from the 346 pa tients was sur gi cally treated in our
Clinic and given anti-emetic ther apy of 2 x 10 mg of
metoclopramide. This group was ret ro spec tively ob served.
Group 2, com pris ing 25 pa tients pro spec tively ob served, was
treated intraoperatively with dexa meth a sone 8 mg. A Group 3 -
25 pa tients pro spec tively ob served was treated with a com bi na -
tion of dexa meth a sone 8 mg af ter the in duc tion of an aes the sia
27
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 27-30 Copyright © Medical Univer sity, Varna
Address for correspondence:
K. Ivanov, Dept. of Gen eral and Op er a tive Sur gery, St. Ma rina Uni -
ver sity Hos pi tal, Prof. P. Stoyanov Med i cal Uni ver sity of Varna;
BG-9002 Varna, 1, Hristo Smirnenski Street, Bul garia
e-mail: teraton@abv.bg
and metoclopramide 10 mg be fore the end of an aes the sia. We
con sid ered pa tients for in clu sion if they were aged 18 years or
more and having balanced anaesthesia during laparoscopic
fundoplicatons, laparoscopic cholecystectomy, laparoscopic
colorectal sur gery, lap aro scopic hernioplasty, laparascopic
varicocele treat ment, lap aro scopic gynaecologic sur gery, lap -
aroscopic abdom inal exploration and biopsy, and laparoscopic
appendectomy.
PROTOCOL
Exclusion criteria were contraindi cations for
metoclopramide and dexa meth a sone; use of antiemetic or
an ti de pres sive drugs; pa tient clas si fied as ASA grade IV
(has se vere sys temic dis ease that is a con stant threat to life);
presence of extra pyram idal motoric disease, malignant
hyperthermia, hepatic insufficiency, pheochromocytoma,
mechanical ileus or epilepsy; intended or probable postop -
erative administration of protocol, artificial respira tion, or
stom ach tube; pa tient preg nant or breast feed ing. Obey of
clin i cal pro to col is pur sue with col leagues from Clinic of
anaesthesia and intensive care from our hospital.
DOCUMENTATION AND FOLLOW-UP
We re corded el i gi bil ity cri te ria and his tory on the day be -
fore surgery. During surgery, details of anaesthesia, rele -
vant drug, and ad verse re ac tions were re corded. Twenty
four hours af ter the end of sur gery the anaesthesiologists
and sur geon vis ited the pa tients to re cord any nau sea and
vom it ing, other ad verse events, and rel e vant drugs.
RESULTS
End points
The ad di tion of 2 x 10 mg, metoclopramide, post op er a -
tively reduced the cumulative incidence of postoper ative
nau sea and vom it ing from 62% in con trolled group to the
42% in com par i son with Group 1. The ap pli ca tion of 8 mg
dexa meth a sone in the Group 2 intraoperatively re duced the
cumulative incidence of postoper ative nausea and vom iting
to 24%. The pa tients in Group 3 who re ceived a com bi na -
tion of dexa meth a sone 8 mg af ter the in duc tion of an aes -
the sia and metoclopramide 10 mg be fore the end of an aes -
the sia re port com plains in 12% of the cases.
Adverse events
Only intraoperatively hypotension and tachy car dia were
clearly re lated to the ap plied anti emetic ther apy and these
events cor re lated with each other.
Predictors of nausea and vomiting and
adverse reactions
Known predictors of postoper ative nausea and vom iting- fe -
male sex, his tory of nau sea and vom it ing af ter sur gery or mo -
tion sick ness, non-smok ing, and post op er a tive opioids - were
associated with increased rates of postoperative nausea and
vom iting. Late application of opioids increased postoper ative
nau sea and vom it ing much more than early ap pli ca tion. The
fre quency of nau sea and vom it ing and ad verse re ac tions de -
pended on the type of sur gery. The pat tern of this as so ci a tion
was dif fer ent for early and late events. Like smok ing, al co hol
consumption was associ ated with less fre quent postoper ative
nau sea and vom it ing. Whereas the num ber of cig a rettes smoked
each day had no ef fect, we de tected a sig nif i cant dif fer ence be -
tween mod er ate and higher al co hol con sump tion. Early post op -
er a tive nau sea and vom it ing was less fre quent in pa tients aged
50 or more but late ep i sodes were more fre quent, as were ad -
verse re ac tions. Obe sity was not as so ci ated with nau sea and
vom it ing, but it seemed to pro tect against ad verse re ac tions.
Late post op er a tive nau sea and vom it ing was more likely to oc -
cur in pa tients who had had nau sea and vom it ing in the early
phase. Res cue drugs given for early post op er a tive nau sea and
vom it ing pre vented new events in the later time pe riod.
DISCUSSION
No sin gle drug has proved to be a uni ver sal so lu tion to
postoper ative nausea and vom iting. It is not feasible to give
very high doses of such drugs be cause of sat u ra tion ef fects
and safety, so com bi na tions of antiemetic and
corticosteroid drugs are a pos si bil ity. We found that 8 mg
dexa meth a sone added to the ba sic in ter ven tion of 10 mg
metoclopramide is ef fec tive, safe, and cheap.
28
Postoperative vomiting in patients after laparoscopic surgery
Variable Group 1 (n-346) Group 2 (n-25) Group 3 (n-25)
All types of PONV 156 (45) 6 (23) 3 (12)
Nausea (regardless vomiting) 91 (26) 3 (12) 2 (8)
Vomiting (regardless vomiting) 97 (28) 5 (20) 2 (8)
Early form (0-12 hours after surgery) 95 (27) 3 (12) 2 (8)
Late form(>12-24 hours after surgery) 61 (18) 3 (12) 1 (4)
Multiple episodes of PONV 55 (16) 3 (12) 1 (4)
Table 1. Postoperative nausea and vomiting outcome (%); Values are number (%)
Strengths and limitations
Our study de sign al lowed us to in ves ti gate the ef fects of
separate application and the com bined application of drugs
from two phar ma co logic groups. In ret ro spect, we should
have re corded more de tails on hypotension and tachy car -
dia. Al though these ad verse events were short last ing and
self lim it ing in most cases, some facts be yond the clin i cal
im pres sion might have been use ful (such as the need for
treatment).
COMPARISON WITH OTHER
STUDIES
A meta-anal y sis re ported that 10 mg metoclopramide was
clin i cally in ef fec tive and did not im prove when com bined
with 8 mg dexamethason (6). Larger dos ages, how ever,
were as ef fec tive as ondansetron or droperidol when added
to dexa meth a sone (2). A ran dom ised dou ble blind trial with
240 chil dren and adults per treat ment arm found that 50 mg
metoclopramide was not effective for postoper ative vom it -
ing but signif icantly reduced postoper ative nausea and
vom it ing (14). Un for tu nately, this pa per did not say when
the drug was given, and the trial was pow ered only for large
ef fects. Other stud ies also found that 20 mg
metoclopramide was ineffective, possibly because of the
small sam ple sizes (40, 129, and 51 pa tients per group)
(15,16,17). Fur ther more, the tim ing of antiemetic pro phy -
laxis seems to in flu ence ef fi cacy (18,19). In most of the
stud ies, metoclopramide was given im me di ately af ter in -
duction of anaesthesia, irrespective of its time of maximum
ef fect and short half life. De spite the neuroleptic prop er ties
of metoclopramide, its ad di tion to dexa meth a sone did not
in crease rates of head ache, diz zi ness, se da tion, or dry
mouth. The in ci dences seen in our trial are sim i lar to those
of low dose droperidol (3).
Clinical implications and future research
We recom mend a com bination of 8 mg dexamethasone
and 10 mg metoclopramide, given be fore the end of sur -
gery. Ad di tional drugs can then be given af ter sur gery, but
the pa tient's risk pro file should be taken into ac count. Res -
cue drugs should be given af ter post op er a tive nau sea and
vom iting to prevent repeat episodes. To im prove existing
risk scores used in guide lines, the role of dif fer ent types of
surgery and of alcohol consumption should be investigated
further (20).
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30
Postoperative vomiting in patients after laparoscopic surgery
PUBLIC AWARENESS AND PERCEPTIONS OF ORGAN DONATION
IN BULGARIA AND ACROSS THE EUROPEAN UNION
Kerekovska A.
Department of Social Medicine and Health Care Organisation,
Medical University of Varna
Reviewed by: assoc. prof. St. Popova
ABSTRACT
The aim of this study is to de scribe com par a tively pub lic aware ness, at ti tudes and per cep tions of or gan do na -
tion and trans plan ta tion among Bul gar ian and the Eu ro pean pop u la tion, and to iden tify those prac tices and
ac tions that can have pos i tive im pacts for Bul garia. The meth ods in volve ex ten sive con tent re view of EU doc u -
menta tion and com para tive data anal ysis of inter national publications containing figures on organ donation.
Main source of in for ma tion is rep re sen ta tive data drawn from the Eurobarometer cross-na tional sur vey on
organ donation. The com para tive EU data on public awareness, attitudes and perception of organ donation
re veals large vari a tions by coun try. Com pared to the ma jor ity of the Eu ro pean pop u la tion, the Bul gar ian re -
spon dents ex press less sup port ive at ti tudes and less pos i tive per cep tions. Bul gar i ans are far less likely than
the Eu ro pe ans as a whole to agree to the do na tion of an or gan from a de ceased fam ily mem ber and to con sent
to own or gans do na tion af ter death. They have sub stan tially lower rates of fam ily dis cus sions about or gan do -
nation. The awareness of Bulgarian popula tion of transplantation legal reg ulations is among the lowest in Eu -
rope. The re sults point to the need for Bul garia to strengthen its in ter na tional co op er a tion and ex change good
prac tices with EU mem ber states. It is im por tant to es tab lish ef fec tive com mu ni ca tion to count on all the so cial
actors included in the transplantation process. Efforts to encourage family discussions on organ donation; to
ed u cate health pro fes sion als, me dia and the pub lic; and to build their con fi dence in the health sys tem and the
trans plan ta tion ser vice would be of high po ten tial for the coun try. These ac tions are all es sen tial for fu ture
positive developments in organ donation and transplantation in Bulgaria.
Key words: organ donation, public awareness and perceptions, Bulgaria, European Union
INTRODUCTION
The num ber of organ donations and trans plantations has
grown steadily across the EU. How ever, the level of or gan
do na tion does not come close to meet ing the de mand, and
nearly 10 peo ple die ev ery day in Eu rope while wait ing for
an or gan (6). The se vere short age of or gan do nors re mains
the main chal lenge that the EU faces with re gard to or gan
trans plan ta tion. Though a uni ver sal prob lem for all Mem -
ber States, there are wide vari a tions across the EU on or gan
do na tion rates, rang ing from 34.6 do na tions per mil lion
peo ple in Spain to 0.5 in Ro ma nia (1,5). It is dif fi cult to at -
trib ute these huge dif fer ences be tween Mem ber States to
one sin gle fac tor, but sev eral rea sons have been iden ti fied,
such as a mix of cul tural, his tor i cal and so cial fac tors com -
bined with char ac ter is tics of the health ser vice and the or -
gani sa tional and le gal as pects of the do na tion sys tem
within a coun try (6,9). The level of pub lic aware ness of or -
gan do na tion and its le gal reg u la tions is a key fac tor in flu -
encing the trans plantation activity of each country (7,8).
There is also am ple ev i dence show ing that sup port ive pub -
lic at ti tudes and pos i tive per cep tions could lead to sub stan -
tial in creases in or gan do na tion rates (9).
Bul garia's re cord of trans plan ta tion ac tiv ity is one of the
low est in Eu rope - with or gan do na tion rates of 1.5 per mil -
lion population (1). Study ing com paratively the Bulgarian
experience and the heterogene ity of public attitudes and
perceptions within Europe will contribute to the identifica -
tion of valu able ac tions that can pos i tively im pact on the
Bulgarian situation of organ donation. There is scope for
cooperation between EU countries and sharing of good
prac tices can help in crease pub lic sup port of or gan do na -
tion and im prove trans plan ta tion rates in Bul garia.
The aim of this study is to de scribe com par a tively pub lic
awareness, attitudes and perceptions of organ donation and
trans plantation among Bulgarian and the European popula -
tion, and to iden tify those prac tices and ac tions that can
have pos i tive im pacts for Bul garia.
31
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 31-34 Copyright © Medical Univer sity, Varna
Address for correspondence:
Al. Kerekovska, Dept. of So cial Med i cine and Health Care Or gani -
sa tion, Fac ulty of Pub lic Health, Med i cal Uni ver sity of Varna
55 Marin Drinov St., Varna 9002, Bul garia
e-mail: kerekovska_a@yahoo.com
MATERIAL AND METHODS
The meth ods in volve ex ten sive con tent re view of EU doc -
umentation and com parative data analysis of international
publications containing figures on organ donation. Main
source of in for ma tion is the rep re sen ta tive data of the Eu ro -
pean Com mis sion drawn from the Eurobarometer
cross-national surveys on organ donation undertaken in
2006 and 2009 with re spon dents through out the EU.
RESULTS
Family Discussions
40% of Eu ro pe ans have raised the is sue of or gan do na tion and
trans plan ta tion with their fam ily, com pared to 59% who have
never broached this sub ject. The anal y sis by coun try re veals a
huge dis par ity be tween re sults for the old est EU Mem ber
States and the most re cent ones, with the lat ter gen er ally re -
cord ing lower rates of fam ily dis cus sion. Coun tries with high -
est fam ily dis cus sion rates are the Neth er lands (74%), Swe den
(62%) and Den mark (58%). The low est lev els of dis cus sion
are re corded among re spon dents in Lat via, Es to nia and the
Czech Re pub lic (15%, 17% and 18% re spec tively) (3). The
data on Bul gar ian pop u la tion also re veals rates among the
low est in the EU. Only 22% of the Bul gar ian re spon dents (4)
have dis cussed the is sue of hu man or gan do na tion and trans -
plan ta tion with their fam ily (Ta ble 1).
Awareness about Regulation of Organ
Donation and Transplantation
Only 28% of the Eu ro pe ans are aware of laws gov ern ing the
do na tion and trans plan ta tion of or gans in their coun try. By con -
trast, 68% of peo ple do not know such laws (3). The anal y sis of
results reveals significant differences by country, with a general
pat tern of higher aware ness lev els in the old est Eu ro pean Un ion
Mem ber States and lower lev els in the most re cent ones. The
high est aware ness level of laws re lat ing to or gan do na tion is
noted in the Neth er lands (64%), fol lowed by Den mark (45%).
Most other coun tries which joined the Eu ro pean Un ion be fore
2004 re cord aware ness lev els in the 20% to 40% range. The
low est aware ness lev els in the EU are noted in the Czech Re -
pub lic and Es to nia (10% and 8% re spec tively), fol lowed by
Lat via and Bul garia - both 15%. (Ta ble 1). There is a strong as -
sociation between fam ily discussion and knowledge of laws. Of
those in the EU who have dis cussed or gan do na tion and trans -
plan ta tion with their fam ily, nearly half (48%) say they know
the laws gov ern ing this area in their coun try. For Bul garia, this
pro por tion is sub stan tially lower - 33% (3,4).
Donating One's Own Organs
The ma jor ity of the Eu ro pe ans (55%) are will ing to do nate
their own or gans af ter their death. Just over one in four is
against the idea (27%), while al most one in five felt un able to
ex press an opin ion on the topic (18%). An anal y sis of re sults
by country reveals some signif icant differences. Populations
of the North ern Eu ro pean coun tries show a higher will ing ness
to do nate their own or gans. The stron gest sup port is noted in
Swe den (83%); high lev els are re corded in Fin land and Bel -
gium (both 72%), and Den mark (70%). At the other end of the
scale, those most re luc tant to do nate their own or gans tend to
reside in Eastern European countries, especially Latvia and
Ro ma nia, where only 25% and 31% of pop u la tion re spec -
tively is will ing to do nate own or gans af ter death (3).
Bul garia also re cords one of the low est sup port for own or -
gans do na tion - just only 42% would be will ing to do nate
their own or gans and 27% are firmly against (4) (Ta ble 1).
In the over all wide vari a tion by coun try in the pro por tion of
in di vid u als who were not sure if they would be will ing to
donate, the greatest uncertainty and indecisiveness is re -
corded for Bul garia, with 31% of the re spon dents un able to
ex press opin ion on the is sue.
Donating an Organ from a Deceased Close
Family Member
Over half of Eu ro pe ans (53%) would agree to do nate an or -
gan from a de ceased close fam ily mem ber if asked in a hos -
pital (3). Considerable differences are apparent by country
in the hypothetical willingness to donate a fam ily mem ber's
or gans. Not sur pris ingly, the coun tries with the high est lev -
els of con sent for do na tion of the or gans of a de ceased rel a -
tive are the same coun tries where high lev els of con sent for
do na tion of one's own or gan are noted. Swe den (73%), Fin -
land (72%), Malta (72%) and Bel gium (68%) re main the
coun tries with high est con sent lev els. The low est lev els of
ac cep tance are noted in Ro ma nia (34%), Aus tria (35%) and
Lat via (36%) (3). The rates for Bul garia (44%) (Ta ble 1),
though not the low est in the EU, are again sub stan tially
lower than the Eu ro pean av er age. A to tal of 27% said they
would re fuse to do nate a de ceased rel a tive's or gans (4).
More over, when not the hy po thet i cal will ing ness but the real
sit u a tion is con sid ered, Bul garia proves to be the EU coun try
with the high est rates of ac tual fam ily re fus als for de ceased
organ donation. In Bulgaria, 80% of relatives of individuals
with brain death re fuse to do nate their or gans, com pared to
10% and 15% re spec tively for Por tu gal and Spain (2).
32
Public awareness and perceptions of organ donation in Bulgaria...
Attitudes to organ donation
and level of legislation
awareness
EU27 Bulgaria
Difference
from EU
average
Has already discussed
donation of organs % Yes 40% 22% - 18%
Aware of legal regulations on
organ donation % Yes 28% 15% - 13%
Willing to donate his/her own
organ after death % Yes 55% 42% - 13%
Would agree to donate an
organ of a deceased close
family member % Yes
53% 44% - 9%
Table 1. Attitudes to organ donation and level of
legislation awareness: Comparative data on the EU and
Bulgaria, 2009.
Over all, re spon dents are much more likely to be un sure
about con sent ing to the do na tion of an or gan from a de -
ceased rel a tive. For the EU as a whole, 22% of the pop u la -
tion re sponded "Don't Know" when asked if they would
con sent to the do na tion of a de ceased rel a tive. The Bul gar ian
population again shows the highest indecisive ness and great -
est un cer tainty - with 34% of the re spon dents not able to ex -
press a cer tain opin ion about will ing ness to do nate close
fam ily's organs (4).
Reasons for Not Donating Organs
On av er age, dis trust of the sys tem and fear of ma nip u la tion of
the hu man body are the dom i nant rea sons for not do nat ing
one's own or gans or those of a de ceased close fam ily mem ber
in the EU coun tries. Al most a third of Eu ro pe ans (31%) who
are un will ing to do nate ei ther their own or gans or those of a
de ceased rel a tive are un able to give a rea son for their re luc -
tance. Of the re main der, a quar ter (25%) are fear ful of ma nip -
u la tion of the hu man body, and one in five (21%) cite dis trust
of the sys tem (ei ther the trans plan ta tion sys tem, con sent sys -
tem, and/or gen eral health and so cial sys tem) as a bar rier to
do na tion. Less than one in ten Eu ro pe ans (7%) do not sup port
organ donation for religious reasons (3). Consider ing barriers
to organ donation on a country level, signif icant differences
are apparent, not necessarily related to region of European Un -
ion or num ber of years as a Mem ber State. Dis trust of the sys -
tem is most prev a lent as a bar rier in Greece (45%), the Czech
Re pub lic (33%), Slovakia (31%), It aly (30%) and Bul garia
(26%). Con fu sion and not cer tainty about rea sons for not do -
nat ing or gans is most prev a lent in Malta (76%), Ire land
(64%), Fin land (53%), Es to nia (52%) and the two new est
Mem ber States, Bul garia and Ro ma nia (both 48%) (3).
A fear of hu man body ma nip u la tion (19%) and re li gious
reasons (4%) are donation barriers of low and insignif icant
prevalence in the Bulgarian population (4), substantially
lower than the EU av er age rates (Figure 1).
DISCUSSION
The com par a tive EU data on pub lic at ti tude and per cep tion
of or gan do na tion and trans plan ta tion re veals very large vari -
a tions by coun try of res i dence. The Bul gar ian so ci ety as a
whole still does not take a pos i tive view of or gan do na tions.
Com pared to the majority of the European population, the
Bulgarian respondents express less supportive attitudes and
less pos i tive per cep tions. Bul gar i ans are far less likely than
the Eu ro pe ans as a whole to agree to the do na tion of an or -
gan from a de ceased fam ily mem ber and to con sent to own
or gans do na tion af ter death. They have sub stan tially lower
rates of fam ily dis cus sions about or gan do na tion. More over,
the knowledge of Bulgarian population on trans plantation le -
gal reg u la tions is among the low est in Eu rope.
The large vari a tions in pub lic aware ness and per cep tions of
or gan do na tion across the EU mem ber states point to the
potential of greater international cooperation in this field,
in clud ing the ex change of good prac tices from coun tries
which have been most suc cess ful in rais ing aware ness and
pub lic ed u ca tion in this field. This could be of ben e fit to
some of the newer Mem ber States whose health sys tems
have fewer re sources and are, there fore, un der more pres -
sure when it comes to trans plantation. Inter national cooper -
a tion could be of great value in par tic u lar to Bul garia,
whose or gan do na tion rates and score of pop u la tion sup port
are among the low est in the EU.
Fam ily dis cus sions on or gan do na tion have been noted as
positively correlated with the support for organ donation
(9). There fore, ef forts to en cour age more open fam ily dis -
cus sions on do na tion and com mu ni ca tion of wishes to the
relatives can contribute to positive evolution in Bulgaria.
Knowledge about organ donation policy and legislation has
also been found to in crease in di vid u als' will ing ness to do -
nate their own or gans and those of a rel a tive (6,9). Pub lic
education and awareness cam paigns on organ donation and
its le gal reg u la tion in Bul garia could help to trig ger this and
change attitudes in a positive direction.
The Bulgarian population proves to be most indecisive in
mak ing de ci sions about will ing ness for do na tion of both -
own and rel a tive's or gans. It also seems to be the most con -
fused and un cer tain about the rea sons for not will ing to do -
nate. These high rates of con fu sion, un cer tainty and in de ci -
sive ness also call for greater in vest ment in tar geted com -
munication and infor mation provision, as well as sys tem -
atic public education.
Dis trust of the sys tem (the healthcare, the trans plan ta tion
sys tem, con sent sys tem, and/or gen eral so cial sys tem) is
also among the most dom i nant bar ri ers to do na tion for the
Bulgarian population. Therefore, building public confi -
dence and cred i bil ity in the health sys tem in gen eral and the
33
Kerekovska A.
Figure 1. Reasons for not donating organs, Bulgaria
and EU average
Source: Eurobarometer 72.3: Results for Bulgaria, 2010.
transplantation sys tem in particular is a way to positively
change pub lic at ti tudes to do na tion and in crease or gan
availability. Greater transparency, objectivity, equity, ac -
count abil ity and con trol would strengthen the cred i bil ity of
the Na tional Ex ec u tive Trans plant Agency and help Bul -
gar ian cit i zens over come their fears, dis trust and skep ti cism
against the re li abil ity of the sys tem.
Rais ing pub lic in volve ment also has a role to play in in -
creas ing sup port for or gan do na tion of the Bul gar ian pop u -
lation. Organ donation and trans plantation activities call for
active partici pation of medical professionals, stakeholders,
au thor i ties and the gen eral pub lic: i.e., of so ci ety as a
whole. Rec og ni tion of the in nate com plex ity of the whole
trans plan ta tion pro cess and of the con se quent need for ac -
tive par tic i pa tion of all its ac tors is a ba sic step for fur ther
ad vance ment of or gan pro cure ment rates in Bul garia.
Therefore, it is crucial to establish effective com munication
to count on all the so cial ac tors in cluded in the pro cess. Im -
portant target audience for the com munication process
should be the health pro fes sion als, the me dia, opin ion lead -
ers, pa tients sup port groups and the gen eral pub lic. Their
continuing education should form an essential element of
the com munication strategy on organ donation and trans -
plantation in Bulgaria.
CONCLUSIONS
Different EU societies have rather different attitudes to -
wards or gan do na tion. The Bul gar ian so ci ety as a whole
still does not take a pos i tive view of or gan do na tions. The
reluctance of individuals to become organ donors or donate
the or gans of de ceased rel a tives is a ma jor fac tor im ped ing
the trans plant pro ce dures in Bul garia.
The low level of pub lic aware ness of or gan do na tion and of
the le gal and eth i cal is sues re lated to the field is a ma jor bar -
rier to more sup port ive per cep tions of the Bul gar ian pop u -
la tion. The high de gree of con fu sion and un cer tainty in
making decisions regarding organ donation is a main char -
acteristic distinguishing Bulgarians from the majority of the
EU pop u la tions. The pub lic sus pi cion and dis trust to the
sys tem re main a ma jor chal lenge for im prov ing pub lic at ti -
tude to wards or gan do na tion in Bul garia.
The com par a tive data anal y sis of pub lic aware ness and at ti -
tudes to or gan do na tion points to the need for Bul garia to
strengthen its international cooperation and exchange good
prac tices with EU mem ber states. Ef forts to en cour age
more open fam ily dis cus sions on or gan do na tion; to ed u -
cate health pro fes sion als, the me dia and the pub lic; and to
build their con fi dence and cred i bil ity in the health sys tem
and the trans plan ta tion ser vice would be of high po ten tial
for the coun try. It will also be im por tant to pool ef forts and
expertise to establish effective com munication to count on
all the so cial ac tors in cluded in the trans plan ta tion pro cess.
These ac tions are all es sen tial for fu ture pos i tive de vel op -
ments in or gan do na tion and trans plan ta tion in Bul garia.
REFERENCES
1. Coun cil of Eu rope. In ter na tional Fig ures on Or gan
Do na tion and Trans plan ta tion Ac tiv ity - Year 2008.
Trans plant News let ter, 2009, 14(1): 27-29.
2. Eu ro pean Com mis sion. Eu ro pe ans and Or gan do na -
tion. Re port. Eurobarometer, 2007.
(http://ec.europa.eu/health/ph_threats/hu man_sub -
stance/doc u ments/ebs272d_en.pdf).
3. Eu ro pean Com mis sion. Eurobarometer Sur vey 72.3
on Or gan Do na tion and Trans plan ta tion. Spe cial
Eurobarometer 333a, 2010. (http://ec.europa.eu/pub -
lic_opin ion/ar chives/ebs/ebs_333a_en.pdf).
4. Eu ro pean Com mis sion. Eurobarometer Fact Sheets on
Or gan Do na tion and Trans plan ta tion. Re sults for Bul -
garia, 2010. (http://ec.europa.eu/pub lic_opin ion/ar -
chives/ebs/ebs_333a_fact_bg_en.pdf).
5. Eu ro pean Com mis sion. Key Facts and Fig ures on EU
Or gan Do na tion and Trans plan ta tion.
2009.(http://ec.europa.eu/health/ph_threats/hu -
man_sub stance/oc_or gans/docs/fact_fig ures.pdf).
6. Eu ro pean Com mis sion. Or gan Do na tion and Trans -
plan ta tion: Pol icy Ac tions at EU Level. Com mu ni ca -
tion from the Com mis sion to the Eu ro pean Par lia ment
and the Coun cil. Brussels, 2007.
(http://ec.europa.eu/health/ph_threats/hu man_sub -
stance/doc u ments/or gans_com_en.pdf).
7. Gross, T., Martinoli, S., Spagnoli, G., Badia,
F. and Malacrida, R. At ti tudes and Be hav ior of
Young Eu ro pean Adults To wards the Do na tion of Or -
gans - a Call for Better In for ma tion. Amer i can Jour -
nal of Trans plan ta tion, 2001, 1:74-81.
8. Mossialos, E., J. Font, C. Rudisill. Does Or gan
Do na tion Leg is la tion Af fect In di vid u als' Will ing ness
to Do nate their Own or Their Rel a tive's Or gans? Ev i -
dence from Eu ro pean Un ion sur vey data. BMC
Health Ser vices Re search, 2008, 8:48.
9. RAND Eu rope. Im prov ing Or gan Do na tion and
Trans plan ta tion in the Eu ro pean Un ion. As sess ing the
Im pacts of Eu ro pean Ac tion. Tech ni cal Re port, 2008.
(http://www.rand.org/con tent/dam/rand/pubs/tech ni -
cal_re ports/2008/RAND_TR602.pdf).
34
Public awareness and perceptions of organ donation in Bulgaria...
LIQ UID CHRO MA TOG RA PHY METHOD FOR THE
SI MUL TA NEOUS QUAN TI FI CA TION OF FAT SOL U BLE VI TA MINS
IN FISH TISSUE
Dobreva D., B. Galunska1, M. Stancheva
Department of Chemistry, 1Department of Biochemistry, Molecular medicine and Nutrigenomics,
Medical University of Varna
Reviewed by: assoc. prof. L. Macedonski
ABSTRACT
The aim of the pres ent study was to de velop sim ple and ac cu rate small-scale method for si mul ta neous de ter -
mina tion of retinol, a-tocopherol, ergocalciferol, and cholecalciferol in ed ible fish tis sue. High per for mance
liq uid chro ma tog ra phy was the method of choice since it pro vides rapid, sen si tive and ac cu rate de tec tion of all
four fat-sol u ble vi ta mins and re quires small amounts of sam ple. The sam ple prep a ra tion pro ce dure was im -
proved us ing sin gle re ac tion tube for both hy dro ly sis and ex trac tion of the analytes. The over all re cov ery ex -
ceeded 76% for retinol and ergocalciferol, 93% for al pha-tocopherol, and 83% for cholecalciferol. The
method pre ci sion (rel a tive stan dard de vi a tion) was be low 10% for all analytes. The method was ver i fied on
real fish tis sue sam ples and the re sults for the tested fat-sol u ble vi ta min con tents were in a good agree ment
with the data given by other au thors.
Key words: fat soluble vitamins, HPLC, fish tissue
INTRODUCTION
Lipids of ma rine fish spe cies are rich source of fat sol u ble
vitamins, related to a diversity of biologically im portant
pro cesses in hu man body. Vi ta min A (retinol), takes place
in photoreception, reg u lates gene ex pres sion and cell di vi -
sion, bone growth, reproduction. The biologically active
iso mer of vi ta min E - al pha-tocopherol acts as an ti ox i dant
pro tect ing mem brane struc tures and lipoproteins from ox i -
dation. Vitamin D3 (cholecalciferol) and its plant iso mer vi -
tamin D2 (ergocalciferol) are of vi tal im por tance for reg u la -
tion of cal cium and phos phate ho meo sta sis.
Fat-sol u ble vi ta mins have been de ter mined so far, in many
dif fer ent sam ples, by a va ri ety of tech niques. Among them
the most widely ap plied are the chro mato graphic tech -
niques mainly HPLC, which pro vides rapid, sen si tive and
accurate methods for vitamin determination and has the ad -
van tages of sol vent econ omy and easy cou pling with other
tech niques. It also re quires small amounts of sam ple. How -
ever, most of the al ready re ported meth ods mea sure in di -
vid ual vi ta min con tent in fish tis sue homogenates
(1,3,9,12,14,15). Mo bile phases con sist ing of mix tures of
three or four types of sol vents or phos phate buff ers have
been re ported (2,11,12,13). De tec tion modes in volved in
the determination of fat-soluble vitamins include UV, di -
ode ar ray (11,15) fluorimetric (14,17), and elec tro chem i cal
(12), as well as MS de tec tion (3,6). Con cern ing sam ple
prep a ra tion, it is rec om mended to use short time and gen tle
ex trac tion meth ods, some times in a dark ened place, since
these vitamins are unstable during com mon procedures.
The aim of the pres ent work was to de velop a sim ple, fast and
accurate method for simultaneous determination of four fat-sol -
u ble vi ta mins: retinol (A), cholecalciferol (D3), ergocalciferol
(D2), and al pha-tocopherol (E) in ed ible fish tis sue.
MATERIAL AND METHODS
Instrumentation and chemicals: A high-per for mance liq uid
chromatograph (Thermo Sci en tific Spec tra SYSTEM)
equipped with UV2000 and FL3000 de tec tors were used.
All sol vents were of HPLC grade. Meth a nol and wa ter was
ob tained by Sigma-AldrichTM, USA. Sub stances of vi ta mins
A, D3, D2 and al pha-tocopherol were all of an a lyt i cal grade
and were sup plied by Supelco (Sigma-AldrichTM, USA).
Chromatographic conditions: For the sep a ra tion of the
fat-soluble vitamins, RP-column, type ODS2 Hypersil™
C18 (250mm ´ 4.60 mm, 5µm), cou pled with RP C18 se -
cu rity guard pre-col umn was used. The col umn tem per a -
ture was kept at 250C. The mo bile phase of the HPLC sys -
tem con sisted of 97% meth a nol (sol vent A) and 3% MiliQ
wa ter (sol vent B). The mo bile phase flow rate was 1
ml/min and the in jec tion vol ume each time was 20 µl.
35
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 35-38 Copyright © Medical Univer sity, Varna
Address for correspondence:
D. Dobreva, Dept. of Chem is try, Med i cal Uni ver sity - Varna,
55 "Marin Drinov" Str, 9000, Varna
e-mail: didobreva@gmail.com
Retinol, cholecalciferol, and ergocalciferol were mon i tored
by UV de tec tion at lmax=325nm, and 265nm, re spec tively.
Alpha-tocopherol was detected by fluorescence at
lex=288nm and lem=332nm. The chro mato graphic con di -
tions were cho sen in terms of peak shape, col umn ef fi -
ciency, chromatographic analysis time, selectivity, and res -
olution.
Sample preparation
The ed ible fish tis sue was filleted with the skin left on and
homogenized using kitchen homogenizer for 3 min.
Alkaline hydrolysis: An aliquot of the ho mog e nized fish tis -
sue sam ple (1.00g) was weighed into a glass tube with a
screw cap. Two ml of 1% methanolic so lu tion of L-ascor -
bic acid and 5ml of 1M methanolic so lu tion of po tas sium
hy drox ide were added. Each time at least three par al lel
sam ples were pre pared and sub jected to saponification at
800C for 20 min.
Liquid-liquid extraction: The fat-sol u ble vi ta mins from the
hydrolysate were ex tracted twice with 4ml n-hex ane by
vortexing for 5 min. The com bined ex tracts were evap o -
rated to dry ness un der gen tle stream of ni tro gen. Fi nally the
dry res i due of the fat sol u ble vi ta mins frac tion was re con sti -
tuted in 200µl meth a nol and 20µl aliquot was in jected in
the HPLC col umn.
Standards and quantification: Stock stan dard so lu tions of
each analyte (1.0mg/ml) were pre pared in 100% meth a nol
and stored at -200C away from light. Work ing so lu tions
were pre pared from these so lu tions and di luted with meth a -
nol prior to anal y sis. In all the cases, the stock so lu tion was
analyzed together with the sam ples. Analyte concentrations
in sam ples were es ti mated on the ba sis of peak ar eas. All
sam ples were an a lyzed in trip li cate. Retinol, al -
pha-tocopherol, cholecalciferol, and ergocalciferol con tents
were cited as means ± stan dard de vi a tion.
RESULTS
Chromatography: Good sep a ra tion of the analytes, in less
than 20 min, was achieved us ing meth a nol/wa ter 93/7 (v/v)
as a mo bile phase. Re ten tion times (tR) were as fol lows:
retinol tR=5.36 min, ergocalciferol tR=13.97 min,
cholecalciferol tR=15.06 min, and al pha-tocopherol tR =
16.95 min. Res o lu tion fac tors were greater than unity in di -
cat ing a suf fi cient sep a ra tion. Fig ure 1 shows the chro mato -
graphic pro files of a stan dard mix ture of four ex am ined vi -
tamins.
Method validation
Linearity: Cal i bra tion curves, based on anal y ses of six di lu -
tions of the cor re spond ing stan dard, were ob tained by
least-squares lin ear re gres sion anal y sis of the peak area of
analytes versus their concentra tion. The follow ing equa -
tions were ob tained: y=1.91e006 x µg for retinol; y=7.73e006
µg for ergocalciferol; y=3.37e006 µg for cholecalciferol, and
2.41e006 µg for al pha-tocopherol. The method was lin ear up
to 3.2µg for retinol, cholecalciferol and ergocalciferol, and
up to 32µg for alpha-tocopherol. Correlation coefficients
ranged from 0.997 to 0.998 (n=3).
Precision: Six rep li cate de ter mi na tions of a fish tis sue sam -
ple were per formed un der op ti mum con di tions to de ter -
mine repeatability. Three replicate analyses of the same
sam ple were made over a pe riod of 3 con sec u tive days to
de ter mine reproducibility. Ta ble 1 shows pre ci sion re sults.
The relative standard deviations (RSDs) of the repeatability
and the reproducibility are £10%.
Recovery: Re cov ery rates were de ter mined by com par ing
the ob served analyte con cen tra tion in the ex tracted sam ple
to those with a stan dard ad di tion of the analyte into the
sam ple. Analytical recovery after hydrolysis, consequent
extraction and chromatography exceeded 76% for retinol
and ergocalciferol, 93% for al pha-tocopherol, 83% for
cholecalciferol.
Verification: The prac ti cal ap pli ca bil ity of the method was
as sessed by the anal y sis of 20 fish tis sue sam ples (Fig. 2).
Retinol con tents ranged from 6.9 to 142.3/100g raw tis sue,
al pha-tocopherol con tents from 308.0 to 1534.1/100g, and
cholecalciferol con tents from 5.8 to 11.4/100g raw tis sue.
36
Liq uid chro ma tog ra phy method for the si mul ta neous quan ti fi ca tion...
Fig.1. HPLC chromatograms of a mixture of standards solutions of retinol (0.8 µg), alpha-tocopherol (8.0 µg), cholecalciferol
(0.8 µg) and ergocalciferol (0.8 µg). (A) Channel 1, UV detection at 325 nm for retinol and 265 nm for cholecalciferol and
ergocalciferol; (B) Channel 2, fluorescence detection at lex = 288 nm and lem = 332 nm for alpha-tocopherol
DISCUSSION
There have been many stud ies of op ti mum saponification
con di tions for the ex trac tion of retinol, al pha-tocopherol,
ergocalciferol, and cholecalciferol from fish tis sues
(9,12,16). The large scale ex trac tion meth ods are ex pen sive
in terms of ap pa ra tuses re quired, cost of sol vents, and time.
This is why we de cided to de velop a small-scale method of
the type de scribed by Sanchez-Machado (11). We used
smaller sam ple amounts (1.0 g) in com par i son with oth ers
(10,12). To determine the optimal hydrolysis conditions we
performed prelim inary studies with different concentra -
tions of KOH in meth a nol (1M and 0.5M). In or der to pre -
serve the fat-sol u ble vi ta mins from ox i da tion we tested two
antioxidants: BHT and ascor bic acid. The findings indicate
that better re sults are ob tained with 1g of sam ple, 1M KOH
in methanol, and 1% ascor bic acid solution as antioxidant.
In or der to achieve better res o lu tion of the fat-sol u ble vi ta -
mins of in ter est, we tested sev eral com po si tions of the mo -
bile phase: 100% meth a nol; 40/60 acetonitrile/ meth a nol
(v/v); 60/40 acetonitrile/meth a nol (v/v), and 97/3 meth a -
nol/water (v/v). Best resolution between vitamins D2 and
D3, which are struc tur ally very sim i lar, was achieved us ing
97/3 meth a nol/wa ter (v/v) at a flow rate 1.0ml/min. Pub -
lished meth ods in di cate the wide use of both nor mal and re -
verse phase col umns (10,16). Us ing con ven tional (RP C18)
and low cost chro mato graphic col umn at col umn tem per a -
ture 250C we obtained satisfactory separation of four tested
fat soluble vitamins.
The lin ear ity of stan dard curves cov ers wide con cen tra tion
range in con cor dance with the pub lished level of the tested
analytes in the ed ible tis sue of dif fer ent fish spe cies. In all
cases, the relationships between the concentration and peak
ar eas were lin ear with co ef fi cients of vari a tion greater than
0.995.
The pre ci sion study was com prised of re peat abil ity and
reproducibility stud ies. A to tal of six rep li cate de ter mi na -
tions of a sam ple were per formed un der op ti mum con di -
tions to determine repeatability. Three replicate analyses of
the same sam ple were made on three con se quent days to
determine reproducibility. The relative standard deviations
(RSDs) of the re peat abil ity and the reproducibility and the
estimated analytical recovery indicate that the present
method can be used for quan ti ta tive anal y ses of the above
mentioned fat-soluble vitamins in fish tissue.
Exam ination of the practical applicability of the method on
real fish tis sue sam ples re veals com pa ra ble re sults with the
data given by oth ers (2,4,5,7,8,10,12,14,15).
CONCLUSIONS
The present method has analytical characteristics (with re -
spect to pre ci sion and re cov ery) al low ing its use for quan ti -
ta tive anal y ses of retinol, al pha-tocopherol, cholecalciferol,
and ergocalciferol in ed ible fish tis sue. Per form ing sam ple
preparation and analyte extraction in a single reaction tube
gives the method the advantage of minimizing manipula -
tion. The method is easy, eco nom i cal and con ve nient for
routine determination of retinol, alpha-tocopherol, and
cholecalciferol con tent in fish tis sues.
ACKNOWLEDGMENTS
This study was fi nanced by the Na tional Sci ence Fund,
Ministry of Education and Science of Bulgaria (Project
DVU 440/2008).
REFERENCES
1. Ñáîðíèê ìåòîäè çà õèãèåííè èçñëåäâàíèÿ,
Íàöèîíàëåí öåíòúð ïî õèãèåíà, ìåäèöèíñêà
åêîëîãèÿ è õðàíåíå, 1999, 1
2. Ahmadnia A., M.A. Sahari, M. Barzegar, S.J.
Seyfabadi and M. Abdollahi, Vi ta mins Con tents
of some Com mer cially Im por tant Fish Spe cies from
37
Dobreva D, B. Galunska, M. Stancheva
Fig. 2. HPLC chromatograms for determination of retinol, alpha-tocopherol, cholecalciferol in a sample of fish tissue homogenate.
Ergocalciferol is non-detectable in the sample. (A) Channel 1, UV detection at 325 nm for retinol and 265 nm for cholecalciferol
and ergocalciferol; (B) Channel 2, fluorescence detection at lex = 288 nm and lem = 332 nm for alpha-tocopherol
South Cas pian Sea, Am.-Eur. J. of Sust. Agr., 2008,
2(3): 285-293.
3. Byrdwell W.C., J. DeVries, J. Exler, J.M.
Harnly, J.M. Holden, M.F. Holick, B.W.
Hollis, R.L. Horst, M. Lada, L.E. Lemar,
K.Y. Patterson, K.M. Philips, M.T.
Tarrago-Trani, and W.R. Wolf, An a lyz ing vi ta -
min D in foods and sup ple ments: methodologic chal -
lenges, Am. J. Clin. Nutr., 2008, 88:554S-7S.
4. Dan ish Food Com po si tion Data bank, De part ment of
Nu tri tion, Na tional Food In sti tute, 2007.
5. Dias M.G., Sanchez M.V., Bartolo H.,
Oliveira L. Vi ta min con tent of fish and fish prod -
ucts con sumed in por tu gal, Electr. J. Env. Agric.and
food chem., 2003, 4: 510-513.
6. G`ren A.C., G. Bilsel, M. Bilsel, Rapid and si -
mul ta neous de ter mi na tion of 25-OH-vi ta min D2 and
D3 in hu man se rum by LC/MS/MS: Val i da tion and
uncertainty assessment, J. Chem. Metrl., 2007, 1:1
1-9.
7. http://fn.cfs.purdue.edu/fish4health/HealthBenefits/
shad(Amer i can).pdf
8. http://wholefoodcatalog.info/food/horse_mack -
erel(raw)/nu tri ents/
9. Huo Ji-Zeng, H.J. Nelis, P. Lavens, P.
Sorgeloos, and A.P. De Leenheer, Determina -
tion of Vi ta min E in Aquatic Or gan isms by High-Per -
for mance Liq uid Chro ma tog ra phy with Flu o res cence
Detection, Anal. Biochem., 1996, 242, 123-128.
10. Kuhnlein H.V., Barthet V., Farren A., Falahi
E., Leggee D., Receveur O., Berti P., Vi ta min
A, D, and E in Ca na dian Arc tic tra di tional food and
adult di ets, J. Food Comp. Anal., 2006, 19: 495-506.
11. Lopez-Cer van tes J., D.I. Sanchez-Machado,
N.J. Rios-Vazquez, High-per for mance liq uid chro -
ma tog ra phy method for the si mul ta neous quan ti fi ca -
tion of retinol, a-tocopherol, and cho les terol in
shrimp waste hydrolysate, J. of Chrom. Aq., 2006,
1105, 135-139.
12. Ostermeyer U., T. Schmidt, Vi ta min D and
provitamin D in fish, Eur. Food Res. Technol., 2005.
13. Rao Sunita D., Raghuramulu N., Vi ta min D and its
related parameters in fresh-water wild fishes, Comp.
Biochem. Physiol., 1995, 111A, 191-198.
14. Ribarova F., R. Zanev, S. Shishkov, N.
Rizov, a-Tocopherol, fatty ac ids and their cor re la -
tions in Bul gar ian food stuffs, J. of Food Comp. and
Anal., 2003, 16, 659-667.
15. Roos N., Chamnan C., Loeung D., Jakobsen
J., Jhilsted S.H., Fresh wa ter fish as a di etary
source of vi ta min A in Cam bo dia, Food Chem., 2007,
103, 1104-1111.
16. Salo-V@@n@nen P., V. Ollilainen, P. Mattila,
K. Lehikoinen, E. Salmela-M`ls@, V.
Piironen, Si mul ta neous HPLC anal y sis of fat-sol u ble
vitamins in selected animal products after small-scale
extraction, Food Chem., 2000, 71, 535-543.
17. Sundl I., Murkovic M., Bandoniene D.,
Winklhofer-Roob B.M., Vi ta min E con tent of
foods: Com par i son of re sults ob tained from food
com po si tion ta bles and HPLC anal y sis, Clin. Nutr.,
2007, 26, 145-153.
38
Liq uid chro ma tog ra phy method for the si mul ta neous quan ti fi ca tion...
EF FECT OF THE PROBIOTIC BIOSTIM LBS IN ACUTE
IN TOX I CA TION AF TER IN DUS TRIAL AC CI DENTS
Georgieva M.1, N. Alexandrov2
1Department of Preclinical and Clinical Pharmacology and Toxicology,
Medical University "Prof. Paraskev Stoyanov" - Varna,
2Department of Toxicology and Alergollogy, Military Medical Academy of Sofia
Reviewed by: assoc. prof. B. Galunska
ABSTRACT
A probiotic is a "live mi cro bial food in gre di ent that, when in gested in suf fi cient quan ti ties, ex erts health ben e -
fits on the con sumer". The pro found re search of a range of Bul gar ian sci en tists has al lowed for the de vel op -
ment in the last 15-20 years of orig i nal Bul gar ian probiotic, milk-acid low-lac tose prod ucts, united in the
Biosim LBS (Lactoflor, Biomilk) se ries. This sur vey gives an over view of the ef fect of probiotic Biostim LBS in
acute in tox i ca tions af ter in dus trial ac ci dents. The mean en ergy val ues in kcal of the nu tri tional ther apy ap -
plied in tra ve nously and via oral route in 186 pa tients with in tox i ca tions with mod er ate se ver ity are pre sented.
The data show that Biostim LBS cov ers a mean en ergy value of 45.36% of the food ap plied orally in the group
with mod er ate and 70.86% in the group of pa tients with se vere in tox i ca tion. These re sults have been achieved
ow ing to the cor rect choice of ther apy which have in cluded mu tu ally ad di tive enteral and parenteral med i ca -
tions. In none of the pa tients ad verse events have been ob served re gard ing the parenteral med i ca tions and the
enterally in tro duced Biostim LBS as well. They ex erted ben e fi cial ef fect on the me tab o lism, im proved body
en ergy lev els and con trib uted to the ab sorp tion of en ergy and pro teins. A spe cial at ten tion should be paid to
the probiotic prop er ties of the vi a ble cells of L. bulgaricus, which fa vor ably in flu ence on the or gan ism of the
patients by improve ment and reg ulation of the inter nal bacte rial equilibrium.
Key words: probiotic Biostim LBS, Lactobacillus bulgaricus, intoxication, energy, nutritional therapy
INTRODUCTION
A probiotic is a "live mi cro bial food in gre di ent that, when
ingested in sufficient quantities, exerts health benefits on
the con sumer". Probiotics ex ert their ben e fits through sev -
eral mechanisms. They prevent colonization, cellular adhe -
sion and in va sion by patho genic or gan isms. Be sides they
have a di rect antimicrobial ac tiv ity and mod u late the host
im mune re sponse (2,4,8-10). The stron gest ev i dence of the
clin i cal ef fec tive ness of probiotics is pro vided by their use
for the treatment of acute diarrhea, attenuation of antibi -
otic-associated gastrointestinal side effects, and prevention
and treatment of allergy manifestations (5-7,11-13,16).
The pro found re search of a range of Bul gar ian sci en tists
has al lowed for the de vel op ment in the last 15-20 years of
original Bulgarian probiotic, milk-acid low-lactose prod -
ucts united in the Biosim (Lactoflor, Biomilk) se ries. Their
com po si tion is rep re sented on Table 1 (1).
The aim of this sur vey was to give an over view of the ef fect
of probiotic Biomilk in acute in tox i ca tions af ter in dus trial
accidents.
MATERIAL AND METHODS
The dairy prod uct Biomilk was ap plied as nu tri tion ther apy
agent in com bi na tion with parenteral so lu tions. The study
cov ered 234 adult pa tients of both gen ders pre sent ing with
dif fer ent types of acute in tox i ca tion. Of them, 48 pa tients
pre sented with se vere in tox i ca tions and 186 ones - with
moderate intoxications. They were hospitalized in the
Clinic of Tox i col ogy, Na val Hos pi tal of Varna, in the
Clinic of Toxicology at the Military Medical Academy and
N.I.Pirogov of So fia. The in tox i ca tions re sulted from a
toxic smoke dur ing fire; inhalatory poi son ing with gas o line
in a closed room; as a con se quence of clean ing of tanks
con tain ing pe tro leum oil prod ucts and of industrial
accidents with polyvinyl chloride and dichlorethane.
The ther apy sched ule in cluded enteral and parenteral med i ca -
tions which en sured the nec es sary en ergy for 24 hours (in kcal)
af ter Har ris-Ben e dict equa tion. The part of the en ergy pro vided
by Biomilk peroral in take in doses of 125 g/day in wa ter so lu -
39
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 39-41 Copyright © Medical Univer sity, Varna
Address for correspondence:
M. Georgieva, Dept. of Preclini cal and Clinical Pharmacology and
Toxicology, Medical University of Varna "Prof. Paraskev Stoyanov"
55 Marin Drinov Str., BG-9002 Varna
e-mail: marieta_md@yahoo.com
tion in the pa tients with mod er ate in tox i ca tion and 250 g/day in
the patients with severe intoxication was estimated. The clinical
investigations were timely approved by the Ethical Com mission
of the Higher Military Medical Institute at the Military Medical
Acad emy of So fia, and The Na tional Emer gency In sti tute "N.
Pirogov" of So fia (Pro to col No. 23/10.XII.1986).
RESULTS
The mean en ergy val ues in kcal, of the nu tri tional ther apy
ap plied in tra ve nously and via oral route in 186 pa tients
with moderate intoxications are presented on Fig. 1.
Fig. 2 dem on strates the mean en ergy val ues in kcal ap plied
as a nu tri tional ther apy in tra ve nously and via oral route in
48 patients with severe intoxications.
Our data show that Biostim LBS cov ers a mean en ergy
value of 45.36% of the food ap plied orally in the group of
pa tients with mod er ate and of 70.86% in the group with se -
vere intoxications.
DISCUSSION
An op ti mal nu tri tion should meet not only en ergy re quire -
ments. By means of ad e quate im port of macro-,
microelements and vi ta mins it should en sure the ful fill ment of
the com plex vi tal pro cesses in the body such as ox i da tion,
degradation, synthesis of new substances and hormones,
thermoregulation, etc. That is the rea son why, for faster pa -
tients' re cov ery, spe cial at ten tion should be paid to the op ti mal
nutrition. Milk fermentation by Lactobacillus bulgaricus (L.
bulgaricus) strains con trib utes to a faster go ing-off of the met -
a bolic pro cesses, to get higher quan ti ties of free amino ac ids,
di-, tri-, and polypeptides, and as a con se quence, an eas ier milk
protein absorption by human organism.
One of the basic contem porary com ponents reflecting the
cor rect ap proach to the pa tients with in tox i ca tion is the
main te nance of the pro tein bal ance and en ergy needs. In the
probiotic Biostim LBS, the pro por tion of pro teins:fats:car -
bo hy drates is 1:0.7:1.8. This is in ac cor dance with WHO
recom mendations (i. e., 1:1:2).
40
Ef fect of the probiotic Biostim LBS...
Fig. 2. Values of the energy requirements and energy
intake in kcal via oral and venous route in patients with
severe intoxications
Fig. 1. Values of the energy requirements and energy
intake in kcal via oral and venous route in patients with
moderate intoxications
INGREDIENTS /100g dry product BIOSTIM LBS
Water 6%
Dry ingredients 94%
Total proteins 23-27%
Soluble proteins 7-9%
Fats 16-20%
Total carbohydrates 52-57%
incl. lactose 0-4%
Galactose 13-15.5%
Glucose 13-15.5%
Saccharose 13-16%
Energy value 450 kcal
Pectin 0.9%
Minerals < 6%
Calcium 1000 mg
Potassium > 1500 mg
Iron 0.8 mg
Phosphorus 780 mg
Vitamin A 0.20 mg
Vitamin D 122 mg
Vitamin B1 0.23 mg
Vitamin B2 1.54 mg
Vitamin C 2.0 mg
Carotene 0.25 mg
Viable LBB cells > 1010
Table 1. Basic characteristics of the products from
Biostim LBS (Biomilk) series.
In our study, the pa tients with mod er ate in tox i ca tions were
given 125 g Biostim LBS daily, which pro vided 565
kcal/day, while those with se vere in tox i ca tions re ceived 250
g Biostim LBD daily, which pro vided 1130 kcal/day. In the
pa tients from both groups, we ob served an im proved ab sorp -
tion of the nu tri ents via enteral route. This is ev i dent from the
in creased en ergy in take via that route dur ing the hos pi tal
stay. Biostim LBS pro vided as a mean oral en ergy in take of
45.36% in the group of pa tients with mod er ate in tox i ca tion
and of 70.86% in the group with se vere in tox i ca tion.
These re sults were achieved ow ing to the cor rect choice of
therapy that included mutually additive enteral and
parenteral med i ca tions. In none of the pa tients ad verse ef -
fects were ob served at all con cern ing the parenteral med i -
ca tions and the enterally in tro duced Biostim LBS as well.
They exerted a beneficial effect on the metabolism, im -
proved the en ergy lev els of the body and con trib uted to the
ab sorp tion of the en ergy and the pro teins.
A spe cial at ten tion should be paid to the probiotic prop er -
ties of the vi a ble cells of L. bulgaricus, which fa vor ably in -
flu ence on the or gan ism of the pa tients by im prove ment
and regulation of the internal bacterial equilibrium (3,14).
Their efficacy in increasing the resistance to internal patho -
genic flora, in mod u lat ing the im mune sys tem, in pro tect ing
the an ti gen translocation in the blood flow, as well as their
fa vour able in flu ence on the hepatic encephalopathy is well
known (13-15).
CONCLUSION
In con clu sion, it should be em pha sized that the cor rect
choice of enteral and parenteral ther apy en sures the max i -
mally ben e fi cial ef fect of the probiotic Biostim LBS for the
patients with intoxications.
REFFRENCES
1. Àëåêñàíäðîâ Í. Ïðîáèîòèöèòå-äîáðèòå
áàêòåðèè íà áúëãàðñêîòî êèñåëî ìëÿêî. Ñîôèÿ,
Mo tion pub lish ing, 2003.
2. Delcenserie V, Martel D, Lamoureux M, Amiot J,
Boutin Y, Roy D. Immunomodulatory ef fects of
probiotics in the in tes ti nal tract. Curr Is sues Mol Biol.
2008;10(1-2):37-54
3. Donaldson M S. Nu tri tion and can cer: A re view of
the ev i dence for an anti-can cer diet, Nutr J. 2004; 3: 19.
4. Doron S, Gorbach SL. Probiotics: their role in the
treat ment and pre ven tion of dis ease. Expert Review of
Anti-In fec tive Ther apy. 2006; 4(2):261-275.
5. Eliz a beth C. Verna, Use of probiotics in gas tro in -
tes ti nal dis or ders: what to rec om mend? Therap Adv
Gastroenterol. 2010 Sep tem ber; 3(5): 307-319.
6. Ezendam J, van Loveren H. Probiotics:
immunomodulation and eval u a tion of safety and ef fi -
cacy. Nu tri tion Re views. 2006;64(1):1-14.
7. Gill H, Prasad J. Probiotics, immunomodulation, and
health benefits. Adv Exp Med Biol. 2008; 606:423-54
8. Gill HS, Guarner F. Probiotics and hu man health:
a clinical perspective. Post grad u ate Med i cal Jour nal.
2004; 80(947):516-526.
9. Goldin BR, Gorbach SL. Clin i cal in di ca tions for
probiotics: an over view. Clin In fect Dis. 2008 Feb
1;46 Suppl 2:S96-100; dis cus sion S144-51.
10. Guid ance for sub stan ti at ing the ev i dence for ben e fi -
cial ef fects of probiotics: pre ven tion and man age ment
of in fec tions by probiotics.
11. Huebner ES, Surawicz CM. Probiotics in the pre -
ven tion and treat ment of gas tro in tes ti nal in fec tions.
Gastroenterology Clin ics of North Amer ica.
2006;35(2):355-365.
12. Liu JE, Zhang Y, Zhang J, Dong PL, Chen M, Duan
ZP. Probiotic yo gurt ef fects on in tes ti nal flora of pa -
tients with chronic liver dis ease. Nurs Res. 2010
Nov-Dec;59(6):426-432.
13. Minocha A. Probiotics for pre ven tive health. Nutr
Clin Pract. 2009 Apr-May; 24(2):227-41.
14. Nova E, Viadel B, Warnberg J, Carreres JE,
Marcos A. Ben e fi cial ef fects of a synbiotic sup ple -
ment on self-per ceived gas tro in tes ti nal well-be ing and
immunoinflammatory sta tus of healthy adults. J Med
Food. 2011 Jan-Feb;14(1-2):79-
15. Qian B, Xing M, Cui L, Deng Y, Xu Y,
Huang M, Zhang S. An ti ox i dant, antihypertensive,
and immunomodulatory ac tiv i ties of pep tide frac tions
from fer mented skim milk with Lactobacillus
delbrueckii ssp. bulgaricus LB340. J Dairy Res. 2011
Feb;78(1):72-9.
16. Wol vers D, Antoine JM, Myllyluoma E,
Schrezenmeir J, Szajewska H, Rijkers GT.
Guid ance for sub stan ti at ing the ev i dence for ben e fi -
cial ef fects of probiotics: pre ven tion and man age ment
of in fec tions by probiotics. J Nutr. 2010
Mar;140(3):698S-712S. Epub 2010 Jan 27.
41
Georgieva M., N. Alexandrov

MANAGEMENT OF POSTGRADUATE EDUCATION IN GENERAL
MEDICINE AT THE MEDICAL UNIVERSITY OF PLOVDIV
Petrova G., R. Assenova1, G. Foreva1, V. Madjova2
Section Medical pedagogy, Public Health Faculty, Plovdiv Medical University,
1Section General Practice, Public Health Faculty, Plovdiv Medical University,
2Department of Family Medicine, Varna Medical University
Reviewed by: assoc. prof. St. Popova
ABSTRACT
The changes in the health care sys tem came along with the more es tab lish ing con cept of per ma nent ed u ca tion.
Management of the educa tion is crucial for training's quality promotion and professional adapta tion of gen -
eral prac ti tio ners (GPs). MATERIALS AND METHODS: The so cio log i cal re search is in the form of an anon -
y mous ques tion naire. It com prises 79 (sev enty-nine) GPs who have com pleted the spe cial iza tion train ing.
RESULTS AND DISCUSSIONS: The men quota and those of women are equal. The av er age age is 41.12±6.67
and the av er age med i cal length of em ploy ment is 13.32±7.21 years. The pre dom i nant part of re spon dents
have no spe cialty (64.56±5.38%), and those who al ready have one spe cialty, are spe cial ists in in ter nal med i -
cine or pe di at rics. The as sess ment for the over all or ga ni za tion of learn ing pro cess - mostly, and it is very good
(39.24±5.49%) and good (34.18±5.34%). CONCLUSION: In terns are not sat is fied with the ra tio the o ret i -
cal/prac ti cal train ing. Keep ing the same du ra tion and in creas ing its ef fi ciency could be the ex pected change.
Key words: postgraduate education, general practitioner
INTRODUCTION
The changes in the health care sys tem in Bul garia for the
past ten years came along with the more and more es tab -
lishing concept of permanent education or lifelong learn -
ing. Now a days adult ed u ca tion is con sid ered in the con -
text of the permanent education concept. Presently adult
education is necessity which can be satis fied in various
ways, by dif fer ent means, where dif fer ent re sults are
achieved (5). Life long learn ing com prises all re sult-ori -
ented activities, both formal and informal, realized
through out life aim ing at im prov ing knowl edge, skills and
com petences (6).
Launched in 2000 health care re form in out-of-hos pi tal care
placed many chal lenges be fore the five med i cal uni ver si ties
in the country. Curriculum and postgraduate programs have
been introduced to the general practitioners (GPs) referring
the pro mo tion of qual i fi ca tion of those who wish to prac tice
in di vid u ally as a fam ily doc tors. Their train ing must be car -
ried out at medical universities with tem porary discontinuing
work and for the pe riod of three years. It is or ga nized in two
directions: theoretical, by lecturers having academic rank,
and prac ti cal, in the form of mod ules in clin ics un der the
guidance of assis tants (tutors). Post-graduate education with
the GPs shall finish with theoretical and practical exam ina -
tion before a state exam ination com mittee.
All the above put an em pha sis on the con tin u ous med i cal
ed u ca tion as a must in main tain ing and pro mot ing GPs
qualification in Bulgaria. Its organization and manage -
ment is cru cial for train ing's qual ity pro mo tion, pro fes -
sional adaptation and realization of general practitioners
in Bul garia.
The present elaboration aims at ex am in ing the en tire or -
ganization, conducting and management of the postgradu -
ate ed u ca tion in Gen eral Med i cine at the MU - Plovdiv.
MATERIALS AND METHODS
The so cio log i cal re search is in the form of an anon y mous
di rect group in ter view. It com prises 79 (sev enty-nine) gen -
eral prac ti tio ners who have com pleted the three-year spe -
cial iza tion train ing in Gen eral Med i cine prior to their state
ex am i na tion at the MU - Plovdiv. The re search was con -
ducted in 2007/2008 ac a demic year through a form of 28
questions, distributed in the follow ing modules: educa -
tional technologies, practical training, control and assess -
ment sys tem, motivation for learning and attitude towards
lecturers. The source sociological infor mation collected has
been processed through the SPSS v. 15.0 software package.
43
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 43-45 Copyright © Medical Univer sity, Varna
Address for correspondence:
G. Petrova, Sec tion Med i cal ped a gogy, Pub lic Health Fac ulty,
Plovdiv Med i cal Uni ver sity,15A V. Aprilov, str.
Bul garia, Plovdiv 4002
e-mail: gkpg21@yahoo.com
RESULTS AND DISCUSSIONS
The anal y sis of re sults shows that the men quota
(44.30%±8,88%) and those of women (55.70%±8,88%))
are al most equal. The av er age age of re search quota is
41.12±6.67 and the av er age med i cal length of em ploy ment
is 13.32±7.21 years. The pre dom i nant part of re spon dents
have no spe cialty (64.56±5.38%), and those who al ready
have one spe cialty, are spe cial ists mostly in in ter nal
medicine or pediatrics.
Stu dents' as sess ment of teach ing qual ity is a rel a tively new
category and practice. It is a com plex pedagogical phenom -
e non, de ter mined by many and var i ous fac tors; its work af -
fect dif fer ent ob jects and pro cesses; it can be in ter preted in
dif fer ent con texts, etc., and in any case it is con sid ered as a
useful feedback in the process of academic education. The
present experience in applying students' assessment as a
part of and in the con text of ed u ca tional qual ity as sur ing
sys tems shows that its va lid ity and re li abil ity are no lon ger
un der dis cus sions to day rather than find ing paths for its
com plete uti li za tion (2). With this re la tion, we have asked
for the opin ion of those in cluded in our re search re gard ing
their assessment for the overall organization of learning
pro cess - mostly, and it is very good (39.24±5.49%) and
good (34.18±5.34%) (Diagram 1). The results received
satisfy us to a considerable degree.
It may be noted that the post-grad u ate ed u ca tion pro vided
in such a way do not sat isfy in terns (64.56±5.38%), they are
not satisfied with the ratio theoretical/practical training. At
this stage the ratio theoretical/practical training is 70/30. It
would be ap pro pri ate this ra tio changed in the fu ture in fa -
vor of practical training. Increasing practical training on the
ac count of the the o ret i cal one would in crease the sense of
achievement from the postgraduate education. Satisfaction
with ed u ca tion is one of the fac tors for in creas ing its ef fi -
ciency, thus, this ed u ca tional qual ity el e ment shall be a sub -
ject mat ter of future scientific and practical elaborations and
researches.
In terns' learn ing as sess ment as a whole cor re lates with their
prac ti cal train ing as sess ment. In this case, too, re spon dents
find that the prac ti cal train ing is or ga nized in a very good
level (35.90±5.43%) and good (23.08±4.77%) level. Keep -
ing the same du ra tion and in creas ing its ef fi ciency could be
a possible change when conducting practical training, ac -
cord ing to in terns. (63.64±5.48%) of re spon dents ex press
the above opin ion. A key fig ure in con duct ing prac ti cal
train ing is one of the as sis tant in the clin ics - a tu tor. Ac -
cord ing to (53.25±5.96%) of re spon dents both par ties ben -
e fit from such a type of ed u ca tion due to the daily work, of
both train ers and learn ers, with pa tients. It seems that in -
terns' idea of contem porary education coincides only with
that regarding the education in General Medicine, Inter nal
Medicine, Pediatrics and Neurology to a certain extent (Ta -
ble 1). It is only 1/3 of all subjects studied during the
three-year course of studies.
The application of modern educational technologies could be a
possible instrument for increas ing knowledge interest and activ -
ity among learn ers. At this stage re gard ing the said mod ules,
44
Management of postgraduate education in general medicine...
Module Number Yes % Sp Number No % Sp
1. General Medicine 52 65.82 5.34 27 34.18 5.34
2. Internal Medicine 35 44.30 5.59 44 55.70 5.59
3. Childhood Diseases 32 40.15 5.52 47 59.49 5.52
4. Surgery, Orthopedics and Urology 12 15.19 4.04 67 84.81 4.04
5. Eye Diseases 30 37.97 5.46 49 62.03 5.46
6. Ear, Nose and Throat 10 12.66 3.74 69 87.34 3.74
7. Cutaneous Diseases 15 18.99 4.41 64 81.01 4.41
8. Infection Diseases, Hygiene and Epidemiology 18 22.78 4.72 61 77.22 4.72
9. Psychiatry 23 29.11 5.11 56 70.89 5.11
10. Phthisiatry 5 6.33 2.74 74 93.67 2.74
11. Obstetrics and Gynecology 29 36.71 5.42 50 63.29 5.42
12. Neurology 33 41.77 5.55 46 58.23 5.55
Table1. Interns’ idea of contemporary education, per modules
Diagram 1. Assessment for learning process
organization in General Medicine
which do not cor re spond with the idea of con tem po rary ed u ca -
tion, in terns' train ing is con ducted in a way, not very dif fer ent
from that with the med i cal stu dents at the MU - Plovdiv. Ac -
cord ing to K. Madjirova (1997) ed u ca tion man age ment ori en -
tation towards innovations aims at modern education, education
of good qual ity, one of the lead ing forces in so ci ety and at the
same time - adapted to the so cial and eco nomic changes (3).
With that re spect, the post-grad u ate ed u ca tion in Gen eral Med i -
cine should pro mote but re peat the ac a demic ed u ca tion in Med -
i cine. In the or ga ni za tion of learn ing pro cess with adults it is fo -
cused on the pro cess of ac quir ing knowl edge and skills (typ i cal
of the andragogical ap proach) rather than on the ed u ca tive con -
tent (typical of the pedagogical approach). Basically, it is as -
sumed that there are many other sources of knowl edge and in -
formation besides the teachers: people, media, educational (and
non-educational) materials, different types of experience (1).
Andragogy has been de vel op ing more and more thor oughly
dur ing the past years which lead to a con tin u ous en large ment,
im prove ment and ex ten sion of its prob lems (4).
CONCLUSION
Our re search is re lated to the learn ing pro cess or ga ni za tion,
its im portance for increas ing training efficiency and quality
at the higher in sti tu tions of learn ing, i.e., the andragogical
is sues in the con text of higher ed u ca tion ped a gogy al low us
to draw the fol low ing significant conclusions:
• There are very good results regarding interns'
assessment for the overall learning process
organization
• Interns are not satisfied with the ratio
theoretical/practical training in the different
subjects
• Keeping the same duration and increasing its
efficiency could be the expected change when
conducting practical training, according to interns
• A key figure in conducting the practical
training is one of the assistant in the clinics - a
tutor. According to respondents such a type of
education is considered partnership where
both trainers and learners benefit from
• Interns' idea of contemporary education
coincides only with that regarding the
education in General Medicine, Internal
Medicine, Pediatrics and Neurology to a
certain extent. It is only 1/3 of all subjects
studied during the three-year course of
studies.
REFERENCE
1. Gyurova V. (2005) Teach ing adults. Ped a gogy, 2nd
part: The ory of the ed u ca tion. Didactics, Ed. T.
Popov, So fia, Tipographica Ltd, 526 p.
2. Ilieva M. (2002) Stu dents' as sess ment of the teach -
ing, So fia HTMU, 174 p.
3. Madjurova K. (1997) New ap proach in man age -
ment in ed u ca tion - state, ten dency and prog no sis
Strat e gies in ed u ca tional and sci en tific pol i tics
4:85-91
4. Petrov P., Atanasova M. (2003) Ed u ca tion for
adults So fia, Veda Slovena-JG, p.256
5. Totzeva Ya. (2001)Prob lems in teach ing adults, So -
fia, Daniela Ubenova, p.167.
6. Yzakova J., Georgieva A. (2002) Life long learn -
ing - def i ni tion, di men sion, strat egy, So fia, Gea,
203p.
45
Petrova G., R. Assenova, G. Foreva, V. Madjova

ALTERED QUALITY OF LIFE IN EPILEPSY:
SIGNIFICANCE OF INTERICTAL DEPRESSION
Todorova K.
First Psy chi at ric Clinic, UMHAT "St. Marina"-Varna
Reviewed by: assoc. prof. M. Arnaudova
SUMMARY
De pres sive dis or ders, as the most com mon interictal psy chi at ric comorbidity in ep i lepsy, with prev a lence
rates of 10-60% of the pa tients, are an im por tant is sue in the man age ment of peo ple with ep i lepsy. AIM AND
METHOD: We as sessed the fre quency, se ver ity and the im pact of comorbid de pres sive dis or der on the qual -
ity of life (QOL) of peo ple with ep i lepsy (PWE). The re search was con ducted on 106 pa tients with id io pathic
ep i lepsy (41 males and 65 fe males), aged 18 to 60 years. The re search pro to col was ap plied interictally.
Comorbid depressive disor der was diag nosed according to ICD-10 diag nostic cri teria for affec tive and delu -
sional dis or ders and sup ported by eval u a tion on Ham il ton De pres sion Rat ing Scale (HAM-D-17). QOL was
mea sured by Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Statis tical anal ysis included anal ysis of
variance, cor relation anal ysis, t-tests anal ysis. RESULTS: Comorbid depres sive disor der affected 30(28.3%)
of all pa tients. Based on HAM-D-17 scores de pres sion was de fined as mild in 24(80%) pa tients, mod er ate in
5(17%) and se vere in 1(3%) pa tient. There were sig nif i cant be tween-group dif fer ences for the QOLIE-31
over all score and all scores on QOLIE-31 subscales which were lower for the pa tients with comorbid de pres -
sive dis or der. A mod er ate cor re la tion was found be tween the interictal de pres sive dis or der and lower scores
for QOLIE-31 over all score and over all qual ity of life, emo tional well-be ing, en ergy/fa tigue and so cial func -
tion ing subscales. CONCLUSIONS: Comorbid de pres sive dis or der is rel a tively com mon in PWE re sult ing in
sig nif i cant re duc tion of QOL of the af fected sub jects. These data clearly high light the need to better ap pre ci -
ate its im por tance in the over all treat ment plan of pa tients with epilepsy.
Key words: depression, epilepsy, quality of life
INTRODUCTION
Mood disor ders have been dem on strated to have a sig nif i cant
adverse im pact on QOL in the general psychiatric literature
and ini tial stud ies in ep i lepsy have sug gested a com pa ra ble ef -
fect (11). De pres sive dis or ders in PWE are the most com mon
interictal psy chi at ric comorbidity with prev a lence rates of
10-60% of the pa tients de pend ing on the type of the se lected
patient populations or differences in methodology for detect -
ing psy chi at ric symptomatology (13,18). De spite this rel a -
tively high prevalence and their multifaceted clinical expres -
sions depres sive disorders often go unrecognized and un -
treated and yet as a part of the bur den of liv ing with ep i lepsy
they rep re sent an im por tant is sue in the man age ment of PWE.
Gilliam et al. (1997) noted commorbid de pres sion as the most
im por tant pre dic tor of QOL, even more pow er ful than the ac -
tual sei zure fre quency (6). These find ings have been rep li cated
by a num ber of au thors, con firm ing the im por tance of the af -
fec tive state of the pa tient in as sess ing QOL (2,14).
Futhermore commorbid de pres sive dis or der seems to ap pear
as a pow er ful pre dic tor of poor prog no sis in ep i lepsy. Peo ple
with ep i lepsy and commorbid de pres sion are more likely to
experience side effects of anti-epileptic treatment, appear more
of ten drug-re frac tory and have a poorer out come af ter ep i lepsy
sur gery compeared to ep i lepsy pa tients with out commorbid
de pres sion (4,9,12,13). All these find ings make ap pro pri ate
and timely treat ment of commorbid de pres sive dis or der an es -
sen tial part of a com pre hen sive treat ment plan for PWE.
AIM of our study was to as sess the fre quency and se ver ity
of comorbid de pres sive dis or der in an adult pa tient pop u la -
tion with id io pathic ep i lepsy with out any other so matic or
neu ro log i cal comorbidity at the time of the psy chi at ric
eval u a tion and to in ves ti gate the im pact of the comorbid
de pres sive dis or der on the QOL of these pa tients.
SUBJECTS AND METHODS
The study was con ducted on 106 pa tients with id io pathic
ep i lepsy (41 males and 65 fe males), aged 18 to 60 years.
The re search pro to col was ap plied interictally.
47
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 47-50 Copyright © Medical Univer sity, Varna
Address for correspondence:
K. Todorova, First Psy chi at ric Clinic, MHAT "Sveta Ma rina"
1, Hristo Smirnenski str, 9010 Varna, Bul garia
e-mail: koralia_todorova@yahoo.com
All subjects underwent clinical psychiatric exam ination.
Comorbid depres sive disorder was diagnosed according to
ICD-10 diagnostic criteria and the diagnosis was supported
by evaluation on Ham ilton Depression Rating Scale
(HAM-D-17) (8). Based on HAM-D-17 scores de pres sion
was de fined as mild (7-17 points), mod er ate (18-24 points)
and se vere (>24 points).
QOL was mea sured by an ep i lepsy spe cific ques tion naire, the
Qual ity of Life in Ep i lepsy In ven tory-31 (QOLIE-31) (3). It
con tains seven multi-item scales that tap the fol low ing health
concepts: emotional well-being, social functioning, energy-fa -
tigue, cognitive functioning, seizure worry, medication effects
and over all qual ity of life. A QOLIE-31 over all score is ob -
tained us ing a weighted av er age of the multi-item scale score.
Higher scores in di cate better QOL. Sta tis ti cal anal y sis in -
cluded analysis of variance, correlation analysis, t-tests.
RESULTS
All en rolled sub jects had a con firmed di ag no sis of ep i lepsy,
based on doc u mented clin i cal data for at least 12 months
and were sei zure-free for at least 72 hours be fore the psy -
chiatric evaluation.
The en tire sam ple in cluded 106 pa tients with mean age
37.6± 11.57 years.
Ta ble 1 pres ents the ep i lepsy spe cific vari ables of the sam -
ple. Data anal y sis re vealed that 30(28.3%) of all eval u ated
pa tients with ep i lepsy were in a de pres sive ep i sode with
dif fer ent se ver ity. Based on HAM-D-17 scores, 24(80%)
of the pa tients had mild de pres sive ep i sode, 5(17%) had
moderate depres sive episode and 1(3%) patient had severe
depres sion.
Pa tients were di vided into two groups ac cord ing to the
pres ence of comorbid de pres sive dis or der. All scores on
QOLIE-31 were re duced for the group of pa tients with
comorbid depres sive disorder. Signif icant between-group
dif fer ences were found for the QOLIE-31 over all score
(t=5.36;p<0.001) and all QOLIE-31 subscale scores: sei -
zure worry (t=3.43;p<0.001), over all qual ity of life
(t=5.07;p<0.001), emo tional well-be ing (t=6.93;p<0.001),
energy/fatigue (t=6.17;p<0.001), cognitive functioning
(t=3.2;p<0.01), med i ca tion ef fects (t=2.09;p<0.05) and so -
cial functioning (t=3.94;p<0.001). A moderate correlation
was found be tween the pres ence of interictal de pres sive
dis or der and re duced scores for QOLIE-31 over all score
(r=-0.38; p<0.01) and the fol low ing health con cepts: over -
all qual ity of life (r=-0.39;p<0.01), emo tional well-be ing
(r=-0.46;p<0.01), en ergy/fa tigue (r=-0.44;p<0.01) and so -
cial func tion ing (r=-0.3;p<0.01). Anal y sis showed that
comorbid de pres sion in flu enced the most emo tional
wellbeing, ac count ing for 21.16% of the vari ance, en -
ergy-fa tigue, 19.36% of the vari ance and over all qual ity of
life, 15.21% of the vari ance. Ta ble 2 pres ents QOLIE-31
between group differences and correlations depending on
comorbidity of epilepsy and depres sive disorder.
DISCUSSION
As pub lished data and our ex pe ri ence show de pres sion in
ep i lepsy is not a "sin gle" or "ho mo ge neous" dis or der but a
heterogeneous condition with various clinical expres sions
as well as different pathogenic mechanisms, clinical
courses and treat ment strat e gies (11,13). Be cause of this
and ac cord ing to ICD-10 cri te ria, we try to stick to the more
correct term "depressive disorders" in epilepsy (13).
Re sults of our study re vealed a prev a lence of comorbid de -
pres sive dis or der in pa tients with ep i lepsy sim i lar to that re -
ported in other stud ies. Al most 1 in 3 en rolled PWE ex pe ri -
enced de pres sive symp toms sug ges tive of a mild or mod er -
ately se vere de pres sive ep i sode (5,13). By con trast, the prev -
a lence of de pres sion in the gen eral pop u la tion is thought to
be 1-3% in men and 2-9% in women (1). All this data con -
firms that ep i lepsy is a risk fac tor for de pres sion and pa tients
with ep i lepsy have a four- to five-fold greater in ci dence of
depressive disorder. The different prevalence rates reported
in the litera ture result from differences in methodology for
detecting psychiatric symptomatology and for selection of
the type of pa tient pop u la tions stud ied (13).
48
Altered quality of life in epilepsy...
Variable Value
Seizure type
· Partial seizures (simple partial,
complex partial, with/without secondary
generalization)
· Generalized seizures (absence, atypical
absence, myoclonic, clonic, tonic, tonic -
clonic, atonic)
66 / 62,3%
40 / 37,7%
Frequency
· Seizure free
· < 12 seizures per 12 months
· ³ 12 seizures per 12 months
16 / 15,1%
29 / 27,4%
61 / 57,5%
Age at seizure onset
· Mean (SD)
· < 18 years
· > 18 years
19,79±13,19
43 / 41,3%
61 / 58,7%
Duration of epilepsy
· Mean (SD)
· < 5 years
· 5 - 10 years
· > 10 years
17,22± 12,32
21 / 20,0%
18 / 17,1%
66 / 62,9%
Seizure severity
· Mean (SD)
· Mild 1 - 3
· Moderate 3,1 - 5
· Very severe 5,1 - 7
3,33± 1,94
48 / 47,1%
28 / 27,5%
26 / 25,5 %
AEM intake
· Without AEM
· Monotherapy
· Polytherapy
12 / 11,3%
50 / 47,2%
44 / 41,5 %
Tabl. 1. Clinical characteristics of the seizures.
More over some stud ies sug gest that there is a bi-di rec tional
interac tion between epilepsy and depres sion based on com -
mon patho genic mech a nisms me di ated by a de creased
serotonergic, noradrenergic, dopaminergic and gabaergic
ac tiv ity (10,13). These data sup ports the con cept of a higher
than ex pected im pact of de pres sion on PWE and con tra dict
the no tion that de pres sion is sim ply a con se quence of hav -
ing any chronic dis or der.
Stud ies sug gest that the pres ence of comorbid de pres sive
dis or der is found to be a very im por tant fac tor af fect ing the
QOL in pa tients with ep i lepsy (2,11,18). F.Gilliam (2002)
reported a linear relation between interictal depressive symp -
toms and QOL, such as the more fre quent and se vere the
symp toms of de pres sion, the poorer the sub jects' QOL (7).
In our study the pres ence of comorbid de pres sive dis or der
re mained a sig nif i cant pre dic tor for QOL. Comorbid de -
pres sive dis or der af fected QOLIE-31 over all score as well
as scores on all in cluded subdomains. QOLIE-31 scores
were sig nif i cantly re duced by comorbid de pres sion and dif -
fer ences be tween groups by de pres sion cat e gory were clin -
ically significant. Sim ilar results were reported by differ ent
au thors in their stud ies (4,11,6,17). The scores on
QOLIE-31 subscales in di cated the neg a tive im pact of
comorbid de pres sion on all as pects of QOL and es pe cially
on emo tional well-be ing and the en ergy-fa tigue do main.
Sim i lar find ings were pub lished re cently by V. Senol et al.
(2007) for pa tients in Tur key (15).
CONCLUSION
De pres sive dis or ders are a fre quent comorbidity of ep i lepsy
that have a very neg a tive im pact on QOL of the pa tients in -
cluding their response to pharmacologic treatment. This
may be due to the fact that de pres sive dis or ders and ep i -
lepsy ap pear to share com mon patho genic mech a nisms that
may ex plain the bidirectional re la tion ship be tween the two
en ti ties and their high comorbid oc cur rence. The sig nif i cant
influence of even mild-moderate depres sion on people's
per cep tion of all as pects of their QOL sug gests the im por -
tance of de pres sion screen ing among peo ple with ep i lepsy.
Diagnosis and treatment of comorbid depres sive disorder
could be an im por tant con tri bu tion to wellness of peo ple
with epilepsy.
REFERENCES
1. Beghi, E., Roncolato, M., Visona, G. De pres -
sion and al tered qual ity of life in women with ep i -
lepsy of child bear ing age. Epilepsia, 45, 2004, 1,
64-70.
2. Boylan, L., L. Flint, D. Labovitz, S. Jack son,
K. Starner, O. Devinsky. De pres sion but not sei -
zure fre quency pre dicts qual ity of life in treat ment-re -
sis tant ep i lepsy. Neu rol ogy, 62, 2004, 258-261
3. Cramer, J., K. Perrine, O. Devinsky, L.
Bryant-Comstock, K. Meador, B. Hermann.
De vel op ment and Cross-Cul tural Trans la tions of a
31-Item Qual ity of Life in Ep i lepsy In ven tory.
Epilepsia, 39, 1998, 1, 81-88.
4. Cramer, J., M. Blum, M. Reed, K. Fan ning.
Ep i lepsy Im pact Pro ject. The in flu ence of comorbid
de pres sion on qual ity of life for peo ple with ep i lepsy.
Ep i lepsy Behav, 2003,4:515-521.
5. Ettinger, A., M. Reed, J. Cramer, for the Ep i -
lepsy Im pact Pro ject Group. De pres sion and
comorbidity in com mu nity-based pa tients with ep i -
lepsy or asthma. Neu rol ogy, 63, 2004, 1008-1014.
6. Gilliam, F., R. Kuzniecky, E. Faught, L.
Black, G. Car pen ter, R. Schrodt. Pa tient-val i -
dated content of epilepsy-specific quality-of-life mea -
surement. Epilepsia, 38, 1997, 2, 233-236.
7. Gilliam F. Op ti miz ing health out comes in ac tive ep -
i lepsy. Neu rol ogy, 2002;58:S9-20.
8. Ham il ton, M. A rat ing scale for de pres sion. J
Neurol Neurosurg Psy chi a try, 23, 1960, 56-62.
9. Hitiris, N., R. Mohanraj, J. Norie, G. Sills,
M.Brodie. Pre dic tors of pharmacoresistant ep i lepsy.
Epilepsy Res, 75, 2007, 2-3, 192-196.
49
Todorova K.
QOLIE - 31 Scale
Epilepsy
without
depression
Epilepsy with
depression t p r p D
Overall score 62,46± 16,72 42,31± 16,31 5.36 < 0,001 - 0.38 < 0,01 14.44 %
Seizure worry 51,01± 29,48 29,94± 25,76 3.43 < 0,001 - 0.26 < 0,01 6.76 %
Overall quality of life 63,45± 16,67 44,75± 18,14 5.07 < 0,001 - 0.39 < 0,01 15.21 %
Emotional well - being 62,76± 14,67 40,26± 15,99 6.93 < 0,001 - 0.46 < 0,01 21.16 %
Energy/Fatigue 62,46± 16,39 40,83± 17,17 6.17 < 0,001 - 0.44 < 0,01 19.36 %
Cognitive functioning 62,50± 21,97 47,06± 23,38 3.20 < 0,01 - 0.25 < 0,01 6.25 %
Medication effects 55,56± 33,29 40,74± 31,37 2.09 < 0,05 - 0.17 < 0,01 2.89 %
Social functioning 65,50± 27,57 41,80± 28,71 3.94 < 0,001 - 0.30 < 0,01 9.00 %
Tabl. 2. QOLIE-31 between-group diffrerences and correlations depending on comorbidity of Epilepsy and Depressive
disorder
10. Hesdorffer, D., W. Hauser, E. Olafsson, P.
Ludvigsson, O. Kjartansson De pres sion and sui -
cidal at tempt as risk fac tor for in ci den tal un pro voked
seizures. Ann Neurol, 2006; 59:35-41.
11. John son, E., J. Jones, M. Seidenberg, B.
Hermann. The rel a tive im pact of anx i ety, de pres -
sion, and clin i cal sei zure fea tures on health-re lated
qual ity of life in ep i lepsy. Epilepsia, 45, 2004, 5,
544-550.
12. Kanner, A. Ep i lepsy and mood dis or ders. Epilepsia,
48, 2007, Suppl. 9, 20-22.
13. Kanner, A. De pres sion in ep i lepsy: a com plex re la -
tion with un ex pected con se quences. Curr Opin
Neurol, 21, 2008, 190-194.
14. Perrine, K., B. Hermann, K. Meador, B.
Vickrey, J. Cramer, D. Hays, O. Devinsky.
The re la tion ship of neuropsychological func tion ing to
qual ity of life in ep i lepsy. Arch Neurol, 52, 1995,
997-1003
15. Senol, V., F. Soyuer, F. Arman, A. Ozturk.
In flu ence of fa tigue, de pres sion, and de mo graphic,
so cio eco nomic, and clin i cal vari ables on qual ity of
life of pa tients with ep i lepsy. Ep i lepsy Behav, 10,
2007, 1, 96-104.
16. Tlusta, E., J. Zarubova, J. Simko, H.
Hojdikova, S. Salek, J. Vlcek. Clin i cal and de -
mo graphic char ac ter is tics pre dict ing qual ity of life in
pa tients with ep i lepsy in the Czech re pub lic: How this
can influence practice? Sei zure, 2008, Jul.19. E-pub -
lished.
17. Tracy, J., V. Dechant, M. Sperling, R. Cho,
D. Glosser. The assossiation of mood with qual ity
of life rat ings in ep i lepsy. Neu rol ogy, 68, 2007, 14,
1101-1107.
18. Zeber, J., L. Cope land, M. Amuan, J.
Cramer, M. Pugh. The role of comorbid psy chi at -
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Behav, 10, 2007, 539-546.
50
Altered quality of life in epilepsy...
EARTHQUAKE IN HAITI AND DISASTER MEDICINE TRAINING
Romanova Hr.1, I. Marinova1, N. Radeva2, M. Marinov3
1Departmet of Hygiene and Disaster Medicine, Medical University - Varna
2Department of Health Management, Medical University - Varna
3Department of Preclinical and Clinical Sciences, Medical University - Varna
Reviewed by: assoc. prof. B. Yustinianova
ABSTRACT
In quiry re search is made among med i cal stu dents - 100 per sons from Med i cal Uni ver sity - Varna at the end of
2010 with ques tion naire con tain ing 10 ques tions for de ter min ing the level of knowl edge about di sas trous sit u -
a tions. From the re search we de ter mine that 52% con sider the Haiti earth quake like the heavi est di sas ter in
the world, 39% point the Pa ki stan floods, 5% - other di sas trous sit u a tions (vol cano ac tiv i ties) and 4% - can
not de ter mine. The ma jor ity 95% an swer that they want to help the suf fer ers but only 41% were do nated in
the do na tion cam paigns, or ga nized by dif fer ent, mainly TV shows pre sent ers. The prog no sis for the con se -
quences of the Haiti earth quake is un fa vor able for 51% from the par tic i pants.
Key words: disastrous situation, Haiti earthquake, disaster medicine
INTRODUCTION
Di sas ters are sud den events, which se ri ously dis turb our daily,
threaten the lives and health of large groups of peo ple (1,2,3).
The earth quake in Haiti 2010 hap pened in 12.01.2010 at
16h 53 min at lo cal time. Mag ni tude was 7.0 to 7.3, the
coun try's most se vere earth quake in over 200 years. It left
be tween 250 000 peo ple dead, 300 000 wounded and 1.6
mil lion home less. The epi cen ter was at 25 km from
Port-au-Price (the cap i tal) and the du ra tion was 2 min 30
sec. In the fol low ing hours there were 12 sec ond ary trem -
ors, but weaker. A sec ond earth quake oc curs with mag ni -
tude of 6.1 on 20.01.2010 at 06h 03 min at 59 km from
Port-au-Prince (4,5,6,7).
The struc ture and or ga ni za tion of the Hai tian state have
suf fered from the in ci dent af ter 3 days, the state of emer -
gency was de clared through out the coun try for a month.
Numerous buildings were also destroyed, including the
Na tional Pal ace and No tre Dame de Port-au-Prince. Ac -
cord ing to in sti tute of Geo log i cal Stud ies US, the earth -
quake would have had a mag ni tude of 7 (equiv a lent to the
en ergy re leased by an H-bomb of about 5 mil lion tonnes).
There was also a se ries of after shocks, re spec tively 5.9,
5.5 and 5.1.
Our goal is to re search the opin ion of stu dents from the
Med i cal uni ver sity - Varna which is the heavi est di sas ter
dur ing 2010 and their knowl edge about this prob lem.
MATERIALS AND METHODS
Re search is made among med i cal stu dents - 100 per sons
from Med i cal Uni ver sity - Varna at the end of 2010 with
questionnaire containing 10 questions for determining the
level of knowledge about disastrous situations.
The half of the ques tions is with pre lim i nary for mu lated an -
swers and the other part is opened ques tions with pos si bil i -
ties for per sonal opin ion.
It is ex e cuted the prin ci ple of the same at ti tude for the all
participants.
The ma chin ing data pro cess ing is made.
RESULTS AND DISCUSSIONS
The par tic i pants in the re search are 2/3 women and 1/3 men
and this cor re spond to the stu dents from the Med i cal uni -
ver sity - Varna, where the pre dom i nated is fe male gen der
(Table 1).
From the re search we de ter mine that 52% con sider the Haiti
earth quake like the heavi est di sas ter in the world, 39% point
the Pa ki stan floods, 5% - other di sas trous sit u a tions (vol cano
ac tiv i ties) and 4% - can not de ter mine (Fig. 1).
51
Scripta Scientifica Medica, 2011; vol. 43 (1), pp 51-53 Copyright © Medical Univer sity, Varna
Address for correspondence:
I. Marinova, Dept. of Hy giene and Di sas ter Med i cine
Med i cal Uni ver sity - Varna, Marin Drinov str. 55, Varna
e-mail: marinovaig@abv.bg
Age 18-22 23-27 Total %
Men 25 25% 6 6% 31 31
Women 61 61% 8 8% 69 69
Table 1. Participants in the research.
The half of the in quired is in formed about pre vi ous earth -
quakes in Haiti.
Pre vi ous earth quakes of high in ten sity oc curred in Haiti in -
clude those that oc curred in 18.10.1751 and 03.06.1770.
The his to rian Moreau de St. Mery re ports that in
Port-au-Prince in 1750 "one of the houses of ma sonry was
not re versed", and in 1770 "the whole town was re versed".
Af ter this there were an other strong earth quakes in 1842,
1887, 1904.
The first after shock in the 2010 earth quake, oc curred 19
min utes af ter the first shock, sug gest ing a wors en ing of the
sit u a tion given the in abil ity to im ple ment first aid in the
minutes follow ing the incident.
The mag ni tude of these rep li cas, ap proach ing 6, is also an -
other fac tor, rare in this type of event, call ing it a ma jor di -
sas ter: by def i ni tion, the ef fects of after shocks "can cause
ma jor dam age to poorly de signed build ings in ar eas re -
stricted. Cause slight dam age to well-de signed build ings."
The is land of His pan iola (shared by Haiti and the Do min i -
can Re pub lic) is lo cated in a seis mi cally ac tive zone be -
tween 2 tec tonic plates: the North Amer i can Plate to the
north and south Ca rib bean plate.
Just af ter the earth quake in 2010, great clouds of dust ap -
peared in the mo ments af ter the earth quake in
Port-au-Prince. This dust is likely due to unreinforced con -
crete buildings; accumulates fears about the possibility that
many such build ings have col lapsed. Poor coun try, Haiti
has no for mal con struc tion stan dards for build ings.
The cit ies of Carrefour (300 000 in hab it ants, de stroyed at
40%), Leogane (200 000 in hab it ants, de stroyed more than
90%) and Gressier, near the quake's epi cen ter, was se verely
affected.
The only pos i tive fact af ter the earth quake was that the air -
port in the cap i tal was prac ti ca ble, per mit ting to bring by air
the help ing peo ple, the ma te ri als for emer gency and the lo -
gistic.
Ban Ki-moon, Sec re tary Gen eral of the UN es ti mated that
some 3 mil lion peo ple could be af fected over 4 mil lion in
the population of Port-au-Prince.
The de struc tion of thou sands of homes and fear of after -
shocks since then have pushed most of the in hab it ants of
the city to spend the night out side. The sur vi vors have no or
lit tle wa ter, food and med i cines. Un til 13 Jan u ary, the field
hos pi tal of the Ar gen tine Air Force, in stalled as part of the
UN since 2004, was the only on-site op er a tional.
Jan u ary 20, an other earth quake of mag ni tude 6.1 was felt
again and an im mediate consequence, a massive exodus
has been ob served.
The earth quake has left the only fea si ble path to the air port,
but the tower was de stroyed. The first land ings have been
monitored since the airports of the Dominican Republic.
The first days af ter the di sas ter, jumbo jets could not land
on the run way. It was there fore nec es sary that their con tents
are trans shipped on the air fields of the Do min i can Re pub -
lic, on air planes of smaller size, al low ing them to flow
through the air port in Haiti.
The port is use less, and the four cranes are un us able, and
this exacerbates the logistical problems for the movement
of ma te rial and hu man means of help.
On site, de liv ery of food and wa ter sur vival it self is dif fi -
cult. The Hai tian pop u la tion lives usu ally two days in ad -
vance of food pan tries, places of life de stroyed for the most
part, is its al most to tal des ti tu tion.
The dif fi culty of trans mis sion is also il lus trated in road in -
fra struc ture, for ex am ple to con nect the coastal cit ies of
South East De part ment, lo cated south of Port-au-Prince,
Jacmel such, also hard hit, you have to take a road strewn
with boul ders and tree trunks that only man ages to avoid by
a motorcycle.
On the fourth day af ter the earth quake, ref u gees flee ing
Haiti by sea, like boat peo ple, were ob served.
On the sixth day af ter the earth quake, about 70 000 bod ies
had been bur ied, mostly in mass graves.
Nei ther morgues and cem e ter ies do not have suf fi cient ca -
pac ity to man age the scale of ca su al ties re corded: firstly ex -
tracted the bod ies from the rub ble had been gath ered in
town squares and on along the road. Con fronted with tele -
vision im ages showing the promiscuity of the survivors and
the dead in the city, com men ta tors from the Hai tian di as -
pora, said the events would mark a long time the trauma of
the na tion.
Health con di tions re quire burial in mass graves, which op -
poses the prac tices in Haiti. In ad di tion, Hai tian voo doo
priests op posed to the meth ods of burial in mass graves, ar -
gu ing that they do not re spect the dig nity of the de ceased.
Drink able wa ter: UNICEF works for the dis tri bu tion of
drink ing wa ter, as in the town of Fonds-Parisien, lo cated
near the brack ish ponds and the bor der with the Do min i can
Republic.
Food As sis tance: sta ple foods such as rice can not be con -
sid ered to feed the pop u la tion, who lost the usual means to
cook with the de struc tion of places of life. Sup ply lav ished
by humanitarian aid has privileged food rations com pact
providing the necessary nutritional rations should provide
power to the af fected pop u la tion in the com ing weeks.
The means of the state to deal with the event are even more
lim ited than in Haiti is the 149th (out of 182) in the hu man
de vel op ment in dex. That is why a large force of mil i tary
forces was de ployed on the ground to sup port and se cure
delivery of humanitarian aid and prevent overflows.
52
Earthquake in haiti and disaster medicine training
Fig.1. The heaviest disaster during 2010.
Several countries, large global corporations and celebri ties
have made many do na tions to help the Hai tian peo ple.
The ma jor ity 95% from the in quired an swer that they want
to help the suf fer ers but only 41% were do nated in the do -
nation cam paigns, organized by different, mainly TV
shows presenters.
Many prob lems re main, in more there is out break of chol -
era, which caused pro tests against the U.N. peace keep ing
forces led to vi o lent at tacks on No vem ber 15.2010 forces
sus pected them of bring ing the chol era strain to Haiti. The
chol era out break had, at that point, killed more than 2100
peo ple since mid-Oc to ber, and sick ened around 15 000.
The strain may have come from the Nep a lese peace keep -
ers, who have a base on the Artibonite river, but the U.N.
does not want peo ple to come to con clu sions and blame the
Nepalese based on "misinformation". How ever, the last
chol era out break in Haiti was forty years ago, and "The
U.S. Cen ters for Dis ease Con trol and Pre ven tion found that
the chol era strain now rav ag ing the coun try matched a
strain spe cific to South Asia, but said they had not pin -
pointed its or i gin or how it ar rived in Haiti."
The half of the par tic i pants (51%) con sid ers that the un fa -
vor able con se quences from the Haiti earth quake 2010 will
con tinue 4-5 years af ter the di sas ter, 32% con sider that the
sit u a tion will be over came for 1-2 years thanks of the in ter -
na tional help, 17% can not make a prog no sis (Fig. 2.).
CONCLUSION
1. From the research we determine that 52% consider the
Haiti earthquake like the heaviest disaster in the world,
39% point the Pakistan floods, 5% - other disastrous
situations /volcano activities/ and 4% - can not
determine.
2. The cholera's consequences are heavier than the
earthquake's consequences.
3. The prognosis for the earthquake's consequences is
unfavorable for 51% from the participants.
REFERENCES
1. Romanova Hr., Disaster medicine (Manual for
med i cal stu dents), Med i cal Uni ver sity, Varna, 2007
2. WHO, Com mu nity emer gency pre pared ness, Geneva,
1999
3. WHO, In ter na tional trial and health, Geneva, 2004
4. http://www.insu.cnrs.fr/a3348,seisme-haiti-12-janvier-
2010.html
5. http://www.20min.ch/ro/news/monde/story/150-000
-morts-confirmees-par-le-gouvernement-31195405
6. http://www.lefigaro.fr/flash-actu/2010
7. http://www.lemonde.fr/ameriques/ar ti cle/2010/02/19
53
Romanova Hr., I. Marinova, N. Radeva, M. Marinov
Fig. 2. Prognosis for overcoming the consequences of
the earthquake.
AUTOR'S INDEX
Abbud A. ...................................19
Alexandrov N. ...........................39
Andonova S...............................7, 11
Arabadzhieva D.........................15
Assenova R................................43
Balabanova M. ..........................23
Bocheva Y.................................7
Bozhkov V. ...............................13
Chernopolsky Pl. .......................13
Deleva N....................................15
Dimitrov I..................................15
Dobreva D. ................................35
Drumeva P.................................23
Foreva G....................................43
Galunska B. ...............................35
Ganeva D...................................11
Geneva S. ..................................15
Georgieva M..............................39
Ignatov V...................................27
Ivanov B. ...................................15
Ivanov K....................................27
Ivanov S. ...................................19
Ivanov T. ...................................13
Kaprelyan A. .............................15
Kerekovska A............................31
Kolev N. ....................................27
Kovachev E. ..............................19, 21
Krasnaliev I. ..............................23
Madjova V.................................43
Marinov M. ...............................51
Marinova I.................................51
Paskalev D.................................7
Petkova D. .................................7
Petrova G...................................43
Plachkov I..................................13
Radeva N. ..................................51
Romanova Hr. ...........................51
Shtilionova S. ............................23
Stancheva M..............................35
Terzieva M. ...............................15
Todorova K. ..............................47
Tonev A.....................................27
Tsonev A. ..................................19
Usheva N...................................7
Velinov V. .................................11
Yotov Y.....................................7
PERMUTERM SUBJECT INDEX
acupuncture, disc herniation, low back pain,
reflex therapy _____________________________15
Cutaneous Pseudolymphomas _______________23
depression, epilepsy, quality of life ____________47
disastrous situation, Haiti earthquake,
disaster medicine___________________________51
disc herniation, acupuncture, low back
pain, reflex therapy _________________________15
epilepsy, depression, quality of life ____________47
fat soluble vitamins, HPLC, fish tissue_________35
general practitioner, postgraduate
education_________________________________43
Haiti earthquake, disastrous situation,
disaster medicine___________________________51
HPLC, fat soluble vitamins, fish tissue _________35
Lactobacillus bulgaricus, probiotic
Biostim LBS, intoxication, energy,
nutritional therapy__________________________39
NT-proBNP, obstructive sleep apnea
syndrome, sleep disordered breathing____________7
obstructive sleep apnea syndrome,
NT-proBNP, sleep disordered breathing__________7
organ donation, public awareness and
perceptions, Bulgaria, European Union _________31
pedunculated, submucous myoma, uterus_______21
postgraduate education, general
practitioner _______________________________43
postoperative nausea, vomiting,
laparoscopic surgery ________________________27
preoperative chemotherapy, primary
cytoreduction, advanced ovarian cancers,
survival rate_______________________________19
primary cytoreduction, preoperative
chemotherapy, advanced ovarian cancers,
survival rate_______________________________19
probiotic Biostim LBS, Lactobacillus
bulgaricus, intoxication, energy,
nutritional therapy__________________________39
public awareness and perceptions,
organ donation, Bulgaria, European Union ______31
subarachnoid hemorrhage, Vasospasm,
transcranial Doppler ________________________11
submucous myoma, pedunculated,
uterus____________________________________21
Vasospasm, subarachnoid hemorrhage,
transcranial Doppler ________________________11
vomiting, postoperative nausea,
laparoscopic surgery ________________________27
INSTRUCTIONS TO AUTHORS
Scripta Scientifica Medica is the official publication of Medical University Prof. Dr. Paraskev Stoyanov, Varna, Bulgaria. It is
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2. Goute, A. M., A. R. Haynes, M. J. Owen. New as pects of psy chotic drug us age.- J. Clin. Psychopharmacol., 8,
1988, No 4, 315-317.
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55
Scripta Scientifica Medica, 2011; vol. 43 (1) Copyright © Medical Univer sity, Varna
SCRIPTA SCIENTIFICA MEDICA, VOL. XXXXIII, (1), pp. 1-56
Editor-in-Chief: Prof. Anelia Klissarova, MD, PhD, DSc
Co-Editor-in-Chief: Prof. Rossen Madjov, MD, PhD
Technical editor: E. Jordanova, A. Antonov
Cover art ed i tor: E. Spasov
Publ. Lit. group: III-3
Sent to print ers: March, 2011
Print sheets: 14
Format: 8/60x84
Ap proved for print ing: April, 2011
To tal print: 300
ISSN 0582-3250
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