Scripta Scientifica Medica Med i cal Uni ver sity

Medical University
Prof. Dr. Paraskev Stoyanov
VARNA, Bulgaria
Vol. 40 (2), 2008
pp. 105-196
An official publication of Medical University "Prof. Dr. Paraskev Stoyanov", Varna
Prof. Anelia Klissarova, MD, PhD, DSc
Rector of Medical University of Varna
e-mail: [email protected]
Assoc. Prof. Rossen Madjov, MD, PhD
Vice Rector of Medical University of Varna
e-mail: [email protected]
Editorial Board:
Assoc Prof. Peter Genev, MD, PhD
Department of Pathoanatomy
E-mail: [email protected]
Assoc. Prof. Boriana Varbanova, MD, PhD
Department of Pediatrics and Medical Genetics
E-mail: [email protected]
Assoc. Prof. Minko Minkov, MD, PhD
Head, Department of Anatomy, Histology and
E-mail: [email protected]
Assoc. Prof. Zhaneta Georgieva, MD, PhD
Vice Rector University Hospital Coordination and
Postgraduate Education
E-mail: [email protected]
Assoc. Prof. Krasimir Ivanov, MD, PhD
Head, Department of Surgery
E-mail: [email protected]
Assoc. Prof. Svetoslav Georgiev, MD, PhD
Department of Internal Medicine
E-mail: [email protected]
Assoc. Prof. Iskren Kotsev, MD, PhD
Department of Hepato - Gastroenterology
E-mail: [email protected]
Assoc. Prof. Negrin Negrev, MD, PhD
Vice Rector for Students Affair
E-mail: [email protected]
Assoc. Prof. Marinka Peneva, MD, PhD
Dean, Faculty of Medicine
E-mail: [email protected]
Assoc. Prof. Stoyanka Popova, MD, PhD
Dean, Faculty of Public Health
E-mail: [email protected]
Assoc. Prof. Vasil Svechtarov, DMD, PhD
Dean, Faculty of Dental Medicine
E-mail: [email protected]
Assoc. Prof. Violeta Tacheva, PhD
Head, Department of Language Teaching,
Communications and Sports
E-mail: [email protected]
Assoc. Prof. Diana Ivanova, MD, PhD
Head, Department of biochemistry molecular medicine
and nutragenomics
E-mail: [email protected]
Assoc. Prof. Valentina Madjova, MD, PhD
Department of Family Medicine
E-mail: [email protected]
Assoc. Prof. Emanuela Mutafova, PhD
Head, Department of Economics
and Healthcare Management
E-mail: [email protected]
Assoc. Prof. Radoslav Radev, MD, PhD
Head, Department of Surgery
E-mail: [email protected]
Nikola Kolev, MD
Department of Surgery
University Hospital "St. Marina"
Rumyana Kuyumdzhieva
Library of the Medical University
E-mail: [email protected]
Kerekovska A., N. Feschieva, K. Dokova, N. Usheva - HEALTH STATUS OF
AND POLICY IMPLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
CASES DURING SEMINAR LESSONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
COURSE OF BIOPHYSICS: A COMPARATIVE ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
ANXIETY LEVELS AND SEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
FOR PROTECTION IN CASE OF DISASTROUS SITUATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
RECEPTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Ivanov K., V. Ignatov, N. Kolev, A. Tonev, D. Hristov, S. Konsulova, B. Balev,
R. Madjov - DIAGNOSIS AND TREATMENT OF LIVER ABSCESSES . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Deenichin G., R. Dimov, V. Molov, Ch. Stefanov - SYNCHRONOUS MALIGNANT
TUMORS OF THE COLON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Dyakov Sv., A. Hinev, M. Siderova, H. Bohchelian, K. Hristozov, V. Platikanov ÅMPHYSEMATOUS PYELONEPHRITIS – CLINICORENTGENOLOGIC DIAGNOSIS,
REQUIRING URGENT SURGICAL TREATMENT CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
COMPARISON OF ABSCESS- AND ELECTIVE TONSILLECTOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
CASE REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
CAVITY IN CASES OF FRONTOETHMOIDAL MUCOCELE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
CORONAL APPROACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Bachvarova S., P. Drumeva, R. Bachvarova, V. Chakalova - ANXIETY AND
DEPRESSION DISTURBANCES IN SOME CHRONIC SKIN DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
S. Racheva - ETIOLOGY OF CHRONIC NON-ALLERGIC URTICARIA . . . . . . . . . . . . . . . . . . . . . . . . . 167
Burulianova I., V. Konstantinova, V. Dokov - SUDDEN INFANT DEATH
SYNDROME - THE CAUSE OF DEATH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Burulianova I., V. Konstantinova, D. Radoinova - METHYL ALCOHOL POISONING A MORPHOLOGICAL STUDY FOR 20-YEARS PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
OF VARNA FOR A 41-YEAR-LONG PERIOD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
15 YEARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
FOOTBALL AND KARATE TRAINING IN PRIMARY SCHOOL PUPILS . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Shishkova A., P. Petrova, À. Tînev, G. Iliev, P. Bahlova, Ogn. Softov,
AU THOR'S INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
PERMUTERM SUBJECT INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
INSTRUCTIONS TO AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Scripta Scientifica Medica, vol. 40 (2008), pp 111-116
Copyright © Medical University, Varna
Kerekovska A., N. Feschieva, K. Dokova, N. Usheva
Department of Social Medicine and Health Care Organisation, Prof. Paraskev Stoyanov Medical
University of Varna
Reviewed by: Assoc. Prof. S. Popova, MD, PhD
This paper sets out to review the situation with regard to health status of the Bulgarian population and its
main determinants. Revealing their recent dynamics, the study also aims to predict the future trends. It tries
to interrelate the diseases burden and its determinants with necessary policy responses. Highlighting the main
challenges it draws out policy implications. The methods involve analysis of the current demographic and
health situation and assessment of its dynamics. Some trends are analyzed comparatively for the different
gender and residence population groups. The study is based on an analysis of previously published reports
and official statistics. It also draws upon a number of national and local health surveys. Targeted and sustained investment is necessary to reverse the negative trends of population health and its social determinants.
Clearly formulated, evidence-based, comprehensive and consistent policy is needed for integrated control of
risk factors and chronic diseases, emphasizing on prevention and health promotion. Tangible political commitment, multisectoral collaboration and public participation are required for developing, implementing and
sustaining healthy public policies.
Keywords: health status, social determinants, policy implications, Bulgaria
The socio-political transformations that have taken place
in Bulgaria since 1989 have had a big impact on the population's health. The dramatic economic and social
changes throughout the 1990s caused serious demographic consequences and generally worsened health indicators - associated with low birth rates; increased mortality rates (especially infant and middle-aged male); net
emigration and falling populations (particularly those of
working age). Demographic change has increased the
proportion of elderly people. The prevalence and burden
of chronic non-communicable diseases substantially increased.
The pattern of increased morbidity and mortality from
vascular diseases and cancer is very much associated
with unhealthy lifestyles such as high rates of smoking,
alcohol consumption and high blood pressure; lack of
exercise, unbalanced nutrition, and substance abuse. Social insecurity during the transition period has been an
underlying health determinant along with rising unemAddress for correspondence:
A. Kerekovska, Dept. of Social Medicine and Healthcare Organisation, Medical University Prof. Dr. Paraskev Stoyanov, 55 Marin
Drinov St, BG-9002 Varna, BULGARIA
E-mail: [email protected]
ployment, poverty and health care system deficiencies.
The health impacts of social and economic factors are
clearly manifested by the socio-economic differences in
population health. Indeed, the transition years in Bulgaria have been characterized by a rapid increase in the
socio-economic, residence and gender differences in
health. Widening inequalities are also observed from an
international perspective, as the gap between Bulgarian
health indicators and those of Western and even Central
European countries has been increasing for the last decades.
These trends of worsening demographic and health indicators, rising prevalence of risk factors and widening inequalities in health are worrying and require more research and
an adequate political response. They will continue to pose a
major challenge for health policy in Bulgaria especially in
the processes of transforming the health care system and
acceding the European Union.
This paper sets out to review the situation with regard to
health status of the Bulgarian population and its main determinants. Revealing their recent dynamics, it also aims to
predict the future trends. It tries to interrelate the disease
burden and its determinants with necessary policy responses. Highlighting the main challenges it draw out some
policy implications.
Kerekovska A., N. Feschieva, K. Dokova ...
The methods involve an analysis of the current demographic and health situation in Bulgaria and assessment of
its dynamics. Some trends are analyzed comparatively for
the different gender and residence population groups. Indicators and tendencies assessments are based on both quantitative data as well as qualitative (expert) information coming from different national (Ministry of Health, National
Centre on Health Information; National Statistical Institute,
national public health centers, etc.) and international
(World Health Organisation, World Bank, etc.) sources.
The study is based on an analysis of previously published
reports and official statistics. It also draws upon a number
of national and local health surveys.
Health Status
The period since 1989 is characterized by a rapid population fall from 8,948,649 to 7,801,273 in 2003 [4,11]. Before 1990, the natural growth in Bulgaria has been positive
although continuously dropping: from 7.2%o in 1970 to
3.4%o in 1980 and 0.8%o in 1989. Since 1990, Bulgaria
has a negative natural growth starting from -0.4%o (in
1990), reaching its maximum of -7%o in 1997, and keeping
negative rates of between -5.2 to -5.8 for the 2001-2004 period [4]. The population loss in the last 15 years is also due
to large-scale emigration of mainly young and active people. Over 600,000 people have left the country between
1989 and 1995. Since 1995, the average annual number of
emigrating individuals has been estimated at 30,000 [8].
Initially, this phenomenon had predominantly political nature, including members of the ethnic Turkish community
in the wake of attempts at forcible assimilation by the previous regime. Later, factors of economic origin started to determine the emigration flows.
The high unemployment rates and the lack of professional
perspective resulted in mass emigration of many young
people seeking better opportunities for education and
greater job satisfaction. This process negatively influences
the overall demographic situation of the country leading to
rapid population fall, intensive aging of the Bulgarian population and negatively impacting upon its birth potential.
The decrease in the young population groups caused by the
emigration along with the persisting low fertility rates
speed up the population-aging trend. While in 1990 the
proportion of people aged 65 and above was 13.4%, it became 17.1% in 2003 along with a parallel decrease in the
youngest population group (under 14 years of age) that
reaches the level of 14.6% in 2003. The population ageing
leads to an increase in the average age, which in the 1990s
changed faster than in the previous decades, and after 2000
exceeds 40 years. Compared to the urban areas, the rural
regions of the country are significantly more affected by the
aging-population process. Data for 2004 [4] reveals average population age of 45.0 years for the rural and 39.3 years
for the urban areas (total country average of 41.0 years).
The population decrease and aging processes in Bulgaria
will further deepen according to projections of independent
studies [13]. The World Bank estimates that the proportion
of 'over 65s' will rise from its current level of 17% to around
28% by 2050 [6].
The declining tendency of births, existing for decades has
accelerated in the 1990s, and birth rates have been decreasing very steeply to roughly half the rates of the pre-transition years. From 13.3%o in 1988, births in Bulgaria have
declined to 7.7%o in 1997 - the lowest in Europe. Despite
the slight increase since late 1990s, it is still one of the lowest birth rates in Europe - 9.0%o for 2004. Total fertility declined from 1.81 in 1990 to 1.29 in 2004, reaching its lowest rates of 1.09 in 1997 [4]. For the last 15 years it has not
exceeded 1.3, which is substantially lower than the level of
2.2 - necessary for replacement of the population. These
negative reproductive tendencies are determined demo-
Table 1. Key Health Indicators for Bulgaria, 1990 - 2004 [4]
Crude death rate per Population growth
rate per 1,000
Total fertility rate
per woman
Infant mortality rate
per 1,000 live births
Birth rate per 1,000
Health status of the bulgarian population: ...
graphically by the intensive process of population aging
and the respective decrease in the number of women in reproductive age. They are also closely related to the social-economic conditions in the country during the transition period such as impoverishment and uncertainty of the
families making the decision for childbirth difficult. Although decreasing, abortions rates are still high in Bulgaria
- about three times the EU average. Bulgaria ranks among
the countries in Europe with the highest birth rates in young
(adolescent) age of maternity, indicating inefficient family
planning. A particular problem for Bulgaria is the high proportion of low birth weight births - increasing from 5.7 per
100 live births in 1986 to 7.2 in 1994 [7] and 8.9 per 100
live births in 2002 [4].
The tendency of constantly increasing mortality existing
since the 1960s (8.1%o in 1960, 10.3%o in 1975 and
12.0%o in 1985) has deepened during the transition years.
During the 1990s, the crude mortality rates steeply increased from 12.9%o in 1993 to 14.7%o in 1997, and keep
a stable but high for the European standards level of about
14.2%o for the 2001-2004 period [4]. This process is observed for both sexes, though with greater intensity among
male population. The most risky age group is men at the
age of 40-59 years whose death rates are much higher than
those for women in the same age group. Mortality rates are
higher in the rural areas - 19.4%o - compared to the urban
ones - 11.9 %o (2004) [4]. The more unfavourable working
conditions, poor life style behaviours (unbalanced nutrition
and alcohol abuse), increasing differences in access to
health services and the quality of health care by place of
residence could have contributed to the poor health status
of men living in the villages and their high rates of premature mortality.
Infant mortality indicators and their dynamics in Bulgaria
are very indicative for the substantial influence of the social, economic and health services factors on population's
health. While infant mortality rates have been steeply decreasing during the 1960s-1970s from 45.1%o in 1960 to
23.1%o in 1975 and continued its downward trend with
slower speed in the next decade to reach 13.6%o in 1988, in
the 1990s they began increasing again to reach its highest
level since 1983 - 17.5 per 1000 live births in 1997 [4]. This
unfavourable dynamics can be related to the worsening
economic conditions in the country as well as to the withdrawal of the national policy from childcare as a priority.
High teenage birth rates in Bulgaria, heavy smoking, poor
nutrition, insufficient knowledge in contraception and sexual behaviour along with the very high rates of prematurely
born and low birth weight babies have contributed to the
worsening trends of this indicator. Since 1998, however,
infant mortality gradually declines to 12.3 per 1000 live
births in 2003 and 11.6 per 1000 live births in 2004 [4].
Though it has been decreasing for the last few years, it still
remains high by the European standards double the EU average rates of 4.9%o [15]. Infant mortality is much higher
in the rural areas (16.5 per 1000 live births for 2004) than in
the urban ones (10.7 per 1000 live births) and this differ-
ence increases during the transition years [4]. Infant mortality is particularly high in the Roma population.
Life expectancy at birth has also decreased during the transition period. During the early 1990s the average life expectancy at birth fell down to the levels of the mid 1960s 70.64 years. The tendency in men has been particularly unfavourable - with a life expectancy of 67.11 years
(1993-1995), which is below the average level of the
1960s. Only after 1998 a slow steady increase in life expectancy has started which reaches 72.4 years for 2004 (68.9
for men and 76.0 for women) [3], still among the lowest in
Europe not only compared with many developed countries,
where it is close to or exceeds 80 years but as well as compared with the other Central and Eastern European countries (CEEC). A growing gap between the male's life expectancy at birth and that of female's is observed in favour
of the women. In 1970 it has been 1 year and now it is
about 6.5 years difference between the two sexes with the
higher mortality of men in their active age contributing to
For the last decades there has been a continuously increasing trend of reported mortality from non-communicable
diseases. Nearly 90 % of all deaths in Bulgaria (2003 data)
are caused by the following groups of diseases: circulatory
system diseases (67.6%), neoplasms (14.1%), accidents
and poisonings (external causes) (3.6%), and diseases of
the respiratory system - (3.1%) [3]. While in the 1960s the
death rate from circulatory system diseases for men in active age was among the lowest in Europe, it started increasing at a rapid pace and in 1995 moved up to a level twice
higher than the EU average (Standardized Death Rates
(SDR) for circulatory system diseases for Bulgaria - 724.03
per 100,000 compared with the EU average of 474.76 per
100,000). Unlike the declining tendencies in Western Europe, this indicator continues its upward trend in Bulgaria
to 967.3 per 100,000 in 2003 and is higher among men
(1009.4 per 100,000) than in women (927.5 per 100,000)
[3]. The SDR in 1970 for cardiovascular diseases for males
aged 0-64 years in the Central and Eastern European Countries (CEEC), including Bulgaria, were similar to the EU
average, but since then in most CEEC they have increased,
and the Bulgarian rates have almost doubled. By 2000,
Bulgaria had one of the highest mortality rates among the
CEEC, and three times the EU rate, which itself has halved
since 1970 [12].
Mortality rates from cerebro-vascular diseases have also increased, with stroke deaths being six times the EU average.
Official mortality data, derived from death certificates,
show Bulgaria to rank near the top for stroke mortality
among European countries to the west of the former Soviet
Union [10]. Official data reveals higher stroke mortality
rates for rural than urban population Mortality rates from
neoplasms have also been increasing from 173.6 per
100,000 in 1990 to 201.8 per 100,000 in 2003 [3].
The transition years developed adverse tendencies in the
morbidity dynamics of the non-communicable and some
communicable diseases in Bulgaria. Many common,
non-communicable diseases have remained more prevalent
Kerekovska A., N. Feschieva, K. Dokova ...
than in the EU such as cardiovascular diseases and stroke.
In addition, some communicable diseases that were previously controlled have begun to rise. The biggest share of all
morbidity is taken by the diseases of the respiratory system
- 37.7% (2002) [4]. The incidence and prevalence rates of
circulatory system diseases have been rising consistently
since the 1970 becoming the major cause of death. The proportion of people with high blood pressure is steadily high
in Bulgaria. It is the most spread chronic disease, which affects 18.3% of male and 24.4% of female population and is
increasingly affecting younger age groups. Local studies
have estimated that a very large proportion of the people
with hypertension, receive inadequate treatment or no treatment at all [1,3].
Along with the high stroke incidence, a great regional variation is observed in Bulgaria, being particularly high in
North-Eastern parts of the country. Stroke register-based
data from a study (2000-01) conducted in defined urban
and rural populations in Varna region (North-East Bulgaria) indicates stroke incidence in the rural areas is
amongst the highest yet reported for a European population. There is a marked gradient in stroke incidence from
very high rates in males living in the rural areas to less elevated rates in females living in the urban areas [10]. The incidence of neoplasms has been consistently increasing during the transition years - from 252.8 per 100,000 in 1990 to
376.4 per 100,000 in 2003 [4].
A number of dangerous communicable diseases in Bulgaria in the past were eliminated or reduced to sporadic
cases by the 1980s. However, the incidences of some of
them have increased substantially since then. The morbidity rate of tuberculosis sharply decreased in the period
1980-1990 (from 178,2 per 100,000 in 1980 to 108,1 in
1989), but in the 1990s the trend reversed. In 2000, the
morbidity rate is 173.4 per 100,000; in 2002 it is estimated
at 188.7; and in 2003 - 168.2 per 100,000. A serious problem since the beginning of the 1990s has been the continuous increase in new cases of tuberculosis. From the level of
25.9 per 100,000 in 1990, the incidence rate rises up to 47.8
in 2002 per 100,000 and stabilizes at this high level (41.7
per 100,000 for 2003) [3]. This tendency is associated with
the impoverishment of the population and its poor nutrition.
The primary health care reform deteriorated the preventive
practices and especially check-ups of the vulnerable groups
in settings with limited access to health services like small
Mental health disorders have increased in Bulgaria for the
last 15 years as alcohol and drug-related psychoses, alcohol
addiction syndromes, schizophrenia, maniac depressive
psychoses, severe stress and adaptation reactions, and psychosomatic disorders have become more frequent.
Determinants of Health
The sharp deterioration of the macroeconomic conditions
in the beginning of the 1990s and the severe economic crisis in 1996-97 substantially deteriorated the living standards of a large number of households. Since 1990 there
has been a significant decline of the income, and in the
1997 the reported real income decrease exceeded
two-thirds compared to the beginning of the decade. In the
late 1990s, the income of 65.5% of the population was under the social minimum, while about half of the population
lived at the limit of the subsistence minimum [2]. Along
with general income decline a deteriorated cost structure
was also observed. Household expenses analysis reveals a
rather high portion of the income (over 40%) to be spent on
food - indicating impoverishment of the population and deteriorated cost structure. The population categories being
most affected by the poverty consequences are Roma ethnic minority groups, long-term unemployed and less educated people.
Unemployment rate in Bulgaria has increased dramatically
since 1990 reaching its highest level during the 1999-2001
period (17.9% in 2000), however slowly declining for the
last years - 16.8% in 2002 and 13.7% for 2003. There is a
large (28%) proportion of long-term unemployment (for
over 3 years) contributing to increased poverty and social
deprivation [5]. Unemployment rates are significantly
higher among the less educated population groups - 33.5%
among those with lower education (primary and secondary
level) compared with 6.8% in those with higher education.
Substantial regional differences are also observed in unemployment rates throughout the country - rural regions being
more affected (16.2%) than the urban ones (12.9%), and
some regions with unemployment rates of over 32% [5].
Rates of tobacco use have risen rapidly in recent decades
with the proportion of smokers in the male population
among the highest in Europe. Just for 5 years - from 1996 to
2001, smoking prevalence in adult population (over 15
years) has increased by 5% - from 35.6% to 40.5%. This
trend has been steeper for the female population - increasing from 16.7% in 1986 to 23.8% in 1996 and reaching
29.8% in 2001. Every second man in Bulgaria is a tobacco
smoker, and this has been a stable and long-lasting tendency - 49.0% in 1986; 49.2% in 1996 and 51.7% in 2001.
Among the 15-24 age group 41.3 % are smokers and over
half (58.5 %) of the Bulgarian population in the age range
of 25-44 smokes Teen-age smoking (13-16 years) has rapidly increased as data for 2002 reveals that 42.7% of the
girls and 31.3% of the boys in this age group smoke. Smoking is higher among the higher social groups [6].
The proportion of regular alcohol users has increased for
the 1986-2001 period from 76.3% to 81.4% in men, and
doubled in women - from 33.6% to 67.0%. The increase
has been particularly high for the youngest age group
(15-24 years), where the increase is from 52% in 1996 to
70.0% in 2001.
Liberalization of prices, decreasing subsidies of agricultural
and food products production, and decline in real income of
the population have led to an increase in the proportion of
income spent on food and shifting consumption to cheaper
foods. This has increased the risk of nutrient deficiencies
and extended the problems of unbalanced and unhealthy
diet of the Bulgarian population established during the preceding years, especially in socially deprived groups. Data
obtained in nationwide nutrition surveys carried out in
Health status of the bulgarian population: ...
1997-98 [9] revealed alarming tendencies in the dietary
habits and nutritional status of the Bulgarian population:
high energy intake due to great amount of fat consumption;
high intake of saturated fatty acids related to the increased
red meat consumption and low fish consumption; insufficient intake of dietary fibres because of increased refined
foods consumption; seasonal deficit of fresh fruit and raw
vegetables intake; high consumption of refined sugar products especially by children and adolescents, and limited variety of foods consumed. Deficient energy and essential nutrients (vitamins, minerals and proteins) intake is observed
for some population groups such as: children and adolescents aged 10-14 years; women 18-30 years old and elderly
people - corresponding to the substantial prevalence of underweight in these groups (15-16%). At the same time,
overweight is highly prevalent (12.6% to 58%) in almost
every age/sex group. Along with the traditional determinants (high smoking prevalence, blood pressure distribution, plasma cholesterol distribution, BMI distribution) the
high burden of vascular disease in Bulgaria especially in rural male population is also determined by some dietary habits such as the high salt intake and seasonal deficit in fresh
fruit and vegetables [10].
According to existing data from several local surveys [1,3],
above 80% of the population aged 15 years and older was
leading an extremely sedentary lifestyle, with low physical
loading at work (91.1% for women and 83.1% for men)
and low physical activity off work (88.7%). A frequent
combination of physical inactivity with other cardiovascular risk factors, such as high blood pressure, obesity and
smoking is also observed by CINDI survey [1]. This survey
also identifies overweight as a serious problem for most
population groups. Data indicates that two thirds of the
Bulgarians aged 25-64 are overweight (BMI 25 or more)
and obesity (BMI 30 or more) prevalence varies between
12% and 24% for men and 14% and 39% for women [1,3].
It is argued whether the worsening health status of the population and the increasing inequalities in health are mainly
due to the socio-economic factors or are mostly explained
by the unhealthy lifestyle behaviours. Their influence on
health, however, cannot be separated, as the socio-economic factors impact on lifestyle and determine a certain
pattern of health-related behaviours. This interrelationship
is demonstrated by the results from local lifestyle surveys
carried out in late 1990s [12] revealing significantly pronounced differences between the distinctive education and
employment groups. Both lower education level and unemployment impacted negatively on the lifestyle behaviours such fruit and vegetables consumption, physical exercise and alcohol use.
Increasing poverty, sustained unemployment, deteriorated
cost structure and consumption pattern, a worsening environment, unhealthy lifestyles, and deficiency of the health
care system - all contribute to the worsening health status of
the Bulgarian population during the transition period.
Men's health is particularly poor especially in rural areas.
The inequalities in health are increasing both between the
different social groups of the Bulgarian society and on a
global level with the other European populations.
These worrying trends are progressing. Impacting negatively on the future of the nation they will continue to pose a
major challenge for health policy. Therefore, urgent action
is needed encompassing adequate political response. The
recommendations for policy implications drawn out in this
respect refer to the following:
· Assessment of the effectiveness of existing health,
demographic, and social policies emphasizing on the
policy for prevention, early detection and control of the
diseases posing the greatest burden to society;
· Development of science-based capacity to solve public
health problems and establishment of infrastructure for
public health research;
· Development and implementation of public health
approaches addressing more effectively the broader
determinants of health in their interrelationships;
· Comprehensive and targeted action towards decreasing
social inequalities in health; Strengthening the
implementation of policies for diminishing poverty,
unemployment and social isolation;
· Giving priority to prevention, health promotion and
evidence-based medicine in policy discussions and
agendas for action;
· Strengthening public health capacity by training of
· Increasing intersectoral collaboration integrating the
efforts of all institutions and involving civic and
community public health action;
· Strengthening activities of the national public health
programmes and decentralizing their implementation
through alerting and mobilizing local governments to
adjust their programmes and choose priorities for health
· Development of a system for risk factors surveillance,
monitoring and control;
· Strengthening the efficiency and stability of the health
system through measures improving its financial
security and access to health services.
Targeted and sustained investment is necessary to reverse
the negative trends of population health and its determinants. Clearly formulated, evidence-based, comprehensive
and consistent policy is needed for integrated control of risk
factors and chronic diseases, emphasizing on prevention
and health promotion. Tangible political commitment,
multisectoral collaboration and public participation are required for developing, implementing and sustaining
healthy public policies. Without a healthy population, Bulgaria, an accession country cannot move forward and runs
the risk of being a burden rather than a contributing and vital member of Europe.
Kerekovska A., N. Feschieva, K. Dokova ...
Âàñèëåâñêè, Í., Âóêîâ, Ì. Ðàçïðåäåëåíèå íà
ðèñêîâèòå çà çäðàâåòî ôàêòîðè ñðåä èçâàäêà îò
äåìîíñòðàöèîííèòå çîíè íà ïðîãðàìà ÑÈÍÄÈ
Áúëãàðèÿ. Ñîöèàëíà ìåäèöèíà, 2003, No 4, 15-18.
Ìèíèñòåðñòâî íà çäðàâåîïàçâàíåòî. Íàöèîíàëíà
çäðàâíà ñòðàòåãèÿ "Ïî-äîáðî çäðàâå çà ïî-äîáðî
áúäåùå íà Áúëãàðèÿ", Ñ., 2001.
Ìèíèñòåðñòâî íà çäðàâåîïàçâàíåòî. Äîêëàä çà
çäðàâåòî íà íàöèÿòà â íà÷àëîòî íà 21 âåê. Àíàëèç
íà ïðîâåæäàíàòà ðåôîðìà â çäðàâåîïàçâàíåòî,
2004. (
Íàöèîíàëåí ñòàòèñòè÷åñêè èíñòèòóò. Íàöèîíàëåí
öåíòúð ïî çäðàâíà èíôîðìàöèÿ. "Çäðàâåîïàçâàíå",
ÌÇ, Ñ., 1970-2004.
Íàöèîíàëåí ñòàòèñòè÷åñêè èíñòèòóò.
Ñîöèàëíî-èêîíîìè÷åñêî ðàçâèòèå íà Áúëãàðèÿ,
2003. Ñ., 2004.
Georgieva, L., Powels, J., Genchev, G.,
Salchev, P. Bulgarian population in transitional period. Croatian Medical Journal, 43, 2002, No 2,
Feschieva, N., Popova, S. Reproductive pattern
in a period of socio-economic change, Bulgaria
(1986-1994). Archives of Public Health, 1996, 51.
Koulaksazov, S. et al. In: Health Care Systems in
Transition. Bulgaria. E. Tragakes, ed. Copenhagen,
European Observatory on Health Care Systems, 2003.
Petrova, S. (ed.) Dietary and nutritional status of
the population in Bulgaria, March 1998. National
Centre of Hygiene, Medical Ecology and Nutrition,
Sofia, 1998.
Powles, J., Kirov, P., Feschieva, N.,
Stanoev, M., Atanasova, V. Stroke in urban and
rural populations in North-East Bulgaria: incidence
and case fatality findings from a 'hot pursuit' study.
BMC Public Health, 2002, No 2, 24.
Rangelova, R. Aging, health status and determinants of health expenditure. Work package II
ENEPRI Project Health and Morbidity in the Accession Countries. Country Report: Bulgaria, 2004
Uitenbroek, D., Kerekovska, A., Feschieva,
N. Health lifestyle behaviour and socio-demographic
characteristics. A study of Varna, Glasgow and Edinburgh. Soc. Sci. Med. 43, 1996, No 3, 367-377.
World Bank. World development indicators 2003 database, 2003 (accessed:
WHO. Highlights on health in Bulgaria. Copenhagen:
WHO Regional Office for Europe, 2001 (accessed:
WHO. European Health for All database. Copenhagen: WHO Regional Office for Europe, 2005 (accessed:
Scripta Scientifica Medica, vol. 40 (2008), pp 117-120
Copyright © Medical University, Varna
Radev R. Zl., G. Bekyarova, M. Marinov, K. Mirchev, M. Hristova
Faculty of Ðathophysiology, Medical University - Varna
Reviewed by: Assoc. Prof. N. Negrev, MD, PhD
Nowadays, high quality education is the centre of attention in every medical school. Searching for new ways to
introduce the educational units is a natural drift for every discipline. Introducing new educational technique:
"Solving of Clinical Case", aims at building a spontaneous bridge between preclinical knowledge and future
work in the hospital in immediate and unattended contact with patients. Clinical case solving is a prerequisite
for increasing the motivation of students, enhancing logical thinking and stimulating the student for additional investigation at home. The clinical case is based on real patients and the history of their diseases and it is
related to the topic of the exercise. It includes the whole data from the moment the patient is seen by doctor for
the first time until definitive diagnosis is formulated and medication prescribed.
The clinical case is divided in two parts, discussed in two subsequent seminar classes. During the first part the
tutor does not give any additional information about the case, he just guides the discussion. The students work
by themselves, formulate hypothesis and argument them by building logical connections between causes and
results, using the model: causes (and conditions) - altered structure - harmed function - clinical symptom - set
of symptoms (syndromes) - disease. At the end of the first part hypothesis are rearranged by their probability.
The students may use the time between the to parts to find additional information on the topic and gain some
knowledge on the hypothesis that have been discussed, using either traditional forms of education - textbooks,
monographies, lectures, original scientific issues and reviews or any kind of source including the www. The
second part is used for discussing what kind of laboratory, functional or instrumental tests are still needed to
prove or exclude the hypothetical diagnosis.
The way it is created, every clinical case emphasizes not only on the biomedical side of the patient's problem,
but also the socio-judicial aspects.
Keywords: new education technique, clinical case, pathophysiology
The high quality of education is in the centre of attention of
every medical school. An innovative approach towards
medical education requires not only changes in traditional
learning curricula (5) but also changes in the way material
is introduced to the student (15). Searching for new ways to
introduce the educational units to the students is a natural
drift for every discipline (12). The end goal is helping the
formation of professionals of high competency. This very
kind of young doctors, having as a foundation a blend of
knowledge, skills and practices acquired during the processes of education will be able to meet the requirements of
EU member-countries for this kind of professionals (3).The
analysis of "Status quo", following the in the course of education, shows that there is à big gap between research and
practice. It takes too long until the scientific discovery goes
all the way to practical application and teaching (6).
Medical students in our university seem to be poorly motivated to use original sources both new issues and reviews.
It appears that most of them prefer to use just the textbooks
or short versions, most of which are too old and cannot replace the real knowledge come from original materials
(13). There are researches suggesting that introduction
problem-based education in medical studies is successful
and also increases the level of interest in the subject (1,2,8,
14). This kind of education shows good results world-wide.
The students are working in small groups - discussing and
interpreting the given data thus the processes of education
is being brought maximally near to clinical subjects, connecting structure and function (7). Plays a key role in connecting basic preclinical disciplines: biochemistry, biophysics, physiology and anatomy on one hand, and on the
other hand clinical disciplines: internal diseases, surgery,
neurology, etc (4). In addition, vast knowledge in the field
of physiology and pathophysiology is a prerequisite for adequate acquisition of general principals in pathology and
pharmacology (11). The considerations stated above in
combination with the experience of own colleagues in the
Medical University - Pleven encouraged us to include new
educational technique as a part of the education on
pathophysiology since 2004 - "Solving of Clinical Case" .It
Radev R. Zl., G. Bekyarova, M. Marinov ...
aims at building a spontaneous bridge between preclinical
knowledge and future work in the hospital in immediate
and unattended contact with patients. Clinical case solving
is a prerequisite to increasing the motivation of the students,
enhancing logical thinking and stimulating the student for
additional investigation at home.
The clinical case is prepared by co-worker in the faculty of
Pathophysiology in MU - Varna. It is based on real patients
and the history of their diseases and it is related to the topic
of the exercise. It includes the whole data from the moment
the patient is seen by doctor for the first time till diagnosis is
formulated and medication prescribed. The clinical case in
divided in two parts which are discussed in two subsequent
seminar classes (exercises in pathophysiology).
The part consists of:
1. Brief presentation of a real patient but under false name
and the complaints he presents with during the first
meeting with doctor, most often this is a general
practitioner (GP).
2. Mnemonic help - a list of medical terms giving hints to
the affected anatomical region, the physiological
deviations, basic pathophysiological reactions,
processes and conditions leading to developing of the
disease , and all addition factor - genetic, congenital,
legal, ecomonic,social factoors,etc help or hinder the
development of the disease.
3. On the basis of the patient's history and using the
mnemonic help the students formulate several
hypothesis for the possible ethilogical factors and
pathogenitic mechanisms, leading to the suspected
4. Patients History - a real history, taken by a physian,as
some of the information irrelavant to the disease has
been omited
5. Physical examition -systems, organs and functions,
including inspetion, percussion, palpation and
6. Rearranging the hypothesis for the susptected disease
by their probabylity, baking their hypthesis up using the
only data form the presentation, history and physical
examinarion. The students are to pick just the first 5 or 6
most probable diagnosys/diseases.
During the first part the tutor does not give any additinal information about the case, he just guides the discussion between the students.The students are woriking alone - formulating hypothesis and argumentating them by explaning
the logical connetions between causes and results, namely:
causes (and conditions) - altered structure - harmed fuction
- clinical symptom - set of symptoms (syndroms) - disease.
At the end of the first part the tutor gives oral direction to
the students how to prepare for the second part. The
studenst may use the time between the to parts to find additional information on the topic and gain some knowledge
on the hypothesis that have been discussed, using either
traditional form of education - textbooks,
monographies,lectures, original scietific issues and review
or any kind of infomation source including the world wide
1. Set of laboratory results that the doctor seaching for the
diagnosis may want to be made. Together with the
labratory results, there are referent values also.
2. Additional fuctional and instrumental tests.As their is a
great variaty the tests are limited to those that are most
commonly used in practice and are relevant to the case,
and giving maximum information, namely: blood
pressure, ECG, EEG, EMG.X-ray, CT.MRI, ect.
3. The final rearrangement of the hypothesis considering
all data from both the first and the second part.and
giving accurate diagnosis,corresponding to the
particular clinical case. The students are encoured to
give ideas about ethilogical or pathological treatment.
All discussions during the two parts are being recorded on
the materials given by the tutor, so they can be used later for
referance and self preparation.
Until now, the faculty of pathophysiology has addapeted
several clinical cases , including diseases like : diabetis
mellitus, hipertension, cronic pancreatitis, peptic ulcer,
chronic kidney failurem and brain vessel disease.
During the first part, the students manage to point out
which are the major conplaints/syptoms form those the patient presents with during the meeting with the GP. Th analysis ot the data show that about 80% of the students take
part in the discussion. During the discussion the general directions, for building hyposthesis about the possible disease, are formed.The mnemoinic help assist in forming of
accurate methodological thinking in a real meeting with
the patient. A small part of the students neglect the mnemonic help, which inevitably reflects on their work on the
clinical case later on. The tutor encouges the students to
write down as many diseases that can lead to those
sympthoms as possible, without giving them any hints. The
students should back up every hypothesis with explanation
on what they have based their conclusions. This aims to develop clinical thinking in the situation of a game, where
there is a history of an actual patient .The students should
explain the pathophysiological patterns pointing causes and
circumstances, risk factor and provoking moments for the
suspected disease. The building of hypothesis contributes
to the in-depth view of the clinical case in question. The experience showed that during discussion on the clinical case
the students are motivate to write more than 20-25 possible
hypothesis, most of whom are able to argument the possibility of their suggestions relevantly adequate and logically
true. It can be marked as a week point that the topic of the
seminar directs the thinking of the students towards the disease without, sometimes without any objective facts baking
Improving the education in pathophysiology by bringing in cliniacal cases ...
this up. The role of the tutor here is to minimize the guessing by provoking a spirit of competitiveness, dividing the
students into small teams of 3 or 2. This aids the creating of
ideas for analysis and oral and written communication between the students (10).
Other authors also report (7,14) that by the history and the
description of the physical examination of a real patient
makes the situation more close to the real work of a doctor,
which increases the students' interest and is relevantly successful.
At the same time, the tutor can evaluate the knowledge of
the students by the reasoning of the hypothesis which are
based on previously studied disciplines. The tutor can draw
the students attention to gaps in their preparation and emphasize on the need for filling them up in the time between
the two parts . In consonance with his professional competency, the tutor can catch if the student manage to use their
knowledge on basic pathophysiology (nosology, types of
pathological processes), in building a hypothesis. He can
ask them directing questions to help the overcome any possible difficulties. The problems in reasoning the hypothesis
are most often due to gaps in the comprehension of the anatomical and physiological substrate of the impairment, poor
preparation on the studied unit in pathophysiology, or trying to use knowledge form introduction to internal diseases
and surgery, as an end of its self, without paying attention to
the pathophysiological mechanism. If time is adequately
divided, at the end of the first part the tutor must have
enough time to draw the attention and the preparation of the
students to the next part so they understand the problems of
the patient properly and thoroughly. Using the World Wide
Web in preparation is of great value and very attractive
(11). The experience with our work with clinical cases
shows that with little exceptions (mainly foreign students,
due to the language barrier), the students are active and motivated to take part in the discussion in the first part of the
clinical case. They are able to identify the facts that they
need the definite solving of the clinical case during the second part.
The results of the second part indicate some decrease in the
activity of the students. Without any doubt, results of laboratory test with the referent values help remembering the
values. These tests, in combination to all the additional
functional and instrumental tests, that can be done give the
future doctor the opportunity to get became acquainted
with them, when it is need to be done, and what kind of information they can give. Unfortunately, because of the simultaneous studying of diagnostic imaging, clinical laboratory and pathophysiology and because of the specificity of
the more complicated diagnostic investigations, the students encounter them in the pathophysiology seminars for
the first time. The help the disciplines in question but it is
brings about certain obstacles in leading active discussion
in the second part of the clinical cases We give an account
of the fact that predominantly more studious students, who
have use the time between the two parts not only to work
with the textbook and other reference books but also to exchange experience with other colleagues, to discuss with
professors from different faculties take part, and of course
to search in the internet (13). The role of the tutor-regulator
here is of great significance. He is able to involve the maximum number of student in the discussion, to put accent on
the risk factors and socially significant diseases and to contribute to increasing the activity of the students. Delaying
maximally the moment of reaching the definite diagnosis,
helping the students to interpret the lab results and the functional-instrumental tests properly, the tutor draws the attention to rearranging the hypothesis for the corresponding
disease, forming, in the course of discussion, the method to
differentiate between the significant and in significant complaints of the patient, emphasizes on the problems of the patients which should be looked at in a medico-biological ,
and socially legal aspect (9). Thus he maintains the interest
and motivation for active position of the students till the end
of the second part.
Nevertheless our modest experience in this field , bringing
in clinical questions during seminar lessons as a part of the
course of pathophysiology we have developed I applied for
the needs of teaching a convenient , attractive and beneficial to the students form of education. It gives the student a
wonderful possibility to build a bridge between preclinical
studies and the work of the doctor with immediate contact
with the patient.
Blumberg, Ph., J. Mi chael, H. Zeitz. Role of
student generated learning issues in problem - based
learning. Teaching and Learning in Medicine, 1990,
vol. 2, N 3, pp 149-154.
Col li ver, J. Effectiveness of problem-based learning
curricula research and theory. Acad. Med., 2000, vol.
75, N 3, pp 259-266.
Conncil of Europe Committee of Ministers, Recommendation N R (90) 21 of the Committee to Member
States on Training Strategies for Health Information
System, adopled by the Committee of Ministers on
the 18 October 1990.
Dimova, S., M. Marinov, K. Demireva.
Pathophysoilogy and the new strategies for medical
education. Bulg. Medicine, 2002, vol. 10, N 2, pp
Good man, L. et al. An experiment in medical education. JAMA, 1991, vol. 265, N 18, pp 2373-2376.
Goswami, U Neuroscience and education: from research to practice? Nat Rev. Neurosci., 2006, vol. 7,
N 5, pp 406-411.
Hud son, J. N., P. Bucvley, I.C. McMillen.
Linking cardiovascular theory to practice in an undergraduate medical curriculum. Adv. Physiol. Educ.,
2001, vol. 25, N 1-4, pp 193-201.
Nor man, G., H. Schmidt. Effectiveness of problem-based learning curricula: theory, practice and paper darts. Med Educ., 2000, vol. 34, N 9, pp 721-728.
Radev R. Zl., G. Bekyarova, M. Marinov ...
Pulanic, D., H. Vrazic, Cuk, M. Petroveski.
Ethiks in medicine: students' opinions on disclosure
of true diagnosis. Croat. Med. J., 2002, vol. 43, N 1,
pp 75-79.
10. Rivers, D. B. Using a course - long theme for
ingucry - based laboratories in a comparative
ghysiology course. Adv. Physiol. Educ., 2002, vol. 26,
N 1-4, pp 317 - 326.
11. Sarbadhikari, S. N. Basic medical science must include medical informatics. Indian J. Physiol.
Pharmacol., 2004, vol. 48, N 4, pp 395-408.
12. Suwandwela, Ch. et al. Long. Term ontcome of
innovative curricular tracks used in four conntries.
Acad. Med., 1993, vol. 68, N 2, pp 128-132.
13. Valdum, C., CH. Zhao, D. Chen. Are current
textbooks good enongh for physiology education? For
example, the ECL cells are missing. Adv. Physiol.
Educ., 2001, vol. 25, N 1-4, pp 123-126.
14. Wolters, M. R. Problem - based learning within
entocrine physiology lectures. Adv. Physiol. Educ.,
2001, vol. 25, N 1-4, pp 225-227.
15. Zeitz H., H. Paul. The alternative curriculum. Chicago Medicine, 1990, vol. 93, N 12, pp 16-20.
Scripta Scientifica Medica, vol. 40 (2008), pp 121-123
Copyright © Medical University, Varna
Bontcheva S., G. Bontchev
Medical University Prof. P. Stoyanov - Varna
Reviewed by: Assoc. Prof. N. Negrev, MD, PhD
The systematical observation on students studying biophysics draws attention on some difficulties, regularly
appearing during laboratory exercises. These difficulties could be easily defined as well as split in groups by
their origins, which is clearly proven using an appropriate questionnaire technique.
Meeting some requirements arisen in last few years, the educational process in biophysical labs undergoes
certain rearrangements. Tracking the distribution of main difficulties met in experimental work and analyzing the students’ response one can judge the capability of academic work.
The aim of this pedagogical research is to find out the main difficulties met by the medical students studying
biophysics, to retrieve the origins of these difficulties and, if it possible, to suggest some measures concerning
their elimination. Furthermore, the presented pedagogical analysis is focused on answering the question:
“Which organization of laboratory exercises is most effective?”. Thus, we can achieve a substantial growth in
quality of education.
Keywords: biophysics, quality of education, pedagogical analysis
· Group II has half a time for assistance in experimental
work, compared to Group I.
Biophysics is among the obligatory preclinical courses during the medical education (2nd term of year I). It consists of
lectures as well as practical exercises. In order to increase
the efficiency of teaching, students are encouraged to be
well acquainted with theory concerning every exercise to
go; and also, they should prepare an empty laboratory report in which they fill in the corresponding experimental
During 2003/04 and 2004/05 academic years two groups of
students (consisted of 28 and 27 peoples, respectively) are
studied in order to determine the main difficulties met by
the students in their course of biophysics. These two groups
were studied identically, offering the students at the end of
every particular exercise the same questionnaire set. The
only difference between 2003/04 (Group I) and 2004/05
(Group II) groups was in the set-up of the laboratory work.
Whereas students in Group I prepare and do the same exercise at a time, Group II was divided in two subgroups, each
working simultaneously on a separate topic. The last one
set-up was provoked by increased number of students per
group, which could not be met by the hardware equipment
Due to difference of work organization between Group I
and Group II, there are some details that should be mentioned here:
· Group II has half a time for checking students’
theoretical preparation, compared to Group I;
Pedagogical diagnostics represents “a good empirical
analysis which, in some cases, could take experimental
forms” [1, p.356]. As a practical activity, the pedagogical
diagnostics “is aimed on ... an adequate and expedient use
as well as future development in pedagogical practice” of
the methods, created by research worker [1, p.357]. One of
the most popular methods, widely used in the pedagogical
analysis, is the questionnaire [2, p.271].
Reliability of the questionnaire results are usually measured
by “agreement rate of the data, collected in number of consequent observations” [2, p.270]. Therefore, in order to
avoid the negative influence of some factors on result’s reliability, identical conditions for investigation are provided
in any stage of the questionnaire research. The questionnaire sets used were the same by the form (written), content
(one and the same questions), type (partially standardized)
and time distribution (end of the exercise).
Each questionnaire set has the general form as follows:
Major difficulties met
A) In general:
a) In theory
b) Connection between theory and practice
c) In experimental work
d) I had no difficulties
Bontcheva S., G. Bontchev
e) Other: .....................
B) In particular:
a) [Answer 1]
b) [Answer 2]
c) [Answer 3]
d) I had no difficulties
e) Other: .....................
Corresponding to the separate type of the topics studied,
every questionnaire set includes different positions in section B): Answers 1-3. Each student of Group I and Group
II was offered to give his answer to the 13 questionnaire
sets in the whole course of biophysics (13 experimental exercises provided).
In summary, results concerning the general part (section A)
of our questionnaire study are represented in Table 1.
Table 1. Results of questionnaire study in summary
(Section A: in general). Answers are given in percents.
À) in general
(Group I)
(Group II)
a) in theory
b) connection between theory and
c) in experimental work
d) I had no difficulties
e) other
Analyzing the results shown, one can draw a set of some
important conclusions. At first, it is obvious that regardless
of exercise’s set-up, approximately half of the students
have no difficulties at all. This leads to the conclusion that
teaching biophysics is well-organized, well-balanced process, so that suitably prepared students can meet the requirements of experimental exercises. In other hand, it is
expected that large number of students (as it is shown –
merely 50%) will encounter problems studying physics and
biophysics: in their last 2-3 years at secondary school their
efforts are usually focused on biology and chemistry (subjects of entrance exam at Medical University) [3].
At second, it is noticeable that the major part of difficulties
is connected to the theory of processes. Traditionally, the
explanation of that fact assumes problems understanding
the mathematical models, vastly used in biophysics. As it is
mentioned above, at the secondary school, the mathematics
along the physics is neglected by the pupils, which intend to
study medicine. Another yet suggestion should be made
here: students organize their self-training incorrectly. Before the particular exercise the main student’s target is prep122
aration of empty laboratory report. That is intolerable, because consumes a lot of time and, sadly, shifts the aim of
teaching from understanding the matter to some technical
work. One possible course to solve this problem is to offer
students a ready set of empty laboratory reports, which
should be filled in with an appropriate data and observations. Such an approach is already accepted by many preclinical departments.
In addition, the results shows that minority of students have
difficulties with experiment itself as well as the connection
between the experiment and theory. Therefore biophysical
exercises are chosen in accordance with students’ skills and
satisfactory explained. Absence of answers of type “e)
other” proves that the general part of questionnaire is comprehensively constructed.
However, the most important conclusion should be drawn
toward the set-up of exercises. Results presented in Table 1
undoubtedly prove that switching the exercise organization
from Group I type to Group II type leads to the significant
decrease of efficiency. Percent of students with no problems falls; percent of students which met difficulties in theory, practice and their connection rises. Such a drawback is
somewhat expected: as it has been mentioned already,
splitting students in two subgroups (as it was done in
Group II) reduces the time for assistance and explanation.
Though, Group II type of organization was set in students’
favor. From some years on, number of students per group
has been increased. Hardware equipment of biophysical lab
cannot meet these changes effectively. In order to involve
every particular student directly in experimental work,
splitting students into separate teams was a reasonable solution. In such a way, generally speaking, there was given an
accent to the practical skills development in return for slight
decrease of teaching efficiency.
Results concerning the special part (section B) of our questionnaire study are represented in Table 2.
Table 2. Results of questionnaire study in summary
(Section B: in particular). Answers are given in
B) in particular
Topics, classified by meaning
(Group I)
(Group II)
1. Understanding physical
2. Working out formulas and
solving equations
3. Constructing and reading
4. Doing experimental tasks
5. Working with tables
6. Other
Difficulties met by medical students in the course of biophysics: a comparative analysis
Examining these results, one can conclude once more that
the major problems met by medical students, studying biophysics, are connected with theory, not practice. However,
splitting the students in two teams doubles the number of
experimental difficulties. That is, reduced assistance time is
definitely insufficient for making students familiar with the
physical devices as well as theory of the topic. But theory
could be understood using textbooks, while developing an
experimental experience – can not. This brightly demonstrates the importance of encouraging students to be engaged in real experimental activities.
Among other particular problems one can outline the work
with graphs, tables and scientific calculators. Frequency of
these topics remains statistically equal comparing Group I
and Group II. Hence, their origins most likely could be
found in some kind of fault in secondary school education.
Taking this in account, we propose establishing a separate
topic to be included into the course of physics/biophysics
In Table 2 appears an unexplained and considerable shift
concerning frequency of answer 6 (other particular difficulties). The reason could be the different rate of ethnical homogeneity of Group I (39% foreign students) and Group II
(26% foreign students). It is well-known phenomenon of
“answers spreading” among the students: giving the same
answer when not sure which one to choose.
shows the persistence of problems observed as well as
the adequacy of questionnaire sets used;
2. Major part of difficulties is assigned to the theory of
biophysics. Instead of making their own laboratory
reports, students should be offered ready (but empty)
ones, including questions concerning each separate
topic, thus encouraging them to understand the root of
the matter being studied. Moreover, it should be kept in
mind that involving students in theoretical work is not
an easy task due to their negative response;
3. It is firmly demonstrated that on-line assistance is
essential not for development of theoretical knowledge,
but for gaining practical experience. This should
underline the importance of keeping the number of
students per group relatively small – corresponding to
the hardware equipment available. Unfortunately, it is
seldom in capability of the department to organize
details of that matter. However, it should be kept in
mind that involving students in experimental work is a
rewarding task (positive response);
4. Special attention needs the fact that medical student
often do have problems with some routine tasks
(working with graphs, tables, calculators). Such a
simple obstacle could dramatically decelerate work and
shifts students’ attention away from the main goal.
Introducing an appropriate training into the course of
physics/biophysics/chemistry should be in help.
Taking into account gathered results as well as their analysis, one can draw some conclusions concerning main difficulties met by medical students in course of biophysics,
their origins and organization of experimental exercises.
On this basis, some measures leading to improvement of
education could also be proposed.
1. Reproducibility of results obtained during two different
years from two different group of students clearly
Bijkov G. Pedagogical diagnostics, Sofia,“St. Kl.
Ochridski” (1999) – in Bulgarian
Bijkov G., Kraevski V. Methodology and methods of
pedagogical investigations, Sofia-Noscow, “St. Kl.
Ochridski” (1999) – in Bulgarian
Bontcheva S., Diagnostics of difficulties met by the
medical students in course of biophysics. Pedagogika,
2 (2005), p. 35-44 – in Bulgarian
Scripta Scientifica Medica, vol. 40 (2008), pp 125-128
Copyright © Medical University, Varna
Stoyanov Zl., M. Marinov
Department of Physiology and Pathophysiology, Medical University - Varna
Reviewed by: Assoc. Prof. N. Negrev, MD, PhD
It is an undisputed fact that anxiety may modulate human stress response. However, the existing data on the
specificity of the psychophysiological reactivity of high-anxious and low-anxious individuals, and on the presence of sex differences in this context, are controversial. The presented review summarizes recent literary
data and analyses some of the neurobiological underpinnings of the sex differences in the association between
anxiety and stress response.
Keywords: anxiety, stress, sex
Anxiety is a complex psychological construct with various
dimensions and manifestations. It contains cognitive, emotional and behavioural components and is accompanied by
various physiological changes, which reflect the activity of
the autonomic nervous system and neuroendocrine axes
In the literature on anxiety and autonomic control there prevail data on increased sympathetic activity, decreased vagal
tonic influence on the heart, and reduced autonomic flexibility. Anxiety is associated with increased heart rate (HR),
reduced respiratory sinus arrhythmia, increased arterial
blood pressure, and higher levels of skin conductance
(4,21,16). Some authors find these autonomic changes to
be logical, as the mechanisms underlying anxiety are
closely connected with the mechanisms of fear and the responses of the type "fight-or-flight" provoked by them (2).
It is no accident that many studies put emphasis on the existing two-way close relationship between anxiety and
stress. It is assumed that anxiety may be both a natural reaction to a stressor and a part of the complex of the stress response, as well as a post-stressor phenomenon (as in
post-traumatic disorder, for example) (2,24). It is also
pointed out that anxiety may modulate the stress response
and the abilities for coping with stress (9,33,19).
Specificity in the psychophysiological
reactivity in low-anxious and high-anxious
One of the interesting questions arising in the context of
anxiety and autonomic control is whether a
psychophysiological stereotyping of the relationship beAddress for correspondence:
Zlatislav Stoyanov, Dept. of Physiology and Pathophysiology, Medical University, 55 Marin Drinov St, BG-9002 Varna, BULGARIA
E-mail: [email protected]
tween anxiety and autonomic control is possible, and
whether there exists specificity in the autonomic reactivity
in low-anxious and high-anxious individuals. In a number
of publications on the problem, independent of the methodological differences (different measures of anxiety, different stressors and conditions) data are presented that point
out that anxiety may moderate psychophysiological reactivity. Reports exist that individuals with high levels of
emotional reactivity and trait anxiety are likely to react with
a more marked increase of HR and blood pressure (7). In
the conditions of cognitive stress Clements and Graham
(10) find out that HR reactivity correlates positively with
trait anxiety. In the experiments carried out by Gonzalez-Bono et al. (18) and concentrated on the anticipatory
autonomic response, a moderating effect of trait anxiety is
again presented: high-anxious individuals demonstrate a
greater HR reactivity. According to results by Gramer and
Saria (19) trait social anxiety exerts a substantial influence
on cardiovascular reactivity in active performance situations: high-anxious individuals overall exhibit greater HR
reactivity. In a more recent publication, however, which
analyses in more detail the cardiovascular effects of the
stressor anticipation period, Gramer and Sprintschnik (20)
present slightly different data, namely, that high socially
anxious individuals overall exhibit lower blood pressure
and HR reactivity. That corresponds with the earlier data by
Wilken et al. (44), who also report of poorer reactivity in
high-anxious individuals. Similar are the data from the population-based study of Young et al. (47): individuals with
high trait anxiety demonstrated reduced cardiovascular reactivity whereas individuals with trait anxiety demonstrated increased reactivity. It is important to draw attention
to the fact that in that study the group of high anxiety subjects consisted predominantly of women. In contrast to the
above, in their study Mauss et al. (28) find out that the
psychophysiological responses of high-anxious individuals
Stoyanov Zl., M. Marinov
during anticipatory anxiety are similar to those of low-anxious individuals. In accordance with them is the opinion of
Barret and Armony (2) that individual differences in trait
anxiety do not affect the autonomic responses associated
with a mental task.
Not so definitive are also some data from the studies analyzing the neuroendocrine activity. Some authors report
that in anxiety disorder patients exaggerated acute
neuroendocrine responses to psychosocial stressors are observed (8). Other studies point out, however, that individuals with high levels of TA have reduced neuroendocrine reactivity to stressors. Jezova et al. (22) established that subjects with high trait anxiety exhibit lower plasma levels of
adrenocorticotropic hormone (ACTH) and cortisol, and
lower stress-induced activation of epinephrine and
norepinephrine secretion. There also exist mixed results:
Gerra et al. (17) report that after a psychological stress the
concentrations of norepinephrine, growth hormone and testosterone increase significantly only in anxious individuals,
but substantial changes in the concentrations of ACTH,
cortisol and epinephrine are absent. Takahashi et al. (36)
find out significant positive correlation between trait anxiety, autonomic reactivity and basal cortisol levels at rest,
but not in stress conditions.
Sex differences in the association between
anxiety and psychophysiological responses
to stress
The reasons for the ambiguous and conflicting results may
be different, but it is not impossible for it to be due to the
fact that the role of the sex has not been analysed in detail
(18): either mixed groups have been studied and the data
for both sexes have been interpreted together, or the conclusions have been reached over observation of only men
(17,21,36), or only women (18,33,19,20).
Concentrating on the role of the sex is well-founded not
only because of the different levels of anxiety reported in
men and women - many authors share the view that women
are more anxious than men (3,31,15,26,11), but also because of the existing data for a different pattern of the association between emotions and physiological parameters in
men and women (30). There are reports that anxious men
show higher reactivity of the diastolic blood pressure and
cortisol secretion while anxious women show more pronounced changes in the HR (13). Under laboratory stress
(public speech) Carrillo et al. (9) find out in men significant
positive correlation between state anxiety and peripheral
pulse volume, but not between state anxiety and HR. In
contrast to that, in women the same authors observe positive correlation between anxiety and reactivity of HR. The
differentiated by sex analysis of our experimental results
suggests the existence of typical cardiovascular responses
to mental stress of low-anxious and high-anxious individuals (27), however the parameters of this stereotyping are reciprocal for men and women, which may mask as a whole
the effect of the anxiety on the cardiovascular response to
stress. So we support the view of Naveteur and
Freixa-i-Baque (32) that anxiety may moderate the
psychophysiological responses to stressful situations, but
unlike them, we believe that in this aspect there exist sex
differences. We will also add that our results do not correlate with the data of Takai et al. (37) as well, about the absence of sex differences in the sympathetic-adrenomedullar
activity during stress in high-anxious and low-anxious individuals. According to the same authors however, during
stress the cortisol levels in high-anxious women are significantly lower that those in high-anxious men.
In several of the researches that study the correlations between anxiety and psychophysiological reactivity to stress
in women (33,19,20), the established type of reaction in
high-anxious and low-anxious individuals is interpreted
within the framework of active coping and energization
and is connected with the subjective evaluations of the individuals as to the gravity of the task, the efforts invested and
the likelihood of success, their perception of stress and the
means to cope with it. There do not exist, however, enough
comparable data for men.
When clarifying the role of the sex in the relationship between anxiety and stress, there should also be taken into account the existence of sex differences in stress reactivity.
Most (but not all) of the data present in literature outline a
tendency to a more acute stress response of the sympathetic-adrenal mechanisms in men when compared to
women (25,23). A different pattern of brain activity in men
and women in stress conditions has also been established.
Mental stress in men is associated with activation of the
right prefrontal cortex and reduced activity in the left
orbitofrontal cortex, while in women structures of the
limbic system become active, like the ventral striatum,
putamen, insula and cyngular cortex (43). At the same time
the dominating right-sided prefrontal activity during stress
in men correlates significantly and with changes in the
physiological parameters like the cortisol response, but the
limbic activation in women correlates quite weakly with
cortisol. In addition to this, in women correlation is established between anxiety related personality traits and regional brain volume in the left anterior prefrontal cortex smaller brain volume in the left anterior prefrontal cortex
underlies the basis for higher anxiety-related traits (46).
The question of the sex differences in the association between anxiety and psychophysiological responses to stress
becomes even more topical due to the fact that in recent
years there are attempts to isolate two different models of
stress response: "fight-or-flight" and "tend-and-befriend"
(39,40,38). As we pointed above, data from our study
showed that high-anxious men are characterized by a more
strongly expressed cardiovascular reactivity under stress,
while high-anxious women are characterized with less expressed response of HR and vascular tone. The "logic" of
the established sex differences in the correlation between
trait anxiety and cardiovascular reactivity could be partly
explained with the mentioned two different models of
stress response: "fight-or-flight", accepted for a "male"
type, and "tend-and-befriend", accepted for a "female" type
(39,40,38). It is known that non-pathological anxiety could
be a useful factor for adequate organization of the behavior
Anxiety and stress response: effects of anxiety levels and sex
under potential threat for the individual (34,6). According
to their evolutionary role (hunters and warriors) men should
have optimally secured reactions of the "fight-or-flight"
type. In that context it seems logical that in men there exists
a marked positive correlation (or maybe potentiation) between anxiety and autonomic stress response. It is possible
for androgens to act as mediators in this association. It is
known that testosterone levels (in principle higher in men)
increase significantly with acute stress (39). There are also
data that make us think that the prenatal organizational effects of testosterone on the brain could be reflected in anxiety as well (14,1).
The stress response of "tend-and-befriend", accepted as
more typical for women, reflects the evolutionary role of
women to ensure the survival of the offspring and for that
purpose it is expedient for them for preserve themselves
through other behavioral strategies (39,40,38). The authors
cited suggest that female responses to stress may build on
attachment/caregiving processes that downregulate sympathetic and hypothalamic-pituitary-adrenocortical responses
to stress. Oxytocin is ascribed a controlling effect in such
situations (29,39,38), and there are data that it increases the
excitability of vagal neurones (12,35) and decreases sympathetic activity (41).
On that background it can be speculated that anxiety
"serves" in different ways the stress response in men and
women. The positive correlation between trait anxiety and
cardiovascular reactivity to stress in men suggests that in
male sex the higher anxiety may act as a catalyst of the autonomic parameters of stress response. If we accept that the
weaker cardiovascular reactivity observed by us in
high-anxious women is a manifestation of downregulation
of the autonomic mechanisms, then we should suppose that
in women the higher anxiety compensates to some extent
the tendency for weaker sympathetic-adrenal reaction and
ensures specific adequacy of the stress response on principle. Here, however, a certain discrepancy arises. The mechanisms of downregulation in "tend-and-befriend" are accepted to be oxytocin-mediated and moderated by the
estrogens and the endogenous opioids (45,39), but these
hormones and peptides are known to have anxiolytic properties (45,39,42). Probably it has to do with a more complex
reaction of the brain regions (cortex, subcortical nuclei,
diencephalon) whose interaction ensures the brain integration of mental and physiological (somatic) functions.
The cohesion of some data from studies of the brain correlates of anxiety and stress gives reason to think that the sex
differences in the association between anxiety and
psychophysiological reactivity to stress reflect the existence of special sex features of the brain integration of cognitive processes, emotions and autonomic control.
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Scripta Scientifica Medica, vol. 40 (2008), pp 129-131
Copyright © Medical University, Varna
Romanova H.
Department of Hygiene and Disastrous situations, Medical University Prof. P. Stoyanov - Varna
Reviewed by: Assoc. Prof. S. Popova, MD, PhD
The sociological research is carried out by the method of individual inquiry with questionnaire, included 32
questions, with students of Medical University. In connection with presentation of the discipline Medicine of
the disastrous situations (catastrophe), it is followed the raise of knowledge and the readiness for protection in
case of disasters. Before the beginning of the teaching about Medicine of the disastrous situations the knowledge of the students about the questions connected with damages with radioactive substances chlorine and
ammonia, are totally insufficient, especially at the foreign students. The level of the preliminary knowledge
about the origin of the epidemics is higher. Better are the knowledge for the right attitude in case of danger of
intestinal infectious diseases than the protection of air dropped infections. The preliminary subjective evaluation of the students for the lack of readiness for protection became positive and the self-confidence increase till
88,33% foreign students and 93,33% Bulgarian students.
Keywords: disaster medicine, protection in case of disastrous situations
The protection against catastrophes (disasters) is leaded in
different directions: preliminary measures, prognosis, observation of the elemental process and active intervention on it,
rescue operations, medical activities and other /3/. The level
of the preliminary preparation and knowledge are of prime
importance for survival and rendering help of the sufferers
/4, 5/. The training and the practical preparation of medical
students about the questions concern the protection and medical help in case of disastrous situations are of extreme importance. When the students in training are convinced of the
necessity for precise knowledge, the process of teaching going easier and the gained knowledge are more lasting /1, 2/.
The purpose of the research is observation, the level of raise
of knowledge and readiness for protection in case of disaster, of students at the beginning and after the training at the
discipline Disaster medicine.
opinion and 5 questions are under the form of situation task.
The principle of anonymity is observed, witch make clear
more objectively the thoroughness of knowledge about
discussed problems and give more reliable rating for the
readiness for protection.
The inquired persons are 120 students between 21-29 years
from third course, subject medicine.
In the statistic processing of the results are used no parametric, alternative and graphical analysis.
At Table 1 is presented the number of the participants, distributed by sex and nationality. Table 1.
Table 1
Participants at the research
The research is leaded in 09.2005 and in the end of 12.2005
at the Medical University – Varna. The sociological research is made by the method of individual inquiry with
questionnaire with 32 questions. Twenty two questions are
preliminary formulated and specified all possible answers.
5 questions are open and it is given a possibility for other
100% 73 60,84% 47 39,16%
Bulgarian students
46,67% 21 17,50% 35 29,16%
Foreign students
53,33% 52 43,34% 12 10,00%
The distribution by sex is: 60,84% men and 39,16%
Romanova H.
At the question “What kind of disasters do you know?” at
the beginning of the training 66,67% of all give and enumerate several natural disasters and 40% know anthropological disasters too; in the end of the training 100% enumerate natural disasters and 93,33% anthropological.
The majority of the inquired put at the beginning like the
biggest danger of disasters in Varna region – storms and
hurricanes 51,17%; in the end of the training – landslides
66,67%. The evaluation the level of danger from anthropological disasters and in the both cases, the students mark
like the biggest, the danger of chemical damages – 35%.
In the beginning of the training insufficient are the knowledge of the inquired refer to pollution with radioactive substances after damages in NPP (nuclear power plants),
mainly in the group of foreign students. The answers of the
question “Which of the following food products could be
polluted in case of through out radioactive substances at the
environment?” are presented at Table 2.
Table 2
Which of the following food products could be polluted in
case of through out radioactive substances at the
Sort of products
Milk and milk
70 58,33%
41,66% 20 16,67%
Bread and bread
68 56,67%
40,83% 19 15,83%
85 70,83%
45,83% 30 25,00%
Meat and meat
65 54,17%
40,00% 17 14,17%
/P<0,05/ between the answers of the Bulgarian and foreign
students in the end of the training.
The knowledge of the inquired students about their behavior in case of damage and pollution of the air with chlorine
and ammonia in the beginning of the course are insufficient. The results are presented at Fig. 1 and Fig. 2.
The knowledge for right behavior in case of pollution with
chlorine and ammonia in the end of the course arise in the
interval of 92-100%.
The level of knowledge in the beginning of the training is
higher about the questions refer to arise of epidemics (Bulgarian and foreign students). According to 70,83% the biggest danger of arise of epidemics will be the use of biological weapon, according to 67,50% - the floods too.
About the question “Which are the possible ways for infection with biological weapon?” – 77,50% respiratory ways,
62,50% - skin and mucous membrane, 50% - alimentary
and only 29,17% - by insects suck blood. The students are
good informed in the beginning of the training that cholera
– 68,33%, anthrax – 75% and plague – 70% are especially
dangerous infections, controlled by World Health Organization (WHO).
Detailed analysis determine that the students` behavior in
case of epidemic in the region, will be visibly incorrect and
that will threaten their health. Completely incorrect 69,17%
will leave the region in case of epidemic and that will lead
to dissemination and change for the worse of the epidemic
situation. 55,83% will act correctly – looking for means for
prophylaxis and 37,50% - information and instructions.
Better are the preliminary knowledge for the right behavior
in danger of intestinal infectious diseases: 87,50% know
that they have to wash regularly their hands; 74,17% will
execute good thermal treatment of the food; 61,67% will
boil the water and 57,50% will regularly clean and disinfect
the toilets. Less are informed for protection of air-dropped
infections: only 61,67% will put cotton-gauze mask;
35% Put cotton-gauze
mask with vinegar (wrong
35,83% Put cotton-gauze
mask with sodium
bicarbonate (right answer)
37,5% Climbing higher
floor (right answer)
38,33% Going lower floor
(wrong answer)
Fig. 1. In result of damage pollution of the air with chlorine at the region where you are appears. What is your
In the end of the course almost all are informed what have
to be made in home conditions in doubt for pollution of
food products with radioactive substances: 93,33% know
that the products have to be washed lavishly with water;
83,33% - have to peel the surface and 70,83% will bone the
meat, salt and boil with salt and soak in acetic solution. In
the research there are not visible statistic differences
52,50% will immunize themselves with lymph; 35% will
ventilate and disinfect; 31,67% will look for a medical help
and only 10% will stay at their homes.
In the end of the training the knowledge of the inquired
about the questions according to protection of epidemics
are as follows: 90-95% for the foreign students and
95-100% for Bulgarian.
Sociological research of students from Medical University – Varna to determine the level of ...
37,17% Put cottongauze mask with vinegar
(right answer)
35% Put cotton-gauze
mask with sodium
bicarbonate (wrong
31,67% Climbing higher
floor (wrong answer)
29,17% Going lower
floor (right answer)
Fig. 2. In case of air pollution with ammonia, what you will do?
In the beginning of the course, particularly significant is the
subjective evaluation of the students, about a readiness for
protection in case of disastrous situations – more than 50%
consider, that they are not prepared. Fig. 3
10,83% Yes
33,34% Particularly
55,83% No
Fig. 3. Do you have readiness for protection in case of
disastrous situations?
In the end of the training the self-confidence of the students
increases and the subjective evaluation for protection in
case of disaster is positive for 88,33% foreign and 93,33%
Bulgarian students.
Predominant number (87,50%) want to have at their
homes, means for protection like: cotton-gauze mask, medical goods, means for cleaning and disinfection in case of
rise of epidemic or other disaster.
The majority of the inquired (83,33%) consider that it is
necessary and obligatory, the knowledge of the population
for protection in case of disaster to be raised: 12,50% - at
will and only 4,17% do not consider raising of knowledge
for necessary. Fig. 4
There are no visible differences at the answers of the inquired students according to their sex and age.
according to damages and pollution with radioactive
substances, chlorine and ammonia, especially of the
foreign students. The right answers increase till
90-100% in the end of the course, without visible
differences according to nationality.
Higher is the level of the preliminary knowledge about
questions, according to rise of epidemics (all students).
Better are the knowledge for right behavior in case of
danger of intestinal infections disease than the
protection of air-dropped infections.
There are not visible differences at the answers of the
inquired students according to their sex and age.
The subjective evaluation for lack of readiness for
protection, transforms into positive and the
self-confidence arise till 88,33% foreign students and
93,33% Bulgarian students, after the training to
Disaster medicine.
The majority of the inquired students (83,33%)
consider that it is necessary and obligatory, the
knowledge of the population for protection in case of
disaster to be raised.
Ãðàäåâ, Ä. Ñîöèàëíà ïñèõîëîãèÿíà ìàñîâîòî
ïîâåäåíèå, èçä. „Ñâ. Êëèìåíò Îõðèäñêè”, Ñîôèÿ,
Éîëîâ, Ã. Áåäñòâèÿ è ìàñîâà ïñèõèêà, Ñîôèÿ,
Ìàðäèðîñÿí, Ã. Åêîêàòàñòðîôè, ÈÊ”Âàíåñà”,
Ñîôèÿ, 1995.
Ðîìàíîâà, Õð. Áåäñòâåíè ñèòóàöèè è
ìåäèöèíñêî îñèãóðÿâàíå, Êîëîð Ïðèíò, Âàðíà,
Ðîìàíîâà, Õð. Ìåäèöèíà íà áåäñòâåíèòå
ñèòóàöèè, ÐÈÀ Ñïåêòðà, Âàðíà, 2007.
1. Before the training to Disaster medicine, the students`
knowledge is absolutely insufficient about questions,
Scripta Scientifica Medica, vol. 40 (2008), pp 133-135
Copyright © Medical University, Varna
Ivanova F.
Laboratory of Clinical Immunology, MU - Varna
Reviewed by: Assoc. Prof. Sv. Balev, MD, PhD
The insulin receptor delivers the signal from the hormone insulin to the target cells. Structurally and functionally it belongs to the superfamily of the receptors with tyrosin kinase activity. Insulin receptor is known
for more than 30 years and during this time a lot of assays for detecting it have been developed. Analyzing the
expression and functional characteristics of this receptor is helpful for better understanding the pathogenesis
of different diseases.
The isulin is long known to the medical science. This hormone was found in 1921 by the Canadian scientists Frederick Banting and Chars Best. The first practical approach of
the gene engineering was the synthesizing of human insulin. The presence of a specific insulin receptor was first proposed by Roth and coworkers in 1971(2). The mechanism
of the biologic effect of this receptor is due to its tyrosin
kinase activity.
The ligands and receptors of the family of the Insulin/Insulin-like growth factor (IGF) take an important role in the
regulation of different processes in the organism - growth,
metabolism, reproduction (5). Besides the two non-allelic
insulin genes another nine ones are discovered, which code
insulin-like peptides. There are at least three different receptors interacting with these ligands - insulin receptor
(IR), receptors for IGF-1 and IGF-2. IR belongs to the family of ligand activated receptor kinases. Other members of
this family are Phospho-c-Abl, EGF Receptor, SAPK/JNK,
p70 S6 Kinase e.c.
Biochemical structure of the IR
The IR is a transmembrane glycoprotein and a member of
the superfamily of the receptors with tyrosin kinase activity.
Unlike the other members it is a heterodimer of two
disulphide bond monomers, each consisting of a- and
b-chain. Insulin binding place of the molecule is on the
a-subunit which has a molecule weight of 135kDa. In contrast the b-subunit (95kDa) has a short extracytoplasmic
Address for correspondence:
Feodora Ivanova, Laboratory of Clinical Immunology, University
hospital "St. Marina", Varna 9010, "Hr. Smirnenski"str. 1,
E-mail: [email protected]
part and a long intracytoplasmic tail with tyrosin kinase activity. The IR is bivalent; the affinity to the first insulin molecule bond is greater than to the second one (4).
The two a-chains form a ligand binding tunnel. The amino
acid sequence responsible for the insulin binding is from
240 to 250 residues - Thr-Cys-Pro-Pro-Pro-Tyr-Tyr-HisPhe-Gln-Asp (8). The insulin molecule binds to the receptor through electrostatic interactions. When the insulin molecule comes into the ligand binding tunnel, it leads to
conformational changes in the receptor and the a-chains
get nearer to one another and so do the b-chains. Thus the
intracytoplasmic tails become close enough to
phosphorilate the appropriate parts. This inner
autophosphorilation of the IR activates it and makes possible the initiation of a cascade of intracellular kinases and a
signal transdusing (10).
Fig.1. Signal delivery pathways of the IR. IR - insulin
receptor; IRS - insulin receptor substrate; PI3K phosphor-inositol-3-kinase; PKC- protein-kinase C;
mTOR - mammalian target of rapamycin; PKB protein-kinase Â; Grb-2 - growth factors adaptor
protein; MAPK - mitogen activated kinase.
The main substrates of the phosphorilation are IRS-1, 2, 3
and 4 (insulin receptor substrate). IRSs are other tyrosin
Ivanova F.
kinases and their substrates - PI3K, Fyn, HSP-2, take part in
the further delivery of the insulin signal into the cell. It is
considered that IRS-1 and 2 have major role in the glucose
metabolism in the hepatocytes, IRS-1 and 3 - in the
adipocytes, and IRS-2 has a crucial role in the signal delivery in the b-cells of the pancreas. PI3K phosphorilates further some serin-treonin kinases, which mediate effects like
glucose assimilation, glyconeogenesis, lipogenesis, protein
synthesis, cell survival (fig.1) (7).
The sequence of the IR is cloned in 1985 and the structure
of exones is described in 1989 by Seino et al. The gene locus is on the short arm of 19. chromosome -19ð13.1. There
are two isoforms of the IR, which differ by twelve amino
acid residues in the C-terminus of the a-chain, encoded by
exon 11. These two forms are marked as 11+ and 11- and
do not have any considerable functional differences (3).
MA-20, B6), as well as for the b-chain (CT-3, 18-44) of the
The flowcytometry is a technique appropriate for evaluating the expression of particular cell surface molecules in the
single cell suspension. Through some standardized procedures the number of IRs on each cell could be measured.
The flowcytometry is useful also for detecting the tyrosin
kinases and their activity, thus for functional characterization of the IR. (Tabl. 1.)
Tabl. 1. Number of IRs, detected on different cells.
Number of
IR per cell
200 000
Rhodes C.J., M. White. Molecular
insights into insulin action and
secretion. European Journal of
Clinical Investigation, 32
(Suppl. 3), (2002) 3-13
2 200
Olefsky J., G.M. Reaven.
Decreased insulin binding to
lymphocytes from diabetic
subjects. The journal of clinical
investigation, vol. 54, 1974,
15 000
Olefsky J. et al. Insulin binding in
diabetes. Diabetes, 26, 1977
700 - 22 000
20 - 350
Adipocytes and
Physiological regulation of the expression
of IR by the intracytoplasmic glucose level
The IR delivers the signal from insulin for increased uptake
and utilization of glucose in the cell. The high level of
intracytoplasmic glucose exerts feed back inhibition on this
process leading to decreasing the expression of IR and thus
to diminishing the glucose uptake. Such lessening of the
IRs is observed in the peripheral tissues and in the b-cell of
pancreas. The high level of intracytoplasmic glucose and
the low level of IRs increase the production and secretion
of insulin (3).
Methods for IR analysis
The researching of the IR started with the radiological assays in the 70's. These methods use insulin conjugated with
I and not conjugated insulin. The radioactive emission of
the samples is measured and insulin binding sites are calculated (6). The modern radiological methods apply
monoclonal antibodies for detecting IR.
There are some assays for visualizing cell surface molecules, which use colloidal gold (cAu) as a marker. These
techniques imply absorption of colloidal gold on some proteins (for example insulin) and the binding of the latest to
some cells is demonstrated through transmission electron
microscopy (9).
Polyclonal and monoclonal antibodies against the IR, IRS,
and PKB are used by immunoprecipitation and Western
Blot techniques for quantitative and qualitative identification of these proteins (7). The antibodies, conjugated with
an appropriate dye, make it possible to detect the IRs
through immunohistochemistry and immunofluorescence.
The monoclonal antibodies are used for allocating the IR in
different tissues in the human organism and this receptor is
appointed as CD220 in the Cluster of Differentiation (VII
Workshop, 2001).
There are different clones of monoclonal antibodies specific for a-chain (83-7, 83-14, 47-9, MA-10, MA-5,
Áîðèñîâà È. Ðåöåïòîðè çà
ïåïòèäíè õîðìîíè, íàó÷åí
îáçîð, ÌÀ, ÖÍÈÌÇ, Ñîôèÿ
Crystalographic and spectrographic methods are applied
for studying the quaternary structure of the IR. In addition
to these data, the three dimensional view and the atomic organization of the complex insulin - IR are characterized
through scanning transmissional electronic micrography
(STEM). This method determines the order, centre of gravity and the rotation of the separated domains (10).
The molecular techniques are widely used for detecting of
some mutation in the genes of IR and the second messengers.
Implication of the expression of the IR in
the pathogenesis of some diseases
In the human organism the b-cells of the pancreas organize
and start functioning about the 25. gestation week and after
that the level of insulin increases. The defects in the development, caused by deficiency of insulin or IR, appear in the
same time of age of the fetus.
Pathophysiological mechanisms of diabetes mellitus type 2
are connected with defects of insulin secretion as well as
peripheral insulin resistance. The insulin resistance has a
crucial role and precedes the clinical manifestation with
some years. It is conditioned by low levels of expression,
lowered affinity and dysfunction of the IR. Massimo
Bacterial structure and antimicrobial susceptibility of ...
Federichi et al. show that muscle cells from patients with
diabetes mellitus type 2 express significantly less IRs and
have triple lower capacity for binding insulin compared to
healthy people (1).
Leprechaunismus represents the heaviest form of insulin
resistance, caused by mutation or absence of IR. It is characterized by retardation in the time of birth and no putting
on weight. Heavy postprandial hyperglycemia and fasting
hypoglycemia in the presence of hyperinsulinemia is observed. It takes years before the b-cells of the pancreas
decompensate (5).
Knowing the mechanisms of regulation of expression and
function of the IR is crucial for understanding the
pathogenesis of diseases like diabetes mellitus type 2,
obesities, syndrome X, as well as other processes associated with metabolism and growth.
Federici M., L. Zucaro, O. Porzio et al. Increased expression of insulin/insulin-like growth factor-i hybrid receptors in skeletal muscle of
Noninsulin-dependent Diabetes Mellitus Subjects.
Journal of Clinical Investigation, 98(12), 1996,
Freychet P, J. Roth, D. Neville. Insulin receptors in liver; specific binding of 125I-insulin to the
plasma membrane and its relations to insulin
bioactivity. Proc Natl Acad Sci USA, 68, 1971,
Hribal M., L.Perego, S. Lovari et al. Chronic
hyperglycemia impairs insulin secretion by affecting
insulin receptor expression, splicing, and signalingin
RIN â-cell line and human islets of Langerhans. The
FASEB Journal, 2003
4. Jianping J., Guidotti G. Construction and characterization of a monomeric insulin receptor. The journal of biological chemistry, vol.57, 2002,
5. Nakae J, Y. Kido, D. Accili. Distinct and overlapping functions of insulin and IGF-I receptors - Endocrine Rewiews 22(6) , 2001, 818-835.
6. Olefsky J., G.M. Reaven. Decreased insulin binding to lymphocytes from diabetic subjects. The journal of clinical investigation, vol. 54, 1974,
7. Paz K., S. Boura-Halfon, L. Wyatt et al. The
juxtamembrane but not the carboxyl-terminal domain
of the insulin receptor mediates insulin's
metabolicfunctions in primary adipocytes and cultured hepatoma cells. Journal of Molecular Endocrinology 24, 2000,419-432.
8. Rafaeloff R., R. Patel, C. Yip et al. Mutation
of the high cysteine region of the human insulin receptor a-subunit increases insulin receptor binding affinity and transmembrane signaling. The journal of
biological chemistry. Vol. 264, No. 27,1989,
9. Warlchol J.B., R. Brelinska, D. Her bert. Analysis of colloidal gold methods for labeling proteins.
Histochemistry, 76, 1982, 567-573.
10. Yip C., P. Ottensmeyer. Three-dimentional structural interactions of insulin and its receptor. The journal of biological chemistry, vol. 278(30), 2003,
Scripta Scientifica Medica, vol. 40 (2008), pp 137-139
Copyright © Medical University, Varna
Ivanov K., V. Ignatov, N. Kolev, A. Tonev, D. Hristov, S. Konsulova,
B. Balev*, R. Madjov**.
Department of General and Operative Surgery, *Department of Imaging Diagnostics,
**Department of Hepato-Biliary Surgery ,University Hospital "St. Marina" - Varna, Bulgaria
Reviewed by: Assoc. Prof. R. Radev, MD, PhD
Pyogenic abscesses are rare and difficult problem for modern surgery because of the high mortality rate. After the 70s of the last century the introduction of new image methods as ultrasound diagnostics, percutaneous
and direct cholangiography and biliary drainage, guided aspiration, and percutaneous drainage of the abscess cavity dramatically changed both the diagnosis and treatment of these patients. The routine diagnostic
methods are ultrasound and CT scan. Percutaneous aspiration and drainage under ultrasound or CT control
is applied as first-line treatment of hepatic abscesses.
Keywords: liver, abscess, CT, ultrasound, percutaneous drainage
Pyogenic abscesses are rare and difficult problem for modern
surgery because of the high mortality rate. In the first 3 decades of the last century the most frequent reason fot that kind
of disease - the pileflebitis, caused by apendicitis, in 75-80% of
cases was the main reason for death. The most frequent cause
for hepatic abscesses in the later periods of last century to
nowadays were the bingn and malign obstructions of biliary
tree, which caused multiple abscesses with total mortality
about 45-50%. After the 70's, with introducing of the methods
for imaging diagnosis as ultrasonogrphy, percutaneus and endoscopic cholangiography and biliac drainage, directed aspiration and percutaneus drainage of abscesses's cavities. The diagnostics and treatment of such cases have changed
dramaticly. At the same time more aggressive operative and
non operative approaches for treatment of hepatobiliar and
pancreatic neoplasm led to increasing the frequency of
pyogenic hepatic abscesses as well as penetration of the infection to the liver on the way of hepatic arteria.
The aim of this study is to follow-up the epidemilogy,
ethiology, bacteriology, diagnosis and treatment of hepatic
abscesses in patients, treated in University Hospital "St.
Marina", Varna.
In University Hospital "St. Marina" for a period of 5 years
/2002 to 2006/ were treated 47 patients with pyogenic
hepatic abscesses, distributed in groups of age and sex as
Table 1 Distribution of the patients with hepatic
abscesses in groups of age and sex.
The median age of the males was 44.4 years, and the median age of the females was 64.7 years.
In the past years the median age of male patients with
heaptic abscesses decrese. Â ïîñëåäíèòå ãîäèíè
ñðåäíàòà âúçðàñò íà ïàöèåíòèòå ñ ÷åðíîäðîáåí àáñöåñ
íàìàëÿâà. The proportion male/female without statistical
significance is with male prevalence.
In dependence of the way of infection's spread, the heaptic
abscesses have an ethiological calssification in 6 grpups:
· Through the biliary ducts
· Through the portal vein
· Direct penetration of the agent
· By trauma
· Through the heaptic arteria
· Cryptogenic abscesses
The cholangiocarcinoma is the most frequent reason for malign obstruction in the past years. [30] The usage of internal
Ivanov K., V. Ignatov, N. Kolev ...
biliar stents in such patients has reflection. The hepatic
metastases are other frequent cause for presence of pyogenic
process. The hepatic arteria become a source of infection in
the past years, because the inreasing of immunosuppresed
patiens and the arterial embolisation. [5,14].
The percent of patients with reducted hepatic function has
droped, probably because the increased frequency of the
abscceses in patients with biliar stents. [14].
Routine methods for diagnosis are the ultrasonography and
CT. The cholangiography remains important diagnostic
tool for 30-40% of the patients. [14].
The CT is with highest sensibility - 93%. That method
could find abscesses with 0.5-1.0 cm in size and that make
this method more sensible then ultrasonography (83%).
The cholangiography is indicated 2/3 of hepatic abscesses,
originated from biliary ducts. Radionucleoid examinataion
of the liver and Ro-graphy of abdomen are less sensitive
methods and are led away from the practice for diagnosis of
hepatic abscesses.
Microbiologic investigation
Results for the microbilogical agents could be attained by
taking a puncture from the hepatic cavity, blie ducts and
hemocultures. The results from the puncture and bile ducts
usually are positive, while only 55-60% of the
hemocultures have bacterial growth. [14].
Table 2. Distribution of microbilogical agents
According to the data in the literature, the most frequent
agents are E. coli, Klebsiela, Streptococcus spp., as in the
past years we can observe a tendency for decreasing the infections with E. Col, and increasing the infections caused
by Klebsiela, Streptococcus spp. and Pseudomonas. A reason for this is the usage of stents. The significant increasing
of the fungi infections is connected with usage of
wide-spectered antibiotics in patients with biliary drainage
in which there are often expression of cholangitis. From the
anaerobic microbs the most common isolated are
Bacteroides spp., Clostridia, Streptococcus spp. [3,6,34].
The most comon agents causing hepatic abscesses in the
University Hospital "St. Marina" - Varna are Ps.
aeruginosa, E. coli, E. Faecalis, Seratia spp. All
microbiologic agents were resistent to mass-applied
beta-lactams. We have observed bacterial sensitvity to
fluochinolons, aminoglucosides, and some of the bacterial
strains are sensitive to macrolides and the strategical antibacterial drugs - carbapanems and cephalosporines (3 and 4
In approximately 35% of the patients wourldwide drainage
of abscces cavity is needed. The percutaneous drainage is
applied as first step in the treatment in 45% of the patients.
In a small per cent carefuly selected patients percutaneous
aspiration without drainage is applied. [13,14,32,33].
In the surgical clinics in University Hospital "St. Marina" Varna as a method of choice in the treatment of hepatic abscesses is the application of percutaneous aspiration and
draiange plcement under ultrasonographic or CT control
and eventual lavage of the abscessic cavity after the aspiration. In single cases with selected patients with small sized
abscesses aspiration of the cavity content without drainage
placement is adequate. After that strict control of the cavity
using the US or CT methods must be applied.
In all cases with hepatic abscesses we have applied
paraenteral and antimicrobic treatment, which started with
wide-spectered antibacterial combination and after identification of bacterial agent and his antibacterial sensitivity adequate drug therapy was prescribed.
Mortality rate and the risk factors that
increase it.
The mortality, conneceted to hepatic abscesses decreases
because of the multiple abscesses mortality drop. Increasing of mortality is observed only in through-hepatic
arteria-penetrated infections. [14].
The risk factors connected with significant increase of mortality rate are [24]:
· Multiple abscesses
· Concomitant malignant disease
· Jaundice
· Hypoalbuminemia
· Leucocytosis
· Bacteriemia
· Fungal infection
· Septic chock
1. The freqency of hepatic abscesses is increased mainly
because of the aggressive approach in treatment of
hepatobiliary and pancreatic neoplasms.
2. The application of biliary stends changes bacterial flora
in hepatic abscesses and the application of
wide-spectered antibiotics in these patients leads to
mixed bacterial infection and fungal infection.
3. The advantage of image diagnostic methods improves
the diagnoses. The development of percutaneous
drainage under CT control contibutes to significant
decrease of the mortality.
4. The biliary tract obstruction and particularly the
obstruction of malignant processes is the mos common
Diagnosis and treatment of liver abscesses
reason of hepatic abscesses. Biliary drainage in patients
with malignant biliary tree obstruction inproves the
survival rate in patients underwent palliative or radical
operation. In these patients, however the hepatic
abscess is more rearly appeared with pain and normal
hepatic function is observed.
There is an increase of the patients with hepatic
metastases in which embolisation of hepatic artria is
applied, also increased are the patients with heavy
immunosuppresion in which hepatic abscesses was
developed. [5,7,16].
The development of US and CT diagnosis contributes
improvement of diagnostic approaces to many diseases.
These examiantions make easier the early diagnosis of
pyogenic abscesses and the application of percutaneous
drainage and in that way improve the patients'
prognosis. CT is diagnostic method of choice. MRI
could be used for the adequate diagnosis, too. But using
CT can increase the examination duration, also the high
price and the lack of possibility for percutaneous
drainage limitates the application of this method. [21].
The importance of anaerobic bacteria is noticed for a
long time. Our data showed that there is no significant
change in the frequency of hepatic abscesses caused by
anaerobic bacteria during the past years. However, the
apppearance of abscesses from multiresistent and
mixed bacteria is comparatively new phenomenon. It is
connected with comaratively high number of patients
with biliary stents, recidiving cholangitis and multiple
antibiotic treatments. The fungal superinfection that is
noticed in patients with malignant blood diseases is in
significance. [5,7,18].
The application and improvement of percutaneous
biliary drainage during the past decade changes
significantly the treatment of patients with hepatic
abscesses. Antibacterial therapy combined with
percutaneous drainage gives excellent results.
[5,8,16,36,38]. The application of percutanepus
drainage is most appropriate for solitary hepatic lesion.
The multiple abscesses caused by biliary tree
obstruction could be treated by percutaneous drainage
of the biliary ducts. Percutaneous and open drainage are
most commonly known as aditional each others
methods and the last one is applied in cases that the first
one had not given success, as well as in patients that
surgical intervention is needed because of other
occasion. Indications for operative treatment are the
multiple abscesses and the therapy with corticosteroides
in patients with ascites.
The combination of percutaneous aspiration and
antibacterial treatment is appropriate only in small
number of cases of small solitary hepatic abscesses and
precise image control. [7,11,36].
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percutaneous aspiration and catheter drainage of
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81:550 -555.
Baek SY, Lee MG, Cho KS, et al. Therapeutic
percutaneous aspiration of hepatic abscesses: effectiveness in 25 patients. AJR Am J Roentgenol.
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WC. Hepatic abscess: changes in etiology, diagnosis
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1988;75:862- 865.
Gerzof SG, John son WC, Rob bins AH, et al.
Intrahepatic pyogenic abscesses: treatment by
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Her bert DA, Fogel DA, Rothman J, et al.
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Herman P, Pugliese V, Montagnini AL, et al.
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Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic
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Lambiase RE, Deyoe L, Cronan JT, et al.
Percutaneous drainage of 335 consecutive abscesses:
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Lipsett PA, Huang CJ, Lillemoe KD, et al.
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DN. Hepatic abscess in cancer patients. Arch Surg
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Mc Fadzean AJS, Chang KPS, Wong CC. Solitary pyogenic abscess treated by closed aspiration and
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Miedema BW, Dineen P. The diagnosis and treatment of pyogenic liver abscesses. Ann Surg.
1984;200:328 -335.
Miller FJ, Ahola DT, Bretzman PA, et al.
Percutaneous management of hepatic abscess: a perspective by interventional radiologists. J VascInterv
Radiol. 1997;8:241-247.
Mischinger H, Hauser H, Rabl H, et al.
Pyogenic liver abscess: studies of therapy and analysis of risk factors. World J Surg 1994; 18:852-858.
Neoptolemos JP, Macpherson DS, Holm J, et
al. Pyogenic liver abscess: a study of forty-four cases
in two centres. Acta Chir Scand. 1982;148: 415-421.
Nordbach IH, Pitt HA, Coleman J, et al.
Unresectable hilar cholangiocarcinoma: percutaneous
versus operative palliation. Surgery 1994;
Northover JM, Jones BJ, Dawson JL, et al.
Difficulties in the diagnosis and management of
pyogenic liver abscess. Br J Surg. 1982;69:48 -51.
Ochsner A, DeBakey M, Murray S. Pyogenic
abscess of the liver. Am J Surg 1938; 40:292-353.
Pen ning ton L, Kaufman S, Cameron JL.
Intrahepatic abscess as a complication of long-term
percutaneous internal biliary drainage. Surgery 1982;
Pitt HA, Nakeeb A, Abrams RA, et al.
Perihilar cholangiocarcinoma: postoperative radiotherapy does not improve survival. Ann Surg 1995;
221:788-798. Pyogenic Hepatic Abscess Over 42
Years 607
Pitt HA. Liver abscess. In: Zuidema GD, ed. Surgery of the Alimentary Tract. 3rd ed. Philadelphia:
WB Saunders, 1991: 152-159.
Pitt HA. Surgical management of hepatic abscess.
World J Surg 1990; 14:498-504.
Rob ert JH, Mirescu D, Ambrosetti P, et al.
Critical review of the treatment of pyogenic hepatic
abscess. Surg Gynecol Obstet 1992; 174:97-102.
Seeto RK, Rockey DC. Pyogenic liver abscess:
changes in etiology, management, and outcome. Medicine (Baltimore). 1996;75:99 -113.
Sil ver S, Weinstein AJ, Cooperman A.
Changes in the pathogenesis and detection of
intraphepatic abscess. Am J Surg. 1979;137:608-610.
Stain SC, Yellin AE, Don o van AJ, Brien
HW. Pyogenic liver abscess. Arch Surg 1991;
Wong E, Khardori N, Carrgsco CH, et al. Infectious complications of hepatic artery
catheterization procedures in patients with cancer.
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Yinnon AM, Hadas-Halpern I, Shapiro M,
Hershko C. The changing clinical spectrum of liver
abscess: the Jerusalem experience. Postgrad Med J
1994; 70:436-439.
Scripta Scientifica Medica, vol. 40 (2008), pp 141-143
Copyright © Medical University, Varna
Deenichin G., R. Dimov, V. Molov, Ch. Stefanov
Department of Surgery III Medical University, Plovdiv
Reviewed by: Assoc. Prof. R. Madjov, MD, PhD
According to literature the synchronous malignant tumors of the colon are 2-11% from all cases of sporadic
nonhereditary colorectal cancer. This big difference in the frequency is due to variations in the accuracy of the
used diagnostic methods, and also to the intentional search for associated lesions. The synchronous tumors
have different biology and prognosis than solitary tumors. Investigations performed with the methods of genetic engineering over p53 gene abnormalities strongly suggest that the great majority of synchronous colonic
adenocarcinomas arise as independent neoplasms and their worsened prognosis is not a result of unusually
early metastatic spread. The aim of our one-year retrospective study was to find out the frequency of these tumors towards all patients with colorectal cancer, the time for correct diagnosis (intraoperationem or before
the operation), and the peculiarities in the surgical tactics. We analyzed retrospectively 106 patients with
colorectal cancer treated in the Department of Surgery III Medical University Plovdiv for one year period
(01.06.2006-01.06.2007), 61 men (57.5%) with mean age 64+-2.5 years and 45 (42.5%) women with mean age
61+-3.1 year.
Keywords: Synchronous malignant tumors, Colon
From the whole number of 106 patients with cancer of the
colon and rectum, 6 were with synchronous malignant tumors of the colon (5.66%). Four of these six cases were
with cancer of the sigmoid colon and descendent colon, and
two with sigmoid colon and ascendent colon localization.
In three of the patients the diagnosis of multiple pathology
was confirmed preoperatively, and in the other
three-intraoperationem because of the impossibility to perform full colonoscopy due to the almost total obstruction of
the distal tumor. The operation in the group of patients with
tumors of the sigmoid and the descendent colon was left
hemicolectomy, while in the other group with combined tumors of the sigmoid and ascendent colon –right
hemicolectomy and resection of the sigmoid colon. All six
patients operated for synchronous tumors of the colon were
in stage III (Dukes C colon cancer).
The frequency of the synchronous tumors of the colon is
high-according to our data is 5.66% from all cancers of the
colon, and because of the bettered diagnosis and the bigger
absolute numbers of the tumors of the colorectal zone is
with a tendency to grow. The genetic engineering proved
the multicentricity of the process, and the hystoanalisis
show, that the patients with colorectal cancer have an unstable epithelium and an uncommon predisposition to develop several mucosal alterations synchronously or
metachronously. We emphasize the need for a full evaluation of the colon in all patients with colorectal carcinoma.
In the case of incomplete preoperative evaluation,
intraoperative colonoscopy is to be considered; if this is not
feasible it should be performed one month after surgery.
We consider the total colectomy to be indicated in specific
situations, and not as an obligatory element in the process
of treatment of the synchronous malignant tumors of the
colon. It is necessary to think about the possibility for such
kind of pathology and to seek it hard.
The synchronous malignant tumors of the colon are unusual, but well known phenomenon and according to literature data are 2-11% from all cases of sporadic nonhereditary colorectal cancer (1), 1.5-7.6% (2), 1.7-9.3% (3),
5-10% (4). This big difference in the frequency is due to
variations in the accuracy of the used diagnostic methods,
and also the intentional search for associated lesions. The
unsuccess of the correct diagnostics of the synchronous tumors results in mistakes in the treatment tactics and worsens the prognosis (5). There is an opinion, based on investigation of 160 patients with total amount of 339 synchronous tumors, according to which the patients with solitary
tumors of the colon and rectum have similar development
of the disease and survival rate as those with synchronous
tumors (6). Much more accepted is the opinion, that the
synchronous tumors have different biology and prognosis
than solitary ones. Investigations performed with the methods of genetic engineering over p53 gene abnormalities using the polymerase chain reaction, followed by analysis
confirm the polymorphism and strongly suggest that the
great majority of synchronous colonic adenocarcinomas
Deenichin G., R. Dimov, V. Molov ...
arise as independent neoplasma and their worsened prognosis is not a result of unusually early metastasis spread (1).
For clinical purposes in practice for staging of the colorectal
cancer in the abdominal surgery is used successfully the
three grade scale of Dukes, including A, B and C, later
modified by Astler-Coller, they include one more grade D.
Nowadays is used the latest modification of the scale from
1978y., proposed from Gunderson and Sosin with subgroups B1 and B2 in stage Duke B, and C1 and C2 in stage
Dukes C.
Modified Duke’s scale:
1. Modified Duke A colon cancer-the tumor penetrates
only the mucosal membrane of the intestinal wall.
2. Modified Duke B colon cancer:
B1-the tumor penetrates in, but not through muscularis
propria of the intestinal wall.
B2-the tumor penetrates in and through the muscularis
propria of the intestinal wall.
3. Modified Duke C colon cancer:
C1-the tumor penetrates in, but not through the
muscularis propria; there is evidence for tumor
changes in the lymph nodes.
C2-the tumor penetrates in and through the muscularis
propria of the intestinal wall; there is evidence for
tumor changes in the lymph nodes.
4. Modified Duke D colon cancer-the tumor is
widespread far away of the lymph nodes borders to the
other organs-liver, lung, bones etc. The tumor can be in
any size including or not including changed lymph
For diagnostic purposes there are proposed different approaches –roentgen images with contract material, fibro
colonoscopy and thorough exploration during the operation. According to some big studies on the subject the investigation with barium enema give unsatisfactory results,
the false negative results from fibro colonoscopy are about
30%, while the intraoperative palpation finds out nearly
60% of the unexpected synchronous tumors (7). It is considered, that the fibro colonoscopy combined with a thorough intraoperative palpation of the whole colon are crucial
for the early diagnosis of the synchronous colorectal cancer
The aim of our one-year retrospective study was to find out
the frequency of these tumors towards all patients with
colorectal cancer, the time and the method for confirming
the correct diagnosis (intraoperationem or before the operation), and the peculiarities of the surgical tactics.
(01.06.2006-01.06.2007), 61 men (57.5%) with mean age
64+-2.5 years and 45 (42.5%) women with mean age
61+-3.1 year.
From the whole number of 106 patients operated in the Department for one-year period for colorectal cancers, 6 were
with synchronous malignant tumors of the colon (5.66%).
Four of these six cases were with cancer of the sigmoid colon and descendent colon, and two with sigmoid colon and
ascendant colon localization. In three of the patients the diagnosis of multiple pathology was confirmed preoperatively, and in the other three-intraoperationem because of
the impossibility to perform full colonoscopy due to the almost total obstruction of the distal tumor. The operation in
the group of patients with tumors of the sigmoid and descendent colon was left hemicolectomy, while in the group
with combined cancer of the sigmoid colon and ascendant
colon–right hemicolectomy and resection of the sigmoid
colon. All six patients operated for synchronous tumors of
the colon were in stage III (Duke’s C colon cancer).
The frequency of the synchronous tumors of the colon is
high-according to our data is 5.66% from all cancers of the
colon, and because of the bettered diagnosis and the higher
absolute number of tumors of the colorectal zone is with a
tendency to grow. The genetic engineering proved the
multicentricity of the process, and the hystoanalisis show,
that the patients with colorectal cancer have an unstable epithelium and an uncommon predisposition to develop several mucosal alterations synchronously or metachronously
(9). We emphasize the need for a full evaluation of the colon in all patients with colorectal cancer. In cases of incomplete preoperative evaluation, intraoperative colonoscopy
is to be considered; if this not feasible it should be performed one month after surgery. We consider the total
colectomy to be indicated in specific situations, and not as
an obligatory element in the process of treatment of the
synchronous malignant tumors of the colon. It is necessary
to think about the possibility for such kind of pathology and
to seek it hard.
We analyzed retrospectively 106 patients with colorectal
cancer treated in the Department of Surgery III Medical
Koness RJ, King TC, Scheechter S, McLean
SF, Lodowsky C and HJ Wanebo. Synchronous
colon carcinomas: molecular-genetic evidence for
milticentricity. Ann Surg Oncology 1066; 3(2):
Fegis G, Ramacciato G, Indinnimeo M, De
Angelis R and P Barillari. Synchronous large
bowel cancer: a series of 47 cases. Ital J Surg Sci
1989; 19(1):23-8.
Synchronous malignant tumors of the colon
Schaal JC, Mondino JC, Paris F, Piat JM and
D Jaeck. Synchronous colorectal cancers. J Chir
(Paris) 1991 Nov; 128(11):476-80.
Pedroni M, Tamassia MG, Percesepe A,
Roncucci L, Benatti P, Lanza G Jr, Gafa R et
al. Human cancer. Microsatellite instability in multiple colorectal tumors. Int J Cancer 1999 Nov;
Feffer VF, Sprekelsen BJC, Di ana FCA,
Perez AJ, Prado VA, Coret GMJ, Puchades
GF and PR Trullenque. Multiple colon tumors.
Diagnosis and follow-up of 450 patients with
colorectal carcinoma. Rev Esp Enferm Dig 1997 Oct;
Passman MA, Pom mi er RF and JT Vetto. Synchronous colon primaries have the same prognosis as
solitary colon cancers. Dis Colon Rectum 1996 Mar;
Chen HS and Sheen-Chen SM. Synchronous and
“early” metachronous colorectal adenocarcinoma:
analysis of prognosis and current trends. Dis Colon
Rectum 2000 Aug;43(8):1093-9.
Tuscano D, D’Amore L, Ne gro P, Scaccia M,
Talacito C, Gosseti F, Flati D and M
Carboni. Double synchronous occluding tumors of
the large bowel: A report of three cases. Surgery Today 1996 Nov; 26(11):926-8.
Martines GEE, Pena REJP, Villanueva-Saenz
E, Alvarez-Tostado FGF and M Are nas-Sanchez. Synchronous neoplasmas in colorectal
cancer. Rev Gastroenterol Mex. 2000; 65(2):63-8.
Scripta Scientifica Medica, vol. 40 (2008), pp 145-147
Copyright © Medical University, Varna
Dyakov Sv.1, A. Hinev1, M. Siderova2, H. Bohchelian2, K. Hristozov2, V. Platikanov3
UMHAT “St. Marina” Varna, Third Clinic of Surgery, Division of Urology, 2UMHAT “St.
Marina” Varna, Clinic of Endocrinology and Metabolic Diseases, 3UMHAT “St. Marina” Varna,
Clinic of Anaesthesiology and Intensive Care
Reviewed by: Assoc. Prof. K. Nenov, MD, PhD
Emphysematous pyelonephritis is a rare and life-threatening suppurative infection of the renal parenchyma
and the perirenal tissues, characterized by spontaneous gas production. Although uncommon, it occurs almost exclusively in diabetic patients (60-80% of the cases). We describe a recent case of a diabetic woman with
emphysematous pyelonephritis, managed by unilateral nephrectomy. While the symptoms are usually general and nonspecific, the diagnostic approach is crucial in many cases. Ultrasonography should be the first diagnostic tool, as it is noninvasive, fast, and cost effective. However, CT scan is more specific and sensitive, and
it should always be taken into consideration, as it enables the proper treatment decisions.
Keywords: emphysematous pyelonephritis, diabetes mellitus, ketoacidosis, ultrasound
Emphysematous pyelonephritis (EPN) is a rare, rapidly
progressive, necrotizing infection, which is mainly characterized by gas production in the renal parenchyma and the
perirenal tissues. It occurs almost exclusively in diabetic
patients, which constitute 60-80% of the cases [2, 5]. However, 15% of the patients present without a prior history of
diabetes [1, 6]. Other risk factors, associated with EPN, include: diabetic ketoacidosis, polycystic kidneys, renal failure, cirrhosis, alcoholism, and malnutrition. Mortality is
within the range between 25 to 80%, and it is even higher in
case of bilateral kidney involvement.
We describe a recent case of a diabetic woman with
emphysematous pyelonephritis, managed by unilateral
A 63-year-old female (PIR, Medical Record No 30554 /
6.11.2007) with 20-year history of diabetes mellitus and
hypertonic disease was admitted to our hospital. She comAddress for correspondence:
Svetoslav Dyakov. Department of Surgery, Division of Urology,
Varna Medical University, 55 Marin Drinov Str., Varna 9002, Bulgaria.
E-mail: [email protected]
plained of fever, chills, nausea, chest and abdominal pain for
the past few days. At admission the patient was conscious but
confused, febrile up to 39oC, tachydyspnoic, tachycardic,
hypotonic with blood pressure 85/40mmHg. The abdomen
was tympanic on percussion, with slow peristalsis, no guarding, rigidity or rebound tenderness, the left side was painful on
palpation. The left flank was painful on percussion. There
were some depressions of the ST-segment on ECG. Therefore, the patient was first admitted in the ICU ward. A few
hours later she was transferred to the Clinic of Endocrinology,
because no myocardial infarction was present and high levels
of blood glucose were detected in the serum. Her laboratory
results were as follows: Hemoglobin 112 g/l, WBC
19.000/mm3, 202 000 platelets/mm3, high cholesterol and triglycerides, BUN 22, Creatinine 231 mcmol/l, serum blood
glucose 25 mmol/l. Blood gas analysis showed metabolic acidosis. The urine was positive for glucose and protein, and the
sediment was rich in WBC. Urine and blood cultures were
negative (however, they both were performed upon triple antibiotic treatment regimen). In the next 36-48 hours the patient
became comatose, her general common condition gradually
worsened, despite the antibiotic and insulin therapy. Consultations with neurologist and pulmologist were performed. Following the consultation of a nephrologist and the US of the
abdomen, a consultation with urologist was done on day 3.
Diagnostic imaging
Brain CT: It was performed after a consultation with neurologist in order to identify any organic cause for the comatose
state of the patient. The brain CT showed no abnormalities.
Dyakov Sv, A. Hinev, M. Siderova ...
Ultrasound of the abdomen: It showed gas collection in the
left kidney area, and in the urinary bladder.
CT of the abdomen: On the whole body scan the stomach
and the bowels were full of gas, and in the area of the upper
pole of the left kidney a gas collection was visible /Fig. 1/.
Transversal scans showed gas in the parenchyma and
subcapsular gas collection in the upper-dorsal area of the
left kidney /Fig. 2/.
proach diagnostic procedure led us to the initial diagnosis.
The final diagnosis of emphysematous pyelonephritis was
made when the abdominal CT was performed. The patient
was consulted by an urologist, who took a decision for immediate surgical treatment. Because of the developing septic shock, an urgent nephrectomy was performed.
Intraoperative findings
The left kidney was approached via transversal laparotomy,
cutting the posterior peritoneal layer. The kidney and the
perirenal tissues were infiltrated and inflamed. The ureter
and the renal vein and artery were ligated and cut. At the
time of the extraction of the kidney, the renal capsule at the
upper pole (at the site of the gas collection) was torn. A sudden, loud crackle was heard and gas with unpleasant odor
spread in the operation theatre. The section of the specimen
revealed small amount of pus in the renal pelvis. The
boundaries of the gas cavity were evident in the upper-rear
subcapsular region, compressing the renal parenchyma
/Fig. 3/.
Fig. 1. Whole body scan, showing gas collection in the
stomach and the bowels, as well as in the area of the
upper pole of the left kidney (arrow).
Fig. 3. Cross section of the surgical specimen. The
boundaries of the gas cavity are shown by arrows.
Fig. 2. Transversal CT scan, showing gas collection in
the left kidney.
The clinical signs were nonspecific, showing evidence of
infection as the main cause for the uncontrolled blood glucose levels. US as a noninvasive, cheap and easy to ap146
Hystological findings
Histological specimen (¹ 12506-10 / 14.11.2007) showed
evidence of chronic inflammatory process with necrosis
that invaded the perirenal and pararenal tissues.
Postoperative period
After surgery, the patient was admitted in the Clinic of Anesthesiology and Intensive Treatment. The operative
wound healed primarily. The drainage tubes and the sutures
were removed in the usual terms. Despite the lack of surgical problems, the stabilizing of the febrile state and the normalized levels of blood glucose, the patient remained comatose and unable to regain spontaneous breathing. Several attempts to be extubated and left to breathe spontaneously were done. However, after any such attempt, just a
few hours later, she had to be intubated again, because of
Åmphysematous pyelonephritis – clinicorentgenologic diagnosis ...
the low saturation. Tracheotomy had to be performed, due
to the long intermittent positive pressure ventilation
(IPPV). Despite all these intensive cares, the respiratory
distress syndrome (RDS) could not be overcome, and the
patient died on the 50th day after surgery.
The first case of emphysematous pyelonephritis was published over 100 years ago [3]. Since then, sporadic cases of
EPN were reported in the literature [1-6].
E. coli (69%), Klebsiella pneumonia (29%) and Proteus are
the most commonly microorganisms isolated from the
blood, or from the urine [6]. The presence of gas is attributed to rapid glucose fermentation by gas producing bacteria. Previous studies have shown that the most common gas
is nitrogen, followed by oxygen, hydrogen, and carbon dioxide [1,2,4,6]
Diagnosis of EPN can be made by plain X-ray,
sonography, although CT scan is more specific and sensitive [4]. As our case illustrates, sonogram gave us the initial
diagnosis and was the reason for a CT. Due to the prevalence of diabetic patients among those with EPN, and the
high mortality rate of EPN [2,5] we recommend US of the
abdomen to be performed immediately after admission. US
is noninvasive, relatively cheap and easy-to-approach diagnostic tool. When EPN is suspected on US, a CT should be
made to confirm the diagnosis. Unfortunately, the US in
our case was made 48 hours after the patient was brought to
the hospital.
Radiologically, four classes of emphysematous
pyelonephritis are described on computed tomography [2].
In EPN Class 1 and 2, the gas is localized in the collecting
renal system and in the renal parenchyma, respectively,
without extension to the extrarenal space. In EPN Class 3A,
as seen in this case, there is extension of gas into the
perinephric space, and in Class 3B, to the pararenal space.
Bilateral EPN, or EPN of a solitary kidney, represent the
most severe forms of the disease (Class 4).
Emphysematous pyelonephritis is associated with a high
mortality rate (40%) when treated with antibiotics alone
[2]. Although milder forms of the disease (Class 1 and 2)
have been successfully treated by a combination of
percutaneous renal drainage and antibiotics, these modalities alone may be insufficient in more severe presentations
of the disease, or in patients presenting with septic shock. In
such patients, early nephrectomy is recommended as the
method of choice [1,2].
The patient in our case had emphysematous pyelonephritis
that clinically resembled ketoacidosis with abdominal pain.
The patient was febrile and appeared toxic. Her abdomen
was diffusely tender with dilated stomach and colon, tympanic on percussion and decreased bowel sounds. US was
suspicious for emphysematous pyelonephritis with gas detected in the kidney and in the bladder. The CT scan proved
to be essential in making the definitive diagnosis.
Emphysematous pyelonephritis is an uncommon,
life-threatening entity, which should always be suspected in
a febrile toxic diabetic patient. The combined use of immediate diagnostic US with CT or MRI, followed by prompt
surgical intervention, could be lifesaving.
Ab dul-Halim, H., E. Kehinde, S. Abdeen, I.
Lashin, A. Al-Hunayaa, K. Al-Awadi. Severe
emphysematous pyelonephritis in diabetic patients.
Urol Int. 2005, 75(2), 123-128.
Huang J., C. Tseng. Emphysematous
pyelonephritis: clinicoradiological classification,
management, prognosis, and pathogenesis.Arch Inter
Med. 2000, 160(6), 797-805.
Kelly, H., W. Mac Callum. Pneumaturia. JAMA.
1898, 31, 375.
Kuo, Y., M. Chen, G. Liu, C. Huang, C. Huang, C.
Huang. Emphysematous pyelonephritis: imaging diagnosis and follow-up. Kaohsiung J Med Sci. 1999,
15(3), 159-170.
McHugh, T., S. Albanna, N. Stew art. Bilateral
emphysematous pyelonephritis. Am J Emerg Med.
1998, 16(2), 166-169.
Muttarak, M., W. Mai. Clinics in diagnostic imaging. Left emphysematous pyelonephritis. Singapore
Med J. 2004, 45(7), 340-342.
Scripta Scientifica Medica, vol. 40 (2008), pp 149-152
Copyright © Medical University, Varna
Marev D.
Department of Otorhinoloryngology, "Sv. Marina" University Hospital,"Prof. P. Stoyanov"- Varna
University of Medicine, Bulgaria
Reviewed by: Assoc. Prof. R. Radev, MD, PhD
Objective: There is still controversy as regards the optimal management of peritonsillar abscess. Opponents
of tonsillectomy á chaud cite an increased postoperative bleeding risk. Most authors who compared the risks
of postoperative haemorrhage after tonsillectomy á chaud and tonsillectomy á froid did not take into consideration criteria such as the age and gender of the patients or the experience of the surgeon. We aimed to eliminate this bias by performing a retrospective study in which a large series of abscess tonsillectomies were
compared with an age- and gender-matched group of elective tonsill. Material and methods: All patients had
been operated on at the Department of Otorhinoloryngology,"Sv. Marina" University Hospital, "Prof. P.
Stoyanov"- Varna University of Medicine 1994 and August 2000. There were 350 patients in the abscess tonsillectomy group (61% male, 39% female; mean age 31.8 years; range 3-88 years) and 311 in the elective tonsillectomy comparison group (61% male, 39% female; mean age 30.0 years; range 2-83 years). Results: In the
abscess tonsillectomy group, 9 patients (2.6%; confidence level 1.1-4.8%) had postoperative haemorrhages
which required treatment under general anaesthesia, compared to 17 (5.5%; confidence level 3.2-8.6%) in the
age- and gender-matched group of "selected" elective tonsillectomies. The difference between these two rates
was not significant (p=0.056). The fairly high rate of haemorrhages in the elective tonsillectomy group was
mainly due to the effect of the age-matching procedure, which excluded a considerable number of usually
unproblematic tonsillectomies for tonsillar hyperplasia in young children. Moreover, our results show that
there is a learning curve for surgeons performing tonsillectomies with regard to postoperative haemorrhages.
Conclusion: There is no increased risk of postoperative haemorrhage for abscess tonsillectomies in comparison to elective tonsillectomies.
Keywords: abscess,tonsillectomy,postoperative haemorrhage
Peritonsillar abscess (PTA) is the commonest deep infection of the head and neck. It occurs most often in older children and young adults (1). Insufficiently treated abscesses
may penetrate into the parapharyngeal space and either
downwards to the mediastinum or upwards to the base of
the skull (2) Sepsis, dyspnoea and other life-threatening
dangers may follow.
There is controversy regarding the optimal management of
PTA. The two major therapeutic strategies are immediate
tonsillectomy (tonsillectomy á chaud) or incision and
drainage of the abscess followed by tonsillectomy á froid
6-12 weeks later (3) Contradictorily, both approaches have
been associated with the highest postoperative haemorrhage rate (4) There are only a few prospective studies (5,6)
comprising a small number of cases in which postoperative
haemorrhage rates have been compared between the two
Retrospective studies of large series of abscess tonsillectomies have used "normal" tonsillectomies (and not tonsillectomies á froid) as controls and have not taken epidemiological factors such as age, gender or smoking habits into consideration. (Young children operated on for simple
tonsillary hyperplasia rarely suffer complications in our experience.) We aimed to eliminate this bias by using similar
control groups. In addition we investigated surgical experience as a potential risk factor for a postoperative haemorrhage.
We retrospectively compared a group of 350 abscess tonsillectomies performed in our department between March
1994 and August 2000 with a group of elective tonsillectomies performed over the same time period, matching patients for age, gender and smoking habit. Owing to the limited number of elective tonsillectomies a 1:1 match for the
three variables could not strictly be performed. Despite this
Marev D.
fact the two groups were statistically comparable concerning age, gender and smoking habits . Further variables
which were not used as criteria for the matching procedure
are listed below. Tumour tonsillectomies were excluded.
The patients in the abscess group (61% male, 39% female)
had a mean age of 31.8 years (range 3-88 years) and 55%
were smokers. In the comparison group of 311 elective tonsillectomies (61% male, 39% female), the mean age was
30.0 years (range 2-83 years) and 50% were smokers. Data
regarding the occurrence of postoperative haemorrhage
and the experience of the surgeons (number of years of
ENT training) were sought by reviewing the patients' medical records.
In both groups tonsillectomy was performed using blunt
dissection under general anaesthesia (GA). Haemostasis
was achieved with bipolar electrocoagulation close to the
tonsillar capsule. Ligature was only performed if bleeding
occurred from visible arterial vessels or larger vessels. In
patients regarded as having a high risk of haemorrhage, e.g.
those with hepatic insufficiency, we stitched the
palatopharyngeal to the palatoglossal arch, but never on the
abscess side.
Beside the total number of bleeding events postoperative
haemorrhage like in most publications was defined as
bleeding that required a return to theatre and an intervention
under GA. Furthermore, we distinguished between primary
(<24 h) and secondary (>24 h) bleeds. Haemorrhage rates
were statistically analysed using confidence levels (CLs) or
the [chi]2 test.
Incidence of postoperative haemorrhagePerforming abscess tonsillectomy did not result in an increase in postoperative haemorrhage. In fact, our data suggest that the risk
of postoperative haemorrhage in this group was reduced
(p=0.056) . Of the 661 tonsillectomies, there were no cases
of haemorrhage that required ligature of the external carotid
artery or embolization.
Abscess tonsillectomy
Of the 350 patients who underwent abscess tonsillectomy,
28 (8%) had documented postoperative haemorrhage: 6/28
of these patients (21%) had recurrent haemorrhage, 5/28
patients bled twice and 1 patient bled 4 times, making a total of 36 bleeding events. Of the 28 patients who experienced postoperative haemorrhage, 9 needed an intervention
under GA (9/350; 2.6%). Three haemorrhages occurred on
the abscess side, four on the contralateral side and in one
patient haemorrhage occurred on both sides. In one case the
bleeding side was not documented.
Elective tonsillectomy
Of the 311 patients who underwent elective tonsillectomy,
36 (11.6%) had postoperative haemorrhage: 8/36 of these
patients (22%) had recurrent haemorrhage, 5 patients bled
twice, 2 patients bled 3 times and 1 patient bled 4 times,
making a total of 49 events. GA was necessary in 19/49
cases of haemorrhage to arrest bleeding (17/311; 5.5%).
Time of occurrence of the postoperative haemorrhageThe
incidence of postoperative haemorrhage within the first 24
h (primary haemorrhage) was comparably rare in both
groups: abscess tonsillectomy, 3/36 (8.3%; CL 1.8-22.5%);
elective tonsillectomy, 5/49 (10.2%; CL 3.4-22.2%). In
both groups there were significantly more secondary (>24
h) than primary haemorrhages.
Abscess tonsillectomy Postoperative haemorrhages occurred
between the day of operation and the 21st postoperative day,
with a maximal incidence of 9 cases on the 6th postoperative
day ; 18/36 haemorrhages occurred after postoperative Day
6 (50%). Thus 9 cases, or just 25% of bleedings, happened
within the first five postoperative days.
Elective tonsillectomy
All haemorrhages took place between the day of operation
and the 19th postoperative day, with a maximum of 6/48
cases on the 5th postoperative day; 23/48 bleeding events
(47%) were seen between postoperative Days 5 and 9 and
>60% after the 5th postoperative day.
Influence of age and gender on postoperative
haemorrhageThe median age of patients who developed
postoperative haemorrhage was 28 years; for those who required GA it was 25 years. For patients aged <16 years only
1/92 (1.1%; CL 0.03-5.9%) had a haemorrhage that required treatment under GA . For patients aged >16 years,
25/569 (4.4%; CL 2.9-6.4%) had to be treated under GA.
The binomic CLs underline a general tendency that patients
aged <16 or even <20 years of age have a smaller risk of a
postoperative haemorrhage. After abscess tonsillectomy,
6/214 (2.8%; CL 1.0-6.0%) male and 3/136 (2.21%; CL
0.5-6.3%) female patients had a postoperative haemorrhage, compared to 11/190 (5.8%; CL 2.9-10.1%) male and
6/121 (4.4%; CL 1.6-7.9%) female patients after elective
tonsillectomy. Among all 661 operations, 17/404 (2.8%;
CL 1.0-6.0%) male and 9/257 (3.5%; CL 1.6-6.5%) female
patients had a haemorrhage. There were 13 smokers and 13
non-smokers among the 26 patients who experienced severe bleeding and the overall incidence of smoking in the
study population was 53%.Experience of the
surgeonsElective tonsillectomy was predominantly performed by trainees in their 1st year of ENT specialization
(101/311 cases; 32.5%) and abscess tonsillectomy by those
in their 2nd year (93/350 cases; 26.6%) .Patients who were
operated on by trainees in their first and second years of
ENT specialization had significantly more bleedings
(4.2%; CL 1.7-8.5%) as a result of abscess tonsillectomies
than those operated on by more experienced trainees
(1.1%; CL 0.1-3.9%). There was no significant difference
between trainees in their first and second years concerning
bleedings after abscess (4.2%) and elective tonsillectomies
Efficiency of prophylactic techniques
As mentioned above, we stitched the palatopharyngeal to
the palatoglossal arch if an increased risk of a postoperative
Post-tonsillectomy haemorrhage: A retrospective comparison of abscess ...
haemorrhage was predicted. This was done in 54/311 patients (17.4%), 9 of whom had postoperative bleeding. A
total of 3/54 cases (5.6%) needed treatment for haemorrhage under GA.
Predisposing factorsAbscess tonsillectomyA total of 19/350
patients (5.4%) were taking anticoagulant medication when
admitted for PTA (aspirin, n=18; coumarin, n=1); 4/19
(21%) of these had postoperative haemorrhage, 2 of whom
required GA. Two patients suffered from arterial hypertension , one of whom developed haemorrhage requiring GA.
Elective tonsillectomyA total of Elective tonsillectomy:14/311 patients (4.5%) were taking anticoagulants,
which were discontinued prior to the operation; 4/14 (29%)
of them presented with haemorrhage, 1 of whom required
GA. Previous medical conditions for this patient group included malignant haematological diseases (chronic lymphatic leukaemia), n=2; arterial hypertension, n=7; and
hepatic insufficiency (pre-liver transplantation), n=4. None
had known bleeding tendencies. Only 2 of these 13
high-risk patients bled postoperatively, 1 of whom had to
be treated under GA.
The incidence of postoperative haemorrhage after tonsillectomy has been reported to range between 2% and 3.5%
(7-12). There is still controversy regarding the rate of postoperative bleeding after abscess tonsillectomy. There have
been no randomized prospective studies with large enough
samples in which tonsillectomy á chaud was compared
with tonsillectomy á froid with regard to the risk of a postoperative haemorrhage. In our department, the abscess tonsillectomy has been standard practice for many years and
we are convinced of its benefits. We did not consider it ethical to offer stab incision and tonsillectomy á froid to our
patients in order to perform a prospective study and therefore used elective tonsillectomy as a control.
In several studies (13) relationships have been shown between the risk of a postoperative haemorrhage after tonsillectomy and both male gender and adulthood. The commonest
indication for performing a tonsillectomy in young children
is tonsillar hyperplasia, although laser tonsillotomy is becoming an increasingly accepted therapeutic alternative. In
teenagers and adults, tonsillectomy is more often undertaken
for recurrent or chronic tonsillitis. A history of chronic tonsillitis represents a risk factor for postoperative haemorrhage, as
a result of fibrosis, scarring and neovascularization of chronically infected tonsils(14). Additionally, there may also be a
relation with dietary trauma. Adults have more autonomy
with regard to dietary intake, which may also explain the frequent occurrence of bleeding directly after discharge. Smoking, alcohol intake and sexual behaviour may also play a
role. These epidemiological factors were ignored in previous
studies in which quinsy tonsillectomy was compared with
unselected elective tonsillectomy.
Elective tonsillectomy is more often practised in children,
whereas PTA rarely occurs in children and hence abscess
tonsillectomy is rarely performed. This may explain the age
distribution in other studies, such as that of Windfuhr and
Chen(15), in which the average age of the abscess group
was 33.4 years (median 29 years) and that of the tonsillectomy group was 24.6 years (median 21 years).
In our unselected group of 350 abscess tonsillectomies,
55% of the patients were smokers, a rate far higher than that
expected from the frequency of smoking in the general
population. This supports the suggestion of Dilkes et al.
(16)that there may be a link between smoking and quinsy.
To avoid these confounding variables we matched our
comparison group with our study group with regard to age,
gender and smoking habits. In our control group of elective
tonsillectomies, the mean age of the patients was 30 years,
61% were males and 50% smokers. Our results showed a
strong statistical tendency for young adults to be the predominant postoperative bleeders; children aged <16 years
rarely bled.
The difference between male (4.2%) and female (3.5%)
bleeders in our study group was not significant, and nor was
smoking statistically correlated with postoperative haemorrhage. Other variables, e.g. arterial hypertension, also did not
influence the haemorrhage rates of the two groups .
Haemorrhage after tonsillectomy predominantly occurs
within the first 24 h after surgery (primary) or else is delayed (secondary), with a peak occurrence after 5-10 days
or even later . Primary haemorrhage is more brisk and profuse than secondary; moreover, it occurs when the patient's
protective airway reflexes are blunted by post-anaesthetic
or narcotic effects . Therefore, most authors consider it to
be more serious than late (secondary) bleeding .
In contrast to those studies in which it was concluded that the
majority of secondary bleedings happened during the first
postoperative days, our data, like those of other studies, show
that the majority of secondary bleedings occur at the end of the
first week or even later. This is the period after which the patient has usually been discharged and bleeding occurs during
the healing phase, in which there is shedding of superficial
eschar. The method of haemostasis used during tonsillectomy
is supposed to have an influence on the timing of postoperative haemorrhage. Some authors reported ligation to be more
associated with primary bleeding and cauterization to be more
associated with secondary bleeding. This may explain the
rather late haemorrhages observed in our study. However,
there is no need for longer postoperative surveillance after an
abscess tonsillectomy than after an elective tonsillectomy with
regard to bleeding risks. The length of postoperative hospitalization is more likely to be dictated by the general state of the
patient, who often feels very ill after abscess formation, which
is characterized by odyno-/dysphagia and the need for complicated tonsillectomy.
Some authors have described a relationship between postoperative haemorrhage after tonsillectomy and surgical experience. Other authors did not find a statistically significant relationship. Most of those authors did not explain the method of
comparison or just compared .trainees with consultants (without subdividing the trainees according to the year of their training) All operations performed by trainees in our institution are
Marev D.
supervised by one of our ENT specialists. Even so, our results
show a learning curve for surgeons doing tonsillectomies. Surgeons in their first and second years of training did not have a
higher rate of haemorrhage for abscess tonsillectomies (4.8%)
than for elective tonsillectomies (5.1%), but they did have
more haemorrhages than more experienced surgeons (1.1%).
There are two possible explanations for this. Firstly, the inexperienced surgeon may have difficulty dissecting the tonsil out
of the right layer and bleeding of the remaining tonsillar tissue
may prompt him/her to perform excessive cauterization. Secondly, the surgeon may aim to reduce the operation time by
performing exaggerated field cauterization. The result will be
the same: excessive cauterization will increase the risk of secondary bleeding by leaving large fields of bacteria-digested
necrosis. Although the majority of haemorrhages in our patients were secondary (occurring after electrocauterization),
none of our patients had a severe haemorrhage that needed ligation of the external carotid artery. A special technique, such
as suturing together the tonsillar pillars, seems to be indicated
for high-risk elective tonsillectomy patients . Our results show
that, with this method, the rate of a postoperative haemorrhage
for these high-risk patients was not higher than that for all
other patients.
Our postoperative haemorrhage rate of 2.6% after abscess
tonsillectomy is comparable with those reported after ordinary tonsillectomy and abscess tonsillectomy and supports
the claim that there is no elevated risk of postoperative
haemorrhage after tonsillectomy á chaud for PTA. Furthermore, our results suggest that, if a comparison group is ageand sex-matched with a typical abscess tonsillectomy
group, the rate of postoperative haemorrhage after elective
tonsillectomy will be even higher (5.5%) than that in other
studies. This should be taken into consideration when appraising previous studies.
Abscess tonsillectomy has advantages over the alternative of
stab incision and elective tonsillectomy. An abscess tonsillectomy relieves the symptoms directly, additionally detects
malignancies presenting as tonsillar abscess and prevents
complications due to incomplete drainage as a result of incision, obscure abscesses of the contralateral tonsil (3.4% of
our patients), multiple abscesses in the ipsilateral tonsil or
even parapharyngeal abscess which may not be detected by
needle aspiration or incision under local anaesthesia .
Without tonsillectomy, abscess recurrence after incision was
reported in up to 22% of cases; in particular, younger patients
will have continuous symptoms such as abscess, recurrent
tonsillitis or episodic pharyngitis in 50-63% of cases .
Neither the duration of the operation nor the duration of
hospitalization is prolonged with an abscess tonsillectomy.
Tonsillectomy á chaud is an economical therapy for quinsy;
at the very least it is cheaper than stab incision and a second
hospitalization for tonsillectomy á froid.
Only in a few types of patient, such as those using anticoagulants, those with bleeding tendencies, those with severe
comorbidity limiting the use of GA and those who are pregnant, do we favour abscess incision and intravenously applied antibiotics only. However, many patients may refuse
to have a tonsillectomy performed subsequently.
Abscess tonsillectomies are not associated with an increased rate of postoperative haemorrhage in comparison
to elective tonsillectomies and therefore represent the medically and economically indicated primary treatment for
PTA, especially in younger patients in whom recurrence of
quinsy is common.
Lock hart R, Parker GS, Tami TA. Role of
quinsy tonsillectomy in the management of
peritonsillar abscess. Ann Otol Rhinol Laryngol 100:
1991; 569-71.
Bonding P. Tonsillectomy á chaud. J Laryngol Otol
87: 1973; 1171-82.
Herbild O, Bond ing P. Peritonsillar abscess: recurrence rate and treatment. Arch Otolaryngol 107:
1981; 540-2.
Kristensen S, Tveteras K. Post-tonsillectomy
haemorrhage: a retrospective study of 1150 operations. Clin Otolaryngol 9: 1984; 347-50.
Chowdhury CR, Bricknell MCM. The management of quinsy-a prospective study. J Laryngol Otol
106: 1992; 986-8.
Fagan JJ, Wormald PJ. Quinsy tonsillectomy or
interval tonsillectomy-a prospective randomised trial.
S Afr Med J 84: 1994; 689-90.
Carmody D, Vamadevan T, Coo per SM.
Post-tonsillectomy haemorrhage. J Laryngol Otol 96:
1982; 635-8.
Myssiorek D, Alvi A. Post-tonsillectomy hemorrhage: an assessment of risk factors. Int J Pediatr
Otorhinolaryngol 37: 1996; 35-43.
Tami TA, Parker GS, Tay lor RE. Post-tonsillectomy bleeding: an evaluation of risk factors. Laryngoscope 97: 1987; 1307-11.
Windfuhr JP, Chen YS. Immediate abscess tonsillectomy-a safe procedure?. Auris Nasus Larynx 28:
2001; 323-7.
Windfuhr JP, Sesterhenn K. Blutung nach
Tonsillektomie. HNO 49: 2001; 706-12.
Windfuhr JP, Ulbrich T. Post-tonsillectomy hemorrhage: results of a 3-month follow-up. Ear Nose
Throat J 80: 2001; 794-8.
Rob erts C, Jayaramachandran S, Raine CH. A
prospective study of factors which may predispose to
post-operative tonsillar fossa haemorrhage. Clin
Otolaryngol 17: 1992; 13-7.
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abscess. II. Cases treated with tonsillectomy á chaud.
J Laryngol Otol 95: 1981; 801-7.
Dilkes MG, Dilkes JE, Ghufoor K. Smoking
and quinsy. Lancet 339: 1992; 1552.
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Scripta Scientifica Medica, vol. 40 (2008), pp 153-156
Copyright © Medical University, Varna
Nedev P.
Department of Neurosurgery, Othorhinolaryngology and Ophthalmology - Medical University
Varna; Clinic of Otorhinolaringology - University Hospital "Saint Marina" -Varna
Reviewed by: Assoc. Prof. D. Marev, MD, PhD
Binder syndrome or maxillo-nasal dysplasia (nasomaxillary hypoplasia) is an uncommon developmental
anomaly affecting primarily the anterior part of the maxilla and nasal complex. A 4-year-old boy with
maxillo-nasal dysplasia (Binder's syndrome), featuring maxillary hypoplasia and relative mandibular
prognathism, combined with acute leucosis. We review the literature and describe how 3-dimensional CT
scanning was used to evaluate the facial morphology. The principal features, diagnosis and management of
the syndrome are discussed.
Keywords: Binder syndrome, maxillo-nasal dysplasia, nasomaxillary hypoplasia
The essential features of maxillo-nasal dysplasia were initially described by Noyes in 1939(1) although it was Binder
in 1962 (2), who first defined it as a distinct clinical syndrome. He reported on three cases and recorded six specific
characteristics - arhinoid face, abnormal position of nasal
bones, inter-maxillary hypoplasia with associated malocclusion, reduced or absent anterior nasal spine, atrophy of
nasal mucosa and absence of frontal sinus (not obligatory).
Despite the frequent presence of dental malocclusion in patients with maxillo-nasal dysplasia, very little is to be found
in the otorhinolaryngologic literature. Traditionally, plastic
surgeons have been more closely involved with the syndrome, presenting different methods of surgical correction
to solve the aesthetic and/or functional problems.
also reduced sagittal development of the nose.
Transversally there was no apparent facial asymmetry. The
lips were competent at rest. Intra-oral examination of the
dentition revealed the presence of all permanent teeth apart
from the third molars (fig. 1. fig. 2. and fig. 3.).
A 4-year-old boy, diagnosed with acute leucosis, attended
the pediatric department following referral from a ENT
specialist. The mid-face profile was hypoplastic, the nose
was flattened, the upper lip was convex with a broad
philtrum, the nostrils were typically crescent in shape due to
the short collumela, and a deep fold between the upper lip
and the nose, resulting in an acute nasolabial angle.
Mid-face hypoplasia was evident with an absence of
fronto-nasal angle reflected in a straight profile. There was
Address for correspondence:
Plamen Kostov Nedev, 23, 9010 Varna, E. Georgiev str. B-10,
e-mail: [email protected]
Fig. 1. A 4-year-old boy with maxillo-nasal dysplasia.
Frontal view of the case
Nasal hypoplasia with reduced naso-frontal angle was
identified with suspected mild hypertelorism. The flat dorsum and short septum of the nose, enlarged nasal angle,
small naso-labial angle, maxillary micrognathism, and augmented upper lip, what makes the concave midface profile
are the symptoms of Binder syndrome (maxillonasal
displasia). There was a mild form of hypertelorism. Radio153
Nedev P.
graphic and CT exams report small anterior nasal spine,
thin labial plate over incisor roots, nasomaxillary
hypoplasia (absence of nasal bone and processus frontalis
maxillae). No other structural abnormalities were seen.
Fig. 2. Right profile view of the case
Fig. 3 A three-dimensional CT image - a small anterior
nasal spine, nasomaxillary hypoplasia (absence of
nasal bone and processus frontalis maxillae).
Many researchers suggest that Binder type maxillonasal
dysplasia does not represent a distinct disease entity or syndrome, but, rather, is a nonspecific abnormality of the
nasomaxillary regions. In most cases, the condition appears
to occur randomly for unknown reasons (sporadically); rare
familial cases have also been reported. The aetiology of this
condition is connected with a disturbance of the
prosencephalic induction centre during embryonic growth.
(3) However, it has been suggested that there is a common
concurrent induction process for both the prosencephalic
area and the vertebrae, accounting for the increase of vertebral anomalies associated with the condition. (4) Birth
trauma has also been suggested as a possible causative factor, but is not further substantiated in the literature.(5) The
possibility of a family history was put forward by Ferguson
and Thompson.(6) However, Olow-Nordenram and
Valentin were unable to disprove the possibility of a genetic aetiology in a study of 50 patients with the condition,
involving 60 families.(7) In a further study of 97 individuals with Binder's syndrome, Olow-Nordenram (8) reported
a positive family history was for 36 per cent. Gorlin et al.
suggest that maxillo-nasal dysplasia is a non-specific abnormality of the nasomaxillary complex. They believed
that familial examples are a result of complex genetic factors, similar to those involved in producing a malocclusion.(9) Nasal bone is formed in the third month of
intrauterine life, from the centers of ossification (cells migrated from the neural crest) next to the cartilage of the nasal bone. In this complicated process, exogenous, genetic,
and chromosomal factors all play a part. There is evidence
that vitamin K-deficiency during human pregnancy can be
caused by some chemicals as lithium, ethanol or the therapeutic use of warfarin or phenytoin. The pregnancy histories of three cases of Binder's syndrome are reported (10).
One was associated with warfarin exposure, one with
phenytoin exposure and one with alcohol abuse. It is proposed that Binder's syndrome can be caused by prenatal exposure to agents that cause vitamin K-deficiency (10). It is
generally agreed that the lack of population frequency data
has affected the evaluation of aetiological findings (5).
Individuals with Binder's syndrome have a characteristic
appearance that is easily recognizable.The characteristic
findings are a failure of development in the premaxillary
area with associated deformities of the nasal skeleton and
the overlying soft tissues. Affected individuals typically
have an unusually flat, underdeveloped midface (midfacial
hypoplasia), with an abnormally short nose and flat nasal
bridge, underdeveloped upper jaw, relatively protruding
lower jaw. The sense of smell is completely normal. Five
per cent of affected individuals have been found to have
hearing loss and 5% nonspecific congenital heart defects(22). Maxillo-nasal dysplasia can also be combined
with other malformations. For example, Olow-Nordenram
and Radberg reported 44.2 per cent of a study sample to
have malformation of cervical vertebrae (7,8). The association with pseudo-mandibular prognathism has also been
described (1,11). In the most severe cases, the syndrome is
associated with true mandibular prognathism, which requires combined orthodontic and surgical treatment (7). As
the literature review shows maxillo-nasal dysplasia is often
combined with different morbid conditions. Maxillonasal
dysplasia is considered as a predisposing factor to frequent
diseases of the upper airway tract. In our patient case the
Binder syndrome is accompanied with acute leucosis.
As a syndrome maxillonasal dysostosis (defective ossification) is characterized by a short nose with a flat bridge, a
short columella, an acute nasolabial angle, perialar flatness,
a convex upper lip and a tendency to angle class III malocclusion (3). Since then there have been many reported cases
of Binder syndrome, but no such diagnosis has been made
antenatally. Binder syndrome, as it is seen in newborns,
children or adolescents, is characterized by the naso-frontal
angle being absent with the nose being hypoplastic with a
small tip. The nostrils are usually half moon shaped and the
The Binder syndrome: review of the literature and case report
upper lip is convex with a high arched palate. Mild
hypertelorism is usually present as well as malocclusion
and a lower overbite. There are various anomalies of the
cervical spine which may be seen, such as separate
odontoid process, spina bifida occulta, short posterior arch
and block verterbrae (11). Strabismus and mild mental retardation have been occasionally described (12). The frontal sinuses are often hypoplastic or absent in 40-50% of
cases (13). When maxillonasal dysplasia is observed at
birth it is usually not thought to be important if it presents as
a single finding. Individuals may also be seen as children or
adolescents by orthodontists or plastic surgeons, and their
facial features are then diagnosed as Binder syndrome (14).
In 1866, Langdon Down described the phenolype of patients with trisomy 21, indicating that they had "skin...deficient in elasticity, giving the appearance of being too large
for the body... The face is flat and broad, and destitute of
prominence…and the nose is small". With that description
Down laid the foundation for two ultrasonographic markers
for this chromosomopathy: the nuchal translucency and the
nasal bone. In 1966, Kisling (15) performed a radiological
study on 68 adults with Down's syndrome and confirmed
the absence of nasal bone in nine of them (12%). Other authors supponed these findings. In 1994, Sandikcioglu (16)
studied aborted fetuses with trisomy 21 and found radiological anomalies of nasal bone in 60% of those (26% absent, 34% hypoplastic). For many years, sonographers have
known that the subjective impression of a "flat profile" can
serve as an indicator of Down's syndrome, but only in
2001, a publication of Cicero et al. (17) revolutionized the
world of the prenatal diagnosis: in 701 high-risk fetuses between 11 and 14 weeks of gestation, nasal bone was absent
in three out of 603 (0.5%) normal fetuses and 43 out of 59
(73%) fetuses with trisomy 21. A study of 5525 fetuses
found absent nasal bone in 70% of trisomy 21 fetuses compared with 0.5% of fetuses with normal genetic characteristics (19). In their latest assessment of the absent fetal nasal
bone in a multiethnic population of 3788, Cicero et al. (20)
found an absent nasal bone in 161/242 (66.9%) of trisomy
21 fetuses compared to 93/3358 (2.3%) of fetuses with normal chromosomes. The ultrasonographic examination of
7054 fetal profile Gamez 2005 (21) a nasal bone hypoplasia
found in 1.8% of cases. Women aged 35 years or more in
current prenatal care are considered high risk for Down
syndrome pregnancy and are therefore routinely offered invasive tests (amniocentesis) in order to exclude chromosomal abnormalities. Nova days there are introduced
noninvasive tests, using useful markers for fetal abnormalities, especially for chromosomal aberrations. (18)
Surgical treatment can be limited only to reconstruction of
the nasal dorsum and apex or additionally maxillary advancement. The management consists of nasal and
maxillary correction followed by orthodontic rehabilitation. The treatment schedule in Binder syndrome depends
on the progress of the symptoms in the face occlusion. Surgical treatment can be limited only to reconstruction of the
nasal dorsum and apex or additionally maxillary advancement. Grafting to the osteo-chondral scafold of the nose can
be carry out from 14-year-old, and osteotomy of the nose or
maxilla should be planned after 18-year-old. It is important
to examine prenatal the facial features as they may well
give an indication of an underlying severe fetal abnormality. However, the finding of a small flattened nose with no
other abnormal features, in a fetus with a normal karyotype,
is likely to carry a good prognosis with the possibility of
satisfactory surgical correction (23).
We could conclude that the survey of the literature did not
disprove the possibility of a genetic etiology, although it
might not be the full explanation for the syndrome. The feature and degree of the abnormality depend on the time of
exposition to harmful teratogenic factors. We recommend
ultrasound screening and noninvasive genetic tests to look
for congenital anomalies as well as assessment of gestational age. In conclusion, individuals with maxillonasal
dysplasia shall be subjected to a treatment planning in collaboration between orthodontists and ENT surgeons.
Noyes FB. Case report. Angle Orthod 1939; 9:
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bones. J Craniofac Genet Dev Biol 1994; 14: 124-34.
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2001. Absence of nasal bone in fetuses with trisomy
21 at 11-14 weeks of gestation: an observational
study. The Lancet 358: 9294.
18. Sieroszewski P., Perenc M., Baoe-Budecka
E., Suzin J. Ultrasound diagnostic schema for the
determination of increased risk for chromosomal fetal
aneuploidies in the first half of pregnancy Journal of
Applied Genetics 2006, 47(2), 177-185
Zoppi MA, Ibba RM, Axiana C, Floris M,
Manca F, Monni G, Absence of fetal nasal bone
and aneuploidies at first-trimester nuchal translucency
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2003; 23(6): 496-500
Cicero S, Longo D, Rembouskus G, Sacchini
C, Nicolaides KH. Absent nasal bone at 11-14
weeks of gestation and chromosomal defects. Ultrasound Obstet Gynecol 2003; 22: 31-35.
Gamez F., Ferreiro P.: Fetal nasal bone as
ultrasonographic marker for trisomy 21 in a low-risk
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September 2005; 5(3): 171-177
Cook, K., Prefumo F., Presti F., Homfray T.,
and Camp bell S. The prenatal diagnosis of Binder
syndrome before 24 weeks of gestation: case report
Ultrasound in Obstetrics and Gynecology Volume 16
Issue 6 Page 578-581.
Scripta Scientifica Medica, vol. 40 (2008), pp 157-160
Copyright © Medical University, Varna
Tonchev T.
Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University
Reviewed by: Assoc. Prof. D. Marev, MD, PhD
The frontoethmoidal mucocele engaging the orbit and neighboring structures is relatively uncommon. The
presented case uses operative treatment with coronal approach in which for reduction and obliteration of the
cavity and the nasofrontal canal the author uses his' own method of a flap that consists of periost and galea
aponeurotica. The article describes the sequence of the treatment and the operation. The case report confirms
a very good postoperative result and lack of recurrence thirty six months after surgery. The author is reviewing the contemporary literature and the clinical approach with this disease.
Keywords: Orbit, Surgery, Frontoethmoidal mucocele, Coronal approach, Reduction, Obliteration
When for one reason or another, the normal drainage of the
secret that is produced by the mucus epithelium has been
disturbed a cystic lesion with a slow expansive growth develops. It is called mucocele (2;3;6;8). The mucocele engages the frontal sinus with its anterior ethmoidal cells in
64% of the cases, the maxillary sinus in 18.6%, the
sphenoidal sinus in 8.4% and independently-the ethmoidal
cells in 6.7% (11). Etiological factors could be: inflammation of the paranasal cavities and the nasal mucus; allergic
rhinosinuitis including nasal polyposis; trauma associated
with dislocation of bone fragments and leading to obstruction of the drainage; tumor processes engaging the nasal canal or the foramen of the sinus; prior surgical treatment and
of course a certain number of cases with unclear etiology
(3;4;6;8). In the presence of some of these preconditions the
mucus collects in the sinus cavity exercising hydraulic
pressure on the surrounding tissues. As a result in the
submucosal layer of the mucosa starts a process of fibroids
transformation, as well as deformation and thinning of the
surrounding bone structures, most often of the orbital wall
(5;9;10). In the cases of prior surgery of the frontal sinus the
bone lamella is removed and the formation grows towards
the orbit (4). The treatment of the patients is operative. Depending on the localization, different methods are being
used. The use of endoscopic methods combined with external access is predominant in the last decades. The incisions
Address for correspondence:
Tsvetan Tonchev, Medical University Varna, Faculty of Dental Medicine, Department of OMFS, 55 Marin Drinov st., 9002 Varna,
E-mail: [email protected]; [email protected]
are made in visually unavailable areas, most often in the
hairy part of the head. For obliteration of the sinus cavity is
used fat tissue or, in the last few years, a combination of non
organic filler (Medpor) and tissue glue (Tissucol) with
haemostatic sheet (Surgicel) (7). For contouring and obliteration a cortical plate taken from the parietal area could be
used as well as titanium grid (2; 7).
The author presents his own method for reduction and
obliteration of the cavity and the nasofrontal canal in a case
of frontoethmoidal mucocele, by using a flap that consists
of periost and galea aponeurotica.
A 72 years old woman has been sent for treatment in the
Department of Oral and Maxillofacial surgery. The patient's current complaints are swelling of the inner upper
part of the left orbit, difficulty in the eye movement and
diplopia. These are dating from 8-10 months back when
during examination a formation in the upper medial quadrant of the left orbit has been discovered. Some 25-30 years
ago the diseased underwent an operation of the frontal sinus
from the same side, which was proven by the old operative
cicatrices medially in the eyebrow area with a length of 3
cm. There was no available data for the size and the type of
the prior operation. The patient has been treated with few
courses of corticosteroid therapy in another hospital on the
occasion of accepted diagnosis pseudotumor of the orbit.
From about 5 years the diseased suffers from badly con-
Tonchev T.
trolled diabetes. During the clinical examination we determine a presence of formation in the upper medial quadrant
of the left orbit, pushing forward the eye bulb in lower lateral position. There are disturbances in the upper and medial eye movement and a presence of diplopia (Fig.1).
Fig. 1
Fig.1 Preoperative view of the patient (bird view): Expressed deformation of the left orbit with pseudoptosis of
the eyelid and exophtalmos
After clinical discussion of the case we agreed to an extirpation of the formation using coronal approach. The advantages of the method are many and undeniable but in the
present case the main motives were the prior operation and
the spread of the formation towards the middle part of the
orbit. After coronal incision we used Raney clips for
haemostasis. Through supraperiostal dissection we reached
level of about 3 cm. from the supraorbital edge, from where
we continued to subperiostal plan (Fig.5). After reaching
the supraorbital edge the cystic cavity was uncovered
(Fig.6). The cyst was removed after partial evacuation of
the content which formatted a cavity neighboring the orbit
(Fig.7). In the lower medial part we identified the
nasolacrimal canal which was curettaged. From the scalping flap we prepared periostogaleal flap for the obturation
of the canal and for partial filling of the cavity formed by
the mucocele (Fig.8). Aspiration drainage, type Redon was
placed and the tissues were sawed layer by layer.
Fig. 4
Fig. 2
Fig. 5
Fig. 3
The CT shows a presence of cystic formation, engaging the
left frontal sinus, part of the anterior ethmoidal cells and the
orbit in its upper medial quadrant. There is a lack of sharp
division between the formation and the eye bulb. There is
no bone wall between the frontal sinus and the orbit
Fig.2 Parasagittal CT reconstruction: The lesion engages
the frontal sinus and the anterior ethmoidal cells; Fig.3 Axial CT: A presence of cystic formation engaging the left
frontal sinus and extending to the middle of the left orbit;
Fig.4 Coronal approach to the two orbits. Fig.5 Uncovering
of the mucocele (the instrument shows the upper edge of
the defect)
Fig.6 Preparation of the periostogaleal flap (arrow) used for
obturation of nasolacrimal canal and partial filling of the
The post operative period was covered by antibiotic treatment and dynamic correction of the data, given the accompanying diseases. The patient was discharged from hospital
in good condition after twelve days. The following check
through ophthalmological examination in the third month
showed a full recovery of the eye movement and lack of
diplopia. One year after surgery the patient had no complaints. The author reports a very good aesthetic result with
correct and symmetrical position of the two eyes. Only in
the medial part of the brow and frontal parasagittal area we
Our Own Method for Reduction and Obliteration of the Cavity in Cases of ...
find caving, due to the flap used for obturation and obliteration of the nasolacrimal canal and the frontal sinus (Fig.9).
The follow-up period is 3 years, for which term no recurrence has been detected.
Fig. 6
with feeding base branches from a. and v. supratrochleares
and a. and v. supraorbitales. We consider a better decision,
than the ones used so far, the use of a flap taken from vital
tissues for filling the defect. Essential disadvantage of the
method is the disturbed symmetry and deformation of the
donor site which especially in young people can be a serious aesthetic issue.
The coronal approach we used gives an excellent opportunity for visualization of the whole supra and inter orbital
segment, the orbit itself, as well as for adequate reconstruction (7). The realization of the incision in the hairy part of
the scalp is a serious aesthetic advantage along with the
above mentioned.
The case presented is interesting mainly for two reasons:
the operative access and the relation towards the sinus cavity. Using endoscopic technique in the presence of prior operative treatment and engagement of the orbit next to the
eye bulb holds some serious risks (3;4).
Fig. 7
Fig.7 External view of the diseased an year after surgery. A
presence of correct and symmetrical position of the eyes.
Vaguely expressed asymmetry in the medial part of the
eyebrow and in the frontal parasagittal area, where the donor site is.)
Still there is no consensus about the treatment of the postoperative cavity (1;7;11). Relatively the methods can be divided into two: the ones purposing obliteration and the ones
which expand the existing nasolacrimal canal for the purpose of better drainage and prevention of the retention leading to the development of mucocele. The most commonly
used method is the one of obliteration with fat tissue, and
the use of tissue glue and bone taken during the operation
from the external lamella of the parietal bone for obturation
of the canal. According to us each of the two methods has
its advantages and disadvantages. Expanding the
nasolacrimal canal for the purpose of better drainage can be
determined as more physiological method as far as the existing anatomical structures are kept untouched. On the
other hand, the presence of cavity covered with epithelium
which characteristics differ from those of the normal sinus
mucosa and has decreased secretory function, is a precondition for inflammation later on in time. The immediate
proximity of the brain predefines the dangerous course of
such inflammation. The method applied for obturation and
obliteration using periostogaleal flap belongs to the first
group of methods. The main advantage is the use of a flap
The main purpose in the treatment of the frontoethmoidal
mucocele is the radical removal of the formation with minimal functional and aesthetic consequences and lack of recurrence. There is a necessity of conducting a wide range of
imaging studies preoperatively for the purpose of pr?cising
the correlation to the orbit and endocranium. The author's
own method is easy for execution and provides a reliable
solution in the cases of small sized bone defects.
Am ble F, et al.: Nasofrontal duct reconstruction
with silicone rubber sheeting for inflammatory frontal
sinus disease: analysis of 164 cases. Laryngoscope
1996; 106: 809-15.
Arrue P, et al.: Mucoceles of the paranasal sinuses:
uncommon location. The Journal of Laryngology and
Otology; 1998, 112: 840-844.
Busaba N, Salman S: Maxillary sinus mucoceles:
Clinical presentation and long-term results of endoscopic surgical treatment. Laryngoscope; 1999, 109:
Chandra A, et al.: Frontoethmoidal mucocele associated with bilateral increased intraocular pressure
and proptosis. Can J Ophthalmol. 2007; 42(1): 143-4.
Chiarini L, et al.: Mucocele gigante dei seni
frontali ad estensione intracranica. Graz/Austria: Eur
Ass Cranio-Maxillo-Facial Surg 2000:40-4.
Marks S, et al.: Mucoceles of the maxillary sinus.
Otolaryngology Head and Neck Surgery; 1997,
Molteni G, et al.: Voluminous frontoethmoidal
mucocele with epidural involvement. Surgical treatment by coronal approach. Acta Otorhinolaryngol
Ital. 2003; 23(3): 185-90.
Pino Rivero V, et al.: Frontoethmoidal mucocele.
Diagnosis and treatment in 7 cases. An
Otorrinolaringol Ibero Am. 2007; 34(4):359-65.
Tonchev T.
Perugini S, et al.: Mucoceles in the paranasal sinuses involving the orbit. Neuroradiology 1982; 23:
10. Rashid M, et al.: Frontoethmoidal mucocele with
intraorbital extension: an unusual cause of diplopia. J
Coll Physicians Surg Pak. 2006 May; 16(5):371-2.
11. Rombaux P, et al.: Endoscopic endonasal surgery
for paranasal sinus mucoceles. Acta Otorhinolaryngol
Belg 2000; 54: 115-22.
Scripta Scientifica Medica, vol. 40 (2008), pp 161-163
Copyright © Medical University, Varna
Tonchev T.
Medical University Varna, Faculty of Dental Medicine, Department of Oral and Maxillofacial
Reviewed by: Assoc. Prof. V. Svestarov, MD, PhD
The purpose of this research is examination of the clinical characteristics, the preparation and the course of
the operative treatment of the tumors of the lacrimal gland. The following article presents four cases where a
lateral orbitotomy with coronal approach is used. A complete excision of the tumor is conducted. The postoperative observation of the diseased varies between 18 and 114 months, and includes an analysis of the results.
Keywords: lacrimal gland tumors, orbital tumors, coronal approach, lateral orbitotomy
nosis and preparations, the operative treatment and the following postoperative period when treating these tumors.
The tumors of the lacrimal gland are relatively rarely found
and are mostly benign. As a whole they represent 9% from
all orbital processes (1). The diseases of the lacrimal gland
are divided into inflammatory and lymphoid, followed by
the metastatic processes and the primary epithelial tumors
(2;3). Primary epithelial lacrimal gland tumors are
histologically similar to those arising in the salivary glands.
The pleomorphic adenoma and adenoid cystic carcinoma
are the most common benign and malignant tumors, respectively (4;5). Given the low frequency of these tumors
many publications offer a description of single cases and
only a few consider larger groups of patients, observed for a
longer period of time (6). The purpose of this study is the
examination of the clinical features, the preoperative diag-
Tab. 1. Anamnestic and paraclinical data in the four
cases (R - Right; L - Left; CT - computer tomography;
MRI - magnetic resonance imaging)
¹ Gender Age
Tab. 2 Clinical data in the four cases (-/+ - anamnesis/examination; ACa - adenocarcinoma; NHL - non-Hodgkin
lymphoma; PA - pleomorphic adenoma)
¹ Exophtalmy
Address for correspondence:
Tsvetan Tonchev, Medical University Varna, Faculty of Dental Medicine, Department of OMFS, 55 Marin Drinov st., 9002 Varna,
E-mail: [email protected]; [email protected]
In the period 1998-2006 in the Department of Maxillofacial
surgery of Naval Hospital –Varna have been operatively
treated 4 diseased with tumor of the lacrimal gland. Based
Tonchev T.
on the hospital’s documentation the author performs an
analysis of the data divided in: gender, age, the beginning
of the disease, the side of the gland and the type of imaging
study (tab. 1). The clinical symptoms, the size of the tumor,
the operative treatment and histological diagnosis, as well
as the term of postoperative observation and the discovery
of reoccurrence can be found in tab.2. Exophtalmometric
study has been made using the Hertel method. The given
data is anamnestic. The sign (-) marks the lack of diplopia,
the sign (-/+) marks cases in which diplopia occurs only on
superior and lateral gaze, (+) marks the presence of
The average age of the patients operated is 59 years, (between 51 and 72) - three women and a man. The period
marking the beginning of the disease until hospitalization is
between 5 and 12 months (8.75 in average). For first sign of
the disease we accept the moment in which the patient realizes the presence of a problem and seeks medical help. In
three of the cases the process engages the right lacrimal
gland, and in one case – the left. The imaging studies include mainly CT, and in one case MRI. In all four cases we
determine well limited tumor formations with benign CT
characteristics, with no data for infiltration of the surrounding structures. The preoperative exam shows marked
proptosis in all 4 patients. The diplopia was analyzed as
anamnestic data and at the same time a clinical exam was
conducted for the discovery of hidden diplopia. The
anamnesis accented on the occurrence of double vision in
everyday duties. The result from the clinical examination
showed manifested diplopia in all 4 patients. The operative
treatment in all four cases included total extirpation of the
tumor. This was conducted trough lateral orbitotomy where
the access was secured with a coronal approach. Tab. 2
shows the dimensions of the tumor in each case. The size of
the tumor after removal varies between 8 ñm3 and 21 ñm3.
The postoperative treatment includes observation by an
ophthalmologist and a maxillofacial surgeon and, in the
case ¹ 2 – a hematologist to determine the postoperative
treatment concerning the leading disease. The surgical
treatment was thorough in the other 3 cases. The postoperative observation was between 18 and 114 months (57.75
months average). During the whole period of observation
no sign for reoccurrence of the disease was found in all four
The lacrimal gland is divided by the orbital septum into two
parts: palpebral which is superficial and orbital which is
deeply situated. The tumors of the lacrimal gland most often originate from the deeper part, which is the reason for
the late diagnostic, and to be accurate- the period when disturbances of the eyesight appear or there is a facial asym-
metry and aesthetics (7). Most of the tumors of the lacrimal
gland are benign and from them the pleomorphic adenoma
is most frequent. The ratio is the same as with the tumors of
the salivary glands (2;4;8). Clinically they appear as well
limited, slowly growing, painless swelling, which in the beginning leads to deformation of the upper external quadrant
of the orbit and as a result leads to ptosis of the upper eyelid,
exophthalmia, decreased mobility of the eyeball and
diplopia. Possible impairment of vision is common. Two of
the patients are diagnosed with these symptoms. The malignant transformation of the pleomorphic adenoma is possible in long term cases or when the excision of the tumor
was not radical enough and there have been conducted
more than one operation. Some authors recommend an operative treatment by excising the tumor after diagnosing it,
excluding the biopsy (3;9). For preoperative diagnostics
fine needle biopsy can be used as minimally invasive and
informative method, enough to precise the surgical treatment. In the present cases this method did not give the information required, which can be explained with the lack of
experience with the conduction of the technique and interpretation of the result.
In cases of malignant tumors of the lacrimal gland the
adenocystic carcinoma is most common, followed by the
adenocarcinoma. The surgical treatment of malignant tumors with such localization is still very discussible. According to some authors there is no substantial difference in
the life expectancy when the capacity of the operation is increased. In confirmation of this fact we give the case in
which the tumor was removed together with the orbital part
of the gland, and the result was ten years outlive and lack of
Almost 25% of non-Hodjkin lymphomas are with extra
nodal localization from which 3% develop in the head and
neck region (12). The tumor is in 5-14% with orbital localization and is the most frequent primarily malignant tumor
of the orbit (13). The tumor most commonly originates
from MALT (mucosa-associated lymphoid tissue) cells or
from the germinal centers of the lymph nodules. In principle the orbital localization of non-Hodjkin lymphoma is
distinguished by slowly growing formation in the orbital
area and the periorbital tissues. Choice of treatment is chemotherapy and radiotherapy. Between 50 and 80% of the
patients are in total remission (14). Typical feature of the
orbital surgery when treating non-Hodjkin lymphoma is
not so much the radicalism of the operative method as the
aspiration for providing enough tissue for histological and
immunehistochemical test for the purpose of exact
typification and a following chemotherapeutic treatment
(15). In the present case the tumor was a non Hodjkin lymphoma connected to the gland and with a volume of 21
ñm3. With the average size of the orbit around 30 ñm3 this
represents around 2/3 of the capacity of the orbit (5). The
patient was in full remission for 56 months after a course of
chemotherapy. The recovery of the anatomical and functional integrity of the operated orbit was complete, with no
disturbances or deficit.
Surgical treatment of tumors of the Lacrimal Gland by Coronal Approach
The diagnosis and the operative treatment of the tumors of
the lacrimal gland require serious knowledge of the pathology of the orbit and is subject of interdisciplinary partnership. The leading role of the ophthalmologist demands
early conduction of imaging study in all cases of asymmetry in the area or deficit in the mobility of the eyeball reported by the patient or determined during examination.
The interpretation of the data based on the imaging studies
requires participation of specialists in orbital surgery. The
decision for operative treatment should be based on a thorough analysis of the clinical and preclinical facts and
should be individual. The results from the operative treatment correlate to the biology of the tumor, the level of the
preoperative diagnosis, the type of the operation and the
possibilities of following treatment if necessary.
Shields J, Shields C, Scartozzi R. Survey of
1264 patients with orbital tumors and simulating lesions: Ophthalmology 2004; 111: 997–1008.
Font R, Shan non LS, Bryan RG. Malignant epithelial tumors of the lacrimal glands. A
clinicopathologic study of 21 cases. Arch
Ophthalmol; 1998;116:613– 6.
P a u l i n o A , H u v o s A G . Epithelial tumors of
the lacrimal glands: a clinicopathologic study. Ann
Diagn Pathol ; 1999;3:199 –204.
Chuo N, Ping-Kuan K, Dryja TP.
Histopathological classification of 272 primary epithelial tumors of the lacrimal gland. Chin Med
Rootman J, Stew ard B, Goldberg R, et al: Orbital surgery: a conceptual approach. Philadelphia,
Lippincott-Raven Publisher, 1995; pp. 75; 79.
Esmaeli B, Ahmadi MA, Youssef A, et al.
Outcomes in patients with adenoid cystic carcinoma
of the lacrimal gland. Ophthal Plast Reconstr Surg,
2004; 20: 22– 6.
Perez D, Pires F, Almeida O, Kowalski L. Epithelial lacrimal gland tumors: a clinicopathological
study of 18 cases. Otolaryngol Head Neck Surg. 2006
Wright J, Rose G, Gar ner A. Primary malignant
neoplasms of the lacrimal gland. Br J Ophthalmol
1992; 76: 401–7.
Chandrasekhar J, Farr D, Whear N.
Pleomorphic adenoma of the lacrimal gland: case report. Br J Oral Maxillofac Surg 2001; 39: 390 –3.
Sturgis C, Silverman J, Kennerdell J, et al.
Fine-needle aspiration for the diagnosis of primary
epithelial tumors of the lacrimal gland and ocular
adnexa. Diagn Cytopathol 2001; 24: 86 –9.
Polito E, Leccisotti A. Epithelial malignancies of
the lacrimal gland: survival rates after extensive and
conservative therapy. Ann Ophthalmol 1993; 25:
Skarin A, Diagnosis in oncology. Unusual sites of
malignancy. J Clin Oncol 2001; 19: 1570–1575.
Hohn J, Suh C, Lee S, Yang W: Primary lymphoma of the eye. Yonsei Med J 1998; 39: 196–201.
Hitch cock S, Ng AK, Fisher D, Sil ver B,
Bernardo M, Dorfman D, Mauch P: Treatment
outcome of mucosa-associated lymphoid tissue/marginal zone non-Hodgkin’s lymphoma. Int J Radiat
Biol Phys 2002; 52: 1058–1066.
Wanyura H, Uliasz M, Kaminski A,
Samolczyk-Wanyura D, Smolarz- Wojnowska
A. Diagnostic difficulties and treatment of non-Hodgkin lymphoma of the orbit. J Craniomaxillofac Surg.
2007 Jan; 35(1): 39-47.
Scripta Scientifica Medica, vol. 40 (2008), pp 165-166
Copyright © Medical University, Varna
Bachvarova S.1, P. Drumeva2, R. Bachvarova3, V. Chakalova3
Clinic of Neurology and Psychiatry, Department of Clinical Medical Sciences, Faculty of Dental
Medicine, 2Clinic of Dermatovenereology and 3Department of Psychiatry and Medical Psychology,
Faculty of Medicine, Medical University of Varna
Reviewed by: Assoc. Prof. R. Shiskov, MD, PhD
A Hospital Anxiety and Depression Scale (HADS) was applied to follow-up the degree of anxiety and depression of 61 patients with skin diseases, 32 males and 29 females aged between 21 and 68 years occasionally examined in the outpatient consulting room of the Clinic of Dermatovenereology at the Medical University of
Varna. The results vary within the limits of slight to moderate aberrations. They demonstrate, however, a
high level of co-morbidity between anxiety and depression. In this respect, anxiety disorders occupy a leading
Keywords: chronic skin disease, anxiety, depression, Hospital Anxiety and Depression Scale, co-morbidity
Chronic skin diseases exert a considerable psychotraumatic
influence on the affected patients. Numerous authors report
a manifested co-morbidity with anxiety and depression.
According to some publications, the percentage of affective
disturbances reaches up to 25-40% (1-3). Certain skin diseases such as acne vulgaris, psoriasis, and eczema present
even with suicidal ideation enhancement (1). The expression of the motional reactions is directly related to the localization and duration of skin lesions. Usually, psychotic
troubles are not shared in the consulting room where, most
commonly, physician’s meeting with the patient takes
place as the patients are seldom admitted to hospital and
most often, exacerbations are mastered under outpatient
conditions only. All this calls for a more comprehensive
study of the psychopathology in the outpatient
dermatological practice.
The purpose of the present study is to follow-up the degree of
anxiety and depression of the patients with chronic skin diseases located on the visible part of the body who are within
their normal society and follow their usual life rhythm.
We used a cross-sectional study design. It covered a total of
61 patients, 32 males and 29 females aged between 21 and
68 years. They presented with chronic skin diseases affecting the open parts of the body. These patients had occasionally undergone medical examinations in the outpatient consulting room of the Clinic of Dermatovenereology at the
Medical University of Varna. The patients with psychotic
diseases, organic disorders of the central nervous system,
psychoactive-drug abuse (i. e., of narcotics, alcohol, and
medicines) as well as with severe somatic diseases were excluded from the study.
A self-assessment Hospital Anxiety and Depression Scale
(HADS) (6) was applied. It consists of 14 questions to be
answered spontaneously by the patients. Every question
presents with for answers scored between 0 and 3 scores.
The questions with odd numbers relate to anxiety while
those with even ones relate to depression. Sums for both
depression and anxiety are calculated alone and give us an
idea about the degree of the aberrations. The span between
0 and 7 is considered a standard one. The rest results correspond to the following characteristics: 8-10 scores - slight;
11-14 scores - median, and 15-21 scores - severe disorders.
The questionnaire is filled-in under anonymous conditions
in order to avoid additional psychotraumatic harmful
agents and thus to obtain more objective results.
Twenty healthy individuals matched according to age and social status who had visited the outpatient examination room on
the occasion of issuing their medical certificates concerning
jobs, arms and ammunition, and marriage in St. Marina Diagnostic and Consulting Centre of Varna served as controls.
The mean parameters of patients’ anxiety and depression
are significantly higher than those of the control individuals
(p < 0,05). Concerning the pathology, there are abnormalities predominantly in the field of anxiety (in 47,54% of the
cases). Their structure is the following: a slight disorder in
Bachvarova S., P. Drumeva, R. Bachvarova ...
62,06%, a median disorder in 24,13%, and a severe disorder - in 13,79% of the cases.
Despite the great number of the affected patients it is evident that the high levels of anxiety are manifested in a small
part of these patients only. The slight and median abnormalities prevail. A more detailed analysis of the results indicates, however, that the patients more often feel strained,
they can not relax, they experience uneasiness when they
need to travel as well as they are attacked by troubling
thoughts during the “greatest part of the time” and “from
time to time, however, not very often”. Panic attacks and
somatic complaints are most rarely observed.
Cosmetic defects on the open parts of the body cause depressive experiences in 36,06% of the patients. In the depression scale, there exist mainly slight disorders. Five patients present with median disturbances and only two female patients present with 17 or 19 scores, respectively,
thus coming close to the borderline states between the median and severe disturbances.
The analysis of the results demonstrates, however, that the
symptoms are, usually, combined and, therefore, pure depressive or anxiety disorders seldom occur, indeed. There
exists co-morbidity where anxiety disturbances occupy a
leading position (in 84,31% of the cases). It is an alarming
fact that independently of the presence of emotional experiences even after the filling-in the questionnaire, nobody of
the respondents has shared with the treating physician some
psychological problem and has asked for a advice for a
consultation with a specialist at all.
Poot et al. (2007) define the necessary knowledge to practice psychodermatology and suggest that the European
Academy of Dermatology and Venereology together with
the European Society for Dermatology and Psychiatry are
able to provide the specific education for dermatologists
and psychotherapists. The diagnostic criteria for psychosomatic research have been found to yield valuable integrative information, in addition to DSM-IV nosology, in a variety of medical dermatological diseases (4).
We could draw the conclusion that the cross-sectional observation performed by us testifies to the high co-morbidity
rate of the chronic skin diseases affecting the visible part of
the body with affective disorders. Underestimation of
psychopathology not only by the dermatologist but also by
the patient can, to a certain extent, reduce the effect of the
treatment of the skin disease as well as to influence, eventually, on the duration of the remission.
The results from our pilot investigation allow us to continue
the dynamic investigations in this field by performing more
detailed analyses of the emotional disorders accompanying
chronic skin diseases according to their diagnosis, patient’s
gender and degree of dissemination of the skin affections as
well as by looking for concrete mechanisms for the improvement of patient’s status within the outpatient
dermatological practice.
Gupta, M., A. Gupta. Depression and suicidal
ideation in dermatology patients with acne, alopecia
areata, atopic dermatitis and psoriasis.- Br. J.
Dermatol., 139, 1998, 846-850.
Milard, L. Dermatological practice and psychiatry.Br. J. Dermatol., 143, 2000, 920-921.
Picardi, A., D. Abeni, C. Melichi, et al. Psychiatric morbidity in dermatological outpatients: an
issue to be recognized.- Br. J. Dermatol., 143, 2000,
Picardi, A., P. Porecelli, P. Pasquini, et al.
Integration of multiple criteria for psychosomatic assessment of dermatological patients.- Psychosomatics,
47, 2006, 122-128.
Proot, F., F. Sammpogna, L. Onnis. Basic
knowledge in psychodermatology.- J. Eur. Acad.
Dermatol. Venereol., 21, 2007, 227-234.
Zigmond, A. S., R. P. Snait. The hospital anxiety and depression scale.- Acta Psychiatr. Scand., 67,
1983, 361-370.
Scripta Scientifica Medica, vol. 40 (2008), pp 167-169
Copyright © Medical University, Varna
S. Racheva
MedicalUniversity - Varna, Clinic of Dermatology and Venerology
Reviewed by: Assoc. Prof. Zh. Georgieva, MD, PhD
The chronic non-allergic urticaria /CNU/ is a frequent malady; almost 25% of a given population has suffered
incidents of Urticaria. Often the causes provoking it remain undiscovered and Urticaria is defined as idiopathic. Besides this form, CNU includes physical Urticaria and urticarial reactions, the secondary causes of
which are other somatic disorders (chronic infections, autoimmune diseases, malign proc-esses etc.) The effective treatment of CNU is set after precise etiological clarification. The research includes 122 patients with
CNU, tested and viewed as having a somatic disorder, physical outside stimuli provoking the urticaria; as allergic reactions to the usual sensibilizing factors are excluded. With 113 of the patients the etiology of the CNU
was clarified: in 55.7% of them the urticaria was connected with other somatic disorders (in 69.1% - chronic
infection, and in 26.4% - with autoimmune disease). In 36.8% of the tested patients various forms of physical
urticaria were proved (33.3% - cholinergic urticaria, 24.4% - cold urticaria, 15.5% - delayed pressure urticaria, 11.1% - solar urticaria). In 7.3% of the cases the urticaria was diagnosed as idiopathic. The conclusions
drawn predetermine the right choice of the respective therapy and prophylactics.
Keywords: Chronic Urticaria, Physical Urticaria, Cholinergic Urticaria, Non-allergic Urticaria, delayed
pressure urticaria, cold urticaria, solar urticaria
The chronic non-allergic urticaria /CNU/ is a frequent malady; almost 25% of a given population has suffered incidents
of urticarial reaction (19). It is a syn-drome of the "nerve
mastoid cell". It is associated with infections, autoimmune
diseases, metabolic disorders, malign processes and physical
stimuli. The chronic urticaria includes various forms of physical urticaria (PU), idiopathic urticaria (IU) and secondary
urticarial reactions, caused by other somatic disor-ders.
The cases of urticaria with a length of over 6 weeks and
with undiagnosed cause are defined as IU. IU covers
25-45% of all urticarial reactions and recent research shows
its autoimmune genesis (10).
PU includes the subgroups of chronic urticaria, shows frequency between 14% and 17% (23,17 ), and is provoked by
physical stimuli, such as trauma, pressure, light, cold, heat,
water, vibrations .
CNU causes considerable therapy problems due to its various
forms and to the mul-tidirectional treatment. This requires
maximum efforts towards the etiological clari-fication of each
concrete case and the personified and adequate treatment approach.
The present research aims to clarify the etiology of the
CNU of a group of patients, tested and observed in the
Clinic of Skin and Venereal Diseases - Varna.
pending on the clinic picture and the medical his-tory, as well
as the clinic observation, the patients were tested for somatic
disorder. With those with data of PU provocative tests were
held with an ice cube (with expo-sure from 1 to 10 minutes)
and a single and repeated pressure test. All patients were tested
for allergic reactions to atopens, bacterial and food allergies,
pollens in order to exclude allergic genesis of the urticaria.
In 113 of the tested patients, etiological clarification of
CNU was achieved (table 1): in 55.7% of the cases the urticaria was connected with another somatic disorder, in
36.8% PU was proven, and in 7.3% of the patients the urticaria was diagnosed as idiopathic due to the lack of concrete data for its causes.
Table 1. Etiology of the Chronic Urticaria (122
Etiologic Diagnosis Number of Patients
Urticaria connected
with other disorders
Physical Urticaria
Idiopathic Urticaria
The research covers 122 patients with CNU, tested and observed for a period of five years in an allergology surgery. De167
S. Racheva
The data received about the frequency of CNU, associated
with other diseases corre-sponds to that in literature.
Montureux P. (1988) establishes chronic infections in 81%
of the cases, but there are authors pointing to a lower percentage (23). The fre-quency of the PU in the research
shows a percentage higher than that in literature ( 23), while
that of IU - lower.
The patients with CNU connected with another disease
showed the following distri-bution (table 2): in 47 patients
(69.11%) a connection with chronic infections (with two
people - rheumatism, with 10 - intestinal parasites, with 5 toxoplasmosis, with 7 - hepatitis C virus infection, with 7 Heliobacter pylori-infection and with 16 - with other banal
infections). In 18 patients (26.7%) CNU was connected
with autoimmune diseases (12 - with autoimmune
thyroditis, 1 - with Lupus erythema-todes, 1 - with
Dermatomyoisits, 4 - with other endocrine diseases). In two
patients (2.9%) the urticaria was on the background of a
malign process (mediastinal tumors) and in one patient
(1.4%) a hereditary angioedema was discovered.
Table 2. Etiology of the Chronic Non-allergic Urticaria,
connected with other diseases
Etiologic Diagnosis
Number of Patients %
Urticaria connected with chronic
Urticaria connected with
autoim-mune disorders
Urticaria connected with malign
Urticaria connected with genetic
The variety of chronic infections, causing CNU which
were established during the research correlate with those in
literature: CNU, associated with hepatitis C virus infection
(28,18), with rheumatism (19), with intestinal parasites
(11). A number of authors point to the direct and indirect
role of Helicobacter pylori infection in the development of
CNU (27,30).
The connection CNU - autoimmune or another endocrine
disorder is discussed at length in literature (9) as the autoimmune thyroditis is named as the most frequent urticaria
cause (9), as well as the tendency of an increase of these
cases (13). The urticaria is assumed to be an autoimmune
disorder (12), proven in over 25% of the cases (11). Many
authors find in 45-50% of the CNU a skin autoimmune disorder (14). The CNU is rarely connected with a malign process; the risk of such a connec-tion is 3% (26).
The physical forms of the CNU in the research showed the
following distribution (Table 3): U. cholinergica was found
in 15 patients (33.3%), U. a'frigore - in 11 pa-tients
(24.4%), U a'pressionem I in 7 patients (15.5 %), symptom-
atic dermo-graphism - in 7 patients (15.5%) and U. solar in 5 patients (11.1%).
Table 3. Etiology of the Physical Forms of Chronic
Non-Allergic Urticaria (45 patients)
Etiological Diagnosis
Number of Patients
U. cholinergica
U. a'frigore
U a'pressionem
U. Solar
The Cholinergic Urticaria according to literature data varies
from 4% (8) to 56% (17) among all forms of chronic urticaria. A number of authors find it more often in the atopens
(15) than in the general population. The agents provoking it
could be various: stress (15), perspiration (15), physical exertion (31), taste stimuli (29), haemodialysis (2).
Urticaria a'pressionem is described as a form of PU, with
frequency of 5% (8) among adults and 24% among children, more often met in the atopens, mediated by histamine,
appearing quickly after pressure and with wheals duration
of 30 minutes. Another form of Urticaria a'pressionem is
the urticaria caused by pressure - delayed type when pressure on the skin makes the mastocytes join the process, but
with an unknown mediator (7,3) and probably a cellular-based reaction (3). This type of ur-ticaria appears 4
hours after the appliance of the physical stimulus and lasts
up to 3 days. The data received from the research of Urticaria a'pressionem (15.5%) in-cludes both types of pressure
urticaria reactions. It has to be taken into account that the
delayed type pressure urticaria very often combines with
other forms of chronic urticaria; with IU (10), with cold 2% and with cholinegic - 11% (1), as well as with delayed
dermographism (1,5).
The cold urticaria is described as inherited (16) or acquired
(24). It can be associated with cryogobulinemia (20), associated with vasculitis (6) or virus infections (4).
The solar urticaria is among 4% to 5.3% of the cases of the
photodermatoses (25), more often associated with atopy. It is
viewed as an IgE mediated reaction, caused by photo allergens with various length of the waves (21) or by nonspecific
photo allergens as photo protection or anti-microbic means,
fragrances, medicaments as promethazin, chlorpromazine.
With the etiology of the CNU considerable importance
have the chronic infections, autoimmune diseases and different physical stimuli (cold, pressure, physical exer-cises,
sun light). The detail clarification of the causes of the urti-
Etiology of Chronic Non-allergic Urticaria
caria in every single case determines the suitable and adequate methods and possible therapy.
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Copyright © Medical University, Varna
Burulianova I., V. Konstantinova*, V. Dokov*
Department of Forensic Medicine, Department of General and Clinical Pathology, Varna Medical
Reviewed by: Assoc. Prof. D. Radoinova, MD, PhD
Studies on the potential role of agents in SIDS have been published over the years in a variety of journals and
involved specific micro-organisms, sleeping position, dysfunction of the central nervous system, damaged
arousal reflex cigarette smoking, lower socioeconomic way of life, specific age. Although, there aren't criteria
to established specific risk factors. SIDS still remains unexplained in spite of thorough case investigation, including complete autopsy, examination of the death scene and review of the clinical history.
Our humble contribution to this problem included 12 sudden death cases in babies from 20 days to 1 year. We
may place our cases in the group of unexpected explained death, because the main cause of death in most babies is pneumonia. The histological changes in lungs were microhaemorrhages in alveoles and interstitium,
congestion, oedema, pulmonary emphysema, atelectases, haemosiderin-laden macrophages, bronchitis and
catharral-desquamating pneumonia or catharralhaemorragic pneumonia, but in two cases there were a purulent pneumonia.
In conclusion most authors consider no laboratory or pathological tests to establish a diagnosis of SIDS and no
lesions are found at autopsy in most cases. Hovewer, as recent reports pointåd out, the affected infant would
not be perfectly well before death. Most authors pointed the histopathological changes in lungs that we established and pointed above.
Studies on the role of agents in SIDS have been published in
a variety of journals. The articles in this issue examine evidence for the involvement of specific micro-organisms,
sleeping position, dysfunction of the central nervous system,
histopathological changes in lungs, heart, damaged arousal
reflex, cigarette smoking, lower socioeconomic way of life,
specific age. Although, there aren't criteria to established specific risk factors and morphological characteristics. SIDS still
remains unexplained in spite of thorough case investigation,
including complete autopsy, examination of the death scene
and review of the clinical history.
Definition and risk factors
Sudden infant death syndrome /SIDS/ is a postmortem
medical diagnosis which stands on a "negative autopsy".
The relative large concentration of deaths in the perinatal
period and infancy and the need to provide explanation for
parents might suggest that clinicians frequently turn to pathologists for information of postmortem examination (5).
Address for correspondence:
Irina Burulianova, Department of Forensic Medicine, Medical University Prof. Dr. Paraskev Stoyanov, 55 Marin Drinov St, BG-9002
e-mail: [email protected]
Sudden death in babies was first reported in London - 1913
year, but the term SIDS was defined iin 1969 at the Second
International Conference as "the sudden death of any infant
or young child, which is unexplained by history, and the
thorough post-mortem examination fails to demonstrate an
adequate cause of death"(3). After 1992 year SIDS is on the
second or third place among leading death causes in babies
between one month and one year. The peak is between 2
and 4 months. There is a seasonal distribution (in January).
Prof. Zekov's investigation revealed that the most babies
died after midnight, particularly in the motning about 4-5
a.m.(1). The upper age limit was defined one year (23).
There are more than 120 different theories on the possible
causes of SIDS. Bed sharing is a very interesting issue. US
study established 64 death cases in babies between a month
and 2 years when they sleep with their mother and father.
Some researchers think that there is any survival advantage
to a baby sleeping with his/her mother. There is an incredible
amount of interactions between two - more arousals (waking
up during the night) of both mother and baby when they
sleep together. Arousal may be an important mechanism to
rescue babies from potentially dangerous situations during
sleep. Dr Fleming believes that it is usually the baby who
wakes the mother not back to front. However, there are not
scientific studies to confirm bed sharing. Some investigations revealed damaged arousal reflex and the babies wasn't
Burulianova I., V. Konstantinova, V. Dokov
able to wake up when arose the problems in breathing, heart
rate, blood pressure and tempereture. Matturi L. at al revealed changes of the neuronal population of medullary arcuate nucleus in SIDS victims.(16). Severe hypoplasia were
established in 30% of the babies morphometrically in this
nucleus. Concerning interleukins, IL-I may cause sudden infant death by depressing brainstem neurons important for the
control of ventilation. In a Norwegian study, cerebrospinal
fluid levels of IL-6 were higher in infants dying of SIDS than
in infants dying violently, but lower than in infants dying of
infectious diseases.
Disfunction of the central nervous system, cardiorespiratory
insufficiency due to infections including atypical immune reactions, and cardiac dysregulation have been discussed during the previous decade. Some authors investigated 387
SIDS cases and established disturbances of the heart after inflammatory diseases of the respiratory tract (70 cases out of
387) (2). Concerning conduction system, Matturri et al. carried out a systematic investigation of this system in 69 SIDS
cases and found no significant differences except for the
presence of resorptive degeneration (in 97% of SIDS cases
compared to 75% of the controls) (17). Dettmayer's study revealed enteroviruses in 22,5%, adenoviruses in 3,2%, Epstein-Barr viruses in 4,8% and parvovirus B19 in 11,2%
SIDS cases (all SIDS cases were 62). Control group samples
were completely virus negative. Applying a comprehensive
combination of molecular and immunohistochemical techniques, their results demonstrate a clearly higher prevalence
of viral myocardial affections in SIDS (9).
There are many articles which have reported about relationship between SIDS and sleeping position. The recent drastic decrease in the number of SIDS cases has been associated with infant sleeping supine instead of prone (15).The
prone position are related with increased risk of SIDS
(10,11,13). In public health review from Sweden
epidemilogical research has shown that prone sleeping is
major risk factor for sudden infant death syndrome (12).
Since 1992 the American Academy of Pediatrics has recommended that infant has to be placed on his back in order
to reduce the risk of sudden infant death syndrome. Since
then , the frequency of prone sleeping has decreased from
about 70% to approximately 20% of US infants and
SIDS-rate - by more than 40%. The reason of death is unknown, but the mechanism is similar like suffocation in soft
materials(cot death).
There are several potentially risk factors - maternal smoking, low socioeconomic position, more black babies and
male sex, the importance of soft bedding and covered airways. Some researchers from New Zealand also found in
their epidemiological studies that bed sharing and cigarette
smoking is associated with a marked increased risk for
SIDS. Cigarette smoking induces nitric oxide production
and retards hypothalamic development by augmented
apoptosis. Fetal haemoglobin induces hypoxia wich is a
stimulator of the immune response, while vasodilatator
gases (CO and NO) reduce hypothalamic function. Hypothalamic failure elevates blood pirogens, induces toxic
shock - a feature of SIDS (19).
Infection is not a new idea, but in 2002 (Emma Ross in the
European congress of Clinical microbiology and infectious
diseases in Milan) is the first time that E.coli was found in
the blood of all SIDS babies. There were significant correlation between endotoxin levels in blood and the various
organs particularly in SIDS cases and child controls and
blood endotoxin levels in SIDS cases were higher in those
infants where there was histological evidence of mild to
moderate inflammation (6). If bacterial toxins are involved
in precipitating SIDS, the possibility of passive immunisation or earlier immunisation of infants with low levels of
antibodies to the toxins might reduce further the numbers of
these deaths (4). There is a considerable evidence suggesting that respiratory viral infection is involved in the genesis
of the sudden infant death syndrome with rates of about 20
% of SIDS victims compared to about 13 % of controls.
Most of the viruses were obtained from children between 3
weeks and 4 months of age (21). Neonatal immaturity of
both the acute febrile response and hypothalamus promote
neonatal protection from SIDS.
Reid (18) poited out that SIDS are associated with serious
pathological changes - elevated hepatic iron, bone marrow
hyperplasia, hypomyelinated respiratory control centres, elevated lung immunoglobulins, cerebral hypoperfusion resemling lesions induces by chronic hypoxaemia,
ischemia, congenital heart disease and congenital
myopathy. Nitric oxide and adenosine are additive as
dilators of coronary blood vessels. Blood pressure collapses. NO binds to cytochrome oxidase inhibiting respiration. When NO reaches dangerous levels, the cell turns on
production of heme oxygenase. Heme is broken down to
iron, carbon monoxide and bile pigments. NO has a huge
affinity for hemoglobin which catalyses NO degradation to
nitrate. Futhermore, NO is a product of smoke and SIDS incidence is higher in smoking mothers. The mixture of exhaled air and the fresh air during sleep (state with carbon dioxide contamination) can be associated with hypoxia and
apnoea and this apnoea can provide an explanation for
some cases of SIDS(6).
Our results
Our humble contribution to this problem included 12 sudden death cases in babies from 20 days to 1 year. We may
place our cases in the group of unexpected explained death,
because the main cause of death in most babies is pneumonia. Only in one of them we have found compound reason
of death - bronchiolitis, pneumonia and meningitis and in
one baby- only meningitis purulenta. The histological
changes in lungs were microhaemorrhages in alveoles and
interstitium, congestion, oedema, pulmonary emphysema,
atelectases, haemosiderin-laden macrophages, bronchitis
catharralhaemorragic pneumonia, but in two cases there
were a purulent pneumonia with the areas of abscedent
pneumonia in one of them. We found these changes also in
the baby with meningitis. Thymic gland has shown a cystic
transformation, diminished number of Hassall's corpuscles
and in one case - a lot of Hassall's corpuscles, but with cys-
Sudden infant death syndrome - the cause of death
tic degeneration and associated phagocytosis by
macrophages ("starry-sky" spaces) - these features are the
marks for acute or accidental involution. In one baby there
was a third type of thymic hyperplasia with prominent cortical zone (this type is a common feature for sudden respiratory death. In one case we established cytomegalovirus infection. We didn't observed seasonal variation.
Most authors consider no laboratory or pathological tests are
available to establish a diagnosis of SIDS and no lesions are
found at autopsy in most cases. Hovewer, as recent reports
pointåd out, the affected infant would not be perfectly well
before death(23). Some authors (22) insisted that hemosiderin-containing macrophages in SIDS cases would be a hallmark of repeated "near-miss" episode that produced pleural
petechiae. They pointed out that the age of death of the babies with pulmonary hemosiderin-laden macrophages but no
evidence of pulmonary inflammation was predominantly between 1 and 3 months. The increase of the alveolar
macrophages could be merely a result of small, but frequent
episodes of aspiration. More late investigation revealed that
higher macrophage counts observed in non-SIDS cases and
those with SIDS - average or below average macrophage
count (8). Other insisted that the siderophages are not increased in SIDS and unexplained pulmonary siderophages
can be a marker for trauma or repeated hypoxia/asphyxia
(20). Severity of pneumonia is one of the most worrisome
problem to make a diagnosis of sudden death. It would be
somewhat subjective and there is no pathological standart to
classify whether the lesion is morbid enough to be a cause of
death. Some authors revealed that proximal and distal tracheal chronic inflammation was less severe in the SIDS
cases than in the control cases and are neither a cause of
SIDS, nor a specific marker for lethal respiratory infection in
infants (24). Clinical experience indicates that interstitial
pneumonitis or bronchiolitis sufficiently severe to cause
death is preceded by clinical illness with signs of lethargy,
tachypnea, respiratory distress, feeding difficulties and/or
apnea (14). Most authors pointed the following
histopathological changes in SIDS: pulmonary congestion,
oedema, microhaemorrhages, increase of alveolar
macrophages, atelectasis, emphysema, bronchitis and pneumonia. These findings are the most often features in almost
all our babies. In Shu's work (21) the majority of the cases of
SIDS (60%) died in the autumn and winter months. The
same in Valdes-Depena's work (23)- in January are the most
death cases. Decrease in the number of SIDS cases has been
associated with infant sleeping supine instead of prone.
1. Unique death distribution with the majority occuring
between 2 and 5 months of age (1week to 1 year).
2. Excessive number of deaths during the winter months.
3. Higher death rates among blacks and male infants.
4. Mother who usually are of a lower socioeconomic
status, predominantly young and with limited
education, sometimes unmarried.
5. Frequently they used legal - tobacco and alcohol before,
during and after pregnancy and illegal drugs.
6. Most authors pointed the following histopathological
changes in SIDS: pulmonary congestion, oedema,
microhaemorrhages, increase of alveolar macrophages,
atelectasis, emphysema, bronchitis and pneumonia.
Based on author's experimental, epidemiological, pathological and pathophysiological, we may conclude that
SIDS include combination of factors:
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pyrogens, Source Med.Hypotheses, 2000 01, 54: 1,
20. Schluckebier, D et al - Pulmonary siderophages
and unexpected infant death, Am J For. Med.Pathol,
vol.23, No 4, Dec 2002, 360-363 278 (1993)
21. Shu F. et all - Role of respiratoty viral infection in
SIDS: detection of viral nucleic acid by in situ hybridization, Journal of Pathology, vol.171: 271-278
22. Stew art, S. Fawcett, J. and Ja cob son, W. - Interstitial haemosiderin in the lungs of SIDS : A
histological hallmark of "near-miss "episodes ?,
J.Pathol, 145, 53-58, 1985
23. Valdes-Depena, M - A pathologist's perspective
on the sudden infant death syndrome -1991. Pathol.
Ann, 27:133-164, 1992
24. Yasuhiro Aoki -Histopathological findings of the
lung and trachea in Sudden Infant Death Syndrome
Review of 105 cases, autopsied at Dade County Medical Examiner Department, Jpn J Legal Med, 48(3),
141-149, 1994
Scripta Scientifica Medica, vol. 40 (2008), pp 175-176
Copyright © Medical University, Varna
Burulianova I., V. Konstantinova*, D. Radoinova
Department of Forensic Medicine, Department of General and Clinical pathology*, Varna Medical
Reviewed by: Assoc. Prof. D. Radoinova, MD, PhD
The clinical manifestations of methanol poisoning have been
the subject of several review articles over the past forty years
(2, 11), though detailed postmortem pathologic studies are
relatively few. The earliest autopsy studies on methanol poisoning have emphasized the acute changes secondary to
hypoxic or ischemic injury to the gray matter, cerebral oedema and acute neuronal injury. Postmortem studies of individuals, who survive intoxication several days or weeks have
shown brain injury characterized by bilateral putamen necrosis, particularly affecting the lateral portions of the nuclei
(1,10). In some of the cases there has also been a dramatic
pattern of white matter hemorrhagic necrosis, involving the
centrum semiovale, especially affecting subcortical regions
/10/. The precise mechanism of methanol toxicity remains a
matter of debate /2/. The observed lesions represent direct
toxic effects of methanol and its metabolities and injury, secondary to anoxia and acidosis. Injury to the putamen likely
represents a selective toxic effect, possibly potentiated by
poor venous drainage. The pathogenesis of the white matter
hemorrhagic necrosis remains unexplained /6/.
The aim of this study was to examine morphological
changes in the internal organs in methyl alcohol poisoning
cases. The records of the Forensic Medicine Department in
Varna Medical University were reviewed retrospectively for
20-years period - from 01.01.1986 to 01.01.2006. There
were 16 methanol poisoning from 8028 autopsies or 0,2%.
The victim's sex was mainly male -14 men (87,5%) and only
2 woman (12,5%). The age of men varies from 30 to
66-years, woman are 50 and 52-years old. The content of
methanol in blood varies from 0,104 %o to 3,05%o in 52-old
woman. We performed microscopical examinations in 7
cases (43,75%), in which there were blocks on disposal.
Address for correspondence:
Irina Burulianova, Department of Forensic Medicine, Medical University Prof. Dr. Paraskev Stoyanov, 55 Marin Drinov St, BG-9002
e-mail: [email protected]
There were cerebral perivascular and pericellular oedema,
congestion, severe degenerative changes in most cases,
particularly around vessels (in one case there were focuses
of encephalomalacia), arteriolar hyalinosis in some vessels
(in most cases). There was a loss of Purkinje cells in the cerebellum in one case and pseudocystes in other case. The
histological changes in lungs were: microhaemorrhages in
alveoles, congestion, oedema, pulmonary emphysema,
atelectases, haemosiderin-laden macrophages. Microscopical changes in the myocardium include interstitial oedema,
congestion, myocardiofibrosis, focal lipomatosis,
hyalinosis in the arterioles. The most prominent changes
were in liver-different kind of fatty degeneration, hydropic
degeneration, hyperemia, intrahepatal cholestasis,
hyalinosis of the arterioles. We found severe renal tubular
degeneration in kidney, capilary dilatation and congestion.
There was congestion in the other organs.
Our results showed that the most frequent changes were:
fatty degeneration in liver, intrahepatal cholestasis, cerebral
oedema, degeneration around brain vessels, hyalinosis, interstitial oedema, lipomatosis, congestion in the myocardium,
renal tubular degeneration, microhaemorrhages in alveoles,
haemosiderophages, pulmonary oedema, emphysema,
atelectases. Most authors revealed the same changes. Except
these histological changes, they investigated putamen,
caudate nucleus, pontine tegmentum and optic nerves and
found necrosis and haemorrhages (3,4,7,8,9). Retinal damage is believed to be due to the inhibition of retinal
hexokinase by formaldehyde an intermediate metabolite of
methanol. In one case we observed pseudocysts in brain. The
same were Mc Lean's results (5). Autopsies revealed cystic
resorbtion of the putamen and the frontocentral subcortical
white matter in addition to widespread neuronal damage
throughout the cerebrum, cerebellum, brainstem, spinal cord.
In one our case there was the loss of Purkinje cells in the cerebellum. We haven't blocks of optic nerves, putamen,
caudate nucleus and pontine tegmentum. We also estab175
Burulianova I., V. Konstantinova, D. Radoinova
lished degeneration in the parietal area of the brain. Mittal et
al. observed degeneration in the parietal cortex in 85,7% of
cases, but putamental degeneration and necrosis in 7,14%
We didn't meet in literature explaining of the cholostasis.
Maybe the mechanism is severe degeneration of the liver
cells. According Mittal (7) liver fatty degeneration was
seen in 67,8% and microvesicular fat in hepatocytes-in
Betta P.G. Forno G (1988) Necrosi emorragica del
putamen da intossicazione acuta da alcool metilico.
Pathologica 80: 215-218.
Bruyn G.W., AL-Deeb S:, Vielvoye
G.J.(1994) Methanol intoxication. In: Handbook of
Clinical Neurology, Vinken PJ, Bruyen GW, Vol 64,
pp 95-106, Eslevier: Amsterdam
Gaul, HP, Wallace CJ, Auer RN, Fong TC
-MR findings in methanol intoxication, Am J.
Neuroradiol., 1995, 16, 1783-1786
Kaye, S.-Insidious methyl alcohol poisoning, Virginia Med. Monthly, 1958, 85, 670.
5. Mc Lean DR, Jacobs H, Mielke BW - Methanol
poisoning: a clinical and pathological stugy.
6. Menne FR et al- Final diagnosis - methanol poisoning, Ann.Neurol, 8: 161-167
7. Mittal BV, Desai AP, Knade KR - 28 fatal out
of the 97 cases of methylalcohol poisoning,
J.Postgrad.Med. 1991, 37, 9-13.
8. Ravichandran RR, Dudani RA, Almeida AF,
Chawla RP, Acharya VN - Methylalcohol poisoning ( Experience of an outbreak in Bombay),
Am.J.Neurol., 1984, 30, 269-274)
9. Sharma HS -Methyl induced optic nerve cupping,
Arch.Ophthalmol., 1999, 117:286-287
10. Suit PE, Esstes ML (1990) Methanol intoxication:
clinical features and differential diagnosis. Cleve Clin
J Med 57:465-471
11. Schneck SA(1979) - Methyl alcohol. In: Handbook
of Clinical Neurology, Vinken PJ, Bruyn GW, Vol
36, pp 351-360, Eslevier:Amsterdam
Scripta Scientifica Medica, vol. 40 (2008), pp 177-178
Copyright © Medical University, Varna
Dokov W. V.
Department of Forensic medicine, Prof. Paraskiev Stoyanov Medical University of Varna
Reviewed by: Assoc. Prof. D. Radoinova, MD, PhD
Introduction. Electrotraumatism (ET) is rare to observe, but it presents a significant problem both for public
health and forensic medicine. Purpose. The purpose of this study is to identify some features and circumstances typical of ET on the territory of Varna District. Material and methods. Forensic medicine documentation has been examined from 16,780 autopsies for the period 1965-2005 performed at the Chair of Forensic
Medicine and Deontology, the Medical University of Varna. The results have been processed by the statistical
methods of alternative, variational and graphical analysis. Results. Over the 41-year-long period, a total of
280 ET autopsies have been performed, which accounts for 1.67% (ð±D1,5) of all autopsies. Lethal injuries by
electric current typically occur in young age. Young males prevail. More than half of the events have been domestic ET. In the studied group, the number of accidents caused by high voltage is about the same as the number of accidents caused by low voltage. Suicide by electric current is relatively rare. A forensic medicine
expert participated in 99 (62.26% ð±D9.55) of the inspections on the scene of accident. Conclusions. ET affects
mainly young males in domestic ÅÒ.
Keywords: Electro-traumatism, Varna District
Electrotraumatism (ET) is rare to observe, but it presents a
significant problem both for public health and forensic
medicine. Its relatively low incidence is not conducive to
major studies due to which there are scarce data on this
problem in literature. This prompted us to undertake the
present study.
The purpose of this study is to identify some features and circumstances typical of ET on the territory of Varna District.
Over the 41-year-long period, a total of 280 ET autopsies
have been performed, which accounts for 1.67% ( ð±D1.5)
of all autopsies. The average age of the deceased from ET is
35.47±2.91 years, within the scope of 1 to 83 years. Male
gender prevails over the female with 242 (86.43%
ð±D4.22) to 38 (13.57% ð±D9.39). The difference in the
relative share between males (M) and females (F) is statistically reliable (p<0.001).
F 31,57%
Ì 86,43%
Forensic medicine documentation has been examined from
16,780 autopsies for the period 1965-2005 performed at the
Chair of Forensic Medicine and Deontology, the Medical
University of Varna. The results have been processed by
the statistical methods of alternative, variational and graphical analysis.
Address for correspondence:
W. Dokov, Department of Forensic Medicine, Medical University
Prof. Dr. Paraskev Stoyanov, 55 Marin Drinov St, BG-9002 Varna,
e-mail: [email protected]
Fig. 1 Distribution by gender of the deceased from
More than half of the cases are domestic ET (DET): 160
(57.14% ð±D7.67), and about 1/3 are labour-related
electrotraumas (LET): 86 (30.71% ð±D9.75). Suicides
Dokov W. V.
(SC) by electric current are relatively rare to observe: 17
(6.07% ð±D11.35)
In 18 cases (6.43% ð±D11.33), there are no data about the
type of the accident on inspection or the autopsy (N/A).
Not Data
these, we could not agree more with the recommendations
given by Nursal TZ, et al (2003 ) according to whom prevention, public discussion of the problem and strict observance of the rules when distributing electric power would
notably reduce this type of traumatism.
While the data given by Celik A, et al (2004) point to a
prevalence of injuries due to electric current of high voltage: 63%, our results show a relatively even distribution of
the cases either of high or low voltage. At the other end of
the scale are the data given by Byard RW(2003): a very rare
occurrence of accidents caused by high voltage.
Our study brings forth a question of pressing interest about
the effectiveness of the process of diagnostics and expertise
in relation to the data from the inspection of the accident
scene. The relatively high percentage of cases (37.74%)
where a forensic medicine expert was not present on the inspection point to feasible opportunities to increase the
speed and quality of expert activities in this direction.
Fig. 2 Structure of ET depending on the type of
Injuries caused by low voltage (<220V), 93 (33.21%
ð±D9.57), and by high voltage (>220V), 91 (32.5
ð±D9.62), are approximately the same number without a
significant difference (ð> 0.5). In 96 cases (34.28 ð±D9.49)
there are no data about the voltage of the electric current at
the beginning of the expertise, which impedes the diagnostic process.
A large part of information significant for the forensic-medical diagnosis and expertise can be ascertained as
soon as the scene of accident is inspected. Forensic-medical
expert participated in 99 inspections (62.26% ð±D.55) out
of a total 159 cases studied by us, but quite a few, 60
(37.74% ð±D12.27), were performed in his absence.
Electrotraumas account for 3.1% (1) respectively 5% (3),
5.1% (5) up to 21% (4) of all cases of burns. Our data have
revealed that ET is observed in 1.67% of all autopsies after
violent or non-violent death.
Our study has discovered a characteristic age-related peculiarity. ET affect mainly young people (õ=35.47±2.91
years) of working age. There is a peculiar distribution of the
cases by gender. We have ascertained that males are mainly
affected (86.43% ð±D4.22). Similar results are reported by
Nursal TZ, et al (2003) and Celik A, et al (2004) according
to whom males are affected in 67% or 95% of the cases, respectively.
The results of our study show that the prevailing part of ET
are domestic or labour-related accident. With results like
Fatal injuries due to electric current are typical of young
There is a prevalence of persons of male gender.
More than half of the cases result from domestic
The injuries due to high or low voltage current are distributed approximately evenly by number in the group under
Borisov VG, Kashin IuD, Oliunina NA. Deep
electrothermal burns Khirurgiia (Mosk). 1995;6
Byard RW, Hanson KA, Gilbert JD, James
RA, Nadeau J, Blackbourne B, Krous HF.
Death due to electrocution in childhood and early adolescence. J Paediatr Child Health. 2003 ;39(1):46-8.
Celik A, Ergun O, Ozok G. Pediatric electrical
injuries: a review of 38 consecutive patients. J
Pediatr Surg. 2004 ;39(8):1233-7.
Nursal TZ, Yildirim S, Tarim A, Caliskan K,
Ezer A, Noyan T. Burns in southern Turkey: electrical burns remain a major problem. J Burn Care
Rehabil. 2003 24(5):309-14.
Henckel von Donnersmarck G, Muhlbauer W,
Herndl E, Schmidt A. Reconstruction of the cranial vault and soft tissues of the skull after
electrotrauma Langenbecks Arch Chir Suppl II Verh
Dtsch Ges Chir. 1989;:847-51.
Scripta Scientifica Medica, vol. 40 (2008), pp 179-181
Copyright © Medical University, Varna
Zlateva S., M. Iovcheva, Marinov P.
Department of Toxicology, Naval Hospital- Varna
Reviewed by: Assoc. Prof. V. Ikonomov, MD, PhD
An analysis of the lethality in cases of acute exogenous intoxications /AEI/ with organophosphate pesticides
/OP/ in Varna region for a period of 15 years -1991-2005 was done. It was established that from 207 patients
with acute OP poisonings there were 40 lethal cases. The frequency of the lethal cases was 19.32%. 28 / 70%/ of
them were men and 12 /30%/ were women. The lethality was significantly higher in men. The proportion of lethal cases in men and women was 2.33: 1. The average age of deceased patients was 59 years. It was reported
that with growing up of the age the average lethality had grown bigger too. All the lethal poisonings were by an
oral ingestion. In 35 cases /87.5%/ suicidal attempts were done and in 5 cases /12.5%/ accidental household
poisonings took place. The main reason about the death was a development of syndrome of multiorgan insufficiency /SMOI/.
Keywords: acute intoxication, organophosphorus pesticide, lethality
The widespread use of OP and their significant toxicity determine the high frequency of intoxications in some countries. /8,19, 22, 24/. During recent years in Varna region the
relative share of OPAEI has grown smaller. /3/. The hospital lethality from these intoxications varies in different studies and is in the range within 20% and 25%. /1,11,12,18,
23,26/.OP are the cause of 10% to 46% of the lethal cases
of all acute intoxications /10,21/. Although the highly toxic
substances were replaced by less toxic OP pesticides and
more contemporary methods of treatment had been introduced the acute OP poisonings continue to have a high lethal rate and represent one of the most serious problems of
the nowadays clinical toxicology. /5,20/. Some omissions
in the first medical aid also contribute to this fact. /4/.
In this relation we have put ourselves a task to study the
lethality from AEI with OP in Varna region during the period 1991-2005 in order to establish the frequency of the lethal outcomes, to analyze the lethality according to sex,
age, years, type of the pesticide, relative part of different
pesticides in the death rate, and also the concrete reasons
for the lethal exit.
Address for correspondence:
Snezha Zlateva, Clinic of Toxicology, Military Medical Academy,
Naval Hospital, Varna,
E-mail: snezha [email protected]
A retrospective study of the hospital case files and the forensic protocols of the autopsies of all 40 patients with lethal outcome previously treated at the Department of Toxicology, Naval Hospital-Varna.
207 patients with acute OP intoxications were treated at the
Department of Toxicology, Naval Hospital-Varna, during
the examined period. Lethal outcome was registered in 40
cases /19.32%/. This frequency corresponds to the frequency shown in the specialized literature in many researches. /1,11,12,18,23,26/. The analysis of the lethality
by years showed significant variances. In 2001 there were
no lethal cases, but there were only 2 patients with OP poisonings during this year. The highest death rate was registered in 1992- 33.3 %, when 21 patients with OP intoxications were treated at the Department of Toxicology.
OP poisonings were the cause of lethality in 25.24% of the
total death rate from acute intoxications. In 28 lethal cases
/70%/ the patient was a man and in 12 lethal cases /30%/ - a
woman. The death rate of male patients was significantly
higher than that of female patients- 2.33: 1. These results
are due to the fact that OP AEI are more frequent in men
than in women /3,5/ as well as to the fact that usually suicidal attempts in men are more grave and lead to more serious poisoning. The distribution of the patients with lethal
OP poisonings according to the age showed lowest death
rate in the age group of young patients / younger than 24
Zlateva S., M. Iovcheva, Marinov P.
years/ and highest in the age group of patients over 60
years. /Table 1/
The main cause of death was development of a syndrome
of multiorgan insufficiency /SMOI/.
Table 1. Distribution of the lethality from OP acute
intoxications according to the age group
Table 3. Causes of death in OP acute exogenous
Age group
Total number
of treated OP Lethal cases
Number of lethal
Syndrome of multiorgan
82.5 %
Heart rhythm disorders
10.0 %
Intermediary syndrome
5.0 %
Myocardial infarction
2.5 %
100 %
Cause of death
Under 24 years
25- 44 years old
7.32 %
45- 60 years old
20.83 %
Over 60 years
30.43 %
Total number
19.32 %
The average age of the deceased patients was 59 years. It
makes an impression that with the growing of the age the
death rate is increasing too. This fact can be explained with
more severe clinical course of the intoxication and less
adaptive potential of the elder patients, a result of existing
serious co morbidity which weakens the resistive and reparative potential in the course of the OP poisoning and
which can undoubtedly influence the clinical course and
outcome of the poisoning.
Lethal outcome from OP poisoning with 5 different OP
pesticides was registered. In one case the type of OP pesticide could not be established. /table 2/. The prevailing part
of the death cases was caused by Dimethoate /Bi-58/- an
OP pesticide with middle toxicity. These results are due to
banishment of the highly toxic and dangerous OP pesticides as Parathion, Intrathion, etc. in Bulgaria and to the
widespread use of Dimethoate in our country nowadays.
Table 2. Relative part of different OP pesticides which
had led to lethal acute exogenous OP intoxication.
In practice the syndrome of multiorgan insufficiency was
the cause of death in 37 cases /92.5 %/. Each of the patients
who had died from immediate cause of death rhythm disorder had clinical data about SMOI as well. With the introduction into use of contemporary methods and means of reanimation and intensive treatment permitting elongation of
the life or survival of the critically ill the OP poisonings
lead to the development of typical symptoms of multiorgan
disorders and multiorgan failure which consequently can
cause the death of the patients. /2,6,9,27/. The lethality of
the patients with SMOI grew from 8.3 % to 100 % with the
increasing of the number of the involved organs and systems with insufficiency. /2/. In two cases the death occurred
after a peripheral type of paralysis of the respiration - development of intermediary syndrome. In one case the immediate cause of death was an acute myocardial infarction in a
patient with coexisting ischemic disease of the heart, on the
eighth day of the intoxication, on the background of slow
restoring of the cholinesterase activity.
Number of the
lethal cases
82.5 %
7.5 %
Nurele D
2.5 %
2.5 %
2.5 %
Not identificated
2.5 %
100 %
OP pesticide
All the described lethal OP poisonings took place after an
oral ingestion of pesticides. 35 cases /87.5 %/ were suicidal
attempts and 5 cases / - accidental household poisonings.
The oral ingestion of a pesticide , especially when done with
a suicidal purpose , leads to a massive entry of great quantity
pesticide in human organism and consequently- to more severe clinical course of the intoxication and high death rate.
We consider that OP acute exogenous intoxications continue to be a serious test for the doctors- toxicologists as
they quite often end with lethal outcome. We establish
lethality of 19.32 %. This relatively high death rate is due to
the severe forms of intoxication - a result mainly of suicidal
attempts with oral ingestion of great quantity of OP and
high average age of the intoxicated. The death rate was
higher in male patients than female. The proportion male to
female patients was 2.33: 1. We report that with the growing of the age the lethality is increasing too. The main cause
of lethal outcome was the development of a syndrome of
multiorgan insufficiency.
Ëóæíèêîâ Å. À., Ë. Ã. Êîñòîìàðîâà. Îñòðûå
îòðàâëåíèÿ, Ìîñêâà, Ìåäèöèíà, 1989.
Lethality from acute intoxications with organophosphate pesticides in Varna region ...
Ìàðèíîâ Ï., Ò. Òàøåâ, Ì. Àñïàðóõîâà.
Ñèíäðîì íà ìíîãîîðãàííà íåäîñòàòú÷íîñò ïðè
îñòðè åêçîãåííè èíòîêñèêàöèè ñ
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Ìàðèíîâ Ï., Ò.Òàøåâ, Þ.Ñúáåâà è äð.
Åïèäåìèîëîãè÷íè òåíäåíöèè ïðè îñòðèòå
åêçîãåííè èíòîêñèêàöèè ñ ôîñôîðîðãàíè÷íè
ïåñòèöèäè âúâ Âàðíåíñêè ðåãèîí â ïåðèîäà íà
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äð. Àíàëèç íà åôåêòèâíîñòòà íà ïúðâàòà
ìåäèöèíñêà ïîìîù ïðè îñòðè åêçîãåííè
èíòîêñèêàöèè ñ ôîñôîðîðãàíè÷íè ïåñòèöèäè â
äîáîëíè÷íèÿ ïåðèîä âúâ Âàðíåíñêè ðåãèîí.
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ëå÷åíèåòî è ïðîãíîçàòà ïðè îñòðèòå åêçîãåííè
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Scripta Scientifica Medica, vol. 40 (2008), pp 183-185
Copyright © Medical University, Varna
Margaritova V.
Plovdiv University "Paisii Hilendarski"
Reviewed by: Prof. A. Klisarova, MD, PhD, D.Sci
Through psychological preparation physical readiness is formed. Psychological preparedness is a complex
phenomena which is a reflection of the level of preparation of an individual for action in different situations.
For many coaches training is the process of physical preparation, but the end result is also heavily influenced
by psychological factors. In the present work we look at the influence of psychological preparation in the
training of football and karate with pupils of primary school age.
Keywords: Psychological preparation, psychological readiness, training
All human action requires a certain amount of physical and
psychological preparation, and in sport this is even more
true. Sports preparation is a whole system of
inter-dependent and mutually conditional aspects physical, technical, tactical, and psychological. Neglect of
one element in the system has a negative effect on results.
Psychological preparation is an important part of the many
educational-training process. Many scholars regard
psychological preparation simply as a test of separate
psychological qualities or process', but by doing so they fail
to fathom the full essence of the phenomena but only
aspects of it. Psychological preparation is an important part
of the many faceted and complex preparation of athletes
and teams.
According to T. Yancheva (1977) psychological
preparation is a prerequisite and a result of the
educational-training process: a prerequisite because the
effectiveness and quality of the sporting performance and
results depend on the level of physical preparation, because
the sporting level reached has a psychological impact.
Indeed, psychological preparation may be even regarded as
the basis for the development of physical preparation.
Vasilev (1987) separates psychological preparation into
four categories: general, specialized, collective and specific. In his opinion psychological preparation forms the
necessary capacities, will and emotional qualities.
Physical preparation is the second sub-structure of
psychological preparation. Different views on physical
preparation veil its essence.
Address for correspondence:
Valentina Margaritova, Plovdiv University "Paisii Hilendarski", 24,
Tsar Asen Str., 4000 Plovdiv, BULGARIA
e-mail: [email protected]
For many authors physical preparation is a sports-education
process for the many aspects of physical development, for
controlling the motor functions and for achieving a certain
level of physical capability (Kr. Rachev, 1987). In our
opinion physical preparation is a condition and a process:
on one hand is the manifestation of physical development,
physical ability and the functional condition of the
individual; on the other hand the process directed towards
reaching a certain level. Therefore physical preparation is
geared towards creating an adequate level of physical
preparation which consists of physical qualities, condition
and process'. Practical action is realized through physical
preparation. Psychological preparation facilitates physical
In the activity of physical exertion the concept of
psycho-physical is used as a unitary combination of
physical and psychological. In the rich theory of personality
and human activity the term psycho-physical has also
emerged. This development has become possible with the
emergence of new mathematical methods for measuring
and modulating the psychological and motor phenomena
and the discovery of the determinants in their indicators.
Due to the basis attained by science, conditions have been
created for the discovery of new aspects of the concept of
psycho-physical. According to D. Kare (1973) sporting
accomplishments are the result, not only of theoretical and
technical preparation, but also of the psychological
preparation of the competitors. In the process of
self-realization psychological preparation plays a key role.
In the modern hectic and changing times the contents of the
human activity area also changing. Mobility in the modern
individual is lessening, physical activity giving way to
The aim of psychological preparation is formation of
psycho-physical preparedness. If we proceed from the
Margaritova V.
assumption of the unity of internal and external activity in
the structure of the activity we define psycho-physical
readiness as - an integral condition which determines the
unity of physical and psychological preparedness in the
structure of the individuals activity during his adaptation to
changing conditions in his environment for a certain period
of time.
Psycho-physical preparedness is a complex phenomena
which reflects the readiness of an individual to act in
different situations. Through it one may control the actions
and behavior of an individual and to diagnose his level of
preparation to accomplish given aims and tasks.
The structure of psycho-physical preparedness is confined
by models, including the correlation dependence between
separate psychological structures, factors, elements and
components. With the increasing power of inter-relations
between constructive factors, elements and components of
the structure of psycho-physical preparedness an adequate
readiness is formed and in the case of a reduction - an
inadequate one. D. Kaikov (1990) investigated the
complex system of steps of adequate preparedness:
standard, raised, high and highly elevated, and inadequate raised, low, demobilizing.
The object of the research is to pinpoint the effects of the
models created by us on primary coaching in football and
karate on the psychological preparedness of pupils at
primary school.
The study encompassed 127 pupils of primary school age,
who were separated into 5 groups: 3 experimental and 2
On I ÅG (experimental group) - football, II ÅG -karate,
boys and III ÅG - karate, girls, the model constructed by us
was put into effect. I ÊG (control group) girls and II ÊG boys trained by standard methods in different sporting
sections. For concrete comparison data on the differences
constituted we used t-criteria of the student with suitable
guaranteed probability. Analysis of the indicators
characterizing the dynamics of the development of
psychological qualities was carried out on the basis of
quantitative characteristics of the various indicators
reflected in the tables. The dynamics of the development of
psychological qualities in the three experimental groups
will be studied through the following statistical parameters:
average mathematical value of variation, standard
divergence, co-efficient of variation, reliability.
The test, through which the psychological preparation of
the children training football and karate is measured, is
temporal awareness. The higher the awareness the children
have of the passage of time, the higher and more adequate
is their level of preparation.
The research illustrates that as a result of training certain
changes in temporal awareness occur. (Òable 1).
In the given time of 17 seconds, research on the first test
shows time passes quicker by 3.2 sec. in KG I, 2.8 sec. in
KG II and 2.9 sec. in KG III, in comparison with the given
control time. In the second test the accuracy in defining the
time taken improves: with a difference of 1.9 sec. in CG I,
1.5 sec. in KG II, 0.2 sec. in EG I, 0.9 sec. in EG II, and 0.8
sec. in EG III. This difference is due to the special methods
used in the training of the two sport types.
Òàble 1. Indicators in the test for temporal awareness
First Test
Second Test
V Difference
² CG
20,2 5,0 25 18,9 3,8 20
19,6 5,1 26 18,5 3,7 20
² EG
19,5 4,0 20,5 16,8 3,5 21
19,8 4,2 21 17,9 3,1 17
19,9 4,5 23 17,8 2,9 16
The improvement in temporal awareness is one of the basic
factors indicating the level of psychological preparation
and the ability of the children to regulate internal stress in
the process of football and karate training.
From the study of the results of temporal awareness we can
surmise that, as a result of the effects of the model, accuracy
is improved as an element of psychological preparation and
a factor of its improvement and creation of an adequate
level of psychological preparation.
In order to form adequate psychological preparation,
perception also plays a key role. Audience perception is
one of the main factors which define the level of
preparation for action in various situations. In table 2 clarity
level and latent time are presented.
First Research
Indicator Group
² CG
3,40 0,58 17 3,75 0,52 14
II CG 3,50 0,54 15 3,75 0,54 14
² CG 3,50 0,50 14 4,00 0,49 12
II CG 3,25 0,52 16 4,25 0,48 11
III CG 3,75 0,48 13 4,25 0,42 10
² CG
4,5 0,69 15 4,0 0,53 13
4,9 0,62 13 4,5 0,66 15
4,8 0,55 11 3,7 0,52 14
4,3 0,53 12 3,5 0,50 14
III ÅG 4,4 0,50 11 3,5 0,49 14
² ÅG
From table 2 it is obvious that the level of clarity in the
control groups has increased slightly: 0.35 for CG I and
0.25 for CG II. The improvement is greater among the
experimental groups: 0.5 in EG's I and II and 1.00 in EG II.
The latent time has also improved significantly: in CG I
lessening by 0.5 sec., 0.4 sec. in CG II, 0.9 sec. in EG I, 0.8
The Influence of Psychological Preparation on Football and ...
sec. in EG II, and 0.9 sec. in EG III. These changes are a
basic indicator through which one can adjudicate an
improvement in the psychological preparation structure.
One may conclude that a substantial change in
psychological awareness is to be observed in the subjects
studied by us who underwent football and karate training.
Furthermore, the latent time for forming the image has a
significant effect on the clarity of the image (r = - 0,62) (fig.
1). This dependence is significant for the regulation and
optimization of psychological preparation, and thus for the
individuals actions: for heightening the clarity of
perception and imagination it is necessary during training
to shorten the time for forming perception.
2. The applied models for psycho-physical preparation
have a significant effect on the formation of
psychological qualities, improving the value of the
indicators and links between them. In karate the model
has a greater effect on the accuracy of psychological
activity and in football - on speed.
1. To research the effectiveness of the model on students in
higher classes.
2. Tested models to be applied in the football and karate
training systems.
Fig. 1. Inter-dependence in the structure of perception
KEY: Latent time for forming perception; Level of
1. Football and karate are activities linked to a high level
of concentration of physical and psychological effort
for quick and accurate action, determined by adequate
psychological preparation.
Âàñèëåâ, Â. Çà ñúäúðæàíèåòî è ñòðóêòóðàòà íà
ïñèõè÷åñêàòà ïîäãîòîâêà. À. Ïðåãëåä. Ñ., 1987
Êàéêîâ, Ä. Ïñèõîôèçè÷åñêà ïîäãîòîâêà çà
äåéñòâèå â åêñòðåìàëíè ñèòóàöèè. Ñ., 1983
Êàéêîâ, Ä. Ïñèõîôèçè÷åñêà ïîäãîòîâêà çà
çàùèòà íà îòå÷åñòâîòî. Ñ.,1990
Ðà÷åâ, Ê. ÒÌÔÂ. Ñ., 1987
Õàðå, Ä. Ó÷åíèå çà òðåíèðîâêàòà.. Translation
from German. Ñ., 1973
ßí÷åâà, Ò. Ïñèõîëîãè÷åñêî îñèãóðÿâàíå íà
ñïîðòíàòà ïîäãîòîâêà. Ñ.,1997
Scripta Scientifica Medica, vol. 40 (2008), pp 187-191
Copyright © Medical University, Varna
Shishkova A., P. Petrova*, À. Tînev*, G. Iliev*, P. Bahlova, Ogn. Softov, E. Kalchev
Medical center “Medica-Albena” EAD, resosrt Albena, Medical university Varna*
Reviewed by: Assoc. Prof. N. Negrev, MD, PhD
BACKGROUND: Knowledge of body composition in health and disease has been a continuing interest for clinicians, because components of the body often provide more useful information than the whole-body measurements of weight, height, and the derived parameter, body mass index. Bioelectrical impedance analysis
(BIA) is a widely used method to estimate body composition. The technology is relatively simple, quick, and
noninvasive. The porpose of this study was to determine the body composition changes of 11-days clinic-based
weight management program. SUBJECTS AND METHODS: For a period of two years (2004-2005) we studied 519 overweight and obese women (BMI, X ±SD, 32,94 ±6,51 kg/m2). The diagnostic protocol included
antropometric data, body composition analyse with Tanita ® leg-to-leg BIA system (model TBF – 300A), blood
analysis, cardiological, dietological and physiotherapeutical specialist consult. All of patients keep to a
low-calory diet, intensive everyday exercise and physioterapy procedures. The lectures course included of basis nutrition, healthy eathing, long-term exercise programm. RESULTS: Weight loss for the group was 2.57
kg. The fat-mass loss was 1.25 kg, free-fat mass was also decrease 1.31 kg. Reductions in circumferenses of
waist and hip for the group was 3.9 cm and 3.09 cm respectively. Basal metabolic rate was significantly reduced (p < 0.001). Patients had improved some components (total cholesterol, HDL cholesterol, fasting glucose, blood pressure). CONCLUSION: These results support the field use of BIA for estimating changes in fat
mass as it is simple to use, requires minimal training and is used across a spectrum of ages, body weights, and
disease states.
Keywords: bioelectrical impedance analysis, body composition, fat mass
Bioelectrical impedance analysis (BIA) was developed in
the 1960s and has emerged as one of the most popular
methods for estimating relative body fat [1–3]. BIA is relatively simple, quick, portable and noninvasive and is currently used in diverse settings, including private clinicians’
offices, wellness centers and hospitals [4]. Òhe technology
actually determines the electrical impedance of body tissues, which provides an estimate of total body water
(TBW). Using these values of TBW derived from BIA,
fat-free mass (FFM) and body fat may then be estimated.
BIA measures the opposition of body tissues to the flow of
a small (less than 1 mA) alternating current. Impedance is a
function of two components (vectors): the resistance of the
tissues themselves, and the additional opposition
(reactance) due to the capacitance of membranes, tissue interfaces, and nonionic tissues [5].
The standard error of estimate (SEE) or prediction error for
BIA is about 3.5% [3]. There is still debate over whether or
not BIA accurately predicts changes in body composition
during a weight loss program [6]. Published studies are
mixed, with some supporting the accuracy of BIA in detecting FFM and body composition changes [7–9], while
others claim there is substantial over- or under-estimation
when compared to the underwater weighing method [10
–15]. Standardization of the procedures used to obtain BIA
measurements is essential to provide meaningful estimates
of TBW or fatness. In principle, BIA would appear to have
many advantages in collecting these body composition parameters. Measurement of impedance is precise, consistent,
easy to obtain, portable, and relatively inexpensive [5].
Single frequency BIA (SF-BIA), generally at 50 kHz, is
passed between surface electrodes placed on foot-to-foot,
hand-to-hand or hand-to-foot electrodes [16, 17]. Nuñez et
al [18] evaluated a single-frequency 50-kHz leg-to-leg BIA
system combined with a digital scale that uses stainless
steel pressure-contact foot pad electrodes. This leg-to-leg
BIA system is functionally different from other BIA systems, which require the use of arm and leg electrodes and
separate measurement of body weight. Data from Nuñez et
al [18] indicated that pressure-contact electrodes provided
impedance measurements and body-composition stimates
that were comparable with those obtained with use of conventional gel electrodes, and offered the advantage of increased speed and ease of measurement.
In most studies evaluating the use of BIA in monitoring
changes in the body composition of obese subjects, subject
numbers were small, very-low-energy diets were used, and
changes in fat-free mass were below the SEE of the BIA
Shishkova A., P. Petrova*, À. Tînev ...
method [10–14, 19-23]. In no studies were subjects randomly
assigned to moderate energy restriction, exercise and
physiotherapeutical procedures as is typical in
multicomponent clinic-based weight-management programs.
This study had 2 objectives: to determine the validity of the
leg-to-leg BIA system in 1) estimating body composition in
obese and overweight man and women and 2) assessing
changes in body composition in these patients after 2 wk
multicomponent clinic-based weight-management programs.
In addition, standardized testing procedures must be followed. Although the relative redictive accuracy of the BIA
method is similar to that of the skinfold method, BIA may
be preferable for the following reasons: (a) the method does
not require a high degree of technical skill, (b) the method is
more comfortable and less intrusive for the client, and (c)
this method can be used to estimate body composition of
obese individuals (31). Recently, less expensive, segmental
bioimpedance analyzers have been marketed. The Tanita®
analyzer measures lower-body resistance between the right
and left legs as the individual stands on the electrode plates
of the analyzer
Subjects and Research Design
Overweight and obese women (n = 519) with no overt disease were take part of weight management program. Subjects were recruited according to these selection criteria obtained from a pre-study medical history questionnaire: 1) in
good health and with no known diseases including cancer,
diabetes and coronary heart disease, 2) pre-menopausal
women, 3) a body mass index (BMI) between 25 and 55
kg/m2, 5) not currently on a weight loss diet and weight stable within 5% of body weight over the past year, 6) less
than 30 minutes of moderate-to-vigorous exercise a day
and 7) not experiencing any pain that would interfere with
full participation.
All subjects were prescribed an energy-restriction diet, exercise program and physiotherapeutical procedures for 2
weeks, with body composition and nutrient intake measured pre-study and after week 2.
Laboratory Procedures
After an overnight fast, subjects came from hotel to the laboratory (~ 200m) at 8,30 AM. For determination of blood
parameters, blood was drawn via an antecubital vein into a
serum tube or in a tube filled with EDTA. Laboratory parameters: hemoglobin, blood glucose levels, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, were determined in a certified laboratory using standard methods.
Height and weight was obtained using a mobile combinat
stadiometer-digital balance (model 225; Seca, Hamburg,
Germany). Fat distribution was investigated by measuring
the waist and hip circumference and calculating the waist to
hip ratio (WHR).
The waist circumference was measured at the smallest circumference between the rib cage and the iliac crest with the
subject standing. The hip circumference was measured at
the widest circumference between the waist and the thighs.
The WHR was calculated by dividing the waist circumference by the hip circumference.
Body composition
In the first day of the weight management program, and the
last week of the 2-wk study, the body composition of all
obese subjects were assessed. In order to ensure the predictive accuracy of these equations, clients must strictly follow
each of the BIA Testing Guidelines. Before testing, subjects were required to adhere to these BIA testing guidelines (3): 1) to not eat or drink within 4 h of the test, 2) to
maintain normal body hydration, 3) to not consume caffeine or alcohol within 12 h of the test, 4) to not exercise
within 12 h of the test, 5) to not take diuretics within 7 d of
the test, 6) to urinate within 30 min of the test, and 7) No
testing of female clients who perceive they are retaining
water during that stage of their menstrual cycle [24].
BIA measurements were taken by using the Tanita ®
leg-to-leg BIA system (model TBF – 300A). The Tanita®
analyzer measures lower-body resistance between the right
and left legs as the individual stands on the electrode plates
of the analyzer. Subjects were measured while standing
erect, in bare feet, on the analyzer’s footpads and wearing
either a swimsuit or undergarments. The system’s 2 electrodes are in the form of stainless steel foot pads. Leg-to-leg
impedance and body mass are simultaneously measured as
the subject’s bare feet make pressure contact with the
electrodes and digital scale.
The body fat monitor/analyzer automatically measures
weight and then impedance. Computer software (a microprocessor) imbeded in the product uses the measured impedance, the subject’s gender, height, fitness level, and in
some cases age, (which have been preprogrammed), and
the weight to determine body fat percentage based on equation formulas. Through multiple regression analysis, Tanita
has derived standart formulas to determine body fat
persentage. Tanita’s equations are generaluzed for standard
adults and athletes.
Specialist consultation
Cardiological consultation. The nurse make the standart
cardiogram and after that, patient visit the cardiologist. Cardiologist examine cardiovascular fitness, blood pressure,
puls, give an interpretation to cardiogram. Seated blood
pressure was measured in duplicate after 10 minutes of rest,
2 to 3 minutes apart. If the readings differed by 4 mm Hg or
higher, then a third reading was taken. Extreme blood pressures were confirmed on a subsequent visit.
Physiotherapy consultation. Physiotherapist examine the health
status, especially condition of the articulations, joints pain and
movement, also skin status and other diseases. Specialist determine the contraindication for physiotherapy and prescribe some
Analysis of body composition using bioimpedance (BIA) data
physical procedures, like anticellulitis massage, termotherapy,
electrotherapy, underwater massage, ets.
Dietology consultation. All of patients have the conversation with dietologist. Specialist determine the daily feeding,
nutrition status, basal metabolic rate and give the recommendation for diet at home. Dietologist have a talk with
group above the basis of nutrition and dietetics.
behavioral principles to modify eating patterns, to initiate
and/or continue moderate exercise and to increase the activities of daily living were introduced. Several daily educational classes (e.g., emotional eating, stress management,
mood management, time management, maintaining behavioral changes), and optional support groups and individual
therapy were provided.
Energy-Restriction Diet
Each subject’s basal metabolic rate (BMR) was estimated
automaticaly using the Tanita ® leg-to-leg BIA system (model
TBF – 300A). Obese subjects were prescribed a 1000–1200
kcal/d diet for 2 wk. The dietary menu was based on National
dietary recommendations (Bulgaria). The goal of the intervention was a weight loss of 0.5–1.0 kg/week. Caloric intake was
restricted using a balanced diet (~ 50% carbohydrates, ~ 30%
protein, 20–60 g fat/day). A minimum volume intake of at
least 2 l was suggested using 1,5 l mineral water or 0,5 l herbal
tea with soft diuretic and laxative effect as beverage. Intentional weight loss was controlled by weight control and by
bioelectric impedance analysis at indicated times. Caloric intake restriction was supported by a behavioural program,
which consisted of group sessions.
Training program
In addition to weight management program, patients underwent a regular training program, which was performed every day per week at a level of 60–80% of their initial heart
rate reserve. The patients arranges in 2 training groups according to intensity and difficulty of exercise. The exercise
routine consisted of 20 min of morning gymnastics, 30 min
complex of curative aerobic gimnastic, 60 – 90 min outdoor walking or jogging (terenkur), aqua-aerobic exercises
in swimming pool with mineral water (25 min), individual
analytic training (up to 60 min), cycle ergometry (60 W, up
to 30 min) and dance teaching (up to 120 min). Patients
wore the pedometer (Tanita ®) every day of study and daily
distance was recorded in an exercise log. A trained exercise
physiologist supervised all exercise sessions, and performed random checks of heart rate. Each exercise session
was supervised to ensure correct technique and to monitor
the appropriate amount of exercise and rest intervals. No
injuries or complications were reported from the exercise
testing and training program.
Physiotherapy program
All of patint’s are prescription for some procedures after the
physiotherapy consultation and assessment of health status.
Everyday are followed procedures: manual massage of the
targeted zones with anticellulitic cream (15 min.), underwater massage (20 min.), electrotherapy procedure (30 to
45 min.), phytotherapy – tea with appetite-depressing and
light diuretic effect.
Behavior modification
The behavioral component of the intervention was based
on the principles and processes of the National Recommendation For Healty Lifestyle (Bulgaria). Motivational and
Subjects complying with all aspects of the study design included 519 overweight and obese women. Baseline characteristics of subjects enrolled in the trial are shown in Table
¹1. Table ¹1 present the mean value, standart deviation
and range of values in pre-intervention study.
Òable ¹. Subject characteristics (n = 519)
Subject Characteristics
Mean ±SD
Age (years)
42.66 ±10.87
22 - 62
Height (m)
162.20 ±5.81
147 - 173
Weight (kg)
86,74 ±17,46
58,00 - 140.8
Body mass index (kg/m2)
32,94 ±6,51
25,10 - 54,90
BMR (kcal)
1565,15 ±187,78
1244 - 2151
BMR (kJ)
6520,72 ±670,55
5249 - 8001
505 ±66
345 - 750
Fat mass (%)
41,25 ±4,86
31,30 - 51,50
Fat mass (kg)
36,47 ±11,33
19,40 - 70.5
Fat-free mass (kg)
50,25 ±6,83
38,6 - 77
Waist circumference (cm)
94,28 ±12,56
77 - 129
Hip circumference (cm)
116,33 ±11,94
98 - 156
0,81 ±0,06
0,64 - 0,95
Impedance (ohms)
Table 2. Weight and antropometric changes from
baseline to post-intervention in a study group (n = 519).
Baseline (SD)
Post (SD)
Weight (kg)
86,74 (17,46)
84,18 (16,73)
- 2,57
Body mass index
32,94 (6,51)
31,93 (6,30)
- 1,00
94,28 (12,56)
90,38 (12,83)
- 3,90
Hip circumference
116,33 (11,94) 113,23 (11,74)
- 3,09
Waist-to-hip ratio
- 0,02
0,81 (0,06)
0,79 (0,14)
Shishkova A., P. Petrova*, À. Tînev ...
Weight and antropometric changes was significantly decrease, weight loss was 2.57 kg (3% of total average group
weight for 2 wk).
The results of body composition change are presented in
Table ¹3. Mean body mass decrease was 2.57 kg with free
fat mass accounting for about 51% of this change. This is
adequat result after the first 2 wk of intensive weight
reduction program, becàuse a main loss is total water in the
body 0.96 kg (73% of reduced free fat mass). The content
of fat mass is reduced with 1.25 kg on the average (49% of
the reduced tissues). In the end of intervention basal
metabolic rate was decråàse.
Table 3. Body composition changes from baseline to
post-intervention in a study group using the Tanita®
analyzer (n = 519).
Fat mass (%)
41,25 (4,86)
41,06 (5,19)
- 0,19
Fat mass (kg)
36,47 (6,83)
35,22 (11,48)
- 1,25
Fat-free mass
50,25 (6,83)
48,94 (5,84)
- 1,31
Total body
water (kg)
36,78 (5,00)
35,82 (4,28)
- 0,96
BMR (kcal)
1565,15(187,78) 1547,37 (176,57)
- 17,79
BMR (kJ)
6520,72 (670,55) 6459,64 (661,73)
- 61,09
These results support the field use of BIA for estimating
changes in fat mass as it is simple to use, requires minimal
training and is used across a spectrum of ages, body
weights, and disease states.
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assessed by bioelectrical impedance, total body potassium and dual X-ray absorptiometry during prolonged
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Does adipose tissue influence bioelectric impedance
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Jebb SA, Cole TJ, Doman D, Murgatroyd PR,
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Bachvarova R. .................165
Bachvarova S...................165
Bahlova P. .......................187
Balev B. ...........................137
Bekyarova G....................117
Bohchelian H...................145
Bontchev G......................121
Bontcheva S.....................121
Burulianova I...................171, 175
Chakalova V. ...................165
Deenichin G.....................141
Dimov R. .........................141
Dokov V. .........................171
Dokov W. V.....................177
Dokova K. .......................111
Drumeva P.......................165
Dyakov Sv. ......................145
Feschieva N. ....................111
Hinev A. ..........................145
Hristov D. ........................137
Hristova M.......................117
Hristozov K. ....................145
Ignatov V.........................137
Iliev G..............................187
Ilnev A.............................187
Iovcheva M......................179
Ivanov K..........................137
Ivanova F.........................133
Kalchev E. .......................187
Kerekovska A. .................111
Kolev N. ..........................137
Konstantinova V..............171, 175
Konsulova S. ...................137
Madjov. R........................137
Marev D...........................149
Margaritova V. ................183
Marinov M.......................117, 125
Marinov P........................179
Mirchev K. ......................117
Molov V. .........................141
Nedev P. ..........................153
Petrova P. ........................187
Platikanov V....................145
Racheva S. .......................167
Radev R. Zl......................117
Radoinova D....................175
Romanova H....................129
Shishkova A. ...................187
Siderova M. .....................145
Softov Ogn. .....................187
Stefanov Ch. ....................141
Stoyanov Zl. ....................125
Tonchev T. ......................157, 161
Tonev A...........................137
Usheva N. ........................111
Zlateva S..........................179
abscess, liver, CT, ultrasound, percutaneous
abscess, tonsillectomy, postoperative
haemorrhage _____________________________149
acute intoxication, organophosphorus
pesticide, lethality _________________________179
anxiety, chronic skin disease, depression,
Hospital Anxiety and Depression Scale,
co-morbidity _____________________________165
anxiety, stress, sex ________________________125
Binder syndrome, maxillo-nasal dysplasia,
nasomaxillary hypoplasia ___________________153
bioelectrical impedance analysis, body
composition, fat mass ______________________187
biophysics, quality of education,
pedagogical analysis _______________________121
body composition, bioelectrical impedance
analysis, fat mass _________________________187
chronic skin disease, anxiety, depression,
Hospital Anxiety and Depression Scale,
co-morbidity _____________________________165
Chronic Urticaria, Physical Urticaria,
Cholinergic Urticaria, Non-allergic
Urticaria, delayed pressure urticaria,
cold urticaria, solar urticaria ________________167
clinical case, new education technique,
pathophysiology __________________________117
Colon, Synchronous malignant tumors ________141
diabetes mellitus, emphysematous
pyelonephritis, ketoacidosis, ultrasound ________145
disaster medicine, protection in case of
disastrous situations _______________________129
Electro-traumatism, Varna District __________177
emphysematous pyelonephritis, diabetes
mellitus, ketoacidosis, ultrasound _____________145
health status, social determinants, policy
implications, Bulgaria ______________________111
lacrimal gland tumors, orbital tumors,
coronal approach, lateral orbitotomy __________161
liver, abscess, CT, ultrasound,
percutaneous drainage______________________137
maxillo-nasal dysplasia, Binder syndrome,
nasomaxillary hypoplasia ___________________153
new education technique, clinical case,
pathophysiology __________________________117
Orbit, Surgery, Frontoethmoidal mucocele,
Coronal approach, Reduction, Obliteration _____157
organophosphorus pesticide, acute intoxication,
lethality _________________________________179
orbital tumors, lacrimal gland tumors, coronal
approach, lateral orbitotomy _________________161
Physical Urticaria, Chronic Urticaria, Cholinergic
Urticaria, Non-allergic Urticaria, delayed pressure
urticaria, cold urticaria, solar urticaria _________167
protection in case of disastrous situations,
disaster medicine__________________________129
Psychological preparation, psychological
readiness, training ________________________183
psychological readiness, Psychological
preparation, training _______________________183
quality of education, biophysics,
pedagogical analysis _______________________121
social determinants, health status, policy
implications, Bulgaria ______________________111
stress, anxiety, sex ________________________125
Surgery, Orbit, Frontoethmoidal mucocele,
Coronal approach, Reduction, Obliteration _____157
Synchronous malignant tumors, Colon _______141
tonsillectomy, abscess, postoperative
haemorrhage _____________________________149
Varna District, Electro-traumatism, __________177
Scripta Scientifica Medica is the official publication of Medical University Prof. Dr. Paraskev Stoyanov, Varna, Bulgaria. It is
currently disseminated among medical university libraries from all over the world on exchange basis. This peer-reviewed annual
accepts for publication original articles, unpublished papers recently presented at national and international congress proceedings,
and book reviews from Bulgarian and foreign authors. The contributions should be devoted to actual topics in contemporary
biomedicine, clinical medicine and interdisciplinary fields as well. They should not have been submitted or accepted for
publication elsewhere. The journal publication is offered to the national and international readership in English only.
The manuscript signed by all the authors has to be submitted in duplicate to the Editor-in-Chief of Scripta Scientifica Medica:
Prof. Anelia Klisarova, MD, PhD, DSc
Medical University Prof. Dr. Paraskev Stoyanov, Varna
55 Marin Drinov Street
BG-9002 Varna
+359-52- 611 899
+359-52- 650 019
[email protected]
The contributors are encouraged to submit the files of the text and figures of their revised manuscripts on a 3,5”-diskette in any
recent MS Word format.
The authors must strictly follow some main instructions listed below.
The manuscript of an original paper should not exceed 7 double-spaced pages with wide margins. The total volume of the text,
tables, and references should not exceed 15000 characters. The structure of the article should include the following sections:
Introduction, Material and Methods, Results and Discussion, and Conclusion(s). Additionally, there should be: a structured
abstract of 200-250 words; key-words (5 to 6 words or non-verbal phrases); a reference list (up to 20 references); a complete
address of the author for correspondence (postal and e-mail address, if available), and, eventually, an appropriate number of tables
and figures. The tables and legends to the figures should be provided on separate sheets. Data sheets of diagrams should be
obligatorily provided. Location of tables and figures should be indicated in the text and on the left margin of the corresponding
page. No data reiteration in the text, tables, and figures is permitted. Photographs and microphotographs have to be sufficiently
contrasted and up to 12x18 cm in size. Black-and-white pictures, drawings and diagrams are accepted only. Cited authors are
ordered alphabetically in the reference list starting with those in the Cyrillic alphabet. Most commonly, these authors should be
identified in the text of the article by Arabic numerals in parentheses. Please, do not make use of CapsLock option at all.
Numbering of all the publications cited in the text should correspond to that in the list of references. Bibliographic citations of
articles in journals should contain initials and names of all the authors (or at least the first six ones), article title, abbreviated title
of the journal according to the style used in Index Medicus (National Library of Medicine, Bethesda, MD, USA), volume, year
of publication, issue number (absolutely obligatory for Bulgarian and Russian journals), and page numbers (from-till). The
citations of books should contain initials and names of the authors (up to three), book title, number of edition (if any), editor(s)
(if any), location of publishing, publishing house and year of publication. Book chapters should contain initials and names of
the authors of the chapter, title of the whole book, editor(s) (if any), location of publishing, publishing house, year of
publication and page numbers (from-till). Congress proceedings should contain along with data as for book chapters, location
and date of the corresponding meeting, kind of materials (abstracts or full papers), and page numbers. Author’s name of the
dissertation, title, location, institution, and year of defence should be indicated. With patents and licences, author’s names (if
any), registration number, and year of publication should be shown. Personal communications containing the name of the
author cited and the date should be accompanied by his (her) permission in written for the corresponding statement.
Let us give some examples.
Biderman, I., S. Somien, Z. Shimshoni. In: Tissue Nutrition and Viability. A. R. Hargens, ed. New York, etc.,
Springer-Verlag, 1986, 121-134.
Goute, A. M., A. R. Haynes, M. J. Owen. New aspects of psychotic drug usage.- J. Clin. Psychopharmacol., 8,
1988, No 4, 315-317.
Youmans, G. P., A. N. Lewin. Tuberculosis. 3rd ed. Philadelphia, etc., W. W. Saunders, 1979.
The authors will receive 25 reprints of their articles along with a sample copy of the issue free of charge.
Editor-in-Chief: Prof. Anelia Klisarova, MD, PhD, DSc
Co-Editor-in-Chief: Assoc. Prof. Rossen Madjov, MD, PhD
Cover art editor: E. Spasov
Technical editor: A. Antonov
Proof-reader: Assoc. Prof. Rossen Madjov, MD, PhD
Publ. Lit. group: III-3
Sent to printers: August, 2007
Print sheets: 23
Format: 8/60x84
Approved for printing: March, 2007
Total print: 300
ISSN 0582-3250
Med i cal Uni ver sity 55 Marin Drinov Street, Varna, BG-9002