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Enteric bacterial infections are characterized by the location of causative agents in the intestine and their distribution in the environment with excrements. Intestinal bacterial infections in Bulgaria are caused by Salmonella spp., Shigella spp., E. coli, Campilobacter spp., Yesinia enterocolitica. For the period 2016-2018, the incidence rate of salmonellosis in Bulgaria was close to that of the European Union (EU). It was 11,21 per 100 000 population in 2017 (14,6%ooo in the EU). The incidence rate of typhoid fever in Bulgaria was lower than that in the EU for the period 2016-2018 – 0.01-0.03 per 100 000 population. Bulgaria had the highest rate of shigellosis in the EU. For the period 2016-2018 it was between 3,33%ooo and 4,07 per 100 000. The incidence of Campylobacter infection in Bulgaria during the period 2016-2018 was between 2,72%ooo and 2,88%ooo and was lower than the EU average. Data on yersiniosis in Bulgaria is incomplete. For the period 2016-2018, 36 cases were reported. E. coli enteritis had a higher average annual notification rate in the 0 to 1 age group (142,65 cases per 100 000 population). The main means of controlling intestinal infection are sanitary measures that prevent the transmission of pathogenic microorganisms with food, water, insects, contaminated hands, etc.


A vital aspect of the medical activity on which the medical care quality directly depends has been the doctor-patient relationship; it is of complex nature and is formed by a number of factors: professional ethics, communication culture of the doctor, the patients’ confidence in the doctor, etc. From an ethical point of view, the confidence of the patient has been an ethical indicator and criterion of particular importance for the quality and interpersonal relationship between the doctor and the patient. Data from the overview of a number of papers, as well as data from our own empirical study, has indicated the presence of a number of unresolved problems in this relationship. That has raised the significant necessity of a more thorough and comprehensive training of the medical staffin professional medical ethics in undergraduate and postgraduate training.


The gastrointestinal tract perforation is one of the leading causes of acute abdomen. Mycotic infections have become a significant clinical problem over the last few decades. Despite the advance in diagnostics and treatment of patients with fungal peritonitis, the mortality remains high.

Objective. The objective of the study was to determine the type and incidence of causative pathogens of acute peritonitis in patients with gastroduodenal perforation, and to estimate the impact of microbial flora on the disease outcome.

Materials and methods. We performed a retrospective study among 83 adult patients with acute peritonitis due to gastroduodenal perforation treated at our centre.

Results. A total of 40 mycotic agents were isolated in 39 of the abdominal samples. The primary mycotic isolates were Candida albicans (52.5%) and C. glabrata (64.3%); C. krusei (14.3%) and C. tropicalis (7.1%) predominated among non-albicans Candida species (35.0%). The most common bacterial agents were Escherichia coli (24.0%) and Enterococcus spp. (24.0%). 77.1% of all enrolled patients survived, and 19 of them deceased due to sepsis and multiple organ dysfunction syndrome.

Conclusion. Candida albicans is the most common mycotic pathogen in patients with acute peritonitis due to gastroduodenal perforation. It is obligatory to examine the peritoneal fluid samples for bacterial and fungal pathogens with determination of their antimicrobial susceptibility profile. Timely initiation of adequate treatment and multidisciplinary approach is crucial for the outcome of patients with fungal peritonitis.


It is well known that the severity of coronary heart disease is associated with a poor prognosis. 70% of patients with NSTEMI have multivascular disease, the percentage being 40% for STEMI patients. Knowing the grade severity of the coronary artery disease has importance for the therapeutic management of the case and to establish the prognosis. However, until now, we have no possibilities to identify these patients before performing the coronarography.

The objective of this study was to establish a correlation between cardiovascular risk factors, ECG changes, echocardiographic changes, GRACE score and the severity of coronary artery disease invasively detected by coronarography, in patients with myocardial infarction without ST-segment elevation.

Material and methods. We performed a study on 125 patients diagnosed with NSTEMI, who performed coronarography. For each patient we noted age, sex, history of high blood pressure, dyslipidemia, chronic kidney disease, smoking habit, HS troponin T levels, LDL cholesterol, triglycerides, C-reactive protein, creatinine clearance, ejection fraction of left ventricle, number of lesions discovered on angiography, GRACE and SYNTAX score.

Results. Of the 125 patients included, 86 (68.8%) were men, with a mean age of 63.66 ± 11.54. The average of the laboratory tests and the parameters studied: creatinine Cl 83.80 ± 33.862 ml / min, FEVS 46.37 ± 7.394%, troponin HS 3533.625 ± 7460.873 pg / ml, CRP 2.811 ± 5.262 mg / dl, LDL 113.618 ± 50.13 mg / dl, triglyceride ± 100.58mg / dl. The mean Syntax score in the studied group was 17, 58 ± 13.65, Grace score 118.80 ± 26.980, and the number of coronary lesions 2.19 ± 1.162 The number of coronary lesions and the SYNTAX score were significantly correlated statistics with age, Grace score, presence of diabetes and chronic kidney disease. With regard to laboratory tests, creatinine clearance proved to be the most important predictor for both the number of vessels affected (r =-0.322, p=0.000) and for the Syntax score (r = -0.323,p=0.000), the latter being influenced also by the level of triglycerides (r = -0.177, p = 0.048) and that of the high sensitive troponin (r = 0.322, p = 0.015).

Conclusions. Independent predictors of multivascular disease in patients with NSTEMI are : age, diabetes, chronic kidney disease, creatinine clearance and Grace score. The severity of the coronary heart disease assessed by the Syntax score, is also correlated with age, history of diabetes and chronic kidney disease, creatinine clearance, Grace score, but also with the value of tiglycerides and high-sensitive T troponin.


Objective: The aim of the study was to determine the molecular mechanisms of mutagenesis in Bulgarian patients with Angelman syndrome (AS). AS is a severe neurodevelopmental disorder caused by loss of expression in brain of the maternally inherited UBE3A gene as a result of various 15q11.2-q13 alterations.

Material and Methods: In total 24 patients (11 boys, 13 girls) from 22 unrelated families with suspected clinical diagnosis AS were analysed. We used methylation specific PCR, multiplex ligation-dependent probe amplification, methylation sensitive MLPA, and direct sequencing of the UBE3A gene.

Results: In 9 families (41%) pathogenic mutations were detected, which confirmed the clinical diagnosis on а molecular-genetic level. In 4 (44%) of these families we found 15q11-q13 region deletion with breakpoints BP1-BP3 or BP2-BP3. In 1 (11%) of the families we found imprinting defect: deletion of the AS-SRO regulatory region (part of the PWS-AS imprinting center). In 1 (11%) of the families we detected a rare finding – paternal uniparental disomy of chromosome 15. In 3 (33%) of the families diff erent point mutations in the UBE3A gene were detected: two novel missence mutations c.488T > C; p.Leu163Ser and c.1832A > T; p.Gln611Leu, and one known frameshift mutation c.2576_2579delAAGA; p.Lys859Argfs*4.

Conclusion: The obtained results helped us to develop a systematic diagnostic algorithm in order to provide proper diagnosis for the patients with AS. Combining excellent knowledge of the molecular mechanisms of mutagenesis and proper molecular-genetic testing approaches is a cornerstone in the management of AS patients, ensuring AS families would receive both adequate genetic counseling and prophylaxis of the disease in the future.


Introduction. Sarcoidosis is a multisystemic disease, that can basically affect any organ of the body, the lungs and the intrathoracic lymph nodes being the most affected. Despite the attempts to understand the exact pathogenic mechanism of the disease, this continues to remain uncertain. Histopathologically, the trademark of sarcoidosis is the presence of nonnecrotizing granuloma.

Case presentation. We report the case of a 33-year-old man without significant past medical history, who is admitted to our clinic for bilateral supraclavicular and axillary adenopathies, progressive asthenia for the last three months and pain in the latero-thoracic region. The patient denies weight loss, odynophagia and fever.

Clinically, the patient is afebrile and has supraclavicular, bilateral laterocervical and axillary adenopathies which are painless, elastic and mobile with a maximum diameter of 1.5 cm. The prehepatic diameter is 16 cm, with rounded inferior edge and the spleen in not palpable.

The laboratory tests reveal moderate inflammatory syndrome, with C-reactive protein (CRP) of 1.4mg/dL (N<0.5mg/dL) and the erythrocyte sedimentation rate (ESR) 65mm/h (N<40mm/h). There is no lymphocytosis or neutrophilia. The ENT (Ear Nose Throat) consultation found no evidence of angina and, combined with the paraclinical investigations, excluded mononucleosis.

Thus, the presumptive diagnosis was difficult because of the non-specific symptomatology and included the following: lymphoma, mononucleosis, sarcoidosis, tuberculosis and systemic vasculitis.

The chest X-ray reveals enlarged pulmonary hilums, diffuse outlined-adenopathic/tumoral aspect, diffuse changes in the pulmonary interstitium and micronodular opacities of medium intensity, being diffusely outlined with the tendency of basal merging on the left side and slight asymmetrical enlargement of the superior mediastinum on the right side, para trachealadenopathic aspect.

The lymph node biopsy reveals the aspect of non-necrotizing granuloma, which suggests the diagnosis of sarcoidosis.

We used the dosage of angiotensin convertase, which reveals high values of 108.20U/L (N 13.3-63.9 U/L). Therefore, a pulmonary clinical evaluation was recommended.

Conclusion. Case of 33-year-old man with sarcoidosis. The diagnosis was difficult, considering the non-specific symptomatology and the numerous pathologies that can be included in the differential diagnosis.


The process of neoangiogenesis is one of the classic hallmarks of a cancer. Its intricate mechanisms have long been one of the major domains in cancer research and a hope for a therapeutic breakthrough. Last decade a new subgroup of non-coding RNA molecules was reported called microRNAs. Literally hundreds of new molecules in this class are being uncovered as pivotal regulators in virtually all intracellular processes. The aim of this study is to classify and review those microRNA molecules that have a role in the processes of tumor angiogenesis and map their places in the regulatory framework of the classical proangiogenic genes and their canonical cascades.


Introduction: Right atrium volume index (RAVI) has recently been reported as a quantitative echocardiographic parameter associated with right ventricular systolic dys-function (RVSD) in patients with pulmonary arterial hypertension (PAH) due to chronic obstructive pulmonary disease (COPD).

Aims: The aim of the current study was to assess right atrium remodeling (RAVI) in COPD patients without echocardiographic parameters of RVSD or PAH at rest and to analyse its association with right ventricular diastolic dysfunction (RVDD) at rest and after exercise – stress-induced RVDD.

Methods: The study was conducted in 104 COPD patients. Pulmonary function tests, blood gas analysis, incremental, symptom-limited cardio-pulmonary test (CPET) protocol and detailed echocardiographic examinations before and 2-3 minutes after peak CPET were applied. The cut-offvalues for stress-induced RVDD were E/e’ > 6.0.

Results: Patients were divided into two groups: patients with stress-induced RVDD (82/104 – 78%) and those without stress-RVDD (22/104 – 22%). RAVI was significantly higher in the group with stress-induced RVDD (23,04 ± 2,67 ml/m2 vs 18,02 ± 2,69 ml/m2) in comparison to those without it. Correlation analysis showed that RAVI was associated with stress-induced RVDD (E/e’) and the distance from the 6 minute walk test (6-MWT), but was not an independent predictor for any of them.

Conclusions: RAVI correlates with stress-induced RVDD parameters (E/e’) in non-severe COPD patients without pulmonary arterial hypertension at rest. It corresponds to the diminished distance from the 6-MWT, but was not an independent factor of reduced physical activity.


Surgical interventions for corrosive stricture of the esophagus are extremely difficult and technically challenging. In this manuscript, we present a patient with esophagectomy due to perforation of a corrosive stricture of the esophagus that underwent malignant transformation and subsequent perforation of a giant duodenal stress ulcus, which occurred 12 days after the intervention. We performed a total esophagectomy, pharyngo- and gastrostomy, suture of the duodenal perforation but the postoperative period was challenging and despite our efforts, the patient died on the 50th postoperative day due to respiratory and renal failure.


Determination of serum glycosylated hemoglobin, blood glucose and insulinemia (Homa IR) can be used in the assessment and prognosis of patients with diabetic versus non-diabetic acute ischemic stroke.