Therapeutic Applications in Dental

Scripta Scientifica Vox Studentium

Volume 1, suppl. 1, 2017

Scripta Scientifica Vox Studentium An official publication of Medical University "Prof. Dr. Paraskev Stoyanov" of Varna

Editor-in-Chief: Krasimir Ivanov, MD, PhD, DSc, Rector, Medical University of Varna, Bulgaria

Editorial Board:

Anton Tonchev, MD, PhD, DSc Evgeni Grigorov, MScPharm, PhD Medical University of Varna, Bulgaria Medical University of Varna, Bulgaria

Christina Grupcheva, MD, PhD, DSc Stefan Peev, DMD, PhD Medical University of Varna, Bulgaria Medical University of Varna, Bulgaria

Diana Ivanova, PhD, DSc Tsvetan Tonchev, DMD, PhD Medical University of Varna, Bulgaria Medical University of Varna, Bulgaria Design and Layout Editing: Web Design and Development: Emilia Yordanova Tsvetan Petrov Publishing Department, Publishing Department, Medical University of Varna Medical University of Varna

Proofreading : Process Management: Yordanka Peteva Magdalena Bliznakova Publishing Department, Student, Medical University of Varna Medical University of Varna MEDICAL UNIVERSITY “PROF. DR. PARASKEV STOYANOV” – VARNA

ABSTRACTS

THE FIFTH

BLACK SEA SYMPOSIUM FOR YOUNG SCIENTISTS IN BIOMEDICINE (BSYSB)

April 6-9, 2017 Varna ORGANIZING COMITEE of BSYSB’2017

MAGDALENA BLIZNAKOVA OC PRESIDENT

TURGAY KALINOV OC VICE PRESIDENT

GEORGE STOYANOV SCIENTIFIC PROGRAMME ORGANISER & WORKSHOPS MANAGER

BOYKO MATEV GENERAL SECRETARY & FUNDRAISING

BORYANA GEORGIEVA TREASURER

EMRAN LYUTFI INTERNATIONAL RELATIONS

DANIELSON KOSHE PUBLIC RELATIONS

DESISLAV DOBREV SOCIAL PROGRAMME ORGANISER

GALLINA DIMOVA OC MEMBER

MARIA RUSEVA OC MEMBER

GRETA GEORGIEVA OC MEMBER

ALEXANDER BOYADZHIEV OC MEMBER

STANISLAV KOCHEV OC MEMBER

ILIYAN DIMITROV OC MEMBER CONTENTS

CASE REPORTS Kalina Chavdarova, Viktor Urbanchich, Joana Andonova, Stayko Chavdarov, Georgi Guzgunov - AN INFANT WITH CONGENITAL HYPOTHYROIDISM AND A DISAPPEARING TUMOR____ 15 Elizabet Miladinova, Aleksandra Gerasimova, Stela Petrova, Radina Dimitrova, Kiril Hristozov - MULTIPLE ENDOCRINE NEOPLASIA TYPE 2A (SIPPLE SYNDROME)______16 Greta Georgieva, Tina Traykova, Miroslav Stoykov, Albena Gencheva, Ivan Gonkov - DENTIGEROUS CYST: A CASE REPORT______17 Veronika Zhelezova, Ivaylo Minev, Dimitar Dimitrov, Veselin Petrov, Niya Rasheva - WILSON’S DISEАSE IN CHILDHOOD- THE HEREDITARY FACTOR: A CASE REPORT______18 Dinnar Yahya, Antoniya Atanasova, Monika Yaneva, Samuela Krasteva, Petya Petrova - PSOAS ABSCESS AS A COMPLICATION OF CROHN’S DISEASE – A CASE REPORT______19 Ani Dzakova, Ersin Ismail, Deniz Hamidov, Snezhana Stancheva, Plamen Dimitrov - CASE REPORT OF PROPOFOL-INDUCED PULMONARY EDEMA______20 Irini Karatsoli, Sezgin Syuli, Simona Nizorkova, Yavor Hinov, Chavdar Bachvarov - ENDOVASCULAR BRONCHIAL ARTERY EMBOLIZATION IN LIFE-THREATING HEMOPTYSIS. A CASE REPORT______21 Yanitsa Dimitrova, Kristina Dimitrova, Hristina Pamukchiyska, Elena Harizanova, Diana Petkova - BIOLOGICAL THERAPY: A RISK FACTOR FOR DEVELOPING TUBERCULOSIS – A CASE REPORT______22 Desislav Dobrev, Daniel Rachev, Miroslav Stoykov, Metodi Abadzhiev - TOOTH SUPPORTED OVERDENTURE UTILIZING PINLAY BALL ATTACHMENTS: A CASE REPORT______23 Ivan Valkadinov, Djuliana Stoilova, Yavor Hinov, Simona Nizorkova, Chavdar Bachvarov - ENDOVASCULAR TREATMENT OF ACUTE ISCHEMIC STROKE - AN ALTERNATIVE TECHNIQUE______24 Lazar Kutin, Elisabeth Bossilkova, Georgi Popivanov, Ventzislav Mutafchiyski - SEVERE CARDIOMYOPATHY IMITATING ACUTE ABDOMEN______25 Djuliana Stoilova, Evgeniya Kalevska, Ivan Valkadinov - CEREBRAL VENOUS THROMBOSIS_____ 26 Boryana Georgieva, Irina Ivanova, Milko Mirchev, Nikolay Georgiev - CARDIAC GASTRIC CANCER IN A PATIENT WITH A BLADDER NEOPLASM: CASE REPORT______27 Dessyslava Nikolaeva, Dimo Nikolov, Stela Stanimirova, Veselin Aleksandrov, Merlin Mehmed - Efraim- EXTRAMEDULLARY PLASMACYTOMA OF THE SKULL BASE DEVELOPING INTO MULTIPLE MYELOMA: A CASE REPORT______28 Dragostina Tsocheva, Katerina Marinova, Borislav Petrov, Rumen Nenkov, Radoslav Radev - GIANT PHYLLODES TUMOR-CASE REPORT______29 Dimo Nikolov, Dessyslava Nikolaeva, Radi Lukanov, E. Ahmed, Valentin Ikonomov - INFLAMMATORY MYOFIBROBLASTIC TUMOUR OF THE KIDNEYS – CASE REPORT______30 Mladena Radeva, Dimitar Grupchev - IRIDOCYCLECTOMY FOR CILIARY BODY MELANOMA - UNIQUE APPROACH AND SURPRISING RESULT______31 Mohamed Swamad, Yanislav Mitkov, Aygulya Akisheva, Dobromir Dimitrov, Chavdar Bachvarov - MULTIDISCIPLINARY APPROACH WITH SURGICAL ONCOPLASTY OF A 46 YO WOMAN WITH BREAST CANCER______32 Merilin Ivanova, Jovana Kitanovska, Kalina Naydenova, Tatyana Betova, Paulina Milanova - WARTHIN’S TUMOR - CASE AND REVIEW______33 Blagovest Belchev, Konstantin Ganchev, Yosif Gerchev, Preslav Penev - HOFFA FRACTURE IN CHILDHOOD______34 Roksana Tsvetanova, Zhenya Marinova, Tsvetan Popov, Yavor Enchev, Bogomil Iliev - COMBINED AUTOGENOUS AND ALLOPLASTIC CRANIOPLASTY IN A 15-YEAR-OLD TRAUMA PATIENT - A CASE REPORT______35 Dragomir Dragomirov, Meriyan Radeva, Natalia Stomatova , Rostislav Manev - Osteomyelitis______36 Liliya Raeva, Boris Botev, Paola Kulicheva, Veselin Boyadzhiev, Lachezar Marinov - A CASE REPORT OF A CHILD WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS - A RARE BUT POTENTIALLY DANGEROUS DISEASE______37 Violeta Dimitrova, Joana Andonova, Viktor Urbanchich, Vesela Zlateva, Maria Dimova - INFECTIVE ENDOCARDITIS IN INTRAVENOUS DRUG ABUSE - A CLINICAL CASE______38 Alexandar Byankov, Teodor Tsanev, Vasil Ivanov - RARE CASE OF A BLADDER CANCER IN AN 18-YEAR-OLD MALE PATIENT______39 Liliya Ilieva, Mira Siderova, Savi Shishkov, Kiril Hristozov - CASE OF EUGLYCEMIC KETOACIDOSIS INDUCED BY SGLT2 INHIBITORS (SODIUM-GLUCOSE COTRANSPORTER 2) IN A DIABETIC PATIENT______40 Abdul Shah, Valentina Dimova, Bilal Hejazi - DIFFICULT TREATMENT OF RECURRENT HAEMOPTYSIS IN POLYMORBID LUNGS – A CASE STUDY______41 Miroslav Stoykov, Nina Nyagulova, Trayan Marinov, Maya Doychinova - AN IRRIGATION PROTOCOL USED FOR THE DEVITALISATION PROCESS OF A RIGHT MANDIBULAR CENTRAL INCISOR WITH A MODERATE ABRASION - A CASE REPORT______42 Diyana Kyuchukova, Simona Nikolaeva, Dilyana Tonkova, Cvetomir Yankov, Branimir Kanazirev - TAVI-PROCEDURE: A BRAND NEW START FOR A PATIENT WITH CLASS 3 NYHA HEART FAILURE______43 Stefan Stefanov, Mustafa Dzhambazov, Dragomir Ivanov, Gergana Trifonova - DENTAL TRAUMA IN CHILDHOOD. REATTACHING A TOOTH FRAGMENT OF ANTERIOR FRACTURED TEETH - CASE REPORT______44 Tsvetan Popov, Daniel Zhelev, Zhenya Marinova, Roksana Tsvetanova, Ilina Micheva - CASE OF A STAGE IIIB HODGKIN’S LYMPHOMA PATIENT TREATED WITH BRENTUXIMAB - MODERN CONCEPTS FOR IMMUNOTHERAPY______45 Ahmed Ahmed, Nalyan Aliadinova, Borislav Todorov, Figen Mustafa, Margarita Trifonova - A CASE REPORT OF METASTATIC BREAST CANCER MANAGED WITH HORMONE THERAPY______46 Yavor Kyumyurdzhiyski, Kaloyan Dobrev, Sibel Yuzeirova, Kolyo Karahristov, Valentina Dimitrova - RESPIRATORY INFECTIONS IN IMMUNOCOMPROMISED PATIENTS______47 Aizaz Tariq, Georgi Davidov, Lilyana Petkova, Nikolay Sapundzhiev - CARCINOMA OF THE NASAL VESTIBULE______48 Velina Kerekovska, Evelina Zlatanova - CLINICAL SIGNIFICANCE OF ELEVATED MACROPROLACTIN LEVELS IN PATIENTS WITH HYPERPROLACTINEMIA. CASE REPORT______49 Veneta Yakimova, Maria Dimova, Krasimira Nenova - INSULINOMA______50 Desislava Nalbantova, Yasen Petrov, Ivona Zhekova, Simona Mileva, Tsvetana Yordanova - PNEUMOCYSTIS CARINII PNEUMONIA IN IMMUNOSUPPRESSED PATIENTS______51 Desislava Nalbantova, Yasen Petrov, Ivona Zhekova, Simona Mileva, Tsvetana Yordanova - PYODERMA GANGRENOSUM – A FEASIBLE OPTION IN THE DIFFERENTIAL DIAGNOSIS OF SOFT TISSUE GANGRENE IN DIABETIC PATIENTS?______52 Kalina Naydenova, Hristo Milev, Katya Todorova, Beatrice Pancheva, Nadya Docheva - PRIMARY EMPTY SELLA SYNDROME: AN UNUSUAL PRESENTATION OF PANHYPOPITUITARISM___ 53 Maneesha De Silva, Simona Angel , Kremen Tsvetkov, Emil Kovachev, Atanas Alexandrov - PLACENTA ACCRETA – A CASE REPORT______54 Doychin Nikolov, Boryana Georgieva, Deyan Anakievski, Rostislav Marinov, Inna Gocheva, Viktor Nikolov - EARLY DISTRIBUTION OF SQUAMOUS PENILE CARCINOMA______55 Joana Andonova, Violeta Dimitrova, Kalina Chavdarova, Maria Dimova, Vesela Zlateva - ADULT-ONSET STILL’S DISEASE - A CLINICAL CASE______56 Vasil Kitanov, Pamela Georgieva, Velichko Penchev, Orlin Asenov - DILEMMAS IN THE CARDIO- VASCULAR TREATMENT APPROACH. ANTICOAGULANT, ANTIPLATELET DRUG OR A COMBINATION?______57 Mariya Levkova, Dimitrina Konstantinova, Tanya Kadiyska, Ivan Donev - INDIVIDUALIZED HORMONAL THERAPY IN PATIENTS WITH BREAST CANCER______58 Teresa Buitrago García, Niarah Ahmad, Maria Dimova, Branimir Kanazirev - LEFT VENTRICULAR NON-COMPACTION CARDIOMYOPATHY______59 Veselin Petrov, Veselin Petrov, Desislava Ivanova - COMPLICATION AFTER CARDIAC CATHETERIZATION IN A PATIENT WITH IHD______60 Hristo Draganov, Kristina Dimitrova, Hristina Pamukchiyska, Elena Harizanova, Diana Petkova - LUNG TRANSPLANTATION OF A PATIENT WITH PULMONARY HYPERTENSION______61 Rene-Alexander Starick, Laura Verna Fierro, Dilyana Tonkova, Stanislava Ivanova, Dobrin Kalchev - SUCCESFUL TREATMENT OF A BIDIRECTIONAL SHUNT - A CASE REPORT______62 Viktor Urbanchich, Kalina Chavdarova, Violeta Dimitrova, Stayko Chavdarov, Georgi Guzgunov - AN INFANT WITH SPONTANEOUS TUMOR REGRESSION______63 Johanna Loehr, Faidra Marazak, Mara Genovefa Marazak - RH INCOMPATIBILITY IN EARLY MEDICAL ABORTION, A MISOPROSTOL CASE REPORT______64 Simona Panteleymonova, Elizabet Miladinva, Aleksandra Gerasimova, Tatyana Cvetkova, Kalina Stoyanova - TOXOCAROSIS (LARVA MIGRANS VISCERALIS) IN ADULT PATIENTS____ 65 Catherina Shirokova, Savi Shishkov, Velina Kerekovska, Mila Boyadzhieva, Kiril Hristozov - A CASE OF CONGENITAL HYPOPITUITARISM______66 Zekie Kasimova, Hristo Popov, Mariya Tsaneva - MIXED EPITHELIAL AND STROMAL TUMOR OF THE KIDNEY: A CASE REPORT______67 Desislava Ivanova, Paolina Kamenova, Merlin Mehmed - CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML): A CASE REPORT______68 Gabriela Kirisheva, Anton Tonev, Alexander Zlatarov, Nikola Kolev, Valentin Ignatov, Georgi Ivanov - CASE VARIATION OF SAINT’S TRIAD______69 Ralica Ruseva, Anton Tonev, Alexander Zlatarov, Mehmed Hadzhiveli, Georgi Ivanov, Boris Andonov, Georgi Valentinov, Nikola Kolev, Valentin Ignatov, Krasimir Ivanov - RETROPERITONEAL HEMATOMA – A CASE REPORT______70 Samuil Marinov, Anton Tonev, Alexander Zlatarov, Mehmed Hadzhiveli, Georgi Ivanov, Boris Andonov, Georgi Valentinov, Nikola Kolev, Valentin Ignatov, Krasimir Ivanov - MINIMALLY INVASIVE MANAGEMENT OF GIANT ESOPHAGEAL POLYP – A CASE REPORT______71

ORIGINAL RESEARCH Petar Valchanov - 3D MODELING IN MEDICINE - FROM DIGITAL TOMOGRAPHY TO A 3D MODEL______72 Ivaylo Zhechev, Boyana Vasileva, Kristiyana Kolewa, Georgi Gaidarov, Desislava Videva - EPILEPSY IN CHILDHOOD – REVIEW OF THE LITERATURE ______73 Maya Nikova, Burdju Cicek, Radost Dimitrova, Yordan Slavov, Berkehan Koroglu - RESTORATION OF SENSATION USING HIGH-TECH PROSTHESES - OVERVIEW______74 Daniel Zhafal, Metodi Metodiev, Yoneli Netsova, Trifon Chervenkov - TRANSGENERATIONAL EPIGENETIC INHERITANCE: DOES IT EXIST?______75 Boyana Vasileva, Georgi Gaidarov, Lili Goguleva, Desislava Videva, Kristiyana Kolewa - EMOTIONAL SELF-CONFIDENCE OF MEDICAL STUDENTS IN BULGARIA______76 Lili Goguleva, Boyana Vasileva, Desislava Videva, Georgi Gaidarov, Irena Kostova - PSYCHO-EMOTIONAL DIFFICULTIES FOR PARENTS WITH THEIR FIRST CHILD______77 Boris Enikov, Irini Karatsoli, Veronika Markova, Bogomil Iliev, Yavor Enchev - BURR HOLE ENDOSCOPE-ASSISTED EVACUATION OF CEREBELLAR HEMATOMAS (ICH)______78 Radost Dimitrova, Burdju Cicek, Yordan Slavov, Berkehan Koroglu, Georgi Shopov - OVERVIEW OF VISUAL PROSTHESES______79 Niarah Ahmad, Dominic Fazel, Teresa Buitrago Garcia, Foteini Tsipou, Veselin Boyadhzhiev - TO WHAT EXTENT DO EXTERNAL FACTORS CONTRIBUTE TO THE DEVELOPMENT OF ALLERGIES?______80 Vasilena Kuzmanova, Atanas Kuzmanov, Stefka Valcheva-Kuzmanova - EXPERIMENTAL RAT MODELS OF PERIODONTITIS – A REVIEW______81 Slavena Georgieva, Tsvetelina Borisova-Papancheva, Georgi Papanchev - SURGICAL VS NON- SURGICAL RETREATMENT OF ENDODONTIC CASES – FACTORS, INFLUENCING THE RETREATMENT CHOICE______82 Ralitsa Yotsova, Dimitar Dochev, Ivelina Hristova, Panayotis Marinov, Yulia Tsulos - COMPARATIVE STUDY OF SINUS LIFT TECHNIQUES – BIOLOGICAL ASPECTS AND OUTCOMES______83 Daniel Rachev, Desislav Dobrev, Borislava Toncheva, Rossen Kolarov - BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW______84 Radina Ivanova, Krasimir Todorov, Georgi Ivanov, Milena Stoyanova - KABUKI SYNDROME______85 Metodi Metodiev, Yoneli Netsova, Daniel Zhafal, Trifon Chervenkov - THE EXTENDED PHENOTYPE______86 Boryana Atanasova, Aleksandra Dzhepkova, Marina Atanasova, Peter Ivanov, Regina Komsa-Penkova - MANAGEMENT OF REPRODUCTIVE HEALTH CONTROL. PAI-1, MTHFR MUTATION AND ANOVULATION______87 Elena Harizanova, Desislava Marinova, Stoyan Pavlov, Doychin Angelov - QUANTIFICATION OF (RE)MYELINATION VIA LUXOL FAST BLUE STAINING IN THE INJURED SPINAL CORD OF ADULT RATS: EFFECTS OF WHOLE BODY VIBRATION______88 Sofia Nikolova, Georgi Georgiev - ECHOCARDIOGRAPHIC ASSESSMENT OF PULMONARY EMBOLISM - MCCONNELL’S SIGN______89 Isil Uyanik, Elis Ismail - ULTRASOUND IN GYNAECOLOGICAL EMERGENCIES______90 Ivaylo Minev, Veronika Zhelezova, Dimitar Dimitrov, Veselin Petrov, Ivona Kocheva - JUST UNIC. (JACK-UP SHOULDER PROSTHESIS FOR TRAUMA INDICATIONS)______91 Dimitar Dimitrov, Valentin Dimitrov, Ivaylo Minev, Veronika Zhelezova, Dimitar Raikov - ORIF OF INTRAARTICULAR FRACTURES OF DISTAL HUMERUS WITH LCP BIPLANAR PLATING______92 Aleksandra Gerasimova, Rumen Hristov, Petar Stamov, Galin Hristov, Sergei Glinkov - T-TUBE ENTEROSTOMY- A METHOD OF TREATMENT FOR INTESTINAL PERFORATION IN NEWBORNS WITH LOW AND EXTREMELY LOW WEIGHT______93 Constantinos Voniatis, Daniella Fehér, Kristóf Molnár, Gyorgy Weber, Angéla Jedlovszky-Hajdú - TISSUE-ENGINEERED POLY(VINYL ALCOHOL) MESH PROSPECTS IN ABDOMINAL HERNIA TREATMENT______94 Nellia Gwasunda, Rafal Al-Rabaey, Vasil Bozhkov, Rosen Madjov - ACUTE APPENDICITIS IN OLDER PATIENTS______95 Ani Raynova, Simona Panteleymonova, Plamen Panayotov - ENDOVENTRICULAR CIRCULAR PATCH PLASTY FOR LEFT VENTRICULAR RECONSTRUCTION______96 Dimana Mitsova, Aleksandra Stefanova, Elena Stoyanova, Plamen Angelov, Anton Dinkov - MALIGNANT HYPERTHERMIA – THE HIDDEN DANGER______97 Burdju Cicek, Ishil Uyanik, Radost Dimitrova, Georgi Shopov, Berkehan Koroglu - OVERVIEW OF FOCUSED ULTRASOUND SURGERY______98 Konstantin Ganchev, Blagovest Belchev, Desislava Simeonova, Dennis Veliev, Preslav Penev - ADAMS PROCEDURE – A METHOD OF REPAIR FOR POST-TRAUMATIC DRUJ INSTABILITY______99 Krasen Tonev, Evgeni Grigorov, Konstantin Kalaidjiev - PHARMACOVIGILANCE AND ENSURING DRUG SAFETY______100 Stela Petrova, Dimitar Koemdzhiev, Petko Iliev, Dimo Nikolov, Kalina Stoyanova - COMPARISON BETWEEN THREE LABORATORY METHODS FOR THE DIAGNOSIS OF CRYPTOSPORIDIUM_ 101 Dimitar Trizlov, Iliyaz Hadzhiev, Aleksandar Yordanov, Valeriy Yordanov - HER-2/NEU - MOLECULAR STRUCTURE AND STATUS. ANTIBODY - TARGETED THERAPY WITH PERTUZUMAB, TRASTUZUMAB AND DOCETAXEL AND THE IMPACT ON OVERALL SURVIVAL (OS) AND PROGRESSION-FREE SURVIVAL (PFS) IN PATIENTS WITH METASTATIC BREAST CANCER______102 Zhenya Marinova, Roksana Tsvetanova, Elena Ivanova, Tsvetan Popov, Antoniya Kisheva - ASSESSMENT OF RIGHT-TO-LEFT SHUNTS USING CONTRAST TRANSCRANIAL DOPPLER ULTRASOUND – ADVANTAGES AND RELIABILITY OF THE METHOD______103 Ivelina Hristova, Slavena Georgieva, Ralitsa Yotsova, Konstantina Velikova, Sirma Angelova - DENTAL TRAUMA. DECORONATION TECHNIQUE AS A SUCCESSFUL METHOD IN THE TREATMENT OF ANKYLOSIS______104 Mustafa Djambazov, Dragomir Ivanov, Stefan Stefanov, Tsonka Dimitrova - ANALYSIS OF THE RISK OF DISTRIBUTION AND PREVENTION OF SEXUALLY TRANSMITTED DISEASES AND UNWANTED PREGNANCY AMONG STUDENTS FROM 9TH TO 12TH GRADE OF PROFESSIONAL SCHOOL OF NATURAL SCIENCES – “ACAD. N. OBRESHKOV” – RAZGRAD______105 Maria Dzhinova, Vasil Yordanov, Siyana Gradanska, Milena Georgieva, Radosveta Andreeva - COOPERATION BETWEEN SPECIALISTS FOR PREVENTION OF EARLY CHILDHOOD CARIES______106 Galini Kalavrytinou, Rosa Marand, Christiana Madjova - LITERATURE REVIEW BASED ON THE CONTRAINDICATIONS OF HYALURONIC ACID PERIORALLY______107 Michael Enchev, Gergana Georgieva, Radost Vasileva - PHOTOGRAPHIC IMAGE REQUIREMENTS IN CONTEMPORARY DENTAL MEDICINE______108 Ersin Ismail, Ani Dzakova, Deniz Hamidov, Meriyan Radeva, Plamen Dimitrov - SLEEP AND HEALTH – TENDENCIES, REASONS AND RISKS OF SLEEP DEPRIVATION______109 Desislava Dokova, Ralitsa Toneva, Daniel Rachev, Desislav Dobrev, Georgi Georgiev - STATISTICAL ANALYSIS OF ORAL HYGIENE HABITS AND ORAL CANCER AWARENESS____110 Martin Krustev, Silvia Filkova, Monika Popova, Luiza Hadzhieva - THE REFLECTION OF EXERCISE ON THE NEW GENERATION______111 Jovana Kitanovska, Merilin Ivanova, Paulina Milanova, Sabie Korenarska, Galya Stavreva - ARTEMISIA ANNUA- A PLANT WITH A GREAT FUTURE______112 Tsvetelina Stefanova, Syana Dimova, Nina Arhangelova, Yordanka Eneva - CONCENTRATION OF NATURAL RADIONUCLIDES IN CALENDULA OFFICINALIS L. FLOWERS______113 Vladislav Stoychev, Mariya Chingalova, Vladislav Velikov, Dimitar Dimitrov, Rositsa Chamova - CURCUMIN - PREVENTION AND THERAPY OF INFLAMMATORY DISEASES______114 Nefize Ilyaz, Mery Koleva, Stefka Valcheva-Kuzmanova, Miroslav Eftimov - DRUG-INDUCED XEROSTOMIA AND ITS POTENTIAL TREATMENT______115 Viktoria Tomova, Ivan Pavlov, Nadezhda Ivanova - EVALUATION OF THE EFFECTIVENESS AND MECHANISM OF ACTION OF HYPERICUM PERFORATUM IN THE TREATMENT OF DEPRESSIVE DISORDERS______116 Georgi Ivanov, Gergana Angelova, Boyan Balev - MEDIAL TIBIAL STRESS SYNDROME - IMAGING AND DIFFERENTIAL DIAGNOSIS______117 Georgii Danylenko, Tatiana Merkulova, Natalia Romanova - IMPLEMENTATION OF STATE POLICY FOR PROTECTION OF CHILDREN’S HEALTH IN UKRAINIAN SCHOOLS______118 Apostolos Pavlos Petridis, Daniela Pechlivanova, Kiril Petrov, Alexander Stoynev - BEHAVIORAL CHARACTERISTICS OF NORMOTENSIVE WISTAR AND SPONTANEOUSLY HYPERTENSIVE RATS WITH AN EXPERIMENTAL MODEL OF DIABETES MELLITUS TYPE 2______119 Victoria Tencheva, Mihaela Zaharieva, Jordan Kozhuharov, Pamela Dragieva, Irina Stoyanova - DOES GHRELIN AFFECT MEMORY?______120 Pamela Dragieva, Mihaela Zaharieva, Krasimir Markov, Jordan Kozhuharov, Miglena Todorova - DOES A KETOGENIC DIET INFLUENCE PATIENTS WITH ALZHEIMER’S DISEASE?______121 Vanesa Dodova, Tsvetelin Tsvetkov, Natasha Ivanova - ESTABLISHING A CONNECTION BETWEEN THE HUMAN PERIPHERAL NERVOUS SYSTEM AND AN UPPER LIMB MECHANICAL PROSTHESIS______122 Gabriela Georgieva, Desislava Simeonova, Christina Grupcheva - LIMBAL STEM CELL TRANSPLANTATION FOR CORNEAL REGENERATION______123 Denitsa Hristova, Maria Zhelyazkova-Savova - A SYSTEMATIC REVIEW OF RESEARCH ON N,N-DIMETHYLTRYPTAMINE______124 Zekie Kasimova, Denitsa Koleva, Milena Avdzhiyska, Tulin Edirne - DEVELOPMENT OF CHRONIC TRAUMATIC ENCEPHALOPATHY IN ATHLETES AFTER REPETITIVE HEAD INJURY______125 Darja Schlothauer, Anastasiia Subbotina, Stefan I. Ivanov - IUD INSERTION IMMEDIATELY AFTER DELIVERY______126 Simona Panteleymonova, Ani Raynova, Radi Lukanov, Svetla Chilikova, Plamen Panayotov - MULTIDISCIPLINARY APPROACH IN COMORBID PATIENTS______127 Miroslav Raikov, Milena Avdzhiyska, Silvia Ianakieva, Dimitar Raikov, Diyan Dimov - CONSERVATIVE TREATMENT OF PES EQUINOVARUS – HISTORY AND RECENT TRENDS_ 128 Keesha Cunningham, Nikolay Sapundzhiev - THE POSSESSION AND DISTRIBUTION OF VARIOUS TYPES OF CERUMEN IN DIFFERENT POPULATIONS AND ITS POSSIBLE ORIGINATION______129 Magdalena Bliznakova, Boyko Matev, Pavel Todorov, Nikolay Nedev - CAPABILITIES OF REHABILITATION MEDICINE IN MUCOVISCIDOSIS PATIENTS TREATMENT______130 Tanya Dimova, Lachezar Radev, Irena Michailova, Diana Zaimova - IN VITRO BIOACTIVITY OF SILVER-CONTAINING SOL-GEL GLASSES: FTIR ANALYSIS______131 Oganes Vardanyan, Ivan Uzunov, Maya Radeva, Kaloyan Georgiev - PRINCIPLES OF PHARMACOKINETIC BOOSTING______132 Stanila Stoeva, Iliyan Kolev, Yulichka Sabeva - RESEARCH ABOUT THE POSSIBILITY OF INCREASING THE BIOAVAILABILITY OF CAPECITABINE______133 Stefanie Degen, Maria Dolores Franco Martinez, Alexander Hinev, Faidra Marazaki, Navneet Magon - VASALGEL™: A NOVEL REVERSIBLE NON-HORMONAL CONTRACEPTIVE FOR MEN______134 Desislava Simeonova, Konstantin Ganchev, Gabriela Georgieva, Liliya Ilieva, Yana Manolova - TOXIC KERATOPATHY ASSOCIATED WITH ABUSE OF TOPICAL ANESTHETICS______135 Boyko Matev, George Stoyanov, Magdalena Bliznakova, Alice Renjilian, Radoslav Spasov - CHOOSING A PARTNER – DOES MALE PERSONALITY PLAY A ROLE IN BREAST SIZE PREFERENCES______136 Malwin Werner, Nikoo Rahimy, Stefanka Racheva - SEXUAL ADVERSE EFFECTS OF FINASTERID 1MG FOR TREATMENT OF ANDROGENIC ALOPECIA IN MEN______137 Elena Stoyanova, Elena Stoyanova, Ersin Ismail, Alexandra Stefanova, Svetoslav Dobrev, Dimcho Tomov - SILICOSIS – CLINICAL MANIFESTATION AND RELATION WITH OTHER PULMONARY AND NON-PULMONARY DISEASES______138 Paola Kulicheva, Zhivko Apostolov, Liliya Raeva, Boris Botev, Dinnar Yahya - THE CONNECTION BETWEEN IBS, ANXIETY AND DEPRESSION______139 Ralitsa Simeonova, Galina Dimova, Rosi Hristova, Anna Todorova - THE PHARMACIST’S RESPONSIBILITY IN REVERSING DRUG-INDUCED NUTRIENT DEPLETION______140 Mehmet Fatih Aydın, Hakan Guzel - DETERMINATION OF RISK FACTORS FOR HYDATID DISEASE AMONG ANIMAL BREEDERS IN DİNAR-AFYONKARAHİSAR______141 Ralitsa Simeonova, Iliya Zhelev, Konstantina Velikova, Galina Dimova1, Rosi Hristova - PHYTOTHERAPY IN THE MANAGEMENT OF MENOPAUSE-ASSOCIATED VASOMOTOR SYMPTOMS______142 Yosif Gerchev, Samuela Krasteva, Monika Yaneva, Dragomir Stoyanov, Zhivko Apostolov - REPROFILING OF ANTIPSYCHOTIC DRUGS FOR CANCER TREATMENT______143 Monika Kalcheva, Hristo Stefanov, Damyan Iliev, Svetlin Varbanov, Yasen Yanev - A STUDY ON STRESS LEVELS, ANXIETY AND DEPRESSION IN STUDENTS AT THE MEDICAL UNIVERSITY OF VARNA ______144 Anastasiia Subbotina, Darja Schlothauer, Johanna Löhr, Elvira Nenashkina - RHESUS INCOMPATIBILITY IN EARLY MEDICAL ABORTION UP TO 8 WEEKS OF GESTATION (ARTICLE REVIEW)______145 Ivelina Borisova, Stanislava Stoycheva, Iliyan Kolev - GADOLINIUM-CONTAINING CONTRAST AGENTS – NOT AS SAFE AS WE THOUGHT______146 Daniel Zhafal, Daniela Angelova, Nikola Garipov, Teodora Stoyanova, Diana Petkova - SOMATOFORM SYMPTOM AND FACTITIOUS DISORDERS______147 Stanislav Morfov, Petar Milkov, Borislav Zlatev, Veselin Marinov - OSTEOPLASTY IN SURGICAL TREATMENT OF CHRONIC EXOGENOUS OSTEOMYELITIS______148 Veselin Marinov, Stanislav Morfov, Plamen Minchev - HIP ARTHROPLASTY - METHOD OF CHOICE FOR SOME TROCHANTERIC FRACTURES______149 Trayan Marinov, Aleksandrina Varbanova, Marina Yordanova, Klementina Moneva, Maya Doychinova - SUCCESSFUL ROOT CANAL TREATMENT MANAGEMENT OF TAURODONT TEETH______150 Martin Karamanliev, Anislav Gabarski, Chavdar Ivanov, Dobromir Dimitrov - CLINICAL EFFECTIVENESS AND COMPLICATION RATE OF CORE NEEDLE BREAST BIOPSY______151 Denis Veliev, Adem Hadjimehmed, Svilena Rangelova, Mukates Velieva, Evelina Zlatanova-Kazakova - RESPIRATORY DYSFUNCTIONS IN ACROMEGALY. ACROMEGALY AND SLEEP APNEA____ 152 Vasil Yordanov, Miglena Balcheva, Siyana Gradanska, Maria Dzhinova - ORAL MANIFESTATION OF SYSTEMIC DISEASES______153 Georgi Stoyanov, Deyan Dzhenkov, Martina Kitanova, Ivan Shterev - CORRELATION BETWEEN KI-67 INDEX AND PATIENT SURVIVAL IN GLIOBLASTOMA MULTIFORME____ 154 Alexandra Goncharova, Majid Shahbazi, Elis Ismail - STRESS URINARY INCONTINENCE IN WOMEN. LASER TREATMENT OPTIONS______155 Vasil Dimitrov, Elina Merashka, Nikola Bonchev, Gergana Ivanova, Dobromir Nguen - USING OF VAC PACK DRESSING FOR TEMPORARY CLOSURE OF AN OPEN ABDOMEN____ 156 Plamen Angelov, Elena Stoyanova, Alexandra Stefanova, Dimana Mitsova, Anton Dinkov - TREATING CROHN’S DISEASE WITH THE MONOCLONAL ANTIBODY VEDOLIZUMAB___ 157 Samuela Krasteva, Yosif Gerchev, Dragomir Stoyanov, Monika Yaneva, Zhivko Apostolov - KETAMINE AND THE FUTURE OF NMDA ANTAGONISTS IN THE TREATMENT OF DEPRESSION______158 Simona Nizorkova, Yavor Hinov, Irini Karatsoli, Ivan Valkadinov, Georgi Todorov - ENDOVASCULAR TREATMENT FOR UNRESECTABLE HEPATOCELLULAR CARCINOMA - TRANSARTERIAL CHEMOEMBOLIZATION (TACE)______159 Aleksandrina Varbanova, Trayan Marinov, Marina Yordanova, Klementina Moneva, Maya Doychinova - COCONUT – THERAPEUTIC APPLICATIONS IN DENTAL MEDICINE____ 160 Siyana Gradanska, Maria Dzhinova, Vasil Yordanov, Miglena Balcheva - GENOMIC TESTS GUIDING THE ADJUVANT SYSTEMIC THERAPY IN WOMEN WITH BREAST CANCER_____161 Ivanina Arabadzhieva, Teodora Karamfilova, Kiril Hristozov, Evelina Zlatanova-Kazakova - THYROTOXIC CRISIS – TREATMENT AND MANAGEMENT______162 Siyana Ilieva, Ahmed Ahmed, Aylin Kerim, Kristiyana Kaleva, Rositsa Chamova - THE POTENTIAL ANTI-TUMOR BENIFITES OF NIGELLA SATIVA______163 Sami Karagöz, Mehmet Fatih Aydın, Suleyman Gokmen - PHYSICAL, CHEMICAL AND MICROBIOLOGICAL QUALITY OF WATER SAMPLES IN KARAMAN PROVINCE______164 Desislava Boyanova, Ivan Angelov, Zlatina Peteva - TOXIC AND THERAPEUTIC EFFECTS OF YESSOTOXIN AND DOMOIC ACID______165 Konstantina Velikova, Denica Koleva, Galina Dimova, Ivelina Hristova, Rumen Iordanov - PREGNANCY WITH TETRALOGY OF FALLOT______166 Georgi Shopov, Yordan Slavov, Ani Dzakova, Dimana Mitsova, Darina Hristova - THE LINK BETWEEN PROCESSED MEAT CONSUMPTION AND CANCER______167 Radi Lukanov, Silvia Gancheva, Elizabet Miladinova, Dessyslava Nikolaeva, Maria Zhelyazkova-Savova - EXPERIMENTAL MODEL OF SUBCLINICAL VITAMIN K DEFICIENCY: ADAPTATION OF THE STUDY OF OSTEOCALCIN______168 Karina Spechter, Mohammed El Samara, Mariya Negreva - ECG CHANGES IN PATIENTS WITH HYPOTHERMIA______169 Alice Renjilian, George Stoyanov, Boyko Matev, Velizar Gaidardzhiev, Nikolay Sapundzhiev - PREAURICULAR SINUS - INCIDENCE IN A BULGARIAN COHORT______170 Evgeni Grigorov, Stanislav Kochev, Jivko Kolev - EXTERNAL REFERENCE PRICING SYSTEM FOR MEDICINES IN BULGARIA______171 Dragomir Ivanov, Mustafa Dzhambazov, Stefan Stefanov, Tsonka Dimitrova - CERVICAL CANCER NOWADAYS. RESEARCH OF PREVENTION AND AWARENESS OF WOMEN BETWEEN 18-35 YEARS OF AGE______172 Jyothis Sajan, Blagovesta Mitkova - PERIVASCULAR ADIPOSE TISSUE AND ITS CLINICAL SIGNIFICANCE______173 Dajana Tsankova, Neli Ermenlieva, Gabriela Tsankova, Tatina Todorova, Mariya Rostamloo - BOTULINUM NEUROTOXIN-CLINICAL USES______174 Turgay Kalinov, Anton Tonev, Alexander Zlatarov, Mehmed Hadzhiveli, Georgi Ivanov, Boris Andonov, Georgi Valentinov, Nikola Kolev, Valentin Ignatov, Krasimir Ivanov - LAPAROSCOPIC APPENDECTOMY VS. OPEN APPENDECTOMY – 5-YEAR EXPERIENCE____175 GUIDELINES FOR AUTHORS______176 Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 AN INFANT WITH CONGENITAL HYPOTHYROIDISM AND A DISAPPEARING TUMOR Kalina Chavdarova1, Viktor Urbanchich1, Joana Andonova1, Stayko Chavdarov2, Georgi Guzgunov2

1Student, Medical University of Varna 2House of Medical and Social Care for Children – Haskovo

ABSTRACT Introduction: This is the case of a patient presenting with congenital hypothyroidism combined with undefined tachycardia and probable ganglioneuroblastoma. Materials and Methods: The patient was a male, born from a third pathological pregnancy in April, 2015, per vias naturales. He was with a birth weight of 2100 g, height - 45 cm, and morphological gestational age 36-37 weeks. There was information about congenital infection transmitted from the mother. The newborn was in damaged general condition with respiratory distress syndrome, but afebrile. The examination determined: tachypnea, dyspnea, general cyanosis, moderate body edema, and hypothermia. The neurological examination showed lack of primitive reflexes and muscle hypotonia. The heart rate was stable and rhythmic. There was no organomegalia. Results: Blood for congenital screening was taken. The results showed high levels of thyroid-stimulating hormone. A few more blood tests were done. Their results confirmed the suspicions of thyroid disease. Also, a chest-ray examination showed suspicion of bilateral bronchopneumonia. A treatment with antibiotics was conducted. A second x-ray was performed. The results were: the shadowed opacities had disappeared, but there was a large thick shadowy formation in the right cardiodiaphragmatic angle, coming from the mediastinum. Conclusion: Hormonal therapy was prescribed for the thyroid disease. After a few months the levels of THS (thyroid-stimulating hormone) were back to normal. But an undefined tachycardia appeared. The formation in the mediastinum was, at first, considered to be ganglioneuroblastoma. After a few more exams it was confirmed that this shadowy formation was the liver. It was migrating because of diaphragmatic weakness but without herniating. Keywords: congenital hypothyroidism, diaphragmatic weakness

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 15 Medical University of Varna Case Reports MULTIPLE ENDOCRINE NEOPLASIA TYPE 2A (SIPPLE SYNDROME) Elizabet Miladinova1, Aleksandra Gerasimova1, Stela Petrova1, Radina Dimitrova2, Kiril Hristozov2

1 Student, Medical University of Varna; 2Department of Endocrinology and Metabolic Diseases, St. Marina University Hospital, Varna

ABSTRACT Introduction: Multiple endocrine neoplasia type 2A is a genetic disease with autosomal dominant inheritance, related to proliferative lesions in the thyroid gland, adrenal medulla and parathyroid glands. Materials and Methods: We present a case report of a 49-year-old man with complaints of weakness, difficult concentration, fatigue, dizziness and hypertensive crises with blood pressure of 190/120 mmHg. After the estab- lishment of elevated levels of metanephrine and normetanephrine, abdominal CT was performed and it detected a lesion in the adrenal glands. Ultrasound of the neck established an enlarged size of the thyroid gland with a hy- poechogenic zone in the right lobe and calcifications. According the elevated levels of calcitonin and suspicions of medullary thyroid carcinoma (MTC), fine-needle aspiration (FNA) biopsy was performed and it confirmed the diagnosis. The patient underwent consequently right and left adrenalectomy, followed by total thyroidectomy with lymph node dissection. Based on the ongoing elevated levels of calcitonin and evidences for a relapse of the disease in the thyroid gland, diagnosed with ultrasound and positron emission tomography (PET/CT), the patient underwent reoperation and radiotherapy. Results: Genetic examination was performed and mutation in the RET protooncogene (PCYS634TRP) in 10th chromosome was established. The same mutation was detected in both brothers of the patient, as well as their children. Conclusion: Sipple syndrome is a condition rarely encountered in practice and it is presented with different penetrance. Based on the type of inheritance of the disease, genetic analysis is recommended for other members of the family, as well as DNA analysis of risk individuals. Genetic carriers of the mutation are recommended for elec- tive thyroidectomy and a follow-up with biochemical and hormonal tests, the same is recommended for other individuals from the family. Keywords: multiple endocrine neoplasia, medullary thyroid cancer, pheochromocytoma, thyroidectomy, adrenalectomy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 16 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DENTIGEROUS CYST: A CASE REPORT Greta Georgieva1, Tina Traykova1, Miroslav Stoykov1, Albena Gencheva2, Ivan Gonkov2

1Student, Medical University of Varna 2Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: A cyst can be defined as a pathological cavity which contains fluid or semisolid material and is lined by an epithelium sac. Dentigerous cysts are odontogenic lesions, the second most common type after the radicular cysts. They are formed from residual remnants of the enamel epithelium and are histologically benign. The aim of the following report is to present a case of a dentigerous cyst with a rapid development and increasing size but asymptomatic course. Materials and Methods: A 30-year-old male was referred to the Department of Oral Surgery at the Univer- sity Medico-Dental Centre because of a diagnosed cystic lesion with a significant size, encompassing the crown of the impacted mandibular third molar (tooth 48). It was found that the lesion was asymptomatic with the only complaint being dull, transitory pain in tooth 47 which was endodontically treated 2 years ago. An analysis of the panoramic radiograph was performed, a CBCT examination was done to determine the exact size, borders of the cystic lesion and its relationship to the mandibular canal and the second molar. After precise diagnostics the chosen method of treatment was radical extirpation of the cyst combined with odontectomy of the impacted molar and extraction of tooth 47. Results: On the panoramic radiograph and the CBCT image a unilocular radiolucency was present, with a well-circumscribed border and visible osteosclerotic margin, enclosing the crown of tooth 48 and the distal root of tooth 47 to the interradicular plate. No asymmetry, crepitation or exudation were present in the affected area. The operation was performed under general anaesthesia. No further complications occurred. Conclusion: Dentigerous cysts frequently show no clinical symptoms. This undoubtedly leads to difficulties in the diagnostics. Therefore, thorough examination shall be performed because early diagnosis reduces the risk of complications during the treatment. Keywords: dentigerous, cyst, diagnostics, operation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 17 Medical University of Varna Case Reports WILSON’S DISEАSE IN CHILDHOOD- THE HEREDITARY FACTOR: A CASE REPORT Veronika Zhelezova1, Ivaylo Minev1, Dimitar Dimitrov1, Veselin Petrov1, Niya Rasheva2

1 Student, Faculty of Medicine, Medical university of Varna 2Department of Pediatrics, St. Marina Hospital, Varna

ABSTRACT Introduction: Wilson’s disease is a rare genetic disorder characterized by excess copper, stored in various body tissues. It usually begins by six years of age, but in most cases presents clinically in the teenage years or early twenties. The disease normally affects the liver, the brain and the corneas of the eyes. Wilson’s disease is progressive and, if left untreated, may cause hepatic or central nervous system dysfunction, and even death. Early diagnosis and treatment may prevent serious long-term disability and life-threatening complications. Treatment is aimed at reducing the amount of copper that has accumulated in the body and maintaining normal copper levels thereafter. Materials and Methods: A girl at the age of 11 was hospitalized with complaints of fatigue, abdominal pain and oedema of the lower limbs. A physical examination revealed ascites in the abdomen and enlargement of the liver. Her laboratory results showed high levels of liver enzymes and low levels of ceruloplasmin. She had been hospitalized 6 times in 4 years. Her brother, age 9, was admitted to hospital due to epigastric pain, vomiting and dark fae- ces. He underwent a fibrogastroscopy, which diagnosed him with chronic gastritis and enteritis. His lab results showed low hemoglobin, high levels of ASAT and ALAT, and low ceruloplasmin. The youngest sister was hospitalized because of a paresis of the right facial nerve, vomiting and epigastric pain. Her examination lead to the diagnosis of her siblings. Results: All three kids were diagnosed with Wilson’s disease, despite their various presentation. There is a 25 % chance for all three of them to inherit the defective genes from both of their parents. Conclusion: In conclusion, Wilson’s disease is a great imitator - it can be mistaken for many illnesses and the key to its diagnosis is an enzyme called ceruloplasmin. Keywords: Wilson’s disease in childhood

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 18 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 PSOAS ABSCESS AS A COMPLICATION OF CROHN’S DISEASE – A CASE REPORT Dinnar Yahya1, Antoniya Atanasova2, Monika Yaneva1, Samuela Krasteva1, Petya Petrova1

1Student, Medical University of Varna 2St. Marina University Hospital, Varna

ABSTRACT Introduction: Crohn’s disease is a chronic inflammatory bowel disease well-known for its serious complications and variable prognosis. We hereby present a recent clinical case as an example of such one. Materials and Methods: A 27-year-old Caucasian man with a short previous history of Crohn’s ileocolitis presented with right lower abdominal and hip pain radiating to the knee joint, inability to extend both hip and knee joints and limping as a consequence of these symptoms. The immediately performed magnetic resonance imaging showed that the patient has a right retroperitoneal psoas abscess, adjacent to the pathologically changed parts of the ileum, caecum and colon, later confirmed by computed tomography and ultrasound of the abdomen and the pelvis. Results: Following the administration of combination of antibiotics and CT-guided percutaneous drainage of the abscess with a pigtail catheter, the patient’s symptoms significantly improved. Other than that, all possible causes for this complication in the differential diagnosis were excluded. As his general condition was stable and gradu- ally improving, surgical resection was not seen as necessary. The patient seemed eligible for initiation of biother- apy with infliximab in addition to the continuous treatment with mesalazine and Enterol. Conclusion: We aim to emphasize that the cause for such serious condition as a retroperitoneal abscess of the psoas muscle nowadays is most likely to be associated with a chronic inflammatory disease of the nearest structures as in Crohn’s disease. It should be among the first diagnoses to be excluded by thorough history and examination, laboratory tests, imaging and multiple biopsies. If confirmed, the complication should be treated with caution and complete collaboration between gastroenterology, radiology and general surgery specialists. Also, conservative treatment appears to be useful not only for induction, but also for avoiding surgical approach. Keywords: psoas abscess, Crohn’s disease complication

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 19 Medical University of Varna Case Reports CASE REPORT OF PROPOFOL-INDUCED PULMONARY EDEMA Ani Dzakova1, Ersin Ismail1, Deniz Hamidov1, Snezhana Stancheva1, Plamen Dimitrov2

1Student, Faculty of Medicine, Medical University of Varna 2Department of Anestesiology and Reanimation, Balchik Hospital, Balchik, Bulgaria

ABSTRACT Introduction: Pulmonary edema after administration of propofol has rarely been reported. A conclusion of an adverse reaction is reached after exclusion of all other possibilities for the development of this pathology. An 18-year-old woman was admitted to a surgical department with abdominal pain localized at the mesogastrium. After consultation with the doctor on duty, she was scheduled for a routine appendectomy. She had a clean medical history, without concomitant diseases and drug allergies. Minutes after the surgical intervention, she developed clinical picture of acute pulmonary edema. Materials and Methods: After an uncomplicated appendectomy, 70 minutes later, the patient was extubated, fully awake and oriented. The saturation was 96% in room air. About ten minutes later, hypoxemia (SaO2 72%), tachycardia and central cyanosis occurred. The consultation with a pulmonologist revealed bilateral coarse crackles throughout both lung fields with normal heart sounds. The body temperature was 36.8°C, heart rate - 88 beats/ min, blood pressure - 109/67 mmHg, and respiration - 22 breaths/min. Results: The saturation rose and remained 90% with an oxygen mask. The anesthesiologist transported the patient to a hospital with an intensive care unit. Furosemide 40 mg for every 6 hours and Digoxin 0.125 mg/day were included in the therapy. A follow-up chest X-ray 5 days after admission showed a resolution of lung infiltrates. No other complications were present and the patient was discharged from the hospital in a stable, asymptomatic condition. Conclusions: There are no other etiological links between the clinical case we have reported and the case reports of other colleagues. People with no history of cardiovascular and other diseases develop acute pulmonary edema after application of propofol - before, during or after the intervention. The pathogenetic mechanisms remain unclear. Keywords: propofol, pulmonary edema, side effects, hypoxemia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 20 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ENDOVASCULAR BRONCHIAL ARTERY EMBOLIZATION IN LIFE-THREATING HEMOPTYSIS. A CASE REPORT Irini Karatsoli1, Sezgin Syuli1, Simona Nizorkova1, Yavor Hinov1, Chavdar Bachvarov2

1Student, Medical University of Varna 2Department of Imaging Diagnostics and Radiotherapy, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Hemorrhage arising from a bronchial arterial source is the most common cause of life-threatening hemoptysis, which is defined as the expectoration of blood originating from the pulmonary parenchyma or the tracheobronchial tree. Significant hemoptysis originates from the bronchial arteries in 90% of cases. It can be acute and can present as medical emergency. Bronchial artery embolization is considered to be the primary and most effective method when confronting a massive hemoptysis. The procedure requires an angiographic study of the anatomy of the bronchial vessels. The artery is reached by a femoral or brachial approach, using a catheter and under fluoroscopic visualization. The embolization may be performed with different agents – particles, gela- spon, coils or glue. Materials and Methods: The case report describes a 9-year-old girl who was admitted with massive hemoptysis. She had to be intubated, with previous anterior and posterior nose tamponade. The girl was admitted with no further complaints or symptoms except the expectoration of blood. Conservative treatment was not effective and after a following attack of massive bleeding she underwent a bronchial artery catheterization. It showed with accuracy the site of hemorrhage to be from the right inferior branch of the vessel, and intra-arterial embolization was performed. Results: The procedure was well tolerated and, as a result, high clinical success was achieved in managing the bleeding. The patient was discharged with no further complications. Conclusion: Bronchial artery embolization is a well-established and well-tolerated procedure. It comes with a better outcome than medical, surgical, or bronchoscopic techniques, especially when facing an acute massive hemoptysis. Keywords: hemoptysis , bronchial artery , hemorrhage , embolization

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 21 Medical University of Varna Case Reports BIOLOGICAL THERAPY: A RISK FACTOR FOR DEVELOPING TUBERCULOSIS – A CASE REPORT Yanitsa Dimitrova1, Kristina Dimitrova1, Hristina Pamukchiyska1, Elena Harizanova1, Diana Petkova2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Crohn’s disease is an autoimmune chronic inflammatory disease that most commonly affects the terminal ileum and the proximal colon. It causes local tissue damage that considerably affects the mucosa and leads to the development of fissures and ulcerations. The contemporary strategy of treatment includes corticosteroids and immunosuppressants, as well as biological therapy with infliximab and adalimumab. Materials and Methods: We present you the case of B.T. - a 21-year-old male diagnosed with Crohn’s disease 3 years ago. He had been subjected to biological treatment for 26 months with adalimumab prior to admittance to St. Marina University Hospital, Varna with clinical manifestation of acute respiratory infection. Physical examination and an imaging test (X-ray) showed no evidence of lobar infiltrate on the left. The persistent manifestation of the disease with fever, no evident recovery despite adequate antibacterial therapy, a history of positive past T-SPOT TB test and undergoing treatment with immunosuppressants required the implementation of additional tests: chest CT, FBS, Mantoux test, microbiology and laboratory testing, in order to determine the diagnosis. Results: Direct bacterioscopy of bronchoalveolar lavage was positive for acid-fast bacteria. Based on the presented data and the clinical course of the disease, the final diagnosis was infiltrative pneumonic form of pulmonary tuberculosis. Tuberculostatic treatment was started in standard doses. Microbiological cultures were positive twice, the second time during tuberculostatic therapy, which required a longer period of treatment. Conclusion: Biological therapy is a risk factor for developing tuberculosis. That requires accurate judgment and exclusion of underlying latent tuberculosis infection before starting the treatment. Monitoring and control tests are highly important for early diagnosis and successful treatment should a specific infection develop. Keywords: tuberculosis, Crohn’s disease, biological therapy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 22 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TOOTH SUPPORTED OVERDENTURE UTILIZING PINLAY BALL ATTACHMENTS: A CASE REPORT Desislav Dobrev1, Daniel Rachev1, Miroslav Stoykov1, Metodi Abadzhiev2

1Student, Faculty of Dental medicine, Medical University of Varna 2Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Various types of treatment for rapidly increasing elderly population with partially or completely edentulous patients may be indicated. Conventional complete dentures and both tooth-supported and implant- supported overdentures are common treatment modalities. The preservation of supporting teeth as overdenture abutments provide efficient prosthetic treatment. Tooth-supported overdentures can be retained with attachments improving both retention and stability. This treatment modality is cost-effective, maintains dental pro- prioception and simultaneously reduces alveolar bone resorption. Materials and Methods: This case report describes the treatment of a 63-year-old man with partially edentulous upper arch and completely edentulous lower arch. The study was carried out at the Department of Prosthetic Den- tal Medicine, Faculty of Dental Medicine, Medical University of Varna. Results: The treatment plan included extraction of teeth with poor prognosis, through periodontal therapy and root canal treatment for the selected teeth. Abutment teeth were prepared 2–3 mm supragingivally in a dome- shaped contour hemispherically rounded in all dimensions. Two pinlay balls were made in the university dental technology laboratory. One complete denture for the upper arch and one overdenture for the lower arch were made. Speaking and chewing functions were restored with a good aesthetical view. Conclusion: Tooth-retained overdentures improve biting force, chewing efficiency and minimize alveolar bone resorption than do conventional complete dentures. Despite the fact that the concept of overdentures has become trendy with the inception of implant dentistry, the treatment costs may not be affordable to most of the patients. That is why a tooth-retained overdenture may be advised whenever few teeth with good support remain as an alternative to dental implants or even total complete denture. Keywords: overdenture, edentulous, implant

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 23 Medical University of Varna Case Reports ENDOVASCULAR TREATMENT OF ACUTE ISCHEMIC STROKE - AN ALTERNATIVE TECHNIQUE Ivan Valkadinov1, Djuliana Stoilova1, Yavor Hinov1, Simona Nizorkova1, Chavdar Bachvarov2

1Student, Medical University of Varna 2Department of Imaging Diagnostics and Radiotherapy, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Stroke is the clinical term that defines the constellation of symptoms of brain infarction. The majority of ischemic stroke cases are due to embolism. The embolus usually originates from the extracranial territory (e.g. heart, carotid bifurcation), travels to the intracranial arteries and occludes the middle cerebral artery (MCA) in most cases, causing a territorial type of infarction, i.e. one including the cortex and the underlying subcortical white matter. The basal ganglia and internal capsule are sometimes also affected, depending on the portion of the artery that is engaged. Thus, typical neurological deficits and imaging signs develop. Spot diagnosis and on-time treatment are crucial for a good outcome. Materials and Methods: In this case report we present two patients with ischemic stroke who were treated with intra-arterial thrombolysis and mechanical thrombectomy, and their respective outcomes. Gen- eral and focal neurological symptoms were observed as well as classical imaging findings, e.g. hemipare- sis, hemisensory deficits, horizontal gaze palsy, hyperdense MCA, loss of grey-white matter differentiation, etc. Results: Emergency catheterization through the right femoral artery by the Seldinger technique was performed. The M1 (horizontal, sphenoidal) segment of the MCA, from the origin to the bifurcation/trifur- cation, was involved in both cases. The lateral lenticulostriate arteries, which branch off the occluded M1 segment, were also secondarily impermeable. Fragmentation and local thrombolysis of the embolus were successful in both cases, with reperfusion of the whole territory supplied by the MCA and following improvement in the clinical findings and imaging studies. Both patients were discharged with only mild neurological deficits. Conclusion: Our report demonstrates two classic cases of ischemic stroke, in which endovascular intra- arterial treatment was successful. The vast clinical improvement in both patients implies the relevance of performing this procedure in the setting of acute brain infarction. Keywords: stroke, mechanical thrombectomy, intra-arterial thrombolysis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 24 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 SEVERE CARDIOMYOPATHY IMITATING ACUTE ABDOMEN Lazar Kutin1, Elisabeth Bossilkova1, Georgi Popivanov2, Ventzislav Mutafchiyski2

1Student, Medical University of Sofia 2Clinic of Endoscopic, Endocrine Surgery and Coloproctology, Military Medical Academy Sofia, Bulgaria

ABSTRACT Introduction: A wide variety of medical conditions could imitate acute abdomen and are a leading cause for mis- diagnoses and wrong decision making in emergency surgery. In order to avoid potentially harmful and serious complications for the patient, the physician must be able to obtain a proper medical history, to conduct a thorough physical exam, to order different kinds of tests and to perform right interpretation of the results. Materials and Methods: Here we present a 78-year-old man admitted to Emergency Department complaining of moderate pain in the right subcostal area and vomiting lasting 2 days. The patient reported a history of myocardial infarction with regular taking of Sintrom. The abdominal examination did not reveal a distended abdomen, guarding or rebound tenderness. Results: Laboratory evaluation revealed: leucocytes – 9.5 109/L, CRP - 42 mg/L, creatinine - 162 µmol/L, INR – 6.3. Abdominal ultrasound showed 3-layered wall thickening of the gallbladder and significant dilatation of the hepatic veins. Further tests showed deterioration of the condition. A working diagnosis of severe acute cholecys- titis was made. Due to inconsistency between the laboratory tests and the physical examination a diagnostic laparoscopy was performed. It revealed a moderate amount of ascites, enlarged and congested liver, swollen gall bladder with no signs of inflammation and an accidental discovery of a malignant formation situated on the transver- sal side of the colon. A minimal resection was performed in order to remove the obstruction. Conclusion: High-grade heart failure as a cause of the presented condition should always be considered, especially in patients over the age 60 years with previous history of acute myocardial infarction. In such cases laparoscopy offers significant diagnostic and treatment benefits as a minimally invasive procedure. In our case it helped avoiding unnecessary laparotomy and cholecystectomy and thus probably saved the life of the patient. Keywords: cardiomyopathy, laparoscopy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 25 Medical University of Varna Case Reports CEREBRAL VENOUS THROMBOSIS Djuliana Stoilova1, Evgeniya Kalevska2, Ivan Valkadinov1

1Student, Medical University of Varna 2Department of Neurology and Neuroscience, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Cerebral venous thrombosis (CVT) is a rare disorder resulting from clot formation in one of the many outflow tracts of the brain. The most affected blood vessels are the superior and lateral sagittal sinuses, but all the cerebral sinuses and veins may be occluded. CVT is often seen as complication of other medical conditions; etiologic and risk factors of the disease vary and the most common include medications (especially third generation oral contraceptives), pregnancy, infections, mechanical traumas, dehydration, hematological conditions such as protein S or C deficiency, thrombocytopenia purpura, antithrombin III deficiency and others. AN important fact is that CVT is a disease affecting more patients in their twenties to forties, so it should be considered in the differential diagnosis of younger patients with relevant clinical symptoms. They are often nonspecific including headache, nausea, vomiting, diplopia, epileptic seizures, papilledema, focal deficits and other, depending on the localization of the thrombosis. A diagnosis is confirmed usually by MRI or CT and especially magnetic resonance venography of the brain. Materials and Methods: In this case report a 37-year-old woman is admitted to the clinic for the first time with a single complaint of severe headache persisting for four days. The somatic and neurologic statuses of the patient were normal. Due to dysmenorrhea the patient was taking Yasmin by prescription from a gynecologist. Results: Contrast-enhanced CT of the brain showed thrombosis of the left transverse and sigmoid sinuses as well as the left internal jugular vein. In conclusion, CVT is an important condition that should be considered not only by neurologists, but also by general practitioners, gynecologists and other specialists because of its general symptoms and serious consequences. The final clinical outcome depends on the complex interrelation between the etiology, localization, severity and evolution of the vascular process, the applied therapy and the existing co-morbidity. Keywords: cerebral venous thrombosis, intracranial sinus thrombosis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 26 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CARDIAC GASTRIC CANCER IN A PATIENT WITH A BLADDER NEOPLASM: CASE REPORT Boryana Georgieva1, Irina Ivanova2,3, Milko Mirchev3, Nikolay Georgiev3

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna 3Clinic of Gastroenterology, St. Marina University Hospital, Varna

ABSTRACT Introduction: The incidence of cardiac gastric cancer is increasing with a general tendency of reducing the severity of gastric cancer in the world. The risk factors for cancers of the cardia are also different; the role of genetic factors of Barrett’s esophagus and smoking is being discussed, while Helicobacter pylori infection is established as not being a carcinogen. Materials and Methods: The aim of this report is to present a case of synchronous development of gastric adenocarcinoma and transitional cell carcinoma of the bladder. Results: A 71-year-old man was admitted at the Department of Gastroenterology with complaints of progressive loss of appetite and asthenoadynamia, abdominal pain in the left hypochondrium and postprandial epigastric fullness. Recently, the condition has started to present also with dysphagia to solids and quickly after that to liquid foods. The patient has a history of Barrett’s esophagus and moderately differentiated papillary transitional cell carcinoma of the bladder (T1N1M0, G2), managed with surgery and 2 courses of chemotherapy in the summer of 2016. Laboratory tests showed hypochromic microcytic anemia (Hb 108 g/l), a tendency to thrombocytosis and elevated CA 19-9 (4x the upper limit of normal). An abdominal ultrasonography found: gastric wall (high part of the stomach body) - 6 mm, rough and focal bladder wall thickening with polypoid masses. Contrast-enhanced ultrasonography and computed tomography didn`t register liver metastases. During the upper endoscopy a carcinoma of the gastroesophageal junction was established: infiltration near the Z-line of a tumor formation, which causes incomplete obturation, and in retroflexed view was seen an oval tumor formation in cardia, histologically confirmed as highly to moderately differentiated adenocarcinoma. Following a decision of an Oncology Commis- sion, the patient was referred for surgical treatment. Conclusion: We analyzed the current recommendations for the behavior of cardia carcinoma of the stomach and the gastroesophageal junction and the mechanisms for synchronous development of gastric adenocarcinoma and transitional cell carcinoma of the bladder. Keywords: gastric adenocarcinoma, gastroesophageal cancer, bladder cancer

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 27 Medical University of Varna Case Reports EXTRAMEDULLARY PLASMACYTOMA OF THE SKULL BASE DEVELOPING INTO MULTIPLE MYELOMA: A CASE REPORT Dessyslava Nikolaeva1, Dimo Nikolov1, Stela Stanimirova1, Veselin Aleksandrov1, Merlin Mehmed - Efraim2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: An extramedullary plasmacytoma (EMP) is a discrete, solitary mass of neoplastic monoclonal plasma cells which is thought to arise from soft tissue. It is a rare lesion to diagnose. 80-90% of tumors develop in the head and neck area, especially the upper airways and paranasal sinuses. When the skull is involved most occur in the calvarium and only a few cases have been described in the skull base. Materials and Methods: A 29-year-old woman complained of frontal headache, diplopia and vision loss of the right eye. Cranial CT revealed a 4/4cm-sized mass engaging the sphenoidal sinus, the clivus and the anterior cranial fossa and an extradural osteolytic lesion in the left parietal region with soft tissue component and bone destruction. Total extirpation of the tumour was performed and further examination concluded extramedullary plasmacytoma. Two months after the end of the local radiotherapy treatment she complained of nausea, vomiting, loss of appetite and severe abdominal and lumbar pain. Clinical examination showed progression of the EMP to multiple myeloma. Due to the aggressive evolution of the disease the patient died shortly after the first course of the systemic polychemotherapy treatment. Results: EMP represents 3% of all plasma cell neoplasms. The median age of patients is 55 years and 75% involve males. It progresses to multiple myeloma in 11-30% of cases at 10 years. Extramedullary plasmacytoma of the skull (EPS) is very rare and only 35 cases have been reported. They present more commonly in female patients (89%) and the cranial base location is the strongest predictor of the development of multiple myeloma. Conclusion: This report presents a case of an uncommon tumour in a rare location in an unexpectedly young patient. Its development supports the data from the little known cases for rapid progression of the EMP of the skull base to multiple myeloma and a lethal outcome soon after. Keywords: extramedullary plasmacytoma of the skull base, multiple myeloma

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 28 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 GIANT PHYLLODES TUMOR-CASE REPORT Dragostina Tsocheva1, Katerina Marinova2, Borislav Petrov2, Rumen Nenkov2, Radoslav Radev2

1Student, Medical University of Varna 2 Department of Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Phyllodes tumors, also known as cystosarcoma phyllodes (CSP) are rare fibroepithelial tumors with an incidence of 0.3-1.0% of all breast neoplasms. They tend to be large, very fast-growing breast tumors, the size of which reaches 10-20 centimeters. Phyllodes tumors may be considered benign, borderline and malignant (10-25%) depending on their histological features and structure. Clinically CSP can lead to the deformation of the breast as well as to ulceration and inflammation of the overlying skin. Materials and Methods: We present a case report of a 48-year-old woman D.Y. who has been admitted and treated several times in different hospitals. In our Clinic of Thoracic Surgery in St. Marina University Hospital she presented with symptoms of extremely enlarged and painful left breast, leak of purulent secretion with a fetid smell. After a physical examination the following changes were discovered: greatly increased size of the left breast (about 70 centimeters), redness and swelling. A presence of a cutaneous fistula projecting over the skin with plenty of quantity putrid fabrics was established in the upper medial quadrant . After the diagnostic process at the Thorac- ic Clinic , the physicians determined that this formation was phyllodes tumor with a giant size. The patient was assessed and scheduled for a radical operative intervention. Results: Intraoperatively, a giant tumor in decay with a size of about 35/40 cm was established. The tumor formation was extirpated by harmonic scalpel and followed by a plastic reconstruction of the breast. During the postoperative period suppuration was not observed. After the control examination, there were no signs of deformation or risk of local recurrence. Conclusion: In this case, because of the beginning of necrosis in the tumor, the patient was wrongly diagnosed and treated for chronic mastitis in the past. Keywords: phyllodes tumor, breast, surgery

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 29 Medical University of Varna Case Reports INFLAMMATORY MYOFIBROBLASTIC TUMOUR OF THE KIDNEYS – CASE REPORT Dimo Nikolov1, Dessyslava Nikolaeva1, Radi Lukanov1, E. Ahmed1, Valentin Ikonomov2

1 Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Inflammatory myofibroblastic tumour (IMT) is a rare condition which includes proliferation of myofibroblasts accompanied with inflammatory infiltrates. It is known to have a wide age range and to affect both males and females. Although its most common site is the lungs, IMT also has extrapulmonary locations which most often include the bladder and rarely the kidneys. Its biological nature varies from a completely benign to a malignant tumour with fatal outcome. Material and Methods: We report a case of a 61-year-old woman, admitted to a hospital with high temperature and anaemia, five months after left nephrectomy due to a myofibroblastic tumour of the kidney. The performed laboratory tests revealed a significant impairment of the GFR and anaemic syndrome. The conducted MRI-scan found multiple hypodense lesions in the right kidney with enlarged paraaortical lymph nodes. PET-scan and CT- scan confirmed the findings. The results of the examinations illustrated a slow progressive chronic failure of the solitary kidney, which suggested a paraneoplastic process due to recurrence of the IMT. Results: Because of the high CRP rates, the patient underwent an antibiotic therapy with Meropenem, without any clinical and laboratory improvement and deterioration of the signs of inflammation. The findings of hypodense lesions and chronic failure combined with the contraindication of nephrectomy, because of a solitary kidney, suggested the admission of Prednisolone, as this type of tumour is cortisol-sensitive. In connection with the glucocorticoids usage, the patient is scheduled for bone density test. She remains under constant observation. Conclusions: The case presents an uncommon occurrence of inflammatory myofibroblastic tumour with the kidneys as a site of progression. It illustrates the recurrent nature of this type of neoplasm and the complications that it brings, according to the organs, which affects. Keywords: myofibroblastic tumour, kidney neoplasm

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 30 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 IRIDOCYCLECTOMY FOR CILIARY BODY MELANOMA - UNIQUE APPROACH AND SURPRISING RESULT Mladena Radeva1, Dimitar Grupchev2

1Student, Medical University of Varna 2TRS Medical Optician, Medical College, Medical University of Varna

ABSTRACT Introduction: We present a rare clinical case of ciliary body melanoma managed with eye-saving operation. Materials and Methods: A 50-year-old woman was diagnosed with increased IOP, very low visual acuity and cataract. On a visit for a second opinion a melanocytic lesion of the iris with a massive “sentinel” vascularization in the entire upper quadrant was noticed. Ultrasound investigation was very suggestive of ciliary body melanoma. The patient rejected the possibility of enucleation and after assessment of risk factors underwent an open-sky iridocyclectomy. She was left aphakic. After surgery, the patient had hemophthalmos for 20 days, after the absorption of which a zone of excised ciliary body was clearly visible on gonioscopy. Histology investigation confirmed the spindle-cell variant of the tumor and subsequent studies (PET scan), three months after surgery, rejected local and distant metastases. Second operation was performed in 6 months and a lens with artificial iris was su- tured horizontally. Results: She is currently presenting with vision of 0.8, normal pressure, and unaffected other ocular structures. Conclusion: Ciliary body melanoma is a life-threatening condition that usually requires enucleation as a treatment of choice. In our case, by performing a novel surgery, we managed to preserve the patient`s eye and thereby provide good quality of life. Keywords: ciliary body melanoma, cataract, sentinel vessel, iridocyclectomy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 31 Medical University of Varna Case Reports MULTIDISCIPLINARY APPROACH WITH SURGICAL ONCOPLASTY OF A 46 YO WOMAN WITH BREAST CANCER Mohamed Swamad1, Yanislav Mitkov1, Aygulya Akisheva1, Dobromir Dimitrov2, Chavdar Bachvarov2

1Student, Medical University - Pleven 2Department of General Surgery, MHAT St. Marina, Pleven, Bulgaria

ABSTRACT Introduction: Modern treatment applications in breast cancer patients require multidisciplinary approach, combined with oncoplasty and reconstructive surgery in some cases. The term multidisciplinary treatment (MDT) encompasses various diagnostic and treatment approaches in the management of patients with breast cancer. The oncoplastic approach is the best current solution, creating a fine balance between radical surgical treatment and preservation of the breast. Materials and Methods: We looked at the patient’s case file from September 10, 2015 until 7 months ago. All the medical documentation was collected upon request from the Department of General Surgery at MHAT Saint Ma- rina, Pleven. The patient, without a history of other pathology, was hospitalized at MHAT Saint Marina, Pleven presenting with a painless, palpable tumour mass in the left breast. Results: The patient underwent clinical examinations, echomammography, mammography, fine-needle aspiration cytology (FNAC), tru-cut needle biopsy (TCB), enhanced body CT and CA 15-3 test. Invasive ductal cancer with axillary lymph node involvement was proven on September 30, 2015 with a clinical stage T2 N2 M0. An MDT meeting recommended neoadjuvant chemotherapy with FEC. After 4 cycles of chemotherapy and 3 cycles of Docetaxel, and a good response on clinical examinations and mammograms, on February 17, 2016, the patient underwent simultaneous left skin-sparing mastectomy and right nipple-sparing mastectomy. Dissection of left axillary lymph nodes was done. Histology showed micropapillary breast cancer and no invasive ductal cancer. Two of the resection margins were positive. MDT meeting recommended staging PET – CT, adjuvant chemotherapy, radiotherapy, hysterectomy with adnexectomy. After chemotherapy and radiotherapy, 7 months after surgery, new PET-CT scans showed no recurrence of the disease or distant metastases. The breasts of the patient were reconstructed 9 months after radical surgery with implants. Conclusion: The MDT approach to treatment is the best current solution as collective decision making from multiple disciplined specialists is far better than one specialist making the sole decision. In cases of heterogeneous cancers, TCB is insufficient. Keywords: breast cancer, MDT, oncoplasty, tru-cut biopsy, skin-sparing mastectomy.

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 32 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 WARTHIN’S TUMOR - CASE AND REVIEW Merilin Ivanova1, Jovana Kitanovska1, Kalina Naydenova1, Tatyana Betova2, Paulina Milanova1

1Student, Medical University – Pleven 2Department of Pathology, Faculty of Medicine, Medical University – Pleven

ABSTRACT Introduction: Warthin’s tumor is the second most common benign salivary gland tumor, also known as papillary cystadenoma lymphomatosum (PCL). It is located almost exclusively in the parotid gland, most commonly arising from the tail. The tumor is bilateral or multifocal, in up to 20% of the cases. Warthin’s tumor almost always occurs in older adults. In men, the peak incidence is in the 7th decade, whereas in women it is in the 6th decade. The disease was named Warthin’s tumor after the pathologist who published the first two case reports in the American literature in 1929. Materials and Methods: The information included in this case report is based on a clinical case and detailed literature review. We present the case of a 66-year-old woman with a Warthin’s tumor of the left parotid gland. The tumor formation was painless with solid elastic consistency, movable, slowly growing and affecting the parotid gland on the left side. Subtotal parotidectomy was carried out without complications in the postoperative period. Results: The pathomorphological survey showed a macroscopic view of well-demarcated encapsulated formation, the inside of which had solid whitish fields with a size of 20 mm. The result from the histological examination led to the diagnosis of Warthin’s tumor, and guided us for the treatment plan. Histologically, the tumor is with papillary and cystic structure composed of cylindrical oncocytic epithelial cells arranged in two layers and lympho- cytic components often with forming of germline. Conclusion: Medical history, clinical examination and all other investigations were indicative of a benign salivary gland tumor. Though the lesion is common, a higher number of incidences will provide better understanding of the pathology of Warthin’s tumor. The treatment consists of partial, subtotal or total parotidectomy with preservation of the facial nerve. A malignant transformation is very rare (only in 0.1% of cases) and it usually involves the epithelial component of the tumor. Keywords: Warthin’s tumor, parotid gland, benign

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 33 Medical University of Varna Case Reports HOFFA FRACTURE IN CHILDHOOD Blagovest Belchev1, Konstantin Ganchev1, Yosif Gerchev1, Preslav Penev2

1 Student, Medical University of Varna 2Clinic of Orthopedics and Traumatology, St. Anna Hospital

ABSTRACT Introduction: Coronal fractures of the femoral condyle, first described by Hoffa in 1904, are an uncommon clinical entity typically seen in adults after higher-energy trauma. These fractures appear to be even more uncommon in children. A young boy presented after sustaining a twisting injury to his left knee. He presented shortly thereafter to the emergency room with a swollen, painful left knee and inability to bear weight. Physical examination revealed a diffusely tender knee with a moderate-sized effusion. He reported significant pain with any type or range of motion. Anterior and lateral radiographs of the knee revealed a hemarthrosis with a minimally displaced fracture to the lateral femoral condyle. Computed tomography scan revealed a minimally displaced coronal shear fracture of the lateral femoral condyle. The patient was placed in a bulky soft dressing and knee immo- bilizer, and underwent open reduction and internal fixation. Hoffa fractures are a unique and uncommon clinical entity that has a different personality than other intra articular fractures of the knee in children. In contrast to adults, these fractures appear to be associated with lower-energy mechanisms in skeletally immature patients. Materials and Methods: The patient underwent surgical treatment. It was made with open reduction internal fixation done with 2 screws using anterior approach. Results: After undergoing rehabilitation, the patient recovered full mobility and functionality of the joint for a period of 30 to 35 days. Conclusion: Hoffa fracture in childhood needs to be treated surgically with open reduction internal fixation in most of the cases by using cannulated screws or Herbert screws Keywords: Hoffa fracture, ORIF

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 34 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 COMBINED AUTOGENOUS AND ALLOPLASTIC CRANIOPLASTY IN A 15-YEAR-OLD TRAUMA PATIENT - A CASE REPORT Roksana Tsvetanova1, Zhenya Marinova1, Tsvetan Popov1, Yavor Enchev2, Bogomil Iliev2

1Student, Medical University of Varna 2Department of Neurosurgery and ENT, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The skull integrity is of utmost importance for the permanent brain protection. Posttraumatic skull defects are disfiguring and potentially hazardous for the underlying brain especially when they are extensive and when they are in children. Cranioplasty represents a classical surgical procedure to repair large skull defects. Nowadays, cranioplasty remains a challenging surgical intervention even for experienced neurosurgeons, particularly when concerning the reconstruction of spacious skull defects in the cosmetically important frontotemporal regions of the child skull. Materials and Methods: We present a 15-year-old female patient with a bone fracture оf the skull caused by direct trauma due to a traffic accident. CT examination of the head showed polyfragmented fracture in the right frontotemporal region with underlying brain contusion. Craniotomy and extirpation of the impressed bone fragments were performed. Autogenous and alloplastic cranioplasty materials were used for total reconstruction of the skull defect. The patient was followed-up clinically and radiologically. Glasgow Outcome Scale (GOS) scores were assessed for 3 months postoperatively. Results: The duration of the cranial reconstruction procedure was 4 hours. Clinically in the postoperative period the patient didn’t develop any neurological deficits and the postoperative CT examination demonstrated excellent cosmetic effect. The patient received antibiotic prophylaxis up to 5 days after surgery. GOS result was 5 at the 3-month follow-up. Conclusion: The data suggests that the combined аutogenous and аlloplastic сranioplasty is a safe and effective treatment option for polyfragmented skull fractures in children. The total cranial reconstruction in children must always consider the eventual forthcoming growth of the skull. Keywords: children, traumatic injury, skull fracture, autologous and alloplastic, cranioplasty

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 35 Medical University of Varna Case Reports OSTEOMYELITIS Dragomir Dragomirov1, Meriyan Radeva1, Natalia Stomatova1 , Rostislav Manev2

1 Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Osteomyelitis is an infection and inflammation of the bone or the bone marrow, caused by an in- fecting organism. Although bone is normally resistant to bacterial colonization, events such as trauma, surgery, the presence of foreign bodies, or the placement of prostheses may disrupt bony integrity and lead to the onset of bone infection. Osteomyelitis can also result from hematogenous spread after bacteremia. Other risk factors are conditions that impair the immune system; circulatory problems as poorly controlled diabetes, peripheral arterial disease, often related to smoking, sickle cell disease; problems requiring intravenous lines or catheters as dial- ysis machine tubing, urinary catheters, long-term intravenous tubing; illicit drugs. Early and specific treatment is important in osteomyelitis, and identification of the microorganisms causing the disease is essential for antibiotic therapy. Staphylococcus aureus is the most frequently isolated microorganism in these patients. Methicil- lin-resistant S. aureus (MRSA) is usually considered a nosocomial pathogen, but it is increasingly acquired in the community Materials and Methods: We present a case that begins as acute osteomyelitis but evolves into chronic condition. The disease occurred after inflammation caused by fracture of the femur. Microbiological and pathological examination is necessary to confirm the diagnosis of osteomyelitis and to proceed to targeted and long-lasting antibiotic therapy, which usually includes combination of antimicrobial agents. Results: If left untreated, the infection can become chronic and cause loss of blood supply to the affected bone. When this happens, it can lead to the eventual necrosis of the bone tissue. It requires surgical removal. Conclusion: This case report offers a basic review of the classification, etiology, epidemiology, pathogenesis, and treatment of osteomyelitis. Keywords: osteomyelitis, methicillin-resistant S. aureus, S. aureus

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 36 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 A CASE REPORT OF A CHILD WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS - A RARE BUT POTENTIALLY DANGEROUS DISEASE Liliya Raeva1, Boris Botev1, Paola Kulicheva1, Veselin Boyadzhiev 2, Lachezar Marinov2

1Student, Medical University of Varna 2Department of Paediatrics and Medical Genetics, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of conditions uniﬁed by the presence of chronic childhood arthritis without an identiﬁable cause. Systemic juvenile idiopathic arthritis (sJIA) is a rare form of this group characterised by systemic autoinflammation. It contributes to about two-thirds of the total mortality rate of JIA and is frequently complicated by macrophage activation syndrome. Clinical manifestations of the disease can be non-specific in the beginning and as a result the diagnosis can be delayed. Materials and Methods: We present a 13-year-old boy hospitalized at the St. Marina University Hospital, Var- na with complaints of a fever over 38oC accompanied by a rash on the trunk. After physical examination, hyper- emic throat, erythematous rash and cervical lymphadenopathy were discovered. The laboratory tests showed leu- kocytes - 19.32x109/L and CRP - 203.78 mg/l. Echocardiography and computed tomography revealed pericardial effusion and splenomegaly. The patient was diagnosed with acute pericarditis and treated with antibiotics but his condition was not improving. After a month he developed symptoms such as dyspnea, cough and joint pains and was admitted urgently to the Hospital. Further examinations were performed showing hemoglobin- 114 g/l, leu- kocytes - 23.37x109/L and pleural effusion in addition of the previous objective symptoms. Results: Due to the clinical presentation, the patient was diagnosed with sJIA. Now he is successfully treated with tocilizumab and methotrexate. Conclusion: The clinicians should be aware of sJIA as a disease with various clinical features in the beginning and the resemblance to infectious or malignant diseases. Early diagnosis and effective treatment are essential to achieve the best outcomes for the patients and to prevent fatal complications. Keywords: systemic juvenile idiopathic arthritis, children, high mortality rate, non-specific clinical manifestation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 37 Medical University of Varna Case Reports INFECTIVE ENDOCARDITIS IN INTRAVENOUS DRUG ABUSE - A CLINICAL CASE Violeta Dimitrova1, Joana Andonova1, Viktor Urbanchich1, Vesela Zlateva2, Maria Dimova2

1Student, Medical University of Varna 2Department of Propaedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Infective endocarditis (IE) is an inflammation of the endocardium affecting most commonly the heart valves. IE in intravenous drug users (IVDU) is associated with high mortality rates and is one of the complications of intravenous drug abuse. Both right-sided and left-sided involvement of the valves is reported with left- sided pathology leading to more severe complications. Predominant microorganisms associated with this condition in IVDU include Staphylococcus and fungal species due to the compromised immune system of that particular group of patients. Materials and Methods: This is a clinical case of a 32-year-old male with a 15-year history of intravenous hero- in drug abuse, a right middle cerebral artery brain stroke from February, 2015 and chronic hepatitis type C. The patient was admitted to a hospital with symptoms of intermittent fever with duration of a few months, which reached 38 °C in the last 10 days, difficulty talking and left leg numbness from two days. Results: After a number of clinical examinations and laboratory tests were carried out, the patient was diagnosed with subacute left middle cerebral artery brain stroke, infective endocarditis with Staphylococcus aureus and grade IV aortic regurgitation. Treatment with antibiotics including Vancomycin, Ceftriaxone, Gentamicin and Ciprofloxacin was immediately initiated, following stabilization of the patient who was to be considered for further surgical treatment having in mind the high-risk group he represented. Conclusions: This clinical case is an example of the severe complications to which drug abuse may lead and the difficulties physicians may experience in the management and follow-up of such high risk patients. Keywords: infective endocarditis, high-risk patients, intravenous drug abuse

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 38 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 RARE CASE OF A BLADDER CANCER IN AN 18-YEAR-OLD MALE PATIENT Alexandar Byankov1, Teodor Tsanev1, Vasil Ivanov2

1Student, Trakia Univesity 2Clinic of Urology, UMHAT Kaspella

ABSTRACT Introduction: The abstract presents a rare case of bladder cancer diagnosed in an 18-year-old male patient. Blad- der cancers are extremely rare in the young population below 20 years of age with probability of occurrence 1:180 000. The case is especially rare for patients who have not been exposed to chemotherapy, cytostatic treatment, bladder augmentation surgery, and other known risk factors. By presenting the case, the abstract aims to raise awareness in the medical community of how to recognize such rare cases. Materials and Methods: The 18-year-old patient is a healthy and active male who had neither ever smoked or drunk, nor had he been exposed to industrial chemicals. The patient arrived with urine examination tests confirming pink hue in the urine (haematuria). He reported intermittent burning sensation when urinating persisting for a year; sometimes experiencing passing frequent, small amounts of urine; and persistent urge to urinate without the ability to do so. The physical examination, ultrasound and scanner of the bladder and the kidneys, showed the existence of а 2x2cm tumor on the left bladder wall. The patient was referred for endoscopic cystoscopy that confirmed the location and size of the tumor. The histology revealed papillary transitional cells with exophytic growth and structure of 3-4 cm. The macroscopic analysis results were also typical for transitional papillary carcinoma. As a result, a resection with bipolar KARL STORZ resectoscope with successive coagulation of the working field was performed. The resected material was extracted and treated with 10%formalin reduction. Additional uro- fluxometria was performed 24 h after the intervention and it confirmed the good results. Results and Conclusion: The clinical case presents a confirmation that the endoplasmic processes of the bladder can develop without the existence of predisposing factors and regardless of the age of the patient. Despite the in- conclusive patient symptoms, bladder cancer must be suspected in the event of macroscopic haematuria. Keywords: bladder cancer, hematuria, rare case, endoscopy, cystoscopy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 39 Medical University of Varna Case Reports CASE OF EUGLYCEMIC KETOACIDOSIS INDUCED BY SGLT2 INHIBITORS (SODIUM-GLUCOSE COTRANSPORTER 2) IN A DIABETIC PATIENT Liliya Ilieva1, Mira Siderova2, Savi Shishkov1, Kiril Hristozov2

1 Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new class of hypoglycemic antidiabetic medications indicated for the treatment of type 2 diabetes by inhibiting the SGLT2 protein in the proximal renal tubule to prevent reabsorption of glucose and facilitate its removal by the kidneys. Materials and Methods: We report case of a 38-year-old woman with unrecognized type 1 diabetes, who developed severe ketoacidosis caused by a sodium-glucose cotransporter 2 inhibitor - Forxiga (dapagliflozin). Results: The patient was misdiagnosed with diabetes type 2 a month and a half before the hospital admission with initial complaints of polydipsia, polyuria, genital pruritus and insignificant weight reduction (1 kg). Family history revealed a mother and an aunt with type 2 diabetes. In this period, she received gliclazide (30 mg/day), met- formin (3 x 850 mg/day) and dapagliflozin (10 mg/day). Four days before hospitalization, the woman complained of nausea, tachydyspnea with gradual deterioration of her general condition. At the hospital admission, the laboratory results showed severe metabolic acidosis (pH: 6.91), positive urinary ketones (+++) and blood glucose level: 11.7 mmol/L. The patient was admitted at the Clinic of Anesthesiology and Intensive Care with severe acidosis and impaired consciousness. The treatment included intravenous insulin, infusions and correction of the electro- lytes and acid-base disorders followed by subcutaneous insulin treatment in a basal bolus regimen. An examination of a panel of antibodies revealed positive GAD 65 (+) with low C-peptide. Conclusion: Diabetic ketoacidosis (DKA) is an acute complication of type 1 diabetes. Glucosuria, insulinopenia and hyperglucagonemia induced by SGLT2 inhibitors are the mechanisms behind normoglycemic ketoacidosis. Keywords: diabetes, ketoacidosis, SGLT2 inhibitors, insulin, glucose

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 40 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DIFFICULT TREATMENT OF RECURRENT HAEMOPTYSIS IN POLYMORBID LUNGS – A CASE STUDY Abdul Shah1, Valentina Dimova2, Bilal Hejazi1

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: This is the case of a 48-year-old female patient presenting with recurrent haemoptysis with an extensive history of pulmonary disease such as tuberculosis and aspergilloma. Comorbidities present in the respective patient have made this scenario much more difficult to understand and treat. Materials and Methods: In 1993 she contracted tuberculosis, which was treated conservatively. Later in 2002, she developed a relapse of the tuberculosis and a lobectomy of the upper left lobe was performed. In 2013, she was diagnosed with aspergilloma and empyema of the left lung and underwent decortication pneu- molysis. Apart from this, the patient has visited hospitals regarding haemoptysis on 3 other occasions, where surgical treatment was refused due to it not being technically possible as the bleeding vessel could not be determined. Most recently, she was admitted to the Clinic on the occasion of complaints for one month with recurrent haemoptysis (200 – 300 ml), which worsened in the last two days. She received 5 infusions of blood and 2 infusions of plasma, showed a better general condition. The haemoglobin value after this was 100g/l and there was no haemoptysis observed in 7 days after her hospital stay. Results: The final decision and course of action for the recurrent haemoptysis is to keep the patient in stable condition via a pharmaceutical route and via infusions because a surgery can cause further complications. Conclusion: In her most recent admission into hospital her situation drastically improved after symptomatic treatment and prophylaxis of infection with antibiotics. The case has presented the importance of symptomatic treatment in a patient with multiple morbidities. This case underlines the fact that not all diseases are curable and we should work on the improvement in quality of life. Keywords: aspergilloma, heamoptysis, polymorbidity, pulmonology

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 41 Medical University of Varna Case Reports AN IRRIGATION PROTOCOL USED FOR THE DEVITALISATION PROCESS OF A RIGHT MANDIBULAR CENTRAL INCISOR WITH A MODERATE ABRASION - A CASE REPORT Miroslav Stoykov1, Nina Nyagulova1, Trayan Marinov1, Maya Doychinova2

1Student, Medical University of Varna 2Department of Conservative Dental Treatment and Oral Pathology, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Chronic dental trauma of the permanent dentition can lead to a pulp canal obliteration. The condition might be difficult to resolve if a proper irrigation technique isn›t performed. Only the simultaneous use of mechanical and chemical preparation techniques allows the endodontist to properly prepare the root canal. The aim of this case report is to present an irrigation technique which effectively removes denticles, residual pulpal tissues and bacteria during endodontic treatment of obliterated root canals. Materials and Methods: For prosthetic purpose the endodontium of a right mandibular central incisor was ne- gotiated. A terminal anaesthesia with 4% Ubistesin was administered. A vital pulpectomy was performed. The root canal was partially obliterated. EDTA-gel (15%) and solutions of 0.9% NaCl (physiological solution), NaOCl (1%) and citric acid (40%) lubricated the canal and evacuated the debris. STEP-BACK technique was used to prepare the canal. Cold lateral condensation was performed to obturate the canal. Glass ionomer cement was applied to restore the occlusal defect. Radiographs were done at the start of the endodontic treatment to determine the working length and at the end - to evaluate the obturation of the root canal. Results: EDTA gel and citric acid solutions proved their effectiveness during the preparation of the obliterated root canal. The smooth walls of the root canal allowed excellent obturation. It was possible to immediately refer the patient for prosthetic treatment. Conclusion: It is imperative to decently lubricate the obliterated canal so as to facilitate the preparation. The chances of fracturing a root canal instrument, forming an apical stop or prepressing debris into the periapical tissues are significantly lowered. Keywords: pulp canal obliteration, irrigation, citric acid, EDTA gel, cold lateral condensation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 42 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TAVI-PROCEDURE: A BRAND NEW START FOR A PATIENT WITH CLASS 3 NYHA HEART FAILURE Diyana Kyuchukova1, Simona Nikolaeva1, Dilyana Tonkova1, Cvetomir Yankov1, Branimir Kanazirev2

1Student, Medical University of Varna 2Department of Propaedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Transcatheter aortic valve implantation (TAVI) is a breakthrough approach for treatment of symptomatic patients with severe aortic stenosis. The procedure is minimally invasive. Risk assessment is mandatory, since TAVI is currently considered only in patients who have a very high surgical risk. Candidates for this procedure must be symptomatic with established severe AS (stage D according to the 2014 AHA/ACC valvular heart disease guidelines) and should have a a life expectancy of more than one year. Materials and Methods: A 75-year-old woman with a high-grade aortic stenosis and accompanying coronary artery disease class III NYHA, hypertension, chronic total heart failure III grade and atrial fibrillation was admitted at the hospital on January 20, 2017, complaining of breathlessness and fatigue. On physical examination she presented with cyanosis of the fingers, orthopneic position in bed and swelling of the feet. Echocardiography determined that the patient had a 3th grade of mitral, aortic and tricuspidal regurgitation with EF – 48 %, diastolic and systolic dysfunction , thus making her an appropriate patient for a TAVI procedure. Results: Surprisingly, only a week afterwards, on control echocardiography, the patient presented with improvement in the grade of the mitral, aortic and tricuspidal regurgitation and EF – 70%, making an incredibly fast recovery. Conclusion: This patient with symptomatic severe aortic valve stenosis and high grade of heart failure NYHA III underwent successful transfemoral TAVI. After the procedure, the patient’s symptoms were markedly improved from NYHA class III to class I. She was discharged without any significant complications and remained free of adverse clinical events after a 6-month follow-up. This case illustrated how remarkable results after TAVI could be. Keywords: TAVI, aortic stenosis, heart failure

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 43 Medical University of Varna Case Reports DENTAL TRAUMA IN CHILDHOOD. REATTACHING A TOOTH FRAGMENT OF ANTERIOR FRACTURED TEETH - CASE REPORT Stefan Stefanov1, Mustafa Dzhambazov1, Dragomir Ivanov1, Gergana Trifonova2

1Student, Medical University of Varna 2Department of Pediatric Dental Medicine, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Coronal fractures of the anterior teeth are a common form of dental trauma that mainly affects children and adolescents. One of the options for managing coronal tooth fractures when the tooth fragment is available is reattachment of the dental fragment. Materials and Methods: We report a case of a 10-year-old boy who was admitted at “Dental Clinic G. Trifono- va” on October 09, 2013, 2 hours after having a trauma in the oral area during sports activities . We observed uncomplicated crown fracture to his maxillary left central incisor, without pulp exposure and without tooth mobility. X-ray showed no root fracture and finished development of the root. Electric pulp test (EPT) showed slightly increased values. The tooth was slightly sensitive to percussion. The fractured tooth fragment was recovered by the patient and maintained in milk. It was only one piece that perfectly matched the tooth. Reattaching fractured fragment technique was performed. Results: Тhe procedure was carried out successfully. After a 3-year follow-up the tooth showed no change of the color and the integrity of the fragment was not compromised. The tooth responded to vitality testing normally. The control x-ray showed no periapical changes. The patient is satisfied with the esthetics and can bite with increased attention. Conclusion: Reattachment of fractured tooth fragments can provide good and long-lasting esthetics (the tooth’s original anatomic form, color, and surface texture). It also restores function, provides a positive psychological response, and is a relatively simple procedure. Patient cooperation and understanding of the limitations of the treatment is most important for a good prognosis. Keywords: dental trauma, coronal fracture, reattachment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 44 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CASE OF A STAGE IIIB HODGKIN’S LYMPHOMA PATIENT TREATED WITH BRENTUXIMAB - MODERN CONCEPTS FOR IMMUNOTHERAPY Tsvetan Popov1, Daniel Zhelev1, Zhenya Marinova1, Roksana Tsvetanova1, Ilina Micheva2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Hodgkin’s Lymphoma (HL) is a malignant lymphoma with distinct histology, biologic behavior, and clinical characteristics. The neoplastic Reed-Sternberg cell is mostly of B-cell origin, derived from lymph node germinal centers but incapable of producing antibodies. Although it is potentially curable, some patients remain primary resistant to standard chemotherapy and appear to be a serious therapeutic challenge. The emerging new agents, however, give new perspectives in the treatment of HL. Materials and Methods: A case report of a 57-year-old man with nodular sclerosis HL is discussed. He was diagnosed in 2012. Seven cycles of chemotherapy by BEACOPP were prescribed as first line treatment with subsequent assessment of the tumor response. Because of the resistant disease, he received four cycles of ICE, four cycles of DHAP, four cycles of IGEV as salvage therapy, followed by mobilization of peripheral stem cells, high-dose chemotherapy BEAM and autologous stem cell transplantation (ASCT). His PET/CT still remained positive after ASCT. Brentuximab vedotin (BV) is an antibody-drug conjugate, consisting of chimeric IgG1 antibody cAC10, specifically targeting human CD30, expressed on Reed-Sternberg cells, and microtubule disrupting agent, monomethyl auristatin E. It is indicated as consolidation therapy following ASCT in patients at high risk of relapse. The human IgG4 anti-PD-1 monoclonal antibody Nivolumab, a checkpoint inhibitor approved in May 2016, is used for resistant HL, relapsed or progressed after ASCT and post-transplantation BV. A survey of the literature was conducted regarding the currently available information about the above-mentioned novel agents and their mechanism of action. Results: After ASCT, the patient was prescribed Brentuximab vedotin as a consolidation therapy and the result of the evaluation by PET/CT after four cycles shows for the first time a complete remission. Conclusion: The concept for cell biology and antibody-based immunotherapy is a modern heuristic approach for discovering innovative therapeutics against resistant HL. Keywords: Hodgkin’s lymphoma, immunotherapy, oncohaematology

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 45 Medical University of Varna Case Reports A CASE REPORT OF METASTATIC BREAST CANCER MANAGED WITH HORMONE THERAPY Ahmed Ahmed1, Nalyan Aliadinova1, Borislav Todorov1, Figen Mustafa1, Margarita Trifonova2

1Student, Medical University of Varna 2Clinic of Medical Oncology, St. Marina University Hospital, Varna

ABSTRACT Introduction: Breast cancer is the most frequently diagnosed life-threatening cancer in women worldwide and the leading cause of cancer death among women. The different forms of breast cancer require specific treatment plans. In the presented case endocrine therapy has a salutary effect on the patient with expressed hormone receptors. Materials and Methods: A 55-year-old postmenstrual woman was diagnosed with highly differentiated multifocal invasive ductal carcinoma including perineural invasion and metastases in the lymph nodes, pT2N2aM0, G1 in 2010.The premenopausal patient then had undergone a radical surgical intervention-quadrantectomy and simple mastectomy of the left mammary gland. Adjuvant chemotherapy and hormone therapy with goserelin and tamoxifen consequently were necessary to block the actions of estrogen. In 2012, during a control check- up, liver metastases were discovered and therefore the patient was given first-line therapy with bevacizumab and capecitabine. Due to further growth of the liver metastases, a second-line therapy with docetaxel and carboplat- in was appointed. As the development of the metastases could not be managed yet, an ultimate third-line anties- trogene and targeted therapy with everolimus and exemestane was required. The efficiency of the treatment, pro- ceeding 4 years already, establishes a steady state disease on PET/CT. Result: Since the patient’s type of cancer was evaluated as estrogen receptor-positive, progesterone-positive and HER2-negative, with an immunohistochemical staining score of 1+, the most appropriate and up-to-date administration is the combination of the mTOR inhibitor-everolimus with aromatase inhibitor-exemestane. Block- ing both pathways not only ameliorated the antitumor activity but also reversed endocrine therapy resistance to mTOR signaling. Conclusions: According to recent researches this composite therapy results in an improved clinical outcome as both life expectancy and quality of life are enhanced. Keywords: breast cancer, hormone therapy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 46 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 RESPIRATORY INFECTIONS IN IMMUNOCOMPROMISED PATIENTS Yavor Kyumyurdzhiyski1, Kaloyan Dobrev1, Sibel Yuzeirova1, Kolyo Karahristov1, Valentina Dimitrova2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Immunosuppressive treatment of patients undergoing organ transplantation, which is administered as a supportive therapy, often leads to severe, potentially life-threatening infections, which can be difficult to treat. Pneumocystis jirovecii and Cytomegalovirus (CMV) are some of the most common pathogens which cause pulmonary opportunistic infections in such patients. Materials and Methods:A 40-year-old man, who had undergone a kidney transplantation in May 2013 was subsequently treated with immunosuppressive drugs like tacrolimus, cellcept and corticosteroids for almost a year. The patient was then admitted to the Clinic of Pulmonology at the St. Marina University Hospital, Varna with complaints of fatigue, shortness of breath, high temperature and a hacking cough. Results: Diagnostic imaging showed infiltrative shades in both lungs. Sputum and blood culture tests yielded no isolated microbiological agents. Antibacterial therapy with Tienam, Targocid and Sumamed was initiated, however, there were persistent fatigue, febrility and a deteriorating respiratory insufficiency, which required the use of non-invasive ventilation. CT of the thorax showed changes, specific for a pneumocystic pneumonia. Conse- quently, Biseptol was added to the therapy. Serological tests confirmed the presence of CMV and a course of treatment with Cymevene was conducted. The patient improved substantially and was discharged and prescribed a home oxygen treatment for 3 months. His condition was influenced favourably by broad-spectrum antibiotics, antiviral therapy and non-invasive ventilation. A CT scan was performed in February 2017 and it showed a residual emphysematous bulla in the third segment of the lung. Conclusion: Treatment with immunosuppressive drugs can be a risk factor for the development of serious opportunistic infections in patients who have undergone an organ transplantation. Such infections are not uncommon and they can be a determining factor for the following therapeutic behaviour. Keywords: pulmonology, immunosuppressive therapy, kidney transplant, opportunistic infection

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 47 Medical University of Varna Case Reports CARCINOMA OF THE NASAL VESTIBULE Aizaz Tariq1, Georgi Davidov2, Lilyana Petkova3, Nikolay Sapundzhiev2

1Student, Medical University of Varna 2Department of Neurosurgery and ENT, Faculty of Medicine, Medical University of Varna 3Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Carcinoma of the nasal vestibule (CNV) is one of the rarest cancers of the head and neck. The nasal vestibule is the gateway to the nasal cavity, it is lined by stratified squamous epithelium and contains structures such as hair follicles, sweat and sebaceous glands. Therefore, it is not unexpected that a tumor can possibly develop from the nasal vestibule. Furthermore, it has different etiology, staging and treatment strategies compared with tumors arising from the nasal cavity. An example of squamous cell carcinoma of the nasal vestibule is reported. Materials and Methods: A 65-year-old man who had been a smoker for 30 years presented with an unclarified tumor in the left nostril. Chief complaints included a lesion in the left nostril, which had been treated with a type of local medication for a year without any success. Biopsy revealed carcinoma of the nasal vestibule. PET-CT revealed no regional or distal involvement. Because of concomitant diabetic retinopathy and impaired vision, the patient refused radiotherapy. He underwent subtotal rhinectomy. Complementary resection of the septum was needed at the second stage because of one positive resection margin. Results: No postoperative complications or recurrences were encountered during a follow-up period of six months. The patient was further subjected to reconstructive surgery with an oblique frontal flap. Conclusion: Surgical treatment of carcinoma of the nasal vestibule is reserved for the management of residual or metastatic cancer or in cases with contraindications to radiotherapy. Due to the anatomical location of the tumor the symptoms can include nasal obstruction, epistaxis and pain although sometimes not all the symptoms are seen in patients and some patients might not have any symptoms at all. Keywords: carcinoma, nasal vestibule

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 48 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CLINICAL SIGNIFICANCE OF ELEVATED MACROPROLACTIN LEVELS IN PATIENTS WITH HYPERPROLACTINEMIA. CASE REPORT Velina Kerekovska1, Evelina Zlatanova2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Hyperprolactinemia is the most common abnormality of the hypothalamic-pituitary axis and is the most frequent manifestation of functional pituitary adenomas. Macroprolactin is a non-bioactive prolactin isoform usually composed of a prolactin monomer and an IgG molecule. Despite being clinically non-reactive, it interferes with immunological assays used for the detection of prolactin. Macrop- rolactin is a significant cause of misdiagnosis, unnecessary investigation, and inappropriate treatment in patients with hyperprolactinemia. Despite its estimated prevalence in up to 46% in patients with hyperprolactinemia, macroprolactin is one of the less commonly considered etiologic factors. Materials and Methods: An overview of scientific publications on the database of the National Library of Medicine and PubMed Central and a case report are presented. Results: We present a case report of a 22-year-old female patient, who was admitted at the Endocrinolo- gy Department of the St. Marina University Hospital, Varna. The patient complains of irregular menstru- al cycle, persisting headache for six months, which is lightly influenced by analgesics, and presents outpatient laboratory results of prolactin (1206 mIU/ml) and normal LH, FSH and E2 levels. The MRI scan of the head shows no pathological findings in the pituitary gland. The levels of the macroprolactin are measured using the polyethylene glycol (PEG) precipitation method and show a total of 952 mIU/ml, and prolactin of only 518 mIU/ml. Conclusion: Macroprolactin is commonly found in patients with hyperprolactinemia; however, neither symptoms nor MRI findings are useful in predicting its presence. Patients with macroprolactinemia commonly have symptoms similar to those with elevation in monomeric prolactin only, but its clinical significance remains uncertain. The presence of macroprolactin should always be suspected in patients with hyperprolactinemia. Keywords: macroprolactin, hyperprolactinemia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 49 Medical University of Varna Case Reports INSULINOMA Veneta Yakimova1, Maria Dimova2, Krasimira Nenova3

1 Student, Medical University of Varna 2Department of Propaedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna 3Department of Clinical Medical Sciences, Faculty of Dental Medicine, Medical University of Varna;

ABSTRACT Introduction: Insulinoma is a rare endocrine pancreatic tumor that is derived from beta cells and produces insulin. Clinically it presents with hypoglycemia, weakness, blurred vision, palpitation, and unconsciousness resulting from endogenous hyperinsulinism. Materials and Methods: A 47-year-old man presented to the Internal Medicine Department with hypoglycemia (1.1 mmol/l), weakness, loss of appetite for a few days, blurred vision and a loss of consciousness. His past medical history included chronic pangastritis, chronic colitis, hypoglycemia (1.6,…2.3 mmol/l), severe weight loss in the past 5 years and episodes of unconsciousness on several occasions. The hematology and biochemistry tests were normal except for the low blood glucose level (2.6 mmol/l). A fasting test was performed and the levels of insulin and blood glucose were measured at the same time, giving the ratio > 3.5 which speaks in favour of an inappropriate insulin secretion. In order to localise the tumor, an MRI of the abdomen and CT - enterography were performed, both of which showed pathological induration of the wall of jeju- num. For a more precise diagnosis an octreoscan is to be performed. The patient was treated with glucose, diazoxide, hydrochlorothiazide and prepared for surgical intervention. Results: The differential diagnoses include insulinoma, noninsulinoma pancreatogenic hypoglycemia syndrome (NIPHS), gastrinoma and VIPomas. Elevated insulin level, hypoglycemia and failure of endogenous insulin sup- pression by hypoglycemia are the hallmark of an insulinoma and disprove other diagnoses. Conclusion: Most insulinomas are benign tumors and have a good prognosis. Treatment in the long-term consists of complete resection of the tumor. Keywords: insulinoma

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 50 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 PNEUMOCYSTIS CARINII PNEUMONIA IN IMMUNOSUPPRESSED PATIENTS Desislava Nalbantova, Yasen Petrov, Ivona Zhekova, Simona Mileva, Tsvetana Yordanova

1Student, Medical University of Varna 2Clinic of Pneumology and Phthisiatry, St. Marina University Hospital, Varna

ABSTRACT Introduction: Pneumocystis carinii pneumonia (PCP) is an opportunistic infection that occurs in immunosuppressed patients. Fever is a main symptom of PCP, along with a dry cough that doesn’t produce any sputum. Oth- er chief symptoms include chest tightness and difficulty breathing as well as fatigue and night sweats. There is no blood test to determine if PCP is present in the body. The diagnostic methods of choice include sputum induction and bronchoalveolar lavage. According to recent research 5-25% of transplant patient are affected by PCP. Materials and Methods: The case report centers on the medical history of a man aged 28 years at the time of the diagnosis. Eight years prior to this, he underwent kidney transplantation, and from then on he was on an immunosuppressive therapy. The patient presented with progressive shortness of breath and fever. On hospitalization his general condition was impaired. At the time he was tachypnoic and the following lab results revealed hypo- capnia and hypoxemia. Results: Overview x-ray examination showed rough reticular pattern of the lungs. Three consecutive CT-scans provided the following information: CT on July 01, 2013 - bilateral pleural effusions; CT on August 02, 2013 – areas of consolidation ground glass opacities; CT on August 21, 2013 – resolution of infiltrative and cystic changes. There was a presence of fibrotic changes. The patient was immediately placed on non-invasive ventilation in a pressure support system, which allowed him to maintain saturation above 90%. The removal of the mask caused severe problems, which prompted the need of a week-long intubation. Antimicrobial and nonspecific antibiotic treatment was conducted. As a result, the patient’s condition improved. Conclusion: Although advances in the care of immunosuppressed patients have dramatically lowered its incidence, PCP remains a challenging clinical problem. Keywords: immunosuppressed, Pneumocystis carinii pneumonia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 51 Medical University of Varna Case Reports PYODERMA GANGRENOSUM – A FEASIBLE OPTION IN THE DIFFERENTIAL DIAGNOSIS OF SOFT TISSUE GANGRENE IN DIABETIC PATIENTS? Elina Merashka1, Victor Iliev1, Teodora Nikolova1, Gulay Ahmedova1, Vasil Dimitrov1, Emil Filipov2 1Student, Medical University-Pleven 2Department of Coloproctology and Purulent-Septic Surgery, UMHAT Georgi Stransky, Pleven

ABSTRACT Introduction: Soft tissue gangrene is a severe and life-threatening complication of diabetes. It is usually caused by a previous injury and following bacterial contamination and infection. In some cases the wound specimens show no bacterial presence so that some, more rare conditions must be taken into consideration. Materials and Methods: We have conducted a histological study, immunological study, and a microbiological analysis of wound samples. Results: We present a clinical case of a 57-year-old diabetic male patient with signs of hard-to-heal ulceration on the left shank which extends its borders after surgical treatment and the wound surface is covered with multiple microabscesses. The multiple microbiological analyses of the wound exudate are negative. After conducting immunological and histological analysis the patient is diagnosed with pyoderma gangrenosum. Conclusion: Hard-to-heal wounds with deteriorated local status after surgical treatment in diabetic patients must be assessed after precisely performed clinical studies and differential diagnosis must be expanded in order to include autoimmune diseases. Keywords: hard-to-heal wounds, pyoderma gangrenosum, diabetes

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 52 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 PRIMARY EMPTY SELLA SYNDROME: AN UNUSUAL PRESENTATION OF PANHYPOPITUITARISM Kalina Naydenova1, Hristo Milev1, Katya Todorova2, Beatrice Pancheva2, Nadya Docheva2

1Student, Medical University - Pleven 2Department of Endocrinology, UMHAT Dr. Georgi Stranski, Pleven

ABSTRACT Introduction: This study is aimed at reporting an rare case of an empty pituitary fossa clinically manifested by severe endocrine dysfunction in a 50-year-old male patient, which was radiologically confirmed years after the initial onset of symptoms. Materials and Methods: A detailed medical history was obtained, medical documents from previous hospitali- sations were reviewed including data from medical procedures, blood and hormonal tests, and imaging results. The chief complaints of the patient included growth failure and cryptorchidism in his childhood along with fatigue, sleep deprivation and infertility which persist in his adulthood and recent abdominal pain in combination with gastrointestinal disorder. Results: The diagnosis was based on the radiological evidence of cerebrospinal fluid within the sella turcica accompanied by the presence of ectopic hypoplastic pituitary gland in the region of the tuber cinereum. The hormonal test results correlated with the clinical presentation of consequent hyposomatotropism, hypogonadism, hypothyroidism and hypocorticism. Hyperprolactinemia, low cortisol levels with inverted rhythm of secretion and hypercholesterolemia were also present in this case. Conclusion: Although most commonly empty sella is an incidental finding in what appears to be asymptomatic patients, this report shows a clinically significant case when diagnosis is delayed resulting in insufficient initial treatment. So despite being rare, when present, it may have severe complications if left untreated such as increased intracranial pressure, cerebrospinal fluid rhinorrhea and vision impairment. These are reasons why patients with Primary empty sella syndrome should undergo endocrine, neurological, and ophthalmological evaluation on presentation. Cardiac evaluation is also of vital importance in cases of hypopituitarism as morbidity in this group of patients is increased. Keywords: primary empty sella, hypopituitarism, diagnosis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 53 Medical University of Varna Case Reports PLACENTA ACCRETA – A CASE REPORT Maneesha De Silva1, Simona Angel2 , Kremen Tsvetkov2, Emil Kovachev2, Atanas Alexandrov2

1Student, Medical University of Varna 2Department of Obstetrics and Gynecology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Placenta accreta is a condition of abnormal placentation and invasion of chorionic villi deep into the uterine wall layers. It represents a life threatening obstetrical emergency leading to severe postpartal hemorrhage. Women at greatest risk are those who have myometrial damage caused by previous cesarean delivery with either an anterior or posterior placenta previa overlying the uterine scar. With the increasing rates of Cesarean section and maternal age the incidence of this condition is also rising – from 1 in 4000 pregnancies in 1970s to 1 in 210 in 2006. The advances in modern ultrasonography are giving the ability to reach the diagnosis antenatally and to prevent a severe morbidity and mortality. Material and Methods: Most commonly (88%) placenta accreta is associated with placenta previa. This poster is presenting an unusual case of placenta accreta attached to the uterine fundus. Result: The pregnancy ended with a normal delivery of a healthy infant. Instrumental revision under ultrasound was performed and finally a subtotal hysterectomy had to be conducted. In order to avoid an emergency cesarean and to minimize the complications of prematurity it is acceptable to schedule an operative delivery at 34-35 weeks of gestation. A multidisciplinary team of experienced physicians is required to secure the best outcomes for both the fetus and the mother. In the recent years new techniques are approaching in order to save the uterus although unconvincing results with these new conservative methods are lacking. The preferable management of placenta accreta remains a Cesarean hysterectomy leaving the placenta in situ. Conclusion: This case study showed that consistent review, observation and imaging is important to diagnose and adapt treatment methods in order to provide the best care possible during pregnancy. Keywords: placenta accreta

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 54 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 EARLY DISTRIBUTION OF SQUAMOUS PENILE CARCINOMA Doychin Nikolov1, Boryana Georgieva1, Deyan Anakievski2, Rostislav Marinov2, Inna Gocheva2, Viktor Nikolov2

1Student, Medical University of Varna 2Clinic of Urology, St. Marina University Hospital, Varna

ABSTRACT Introduction: Penile carcinoma is mostly a squamous cell carcinoma (SCC), usually originating from the epithelium of the inner prepuce or the glans. At least one third of the cases can be attributed to HPV-related carcinogenesis. The incidence of penile cancer increases with age, peaking during the sixth decade of life. However, the disease does occur in younger men. Materials and Methods: This abstract features case reports of two patients, aged 44 and 54, respectively, admitted for the first time at the Clinic of Urology at St. Marina University Hospital (Varna, Bulgaria) with similar complaints of non-healing tender lesions in the region of the penis, lasting more than one year. Results: After taking into consideration these complaints, patient no.1 (aged 44) was hospitalized and referred to a CT scan. The CT scan revealed a tumor formation in the corpus of the penis, as well as multiple swollen lymph nodes bilaterally. After the diagnostics an operative intervention – penile amputation and lymphadenectomy was chosen as treatment. Incision biopsy of the operative material revealed a highly differentiated penile squamous cell carcinoma – T2, N0, Mx, G1 (low-grade). Patient no. 2 (aged 54) was admitted into the Clinic of Urology with highly differentiated invasive penile squamous cell carcinoma, diagnosed a month prior. A CT scan of the abdomen and the lesser pelvis was made with the intention of staging the tumor. The scan confirmed an infiltration of the scrotum and the testes. Packages of lymph nodes were visible bilaterally as well as along the iliac blood vessels. Emasculation and lymphadenectomy were chosen as treatment. The incision biopsy confirmed the diagnosis - T3, N3, Mx, G1 (low-grade). Conclusions: The presented case reports prove that the lack of timely consultation with a specialist can lead to radical operative interventions on the male reproductive system, leading to psycho-social discomfort. Keywords: penile carcinoma, squamous cell carcinoma

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 55 Medical University of Varna Case Reports ADULT-ONSET STILL’S DISEASE - A CLINICAL CASE Joana Andonova1, Violeta Dimitrova1, Kalina Chavdarova1, Maria Dimova2, Vesela Zlateva2

1Student, Medical University of Varna 2Department of Propaedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Adult-onset Still’s disease (AOSD) is a type of systemic onset juvenile idiopathic arthritis. Major criteria include high spiking fevers > 38.5 °C, arthralgia or arthritis, a transient, nonpruritic salmon-colored rash and leukocytosis. Minor criteria may include sore throat, lymphadenopathy, negative rheumatoid factor, abnormal liver function tests, hepatomegaly or splenomegaly. Five criteria are needed for diagnosis with at least two of them being major. The condition may present with a sudden onset and symptoms may disappear and never occur again after treatment initiation, it may also turn into a chronic arthritis or, if affecting internal organs, may lead to severe complications. Materials and Methods: This is a clinical case of a 24-year-old female whose symptoms started during pregnancy and continued postpartum. Therefore, she was admitted to St. Marina University Hospital, Varna for diagnostic management. Symptoms included fever of 38.6 °C, a rash affecting the upper body and limbs, joint pain and edema in the knees, wrists and ankles with a duration of one month. Antibiotic treatment that was initiated during that period of time did not account to any improvement of the patient’s condition and the fever persisted. Results: A number of clinical examinations and laboratory tests were carried out to exclude sepsis condition or an underlying autoimmune disorder and the patient was diagnosed with AOSD. Treatment with glucocorticoids- Urbason 60 mg, NSAIDs and gastroprotectants was immediately initiated. The rash and joint pain disappeared and an improvement of the patient’s condition was reported. Conclusions: This clinical case is an example of a patient with fever of unknown origin and contributes to the fact that Still’s disease is a diagnosis of exclusion but should be taken into account in the process of diagnosing and managing unexplained fever conditions. Keywords: adult-onset Still’s disease

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 56 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DILEMMAS IN THE CARDIO-VASCULAR TREATMENT APPROACH. ANTICOAGULANT, ANTIPLATELET DRUG OR A COMBINATION? Vasil Kitanov1, Pamela Georgieva1, Velichko Penchev2, Orlin Asenov2

1Student, Medical University-Pleven 2Second Clinic of Cardiology, UMHAT Dr. Georgi Stranski - Pleven, Bulgaria

ABSTRACT Introduction: Antithrombotic agents are drugs which prevent or reduce blood clotting by manipulating the various pathways of blood coagulation. They are prescribed to patients who are at high risk of getting clots, because they prevent thrombotic cerebrovascular and cardiovascular disease. Both of groups can be used separately or in a combination. Questions arise when the patient has numerous cardiovascular diseases. For illustration, authors present a clinical report about the difficulties in the treatment of a patient with atrial fibrillation, history of two myocardial infarctions and coronary-artery bypass graft (CABG). The aim is to show the indications for using anticoagulants and/or antiplatelet drugs, when and how to combine them, the risk and benefits of using antithrombotic drugs. Materials and Methods: A 65-year-old male patient, complaining of acute palpitations, breathlessness, accompanied by high values of blood pressure (180/100 mmHg). He has a long history of cardiovascular diseases. They started with an arterial hypertension in 1995, followed by two myocardial infarctions in 2000 and 2002. In 2008, three coronary-artery bypass grafts were made. Thereafter, the patient did not have any stenocardial pain. One year ago he had an episode of atrial fibrillation. Before arriving in the hospital, the patient was only on Aspirin therapy without any anticoagulant agents. At discharge from the clinic his therapy was changed. Results and Conclusion: Anticoagulants represent the mainstay of therapy for most patients with atrial fibrillation. Patients on oral anticoagulation often require concomitant antiplatelet therapy, mostly because of coronary artery disease. However, the combination of oral anticoagulation and antiplatelet therapy increases the bleeding risk. The question of whether or not combination antithrombotic therapy is beneficial in terms of a reduction in fatal and non-fatal vascular events in atrial fibrillation is an important question which essentially remains un- answered. Keywords: anticoagulants, antiplatelet agents, therapy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 57 Medical University of Varna Case Reports INDIVIDUALIZED HORMONAL THERAPY IN PATIENTS WITH BREAST CANCER Mariya Levkova1, Dimitrina Konstantinova1, Tanya Kadiyska2, Ivan Donev3

1Department Medical Genetics, Faculty of Medicine, Medical University of Varna 2GMDL “Genika“, Sofia 3Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Tamoxifen is a selective estrogen receptor modulator (SERM) which is used in the treatment and prevention of breast cancer. It is a standard therapy for breast cancer in women. The CYP2D6 is one of the main enzymes responsible for converting tamoxifen into its major active metabolite, endofixen. Variants in the CYP2D6 allele may lead to reduced or absent enzyme activity. Individuals who carry these variant alleles may have reduced plasma concentrations of endoxifen and be intermediate or poor metabo- lizers. That is why it is recommended to study the CYP2D6 genotypic heterogeneity before administering tamoxifen in order to provide an individualized hormonal therapy of breast cancer. Aromatase inhibitors are a class of drugs, which block the enzyme aromatase and are used in the treatment of breast cancer in postmenopausal women. Aromatase catalyzes the last steps of estrogen biosynthesis and it is a cytochrome P450 enzyme complex that is encoded by CYP19. Variants in CYP19A1 may be important, regarding both the efficacy and toxicity of aromatase inhibitors. Materials and Methods: We tested 4 women for CYP2D6 genotypic heterogeneity and 2 for CYP19A1 genetic variations. All of them had beeen diagnosed histologically with estrogen – and progesterone – receptor - positive breast cancer. We used PCR amplification method and Sanger sequencing. Results: One of the patients was an intermediate tamoxifen metabolizer, one of the patients was a heterozygous carrier for CYP19A1 genetic variations. Conclusions: It is of great significance for the treatment of breast cancer to test patients for their drug metabolism activity in order to provide a personalised approach in treating breast cancer. Keywords: genetics, breast cancer, treatment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 58 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 LEFT VENTRICULAR NON-COMPACTION CARDIOMYOPATHY Teresa Buitrago García1, Niarah Ahmad1, Maria Dimova2, Branimir Kanazirev2

1Student, Medical University of Varna 2Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Noncompaction cardiomyopathy (NCCM) is a rare and considerably young entity characterized by a two-layered left ventricular myocardium composed of a thin compacted epicardium and a thick trabeculat- ed endocardium with deep intertrabecular recesses, as a result of morphogenetic abnormalities in embryological development. Its clinical manifestation is widely variable, from asymptomatic to arrhythmias, thromboembolic events and heart failure. Materials and Methods: Several echocardiographic criteria have been proposed and were taken into consideration for the diagnosis of the two patients with NCCM we present. Cardiac magnetic resonance, for its superiori- ty in imaging of the apex and endocardial fibrosis, and 24-hour Holter ECG monitoring, to determine any possible clinically significant arrhythmias, were also used. Results: Our patient A is a 47-year-old woman, who presented with acute left-sided heart failure (EDV 113ml; ESV 75ml; EF 33’5%), precipitated by a hypertensive crisis (BP 220/120), while our patient B is a 68-year-old man with congestive heart failure, NYHA class III (EDV 124ml; ESV 67ml; EF 45’8%), who had history of complete AV block, subendocardial infarction and several comorbidities. Echocardiography showed in both cases systolic and diastolic dysfunction, moderate mitral regurgitation, mild tricuspid regurgitation and the characteristic myocardial structure of NCCM, which was further confirmed by cardiac magnetic resonance. Additionally, the ECG of patient A demonstrated intraventricular conduction abnormalities, LA enlargement and nonspecific ST-T changes. Conclusion: NCCM still waits for unification of diagnostic criteria and guidelines, which would not only have an impact on its prevalence, but also allow better management and prevention of its complications. Until then, the need for a comprehensive approach, including several diagnostic criteria and investigations, is emphasized. Keywords: noncompaction, hypertrabeculation, cardiomyopathy, heart failure

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 59 Medical University of Varna Case Reports COMPLICATION AFTER CARDIAC CATHETERIZATION IN A PATIENT WITH IHD Veselin Petrov1, Veselin Petrov2, Desislava Ivanova1

1Student, Medical University of Varna 2Department of Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: An 86-year-old female patient was being treated for acute myocardial ischaemia by means of catheterization of the right radial artery and insertion of a coronary stent, thus managing the ischaemia. In the next 24 hours, however, a large haematoma of the right forearm occurred, and at the puncture site false aneurysm of the radial artery was formed, in which a big thrombus was located. This lead to swelling, bluish colour, pain and difficulties in the movement of the forearm. At the puncture site a spheric sacciform aneurysm was found with big sidewall thrombus and small residual lumen, through which the blood flowed. Materials and Methods: The patient was operated on – opening and preparing of the radial artery and clamping of the right radial artery. The aneurysmal sac was opened, thrombectomy was performed and the artery was su- tured by 6/0 monofilament suture. Results: The patient was managed and discharged with stable haemodynamics, very good general condition and pulsations in the right radial artery. Conclusions: In rare cases after interventional procedures in the arterial system, lesions in vascular wall occur, resulting in the formation of pathological structures – аneurysms at the puncture site. Oftentimes hemorrhages occur, which is inevitable after breaking the integrity of the artery, thus forming large, for the diameter of the vessel, foramen. Metal guide wires, balloons and stents pass through the puncture in order to keep the artery hole open. In elderly patients, the trauma of the vessel is one of the main reasons for developing such a complication. Keywords: cardiac catheterization, surgery, ischaemia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 60 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 LUNG TRANSPLANTATION OF A PATIENT WITH PULMONARY HYPERTENSION Hristo Draganov1, Kristina Dimitrova1, Hristina Pamukchiyska1, Elena Harizanova1, Diana Petkova2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Pulmonary hypertension is a condition that is characterised by increase in the blood pressure in the pulmonary artery above 25 mmHg at rest and above 30 mmHg during exercise. The disease has a poor prognosis and is fatal despite contemporary treatment. Materials and Methods: We present a case of a 36-year-old man, complaining of progressive dyspnea and dry ir- ritating cough. At the age of 3, he had a surgical intervention for persistent ductus arteriosus. In 2011, he was diagnosed with paralysis of the left vocal fold and high-degree pulmonary arterial hypertension. A number of non- invasive and invasive tests, among which electrocardiography, echocardiography and chest CT scan with contrast, were performed. Results: The results from these tests revealed high pressure in the right ventricle and in the right atrium, severe tricuspid regurgitation, blood pressure of 80 mmHg in the pulmonary artery (above normal), 6 MWDT 316m and dyspnea that required breaks during the test. The final diagnosis was pulmonary arterial hypertension – group I, and targeted treatment with Tracleer and Revatio was started in addition to diuretic therapy. Anticoagulants were not included, because of recurrent episodes of hemoptoe. Despite the treatment, progression of the disease required further actions to be taken. Thus, in 2016 the patient was assessed as a suitable candidate for lung transplantation and the procedure was performed in Vienna. After the surgery, the quality of life and physical state of the patient improved. Conclusion: Early diagnosis and adequate treatment greatly improve the prognosis and the quality of life of patients with pulmonary arterial hypertension. Keywords: pulmonary arterial hypertension, lung transplantation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 61 Medical University of Varna Case Reports SUCCESFUL TREATMENT OF A BIDIRECTIONAL SHUNT - A CASE REPORT Rene-Alexander Starick1, Laura Verna Fierro1, Dilyana Tonkova1, Stanislava Ivanova1, Dobrin Kalchev2

1Student, Medical University of Varna 2First Cardiology Clinic, St. Marina University Hospital, Varna

ABSTRACT Introduction: Secundum atrial septal defects are some of the most common congenital heart defects. The placement of an Amplatzer Septal Occluder to close the atrial septal defect (ASD) is performed to treat the defect. A 45-year-old woman was admitted at the St. Marina University Hospital in Varna, Bulgaria with a diagnosis of ASD type II, which was already made at the Charité Hospital in Berlin, Germany. She was treated there for AV nodal reentry tachycardia and respiratory infection two years ago and with bidirectional shunting across the defect. Materials and methods: Over a course of two months the patient received loop diuretics (Torasemide), reducing preload and afterload, as well as Fostair 100/6 (Beclometasone + Formoterol) to treat the respiratory symptoms. Finally, contrast echocardiography showed no bidirectional shunting and interventional procedure of device closure of the ASD was undertaken, making use of the Amplatzer Septal Occluder. NT-pro-BNP levels, before the closure of the defect, were elevated and afterwards, on follow-up on day 7 and day 30, they were close to normal range. Results: After two months, the patient showed significant improved performance, decreased biomarkers and no left to right shunting on colour Doppler. The increased blood flow to the right heart lead to pulmonary hypertension predisposing the patient to respiratory tract infections. In order to effectively treat the patient with elevated pressure of the right heart, pretreatment with diuretics and brochoactive drugs was necessary. Conclusion: Successful placement of an Amplatzer Septal Occluder to close the ASD II was performed after pretreatment of the patient. Keywords: atrial septal defects (ASD), loop diuretics, Amplatzer Septal Occluder

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 62 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 AN INFANT WITH SPONTANEOUS TUMOR REGRESSION Viktor Urbanchich1, Kalina Chavdarova1, Violeta Dimitrova1, Stayko Chavdarov2, Georgi Guzgunov2

1Student, Medical University of Varna 2House of Medical and Social Care for Children – Haskovo

ABSTRACT Introduction: Neuroblastoma is a developmental tumor arising from the embryonic sympathoadrenal lineage of the neural crest, with extracranial localization in most cases. It is the primary cause of death from pediatric cancer for children between the age of 1 and 5. However, many infants under 18 months have a high likelihood of undergoing spontaneous regression without chemotherapy. This is the case of an infant with a tumor mass, located in the posterior cranial fossa and diagnosed with congenital hydrocephalus. The patient was a male, born in August 2015 by C-section. He had a birth weight of 3500 g, height - 49 cm, morphological gestational age - 38. He was diagnosed with malformation syndrome during the prenatal development. Results: A CT scan of the infant’s head showed a 4/5 cm volumetric tumor mass in the middle line of the posteri- or cranial fossa, causing mass effect. After histological and CT evaluation the tumor was defined as neuroblastoma. It was established to be inoperable because of its invasive character, engaging the cerebellum and upper spinal structures. In addition, transfontanelle ultrasound was made and suggested evidence for hydrocephalus and dilatation of the third and both lateral ventricles. As a palliative measurement a ventriculoperitoneal anastomosis was made. After a couple of months, a second ventriculoperitoneal anastomosis was needed and the new CT scan of the head showed no signs of the existing neuroblastoma. Conclusion: Neuroblastomas show a remarkable capacity to undergo spontaneous regression. A greater understanding of the mechanisms and further exploration of this issue might allow the identification of tumours that have the capacity to undergo spontaneous regression and to induce regression in susceptible tumours using pharmacological, biological or immunological approaches. Keywords: tumor regression , congenital hydrocephalus

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 63 Medical University of Varna Case Reports RH INCOMPATIBILITY IN EARLY MEDICAL ABORTION, A MISOPROSTOL CASE REPORT Johanna Loehr1, Faidra Marazak1, Mara Genovefa Marazak2

1Student, Medical University of Varna 2Asklepieon Private Clinic, Heraklion, Greece

ABSTRACT Introduction: The Rhesus factor is an erythrocyte surface antigen which is inherited separately from the AB0 system. The trait Rh+ refers to the presence of the surface antigen whereas Rh- implies its absence. Rhesus incompatibility occurs when an Rh- mother is pregnant with an Rh+ child, leading to formation of Rhe- sus antibodies in the maternal blood. In 90% of the cases, sensitization occurs during delivery, thus leading to a future second incompatible pregnancy. Other reasons for fetomaternal blood transfusion are trauma, abortion, miscarriage or invasive methods. In this case report, a medical abortion with misoprostol and Anti D administration at 6 weeks of gestational age of an Rh minus woman with positive paternal Rhesus status is presented. Materials and Methods: The patient was a 19-year-old Rhesus negative female patient with positive pregnancy urine test seeking abortion. The paternal Rhesus was positive. Beta pregnancy test: 2698 mIU/ml and ultrasound findings reveal presence of gestational sack (6 weeks gestational age). Full blood examination and ECG were normal. No contraindications for medical abortion were present and the Misoprostol alone regimen was chosen for medical abortion with 8 tablets of Cytotec (misoprostol) sub- lingually and intravaginally. The patient was not hospitalized. Prophylactic antibiotics (vibramycin) were administered and NSAIDS were recommended for pain management. There was also administration of Rhophylac, IM, within 72 hrs and patient observation for at least 20 minutes following the administration. Results: One day post misoprostol regimen administration, ultrasound examination revealed an absence of gestational sack with 11 mm endometrial thickness. This regimen resulted in a complete abortion with no adverse side effects, such as vomiting, diarrhea or abdominal cramps. Follow-up ultrasound, revealed 6.3 millimeters of endometrial thickness. Conclusion: There is not enough evidence concerning the application of Anti D Serum after medical abortion in Rhesus minus pregnancies before the 12th week of gestation. Further longitudinal studies and consecutive follow- up of treated patients are obligatory for establishing evidence-based guidelines. Keywords: medical abortion, Rhesus incompatibility, Anti-D prophylaxis, misoprostol case report

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 64 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TOXOCAROSIS (LARVA MIGRANS VISCERALIS) IN ADULT PATIENTS Simona Panteleymonova1, Elizabet Miladinva1, Aleksandra Gerasimova1, Tatyana Cvetkova1, Kalina Stoyanova2

1Student, Medical University of Varna 2Department of Infectious Diseases, Parasitology and Dermatovenereology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Toxocarosis (LMV) is an infection caused by Toxocara spp. Dogs, cats, foxes and other animals play a general role in the transmission and people are accidently infected by ingesting eggs from the environment. In the majority of studies children are identified as a risk group due to their improper hygiene. Increased threat of exposure exists in some professions - veterinarians, zoo technicians, animal shelter employees, etc. Most common symptoms include headache, fever, coughing/wheezing, asthma, urticarial rush, strabismus, liver enlargement, abdominal pain, inflammation of the lungs, weight loss and others. The aim is to present two clinical cases of VLM in adult patients in which the diagnosis is confirmed years after the manifestation of the initial symptoms. Materials and Methods: A retrospective analyses of the clinical history, the course of the infection and the laboratory results were performed. Results: In patient A, the clinical course was comprised of recurring bronchitis, urticarial rashes, dyspepsia and psychopathic episodes for more than 3 years. In patient B for more than 10 years various allergic episodes were observed. The positive ELISA-IgG antibodies for Toxocara spp. were the base for establishing the diagnosis. In both cases the positive results were confirmed by Western blot assay. After the definition of the diagnosis the patients were successfully treated with antiemetic agents. Conclusion: The unspecific clinical signs of VLM and the exclusion of the individuals outside the risk groups can result in misdiagnosis, unnecessary treatment and deterioration of the quality of life of the infected. The correct diagnosis and proper etiological treatment gives a chance for complete health recovery. Keywords: toxocarosis, larva migrans visceralis, infection

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 65 Medical University of Varna Case Reports A CASE OF CONGENITAL HYPOPITUITARISM Catherina Shirokova1, Savi Shishkov1, Velina Kerekovska1, Mila Boyadzhieva2, Kiril Hristozov2

1 Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Congenital hypopituitarism is a condition, presenting with partial or total loss of a single or multiple hormones, secreted by the anterior and/or posterior part of the pituitary gland. Patients have damaged hormone sequences and certain deficits depending on the hormone/s that is absent. Studies point the etiology of the condition as multi-sided – abnormal development, molecular and recently found genetic patterns. Materials and Methods: We present a case of a 21-year-old male patient, first diagnosed with bilateral cryptorchidism 10 years ago. Later on, he developed fatigue, nausea, vertigo and dry scaly skin. The further endocrinology tests showed low levels of adrenocorticotrophic hormones, glucocorticoids, thyrotrophic hormone and gonadotrophins, including low testosterone levels. Physical examination revealed metatarsal bone abnormalities and no signs of puberty development. The family history of the patient also shows a relation between his parents (distant cousins) and another present relative - an older brother with normal development. Results: In this case these four pituitary hormones are absent: corticotrophic, thyrothophic, somatotrophic and gonadotrophic hormone and the results from the MRI study point out hypoplasia of the anterior pituitary gland, enlargement of the posterior part and an absent infundibulum. X-ray results of the hand show retardation of the bone age (consistent with the one of a 12- or 13-year-old boy). Conclusion: Results of the diagnostic tests and procedures lead to the suspicion that in the present case there is a genetic abnormality in the SOX3 gene consistent with the anterior pituitary hypoplasia and an ectopic posterior part. Keywords: hypopituitarism, genetics, pituitary gland

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 66 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MIXED EPITHELIAL AND STROMAL TUMOR OF THE KIDNEY: A CASE REPORT Zekie Kasimova1, Hristo Popov2, Mariya Tsaneva3

1 Student, Medical University of Varna 2Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University of Varna 3Department of Preclinical and Clinical Sciences, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Mixed epithelial and stromal tumor (MEST) of the renal pelvis, also known in the past as cystic hamartoma is a rare benign tumor, recently recognized as a distinct clinical and pathological entity. This complex neoplasm is composed of a mixture of stromal and epithelial elements. Women are more often involved (ratio of women to men 6:1), especially perimenopausal women. It was originally described in 1973 by Block as a congenital mesoblastic nephroma. The term MEST was credited to Michal and Syrucek in 1998. Methods and Materials: A 54-year-old woman underwent laparotomy because of pheochromocytoma. In addition, another tumor was found in the left kidney - a partly cystic and partly solid mass in the renal pelvis, so left-sided nephrectomy was carried out. Results: Macroscopically, the lesion in the renal pelvis had an oval form, measuring 15/8 cm, well circumscribed from the surrounding parenchyma, and with fatty tissue at the periphery; the cut surface revealed multiple cysts of varying size, showing papillary projections on the inner side. On histological examination, a well-delineated tumor was seen, composed of cysts of varying size lined by columnar and cuboidal epithelium. Surrounding stroma showed a mixture of an ovarian type of stroma and eosinophilic loci resembling white bodies and a lot of calcifications. Conclusion: Only about 200 cases of MEST have been described in the literature. Mixed epithelial and stromal tumor of the kidney usually presents in perimenopausal women as a partially cystic mass, and its growth may be influenced by hormones. In the literature, there is no other description of coexisting MEST and pheochromocytoma. Keywords: mixed epithelial and stromal tumor, MEST, renal cyst, pheochromocytoma

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 67 Medical University of Varna Case Reports CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML): A CASE REPORT Desislava Ivanova1, Paolina Kamenova1, Merlin Mehmed2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Chronic myelomonocytic leukemia (CMML) is a type of cancer that starts in blood-forming cells of the bone marrow and invades the blood. This disease is rare in young people. Almost 9 of 10 of cases are diagnosed in people 60 and older. CMML occurs more often in men than in women. CMML patients have a high number of monocytes in their blood. These monocytes can settle in the spleen or liver and cause hepatosplenomegaly. Low numbers of other types of blood cells cause many of the signs and symptoms of CMML like anemia, leukopenia, thrombocytopenia. CMML has features of both myelodysplastic syndrome and my- eloproliferative disorder. CMML is split into 2 groups based on cell counts in the blood and bone marrow. Patients with CMML-1 tend to live longer than those with CMML-2. Materials and methods: This case report describes a 62-year-old male patient who was admitted to the Hae- matology Department complaining about episodes of weakness, dizziness, ecchymosis, bone pain and ic- teric sclera. Two years prior he was diagnosed with ischemic stroke, thrombocytopeniа and myeloma data. Echography, haematological analysis and computer tomographic scan revealed: paraprotein IgM kappa- 4,8%=3,9 g/l; hyperdense areas in the iliac bones (7mm); enlarged lymph nodes in the mediastinum, and hepatosplenomegaly. Results: A trepanobiopsy showed a hypercellular bone marrow with erythroid hyperplasia and interstitial fibrosis grade 2. After the cytogenetic and the myelogram the patient was diagnosed with CMML-2. Conclusion: After treatment, the disease proceeds chronically and it is necessary to do control checkups. About 15% to 30% of CMML patients go on to develop acute myeloid leukemia. Keywords: chronic myelomonocytic leukemia, CMML

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 68 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CASE VARIATION OF SAINT’S TRIAD Gabriela Kirisheva1, Anton Tonev2, Alexander Zlatarov2, Nikola Kolev2, Valentin Ignatov2, Georgi Ivanov2

1Student, Medical University of Varna 2Department of General and Operative Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The classic Saint’s triad involves hiatal hernia, gall stones and diverticulosis of the colon. This condition was described for the first time by Professor C. F. M. Saint from the University of Cape Town a quarter of a century ago. There might be some variations of this kind of pathology. Materials and Methods: In this paper we describe three cases of different variations of Saint’s triad. The first patient was with hiatal hernia, cholelithiasis and umbilical hernia, the second one was with the same combination of diseases and the third one was with gall stones and diverticulosis of the colon. All three patients were female and overweight ( body mass index of 25.0-29.9 kg/m2) with a history of pregnancy and surgical treatment of cholelithiasis. Additionally, the three patients had two of the three conditions of Saint’s triad. Results and conclusion: Based on the analysis of the pathogenesis of these three cases, we considered that these four diseases (Saint’s triad and umbilical hernia) are associated with one another. Obesity is a risk factor for umbilical hernia also for Saint’s triad. History of pregnancy , female sex and older age might also be connected to umbilical hernia and Saint’s triad. Knowing the variations of this condition is very important for the general surgeon. It shows us, that three completely different pathologies might be related. The possible pathogeneses are the systematic connective tissue diseases, which are caused by an impaired activity of MMP-2 . We have to know that if we find one of them in a patient, we also have to look for the other components of Saint›s triad. Keywords: Saint’s triad, umbilical hernia, gall stones, hiatal hernia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 69 Medical University of Varna Case Reports RETROPERITONEAL HEMATOMA – A CASE REPORT Ralica Ruseva1, Anton Tonev2, Alexander Zlatarov2, Mehmed Hadzhiveli2, Georgi Ivanov2, Boris Andonov2, Georgi Valentinov2, Nikola Kolev2, Valentin Ignatov2, Krasimir Ivanov2

1 Student, Medical University of Varna 2Department of General and Operative Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The acute hemorrhage of the adrenal glands is a rare condition. Trauma is the most common cause, but non-traumatic etiology has been reported. Materials and Methods: We present a case of a 67-year-old patient, who came to our clinic with complaints of strong, unbearable pain in the upper part of abdomen, pale skin and cyanosis on the face. The CT results showed a retroperitoneal hematoma or a highly vascularized tumor formation, as well as intraperitoneal free fluid. The unstable hemodynamics, the shock and the temporary cardiac arrest could not be controlled with a conservative treatment. The patient’s condition, the increased quantity of the retroperitoneal hematoma and the intraperitoneal free fluid required emergency surgery. During the operation we found a rupture of the left adrenal gland and a crossing of the hematoma in the right part of the retroperitoneal space. We performed left adrenalectomy. Results: In the early postoperative period, the condition of the patient remained critical despite the postoperative intensive care and the compensation of the blood loss and that led to a lethal outcome. Conclusion: The formations of the adrenal glands may present a diagnostic challenge and difficulty in choosing a treatment approach. This is due to the a wide range of differential diagnoses (adenoma, cysts, pheochromocytoma, myelolipoma, metastases or primary carcinoma), the evaluation of hormonal activity and differentiation between benign and malignant formations. Surgical treatment is indicated in those cases with potentially malignant formations and with a risk of spontaneous rupture. Keywords: hematoma, adrenal gland, adrenalectomy, retroperitoneal

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 70 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MINIMALLY INVASIVE MANAGEMENT OF GIANT ESOPHAGEAL POLYP – A CASE REPORT Samuil Marinov1, Anton Tonev2, Alexander Zlatarov2, Mehmed Hadzhiveli2, Georgi Ivanov2, Boris Andonov2, Georgi Valentinov3, Nikola Kolev2, Valentin Ignatov2, Krasimir Ivanov2

1 Student, Medical University of Varna 2Department of General and Operative Surgery, Faculty of Medicine, Medical University of Varna 3First Clinic of Surgery, St. Marina University Hospital, Varna

ABSTRACT Introduction: The benign tumors of the esophagus are rare disease. Their size has a great variation – from a few centimeters to taking up the whole length of the esophagus. Usually, they present with dysphagia, anemia and in some cases - aspiration or protrusion through the mouth. The polyps are mainly of fibroepithelial origin. Most of them are treated surgically with cervicotomy or esophagotomy. Materials and Methods: We present a case of a 65-year-old male patient with a large 18x5 cm esophageal polyp with an origin from the upper esophagus after the hypopharynx. The preoperative computed tomography angiography excluded the presence of large vessels in the polyp stalk and that helped to establish the surgical strategy – injection of aethoxysklerol at the polyp base and resection with the help of laparoscopic vessel sealer and divider (LigaSure™). The transoral endoscopic approach was achieved using Weerda di- verticuloscope. Results: The polyp was resected successfully. The vessel sealer provided excellent hemostasis and no damage to the surrounding tissues. The only limitation of the transoral approach was due to the large size of the polyp, which had to be extracted via gastrotomy through a 5cm midline laparotomy incision. The postprocedural period was uneventful, liquid food intake was restored on the 2nd postprocedural day and solid food on the 3rd day. The patient was discharged on the fifth day. After one-year follow-up no recurrence was detected. Discussion: Various approaches have been described for the removal of large esophageal polyps, varying from transoral hybrid approach, cervical approach, thoracoscopic approach and even esophagectomy according to the experience of the institution. Due to the benign characteristics of the disease more minimally invasive approach is preferred and it should be offered to the patient. Conclusion: Preoperative staging of the disease is essential to determine the operational approach that will be applied. The LigaSure device can provide safe hemostasis and facilitate the resection of the polyp stalk. The minimally invasive approach even in cases of large esophageal polyp is safe and feasible and the tumor can be easily extracted via small laparotomy and gastrotomy. Keywords: benign tumor, esophageal polyp, endoscopic approach

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 71 Medical University of Varna Original Research 3D MODELING IN MEDICINE - FROM DIGITAL TOMOGRAPHY TO A 3D MODEL Petar Valchanov

Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Three-dimensional (3D) modeling is a digital process, which allow us to create an anatomically correct 3D model. It can demonstrate the anatomical structures in the body on a multiplanar scale. 3D models can be used in medicine for presentational, educational, scientific, diagnostic and therapeutic purposes. Materials and Methods: 3D modeling requires a desktop computer or an end-user workstation, and a commercial or open-source software, which includes: software for medical image informatics, 3D CAD or a 3D sculpting program and, depending on the purpose of the model, 3D engine for 3D visualization or a 3D slic- ing program for 3D printing. Results: The 3D model is generated by precise morphological data, which are acquired through microscopic or tomographic medical imaging. With a segmentation software, a label map is created - the parts of the imaging, which will be included in the model. From the label map the segmentation software generates the raw 3D model, which has to be subsequently processed with a 3D sculpting software. The final model can be used as a 3D visualization, volumetric 3D hologram or it can be built with a 3D printer. Conclusions: 3D models have many benefits over traditional 2D models (pictures, illustrations): the aspects of the morphological structures can be observed freely, from different angles and in a higher level of details, they can be animated, instant calculations can be made on the targeted structures and lastly, they can easily be 3D printed with synthetic or biological materials. The 3D modeling can be performed with open-source software on a desktop computer or with commercial software on end-user workstation, depending on the complexity of the imaging and the required quality of the final 3D model. However, it requires some basic software, visual, medical and artistic skills. Keywords: anatomy, 3D modeling, imaging, CAD, 3D visualization

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 72 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 EPILEPSY IN CHILDHOOD – REVIEW OF THE LITERATURE Ivaylo Zhechev1, Boyana Vasileva2, Kristiyana Kolewa3, Georgi Gaidarov3, Desislava Videva3

1Student, Medical University of Varna 2Faculty of Cognitive Sciences, New Bulgarian University 3Student, Medical University - Sofia

ABSTRACT Introduction: Epilepsy is a disorder characterized by repeated attacks – motor, sensory, autonomic, mental and behavioral, which are expressed with a characteristic electroencephalograph finding during an attack. The attack starts from an epileptogenic locus and can spread or remain in the locus. The epileptogenic locus could be or not with an abnormal macroscopic view. In all cases, the locus is with reduced threshold of excitability. Lack of sleep, stress, alcohol and others may be provoking factors for an epileptic attack. The presence of only one attack is not a criterion for diagnosing epilepsy. Epilepsy is one of the most common neurological disorders. The disorder is most commonly seen in childhood. The nature, severity, incidence of disease and contingent of patients show that the disease has a great social significance. The aim is an analysis of predisposing factors for the occurrence of epilepsy in childhood. We present an overview of available data for epilepsy in children and the responsible factors for the occurrence of the disorder. Materials and Methods: An analysis of epidemiological studies was conducted. Literature review of the available scientific data in the last 5 years was done. Results: The genetic role for the occurrence of epilepsy is undeniable, but in over 60% of cases there is no detected clear cause of disease. With age the percentage of trauma associated epilepsy is increased and accord- ingly the incidence of unexplained cases of epilepsy - reduced. Conclusion: As a multifactor disease, epilepsy remains difficult for early diagnosis and prevention. In this aspect, great hopes are genetics and the discovery of the human genome. Keywords: epilepsy, childhood, factors, psychological disorder

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 73 Medical University of Varna Original Research RESTORATION OF SENSATION USING HIGH-TECH PROSTHESES - OVERVIEW Maya Nikova1, Burdju Cicek1, Radost Dimitrova1, Yordan Slavov1, Berkehan Koroglu2

1Student, Medical University of Varna 2Department of Physiology, Medical University of Varna

ABSTRACT Introduction: Rapid development of carbon-fiber technology, 3D printing, neuroscience and biomedical engineering have made possible the creation of more functional, lifelike, strong, durable and consciously controlled prostheses. Whilst impressive, all these developments do not make the prostheses a part of the body but rather an additional tool. However, recent breakthroughs show a promise of giving somatosensation to the limb prostheses. Materials and Methods: The information for this scientific overview was gathered using the search platform of PubMed and using the keywords: limb, prostheses, sensation, cortex, neuroprostheses. The articles used in this review are all written after the year 2013 and have been published in peer-reviewed journals with impact factor. Results: Research in the fields of neuroscience and biomedical engineering has led to the development of prostheses which have somatosensation. All prostheses developed this far are currently on the animal testing stage of clinical research. Acquiring somatosensation is accomplished by using appropriate receptors in the prostheses to gather the needed information which is sent to a neural interface (consisting of microelec- trons) implanted in the somatosensory cortex. Using the interface, intracortical microstimulations (ICMS) stimulate the various mapped out areas of the somatosensory cortex and provide the sensation of touch, pressure, etc. Conclusion: Despite the innovative nature of these prostheses they are still not ready to be used by human patients. This is due to the numerous risks that accompany the implantation process and the actual function of the prostheses and the brain interface. These problems, however, may soon be overcome due to the rapid development of neuroscience and biomechanical engineering. Keywords: limb, prostheses, sensation, cortex, neuroprostheses

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 74 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TRANSGENERATIONAL EPIGENETIC INHERITANCE: DOES IT EXIST? Daniel Zhafal1, Metodi Metodiev1, Yoneli Netsova1, Trifon Chervenkov2

1 Student, Medical University of Varna 2Department of Paediatrics and Medical Genetics, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Epigenetic inheritance refers to the mechanisms for transmission of gene regulatory information which is not coded in the DNA sequence (i.e. not genetic) through successive cellular divisions (mito- sis and/or meiosis). It plays a crucial role for the development and importantly, through epigenetic changes, environmental influences (food, smoking, etc.) can be “remembered” and could have long lasting effects after exposure. Transgenerational epigenetic inheritance (TEI) refers to the transmittance of epigenetic information between successive generations and it is generally accepted that such a process (with a few excep- tions) does not occur as there is extensive epigenetic reprogramming and every new generation starts with an epigenetically “clean slate”. Currently, there are convincing demonstrations of transgenerational inheritance of an epigenetic state at a few loci in plants and mice and the evidence in humans is mainly indirect. Nonetheless, even if the epigenetic state of a small number of genes in humans is transgenerationally inherited, it would herald a major shift in the way we think about the inheritance of phenotype. With this in mind, our aim is to review current literature to assess the evidence for existence of TEI in humans and to review its possible mechanisms. Materials and Methods: We performed a PubMed search and analysis of articles containing the term “transgenerational epigenetic inheritance” in their title. Results: At the time of writing there were 31 articles indexed in PubMed corresponding to the given search criteria, nine of which concern TEI in humans. A major drawback in the field is the lack of a clear definition of transgenerational epigenetic inheritance and clear discrimination from inherited epimutation. There are no articles presenting solid evidence for the TEI phenomenon in humans. Possible key mechanisms of transmission are DNA methylation, histone modifications, and non-coding RNAs. Conclusions: There is still lack of solid evidence for the phenomenon of transgenerational epigenetic inheritance in humans. Keywords: transgenerational, methylation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 75 Medical University of Varna Original Research EMOTIONAL SELF-CONFIDENCE OF MEDICAL STUDENTS IN BULGARIA Boyana Vasileva1, Georgi Gaidarov2, Lili Goguleva3, Desislava Videva2, Kristiyana Kolewa2

1Faculty of Cognitive Sciences, New Bulgarian University 2Student, Medical University - Sofia 3 Student, Medical University of Varna

ABSTRACT Introduction: Studying medicine is an occupation related to daily physical and mental stress for students. The nature of the training and its duration are factors which can affect the psyche of the student. Clash of expectations and reality can affect emotionally unstable students and this is reflected in their performance and satisfaction. The aim of this study was to answer what the emotional stability of medical students in Bul- garia is and determine whether there is any connection to certain factors of the environment. Materials and Methods: Data were collected on the basis of the questionnaire method. The survey was conducted anonymously. Results: The number of participants was 152. The largest factor influencing the confidence of the respondents was the teacher (46.7%), followed by the opinion of colleagues (40.8%) and that of the patients (12.5%). To assess stress before the exam period, during the exam period and the night before the exam, the surveyed used a scale from 1 to 10. Thus, three clear graphics which shows how the stress escalate progressive- ly emerged. The highest number (47.4%) of the participants were influenced only by specific grades at the university, 38.8% are influenced by all of their grades, while 13.8% are not affected by grades at all. Of those surveyed - 33.6% have physicians in their families and a member with a different medical education (7.2%). A quarter of the respondents were influenced by their parents when choosing education. Education-related trouble when sleeping was reported by 24.3% of the students and 19.7% have trouble sleeping not related to it. A certain part of the respondents (28.9%) described themselves as emotionally stable and 8.6% - as emotionally unstable. Conclusion: The role of the teacher stands in the foreground when it comes to building self-esteem in students. The dependence of the majority of students on grades influences their satisfaction and further development. This shows that the quantitative assessment of a person of art is irrelevant but also harmful to the construction of future doctors. Keywords: emotional confidence, medical students, survey

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 76 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 PSYCHO-EMOTIONAL DIFFICULTIES FOR PARENTS WITH THEIR FIRST CHILD Lili Goguleva1, Boyana Vasileva2, Desislava Videva3, Georgi Gaidarov3, Irena Kostova3

1Student, Medical University of Varna 2Faculty of Cognitive Sciences, New Bulgarian University 3Student, Medical University - Sofia

ABSTRACT Introduction: Caring for children is associated with a number of difficulties for parents. Raising the first child has more influence on the psyche and social life of parents because no one is born ready to be a parent. This study focuses on the psycho-emotional difficulties of parents when caring for their first child. This way, we can mark up some aspects for future research in this little explored area. Materials and Methods: Data were collected with a questionnaire method among 30 young parents. The survey was conducted anonymously. Results: The age distribution was as follows: 50% of respondents were aged 19-25,43.3% - 26-30 years old and 6.7% were 31-35 years old. The married respondents at the time of the study were 53.3%. The percentage of children with special needs was 6.7%. Insomnia was declared by 80% of respondents as ¼ of them have been subjected to extreme sleep deprivation. Having a kid had a negative impact on the social life according to 13.3% of the respondents and for 40% the impact was positive. Self-assessment of social activity shows that 1/3 of respondents keep their activity relatively low in all periods,1/3 have a busy social life and for 1/3 – the level of social activity goes from high to low after having a child. Despite this, ¾ of the respondents from the last 1/3 return to their previous lifestyle and ¼ continue with the new less active social life. The share of respondents who did not receive any help from a spouse or a friend was 16.7%. To the question “What is the best age for first child?”,73.3% replied 25-30 years, 20% indicated 19-25 years and 6.7% - 31-35 years. Conclusion: Having a child, especially when it is for the first time, is a difficult period for young and unpre- pared parents. New commitments related to time and money, and the emotional commitment to the child impact the psychological state of the parents. Despite the difficulties, the birth of a child in the family is a wonderful event, carrying more joy than burden. Keywords: psycho-emotional, difficulties, motherhood, children

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 77 Medical University of Varna Original Research BURR HOLE ENDOSCOPE-ASSISTED EVACUATION OF CEREBELLAR HEMATOMAS (ICH) Boris Enikov1, Irini Karatsoli1, Veronika Markova1, Bogomil Iliev2, Yavor Enchev2

1 Student, Medical University of Varna 2Department of Neurosurgery and ENT, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Cerebellar hematomas frequently represent surgical emergency due to the limited space of the posterior cranial fossa. They could cause cerebellar edema and dislocation, obstruction of the aqueduct of Sylvius, obstruction or penetration of the fourth ventricle, compression of the brain stem and in the most severe cases - cerebellar tonsillar herniation. In patients with cerebellar hematomas, neurosurgical treatment could be performed by different methods. The minimally invasive burr hole craniotomy with endoscope-assisted evacuation of the life-threatening cerebellar hematomas represents a viable technique of surgical treatment. Materials and Methods: For a period of 5 years, 14 burr hole endoscope-assisted evacuations of cerebellar hematomas were accomplished. Patient selection was based on defined criteria derived from a profound analysis of the pertinent literature. The patients were followed-up clinically and radiologically as morbidity, mortality, and rebleeding rates were specified. Glasgow Outcome Scale (GOS) was studied three months after the procedure. Results: Transparent trocars were used for endoscope-assisted evacuation of cerebellar hematomas with penetration into the ventricular system in 5 patients and in 9 without penetration. The timing of the procedures was within 24 hours after the clinical manifestation. The mean operative time was 65 minutes. The mortality rate was 28.5 % (4 cases). The morbidity associated with hydrocephalus was 14.28% (2 cases)- VPA shunts were placed 1 month after surgery. Percentage of repeat bleeding was 21.4% (3 cases). GOS average result was 4 at 3-month follow-up. Conclusion: The data suggest that the minimally invasive endoscope-assisted evacuation is an effective and reliable treatment option for cerebellar hematomas. Keywords: cerebellar hematoma, burr hole craniotomy, endoscope-assisted evacuation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 78 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 OVERVIEW OF VISUAL PROSTHESES Radost Dimitrova1, Burdju Cicek1, Yordan Slavov1, Berkehan Koroglu2, Georgi Shopov1

1Student, Medical University of Varna 2Department of Physiology, Medical University of Varna

ABSTRACT Introduction: Ophthalmic diseases such as retinal dystrophies (retinitis pigmentosa), glaucoma, etc., damage eyesight and as a result leave the patient partially or fully blind. This is due to the destruction of different types of cells in the retina – photoreceptor cells, bipolar neurons, amacrine neurons and others. Re- cent developments in biomechanical engineering and surgery have enabled us to implant prostheses in the retina, optic nerve and visual cortex thus enabling us to manually send electrical impulses to the respective parts of the visual pathway. Using these methods, clinical trials throughout have shown partial restoration of sight measured by improvement in basic object recognition, motion detection, letter and word reading under specific conditions. Materials and Methods: The information for this scientific overview was gathered using the search engine of PubMed and the keywords: bionic, eye, retinal, prostheses, eyesight. The articles used in this review were all written after the year 2012 and have been published in peer-reviewed journals with impact factor. Results: Depending on the specific damage sustained by the visual pathway, there are several types of prostheses that could be implanted in the patient. Some of the most frequently used are Argus I, Argus II, the Learning Retinal Implant system (LRI) and the EPI-RET3 Implant. All of them have been used in clinical trials and have improved different aspects of the patients’ eyesight. Conclusion: Development of visual prostheses has come a long way and is used today to partially restore several aspects of the patients’ vision. There are still factors limiting the capabilities of the different types of prostheses. However, with the rapid development of biomechanical engineering and the surgical practice these factors are sure to be surpassed in the near future. Keywords: bionic, eye, retinal, prostheses, eyesight

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 79 Medical University of Varna Original Research TO WHAT EXTENT DO EXTERNAL FACTORS CONTRIBUTE TO THE DEVELOPMENT OF ALLERGIES? Niarah Ahmad1, Dominic Fazel1, Teresa Buitrago Garcia1, Foteini Tsipou1, Veselin Boyadhzhiev2

1Student, Medical University of Varna 2Department of Pediatrics and Medical Genetics, Medical University – Varna

ABSTRACT Introduction: Allergies are a widespread condition affecting 30-35% of the population at some stage in their life. The prevalence of allergic diseases continues to rapidly rise globally each year according to the World Allergy Organization (WAO), whilst the cause remains unknown. Materials and Methods: Our aim was to determine to what extent external factors can contribute to the development of allergies. A cross-sectional study was undertaken in March 2017 using anonymous questionnaires. The questionnaires were distributed on social media to ensure a wide range of participants of all ages. Information about the kind of allergens implicated and the severity of the allergic reaction was collected. Of particular interest was the age group where the allergies first appear, the mode of delivery (vaginal or Caesarian section) and if the pregnancy was to term, breastfeeding practices, the type of area they grew up in, activity and stress levels, lifestyle choices (smoking, diet rich in plants), their BMI, as well as family history of allergies. Results: Results from 121 participants were obtained and analyzed. The investigation revealed that one of the most prominent factors increasing the risk of the development of allergies was if an individual was born prematurely, as 100% were found to have allergies. Additionally, of those who were not breastfed, 77% had allergies, whilst 23% did not. Furthermore, of those living a very stressful life, 71% had allergies. Moreover, other risk factors included being delivered by Caesarian section, raised in a city, having minimal daily activity, smoking and having increased BMI. Conclusions: Although our results are promising, we believe that additional research is needed in order to better define the correlations between external factors and the development of allergies. Keywords: allergy, external, environmental, factors

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 80 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 EXPERIMENTAL RAT MODELS OF PERIODONTITIS – A REVIEW Vasilena Kuzmanova1, Atanas Kuzmanov1, Stefka Valcheva-Kuzmanova2

1 Student, Medical University of Varna 2 Department of Preclinical and Clinical Pharmacology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Periodontitis is a highly prevalent chronic inflammatory disease characterized by a progressive loss of gingival tissue, the periodontal ligament and adjacent supporting alveolar bone leading to early tooth loss. The purpose of this review was to summarize the literature data on rat periodontitis models. Materials and Methods: Literature was accessed through PubMed and Scopus. Articles, including reviews and animal studies, were analyzed to establish the currently used rat models of periodontal disease. Results: The literature shows that the rat is the most extensively studied rodent for the pathogenesis of periodontal disease because periodontal anatomy in the molar region shares some similarities with that of humans. Under natural conditions, the rat appears to be extremely resistant to periodontal diseases. Never- theless, periodontitis can be experimentally induced. There are 4 types of models according to the causative factor: bacteria or bacterial products, diet, ligature, and surgery. The inoculation of bacteria (Porphyromo- nas gingivalis, Aggregatibacter actinomycetemcomitans or Fusobacterium nucleatum) may cause periodontitis. Periodontal inflammation can also be induced by a single intragingival injection of lipopolysaccha- rides from bacteria such as Aggregatibacter actinomycetemcomitans and Salmonella typhimurium. The dietary models are induced by feeding the animals a carbohydrate-rich high-calorie diet. In the ligature-induced model, a plaque retentive silk or cotton ligature is fixed in the gingival sulcus around the molar teeth. A surgical model in rats has been proposed in the last 10 years. This model consists of surgically creating a periodontal defect in the form of fenestrations on the radicular surfaces of the second mandibular molars. Conclusion: Experimental periodontitis models in animals are a very important tool for the investigation of the disease pathogenesis and the possible new therapies. Keywords: periodontitis, experimental models, rats

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 81 Medical University of Varna Original Research SURGICAL VS NON-SURGICAL RETREATMENT OF ENDODONTIC CASES – FACTORS, INFLUENCING THE RETREATMENT CHOICE Slavena Georgieva1, Tsvetelina Borisova-Papancheva2, Georgi Papanchev3

1Student, Medical University of Varna 2Department of Conservative Dentistry and Oral Pathology, Faculty of Dental Medicine,Medical University of Varna 3Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Endodontic retreatment describes a root canal procedure performed on a tooth that has previously had a root canal treatment. One of the main reasons for the failure of the initial treatment is bacterial contamination, leading to an inflammatory response characterized as apical periodontitis, granuloma, radicular cyst or abscess. The preservation of the tooth in such cases requires a retreatment, which can be performed non-surgical, surgical or combined. The aim or this work is to systemize the main indications for each treatment option by describing their advantages, disadvantages, as well as possible difficulties when performing it. Materials and Methods: We have studied numerous articles and publications, so that we can present the main factors influencing the different retreatment options. In order to visualize some of the main indications, requiring a retreatment, we are presenting a clinical case, which demonstrates a combined –surgical and non-surgical retreatment of an endodontically treated tooth. Results: When considering treatment for a tooth that has not healed successfully with root canal therapy there are some factors to pay attention to such as root canal system anatomy, root length, patency along the root canal, level of the lesion, structural integrity of the tooth, periodontal status and possibility of coronal reconstruction. All retreatment options present difficulties and possible risks which can lead to non-healing of the apical pathology, possible damaging of the tooth stability and even tooth loss. Conclusion: The longevity of an endodontically retreated tooth depends on the accuracy of the diagnosis, root canal irrigation, preparation, obturation and final restoration. Proper follow-ups, both clinical and radiographic, and thoughtful consideration of the retreatment option – surgical, non-surgical or combined can lead to long-term success and preservation of the tooth. Keywords: retreatment, surgical, non-surgical

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 82 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 COMPARATIVE STUDY OF SINUS LIFT TECHNIQUES – BIOLOGICAL ASPECTS AND OUTCOMES Ralitsa Yotsova1, Dimitar Dochev2, Ivelina Hristova1, Panayotis Marinov1, Yulia Tsulos1

1Student, Medical University of Varna; 2Clinic of Vascular Surgery, St. Marina University Hospital Varna

ABSTRACT Introduction: Sinus lift procedures have undergone various modifications and improvements throughout the years. The aim of this study is to compare the most common techniques (lateral and crestal) and their use according to the clinical case. Materials and Methods: We collected data from numerous researches and conducted a survey among several doctors of dental medicine. We also managed to participate in the follow-up examinations of some of the patients who had undergone such a procedure. The patients (age 20-60 years, irrespective of gender) were equally divided into 2 groups – in the first group the direct method (lateral antrostomy) was used and in the second one – the indirect (crestal approach). The patients from both groups were followed-up post-opera- tively on the 1st, 2nd, 3rd, 6th and 12th week. The implant stability was checked on the 1st, 2nd, 3rd and 6th month. We took into account the following criteria: - Clinical assessment – pain, gingival inflammation and swelling, implant stability - Radiological assessment – graft uptake and bone-implant connection, bone augmentation Results: There was a slight prevalence of patients who suffered pain, gingival inflammation and swelling when using the direct method. However, there was no statistically significant difference in these clinical aspects. We must emphasize the reduction of post-operative discomfort and complications when a piezoelec- tric unit was used. The comparison of bone height augmentation showed almost two times greater results in the 1st group than the 2nd one. This could be contributed to the use of bone grafting materials. Conclusion: The results of our survey corresponded to those of some previous researches and prove that if both methods are applicable in a case, the decision depends mainly on the needs of bone height augmentation. Keywords: sinus lift, comparative research, direct method, indirect method

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 83 Medical University of Varna Original Research BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW Daniel Rachev1, Desislav Dobrev1, Borislava Toncheva1, Rossen Kolarov2

1Student, Medical University of Varna 2Department of Oral and Maxillofacial Surgery and Specialized Imaging Diagnostics, Faculty of Dental medicine, Medical University of Varna

ABSTRACT Introduction: Bisphosphonates are efficiently used to treat osteoporosis, bone metastases of malignant tumors, Paget’s disease and multiple myeloma. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) represents a severe side effect, consisting of progressive bone destruction in the maxillofacial region. The aim of the study is to present clinical information from patients diagnosed with medication-related osteonecrosis of the jaw. Materials and Methods: A retrospective study was performed involving 32 patients hospitalized at the Spe- cialized Hospital for Maxillofacial Surgery in Sofia, Bulgaria with diagnosis of osteonecrosis of the jaws. The selection criteria of the patients were based on the existence of history of bisphosphonate treatment. Results: Thirty-one patients were on a bisphosphonate therapy for bone metastasis. Among cancer patients, the use of denosumab and zoledronic acid was reported. One patient had received oral treatment with iban- dronic acid for osteoporosis. In 23 patients, the bone lesions involved the lower jaw, while in 9 patients the lesions persisted in the maxillary bone. Twenty-eight patients were diagnosed with a second stage of BRONJ. Exposed bone, purulent secretion, fistulas and swelling were clinically observed among patients. All of the patients received antibiotic treatment for BRONJ, while 2 of them were treated surgically. All patients were discharged with improvement after the treatment. Six patients were hospitalized again after time due to remission. Conclusion: In conclusion, the study shows that BRONJ is mainly associated with the use of denosumab and zoledronic acid. Most of the patients seek medical attention in second stage of osteonecrosis. The recommended conservative treatment with antibiotics can lead to remission only in some cases. Keywords: bisphosphonate, osteonecrosis, jaws

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 84 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 KABUKI SYNDROME Radina Ivanova1, Krasimir Todorov1, Georgi Ivanov1, Milena Stoyanova2

1Student, Medical University of Varna 2Department of Genetics, Medical University of Varna

ABSTRACT Introduction: Kabuki syndrome is a rare genetic disorder characterized by mental retardation and typical facial appearance presented by long palpebral fissures with eversion of the lateral third of the lower eyelids and a broad depressed nasal tip. Other clinically heterogeneous symptoms are congenital heart defects, neurological and endocrinological problems, short stature and skeletal abnormalities, postnatal growth deficiency. The aim of the study is to present a rare disease and follow the diagnostic process and management. Materials and Methods: Articles about the syndrome were systematically reviewed. Information about the condition was gathered by using print and digital sources. Results: Because of the low incidence of Kabuki syndrome worldwide, the diagnostic process, and in particular mentioning Kabuki syndrome in the differential diagnosis, is very difficult. There are some clinical criteria which have to be present to make the clinical diagnosis. There are specific criteria for the different age groups. The next step is cytogenetic and molecular analysis, which can confirm the exact type of mutation causing the disorder. The management of the condition includes all kinds of specialists, such as neurologists, cardiologists, endocrinologists, dentists and other, depending on the abnormalities of the certain individual. Psychological consultations can also be needed. A genetic consultation for the next pregnancy is recommended due to the possibility that the condition is inherited by the parents. Conclusion: It is thought that if the abnormalities that can cause problems in the future are properly treated in childhood age, the long-term prognosis is good. Life expectancy depends mostly on the cardiac problems and immunological complications. Keywords: Kabuki, congenital, diagnosis, management

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 85 Medical University of Varna Original Research THE EXTENDED PHENOTYPE Metodi Metodiev1, Yoneli Netsova1, Daniel Zhafal1, Trifon Chervenkov2

1Student, Medical University of Varna 2Department of Paediatrics and Medical Genetics, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The extended phenotype is a particular way of approaching the biological and evolutionary concept of the phenotype. The genotypic manifestation (phenotype) will be viewed beyond the limits of an individual’s body. Extending past the organism to the other phenotype could be seen as a unique way of ad- justing to the conditions of the environment. Parasites that manage to extend their phenotype, thus chang- ing the phenotype of their hosts deliver a marvelous representation of the extended phenotype and the idea that a gene has many different effects on its environment, inside or outside the body. Materials and Methods: Using the book ‘The Extended Phenotype’ and several research papers three examples will be presented. Results: The first example is the Dicrocoelium dendriticum (fluke) and its life cycle. Following several studies of the biology of Dicrocoelium dendriticum, the utterly complex way this microorganism passes through will be presented. The way it manipulates two completely different types of organisms, namely the Cochlico- pa lubrica and Formica fusca will be explained in further detail. The ‘fluke’, deliberately turning the black colored ant into a parasite-driven organism, ensures a further infestation of its final host - either a sheep or a human, causing serious liver damage. The second example is the Spinochordodes tellinii. This organism in- fects grasshoppers and upon reaching its adult form, brainwashes its host through mimicking neurotrans- mitters and endocrine proteins, making the grasshopper seek out and plunge into water. The third example is the malaria parasite and especially the way it makes infected female mosquitoes that carry the parasite significantly more attracted to human breath and odors than uninfected mosquitoes. Conclusions: It can be concluded that that the extended phenotype is not only an idea but a steady phenomenon among different organisms. Keywords: phenotype, parasytes

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 86 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MANAGEMENT OF REPRODUCTIVE HEALTH CONTROL. PAI-1, MTHFR MUTATION AND ANOVULATION Boryana Atanasova, Aleksandra Dzhepkova, Marina Atanasova2, Peter Ivanov3, Regina Komsa-Penkova3

1Student, Medical University of Pleven 2Bachelor of Healthcare Management , Medical University of Pleven 3Department of Chemistry, Biochemistry, Physics and Biophysics, Faculty of Biochemistry, Medical University of Pleven

ABSTRACT Introductions: Pregnancy is one unique process, which involves genetic material from the fetus, the mother, and the father. All have their own part with their own physiological particularity. The polycystic ovary syndrome (PCOS) is a heterogeneous endocrinological disorder, which is considered to be the most common cause of infertility. Anovulation in women with PSOC is still not completely understood, that is why the aim of this study is to investigate if there is a real connection between the plasminogen activator inhibitor-1, MTHFR and PSOC or this is only a coincidence. Materials and Methods: For this study, we engaged 83 women divided into two groups, matched for age and weight, known as case and control. Fifty-eight women with PCOS and 25 weight- and age-matched healthy control volunteers participated in this survey. All participants gave a written informed consent. DNA was isolated from venous blood and PAI-1 4G/5G polymorphism and MTHFR was investigated. Results: The case group with MTHFR indicator N/M genotype are 48%, followed by N/N - 43%, and M/M - 9%. Controls with N/N are 65%, followed by N/M - 25%, and M/M - 10%. Patients with PAI-1 4G/5G are 47%, followed by 4G/4G - 34% one of the highest numbers, and those with a genotype 5G/5G are 19%. The carrier status in the controls was 17%, 66% and 17% respectively for 5G/5G, 4G/5G, 4G/4G genotype, (or 2.4, ci 0.67 – 9.48, p – ns for carrier status of 4G/4G genotype). Conclusion: If we could manage our health we should start it as soon as possible. PAI-1 and MTHFR are in a very close connection. Each of them plays a significant role in the human body and health. We can perform a DNA test, watch the levels of homocysteine and B12, manage sport and food. However, our research may serve as a pilot study from which we can conclude that this is only the beginning. Keywords: PAI-1, methylene-tetra-hydro-folate-reductase, polycystic ovary syndrome, reproduction

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 87 Medical University of Varna Original Research QUANTIFICATION OF (RE)MYELINATION VIA LUXOL FAST BLUE STAINING IN THE INJURED SPINAL CORD OF ADULT RATS: EFFECTS OF WHOLE BODY VIBRATION Elena Harizanova1, Desislava Marinova2, Stoyan Pavlov2, Doychin Angelov3

1Student, Medical University of Varna 2Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical University of Varna 3Anatomical Institute, Faculty of Medicine, University of Cologne

ABSTRACT Introduction: The usefulness of whole-body vibration (WBV) as a therapeutical method after spinal cord injury (SCI), has received little attention in animal SCI-models and clinical settings. Materials and Methods: We performed severe compressive SCI at a low-thoracic level in Wistar rats followed by daily WBV starting 1, 7, 14 or 28 days after injury (WBV1, WBV7, WBV14, WBV28) and continued for 12 weeks after the injury. As controls served rats euthanized in the first 2 weeks post SCI (subacute), with no WBV training (Sham), treated with passive flexion-extension (PFE) and intact animals. The changes in the average optical density (OD/µm2) of white matter in luxol fast blue stained longitudinal sections through the spinal cord were measured. Three types of regions of interest (RoIs) were considered: area with visible damage; a region, adjacent to the damage (penumbra); and distant visibly undamaged area. In an attempt to improve the previously used method for quantification we added a fourth RoI type- tissue bridges in the periphery of the damaged area- as one of the possible morphological substrates for the restoration of connec- tivity. Results: The average OD in the visibly damaged areas was low in all animals as compared to intact ones, and there were no differences amongst the treatment groups. The penumbra and the distant visibly undamaged area showed different degree of remyelinaton in the different groups. Conclusion: The analysis of the ODs suggests that WBV7 and WBV14 enhance remyelination in the penumbra of the injury as well as in distant seemingly intact tissues. Results were compared to our previous measurements that didn’t discriminate between grey and white matter. Keywords: remyelination, luxol fast blue staining, rats, whole-body vibration

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 88 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ECHOCARDIOGRAPHIC ASSESSMENT OF PULMONARY EMBOLISM - MCCONNELL’S SIGN Sofia Nikolova1, Georgi Georgiev2

1Student, Medical University - Sofia 2Department of Anesthesiology and Intensive care, Medical University - Sofia

ABSTRACT Introduction: Pulmonary embolism (PE) is a complication of deep vein thrombosis, presenting with various clinical features. While the majority of cases remain unexpressed, some patients manifest with symptoms from dyspnea and tachypnea to acute cor pulmonale. Accurate diagnosis in the intensive care unit (ICU) or emergency department (ED) is crucial and requires various examinations, including bedside echocardiography. Materials and Methods: This research included 34 systematic reviews and clinical cases acquired from PubMed and Science Direct, using the keywords PE, echocardiography, and McConnell’s sign. Results: Pulmonary embolism is a condition that could remain unexpressed or result in a sudden death, depending on the size of the embolus entering the pulmonary vasculature. Up to 60% of cases of PE are asymptomatic and resolve on their own; however in cases with major vessel occlusion the patient faces life-threatening conditions such as severe hypoxemia or acute cor pulmonale. These cases are linked to high mortality rates, requiring early detection and specific management. The diagnostic process includes routine tests, such as chest radiography. However, bedside echocardiography allows fast and accurate diagnosis based on a distinct set of criteria. Echocardiographic features of PE include severely dilated right ventricle (RV) with decreased systolic function, septal flattening, with normal movement and size of the left ventricle. McConnell’s sign is pathogno- monic for PE. It is a type of an RV dysfunction consisting of akinesia of the mid-free wall but normal motion of the apex. The aim of this review is to analyze the clinical significance of McConnell’s sign in diagnosing acute pulmonary embolism. Conclusions: Acute PE is a life-threatening condition, requiring urgent and accurate diagnosis for proper patient management. McConnell’s sign is the most distinct echocardiographic finding described in patients with acute PE. It may be useful in cases of massive pulmonary embolism in which a rapid presumptive diagnosis is required in ICU/ED settings. Keywords: pulmonary embolism, echocardiography, McConnell’s sign

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 89 Medical University of Varna Original Research ULTRASOUND IN GYNAECOLOGICAL EMERGENCIES Isil Uyanik1, Elis Ismail2

1 Student, Medical University of Varna 2Department of Obstetrics and Gynaecology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The increased development of ultrasonography as a diagnostic tool and its safe, non-invasive, patient-accepted factors make it the preferred imaging modality for gynaecological emergencies. Since the indications of ultrasound usage are numerous, choosing the type of ultrasound depending on the clinical picture of the patient and the hospital amenities varies. Materials and Methods: The information for this scientific review was gathered using the search platform of Google Scholar using the keywords “gynaecology”, “ultrasonography”, “emergency”. All of the articles used in this review have been published in peer-reviewed journals with impact factor. Results: The safety of ultrasonography for all stages of known and unknown pregnancies make it a preferred imaging diagnostic tool for the female pelvis in general. Patients arriving with complaints of abdominal or pelvic pain and vaginal bleeding may have vastly different diagnosis despite the common symptoms, therefore, they would need a different therapy course. Ultrasound can aid in differentiating quickly and ac- curately among many of the causes at admission to emergency room. At the top of the list are complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Depending on the clinical indications, most of the used ultrasound types are abdominal, transvaginal, pelvis or point-care ultrasound for gynaecological emergencies. Patient care is managed actively and based on observation the treatment might be maintained or changed depending on the overall results. Conclusion: Ultrasound is among the most common diagnostic tools especially the transvaginal type, followed by medical history, clinical examination and laboratory tests. Therefore, even when it precedes other imaging tests, being competent in it is still a core skill for clinical care in both gynaecology and emergency medicine because of its efficiency as a tool in decision making. Keywords: gynaecology, ultrasonography, emergency medicine

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 90 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 JUST UNIC. (JACK-UP SHOULDER PROSTHESIS FOR TRAUMA INDICATIONS) Ivaylo Minev, Veronika Zhelezova, Dimitar Dimitrov, Veselin Petrov, Ivona Kocheva

1 Student, Medical University of Varna 2 Clinic of Orthopedics and Traumatology, St. Anna University Hospital, Varna

ABSTRACT Introduction: Adjustable shoulder prosthesis is used for complex fractures. Indications for this system are: a three-part humeral fracture in an osteoporotic bone and four-part fractures (except where the head is no longer attached at all). In case of symptomatic avascular necrosis of the humeral head, it is possible to transform the system from an osteosynthesis device to a hemi-prosthesis by removing the staple and exchanging it with the head, placed on the same morse taper of the stem. If the indication justifies a prosthesis, then the system allows for simple prosthetic head height adjustment and optimum tuberosity repair. Materials and Methods: We present a report on 26 Bilboquet devices with an average follow-up of 25 months. The peripheral support of the humeral head is optimal in resisting varus displacement. A prospective study of 22 Bilboquet cases with an average follow-up of 34 months was conducted. Place in the therapeutic arse- nal – on average for every 100 proximal humerus fractures: 20% are treated by prosthetic arthroplasty; 53% are osteosynthesised by a centromedullary nail or locking screw-plates and 27% can potentially be treated by a system with stem and humeral head staple. Results: This system allows for rapid and controlled, stable anatomical osteosynthesis of complex fractures of the upper extremity of the humerus allowing for regular tuberosity and humeral head consolidation. The stem/sleeve placed in the humeral diaphysis shaft allows for adjustable height distraction of the fracture site to restore the anatomy of the metaphyseal – cephalic position. Consolidation was obtained in all cases. There was no secondary tilt of the head nor migration or non-union of the tuberosites. Conclusion: This works aims to popularize this method in Bulgaria. Just Unic expands the possibilities of better and faster functional recovery. Keywords: orthopedics, traumatology

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 91 Medical University of Varna Original Research ORIF OF INTRAARTICULAR FRACTURES OF DISTAL HUMERUS WITH LCP BIPLANAR PLATING Dimitar Dimitrov1, Valentin Dimitrov2, Ivaylo Minev1, Veronika Zhelezova1, Dimitar Raikov3

1 Student, Medical University of Varna 2Department of Orthopedics and Traumatology, MHAT Shumen 3Department of Orthopaedics and Traumatology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Intraarticular fractures of the distal humerus are relatively rare, most frequently occurring in people in their forties. The mechanism is either a low-energy trauma, when direct hit on the elbow occurs due to a fall in the forward direction, or high-energy ones. Clinical symptoms include pain, swelling, impaired movement and disfiguration of the elbow. Standard anteroposterior and lateral radiographs of the elbow are usually sufficient for diagnosis. The AO/OTA classification is based on the fracture line location and the degree of articular involvement. These intraarticular traumas are termed as type C fracture (AO classification). Materials and Methods: During the period 2015-2017 a total of 18 of patients were admitted with distal humeral fractures. Five of them (28%) were with type C – intraarticular fractures. In all cases open reduction and internal fixation was performed. We used posterior transolecranial approach and chevron-shaped olec- ranon osteotomy. Once the articular surface is exposed the fracture haematoma is evacuated, and all free fragments are removed. K-wires were placed through the medial and the lateral segments to provide provi- sional fixation. Definitive reduction and fixation was done using biplanar plating with anatomically pre- contoured LCP. Results: We used Broberg and Morrey rating scale for evaluation. There were 3 patients with excellent score, 1 good, 1 fair. The mean lack of extension was 8°, mean flexion - 130°, prono-supination was reduced to 155°, with prevalence of pronation. There were no patients with early radiograph signs of arthrosis or osteonecrosis. Conclusion: The elbow joint is inherently prone to stiffness. The functional outcomes are in correlation with the achieved anatomic reduction and stable fixation, while avoiding prolonged immobilization. Using biplanar LCP gives better mechanical resistance, higher stability, and fragment compression, in comparison to uniplanar plating or non-locking plates. Thus, resulting in shorter immobilization, earlier rehabilitation and regaining full range of elbow motion. Keywords: distal humerus, LCP, ORIF

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 92 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 T-TUBE ENTEROSTOMY- A METHOD OF TREATMENT FOR INTESTINAL PERFORATION IN NEWBORNS WITH LOW AND EXTREMELY LOW WEIGHT Aleksandra Gerasimova1, Rumen Hristov2, Petar Stamov2, Galin Hristov2, Sergei Glinkov3

1 Student, Medical University of Varna 2Department of Pediatric Surgery, St. Anna University Hospital, Varna 3Department of Clinical Medical Sciences, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Perforation of the bowel is a complication consisting of different types of intestinal obstruction in childhood and infancy- volvulus, invagination, atresia, meconium ileus, and necrotizing enterocolitis. This condition is life-threatening, requiring urgent surgical intervention, which usually is exteriorization of the bowel and enterostomy. This, on the other hand, is related to prolonged anesthesia and operat- ing time - one of the main disadvantages of this approach. On the other hand, second surgery is needed to recover normal bowel passage. Materials and Methods: The use of T-tube (Kehrs’ tube) as an approach of temporary decompression of gastrointestinal tract is illustrated with four of the cases of intestinal perforation at the Department of Pediat- ric Surgery at the St. Anna University Hospital, Varna. In two of them, perforation occurred due to invagination, in one, the reason was spontaneous perforation and in the other - meconium ileus. Results: Normal bowel passage was recovered up to the 10th postoperative day and after extraction of the drain the fistula was recovered secondary. The surgical intervention was well tolerated by patients and without associated complications. Conclusion: Application of a T-tube drain on the place of perforation solves largely the problems associated exteriorization of the bowel and enterostomy. Such problems are different complications, which can occur during the postoperative period- infection, prolapse, formation of fistula, hemorrhage and others. It is a sparing and effective method of choice, which is easy to perform technically. The main advantage of the T- tube enterostomy compared to a conventional technique is that a second surgery for recovery of normal passage is not necessary. Additional advantages are the simplicity of extraction of the T-tube and fast closure of the site after that. Our research in Medline database established that this approach is associated with less percentage of complications and mortality in comparison to the convention technique. Keywords: T-tube enterostomy, intestinal perforation, volvulus, necrotizing enterocolitis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 93 Medical University of Varna Original Research TISSUE-ENGINEERED POLY(VINYL ALCOHOL) MESH PROSPECTS IN ABDOMINAL HERNIA TREATMENT Constantinos Voniatis1, Daniella Fehér2, Kristóf Molnár3, Gyorgy Weber3, Angéla Jedlovszky-Hajdú3

1Student, Semmelweis University 2Department of Surgical Research and Techniques, Semmelweis University 3Departement of Biophysics and Radiation Biology, Semmelweis University

ABSTRACT Introduction: As one of the most frequent disorders treated in general surgery, treatment of hernias has evolved throughout the years with the current first-choice treatment being hernioplasty via a laparoscopic or open-surgery approach. Currently applied non-biodegradable surgical meshes may cause complications more often than expected. The aim of our research was the synthesis and production of a biocompatible, biodegradable surgical mesh that could serve as a potential candidate for abdominal hernia repair. Materials and Methods: Nanofabricated poly (vinyl alcohol) (PVA) scaffolds were produced via electrospinning from a mixture of PVA and glutaraldehyde (GDA) solutions. Post electrospinning processing included folding, compression and cross-linkage formation via scaffold immersion in HCl solution. Samples were sterilized with ClO2 then stored in PBS at 37 C. The mechanical properties were assessed by an Instron 5942, in different setups recreating surgical conditions. In vivo examination was performed on Wistar Rats (n=45), which were randomly sorted into three groups of 15 animals each. In Group I and II, an artificial abdominal defect (2 x 2 cm) was created then PVA meshes (D: 2.5 cm) were used to repair it. Group III was a control group where only an incision on the skin and muscle was made. Animals were terminated after the 7th, 14th, 28th, 90th and 180th postoperative days. Implants were evaluated macroscopically and micro- scopically. Results: All animals survived until termination date. Upon inspection, no signs of infection or other adverse reaction were found in the environment of the scaffolds. Adhesion formation was found along the suture line rather than the PVA scaffold itself proving its biocompatibility. Histological examination revealed that the meshes were integrated to the host tissue and kept their structure. Conclusion: Our positive results reinforced that a PVA nanofabricated mesh is biocompatible and could be a viable candidate in treatment of abdominal hernias in the future. Keywords: abdominal hernia, nanotechnology, tissue-engineering, poly(vinyl alcohol)

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 94 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ACUTE APPENDICITIS IN OLDER PATIENTS Nellia Gwasunda1, Rafal Al-Rabaey1, Vasil Bozhkov2, Rosen Madjov2

1Student, Medical University of Varna 2Department of Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The aim of this project is to aid in finding and distinguishing the diagnosis of acute appendicitis in older patients. As a result of socio-economic development and achievements in the field of medical science, the average life expectancy is increasing in Bulgaria, as in most countries. This has led to an increase in the number of older patients diagnosed with acute appendicitis. Acute appendicitis is one of the most common diseases presenting with severe abdominal pain and requiring surgery in all cases. While it is typically associated with younger patients, the demographic changes lead to an increased rate of incidence in adult or elderly patients, in which the diagnosis of acute appendicitis is a more complex and challenging process compared to young or middle-aged patients. The reasons for this could be the atypical clinical presentation and enhanced communication problems, as well as several differential diagnoses. Materials and Methods: During the period between 2007 and 2016 a total of 243 patients with acute appendicitis were admitted and operated at the St. Marina University Hospital. Of them, 141 were women (58.1%) and 102 - men (41.9%) with the ratio 1.4: 1. The patients were divided into two groups: of up to 60 years old and over 60 years. The most frequent reported symptoms were: pain in the right lower quadrant, elevated values of leucocytes, fever and anorexia. Results: The ratio of destructive forms of acute appendicitis between the two groups was 64.8% (over 60y) and 35.2% (up to 60y). Conclusion: Acute appendicitis is one of the most common diseases occurring with abdominal pain, requiring surgery. In elderly patients, the diagnosis is difficult because of atypical clinical presentation, extended differential diagnosis, delayed hospital visit and communication difficulties. Keywords: acute appendicitis, surgery, old age

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 95 Medical University of Varna Original Research ENDOVENTRICULAR CIRCULAR PATCH PLASTY FOR LEFT VENTRICULAR RECONSTRUCTION Ani Raynova1, Simona Panteleymonova1, Plamen Panayotov2

1Student, Medical University of Varna 2Department of Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The incidence of heart failure (HF) has increased in the developed countries. Decompensated HF has advanced structural cardiac disease despite optimal medical therapy and carries an extremely poor prognosis. Endoventricular circular patch plasty, or the Dor procedure, is a surgical option in patients with coronary artery disease (CAD), postinfarction aneurysm or ischemic dilated cardiomyopathy. The aim of this study was to evaluate the 9-year experience of this procedure in the Department of Cardiac Surgery at St. Marina University Hospital, Varna. Materials and Methods: Retrospective analysis was conducted by a review of patient records. From March 2008 to March 2017, endoventricular circular patch plasty was performed in 23 patients (17 males and 6 females), mean age 63.2 (52-75) years. All patients presented with heart failure and/or angina. Postinfarction left ventricular (LV) aneurysm was present in all patients. Multivessel CAD was diagnosed in 18 patients (78.3%). Moderate to severe mitral regurgitation was found in 10 patients (43.5%). In five cases (21.7%), surgery was performed on emergency or urgent basis. Results: All patients underwent the Dor procedure. Coronary artery bypass grafting was performed in 20 patients (87%). Aortic valve replacement was performed in one. Endocardectomy for treatment of ventricular tachycardia was performed in one. Intra-aortic balloon pumping was used postoperatively in 7 patients. The mean LV ejection fraction was 28% (16% to 46%) preoperatively and 39.2% (27% to 49%) at discharge. The mean LV end-diastolic volume decreased from 190ml (106 to 320ml) to 113.8ml (56 to 185ml) postoperatively. The survival rate was 82.6%. The mean postoperative hospital stay was 13.4 days (7-24). Conclusion: Endoventricular circular patch plasty successfully restores the LV geometry and function. Re- sults from the Dor procedure show an improvement in cardiac and clinical status and in the survival rate. Keywords: left ventricle aneurysm, surgical ventricular reconstruction, Dor procedure, coronary artery disease, heart failure

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 96 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MALIGNANT HYPERTHERMIA – THE HIDDEN DANGER Dimana Mitsova1, Aleksandra Stefanova1, Elena Stoyanova1, Plamen Angelov1, Anton Dinkov2

1Student, Medical University of Varna 2Department of Propaedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Malignant hyperthermia (MH) is a life-threatening elevation in body temperature usually resulting from a hypermetabolic response to concurrent use of a muscle relaxant and an inhalational general anesthetic. The muscle relaxant involved is usually succinylcholine and the inhalational anesthetic is most often halothane, but other anesthetics such as isoflurane, sevoflurane and desflurane may also be involved. Manifestations can include muscle rigidity, hyperthermia, tachycardia, tachypnea, rhabdomyolysis, and respiratory and metabolic acidosis. The diagnosis is clinical. Patients at risk can be tested for their susceptibility. The highest priority treatments are rapid cooling and aggressive supportive measures. Materials and Methods: The information for this scientific review was gathered from several articles, all of them written after the year 2013. The articles were found by using the keywords: malignant, hyperthermia, anesthesia, complications. Results: Malignant hyperthermia affects about 1/20,000 people. Susceptibility is inherited, with autosomal dominant inheritance and variable penetrance. Most often, the causative mutation affects the ryanodine receptor of the skeletal muscles. However, more than 22 other causative mutations have been identified. Malig- nant hyperthermia may develop during anesthesia or the early postoperative period. Clinical presentation varies depending on the drugs used and the patient’s susceptibility. During an episode of malignant hyperthermia, a medicine called dantrolene, which is a postsynaptic muscle relaxant, is often given. Conclusion: Malignant hyperthermia is a very serious condition, which must not be neglected. It is often discovered after a person is given anesthesia during surgery. The possibility of developing MH should be taken into consideration before every surgery, because it could lead to a fatal ending. Keywords: malignant, hyperthermia, anesthesia, inherited, life-threatening

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 97 Medical University of Varna Original Research OVERVIEW OF FOCUSED ULTRASOUND SURGERY Burdju Cicek1, Ishil Uyanik1, Radost Dimitrova1, Georgi Shopov1, Berkehan Koroglu2

1 Student, Medical University of Varna 2Department of Physiology, Medical University of Varna

ABSTRACT Introduction: Undergoing surgery takes a toll on the body due to the invasiveness of the surgical procedures. Surgeons try to create new, less invasive methods and techniques in order to shorten the recovery time and to minimize potential risks for their patients. Focused ultrasound (FU) has the potential to solve all of the problems connected with the invasiveness of the surgical procedures. The ultrasound beams can be focused on a specific target (tumor) by using radiators, lenses, or reflectors. In most surgical cases an MR is used to guide the focused ultrasound and to ensure correct targeting by obtaining thermal images during sonication. Material and Methods: The information for this overview was gathered using the search platform of PubMed and using the keywords: focused; ultrasound; surgery; oncology; surgical; methods. The articles used in this review are all written after the year 2010 and have been published in peer-review journals with impact factor. Results: FU is an extremely effective and efficient method in removing the targeted tissue. This is due to various damaging effects of the FU. Some of these effects are creating heat on the targeted area, causing necrosis, or creating microbubbles, which upon collapsing create a shockwave that mechanically damages the tissue. Due to these effects FU is becoming more widely used. Conclusion: Using FU, surgeons could minimize the risks for their patients while at the same time increase the effectiveness and efficiency of the procedure. Whilst focused ultrasound surgery is not fully developed and more research is needed, it shows the potential to become the gold standard in some surgical procedures. Keywords: focused, ultrasound, surgery, oncology, surgical, methods

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 98 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ADAMS PROCEDURE – A METHOD OF REPAIR FOR POST-TRAUMATIC DRUJ INSTABILITY Konstantin Ganchev1, Blagovest Belchev1, Desislava Simeonova1, Dennis Veliev1, Preslav Penev2

1Student, Medical University of Varna 2Clinic of Orthopedics and Traumatology, St. Anna University Hospital

ABSTRACT Introduction: The triangular fibrocartilage complex (TFCC) is a ligamentous and cartilaginous structure that suspends the distal radius and the ulnar carpus from the distal ulna. It consists of a triangular fibrocartilage disc, radioulnar ligaments (RUL) and ulnocarpal ligaments (UCL) and is considered the main sta- bilizer of the distal radioulnar joint. The etiology of TFCC injuries consists of falls onto pronated hyperex- tended wrist, forced rotational movements or they are in association with distal forearm fractures. Patients report trauma followed by ulnar-side wrist pain, swelling, sound of clicking during supination or pronation and later on - loss of grip strength. Two specific classifications are used. The Palmer classification gives accurate anatomical location of the lesion while the five-graded Atzei-EWAS classification is used to determine the severity of the rupture. Stabilization of the distal radioulnar joint with reconstruction of distal radioulnar ligaments as outlined by Adams is indicated if a refixation of the triangular fibrocartilage complex is no longer possible and there are no present arthrotic changes. Materials and Methods: Ten patients with distal radioulnar joint instability caused by 4th grade TFCC tears were diagnosed and admitted to the Clinic of Orthopedics and Traumatology in St. Anna University Hospi- tal, Varna for the interval 2013-2017. The procedure of Adams was the surgical method of choice for all of them. Results: MAYO wrist score was used for evaluation of the patients’ pre- and postoperative conditions. The results showed restored stability, relieved symptoms and attained near-physiological levels of pronation and supination after the surgical procedure. Conclusion: TFCC injuries are not to be treated lightly as they trouble the mechanics of the DRUJ. Surgical treatment is considered superior to the conservative, and the Adams procedure is an effective method of approach towards the 4th grade tears. Keywords: TFCC, DRUJ, Adams procedure

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 99 Medical University of Varna Original Research PHARMACOVIGILANCE AND ENSURING DRUG SAFETY Krasen Tonev1, Evgeni Grigorov2, Konstantin Kalaidjiev3

1Student, Medical University of Varna 2Department of Pharmaceutical Sciences and Pharmaceutical Management, Faculty of Pharmacy, Medical University of Varna 3Student, Medical University of Sofia

ABSTRACT Introduction: Nowadays medication therapy plays a crucial role in modern medicine. Consequently, drug molecules and pharmaceutical preparations must fulfil the requirements for quality, efficacy and safety. Since ensuring patient safety is embedded in the underlying maxim of medicine – “Primum non nocere.”, understanding and preventing adverse drug reactions and drug-related problems is pivotal to the clinical outcome of the therapy. The aim of the present work is to present a brief history of pharmacovigilance, its evolution over the years, the challenges it faces and new opportunities for future development. Materials and Methods: A search of up-to-date scientific research on the problem was carried out in several web databases (Science Direct, PubMed and Google Scholar). Results: Through various drug-related tragedies ranging from chloroform during the 19th century, passing through the thalidomide crisis in the late 1950s, the oral biguanide phenformin during the 1980s and even rofecoxib and valdecoxib in the new millennium, it has become clear that pharmaceutical companies should provide a clear proof of safety for new investigational drugs. Furthermore, drug molecules should be subject to rigorous post-authorization monitoring. Data in the form of signals about suspected adverse drug reactions is being gathered daily through “yellow cards” filled out by healthcare professionals worldwide. It is then analysed to assess if there is a causal relationship between drug intake and the development of unknown or undocumented adverse drug reactions. In recent years, however, there has been an increasing interest in finding new ways for generating signals including, for instance, the use of user posts in social media user posts. Conclusions: The emergence and development of pharmacovigilance and the acceptance of drug safety reg- ulations are among the milestones of modern medicine. Furthermore, generation, monitoring and assessment of various reports of adverse drug reactions greatly contribute to providing the public with safer yet effective medications. Keywords: pharmacovigilance, drug safety, adverse drug reactions

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 100 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 COMPARISON BETWEEN THREE LABORATORY METHODS FOR THE DIAGNOSIS OF CRYPTOSPORIDIUM Stela Petrova1, Dimitar Koemdzhiev1, Petko Iliev1, Dimo Nikolov1, Kalina Stoyanova2

1Student, Medical University of Varna 2Department of Infectious Diseases, Parasitology and Dermatovenerology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Human cryptosporidiosis is caused by infection with apicomplexan protozoan of the genus Cryptosporidium (C. hominis and C. parvum). Cryptosporidium is widely recognised as a cause of acute gastroenteritis with diarrhoea, abdominal pain, nausea or vomiting. It mainly affects children but can presents as a potentially life-threatening disease in immunocompromised individuals. The aim of this study is to compare three different methods for the detection of Cryptosporidium: modified Ziehl-Neelsen acid-fast (MZN-AF) stain, ELISA Cryptosporidium Ag test and quick immunochromatographic test in the scope of their utility as diagnostic procedures in patients with diarrhoea. Materials and Methods: The three methods were used for laboratory testing of outpatient and hospitalized individuals with diarrhoea, abdominal pain and other unspecific symptoms of GI tract. Results and Discussion: MZN-AF staining is used to confirm the presence of Cryptosporidium oocysts in faecal smear. This method is very specific but less sensitive for the laboratory diagnosis and requires an experienced microscopist for interpretation of the results. ELISA Cryptosporidium Ag test is an enzyme im- munoassay for the determination of Cryptosporidium parvum and Cryptosporidium hominis antigens in human stool samples and requires trained laboratory technician and specialised equipment for its execu- tion. Cryptosporidium/Giardia Combi immunochromatographic test is quick and easily performed procedure for in vitro determination of Cryptosporidium and/or Giardia duodenalis antigens in stool samples. Both immunological tests have good sensitivity and specificity. Conclusions: MZN-AF staining stool concentration is the gold standard in clinical laboratories due to its specificity and affordability. Immunochromatographic test is the method of choice for quick identification of intestinal protozoan parasites as a cause of diarrheal infection in both outpatient and hospitalized patients for their proper and swift etiological treatment. Keywords: Cryptosporidium spp., cryptpsporidiosis, Modified Ziehl-Neelsen stain, ELISA test, Immuno- chromatographic test

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 101 Medical University of Varna Original Research HER-2/NEU - MOLECULAR STRUCTURE AND STATUS. ANTIBODY - TARGETED THERAPY WITH PERTUZUMAB, TRASTUZUMAB AND DOCETAXEL AND THE IMPACT ON OVERALL SURVIVAL (OS) AND PROGRESSION-FREE SURVIVAL (PFS) IN PATIENTS WITH METASTATIC BREAST CANCER Dimitar Trizlov1, Iliyaz Hadzhiev1, Aleksandar Yordanov1, Valeriy Yordanov2

1Student, Medical University of Varna 2Complex Oncological Center - Ruse

ABSTRACT Introduction: HER-2 positive breast cancer is one of the most aggressive and rapidly growing neoplasms, due to the amplification and overexpression of the HER-2/neu gene. The exceeding presence of the receptor on the cell’s membrane makes it a valuable treatment target. Materials and Methods: HER-2 receptors are among the main factors controlling the cellular growth, di- vision and self-repair. In approximately 25% of breast cancers, the HER-2 gene mutates, producing too many copies of itself. Several methods are possible for discovering the HER-2 status: immunohistochemistry (IHC) and in situ hybridization (ISH, FISH, CISH, Dual-ISH tests). Positive results on these tests quali- fy patients for specific antibody-targeted therapy with trastuzumab and pertuzumab. The therapy includes docetaxel combined with trastuzumab or with both trastuzumab and pertuzumab. Scientific studies analyze key aspects such as OS and PFS by conducting double-blind studies comparing pertuzumab+trastuzum ab+docetaxel with placebo+trastuzumab+docetaxel. Poll among oncologists was also used to review the efficacy of both treatments. Results: The result of the study, used as reference, showed that the PFS was prolonged by 6.1 months - from 12.4 in the control group to 18.5 in the group, using pertuzumab, instead of placebo. The OS rates improved from 40.8 to 56.6 months – a 15.8 months increase. Distinct side effect of the treatment - left ventricular dysfunction also drops by 3.9% in the pertuzumab group (from 8.3% to 4.4%). Data, gathered from the study, is further validated by the oncologists polled. The results can be explained by delving into the action mechanism of pertuzumab, which blocks heterodimerization of the HER-2 receptor with other members of the ErbB family, thus complementing the effects of trastuzumab. Conclusion: The pertuzumab+trastuzumab+docetaxel treatment shows significantly better results in OS and PFS, as opposed to placebo+trastuzumab+docetaxel, when used as first line of therapy, simultaneously lowering cardiovascular side effects. Keywords: HER-2/neu, overall survival, progression-free survival, antibody-targeted therapy, pertuzumab, trastuzumab

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 102 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ASSESSMENT OF RIGHT-TO-LEFT SHUNTS USING CONTRAST TRANSCRANIAL DOPPLER ULTRASOUND – ADVANTAGES AND RELIABILITY OF THE METHOD Zhenya Marinova1, Roksana Tsvetanova1, Elena Ivanova1, Tsvetan Popov1, Antoniya Kisheva2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: It is estimated that 25-30% of the world’s population has patent foramen ovale (PFO). The majority of these people have no problems associated with this condition. However, in recent years, it has been suggested that patients with cryptogenic strokes or transient ischemic attacks (TIA) have a higher prevalence of PFO. Contrast transcranial Doppler (cTCD) ultrasonography is a very sensitive, noninvasive, portable technique which can be used for evaluation of right-to-left shunt (RLS) via a PFO. Materials and Methods: In this study, a group of 19 patients, 9 males and 10 females, at a mean age 45±2 with cryptogenic ischаemic stroke were investigated by cTCD of both middle cerebral arteries (MCA). The technique is performed with intravenous application of 10 mL agitated saline without and subsequently with the Valsalva maneuver (VM). The appearance of bubbles in the MCA is detected, thereby suggesting the diagnosis of RLS. Magnetic resonance imaging (MRI) of the brain was performed. Results: In approximately 58% of the evaluated patients microembolic signals (MES) were detected in MCA suggesting existence of RLS, which was confirmed by transesophageal echocardiography (TEE). In 7 patients, MRI revealed multiple ischaemic lesions. Conclusion: PFO appears more often in patients with cryptogenic stroke than in the general population. The cTCD technique has a similar sensitivity and specificity as cTEE, which is considered a standard method for detecting RLS. But while routine TEE application is often limited in patients with acute stroke because of acute illness, coagulopathy, and lack of patient cooperation, TCD is noninvasive and reportedly safe in patients with embolic stroke of undetermined source (ESUS). In summary, the availability of simple highly sensitive diagnostic techniques such as TEE and TCD for RLS assessment seems to supply a large amount of data on the relevance in the treatment of this condition and both methods must be considered complementary. Keywords: patent foramen ovale, transcranial Doppler sonography, right-to-left shunt, stroke

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 103 Medical University of Varna Original Research DENTAL TRAUMA. DECORONATION TECHNIQUE AS A SUCCESSFUL METHOD IN THE TREATMENT OF ANKYLOSIS Ivelina Hristova1, Slavena Georgieva1, Ralitsa Yotsova1, Konstantina Velikova1, Sirma Angelova2

1Student, Medical University of Varna 2Department of Pediatric Dental Medicine, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Dental trauma is a common condition among children which occurs more often at the age of 8-12 years. Posttraumatic dental ankylosis is a major problem that can be solved with decoronation. This is a technique developed in 1984 to remove ankylosed teeth and increase marginal bone levels in young growing individuals. Materials and Methods: After studying different articles and researches we have tried to describe the main advantages of the decoronation technique. Results: The decoronation technique is suggested as an alternative treatment to the extraction of ankylosed teeth which attempts to preserve its surrounding alveolar bone and prevent tooth infra-positioning. This procedure involves gingival mucoperiosteal flap elevation, subcrestal removal of the tooth crown leaving the root in its alveolus to be replaced by bone. Following complete crown removal, the existing root canal filling is removed to prevent foreign body reaction. The preservation of decoronated roots in the alveolar process helps maintain existing bone volume and enables vertical bone growth which can be observed cor- onally to the decoronated root. Studies show that in early mixed dentition (age 7–10 years) cases – decoronation should be performed within 2 years, whereas in late mixed dentition (age 10–12 years) cases – a decision based on the individual case should be made. Conclusion: In conclusion, we can summarize that dental trauma often results in tooth ankyloses, which can lead to serious complications such as root resorption, tooth infra-position, or can affect the development of the alveolar ridge. The adequate treatment in such cases requires performing the decoronation technique, which not only helps in preserving the bone volume but also complements the future prosthetic treatment. Keywords: dental trauma, decoronation technique, ankylosis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 104 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ANALYSIS OF THE RISK OF DISTRIBUTION AND PREVENTION OF SEXUALLY TRANSMITTED DISEASES AND UNWANTED PREGNANCY AMONG STUDENTS FROM 9TH TO 12TH GRADE OF PROFESSIONAL SCHOOL OF NATURAL SCIENCES – “ACAD. N. OBRESHKOV” – RAZGRAD Mustafa Djambazov1, Dragomir Ivanov1, Stefan Stefanov1, Tsonka Dimitrova2

1Student, Medical University of Varna 2Department of Biology, Medical College, Medical University of Varna

ABSTRACT Introduction: As contemporary as it looks to young people between 16 and 18 years of age, early sexual activity has its high price. Along with the strong emotions of falling in love, there come unwanted pregnancy and sexually transmitted diseases. These diseases are characterized by diverse clinical symptoms but they have the same mechanism of transmission and spread of infection - sexual contact. The aim of this study is to investigate the awareness of students from 9th to 12th grade from the Professional School of Natural Sci- ences – “Acad. N. Obreshkov” - Razgrad of the risks, prevalence and the prevention of STDs and unwanted pregnancy. Materials and Methods: The study covered high-school students from 9th to 12th grade from the Profession- al School of Natural Sciences – “Acad. N. Obreshkov” - Razgrad in January 2016. A hundred students participated in the survey. There were 52 girls and 48 boys. A poll with 14 questions was developed for this study – 12 multiple choice questions and 2 open-ended questions. The processing and data analysis used documentary, statistical and graphical methods. Results: Students from the 9th grade were chosen as the lower end in determining the scope of the study. More than 1/3 (38%) of the students said they had casual sex, which increased significantly in students from 11th and 12th grade. Approximately half of the participants (42.10%) said that they were using protection during intercourse. Only 10.50% of all stated that they never used protection. The most commonly used protection was a condom combined with contraceptive drugs or intrauterine devices. Conclusion: The results show that young people are familiar with the basic methods of prevention, not only for pregnancy but also for STDs. The main sources of information for them are the Internet and conversa- tions with parents. Keywords: students, sexually transmitted diseases, awareness, prevention, unwanted pregnancy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 105 Medical University of Varna Original Research COOPERATION BETWEEN SPECIALISTS FOR PREVENTION OF EARLY CHILDHOOD CARIES Maria Dzhinova1, Vasil Yordanov1, Siyana Gradanska1, Milena Georgieva2, Radosveta Andreeva2

1Student, Medical University of Varna 2Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical University Varna

ABSTRACT Introduction: Early childhood caries (ECC) is the presence of more than one decayed (non-cavitated or cavitated lesions), missing due to decay or filled tooth surface in any primary tooth in a child 71 months old or younger. This indicates a particularly virulent form of caries, which starts soon after teeth erupt and proceeds rapidly. Materials and Methods: The research has been made by comparing different textbook sources in pediatric dentistry and scientific databases. ECC is a result of an interaction between all the factors involved in the development of typical lesion. When feeding via a nursing bottle while the infant sleeps, the liquids pool around the teeth surfaces and this causes severe destruction. A necessary factor for developing a lesion is the colonization of Streptococcus mutans and Lactobacillus spp. Salivatory flow is decreased during sleep so the clearance of the liquid and carbohydrates from the oral cavity is very slow. The anatomy of teeth can be a cariogenic factor for certain teeth. Results: From the earliest gynecological examinations during pregnancy the mother should be informed about all the nutrients she should take for normally developed permanent and deciduous dentitions. After the baby is born, all the examinations are done by a pediatrician. If there are some visual problems such as brown and white lesions or teeth destruction the child must be referred to a pediatric dentist. Parents should follow strictly all the recommendations from the specialists. The first visit to the dentist is very important because the dentist must explain how to maintain a good oral hygiene to the parents. Conclusion: ECC is a disease not only of the teeth but it also affects the overall health of children. As the treatment of ECC is difficult and expensive, all participating specialists should make an effort in preventing the disease and its early detection. Keywords: early childhood caries

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 106 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 LITERATURE REVIEW BASED ON THE CONTRAINDICATIONS OF HYALURONIC ACID PERIORALLY Galini Kalavrytinou1, Rosa Marand1, Christiana Madjova2

1Student, Medical University of Varna 2Department of Conservative Dentistry and Oral Pathology, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Over the last decades, the utilization of hyaluronic acid dermal fillers has resulted in the ad- vancement of the field of aesthetic dentistry. Aesthetic dentists realize that facial soft tissues serve as a frame for their restorative artwork. Soft-tissue augmentation with hyaluronic acid (HA) fillers is currently one of the most popular dental cosmetic procedures. Common sites of injection are the perioral and maxillofacial regions. In this report we present and compare 16 different types of hyaluronic acid dermal fillers, according to their side effects. Materials and Methods: Our sources of information are obtained from the literature review of scientific databases as Google Scholar and PubMed. The keywords used are “hyaluronic acid” and “dermal filler”. The used literature is reported in peer-reviewed publications. The articles are in English language, dating after the year 2010. Results: From 16 types of hyaluronic acid fillers, which are approved by the Food and Drug Administration (FDA), 5 are the most biocompatible and have the longest duration. Complications with dermal fillers are rare. Belotero Balance, HylaForm, Juvederm Ultra/Ultra plus, Perlane and Elevess are proven to be the saf- est alternatives. They have expected and short-lived side effects such as redness, swelling and tenderness. Infection is quite uncommon and can usually be managed with either antibiotics or antivirals, depending on the clinical features. Conclusions: The hyaluronic acid dermal fillers constitute a revolution for contemporary cosmetic dentistry, because they are a corporeal substance and have minimum side effects. In order to refrain from the side effects, it is best to visit a qualified and experienced dentist, and follow the post-treatment protocol instructions. Keywords: hyaluronic acid, dermal filler, side effects, dentistry

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 107 Medical University of Varna Original Research PHOTOGRAPHIC IMAGE REQUIREMENTS IN CONTEMPORARY DENTAL MEDICINE Michael Enchev1, Gergana Georgieva1, Radost Vasileva2

1 Student, Medical University of Varna 2Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: Dental photography is an auxiliary method for clinical diagnostic patient service, education, as well as a method for clinical comparisons. It is an implemented in science medium after its discovery in 1840 when Donnè and Foucault took a photograph of cross-section of bones and teeth. Before its discovery, visual presentations of medical or dental manipulations in journals, medical lectures or medical literature books were made by medical illustrations. The dental photography ones with higher quality and more credi- ble are of great significance to the education, communication and comparison studies in contemporary dental medicine. The aim of the current scientific study is to clarify the basic guidelines and requirements for images in dental medicine. Materials and Methods: Data from scientific journals, articles and textbooks has been researched and compared. The research is done electronically and the following keywords have been used: “images in medicine”, “dental photography requirements”. The groundwork method used is analysis of literature data. Results: The fundamental requirements towards the images for dental and medical purposes are authentic- ity and quality imaging. Achieving that goal in dental medicine is done by using the right equipment and certain image standards. Only then, images could be compared and the results analyzed. The fundamental requirements are: image sharpness, standard image frame size, right image exposure, and correct color rendition. Using the right contrast for extraoral images is of great essential. A mirror system is fundamental when taking images intraorally. Conclusions: In contemporary dental medicine using dental photography fulfills the requirements of authentic imaging only when using the right equipment to achieve this goal. Keywords: images in medicine, dental photography requirements

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 108 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 SLEEP AND HEALTH – TENDENCIES, REASONS AND RISKS OF SLEEP DEPRIVATION Ersin Ismail1, Ani Dzakova1, Deniz Hamidov1, Meriyan Radeva1, Plamen Dimitrov2

1Student, Medical University of Varna 2Anesthesiology and Reanimation Department, Balchik Hospital, Balchik, Bulgaria

ABSTRACT Introduction: Modern science appreciates the role of sleep and discovers broad fields in the study of its pathogenesis, morphological substrate and flow. Sleep structure, like an individual’s personality, is a product of diverse environmental stimuli and dynamic endogenous interactions. Several different methodolog- ical approaches of the epidemiologists give varying degrees of confidence in the strength of association between the exposure (sleep duration) and disease. In this study we estimated the trends in sleep duration in different age groups. We outlined the main reasons behind disturbed sleep habits and their health consequences. Materials and Methods: Several official papers based on metabolic consequences of sleep deprivation and circadian rhythm disruption were observed. We conducted an anonymous electronic poll which included 100 people divided into 5 age groups (15-20; 20-25; 26-40; 41-65; 65+) with a ratio of the sexes 1: 1. Values of actual and necessary sleep were explored and the reasons for the variations analyzed. Results: Moderate to significant differences between the time people spend sleeping and what they need to be in optimal condition were found. The results reveal sleep deprivation in all age groups except people over 65 years old. It is mostly represented in 21-25 year olds, reaching 20% (or an average of 1.65 lost hours of sleep). A major cause for not getting enough sleep was designated to getting up early in the morning - 45% (or 68% for aged 15-25). A total of 28% of the respondents reported that they have been having constantly disrupted sleep throughout the years. Conclusions: A number of studies have evaluated the role of sleep deprivation as a risk factor for cardiovascular, metabolic, neurodegenerative diseases and cancer. We believe that the external environment should adapt to people. The opposite has proven to be difficult and unhealthy. Keywords: sleep deprivation, electronic poll, disrupted sleep

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 109 Medical University of Varna Original Research STATISTICAL ANALYSIS OF ORAL HYGIENE HABITS AND ORAL CANCER AWARENESS Desislava Dokova1, Ralitsa Toneva1, Daniel Rachev1, Desislav Dobrev1, Georgi Georgiev2

1Student, Medical University of Varna 2Department of Conservative Dental Treatment and Oral Pathology, Faculty of Dental medicine, Medical University of Varna

ABSTRACT Introduction: Oral hygiene habits are fundamental for the patients’ oral and general condition. Multiple scientific reports state that poor oral hygiene can be the trigger factor for tooth loss, occurrence of oral lesions and even for the development of oral cancer. The aim of the study is to present statistical analysis of oral hygiene habits among people of different age groups as well as their awareness of oral cancer development. Materials and Methods: A survey involving the completion of a specially designed questionnaire was carried out among the people of the city of Varna, Bulgaria. The questions were selected to give information about the patients’ oral hygiene habits. In addition, the patients who filled out the questionnaire form were invited to undergo a prophylactic examination for oral lesions and oral cancer as a continuation of the survey. Results: A total of 380 questionnaires were filled out and 35 patients responded to the invitation and attend- ed a prophylactic check-up. The survey provided statistical information about the frequency of the patients’ dental visits, their oral hygiene habits, tooth loss, prosthesis and family history for oral cancer. In 6 of the patients (17%), who went through examination, lesions of doubtful origin were found. Conclusion: People above the age of 65 appeared to have poorer oral hygiene habits and fewer visits to the dentist than people from other age groups. Patients above 60 years proved to be less aware of the occurrence of oral lesions. Keywords: oral hygiene, oral cancer, lesions

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 110 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 THE REFLECTION OF EXERCISE ON THE NEW GENERATION Martin Krustev1, Silvia Filkova2, Monika Popova1, Luiza Hadzhieva1

1Student, Medical College of Varna, Medical University of Varna 2TRS “Rehabilitator and medical cosmetics”, Medical College of Varna, Medical University of Varna

ABSTRACT Introduction: Our health, tonus and overall well-being are in a constant relationship with a number of factors. One of the most important ones being, as evolution set it - physical activity. Unfortunately, in recent years the nature of our day-to-day life has changed for the worse as sedentary life has taken the place of the active one, even for the youngest. This tendency has led to an unheard of amount of overweight youngsters and such with an impaired metabolism. Materials and Methods: To get to the bottom of this worldwide problem, we prepared and conducted a survey. The answers we received showed us the parents’ views of what an increased amount of activity correlates to in their children’s physical and mental health. The survey was aimed towards the parents of children between 7 and 12 years of age. In it, we asked a number of questions which cover the parent’s view on exercise, the connection with their child and their willing- ness to discipline them towards a healthy lifestyle. Results: The results showed that there is a substantial number of children that have little to no physical activity, but fortunately the tendency is for parents to be willing to make the first step towards a healthier, more active lifestyle. Conclusion: Sedentary life leads to an increasingly overweight and unhealthy society. Children should be guided towards an active way of living by their parents not only with words but with an example. New and upcoming sports are a good way to stimulate the children’s attention towards exercise and with that to lead to a healthier society. Keywords: exercise, movement, youngster, health, parents

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 111 Medical University of Varna Original Research ARTEMISIA ANNUA- A PLANT WITH A GREAT FUTURE Jovana Kitanovska1, Merilin Ivanova1, Paulina Milanova1, Sabie Korenarska1, Galya Stavreva2

1Student, Medical University of Pleven; 2Department of Pharmacology, Medical University of Pleven

ABSTRACT Introduction: Artemisia annua is a common type of sweet wormwood, an herb employed in Chinese traditional medicine and introduced throughout the world. It belongs to the family of Asteraceae and has fern- like leaves, a camphor-like scent and bright yellow flowers . The glandular structures found on their surface produce a wide range of bioactive compounds and contain the chemical artemisinin. Its remarkable properties are the key to its malaria- and cancer-fighting effects. Materials and Methods: For our research we used a wide spectrum of sources including many medical articles, books, encyclopedias and well-known medical journals and, of course, the information and the knowledge of our academic mentor. Results: This study goes through the main stages of pharmacological development of artemisinin including the discovery of its effects and mechanisms of action. We present shortly the well-known effect on malaria and explain in details the most recent studies proving artemisinin’s anti-cancer effects. In short, cancer cells tend to express high levels of the transferrin receptors for internalizing iron which is a useful difference from normal cells along with the difference in the iron transport and this is the reason why artemisinin compounds kill only cancer cells and spare normal ones. Conclusion: In conclusion artemisinin, like many marvels of modern medicine, has been discovered by accident but series of experimental studies show that artemisinin is highly effective against a variety of cancers. Leukemia and colon cancer are the two types where its influence is most widely explored. The result from our study, we believe, would inform the audience about the latest scientific discoveries in the field, which is in any case beneficial. Keywords: artemisinin, cancer, malaria

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 112 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CONCENTRATION OF NATURAL RADIONUCLIDES IN CALENDULA OFFICINALIS L. FLOWERS Tsvetelina Stefanova1, Syana Dimova1, Nina Arhangelova2, Yordanka Eneva3

1Student, Medical University of Varna 2Department of Theoretical and Applied Physics, University of Shumen 3Department of Physics and Biophysics, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Flowers of Calendula officinalis L., are widely used in folk medicine for number of medical conditions, such as wound healing, jaundice, blood purification, and as an antispasmolitic. Natural radionuclides are being absorbed together with water and minerals from soil and atmosphere by plants. Trans- fer of radionuclides represents a radiological risk to humans. The study of radionuclides concentration is of great significance. The aim of this work is to investigate radioactive contamination levels in Calendula officinalis L. Transfer coefficients of radionuclides from soil to herb were determined for the terrain around the village of Yagnilo, Northeast Bulgaria. Materials and Methods: Samples of flowers of Calendula officinalis L. were collected in July. Soil sample was obtained from 10 cm ground depth where calendula grows. Flowers and soil were air exsiccated and levigated. Measurements of dry powdered flowers of calendula and soil were carried out with a low-background gamma-ray Ge(Li) spectrometer at the University of Shumen. The obtained gamma spectra were processed with the computer program Anges. Radioisotopes are determined by their energies. The transfer factors of soil-plant were calculated. Results: Values for the specific activity of natural radioisotopes in calendula flowers and soil were obtained. Photopeaks of intense gamma emission from uranium series nuclides, 214Bi and 214Pb, thorium series nuclides 228Ac and 208Tl and gamma transition of 40K were observed. Artificial radionuclides of technogenic origin were not found. Conclusions: Specific activities of radionuclides were compared to maximum levels of natural radionuclides. Public health is not at risk having in mind these levels. Transfer factors (TFs) were in the range of 1 up to 50. Keywords: gamma-ray spectrometry, Calendula officinalis L., natural radionuclides, soil

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 113 Medical University of Varna Original Research CURCUMIN - PREVENTION AND THERAPY OF INFLAMMATORY DISEASES Vladislav Stoychev1, Mariya Chingalova1, Vladislav Velikov1, Dimitar Dimitrov1, Rositsa Chamova2

1Student, Medical University of Varna 2Department of Hygiene, Disaster Medicine and Epidemiology, Faculty of Public Health, Medical University of Varna

ABSTRACT Introduction: Curcumin is an active polyphenol derived from the spice turmeric, popular in Asian cuisine. Generally believed to be beneficial for human health, it has been an object of scientific studies for the last half century. It has been tested on animals many times, and it has proved to be safe and non-toxic for humans. Analyzing extensive studies, we found out that curcumin has chemopreventive and anti-inflammatory properties. In the near future, this may turn it into a valuable tool in relieving and completely curing cancer, type 2 diabetes and obesity. Materials and Methods: We based our survey on a meta-analysis of 4 researches published in PubMed and the website of the American Diabetes Association. Results: Extensive clinical researches found that curcumin induces apoptosis in cancer and pre-cancer cells. The turmeric derivative affects cell-signaling pathways of cancer cells and inhibits their cell cycle. Curcum- in reduces chronic inflammation by directly interacting with white adipose tissue and suppresses the activation of tumor necrosis factor-α, interleukin-6 and monocyte chemoattractant protein-1 by immune cells. In 2012, a diabetes research was conducted on a group of 240 patients classified as pre-diabetic. Subjects were randomly chosen to receive either curcumin or placebo capsules. To assess the progression of T2DM (type 2 diabetes mellitus), parameters such as insulin-resistance and changes in β-cells were monitored. After 9 months, 16.4% of the subjects in the placebo group developed T2DM. None of the patients in the curcumin- treated group developed diabetes and they showed an overall better function of the pancreatic β cells. Conclusions: Based on the data acquired through the research, we found an opportunity to introduce curcumin into clinics for treatment, prevention and therapy of inflammatory diseases such as T2DM and obesity related diseases. As of recently curcumin has been used in aiding chemo- and radiotherapy in battling cancer. Keywords: curcumin, chemopreventive, anti-infammatory, diabetes ,obesity, cancer

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 114 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DRUG-INDUCED XEROSTOMIA AND ITS POTENTIAL TREATMENT Nefize Ilyaz1, Mery Koleva1, Stefka Valcheva-Kuzmanova2, Miroslav Eftimov2

1Student, Medical University of Varna 2 Department of Preclinical and Clinical Pharmacology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Xerostomia is a medical term meaning dry mouth due to lack of saliva. The symptoms include: dryness, thirst, bad breath, difficulty when chewing, dry red tongue, etc. Xerostomia increases the risk of gingivitis, tooth decay, mouth infections and can also make it hard to wear dentures. Causes of dry mouth include diseases (Sjögren’s syndrome, acquired immune deficiency syndrome, Alzheimer’s disease, diabetes, anemia), head and neck radiotherapy, nerve damage, dehydration and adverse effects of medications. The aim of the present study was to summarize drugs that can induce xerostomia, to show methods of its prevention and potential treatment. Materials and Methods: A literature review of the relevant studies published in PubMed and Scopus was made and the results were summarized. Results: As literature shows, over 1800 drugs in more than 80 drug categories have the ability to induce oral dryness. It is most common with muscarinic antagonists, antihistamines, diuretics, some antidepressants and antihypertensive drugs. The predominant mechanisms of drug-induced xerostomia are: M3 receptor blockade in the salivary glands (muscarinic antagonists, antihistamines, and tricyclic antidepressants) and loss of body fluids (diuretics). A muscarinic agonist (pilocarpine, cevimeline) can be used for the treatment of xerostomia. Patients are advised to drink plenty of water, to chew sugarless gums, to avoid tobacco and alcohol. Conclusion: Prolonged xerostomia can cause serious dental problems. Therefore, dentists should advise the patients about its prevention and treatment. In severe drug-induced xerostomia, they can recommend the substitution of some drugs with others which have similar efficacy and are devoid of that adverse effect. Keywords: xerostomia, drug-induced, prevention, treatment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 115 Medical University of Varna Original Research EVALUATION OF THE EFFECTIVENESS AND MECHANISM OF ACTION OF HYPERICUM PERFORATUM IN THE TREATMENT OF DEPRESSIVE DISORDERS Viktoria Tomova1, Ivan Pavlov1, Nadezhda Ivanova2

1Student, Medical University of Varna 2Department of Pharmaceutical Technologies, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Hypericum perforatum (HP), also commonly rеfеred as St John’s wort, is a medical plant traditionally used for its antidepressant-like properties. The purpose of the study was to assess the effectiveness of St. John’s wort in the treatment of depressive disorders in comparison to some commonly used antidepressants. Materials and Methods: Our research was based on literature found in the scientific databases Biomed, Pubmed and Oxford Academic with keywords: Hypericum and depression. Results: Naphtodianthrone hypericin and the phloroglucinol derivate hyperforin are shown to be the main phytochemicals responsible for the antidepressive properties of HP, though flavonoids are also proven to play a role. Some clinical studies testify that certain HP preparations are equal to or even exceed the effect of certain conventional antidepressants such as fluoxetine, paroxetine etc. in the treatment of depressive disorders. HP extracts have a very good tolerability with their adverse reactions being closer to those of placebo. However, hypericin has a unique cutaneous phototoxic effect in higher doses. Studies on the mechanism of action of HP extracts reveal GABAA, GABAB, glutamate and adenosine receptors agonistic properties; se- rotonin, dopamine and noradrenaline reuptake inhibitory activity and monoaminooxidase (MAO) A and B inhibition in vitro. In addition, it is shown that HP extracts cause downregulation of beta-adrenergic and upregulation of the 5-HT receptors in the frontal cortex, which changes neurotransmitter concentrations in the brain areas related to depression. Conclusion: Although HP shows promise in the treatment of depressive disorders, clinical trials with a larg- er sample size are needed to examine further its effectiveness and mechanism of action. Keywords: Hypericum perforatum, depressive disorders

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 116 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MEDIAL TIBIAL STRESS SYNDROME - IMAGING AND DIFFERENTIAL DIAGNOSIS Georgi Ivanov1, Gergana Angelova1, Boyan Balev2

1Student, Medical University of Varna 2Department of Imaging Diagnostics and Radiotherapy, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Medial tibial stress syndrome (MTSS) includes a spectrum of stress injuries that occur at the medial tibia. It is a collective term used to describe numerous types of lesions with involvement of the tibial bone and can also refer to the earlier manifestations of a tibial stress lesion before an actual fracture component can be identified. Exertional leg pain is the most common manifestation of MTSS and can often be disabling for the patients as well as progress to other serious complications. Therefore, MTSS must be diagnosed and treated properly without excessive invasive procedures. Materials and Methods: The patients were evaluated with detailed medical history, physical examination and diagnostic imaging studies. Review of all imaging studies – Radiography (Ro) , Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) was performed on a PACS workstation. The literature was systematically reviewed by comparing multiple databases and scientific publications regarding musculoskele- tal imaging and diagnostics. Results: The purpose of this study is to review the various findings of MTSS in different patients and its presentation on different modalities ,thus narrowing down the differential diagnosis of MTSS in the context of its radiographic features. Conclusions: MTSS has a wide variety of radiological manifestations. The following findings are considered indicative of MTSS: mild osteopaenia, periosteal fluid, marrow oedema, anterior cortex involvement, intracortical signal changes . On the basis of these direct findings no further diagnostic investigations are usually needed. Their role is essential for making the correct diagnosis and precludes the need for invasive procedures, therefore avoiding additional trauma for the patients. Keywords: stress fracture, stress trauma, MTSS, traumatology, radiology

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 117 Medical University of Varna Original Research IMPLEMENTATION OF STATE POLICY FOR PROTECTION OF CHILDREN’S HEALTH IN UKRAINIAN SCHOOLS Georgii Danylenko1, Tatiana Merkulova2, Natalia Romanova2

1Department of Hygiene and Social Medicine, V.N. Karazin Kharkiv National 2Department of Hygiene of School-Age Children and Adolescents, Health Protection Institute for Children and Adolescents of the National Academy of Medical Sciences of Ukraine

ABSTRACT Introduction: The health of children is a prime indicator of achieving the social objectives of the state. The school reflects the policy of the state in society. At the same time, the health of school-age children is seen as the ability to fulfil effectively social functions taught by the school. Materials and Methods: The research is based on the results of an anonymous survey of 1399 schoolchildren in grades 9-11 in a large megalopolis, a small town and a village. The questionnaire included questions about the characteristics of the lifestyle and educational activity, bad habits, and subjective assessment of their health. Results: The 54% of children in the megalopolis, 52% in the small town and 64% in rural areas consider themselves healthy. They were mostly boys, the gender difference is more pronounced in urban areas. The harmful habits prevalence depends on the place of residence. The percentage of schoolchildren, mostly boys, having their first experience of smoking at 7-9 years old is 14%. About 4% of high school students admit that they have already formed a habit to drink alcohol. Smoking, drinking and drugs are more pronounced in urban areas, the use of wine - in the villages. In a large city school the physical activity level was also higher. The greatest number of students (29.3%) who go to school with pleasure is in the small town, the lowest number (17.8%) is in the village. Conclusions: School as the implementer of health-preserving behavior is less successful in the village. De- spite the high prevalence of harmful habits among schoolchildren, the strategies of countering this are more diverse and effective in a large metropolis. Keywords: school-age children’s health, lifestyle, harmful habits, health-preserving behaviors

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 118 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 BEHAVIORAL CHARACTERISTICS OF NORMOTENSIVE WISTAR AND SPONTANEOUSLY HYPERTENSIVE RATS WITH AN EXPERIMENTAL MODEL OF DIABETES MELLITUS TYPE 2 Apostolos Pavlos Petridis1, Daniela Pechlivanova2, Kiril Petrov3, Alexander Stoynev3

1Student, Faculty of Medicine, Sofia University ‘’St. Kliment Ohridski’’ 2Institute of Neurobiology, Bulgarian Academy of Sciences; 3Department of Pathophysiology, Medical Faculty, Medical University of Sofia

ABSTRACT Introduction: Modern lifestyle is often characterized by decreased physical activity, regular intake of satu- rated and trans-fatty acids and increased physical and emotional stress, which are a prerequisite for the increased incidence of type 2 diabetes (diabetes mellitus, DM2). Recently published studies showed a positive correlation between DM2 and spontaneous hypertension in the deterioration of the sensory nerve function and the occurrence of peripheral diabetic neuropathy. The purpose of this study was to characterize the behavioral changes induced by an experimental model of diabetes in normotensive and spontaneously hypertensive rats. Materials and Metods: DM2 was induced by the combination of a high-fat diet (2 months) with a sub diabe- togenic dose of streptozotocin (30 mg/kg, intraperitoneally). The experimental model of DM2 was induced in two rat strains: normotensive Wistar and spontaneously hypertensive rats (SHR). The exploratory activity and locomotion were studied by an open field test, the level of anxiety by an elevated plus maze test and working memory was tested by an object recognition test. Results: The present results confirmed that SHRs are characterized by higher motor activity and less anxiety-like behavior compared to normotensive Wistar rats. DM2 induced a remarkable decrease in motor activity in both strains. However, this effect was more pronounced in SHRs. Moreover, DM2 impaired the working memory in SHRs without affecting this type of memory in normotensive animals. Conclusions: Data from this study showed that SHRs are more vulnerable to DM2 in regard to behavioral alterations provoked by the metabolic disease. The results could provide a basis for further testing of the effects of existing and new antihypertensive and antidiabetic drugs on the comorbid hypertension with diabetes type 2. Keywords: hypertensive rats, diabetes mellitus, behavioral changes

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 119 Medical University of Varna Original Research DOES GHRELIN AFFECT MEMORY? Victoria Tencheva1, Mihaela Zaharieva1, Jordan Kozhuharov1, Pamela Dragieva1, Irina Stoyanova2

1Student, Medical University of Varna 2Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Ghrelin (Ghr) is an acylated 28-amino acid peptide initially related to the regulation of food intake, body weight, adiposity and glucose metabolism. However, Ghr-ergic neurons were also detected in the central nervous system (CNS) – in the hypothalamic arcuate, paraventricular and supraoptic nucleus and the ependimal layer of the third ventricle. There are two forms of ghrelin: acylated, the receptor of which is a growth hormone secretagogue receptor (GHSR1a), and des - acyl Ghr, the receptor of which has not been identified yet. Materials and Methods: Our study is based on a literature survey (PubMed) using the following keywords: ghrelin, neurodegenerative diseases, memory, synaptophysin. Results: As previously reported, Ghr participates in the regulation of some high brain functions such as sleep-wakefulness, learning and memory formation. Animal studies show that acyl-Ghr has a stimulating effect on neuronal activity and synaptic plasticity, including changes in synapse morphology and number. Ghr increases dendritic spine formation and synaptogenesis, as well as earlier onset of neuronal activity and generation of mature network activity patterns. The synaptogenic effect is demonstrated by the increased levels of the presynaptic marker synaptophysin. Additionally, Ghr is beneficial for the recovery of memory, mood and cognitive dysfunction after stroke or traumatic brain injury. On the other hand, chronic neurodegenerative disorders such as Alzheimer’s, Parkinson’s and Huntington’s disease are characterized by synaptic and neuronal loss in motor, sensory or cognitive systems, leading to cognitive and motor decline. Furthermore, it has been found that there is a strong correlation between metabolic changes and neurodegenaration. Conclusions: The results from this literature researches suggest that acyl-ghrelin could be used as a potential new pharmaceutical approach to the neurodegenerative disorders. Keywords: ghrelin, neurodegenerative diseases, memory, synaptophysin

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 120 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DOES A KETOGENIC DIET INFLUENCE PATIENTS WITH ALZHEIMER’S DISEASE? Pamela Dragieva1, Mihaela Zaharieva1, Krasimir Markov1, Jordan Kozhuharov1, Miglena Todorova

1Student, Medical University of Varna 2Department of Biochemistry, Molecular Medicine and Nutrigenomics, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: The ketogenic diet (KD) is a low-carb, high-fat diet, which forces the body to burn fatty acids instead of glucose for ATP synthesis. This metabolism of ketone bodies ( kb ) is activated during fasting and when glucose levels are diminished. Ketone bodies are another essential source of energy for the organism and their delivery is vital especially to the central nervous system and to the muscular tissue of the heart. The ketogenic diet is used in different kinds of neurodegenerative diseases such as Alzheimer’s disease. Materials and Methods: Our study is based on a literature survey (PubMed). We used the following keywords: ketogenic diet, Alzheimer’s disease, ketone bodies metabolism, KD’s effect on neuronal degeneration, memory. Results: Alzheimer’s disease (AD) is a progressive neurological disease, which affects multiple brain functions, including memory, ability to learn new things, thinking, language function and behavior. Studies show that neuronal excitability is enhanced in patients with Alzheimer’s disease. The pathological processes of AD involve neuronal degeneration with accumulation of abnormal cellular products such as ﬁbrillary plaques and tangles. However, there is evidence that points to alterations in the function of the extant neural circuits and mitochondrial homeostasis. Studies show numerous experiments with transgenic AD mice and AD patients on a KD that reveal improvement in mitochondrial function and reduced expression of amyloid precursor protein and β-amyloid. Researches also show that by altering energy metabolism with the KD, rates of degeneration of certain neural structures and functions might be slowed down, due to the fact that ketone bodies have a neuroprotective effect against the toxicity of β-amyloid plaques. Conclusions: The results from this literature research suggest that the ketogenic diet may be used as an effective treatment approach towards Alzheimer’s disease through a variety of metabolism-induced mechanisms that can reduce the causes of the disease. Keywords: ketogenic diet, Alzheimer’s disease, ketone bodies metabolism, KD’s effect on neuronal degeneration, memory

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 121 Medical University of Varna Original Research ESTABLISHING A CONNECTION BETWEEN THE HUMAN PERIPHERAL NERVOUS SYSTEM AND AN UPPER LIMB MECHANICAL PROSTHESIS Vanesa Dodova1, Tsvetelin Tsvetkov1, Natasha Ivanova2

1Student, Medical University of Varna 2Department of Physics and Biophysics, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: In recent decades a variety of different methods have been developed in an attempt to connect mechanical prostheses to the human nervous system. This can be achieved through the implantation of electrodes either in the nerves of the peripheral nervous system or directly into the central nervous system. The established connection must be able to transfer afferent and efferent data with the same accuracy. The use of such technology in manufacturing mechanical prostheses will drastically increase the patients’ quality of life, since it allows them to use their prosthesis in a much more similar way to that of a natural limb. The aforementioned electrodes can be divided into two categories. The first ones are extraneural electrodes, which are implanted on the surface of the nerve, without compromising the integrity of the nerve fascia. The second ones are intraneural electrodes, which penetrate into the nerve’s fascia and connect to the nerve fibers directly. The latter provide a more fine-tuned stimulation due to their contact with individual nerve fibers as opposed to the nerve as a hole. Materials and Methods: Different resources were used to gather enough information and draw a comparison between the types of electrodes used in establishing a connection between an upper limb mechanical prosthesis and the nerves of the human peripheral nervous system. The comparison is based on two core characteristics: effectiveness of stimulation and potential harmful effect on the nerve and its surrounding tissue. Central nervous system connections will not be included in this comparison. Results: Considering the gathered information, the following results were achieved: the more effective the stimulation an electrode provides, the higher the risk of harming the nerve. Conclusion: The development of this new technology can enormously change peoples’ lives for the better. However, a great amount of research and tests should be made in order to precise it. Keywords: peripheral nervous system, upper limb mechanical prosthesis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 122 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 LIMBAL STEM CELL TRANSPLANTATION FOR CORNEAL REGENERATION Gabriela Georgieva1, Desislava Simeonova1, Christina Grupcheva2

1Student, Medical University of Varna 2Department of Ophthalmology and Visual Sciences, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The corneal epithelium is a fast regenerating , protective shield, maintained by the proliferation of stem cells, located in the limbus. In cases of compromised ocular surface due to chemical burns, severe trauma injury, Stevens-Johnson syndrome , HSV infection, radiation keratopathy, or contact lens induced keratopathy, the limbal stem cell activity reduces to a different degree. Eyes with a limbal stem cell deficiency produce inefficient epithelium, which ultimately leads to decreased vision and comfort due to corneal irregularity. Treatment for these conditions has become more advanced recently by utilising limbal stem cell transplantation techniques, using allo- or autotransplants. Materials and Methods: Review of literature and clinical cases reveal several strategies for treatment, including keratolimbal allograft transplantation, cultured limbal epithelial transplantation and autologous limbal epithelial transplantation. In cases of bilateral total stem cell deficiency, a keratolimbal graft is obtained from a corneal bank, and transplanted onto the recipient eye. Living relative might also be used as a donor but with caution. When the deficiency is unilateral, the healthy eye of the patient may serve as a source of autologous limbal stem cells. After a small biopsy, the cells are either cultivated in a laboratory before transplantation, or directly “seeded” onto the damaged eye surface using an amniotic membrane as a vehicle. Results: The primary measure of success in a treatment of limbal stem cell deficiency is the clinical presence of a stable ocular surface epithelium with no superficial corneal vascularization. Due to the high risk of immune rejection, treatment with an allograft offers poor long-term outcome when compared with the autograft transplantation. Several studies have proven the cultivated limbal epithelial transplantation to be a procedure with a success rate over 72%. One clinical trial on the autologous limbal epithelial transplantation demonstrates that at a median postoperative follow-up of 1.5 years (range, 1–4 years), 95 out of 125 eyes maintained a successful outcome. The main reasons for failure were acid injuries and severe symblepharon. Conclusion: Cultivated limbal epithelial transplantation and autologous limbal epithelial transplantation are reliable techniques for long-lasting corneal reconstruction and vision restoration in unilateral limbal stem cell deficiency. Autologous limbal epithelial transplantation is probably preferable particularly where cell cultivation facilities are unavailable. Keywords: limbal stem cell deficiency, limbal stem cell transplantation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 123 Medical University of Varna Original Research A SYSTEMATIC REVIEW OF RESEARCH ON N,N- DIMETHYLTRYPTAMINE Denitsa Hristova1, Maria Zhelyazkova-Savova2

1Student, Medical University of Varna 2 Department of Preclinical and Clinical Pharmacology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The effects of the endogenous hallucinogen N,N-dimethyltryptamine are poorly understood and its medical significance is widely unknown. A small number of studies regarding its biochemical, pharmaceutical and physiological role have been conducted and the efficacy of its therapeutic potential is pres- ently disregarded. How can scientists proceed in gaining insight into DMT and discovering possible medical uses of this substance? Materials and Methods: Published articles from 1964 to the present year have been reviewed and the outcome of the studies summarized. The results of drug action, therapeutic use and potential were investigated . Studies that appeared to have little medical purpose or those, which focus on the use of Ayahuasca, a South American ritual drink containing N,N-dimethyltryptamine and a monoamine oxidase (MAO) inhibitor of plant origin, have been excluded. Results: The research conducted between 1964 and 1987 seems to be an approach to understanding general chemical and biochemical properties of the substance (e.g. metabolites, tolerance, distribution, toxicity, etc.). Rick Strassman, who conducted a broad study from 1990 till 1994 has initiated a recurring interest in the field of psychopharmacology towards DMT. Thus, in the following years, the research was focused on the therapeutic gain of N,N-dimethyltryptamine but resulted mostly inconclusively leading to suggestions of further research. The findings have shown contradictions of already established knowledge, especially for receptors like the sigma-1 receptor, the only direct agonist of which is found to be N,N-dimethyltryptamie. Conclusion: The studies that now need to be conducted should analyze the correlations between psychiatric diseases (e.g. schizophrenia), purpose of the normal endogenous production and exact action, and the already suggested in various studies therapeutic importance. The low amount of knowledge about the drug action (in case of pharmaceutical use), its targets and drug effect should motivate researchers to gain more insight. Keywords: DMT, systematic review, sigma-1 receptors, pharmacology, endogenous hallucinogen

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 124 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DEVELOPMENT OF CHRONIC TRAUMATIC ENCEPHALOPATHY IN ATHLETES AFTER REPETITIVE HEAD INJURY Zekie Kasimova1, Denitsa Koleva1, Milena Avdzhiyska1, Tulin Edirne2

1Student, Medical University of Varna 2Department of General and Clinical Pathology, Trakya University - Edirne

ABSTRACT Introduction: Chronic traumatic encephalopathy is a state presenting with cognitive, behavioral, or motor abnormalities in athletes, especially within the boxing community and used to be referred to by various terms, such as “punch drunk,” “goofy,” and “slug-nutty”. Later, a more formal term was introduced bearing more medical validity - dementia pugilistica. By the end of the XX century it was concluded that this form of neurodegenerative disease was in fact similar to and yet different from other cases of neurodegeneration. As more evidence came forward about this condition a term coined by Miller became most widely used - chronic traumatic encephalopathy (CTE). The issue received more attention thanks to Omalu’s research. Materials and Methods: This review summarizes data from recent studies, findings and records in the literature on sport-related concussion in a significant number of cases of neuropathologically verified CTE and the detailed findings of CTE in 3 professional athletes, 1 football player and 2 boxers. Results: The clinical picture of CTE is associated with behavioral and personality changes, loss of attention and concentration, short-term memory loss, parkinsonism, and speech and gait abnormalities. Micro- scopically, CTE can be described as a tauopathy with preferential involvement of the superficial cortical layers, irregular patchy distribution in the frontal and temporal cortices, propensity for sulcal depths, prominent perivascular, periventricular, and subpial distribution, and marked accumulation of tau-immunore- active astrocytes. Deposition of A-amyloid, most commonly as diffuse plaques, occurs in fewer than half of the cases. Conclusion: Chronic traumatic encephalopathy is a neuropathologically distinct slowly progressive tauopathy with a clear environmental etiology which suggests a significant public health risk for persons who suffer repetitive mild traumatic brain injuries (TBIs). Early identification and prevention of this disease has become a critical focus of current studies. Keywords: athletes, concussion, dementia, encephalopathy, neurodegeneration, tau protein

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 125 Medical University of Varna Original Research IUD INSERTION IMMEDIATELY AFTER DELIVERY Darja Schlothauer1, Anastasiia Subbotina1, Stefan I. Ivanov2

1Student, Medical University of Varna 2Department of Obstetrics and Gynaecology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Free access to contraception should be an essential right in a woman’s life. Recent research revealed that almost 50% of the pregnancies in the United States were not planned with half of these women reporting using some type of contraception before conception. Intrauterine devices (IUD) are the most effective contraceptive method preferred by the majority of multiparous women postpartum. In the developing world, the option of immediate IUD insertion has several benefits that outweigh the slightly increased risk of infection. The goal of this literature review is to outline the benefits and the efficacy of the immediate postpartum IUD insertion. Materials and Methods: Several scientific databases such as AccessMedicine and PubMed, have been searched by limiting the search to English and German language. The following keywords have been used: IUD, postpartum, insertion, after, delivery and immediately. Three books in the Obstetrics/Gynecology col- lection and several articles overall have been found and screened.The goal of this research is to outline the benefits and the efficacy of immediate postpartum IUD insertion. Results: Immediate IUD insertion reduces the risk of a future unplanned pregnancy. It is a safe, low-cost, highly efficient and prolonged contraceptive method. Women, especially in developing countries, who have just given birth often face difficulties, such as taking care of the newborn, lack of family support system and low economic and social environments. These circumstances lead to a decreased number of women return- ing to the clinic for their postpartum visit. Thus, the early postpartum IUD insertion is a cost- and time-effective method. Conclusion: Even though the rate of expulsion in the immediate postpartum IUD insertion is higher than placing the IUD at a later phase, the benefits may outweigh the disadvantages in cases of women living in developing countries with limited access to postpartum healthcare. Also, in developed countries this method would decrease the number of unwanted pregnancies. Keywords: IUD, postpartum, insertion, after, delivery, immediately

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 126 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 MULTIDISCIPLINARY APPROACH IN COMORBID PATIENTS Simona Panteleymonova1, Ani Raynova1, Radi Lukanov, Svetla Chilikova2, Plamen Panayotov2

1Student, Medical University of Varna 2Department of Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Comorbidity is very common among patients with cancer and it is a real challenge to be treated. Multidisciplinary team (MDT) meetings are defined as a model for managing cancer in comorbid patients. The importance of communication between different specialists correlates with the effectiveness of the treatment and survival rate of patients. Materials and Methods: The records of all patients were evaluated retrospectively. The preoperative evaluation for all patients included physical examination, laboratory tests, X-ray, ECG, echocardiography, and computed tomography. Results: Our study presents 9 patients diagnosed with tumors, involving more than one organ and com- pressing adjacent organs. MDT approach was performed in all of them at the Department of Cardiac Sur- gery at the St. Marina University Hospital, Varna. Five of the patients were diagnosed with renal cell carcinoma, and one with papillary renal cell carcinoma. In one, a mediastinal cyst was found, another patient was diagnosed with mediastinal malignant carcinoid. One patients had a solitary fibrous tumor localized in right chest. In 8 of them median sternotomy was performed, in 1- mini-sternotomy, in 1- thoracotomy, in 1- bispinal transverse laparotomy, in 3 of them upper midline laparotomy with right transverse incision was performed; in 1- transverse right incision. The MDT meetings in 6 patients included a urologist, a vascular and a cardiac surgeon. In 3 other patients, the MDT approach involved a cardiac and a thoracic surgeon. All of the patients except one survived and were discharged. Resection of the tumor gives an opportunity for better results from target therapy. Conclusion: Treatment in every patient and each disease is individual. The goal in carcinoma patients is to increase the therapeutic and surgical benefit and improve the quality of the patient’s life. Multidisciplinary approach in patients with this comorbidity is a necessary and effective treatment of choice. Keywords: multidisciplinary team meetings, tumor, comorbidity

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 127 Medical University of Varna Original Research CONSERVATIVE TREATMENT OF PES EQUINOVARUS – HISTORY AND RECENT TRENDS Miroslav Raikov1, Milena Avdzhiyska1, Silvia Ianakieva1, Dimitar Raikov2, Diyan Dimov3

1Student, Medical University of Varna 2Department of Orthopaedics and Traumatology, Faculty of Medicine, Medical University of Varna 3Department of General and Operative Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Pes equinovarus also popular as congenital clubfoot is a combined foot defect, presented by plantar flexion, invertion, and adduction. The treatment of this condition is conservative and operative. The aim of the treatment is to establish the impact on the pathology of the ligaments, tendons and muscles that determine the degree of resistance and the likelihood of recurrence of the disease. Nowadays, the general trend of treatment is the conservative approach, because of the proven much lower residual reactions and relapses that follow the surgeries. Materials and Methods: The conservative methods of treatment of clubfoot are: - Method of Kite – it consists of a series of manipulations, followed by plaster boots with typical manipulations over the foot. - “French method” – It is generally a kinesitherapeutical method with a gradual increase of the intensity of manual stimulation of muscles and stretching of ligaments, temporary immobilised by either day or night splints. The manipulation is performed every day and it’s followed by elastic adhesive tapes to maintain the position. - Method of Ponseti – the most popular one nowadays – serial casting and gradual complex reduction of the foot deformed elements. This method includes of 8 casts – the first 3 usually correct the foot to a plantigrade foot, next 4-5 casts continue and hold the position in a hypercorrection of the foot (supination and abduc- tion). After the casts, the treatment continues with Dennis Brown’s splints until the 2nd-3rd year. Results: From the listed methods, the one of Ponseti gives the best results in the treatment of clubfoot. The method of Kite presents an unsatisfactory result and has many critics from the recent data. The “French method” requires a lot of time and patience from parents and physicians. Conclusion: Presenting much lower grades of complication rate and relapses, conservative treatment approaches of clubfoot deformities become a golden standard in clubfoot treatment worldwide. Keywords: pes equinovarus, treatment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 128 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 THE POSSESSION AND DISTRIBUTION OF VARIOUS TYPES OF CERUMEN IN DIFFERENT POPULATIONS AND ITS POSSIBLE ORIGINATION Keesha Cunningham1, Nikolay Sapundzhiev2

1Student, Medical University of Varna 2Department of Otorhinolaryngology, Faculty of Medicine, Medical University Varna

ABSTRACT Introduction: The study was carried out to gain an insight into the distribution of different types of cerumen (ear wax) in different populations and to discuss the possible cause of origin for the discrepancy. It has already been established that majority of the Caucasian and African populations have the wet type of cerumen whereas majority of Asian population has the dry type due to a single-nucleotide polymorphism in the ABCC11 gene on chromosome 16. Materials and Methods: A simple observation was carried out at the hospital with cerumen samples that had already been obtained from one group of individuals from Caucasian and African origin. Corresponding- ly, another group of individuals from Asian origin were simply enquired about the nature of cerumen pos- sessed. Moreover, published literature was reviewed for possible suggestions of causes for developing wet and dry types. Results: 8/10 samples obtained from Caucasian (Bulgarian) individuals and one African individual were observed to be wet whereas only 2/10 were dry. In contrast, only 3/10 Asian individuals claimed to possess wet cerumen and a majority of them 7/10 - dry. Conclusion: The previously published data about the type of cerumen in different populations were further established by the investigation. Furthermore, a possible cause for the particular mutation was suggested by literature to be due to a result of positive selection that favoured the East Asian population to adapt to the cold environment that they formerly lived in. However, further studies could be carried out to determine any influence of wet or dry cerumen on earwax impaction and any impact it may have on different methods of treatment. Keywords: cerumen, single-nucleotide polymorphism

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 129 Medical University of Varna Original Research CAPABILITIES OF REHABILITATION MEDICINE IN MUCOVISCIDOSIS PATIENTS TREATMENT Magdalena Bliznakova1, Boyko Matev1, Pavel Todorov1, Nikolay Nedev2

1Student, Medical University of Varna 2TRS “Rehabilitator and Medical Cosmetics”, Medical College, Medical University of Varna

ABSTRACT Introduction: Mucoviscidosis is a genetic autosomal recessive disease, occurring in adults and children alike. It results from a mutation in the CFTR gene, responsible for a protein that regulates membrane per- meability and ion transport in the epithelium surface in numerous systems in the organism. Its effects are most noticeable in the respiratory tracts, the pancreatic tracts, the intestines, the biliary tracts, the sweat glands and others. Regarding the respiratory system, most characteristic are the changes in the chlorine channels. Their function is restricted by the presence of a thick, viscous secretion, the removal of which is difficult or even impossible. This viscous secretion can become infected by various microorganisms, leading to inflammation and complications in the general state of the patients. The pathological changes in the aforementioned systems result in the progression of the disease and a drastic reduction of the quality of life of the patients. Rehabilitation medicine and physical medicine have an essential role in complex pulmonary ventilation therapy. Materials and Methods: A limited search with the keywords “cystic fibrosis”, “physiotherapy”, “exercises” and “drainage” was conducted using the NCBITM and PubMedTM databases, which yielded over 20 articles, 10 of which were selected and thoroughly analyzed. The aim of this research is to present the capabilities of medical rehabilitation, the experience of specialists in the field and the expected benefits of medical rehabilitation in mucoviscidosis treatment. Results: Multiple authors recommend the usage of rehabilitatory tools in the complex treatment of the disease. Treadmill exercises, respiratory gymnastics, including autogenic drainage, body posture training and training in the use of expectoration aid, all show promise in the amelioration of respiratory indicators. Conclusions: These recommendations, barring cases with individual contraindications, should be used and incorporated as a mandatory element in the rehabilitation care of mucoviscidosis patients. Keywords: cystic fibrosis, physiotherapy, exercises, drainage

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 130 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 IN VITRO BIOACTIVITY OF SILVER-CONTAINING SOL-GEL GLASSES: FTIR ANALYSIS Tanya Dimova1, Lachezar Radev2, Irena Michailova3, Diana Zaimova2

1Department of Pharmaceutical Sciences and Pharmaceutical Mаnagement, Faculty of Pharmacy, Medical University of Varna 2Department of Fundamental Chemical Technology, University of Chemical Technology and Metallurgy, Sofia 3Department of Silicate Technologies, University of Chemical Technology and Metallurgy, Sofia

ABSTRACT Introduction: The sol-gel glasses (BG) have been used for various biomedical applications, such as ortho- pedic, dental grafting and tissue engineering. The main purpose of the presented article is the preparation and evaluation of carbonate apatite formation on the BG in SiO2-CaO-P2O5-xAg2O system, where x=0,1,2 and 4wt.% Ag2O (BG/Ag), after soaking in a simulated body fluid (1.5 SBF) for 12 days in static conditions. Materials and Methods: BG/Ag were synthesized from tetraethyl orthosilicate (TEOS), calcium oxide (CaO), phosphoric acid (H3PO4) and silver nitrate (AgNO3) as sources. TEOS was stirred into the mixed solvent of

C2H5OH and H2O with a very small amount of HCl in the volume ratio TEOS:C2H5OH:H2O:HCl=1:1:1:0.01.

The mixture of calcium phosphate (CP) and appropriate amount of AgNO3 was added to SiO2 sol under stir- ring for 20h. The mixed sol obtained was gelated at 120oC for 12h and 600oC for 6h. Results: X-ray powder diffraction (XRD) of the synthesized samples showed that the presence of some crystalline phases is dependent on the gel composition. XRD proved the presence of CaCO3, wollastonite, HA and metallic Ag in accordance with gel compositions. Fourier transform infrared spectroscopy (FTIR) of the prepared BG showed the presence of basic absorption bands, corresponding to the different chemical bands and crystalline phases, in agreement with XRD results. FTIR of the examined samples, after soaking in 1.5 SBF solution for 12 days, confirmed that B-type carbonate apatite was formed preferentially on the soaked surface.

Conclusions: BG in SiO2-CaO-P2O5-xAg2O system (x=0,1,2 and 4wt.% Ag2O) were synthesized via a polystep sol-gel method. After immersion of the studied BG in 1.5 SBF solutions for 12 days in static conditions, FTIR 2- revealed the presence of some CO3 bands, i.e. after soaking carbonate apatite (CO3HA) may be formed on the surface of the prepared sol-gel glasses. On the basis of FTIR results, we can assume that B-type CO3HA preferentially formed on the soaked samples. Keywords: bioglass, sol-gel, FTIR, in-vitro bioactivity

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 131 Medical University of Varna Original Research PRINCIPLES OF PHARMACOKINETIC BOOSTING Oganes Vardanyan1, Ivan Uzunov1, Maya Radeva2, Kaloyan Georgiev3

1Student, Medical University of Varna 2Department of Pharmacology, Toxicology and Pharmacotherapy, Faculty of Pharmacy, Medical University of Varna 3Department of Pharmaceutical technologies, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Drug-drug interactions can occur on every pharmacokinetic level, including absorption, distribution, metabolism (biotransformation) and excretion. The most common and most studied drug-drug interactions occur at the level of biotransformation, where the cytochrome P450 family plays the major role. In most cases, inhibition of CYP enzymes by one drug, can lead to increased serum levels of other simultaneously administered drugs and to a greater potential for toxicity. In the pharmacokinetic boosting concept there is a benefit of such drug-drug interaction, where alterations in metabolic rates of one pharmaceutical agent through the inhibitory effects of another agent lead to increases in plasma concentrations and prolongation of the half-life of the co-administered agent. Materials and Methods: For the purposes of this review, we have studied two literature databases (Pubmed and Science direct). Keywords used in the search were: “ritonavir”, “cobicistat”, “ pharmacokinetic “, and “boosting”. Results: This boosting concept is widely used in the treatment of HIV infections. The most studied drugs are ritonavir (initially developed as an HIV PI, but it is currently used primarily as a PK boosting agent) and cobicistat. Ritonavir is a very potent CYP3A4 inhibitor, also able to inhibit or induce other CYP subfami- lies, which is responsible for a large number of drug-drug interactions. Cobicistat, was approved in 2012. Its unique pharmacological property is the selective inhibition of CYP3A. Both drugs, ritonavir 100 mg and cobicistat 150 mg, nowadays are used as a combined ART-boosting agents together with a second-generation PI, i.e., atazanavir or darunavir. In 2015, the first boosted protease inhibitor in fixed dose combination - Rezolsta® (darunavir/cobicistat) was approved. Conclusion: Pharmacokinetic boosting is a very promising concept. It can be used on the one hand to reduce the dose of the boosted drug and on the other - to increase compliance and to improve adherence. Keywords: ritonavir, cobicistat, pharmacokinetic, boosting, enhancement

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 132 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 RESEARCH ABOUT THE POSSIBILITY OF INCREASING THE BIOAVAILABILITY OF CAPECITABINE Stanila Stoeva1, Iliyan Kolev2, Yulichka Sabeva3

1Student, Medical University of Varna 2Department of Pharmaceutical Sciences and Pharmaceutical Management, Faculty of Pharmacy, Medical University of Varna 3Department of Pharmacology, Toxicology and Pharmacotherapy, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Capecitabine is an antimetabolite that belongs to the fluoropyrimidine carbamate class. It is a chemotherapy medication used to treat breast, gastric and colorectal cancer. Inside the organism, this pro-drug is converted to the active 5-fluorouracil (5-FU) that causes cell injury via RNA- and DNA-related mechanisms. The conversion is a three-step process with the participation of the enzymes - carboxylesterase (CES), cytidine deaminase and thymidine phosphorylase that are present in healthy and tumor cells. This research, specifically, is dedicated to CES isozymes CES1A1 and CES2, which convert Capecitabine to 5’-de- oxy-5-fluorocytidine (5’-DFCR). Materials and methods: To determine Capecitabine we have used: Thermo Scientific Dionex UltiMate 3000 Analytical LC System, VWD-3100 variable wavelength detector, Thermo Scientific™ Chromeleon™ 7.2 Chro- matography Data System software. The chromatographic analysis was carried out by using a mobile phase of methanol: buffer (water with 1% formic acid) with a Thermo Scientific Accucore C18 (100 mm x 4.6 mm, 2.6μ) analytical column in gradient mode with UV detection at 310 nm. Results: Recently, the structure of the active centre of isozymes CES1A1 and CES2 has been successfully determined. This allows the exploration of new or already known substances with structural similarity. It is important to investigate such supplements that could assist in the treatment without increasing the risk of adverse effects. A sensitive, accurate and reliable method for the determination of Capecitabine in pharmaceutical dosage forms and in human plasma was developed using a RP-HPLC. The established LOD and LOQ values allow us to conduct monitoring of the bioavailability of Capecitabine after CES-inhibitors application. Conclusions: Based on the established relationship between structure and biological activity of known CES inhibitors new potential inhibitors with natural origin could be offered. Using the RP-HPLC allows us to research the pharmacokinetic parameters of Capecitabine after CES-inhibitors in further investigations. Keywords: Capecitabine, carboxylesterase, RP-HPLC

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 133 Medical University of Varna Original Research VASALGEL™: A NOVEL REVERSIBLE NON-HORMONAL CONTRACEPTIVE FOR MEN Stefanie Degen1, Maria Dolores Franco Martinez1, Alexander Hinev2, Faidra Marazaki1, Navneet Magon3

1Student, Medical University of Varna 2Department of Surgery, Faculty of Medicine, Medical University of Varna 3Department of Obstetrics and Gynaecology, Army College of Medical Sciences, New Delhi, India

ABSTRACT Introduction: With estimated 85 million unintended pregnancies, currently occurring annually worldwide, half of which end in abortion and 13% in miscarriage, the need of an effective, long-lasting, devoid of side effects and complications male contraceptive is evident. The aim of the present study was to summarize the various methods and techniques currently applied in male contraception; to evaluate their pros and cons, and to compare them with those of Vasalgel™ - a male contraceptive recently developed in the US. Materials and Methods: A comprehensive PubMed search using the keyword “male contraception” was performed. Articles, published in full text, as well as published in the official journals of EUA, AUA and SIU, were extracted and analysed. Special attention was given to Vasalgel™. Results: Various methods and techniques for male contraception are described in the current literature: from male condoms, spermicides, periodic abstinence and withdrawal to hormonal contraceptives and va- sectomy. However, they have their limitations and side effects. The demand for a non-hormonal, highly effective male contraceptive is increasing, to reduce the incidence of unplanned pregnancies and their related sequelaes. Our study shows that appears to be effective by blocking sperm from passing through the vas def- erens as its primary mode of action. The product might be easily flushed from the vasa deferentia to restore the sperm flow, if necessary. Conclusion: The present review confirms that Vasalgel™ is a perspective, highly effective, novel non-hormonal male contraceptive that has the potential to gain wide popularity among men in the near future, especially in developing countries. Further studies on animals and humans, however, assessing the safety and durability of the Vasalgel™ block, as well as the success in flushing the gel from the vasa deferentia to return sperm flow, are sorely needed. Keywords: male contraception, Vasalgel™

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 134 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TOXIC KERATOPATHY ASSOCIATED WITH ABUSE OF TOPICAL ANESTHETICS Desislava Simeonova1, Konstantin Ganchev1, Gabriela Georgieva1, Liliya Ilieva1, Yana Manolova2

1Student, Medical University of Varna 2Department of Ophthalmology and Visual Sciences, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Topical corneal anesthetics abuse is a self-inflicted injury. Prolonged and uncontrolled uses of topical anesthetics have a significant probability of leading to various complications as a result of the morphological changes they induce in the corneal structure. Topical anesthetics compromise tear function by decreasing aqueous tear secretion, disturbing film stability and decreasing blink rate which leads to greater exposure of the cornea to outside factors, thus decreasing the protective function of the corneal epithelial cells. As a result, both the corneal epithelial barrier and the re-epithelialization process are disrupted, which is the main factor in the pathogenesis of the toxic keratopathy. The most prescribed topical anesthetics in practice are tetracaine, proparacaine and oxybuprocaine. All of the above-mentioned drugs have been described as abusive and addicting medications. Loss of vision, intense pain, severe photophobia and red eye are the most frequently reported symptoms by patients. Materials and Methods: Medical records of four patients were used for the purpose of this poster. The severe pain, persistent epithelial defects and progressing stromal thinning that were found during the initial examination did not improve with medical treatment, thus, the patients underwent amniotic membrane transplantation (AMT) and cross-linking. Results: After the treatment, the symptoms of photophobia and pain were relieved. A complete corneal epithelialization and total reduction of the corneal infiltrate were ascertained in a period of 2 weeks. Conclusion: Topical anesthetic abuse can lead to serious ocular complications. After proper diagnosis, the first step of treatment is the cessation of drug abuse. In addition to medical treatment, early AMT and cross- linking has an advantage of early pain relief and consequential elimination of the need for topical anesthetic application. Keywords: kerathopaty, AMT, cross-linking

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 135 Medical University of Varna Original Research CHOOSING A PARTNER – DOES MALE PERSONALITY PLAY A ROLE IN BREAST SIZE PREFERENCES Boyko Matev1, George Stoyanov1, Magdalena Bliznakova1, Alice Renjilian1, Radoslav Spasov2

1Student, Medical University of Varna 2Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The myriad of psychosocial factors that contribute to the process of selecting a mate for either gender in humans, has been subject to numerous studies in the past. However, there is very little evidence on the formation of sexual attraction. The aim of this study is to investigate the correlation between the male psyche and the preferred female breast size in accordance with it. Materials and Methods: To determine the males’ perception of their own socioeconomic status, a short- ened version of the Big Five personality test proposed by Beatrice Rammstedt and Oliver P. John, containing 10 questions, was used. Breast size preference was determined via a standardized graphic, depicting 4 breast sizes (A trough D) on a female body with no additional features such as waist to hip ratio, hair, skin and eye color, which could potentially influence the choice. The questionnaire, along with the image was distributed to males via an anonymous online form. Results: A total of 65 males filled out the test: mean age 21.67, standard deviation ±2.91, median 21, range 18 (17-35 years of age). The most preferred breast size was C with 53.8% (n=35), the second was B with 35.4% (n=23), the third was D with 7.7% (n=5) and the least preferred one was A with 3.2% (n=2). However, there was no statistically significant data (p<0.05) that suggested a correlation between the preferred breast size in females and the age or personality type in males. Conclusions: Some studies suggest a correlation between the socioeconomic and behavioral status of males and the preferred breast size in their female partners. This according to some authors is a modified evolu- tional instinct that has become socially acceptable. However, our study did not manage to establish such correlation based on the male personality and performance. Keywords: breast size, socio-economic status, mate selection

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 136 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 SEXUAL ADVERSE EFFECTS OF FINASTERID 1MG FOR TREATMENT OF ANDROGENIC ALOPECIA IN MEN Malwin Werner1, Nikoo Rahimy1, Stefanka Racheva2

1Student, Medical University of Varna 2Department of Infectious Diseases, Parasitology and Dermatovenereology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Finasterid is a 5-alpha reductase inhibitor which is considered as first-line treatment for an- drogenetic hair loss in men. Patients are required to take the medications indefinitely to maintain its effect despite the lack of research regarding long-term adverse effects. Concerns arise regarding the adverse effects of these medications potentially causing long-term sexual adverse effects in men even after discontinuation of drug intake. In our presentation, we want to provide a review of the safety and the risks regarding the sexual side effects for men with long-term intake of Finasterid 1mg. Materials and Methods: A PubMed database search was conducted for recent English language publications from 2010 to February 2017. Abstracts and articles were then screened to identify the relevant publications. Results: The manufacturer Merck&Co conducted several trials about the sexual adverse effect of Finasterid 1mg and 5mg especially regarding sexual dysfunctions. Three controlled trials with 1,879 study participants concluded that only a few more participants experienced a decrease of libido, erectile dysfunction and ejac- ulation disorders compared to the control placebo group (1.4% sexual dysfunction in Finasterid group compared to 0.9% in placebo group). In contrast to this result, another trial by an independent source reviewed 4,910 reports from young men using finasteride in the United States Food and Drug Administration Adverse Event Reporting System (FAERS) and found that 11.8% reported sexual dysfunction after Finasterid treatment. On average, sexual dysfunction occurred 1.8 years after starting Finasteride 1mg daily and lasted 5.4 months after stopping the medication. Conclusion: Sexual adverse effects, such as a decreased libido, erectile dysfunction, and decreased ejacu- late, have been reported in varying percentage of men depending on the study. The studies usually describe mild effects, with large studies suggesting the symptoms improve over time. Further trials and studies are vital to rule out short- and long-lasting sexual adverse effects. Keywords: Finasterid, hair loss, androgenic alopecia, sexual adverse effects

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 137 Medical University of Varna Original Research SILICOSIS – CLINICAL MANIFESTATION AND RELATION WITH OTHER PULMONARY AND NON-PULMONARY DISEASES Elena Stoyanova1, Elena Stoyanova1, Ersin Ismail1, Alexandra Stefanova1, Svetoslav Dobrev1, Dimcho Tomov2

1Student, Medical University of Varna 2Department of Hygiene, Disaster Medicine and Epidemiology, Faculty of Public Health, Medical University of Varna

ABSTRACT Introduction: Silicosis is one of the most common occupational diseases worldwide. The risk groups include mostly workers from mines, foundries, sandblasting and glass manufacturing – people exposed to crystalline silica dust. Clinically, silicosis can present in three different forms – acute, chronic and acceler- ated, according to the dose and period of exposure. All of them lead to fibrosis aggravating to decreased lung capacity and respiratory failure. There is a risk of developing silicosis in a broad variety of industrial activities, which is related to morbidity with pulmonary and non-pulmonary diseases. Results: It is difficult to prove a casual connection for a co-existence of two or more diseases. However, the susceptibility of silicosis patients for developing certain illnesses such as tuberculosis is indisputable (2.8 to 39 times higher risk). On the other hand, the relation between silica dust exposure and other pulmonary and mostly non-pulmonary diseases is moderate, mild or statistically insignificant. Also, the form of silicosis and its progression provide the conditions necessary for their development. Materials and Methods: Three full-text articles on the exploration of silicosis were briefly analyzed. They include longitudinal studies during the period 1968-1995, conducted at major mines in China, the US, Mon- golia and Brazil. Excerpts from their results were systematized in building the image of silicosis as an independent disease and pathogenic level of other diseases. Also, representative radiological and histological samples were used to demonstrate the findings and signs of deterioration of the condition. Conclusions: Based on the fact that silicosis is an incurable disease, prevention is the only way of dfeating it. Mortality has been reduced by 97% for the last 60 years. Keeping silica dust away from the workers lungs ensures lower pulmonary and related non-pulmonary morbidity and also longer life-expectancy. Keywords: silicosis, silica dust, co-existent diseases, morbidity, prevention

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 138 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 THE CONNECTION BETWEEN IBS, ANXIETY AND DEPRESSION Paola Kulicheva1, Zhivko Apostolov2, Liliya Raeva1, Boris Botev1, Dinnar Yahya1

1Student, Medical University of Varna 2Second Psychiatric Clinic, St. Marina University Hospital, Varna

ABSTRACT Introduction: Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by three major symptoms : abdominal pain, diarrhea and constipation. A large number of studies suggest the importance of the brain - gut interaction in IBS. According to the latest researches, it was determined that IBS affects around 11% of the population globally, 50% to 90% of them report psychiatric disorders including depressive symptoms such as exhaustion, sleeping problems and loss of appetite, generalized anxiety disorder, social phobia, posttraumatic stress disorder, panic disorder and somatization disorder. Materials and Methods: We systematically searched online databases for randomly selected samples of general community populations. The current research outlines conclusions from data obtained from a wide- ranging and selected at random population sample that may elucidate these relations. Results: Studied data shows that IBS occurs in over 40% of individuals with panic disorder, and in patients with IBS, 25% to 30% have panic disorder, which has lead to speculation about potential common pathophysiology between the two. According to several studies, generalized anxiety disorder is more common in the early course of irritable bowel syndrome, whereas depression is prevalent in patients with chronic IBS symptoms. On the contrary, psychiatric patients suffering from depression and generalized anxiety disorder have a significantly increased prevalence of IBS. Conclusion: The gathered information suggests that there are common neurobiological factors involving brain-gut interactions, depression and anxiety. The available data suggest diagnostic overlap between psychiatric disorders and irritable bowel syndrome, with similar demographic and clinical characteristics of the patients. Keywords: irritable bowel syndrome, psychiatric disorders, IBS

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 139 Medical University of Varna Original Research THE PHARMACIST’S RESPONSIBILITY IN REVERSING DRUG-INDUCED NUTRIENT DEPLETION Ralitsa Simeonova1, Galina Dimova1, Rosi Hristova1, Anna Todorova2

1Student, Medical University of Varna 2Department of Pharmaceutical Science and Pharmaceutical Management, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Аt present, it is commonly known that inadequate dietary intake can result in deficiencies of minerals and vitamins. Despite that, it is still less appreciated that pharmaceutical agents also have a negative impact on nutrients through a variety of mechanisms. Nowadays, this problem is on the rise especially for susceptible patients and/or patients on long-term medication therapy. Materials and Methods: An analysis of scientific web databases on the problem was performed and different lessons designed for continuing education for pharmacists were reviewed. On the basis of the analyzed lessons a questionnaire was created and conducted in Varna with the objective of displaying the practicing pharmacists’ awareness of drug-induced nutrient depletion. Results: The overview of literature resources shows that drug-induced nutrient depletion is а rising problem. Special attention when consulting at the pharmacy should be paid to geriatric, cancer patients and patients with diabetes, obese or patients on weight loss programs. Some of the most used medications that neg- atively impact one’s nutrient status are the following – antacids, anticonvulsants, diuretics, antidiabetic, anti-inflammatory, cardiovascular, cholesterol-lowering drugs (HMG-CoA reductase inhibitors), estrogen- based replacement products. Survey results show that pharmacists are very knowledgeable about the impact of antibiotics on our gastrointestinal microbiota and reversing it, but their acquaintance with the negative effects of other medications on one’s nutrient status is uncertain. Conclusion: Living in years of deteriorated nutritional value of healthy food as well in addition to unhealthy food and chronic diseases, drug-induced nutrient depletion is an additional complication that should not be ignored. This is why, it is advisable for the studied issue to be included in future lessons for continuing education for pharmacists in Bulgaria. Keywords: drug-induced, depletion; nutrients, pharmacists, acquaintance

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 140 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 DETERMINATION OF RISK FACTORS FOR HYDATID DISEASE AMONG ANIMAL BREEDERS IN DİNAR- AFYONKARAHİSAR Mehmet Fatih Aydın1, Hakan Guzel2

1Faculty of Health Sciences, Karamanoglu Mehmetbey University, Karaman, Turkey 2District Directorate of Agriculture, Dinar-Afyonkarahisar, Turkey

ABSTRACT Introduction: Hydatid disease is a zoonotic parasitic infection caused by a tapeworm called Echinococcus granulosus. This study aimed to determine the risk factors for hydatid disease among animal breeders in the Dinar-Afyonkarahisar province of Turkey. Materials and Methods: Between July 2015 and May 2016 a questionnaire form including risk factors for hydatid disease was applied by face-to-face interviews of 95 individuals. Survey data were analysed by percentage. Results: The average of age was calculated as 44.87. It was determined that 45.26% of animal breeders have no information about hydatid cyst, 38.94 % don’t administer antiparasitic drugs to animals, 68.42% will not be able to recognize hydatid cyst while slaughtering and 24.21% have seen hydatid cyst while slaughtering. We asked “Do you have some information about transmission of the disease?” and 80.00% of animal breeders said “No”. The percentage of participants who reported that there were some individuals who have caught hydatid disease around them was 2.10%. Most of the participants (56.84%) indicated that infected organs should be given to dogs or put in the rubbish box and 50.52% of the individuals reported that their dogs can enter easily into barns and they give giblets to dogs. Also, the percentage for animal breeders who don’t administer antiparasitic drug to their dogs was 57.89%. Conclusion: It was detected that the animal breeders in Dinar- Afyonkarahisar have insufficient information about certain aspects of hydatid disease and also we detected some risk factors for the disease. Keywords: hydatid disease, animal breeder, risk factor, Dinar, Turkey

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 141 Medical University of Varna Original Research PHYTOTHERAPY IN THE MANAGEMENT OF MENOPAUSE- ASSOCIATED VASOMOTOR SYMPTOMS Ralitsa Simeonova1, Iliya Zhelev2, Konstantina Velikova1, Galina Dimova1, Rosi Hristova1

1Student, Medical University of Varna 2Department of Pharmaceutical Technologies, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Menopause is the permanent cessation of menstruation for at least 12 consecutive months which results from the loss of ovarian follicular activity. Although it is a normal and natural part of aging occurring on average at age of 51 years, most menopausal women develop symptoms, which may deteriorate their quality of life for around one third of their life span (given the mean female life expectancy in Bul- garia of 78 years). The most common complaints are the vasomotor symptoms (VMS: hot flashes and night sweats). Hormone therapy was the gold standard of care for menopausal symptoms before the release of the Women’s Health Initiative. Afterwards, women became reluctant or anxious to use hormone therapy and sought natural non-hormonal alternatives. Materials and Methods: An analysis of accessible articles in scientific web databases (PubMed, ScienceDi- rect and Google Scholar) on the problem was conducted. Collected data considering evidence in alleviating vasomotor symptoms by popular herbal remedies was further reviewed and summarized. Results: Botanical supplements are considered to act through a number of different mechanisms of action including estrogenic, progestogenic, and/or serotonergic pathways that might mimic the actions of endogenous substances. But clinical studies of the main herbal drugs used to alleviate vasomotor symptoms either did not suggest significant efficacy (as not being superior to placebo) or were limited, and inconsistent, or show different improvements: in well-being, depression, health scores. Thus, patients should be informed to be cautious of possible side effects notwithstanding the general perception of that something is safe if it is of natural origin. In case of adverse reactions, women should be referred to specialists for reconsideration of their therapy. Conclusion: To conclude, as the evidence for phytotherapeutic menopausal VMS relief is both scarce and unconvincing, there is definitely a continued need for further work on the effectiveness and long-term safety of herbal medicinal products. Keywords: phytotherapy, effectiveness, menopause, vasomotor symptoms

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 142 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 REPROFILING OF ANTIPSYCHOTIC DRUGS FOR CANCER TREATMENT Yosif Gerchev1, Samuela Krasteva1, Monika Yaneva1, Dragomir Stoyanov1, Zhivko Apostolov2

1Student, Medical University of Varna 2Second Psychiatric Clinic, St. Marina University Hospital, Varna

ABSTRACT Introduction: Drug reprofiling is an important and substantial part of discovering new pharmacological approaches, especially when it comes to cancer treatment. Antipsychotic drugs are widely used in oncology for their proven benefits in ameliorating chemotherapy-induced nausea and vomiting, which allows researchers to observe additional effects in large group of patients without exposing them to any undue risk. On the other hand, latest studies show correlation between the antipsychotic treatment and the incidence of both benign and malignant tumors, which puts the patients suffering from different mental disorders in a greater risk of developing certain types of cancer. Materials and Methods: We performed a review of articles containing results of multi-centric in vivo and in vitro trials published on PubMed and ScienceDirect. Results: Recent studies prove that both first-generation antipsychotics such as thioridazine and pimozide, and second-generation antipsychotics such as risperidone and aripiprazole merit further research of their ability to reverse resistance to chemotherapy, improving the anticancer activity of numerous antineoplastic agents and inhibiting tumor growth. Risperidone is shown to be potentially effective in the treatment of adenocarcinoma, while thioridazine and aripiprazole enhance the sensitivity to antineoplastic drugs by alter- nating the marker expression of cancer stem cells. Conclusion: Antipsychotic drug co-administration in patients with different types of cancer provides a new therapeutic opportunity and better understanding of cancer biology. Chemical genomics mark a new era in pharmacological investigations, expanding the treatment range of already known drugs. Both the health and economic benefits of such biotechnological approach are immeasurable. Keywords: antipsychotic drugs, cancer treatment, drug reprofiling

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 143 Medical University of Varna Original Research A STUDY ON STRESS LEVELS, ANXIETY AND DEPRESSION IN STUDENTS AT THE MEDICAL UNIVERSITY OF VARNA Monika Kalcheva1, Hristo Stefanov1, Damyan Iliev1, Svetlin Varbanov2, Yasen Yanev1

1Student, Medical University of Varna 2 Second Psychiatric Clinic, St. Marina University Hospital, Varna

ABSTRACT Introduction: The aim of the study was to assess the level of stress, anxiety and depression in students at the Medical University of Varna. Materials and Methods: We conducted a cross-section study between February 17, 2017 and February 24, 2017 involving 205 students at the Medical University of Varna. The students were of different age, gender and specialties – 76.6% (157) female, 23.4% (48) male, 17.5% (36) first- and second-year students, 20% (41) third-year students, 34% (70) fourth-year students, 20% (41) fifth-year students, 8.3% (17) sixth-year students. The number of medical students was 123, 50 were pharmacy students, 9 - dental medicine students and 23 were students from other medical programs. We used three different questionnaires in our study - a stress-level questionnaire (PS-1) consisting of 14 questions, the State -Trait Anxiety Inventory (STAI) and the Patient Health Questionnaire (PHQ-2) Results: Experiencing situations as stressful “often” or “very often” was reported by 141 or 68% of the participants. The mean score of the stress questionnaire was 45.64 with a minimum of 23 and a maximum of 70 (Std. Deviation – 9.783). Score of (STAI) TR-A: Mean - 53.25 (Std. Deviation - 14.983), minimum – 20, maximum – 80. Score of (STAI) TR-B: Mean - 51.86 (Std. Deviation - 13.257), minimum – 20, maximum - 80. Score of (PHQ-2): Mean – 2.81 (Std. Deviation - 1.872), minimum – 0, maximum – 6. The results showed a positive correlation between stress and state-anxiety (r= .745**, p< .001), trait-anxiety (r= .750**, p< .001), depression (r= .585**, p< .001). Conclusion: The students at the Medical University of Varna experience relatively high levels of cumulative stress. There is a positive correlation between stress, anxiety and depression. These results are alarming and need further examination and careful consideration. Keywords: stress, anxiety, depression

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 144 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 RHESUS INCOMPATIBILITY IN EARLY MEDICAL ABORTION UP TO 8 WEEKS OF GESTATION (ARTICLE REVIEW) Anastasiia Subbotina1, Darja Schlothauer1, Johanna Löhr1, Elvira Nenashkina2

1Student, Medical University of Varna 2Obstetrician, Next Generation Clinic, St. Petersburg, Russia

ABSTRACT Introduction: The D Antigen is a specific red blood cell surface protein. Its presence (RhD pos) or absence (RhD neg) is genetically predetermined. In regard to the field of obstetrics, the antigen absence on the mother’s red blood cells is a matter of concern once such a woman becomes pregnant with an RhD pos. fetus as rhesus incompatibility would take place. Once an RhD neg. woman gives birth or undergoes an invasive procedure such as abortion, post-sensitization could happen because D Antigen development takes 35 to 45 days after conception. Even early abortion that takes place up to the 8th week of the pregnancy, involves the risk of unpredictable onset of an alloimmunization process leading to complications in future pregnancies. Materials and Methods: We have conducted a literature review using database sources including AccessMed- icine, PubMed and ScienceDirect. Conflicting evidences were found among a limited number of researches. Consultation with the British Pregnancy Advisory Service took place in order to learn about present practices. Results: From 2 up to 5 percent of RhD neg. women could produce antibodies as a response to fetal RhD pos. cells entering maternal circulation and not develop alloimmunization reaction in early medical abortion. Small number of studies support that administration of anti-D immunoglobulin (Ig) after abortion leads to decreased alloimmunization development with few side effects. So far, there are no longitudinal studies that would prove the beneficial effect of anti-D Ig administration after early medical abortion. Conclusion: The administration of anti-D Ig in RhD neg. women undergoing abortion with RhD pos. fetus is still a subject of debate and demands further investigation. Therefore, doctors have to follow their country guidelines, which vary substantially. For example, the United States suggest prophylactic anti-D administration after 12 weeks of gestation whereas in the United Kingdom it is recommended to give anti-D antigen to every non-sensitized RhD neg. woman after medical abortion regardless of the duration of gestation. Keywords: rhesus, incompatibility, early, abortion

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 145 Medical University of Varna Original Research GADOLINIUM-CONTAINING CONTRAST AGENTS – NOT AS SAFE AS WE THOUGHT Ivelina Borisova1, Stanislava Stoycheva1, Iliyan Kolev2

1Student, Medical University of Varna 2Department of Pharmaceutical Sciences and Pharmaceutical Management, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Gadolinium-based contrast agents (GBCA) are extensively used as magnetic resonance imaging (MRI) contrast agents owing to their outstanding signal enhancement, low immunogenicity, and easi- ness of chemical modification. GBCA are most commonly used for enhancement of vessels in MR angiography or for brain tumor enhancement associated with the degradation of the blood-brain barrier. In 2006, however, a negative association between the use of GBCA and the development of nephrogenic systemic fibrosis (NSF) has been reported for the first time in patients with acute and chronic renal failure. An isolated case of gadolinium-induced NSF has also been registered in Bulgaria in November 2009. Nephrogen- ic systemic fibrosis (NSF) is a rare and serious syndrome, which was recognized in 1997. It consists of fibrosis of skin, joints, eyes, and internal organs. The mechanism of NSF is not fully understood despite extensive research. The most common symptoms include bone/joint pain and head/neck symptoms including headache, vision change, and hearing change manifested within 2 to 8 weeks after the patients had been exposed. Materials and Methods: We have used public internet databases – PubMed, SCOPUS, MEDLINE, and EM- BASE. Results: Collected data from different sources shows that GBCA can be extremely toxic to patients with impaired kidney functions, in patients around the time of liver transplantation, in newborn babies less than four weeks of age, etc. Conclusions: In order to preserve the patients’ health, physicians should be more aware of GBCA`s side effects and the patient`s history before every MRI, to restrict the dose to the minimum recommended and all patients should be screened for kidney problems before injection with these types of agents. Keywords: gadolinium, magnetic resonance imaging, nephrogenic systemic fibrosis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 146 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 SOMATOFORM SYMPTOM AND FACTITIOUS DISORDERS Daniel Zhafal1, Daniela Angelova1, Nikola Garipov1, Teodora Stoyanova1, Diana Petkova2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Somatoform symptom disorders (SSD) and factitious disorders are part of a new category of psychiatric disorders, which can lead to unsuccessful medical treatment of patients. These disorders are cases where a person will be reporting symptoms that are not actually caused by pathological changes and might mislead the physician. Factitious disorders on one hand, are cases where a patient simulates physical signs that he is aware are fake. On the other hand, SSD is when the patient actually believes that he is experiencing said symptoms, although there is no somatic reason or evidence for them. Materials and Methods: The information presented is а result of gathering and analyzing information from various sources including researches and statistical analysis from the websites Physio-pedia and Health Re- search Funding (2015), as well as from the Diagnostic and Statistical Manual of Mental Disorders DSM-5 (2013). Results: Both groups of disorders are diagnosed based primarily on negative criteria and are often misdiagnosed. Yearly, these disorders cost the health care system a great deal of tests and procedures. There are some specific behavioral patterns that can alarm a physician into suspecting the patient suffers from one of these disorders. Studies show a greater frequency of SSDs in women. People with lower education are more likely to suffer from SSD as well, and those with a lower economic status also. Conclusion: A physician can face great difficulties diagnosing these conditions. Moreover, being so rare, a physician should never show doubt in the patient’s complains, and should take them seriously yet with caution. Finally, although these patients are complaining about false symptoms, they are indeed sick and need to be treated. Keywords: factitious, somatoform, disorders, mental, psychiatry, symptoms

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 147 Medical University of Varna Original Research OSTEOPLASTY IN SURGICAL TREATMENT OF CHRONIC EXOGENOUS OSTEOMYELITIS Stanislav Morfov1, Petar Milkov2, Borislav Zlatev3, Veselin Marinov4

1Student, Medical University of Varna 2Department of Orthopaedics and Traumatology, Faculty of Medicine, Medical University of Varna 3Military Medical Academy, Sofia 4Naval Hospital-Varna, Military Medical Academy, Sofia

ABSTRACT Introduction: The aim of our research is to show the role of osteoplasty and surgical treatment of chronic exogenous osteomyelitis and to present exact rules of performing its different types - primary osteoplasty (PO – right after the renovation of the area of the infection), primary delayed osteoplasty (PDO – till the 30th day after the renovation of the area of infection ) and secondary osteplasty (SO – after more than 30 days after the renovation of the area of infection ). Many authors recommend performing of PO and many others claim that the best way of performing the procedure is PDO, based on results of their own researches. The dispute PO or PDO (SO) has continued for many years, but recently with the improved possibilities of planning ahead, the various ways of antibacterial treatment, the osteoplasty suggestions of the second group authors is starting to sound more convincing. Materials and Methods: We present 255 patients suffering from chronic exogenous osteomyelitis with defect of the bones, which means cases, in which two types of activities need to be performed:1. Removing bone infection from the osteomyelitic area by sanitizing it; 2. Creating good conditions for the bone consolidation via fixation (internal, external) and osteoplasty. Results: In 205 cases, we have sanitized the osteomyelitic area by using fixation and osteoplasty at the same time (PO). In 50 cases, because of the inability to perform PO, we proceeded with PDO or SO later. A good result would be a lack of bone infection and presence of bone consolidation for the first year. We observed that in 90% of PO and 60% of PO and PDO. Because of our database, we consider that PO should be prioritized if sanitizing the osteomyelitic area is performed perfectly. Conclusions: Based on our data we consider that PO is a priority if the renovation of the area of infection is performed perfectly. Keywords: osteoplasty, osteomyelitis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 148 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 HIP ARTHROPLASTY - METHOD OF CHOICE FOR SOME TROCHANTERIC FRACTURES Veselin Marinov1, Stanislav Morfov2, Plamen Minchev1

1Naval Hospital-Varna, Military Medical Academy, Sofia 2Student, Medical University of Varna

ABSTRACT Introduction: We present 25 cases of operated patients, diagnosed with trochanteric fractures of the femur, which by definition should be treated by osteosynthesis. Materials and Methods: In these presented cases, we show an alternative method - hip arthroplasty (uni- polar or bipolar), striving mainly to avoid both prolongation of bed healing and not putting pressure on the operated leg (which is needed after osteosynthesis for a period of at least 45 days). Results: After arthroplasty, the patients can stand up and start putting pressure on the operated leg two days after the operation (50% of body weight on the operated limb for a period of 15 to 30 days, and after that - 100% of body weight). More indications for arthroplasty are:1. Definite - coxarthrosis 3th and 4th grade. 2. Relevant: a) when an early rising of old and/or frail patients is needed; b)severe osteoporosis, which would prolong the period of consolidation after osteosynthesis. When it is possible to put weight on the operated limb earlier, the probability of complications from prolonged bed rest is lower, and delayed weight putting can cause thromboembolism, hypostatic pneumonia and decubitus ulcers. Conclusions: We based our consideration on our database and results, comparing them with a group of 25 trochanteric fractures, operated by the method of osteosythesis. We defined arthroplasty in our study: 1. Pa- tients with better chances to outlive the critical period; 2. A method of less complications; 3. A method, after which a second surgery is not needed. We consider that arthroplasty after certain trochanteric fractures is a good alternative method when it is needed. Keywords: hip arthroplasty, trochanteric fractures

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 149 Medical University of Varna Original Research SUCCESSFUL ROOT CANAL TREATMENT MANAGEMENT OF TAURODONT TEETH Trayan Marinov1, Aleksandrina Varbanova1, Marina Yordanova1, Klementina Moneva1, Maya Doychinova2

1Student, Medical University of Varna 2Department of Conservative Dental Treatment and Oral Pathology, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: The aim of this scientific literature review is to compare the management of different root canal treatments of taurodont teeth and to highlight the most appropriate techniques. Materials and Methods: All the data were gathered using several search engines and the target articles were case reports and literature reviews. Results: The results show that the main difficulties regarding root canal treatment of taurodont teeth were related with the abnormal morphology and anatomy of the root canal system and that requires modern shaping, irrigating and filling techniques and the use of magnifying equipment. Our analysis reveals the most suitable shaping technique for root canal treatment of such teeth is RECIPROC® systems. Due to the abnormal root canal system the irrigation protocol must include passive ultrasonic irrigation of the solutions. The filling must be modified warm lateral condensation in the apical part of the canal and warm vertical compaction in the coronal part of the canal and in the elongated pulp chamber. Conclusion: As a conclusion, root canal treatment of taurodont teeth is a challenge regardless of the diagnosis of the tooth or the type of taurodontism. The clinicians should be using all the benefits of modern endodontics. Mesotaurodont and hypertaurodont teeth are associated with X-linked inherited syndromes and when diagnosing such teeth, genetic consultation and analysis is recommended. More studies should be focused on the issues of prevalence of this condition in our country and more advanced protocol for root canal treatment of each type of taurodont teeth is needed. Keywords: taurodont, taurodontism, root canal treatment, endodontics

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 150 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 CLINICAL EFFECTIVENESS AND COMPLICATION RATE OF CORE NEEDLE BREAST BIOPSY Martin Karamanliev1, Anislav Gabarski1, Chavdar Ivanov1, Dobromir Dimitrov2

1Student, Medical University - Pleven 2Oncosurgical Department, UMHAT “Dr. G. Stranski”, Pleven

ABSTRACT Introduction: Core needle biopsy is a standard method in breast cancer diagnosis. It gives information about the breast cancer type, the hormone receptor and HER2 status, which determines the further behavior and treatment. Our aim is to establish the effectiveness of the core needle biopsy and the complications that might follow. Materials and Methods: A retrospective clinical study of all patients with suspicious for malignancy breast mass who have undergone core needle biopsy followed by operative treatment between January 2014 and De- cember 2015 at UMHAT “Georgi Stranski” - Pleven, was undertaken. Core needle biopsy was performed using a Tru-cut gun with an 18-gauge needle. The lesion was manually immobilized and the needle was insert- ed under visual control or ultrasound guided. Results: A total of 79 Tru-cut biopsies followed by operative treatment were performed on patients with palpable lesions during the study period. All of the patients were women. The median age was 64 years old (range: 37 to 91). The results showed: an overall diagnostic accuracy of 98.73%, sensitivity - 98.67%, specificity – 100%, positive predictive value – 100% and 80% negative predictive value. Mild complications such as suffusions in 3 patients (3.79%) and 34.18% (27 patients) slight postoperative pain were recorded. Serious complications were recorded in one case with pneumothorax or 1.27%. Conclusion: The core needle biopsy is effective, highly specific and sensitive method for diagnosis of breast cancer with rare serious complications. Compared to open biopsy, the core needle biopsy is a safer and eco- nomically more sufficient method with less hospital stay, less postoperative pain and fewer complications. Keywords: core needle biopsy, Tru-cut biopsy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 151 Medical University of Varna Original Research RESPIRATORY DYSFUNCTIONS IN ACROMEGALY. ACROMEGALY AND SLEEP APNEA Denis Veliev1, Adem Hadjimehmed1, Svilena Rangelova1, Mukates Velieva1, Evelina Zlatanova-Kazakova2

1Student, Medical University of Varna 2Department of Endocrinology, St. Marina University Hospital, Varna

ABSTRACT Introduction: Acromegaly refers to an abnormal growth of some bones and tissues due to excessive action of insulin-like growth factor-1 (IGF-1). It occurs after the growth plate cartilage fuses in adulthood. Acro- megaly is an insidious disease, which is often diagnosed late in its course. The diagnosis is often preceded by around 10 years of active but unrecognized disease. The most frequent clinical manifestations of acromegaly affect the skin and joints. Patients with acromegaly are also at increased risk of cardiovascular, cerebrovascular and respiratory disorders, and a development of neoplastic lesions. Materials and Methods: Prof. Francesco Cavagnini, MD, PhD (ITA), Dr. Mark Gurnell (UK) and Dr. Eve van Cauter (US)’s studies have revealed high prevalence of many different respiratory problems among patients with acromegaly. The aim of the present report is to focus on the life-threatening conditions that acromegaly causes and the importance of early diagnosis. Camilo et al. 2013 (Brazilian scientists) compared 20 acromegaly patients with 20 healthy controls. The results showed extensive alterations in respiratory functions in patients with acromegaly. Results: The findings in this study showed a significant decrease of the functional capability of the respiratory system. Bronchiectasis was found in 35% of acromegaly patients and almost every patient had an ob- structive type of sleep apnea. Dr. M. Gurnell and Dr. E. van Cauter found similar results in their studies. Ad- ditionally, they revealed that 4 out of 5 acromegaly patients experienced severe sleep apnea. This condition leads to higher risk of mortality as it induces a number of metabolic derangements such as arterial hypertension, metabolic syndrome and diabetes, making the occurrence of cardiovascular events more frequent. Conclusion: Respiratory disorders related to acromegaly appear to be complex in their origin and development. Furthermore, they appear as two main respiratory dysfunctions, being sleep apnea and impaired respiratory function. It is important for the patients to be diagnosed at the early stages of the disease, in order to be able to receive an adequate treatment for respiratory disorders. Keywords: acromegaly, respiratory disorder, sleep apnea, growth hormone, diagnosis

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 152 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ORAL MANIFESTATION OF SYSTEMIC DISEASES Vasil Yordanov1, Miglena Balcheva2, Siyana Gradanska1, Maria Dzhinova1

1Student, Medical University of Varna 2Department of Conservative Dentistry and Oral Pathology, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: The oral cavity, apart from being the beginning of the gastrointestinal tract and playing a role in the speech, can also be a basis for symptoms, connected with systemic diseases. The most serious problems concerning dental professionals include caries, oral ulcers, mucosal erythema, gingival bleeding and hypertrophy, soft tissue exophytic masses, dry mouth, facial pain, movement disorders, tooth abnormalities, abnormal dental wear, tooth/mucosal discoloration, developmental and bone pathology. Materials and Methods: Oral manifestations of systemic diseases can be evaluated through a variety of methods. Careful examination of the oral cavity is still the most important procedure. It may reveal mucosal changes, periodontal inflammation and bleeding, and the general condition of the teeth. Biopsy is an obligatory method for diagnosing cancer and precancerous lesions. Even then, there is a possibility for a mistake. The function of oral organs is assessed as a malfunction may indicate an unnoticed until now health problem. Pain symptoms should never be underestimated. Results: Dental specialists should have in mind that even the smallest irregularity may be connected to an undiagnosed systemic disease. Oral ulceration may be found in patients with lupus erythematosus, pem- phigus vulgaris, or Crohn’s disease. Severe periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus infection, thrombocytopenia, and leukemia. An understanding of the relationship between systemic disease and oral pathology is important with respect to establishing the diagnosis and determining the complexity of the following treatment. Conclusion: Careful examination of the oral cavity may reveal findings indicative of an underlying systemic condition, and allow for early diagnosis and treatment. All fields of medicine should work together in the best interest of patients. Keywords: systemic disease, oral manifestation

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 153 Medical University of Varna Original Research CORRELATION BETWEEN KI-67 INDEX AND PATIENT SURVIVAL IN GLIOBLASTOMA MULTIFORME Georgi Stoyanov1, Deyan Dzhenkov2, Martina Kitanova2, Ivan Shterev3

1Student, Medical University of Varna 2Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University of Varna 3Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Glioblastoma multiforme (GBM) is a class IV astrocytic tumor, the most malignant of the four groups of tumors with astrocytic differentiation as per the revised 2016 WHO classification of CNS tumors. Historically, patients with GBM have had a very poor survival rate. The aim of this study was to establish whether a correlation between the Ki-67 index of GBM tumor samples and patient survival exists. Materials and Methods: Forty-one GBM tumor samples were tested for their IHC reaction with Ki-67 after their original H&E and other IHC slides were reviewed by a single author and blind coded to ensure non-suggestive analysis of the results. The Ki-67 positivity index of the nuclei was estimated after digitalization of the slides, using the Leika Aperio AT2 slide scanner and calculated by the ImmunoRatio automated count- ing tool on the digital slides. The individual Ki-67 index and patient survival of each case were statistically compared after the cases were decoded. Results: The forty-one GBM cases had a mean Ki-67 index of 17.34%, standard deviation ±10.79 (p>0.05), with the lowest index being 2% and the highest one being 46%. Statistical analysis of the Ki-67 index divided dichotomously into two groups (low and high) and patient survival revealed that cases with a high Ki-67 index had no significant difference in survival when compared to those with low expression. Conclusion: Based on the reported results the mean Ki-67 percentage of positive nuclei in GBM tumor samples cannot be used to estimate the survival of patients. However, Ki-67 remains a valuable IHC tool in pathology. Keywords: glioblastoma, IHC, CNS tumor, survival

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 154 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 STRESS URINARY INCONTINENCE IN WOMEN. LASER TREATMENT OPTIONS Alexandra Goncharova1, Majid Shahbazi1, Elis Ismail2

1Student, Medical University of Varna 2Department of Obstetrics and Gynaecology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: According to the International Continencе Society (ICS), urinary incontinence is the invol- untary loss of urine that represents a hygienic or social problem to the individual. However, this problem is very heterogeneous presenting variably in the clinic, and having very different pathogenesis behind it. Therefore, the treatment plans for stress, urge, overflow and bypass UIs differ widely. The estimated prevalence of stress urinary incontinence (SUI) in adult women ranges from 4% to 35%. The primary mechanism of SUI is inability to transmit increased intra-abdominal pressure to the urethra. Materials and Methods: The aim of the research was to review and compare currently available laser treatment options for SUI. We have researched PubMed and PMC databases using keywords: “urinary incontinence”, “stress urinary incontinence”, “laser treatment’’. After reviewing the available literature we have selected four articles as being contemporary and the most relevant to the subject. Results: Currently available first line treatment methods of SUI are behavioural modifications and physical therapy. Second line treatments are surgical. First line methods results depend on the patient’s compliance and age. The surgical option has possible complications of urinary retention, chronic urinary infection, perforation of the urethra during surgery and foreign body reaction to the implant. Non-ablative laser therapy is a non-invasive, non-compliance dependent new option for treatment. SUI patients have a higher prevalence of defective collagen in the pelvic floor compared to the healthy women without SUI. Therefore, stimulation of collagen proliferation by laser should treat the condition. Conclusion: CO2 or Er:YAG non-ablative laser methods focus on increasing the temperature of the anterior wall of the vaginal mucosa enough to stimulate synthesis of new collagen fibrils without damaging the epi- dermis layer, so as to decrease the downtime after the treatment and eliminate the need for anaesthesia during the procedure. The treatment is promising, however, available pilot studies on the matter have several limitations such as small patient population, exclusion criteria that include major risk factor for SUI, short follow-up time, loss of patient population during the follow-up. Keywords: urinary incontinence, stress urinary incontinence, laser treatment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 155 Medical University of Varna Original Research USING OF VAC PACK DRESSING FOR TEMPORARY CLOSURE OF AN OPEN ABDOMEN Vasil Dimitrov1, Elina Merashka1, Nikola Bonchev1, Gergana Ivanova1, Dobromir Nguen2

1Student, Medical University - Pleven 2Department of Coloproctology and Septic Surgery, UMHAT “Dr. G. Stranski”, Pleven

ABSTRACT Introduction: The open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The major problem in managing the open abdomen is control of intra-abdominal fluid secretion, facilitation of abdominal re-exploration and preservation of the fascia for abdominal wall closure. The method of temporary abdominal closure (TAC) may play a role in the patient outcome. Over the years, negative pressure wound therapy has become an increasingly popular technique for temporary abdominal closure and has been widely used by surgeons. VAC pack dressing for temporary abdominal closure is a simple method utilizing dressing supplies that are readily available in any op- erating room. Materials and Methods: We have performed a literature review of the scientific topic using the PubMed and Springer link databases. We also show our experience with the using of VAC pack dressing for temporary abdominal closure. Results: Our initial experience shows that increasing primary fascia closure, reducing the formation of en- teroatmospheric fistulas, reduced mortality prevents abdominal compartment syndrome. It also allows for the control and measurement of abdominal fluid drainage. The use of this system is in its initial phase and we still do not have the amount of cases usually considered statistically significant. Conclusion: VAC pack therapy is a safe and effective modality in the treatment of an open abdomen and should be considered in the treatment of this problem. Using VAC pack dressing is associated with significantly higher primary fascia closure and lower mortality among the patients who require an open abdomen. Keywords: VAC pack, open abdomen, temporary abdominal closure

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 156 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TREATING CROHN’S DISEASE WITH THE MONOCLONAL ANTIBODY VEDOLIZUMAB Plamen Angelov1, Elena Stoyanova1, Alexandra Stefanova1, Dimana Mitsova1, Anton Dinkov2

1Student, Medical University of Varna 2Department of Propedeutics of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Crohn’s disease is an autoimmune gut disorder that causes chronic inflammation of any part of the gut, usually the end of the ileum or the colon. The symptoms can be mild to severe, but the most common ones are abdominal pain and diarrhea, tiredness, weight loss and joint pain. An abnormal immune reaction to some intestinal bacteria is known to be one of the reasons for the disease, but genetic predisposi- tion could also be suspected. Materials and Methods: Several medical articles, researches and publications along with some clinical trials of vedolizumab were observed and summarized in this review. Results: The treatment of Crohn’s disease depends on its severity. There are medical, surgical, both medical and surgical, or dietary method treatments. A drug, called vedolizumab was approved recently. It is a gut-specific monoclonal antibody. It blocks the movement of T and B immune cells into the gastrointestinal tract, which suppresses the inflammation and does not affect the rest of the immune system. An investigation was conducted from 2008 to 2012 to test its effectiveness. Vedolizumab was given to 225 patients and 149 received placebo in cohort I, in cohort II - 521 patients received open-label vedolizumab. At week 6, 47.1% of the 225 patients, 44.3% of the 521 and 25.5% of the 149 had a clinical response; 40.9% of the 225, 36.7% of the 521 and 24.8% of the 149 had a mucosal healing; and 16.9% of the 225, 19.2% of the 521 and 5.4% of the 149 had a clinical remission. Conclusion: Vedolizumab has many advantages over the existing treatments for adult patients. It has few side effects and it only affects the immune system in the GI tract. Keywords: gut disorder, Crohn’s disease, treatment, vedolizumab, immunosuppression

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 157 Medical University of Varna Original Research KETAMINE AND THE FUTURE OF NMDA ANTAGONISTS IN THE TREATMENT OF DEPRESSION Samuela Krasteva1, Yosif Gerchev1, Dragomir Stoyanov1, Monika Yaneva1, Zhivko Apostolov2

1Student, Medical University of Varna 2Second Psychiatric Clinic, St. Marina University Hospital, Varna

ABSTRACT Introduction: Major depressive disorder affects around 16 per cent of the world population at some point in their lives. Despite the availability of numerous monoaminergic antidepressants, most patients require weeks or months to respond. The glutamatergic NMDAR antagonist ketamine exerts rapid and sustained antidepressant effects after a single dose in patients with depression, but its use is associated with undesirable side effects. Ketamine is widely used as anaesthetic, it has been approved for use for over 45 years and carries no patent protection. That is why it is very unlikely for pharmaceutical companies ever to pay for costly long-term studies. However, the American Psychiatric Association Council of Research Task Force on Nov- el Biomarkers and Treatments asked many medical experts to provide a consensus statement on the benefits and the risks of ketamine treatment. “Off-label” prescriptions for depression have grown dramatically in recent years. Materials and Methods: We have researched articles from sciencedirect.com, scholar.google.com, pubmed. com. Results: Recent studies have confirmed that ketamine provides rapid and robust relief to those suffering from severe depression. Unfortunately, there is limited research to advise doctors on the best doses and length of ketamine treatment where patients will benefit the most. Also, it is unknown whether ketamine can provide long-lasting relief for depression without dangerous side effects. Conclusion: Ketamine has many advantages over currently used antidepressant medications. It acts quickly and has long-lasting effects, but it is addictive, can induce psychosis and has serious cardiovascular side effects. Future research will be needed to find out how ketamine works biochemically and if it is possible to develop ketamine-like drugs without the unwanted side effects. Keywords: depression, major depressive disorder, ketamine, NMDA

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 158 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ENDOVASCULAR TREATMENT FOR UNRESECTABLE HEPATOCELLULAR CARCINOMA - TRANSARTERIAL CHEMOEMBOLIZATION (TACE) Simona Nizorkova1, Yavor Hinov1, Irini Karatsoli1, Ivan Valkadinov1, Georgi Todorov2

1Student, Medical University of Varna 2Department of Imaging Diagnostics and Radiotherapy, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Hepatocellular carcinoma (HCC) is now acknowledged as the third leading cause of cancer-related deaths worldwide, with 660,000 people affected annually. Unfortunately, due to the lack of screening programs, HCC is often diagnosed in an advanced stage. Therefore, palliative treatment becomes the main source of therapy for patients in terminal stages of the disease. Transarterial chemoembolization (TACE) is an interventional loco-regional procedure, performed to alleviate symptoms and prolong survival rate in patients with surgically unresectable HCC. TACE combines the administration of chemotherapeutics (doxoru- bicin, cisplatin and mitomycin C) and embolic agents (lipoidol and gelatin sponge) through the main feeding artery of the tumor. The rationale of this method is to cause necrosis of the tumor tissue while avoiding damage to the surrounding healthy liver. Materials and Methods: A retrospective analysis was held for the period 2012-2015 that included 12 patients, treated at the St. Marina University Hospital. The study documented information from the patients’ medical records. We had 11 patients (91.7%) with HCC and 1 (8.3%) with ChCC (cholangiocarcinoma), with classification based on the Child-Pugh scale. Five out of the 12(41.6%) were with a single, solitary lesion, while 7 (53.3%) were with multifocal lesions, with predominant right hepatic lobe localization in 10 out of 12(83,3%). The aim of this study is to evaluate the outcome of the treatment in those patients. Results: The comparative analysis between TACE and systemic chemotherapy results proved a significantly better response to the treatment with TACE, with an estimated survival rate of 38 weeks in comparison to 30 weeks in favor of TACE. Conclusion: TACE is method for palliative patient care which shows better survival rate when compared to conventional treatment. Our study suggests that TACE is more relevant in the treatment of unresectable HCC patients. Keywords: hepatocellular carcinoma, TACE, survival rate

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 159 Medical University of Varna Original Research COCONUT – THERAPEUTIC APPLICATIONS IN DENTAL MEDICINE Aleksandrina Varbanova1, Trayan Marinov1, Marina Yordanova1, Klementina Moneva1, Maya Doychinova2

1Student, Medical University of Varna 2Department of Conservative Dental Treatment and Oral Pathology, Faculty of Dental medicine, Medical University of Varna

ABSTRACT Introduction: The aim of this scientific literature review is to analyze the data on the current use of coconut oil in dental medicine and to evaluate the need of further studies. Materials and Methods: Related articles were gathered and reviewed using several search engines. Target articles were clinical trials, randomized studies, case reports and reviews. The data were objectively analyzed and a systematic review was made. Results: The application of products from coconut - coconut oil and water are not significantly represented in dentistry. Our analysis showed that the main reasons for the use of coconut are because of its antifungal and antibacterial qualities and he is mainly compared to the gold standard in dentistry – chlorhexidine. It is an easily usable, safe and cost-effective agent with minimal side effects. It has significant reduction in values of S. mutans count, Lactobacillus count, plaque scores, and gingival scores comparable to chlorhexidine. Conclusion: In conclusion, more studies should be focused on the Cocos nucifera, in order to evaluate its potential use in dental medicine. Given the positive effects of this oil in the oral cavity, our opinion is that its active ingredients should be incorporated in oral hygiene means. Coconut oil could be an alternative of chlorhexidine in the formula of products for oral hygiene, because it has known benefits such as: antiseptic properties, safe for oral tissues, affordable. Moreover, no side effects have been reported yet. We also recommend researching its potential use in the corrective and supportive phase of periodontal therapy. There are no studies regarding the immunomodulating effect of coconut oil. The application of coconut oil in herpes treatment is debatable and more studies should be carried out. Keywords: coconut oil, coconut water, Cocos nucifera, essential oil, dental medicine

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 160 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 GENOMIC TESTS GUIDING THE ADJUVANT SYSTEMIC THERAPY IN WOMEN WITH BREAST CANCER Siyana Gradanska1, Maria Dzhinova1, Vasil Yordanov1, Miglena Balcheva2

1Student, Medical University of Varna 2Department of Conservative Dentistry and Oral Pathology, Faculty of Dental Medicine, Medical University of Varna

ABSTRACT Introduction: The decision to initiate adjuvant chemotherapy after surgery in patients with estrogen receptor-positive and lymph node-negative early stage breast cancer, has traditionally been guided by clinical and pathological factors (characteristics of the patient and the tumor), in conjunction with the clinician’s and the patient’s preferences. Many of these patients are exposed to adjuvant chemotherapy toxicity and cost with little or no clinical benefit, and identifying those who do benefit, remains a challenge. Gene-expression profiling is an emerging clinical strategy which evaluates cancer recurrence risk by using genomic information in order to support better decision-making about adjuvant chemotherapy. Materials and Methods: In this research we analyzed three types of gene-expression-profiling tests of breast cancer. A multigene immunohistochemistry-based test, known as MammoStrat, classifies breast cancer patients into low-, moderate- or high-risk categories for disease recurrence. The MammaPrint assay is a sev- enty-gene signature developed using tumor tissue from young women (less than fifty-five years of age) with node-negative disease. OncotypeDX is a twenty-one-gene-expression profiling that provides a probability of recurrence score for women with early stage (Stage I or II), estrogen receptor-positive, node-negative breast cancer, and categorizes patients as low-, intermediate- , or high- risk for distant metastasis in the next five to ten years. Results: A high-risk result is correlated with distant breast cancer recurrence rate, hormone therapy benefit, and chemotherapy benefit. A lower score is correlated with a lower risk of distant breast cancer recurrence, lower benefit of chemotherapy, and greater benefit of hormone therapy. Conclusion: Use of gene-expression profiling along with clinical and pathological classification of early- stage breast cancer provides the physician with additional information about adjuvant systemic therapy in these patients in order to maximize efficacy and minimize adverse side effects. Keywords: breast cancer, systemic therapy

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 161 Medical University of Varna Original Research THYROTOXIC CRISIS – TREATMENT AND MANAGEMENT Ivanina Arabadzhieva1, Teodora Karamfilova1, Kiril Hristozov2, Evelina Zlatanova-Kazakova2

1Student, Medical University of Varna 2Department of Endocrinology and Metabolic Diseases, St. Marina University Hospital, Varna

ABSTRACT Introduction: Thyrotoxic crisis is a life-threatening complication of thyrotoxicosis. It might be caused by insufficient thyrostatic therapy or other diseases, mostly those with fever and inflammation, surgery and others. Materials and Methods: Usually, evidence of prior hyperthyroidism or past surgery on the thyroid gland can be found in the medical history of the patient. The typical symptoms include adynamia, tremors, hyperthermia, extreme tachycardia with frequent arrhythmias, hypotension, possibly vomiting and dehydration. Usually, the patients are with low BMI (body mass index) and severe muscle weakness. The symptoms leading to thyroid pathology are exophthalmos (or signs of thyroid - associated ophthalmopathy) and an enlarged thyroid. From a clinical point of view there are three stages of severity of the thyrotoxic crisis. They do not correlate with the serum levels of thyroid hormones but in all cases they are beyond the normal range. Results: The total mortality rate of thyrotoxic crisis today is oscillating around 15-20%. Therefore, its occurrence must be prevented by early diagnosis of hyperthyroidism, proper treatment and avoiding the application of iodine-containing substances especially when hyperthyroidism is already present. Conclusion: The diagnosis of thyrotoxic crisis is based mostly on clinical and not on hormonal evidence. It is a life-threatening situation. It is appropriate to test a serum for the study of TSH, FT4, but the treatment must begin even before the hormonal results. The treatment goals are to control the haemodynamic ,to correct the hyperpyrexia and neuro-psychic excitability and to block the hypersecretion of thyroid glands. It includes glucose-saline solutions, glucocorticoids, antithyroid, iodine medicine, beta blockers, benzodiaz- epines and other symptomatic agents. All types of surgery must be performed after the function of the thyroid gland is normalized. Keywords: thyrotoxic crisis, treatment

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 162 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 THE POTENTIAL ANTI-TUMOR BENIFITES OF NIGELLA SATIVA Siyana Ilieva1, Ahmed Ahmed1, Aylin Kerim1, Kristiyana Kaleva1, Rositsa Chamova2

1Student, Medical University of Varna 2Department of Hygiene, Disaster Medicine and Epidemiology, Faculty of Public Health, Medical University of Varna

ABSTRACT Introduction: Neoplastic diseases fall into the group of socially significant diseases. The fight against these diseases is extremely difficult and prevention still remains the only effective way to deal with them. Herbal medicine is a modern field of medicine, which studies different plants, especially herbs and their application in cancer treatment. One of the not-so-popular herbs is Nigella Sativa, also known as black seed or black cumin. It is an annual flowering plant, which is grown almost all over the world, but it is native to Southern and Southwest Asia. It belongs to the botanical family Ranunculaceae. Chemical analysis of Nigella sativa oil shows that it contains of thymoquinone, dithymoquinone, transanethole,conjugated linoleic acid, nigil- line and melanthin. Materials and Methods: A documentary approach was used. A targeted thematic analysis of scientific publications available in PubMed and Science Direct is presented. Results: The most crucial aspects of the anti-tumor properties of Nigella sativa are: anti-proliferative and pro-apoptotic (decreases TNFα,IL-6, prolactin, estradiol, progesterone and increases caspase-3,8,9 and p53), anti-oxidant and cytotoxic (decreases ROS,NO and lipid peroxides, increases GSH), anti-mutagenic (decreases genomic mutations and increases DNK replication fidelity, DNA repair, degradation of mutagens), anti-metastatic (decreases PAI-1, t-PA, u-PA) and NK toxic effects (increases TNF-α and IFNγ). Expo- sure of MCF-7 breast cancer cells to aqueous and alcohol extracts alone or in the presence of descending po- tency for H2O2 completely inactivated growth of these cells, suggesting that N.sativa, alone or in combination with oxidative stress, is an effective anti-cancer agent Conclusion: As part of a holistic approach to oncologic diseases, Nigella sativa fractions can be used in combination with chemotherapeutic agents to control the disease. Keywords: Nigella Sativa, anti-tumor

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 163 Medical University of Varna Original Research PHYSICAL, CHEMICAL AND MICROBIOLOGICAL QUALITY OF WATER SAMPLES IN KARAMAN PROVINCE Sami Karagöz1, Mehmet Fatih Aydın2, Suleyman Gokmen3

1Public Health Laboratory, Karaman, Turkey 2Faculty of Health Sciences, KaramanogluMehmetbey University, Karaman, Turkey 3Technical Vocational School of Higher Education, Karamanoglu Mehmetbey University, Karaman, Turkey

ABSTRACT Introduction: Water quality is important to protect public health and also for the environment. There are several microorganisms transmitted by drinking unsafe water. This study aimed to determine the physical, chemical and microbiological quality of water samples in rural and urban areas of the Karaman province. Materials and Methods: Natural spring, city and pool water samples were collected into sterile bottles of 250 milliliters and non-sterile bottles of 1500 milliliters for microbiological and physico-chemical analysis, respectively, from January to July 2016. Some physico-chemical parameters (taste, color, odour, turbidi- ty, total hardness, transparency, pH, ammonium, chlorides, phosphate and nitrates) were analyzed. Chemi- cal analyses were performed by using commercial kits. Before bacterial inoculation, water samples were fil- tered by a membrane filtration system and analyzed in terms of coliform bacteria. The results of the physical, chemical and microbiological experiments of water samples were evaluated according to World Health Organization standards. Results: Twenty-eight of the 71 drinking water samples of special request, 156 of 301 drinking water samples for control, 3 of 24 water samples of pool water and none of 18 drinking water for market surveillance and inspection were found unsafe in terms of microbiological analysis. Nine of 52 drinking water samples of special request, none of 267 drinking water samples for control and 19 of 25 water samples of pool water were found unsafe in terms of physico-chemical analysis. Conclusion: In conclusion we determined the physical, chemical and microbiological quality of water samples in the Karaman province of Turkey in comparison with the international standards. It was detected that some water samples in Karaman province were found unsafe for microbiological and for some physico- chemical criteria. It was evaluated that the reason for unsafe pool water results was related to bacterial contamination of pools and artesian well water source. Keywords: water safety, Karaman, physicochemical and microbiological quality

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 164 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 TOXIC AND THERAPEUTIC EFFECTS OF YESSOTOXIN AND DOMOIC ACID Desislava Boyanova1, Ivan Angelov1, Zlatina Peteva2

1Student, Medical University of Varna 2Department Chemistry, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: In the last decades the discovery of metabolites with biological activities from marine organisms has increased signiﬁcantly. Marine toxins are naturally produced by some microalgae, accumulate in filter-feeding organisms and, through the food chain, find their way to humans causing severe illnesses. Despite the poisoning effect, some of the marine toxins, e.g. yessotoxins (YTX) and domoic acid (DA) are of medical interest due to their potential role as anti-allergic and anti-cancer compounds. Materials and Methods: The review is based on papers published in journals with impact factor in the last five years. Crucial point in the papers selection is also the experience of the authors in the related topic. Results: Both domoic acid and yessotoxins can be determined as lipophilic due to their chemical structure. DA is a potent neurotoxin that acts as a glutamate antagonist. Symptoms of oral exposure to higher doses are well known. Low doses elicit gastrointestinal effects that are often underestimated. Hereby, studies about the effect of repetitive low-level exposure and its contribution to chronic health consequences are summarized. Yessotoxins are very powerful compounds that cause mitochondrial alternations. However, local applications of YTX around established tumours decreases their growth in the absence of any significant toxicity, which reveals the role of YTXs as an anti-cancer drug. The use of YTXs in the treatment of allergic and asthmatic processes is also discussed. Conclusion: Although both domoic acid and yessotoxins have a poisonous effect, low doses of exposure have a different cellular impact. Domoic acid intoxication, even asymptomatically, has a chronic impact. On the other hand, yessotoxins in low concentrations could be used for treating different diseases. Keywords: marine biotoxins, domoic acid, yessotoxin, intoxication, anti-cancer drug

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 165 Medical University of Varna Original Research PREGNANCY WITH TETRALOGY OF FALLOT Konstantina Velikova1, Denica Koleva1, Galina Dimova1, Ivelina Hristova1, Rumen Iordanov2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Tetralogy of Fallot is a congenital heart defect that is present at birth. It features four problems: a ventricular septal defect, pulmonary stenosis, a right ventricular hypertrophy and an overriding aorta. The cause of the tetralogy of Fallot is not known and it is most often diagnosed in the first few weeks of life due to either a loud heart murmur or cyanosis. Children having a tetralogy spell will initially become extremely irritable in response to the critically low oxygen levels and may become sleepy or unresponsive if the severe cyanosis persists. The aim of our research was to evaluate the pregnancy outcome in women with tetralogy of Fallot. The study was a retrospective analysis of maternal and perinatal outcome in 3 women with TOF treated in a cardio- obstetric unit. One of the women with this uncorrected congenital heart defect had one child. Obstetric and cardiac complications were more frequent in the uncorrected tetralogy. Materials and Methods: A retrospective analysis of maternal and perinatal outcome of pregnancies in women with TOF who were seen in the obstetrics unit in Varna’s hospital - Maichin Dom. All women were super- vised in the cardio-obstetric clinic under joint supervision of obstetrician and cardiologists. These women were kept under observation post partum. Results: The outcome of our research was that in the women with a corrected condition - there were 100% live births to term. In the uncorrected woman there was one preterm birth. There was 1 neonatal death in the uncorrected woman, too. No baby was determined to have a congenital anomaly, including congenital cardiac malformations. Conclusion: Tetralogy of Fallot carries substantial risk to mother and fetus. Surgical correction is associated with improved maternal and perinatal outcome. These patients need detailed pre-pregnancy evaluation and should be under joint supervision of an obstetrician, a cardiologist, a congenital cardiac surgeon, and an anesthetist. Keywords: risk, pregnancy, tetralogy of Fallot, complications

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 166 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 THE LINK BETWEEN PROCESSED MEAT CONSUMPTION AND CANCER Georgi Shopov1, Yordan Slavov1, Ani Dzakova1, Dimana Mitsova1, Darina Hristova2

1Student, Medical University of Varna 2 Department of Preclinical and Clinical Sciences, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Processed meat is mainly made from pork or beef meat that has been transformed by salt- ing, fermentation, smoking, curing and other processes in order to improve its flavor or to extend its shelf life. In 2015, processed meat has been classified as carcinogenic to humans - Group 1(same group as tobacco smoking and asbestos). Processed meat contains a lot of fat and heme iron, which can promote carcinogenesis. Processing and cooking can also generate specific heterocyclic amines (HCAs), polycyclic aromatic hydrocarbons (PAHs) and N-Nitroso compounds (NOCs) that are actually mutagens and animal carcinogens. Materials and Methods: The information was obtained from relevant studies and reports published since and before the IARC classified processed meat as carcinogenic to humans. Results: A few experimentally tested hypotheses may explain why processed meat consumption is linked to cancer risk. Cooking meat at high temperature leads to the development of carcinogenic HCAs and PAHs. Also, carcinogenic NOCs are found in processed meat and high-fat diets could boost carcinogenesis. Studies suggest that frying at high temperatures, grilling and roasting lead to the formation of mutagenic and carcinogenic HCAs. NOCs are alkylating agents that can react with the human DNA. Many NOCs are proven to be the reason for the development of cancer in laboratory tested animals. Conclusion: In conclusion, the combination of HCAs, PAHs and NOCs and the high amount of animal fats found in processed meat could be the reason for the strong carcinogenic effect it has on humans. It is important for people to reduce the daily consumption of processed meat in order to avoid the risk of colorectal and other types of cancer, because the more processed meat we eat, the higher the risk gets. Keywords: processed meat, cancer, polycyclic aromatic hydrocarbons, heterocyclic amines, N-nitroso compounds, animal fat

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 167 Medical University of Varna Original Research EXPERIMENTAL MODEL OF SUBCLINICAL VITAMIN K DEFICIENCY: ADAPTATION OF THE STUDY OF OSTEOCALCIN Radi Lukanov1, Silvia Gancheva2, Elizabet Miladinova1, Dessyslava Nikolaeva1, Maria Zhelyazkova-Savova2

1Student, Medical University of Varna 2 Department of Preclinical and Clinical Pharmacology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Vitamin K (VK), comprising VK1 and VK2, is involved in the post-translational gamma glu- tamyl-carboxylation of VK dependent proteins (Gla-proteins). The VK dependent factors of coagulation are carboxylated in the liver with the participation of VK1. Other Gla-proteins, among which osteocalcin, are dependent on the extrahepatic pool of VK2. To study the physiological functions of osteocalcin, we utilized warfarin as a VK antagonist to impair the carboxylation of osteocalcin, based on the original method of Price et al. (1994). An added suitable dose of VK1 was supposed to prevent bleeding, yet allowing the effect of warfarin on osteocalcin. Materials and Methods: To establish the necessary doses of drugs, we conducted two consecutive experiments each including 20 male Wistar, divided into a control and an experimental group. Initially, the experimental rats were treated with high dose subcutaneous warfarin with simultaneous administration of VK1 by gavage. Because of hemorrhages that developed in some rats, the dose of warfarin was reduced after the first week and the dose of VK1 was increased. Six rats out of ten survived at the end of the 4 weeks of treatment. In the second 4 weeks of the experiment it was confirmed that the selected doses were well-tolerated. Subsequently, plasma levels of uncarboxylated (ucOC) and carboxylated (cOC) osteocalcin were determined using ELISA kits. Results: As expected, the levels of cOC in the experimental group were significantly lower and those of ucOC were about ten times higher compared to the control group. With the doses of warfarin and VK1 thus determined, we were able to selectively inhibit the carboxylation of osteocalcin by VK2, while avoiding the risk of bleeding. Conclusion: The model of subclinical VK deficiency can be useful as a tool to study the physiological roles of Gla proteins and particularly of osteocalcin. Keywords: vitamin K, deficiency

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 168 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 ECG CHANGES IN PATIENTS WITH HYPOTHERMIA Karina Spechter1, Mohammed El Samara1, Mariya Negreva2

1Student, Medical University of Varna 2Department of Internal Diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Hypothermia is defined as a condition, in which the body core temperature is below 35°C. The most common causes are due to environmental circumstances, e.g. exposure to cold weather. Non-environmental causes are uncommon, but also should be taken into consideration, e.g. hypothermia with diabetic ketoacidosis. Our aim is to draw attention to the changes in the electrocardiogram (ECG), which are characteristic for the patients with hypothermia. Materials and Methods: We conducted a literature review using Pub Med, Google Scholar, and MedlinePlus databases from 1984 until March 2016. We used keywords like hypothermia, ECG in hypothermia, cases of hypothermia and accidental hypothermia. We included reviews published in journals with evidence-based medical publications. Results: In a normal 12-lead ECG obtained from a hypothermic patient, a broad spectrum of changes can be observed, they could be confusing and necessitating some extra tests and exams. Some of them may seem similar to those found in acute coronary ischaemia and pericarditis. The T wave can show varied differences, e.g. the T wave can be negative in lead V2-V6. PR, QT and QRS intervals can be differently prolonged. Most specific for hypothermia is the J point elevation, also called Osborne wave, an extra elevation after the QRS complex. The wave correlates directly with the body temperature, the amplitude increases with the decreasing temperature. Hypothermic patients may present with different atrial or ventricle rhythm disorders. Bradyarrhythmias are typical of those patients incl. atrial fibrillation with slow ventricular response, varying degrees of AV block, etc. All ECG changes disappear after rewarming the patients. Conclusion: Hypothermia often results in ECG changes, and should be recognised by the emergency doctors, because they have a diagnostic and prognostic importance. The special findings should be detected as early as possible to provide patients the correct treatment. Keywords: ECG, hypothermia

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 169 Medical University of Varna Original Research PREAURICULAR SINUS - INCIDENCE IN A BULGARIAN COHORT Alice Renjilian1, George Stoyanov1, Boyko Matev1, Velizar Gaidardzhiev1, Nikolay Sapundzhiev2

1Student, Medical University of Varna 2Department of Neurosurgery and ENT diseases, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: The preauricular sinus (PauS) is a variable inherited congenital malformation. It results from a defect in the development of the pharyngeal arches and is characterized by a foramen or a dimple, most commonly located on the crus of the auricular helix. The structure can often become inflamed and gar- ners an interest from ENT specialists and pediatricians. The aim of this study was to establish the incidence of the PauS as the structure shows great variety in its presence in different populations. Materials and Methods: A total of 61 individuals, 36 males, 25 females, mean age 23.25 years, standard deviation ±9.63, median age 20 and a range of 50 (minimal age 19 and maximal 69) were specifically assessed for the presence of a PauS. A structure was considered a PauS when present in the region of the crus of the auricular helix as a preexisting dent, dimple or foramen and not because of an ear piercing. The set criteria were identical to similar studies of the organ. Results: Of all assessed individuals 3.28% (n=2) had a PauS. No correlation between the presence of the structure and the gender and age of the assessed individuals could be found. Of the identified individuals that had the structure, one had a left-sided unilateral PauS, while the second one had a bilateral structure and a clear family history of close relatives with PauS. However, the relatives of the second patient were not included in the cohort, as they were not directly examined in the study. Conclusion: The incidence of the PauS in our study cohort is similar to that of other European countries. The presence of the structure is of interest for medical specialist as in can lead to varying health issues. Fur- ther studies on the type of inheritance may be advocated. Keywords: preauricular sinus, ENT, statistics, cohort

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 170 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 EXTERNAL REFERENCE PRICING SYSTEM FOR MEDICINES IN BULGARIA Evgeni Grigorov1, Stanislav Kochev2, Jivko Kolev1

1Department of Pharmaceutical Sciences and Pharmaceutical Management, Faculty of Pharmacy, Medical University of Varna 2Student, Medical University of Varna

ABSTRACT Introduction: European Union member states are free to develop their national and regional pharmaceutical pricing and reimbursement policies, as long as they comply with the Transparency Directive. External reference pricing (ERP), also called “External price referencing” has become one of the most common cost- containment tools to reduce prices for medicines. The objective of the study is to provide an overview of the ERP system in Bulgaria and to analyze the potential issues related to criticism of the entire process. Materials and Methods: A systematic structured legislation review as well as a consultation with representa- tives from the competent national authority were conducted to identify and characterize the use of ERP in Bulgaria. All the collected data were processed in figures and tables. A PEST analyses was also performed to evaluate the impact political, economic, social, and technological factors might have on the ERP system. Results: In Bulgaria, the use of ERP for setting the price of pharmaceuticals is based on legislated special pricing rules. The National Council on Prices and Reimbursement of Medicinal Products is the state body under the Minister of Health, which endorses and registers the prices for medicinal products. The number of reference countries included in the basket is 17. Twelve of them are primary and five are complementary. The lowest price among all reference countries is used in Bulgaria. Prices are re-evaluated on a monthly basis after the initial price has been set. We describe also the ERP impacts on the prices of pharmaceuticals and discuss some possible cross-country coordination issues in EU and Member States. Conclusions: ERP is actively used in Bulgaria to achieve cost-containment of prescription medicines included in the positive drug list. Its application and potential impacts remain highly debated, but are still considered to be the most effective action for keeping the prices of pharmaceuticals low. Keywords: Bulgaria, reference pricing, medicines, system

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 171 Medical University of Varna Original Research CERVICAL CANCER NOWADAYS. RESEARCH OF PREVENTION AND AWARENESS OF WOMEN BETWEEN 18-35 YEARS OF AGE Dragomir Ivanov1, Mustafa Dzhambazov1, Stefan Stefanov1, Tsonka Dimitrova2

1Student, Medical University of Varna 2Department of Biology, Faculty of Pharmacy, Medical University of Varna

ABSTRACT Introduction: Cervical cancer is the most frequently observed cancerous disease in women, right after breast cancer. Fortunately, modern science offers effective and easily accessible methods for diagnosing the disease, which increases the percentage of successful treatments. But are women aware of these methods? The aim of this study is to examine how informed the women are about cervical cancer. The acquired data is directed towards the prevention of the disease. Materials and Methods: The study began in 2017, in the form of an online survey, taken by 100 female volunteers. The lowest age limit for the participants is 18, and the highest is 35. The survey contains 7 questions. Statistical and graphic methods are used to process the data. Results: We started the study with questions targeting the reasons which cause the disease. A high percentage of the women - 93% know that HPV is the cause for cervical cancer; 78% of the participants are aware that the virus is sexually transmitted. The next questions covered the testing for early diagnosis of the disease. 56% of the participants visit a gynecologist once or twice per year, the rest shared that they rarely (21%) or never (23%) visit a gynecologist. 70% of the participants know about PAP-tests and 55% of them get tested. The last question has to do with the precautions that our volunteers would take to prevent getting infected. Only 8% would get vaccinated , 9% would use contraceptives, 20% would visit the gynecologist on a regular basis and 63% would choose all options. Conclusion: The study shows that the women are well-acquainted with the cause of the disease and the ways to get tested. There is a positive tendency, connected to the prevention of the disease. Keywords: cervical cancer, prevention, awareness

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 172 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 PERIVASCULAR ADIPOSE TISSUE AND ITS CLINICAL SIGNIFICANCE Jyothis Sajan1, Blagovesta Mitkova2

1Student, Medical University of Varna 2Department of Anatomy, Histology and Embryology, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Obesity is an enormous social problem associated with substantial modulation of adipose tissue structure, involving adipogenesis, angiogenesis, and extracellular matrix remodelling tissue archi- tecture and function. Perivascular adipose tissue (PVAT) is an accumulation of adipose tissue around vasculature, which releases a variety of biologically active molecules, such as adipokines and cytokines, to reg- ulate vascular smooth muscle cells. Undoubtedly, PVAT monitors endothelial function and its role can be protective or detrimental. Cardiovascular disease (CVD) is highly associated with obesity and the metabolic syndrome. Risk factors for CVD are: hypertension, dyslipidaemia, increased visceral adipose tissue mass, diabetes, obesity etc. It is still unclear how adipose tissue depot contributes to the pathogenesis of CVD and because there is a lack of data regarding the morphogenesis of vascular alterations, we aimed to investigate morphological changes of both blood vessel wall and adipose tissue in cases with CVD and whether peri-coronary epicardial adipose tissue (EAT) is associated with vascular risk factors and coronary atherosclerosis. Material and Methods: Material was received from the necropsies of patients who suffered a cardiovascular attack. A classical histological technique was applied. Results: We found alterations that affected blood vessels; wall-intima was thickened, which was in fact fibrosis and increased epicardial adipose tissue. The luminal surface of the intima formed a markedly wavy configuration. PVAT was increased in amount and surrounds the blood vessels. Conclusions: Coronary artery segments involved in cardiovascular disease are characterized by diffuse in- timal thickening without lipid or calcium content. The results support the hypothesis that EAT affects coronary atherosclerosis and possibly coronary risk Keywords: perivascular adipose tissue, adipocytes, cardiovascular disease, obesity, coronary artery

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 173 Medical University of Varna Original Research BOTULINUM NEUROTOXIN-CLINICAL USES Dajana Tsankova1, Neli Ermenlieva2, Gabriela Tsankova2, Tatina Todorova2, Mariya Rostamloo1

1Student, Medical University of Varna 2Department of Preclinical and Clinical Sciences, Medical University of Varna

ABSTRACT Introduction: Botulinum neurotoxin (BoNT) is produced by the spore-forming anaerobic bacterium Clos- tridium botulinum, which causes botulism. The symptoms of the disease are severe, expressed in tiredness, nausea and vomiting. At a later stage, loss of head control and floppy movements due to muscle weakness, blurred vision, drooping eyelids (ptosis), difficulty swallowing or speaking, trouble breathing are observed. Death may occur due respiratory paralysis or cardiac arrest. Muscle paralyses are caused by BoNT that blocks acetylcholine release – the neurotransmitter of the nerve impulses to muscle fibers. (BoNT) is the most poisonous biological substance known to mankind but it has successfully established itself as a therapeutic agent over the years. This agent has found numerous uses in medicine and has been advocated for many other conditions such as aesthetic reduction of facial wrinkles. The aim of our literature review is to summarize the scientific data about current uses of botulinum neurotoxin in medicine. Materials and Methods: The search for articles published in English from 1990 to 2016 was conducted. The review contains data from 38 research papers. Results: Since its development more than 2.5 decades ago, botulinum neurotoxin has become a drug in various fields in medicine. It turns out to be extremely effective in care of different disorders such as dystonia ,urine incontinence, distortion or deformation of limbs at birth, hypersalivation, chronic anal fissures, allergic rhinitis, stammer, bruxism, Frey’s syndrome, cerebral palsy and others .It has also found widespread use in correction of glabellar wrinkles. Conclusion: Because of its high efficiency and safety of application, BoNT may have usage in various fields of medicine. Keywords: botulinum neurotoxin, clinical uses, side effects

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 174 Medical University of Varna Fifth „Black Sea Symposium for Young Scientists in Biomedicine”, April 6-9, 2017 LAPAROSCOPIC APPENDECTOMY VS. OPEN APPENDECTOMY – 5-YEAR EXPERIENCE Turgay Kalinov1, Anton Tonev2, Alexander Zlatarov2, Mehmed Hadzhiveli2, Georgi Ivanov2, Boris Andonov2, Georgi Valentinov2, Nikola Kolev2, Valentin Ignatov2, Krasimir Ivanov2

1Student, Medical University of Varna 2Department of General and Operative Surgery, Faculty of Medicine, Medical University of Varna

ABSTRACT Introduction: Appendectomy is the most common surgical procedure performed in emergency surgery. There is still discussion which technique is more reliable and appendectomy is still being performed by open-access and by laparoscopic methods. In our study, we compare the laparoscopic approach and the open approach in the treatment of acute appendicitis. Our aim is to compare the laparoscopic versus open appendectomy for operative time, length of hospital stay, postoperative pain, complication rate, and return to normal activity. Materials and Methods: For the period January 2011 - December 2016, 124 patients have undergone appendectomy, of which - 52 underwent laparoscopic and 72 -conventional appendectomy Results: In our retrospective study we found that the laparoscopic appendectomy was associated with a shorter hospital stay (median 2.3 days in LA and 2.9 days in OA), with less need for analgesia and with a faster return to daily activities (7.1 days in LA and 9.2 in OA). The total number of complications was less in the LA group with a significantly lower incidence of wound infection (2.5 % vs 15.3 %, P <0.05). Operative time was significantly shorter in the open group (median - 42 min. in OA and 69 min. in LA). Conclusion: Laparoscopy is safe and effective surgical intervention for acute appendicitis and it offers clinically useful advantages versus the open method (including shorter hospital stays, reduced postoperative analgesia, faster recovery of food intake, lesser percentage of wound infection) against only marginally higher hospital costs. Keywords: laparoscopic, appendectomy, appendicitis, surgery

Scripta Scientifica Vox Studentium, vol. 1, suppl. 1, 2017 175 Medical University of Varna GUIDELINES FOR AUTHORS

GENERAL INFORMATION: Scripta Scientifica Vox Studentium publishes articles aimed to provide the most current information in various medical fields. The following types of articles are approved for publication: Invited Reviews (more than 6 pages and no restrictions regarding the number of References) Original Articles (up to 6 pages, containing original research or statistical or systematic analysis on existing research; with an structured Abstract and structured Content; around 30 references are recommended) Case Reports (up to 3 pages, around 15 references; the Abstract does not need to be structured) Letters to the Editor (up to 2 pages and up to 5 references) The manuscripts can be submitted through the online submission system, which requires a registration in order to use it.

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176 Methods: Should describe the design of the study (randomization, cross-over, prospective or retrospective etc.), the setting (hospital, university or private practice, primary or tertiary care etc.) and the patients or participants in the study. Should also give details of the numbers and descriptions of patients, participants of samples in the study and detailed information about treatment, intervention, technique or procedure. Results: should be summarized with relevant statistical indices, following the requirements for tables and figures. Discussion: must review the relevant literature on the subject and discuss the findings of the current study in ther differences and similarities. Conclusions: that are directly supported by the data should be stated, with equal emphasis on positive and negative findings. Pages should be single-spaced, Times New Roman should be used throughout, sized at 12 pt. Captions should be used within the body of the manuscript to outline important points. The text of the manuscript should be submitted in Microsoft Word .doc/.docx format.

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177 NOTE: If there are any references the original titles of which are in a non-Latin alphabet, they should be translated or transcribed. At the end, in brackets, there should be the original language, e.g. (in Bulgarian)

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178 3. Since the journal has a Blind Review policy, the instructions in Ensuring a Blind Review have been followed; 4. The manuscript submitted for publication has been developed by the Author/Authors; 5. When using texts, figures, data and other materials from other authors, the sources shall be quoted in the article, as appropriate and the Author/Authors should possess all the necessary permissions for their use; 6. The Author/Authors are acquainted with the Ethical principles for publication in the journals of the Medical University of Varna. 7. All the metadata entered in this Journal should be in English or at least written using the Latin alphabet.

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179 SCRIPTA SCIENTIFICA VOX STUDENTIUM, volume 1, supplement 1, 2017

Editor-in-Chief Krasimir Ivanov, MD, PhD, DSc

Design and Layout Editor: Emilia Yordanova Cover Design: Hristina Hristova Proofreading: Yordanka Peteva

Publ. Lit. group: III-3 Sent to printers: March, 2017 Print sheets: 45 Format: 8/60x84 Approved for printing: April, 2017

Publisher: Medical University of Varna 55 Marin Drinov Street, Varna 9002, Bulgaria www.mu-varna.bg http://press.mu-varna.bg/ojs/index.php/ssvs 2017, Medical University "Professor Paraskev Stoyanov" of Varna