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Background: The prevalence of myopia has increased in recent years, with changes being dynamic and uneven in different regions. The purpose of this study is to evaluate the prevalence of visual impairment caused by myopia in Bulgarian school children, associated risk factors, and health care coverage.Methods: A cross-sectional study among 1401 children (mean age 10.38, standard deviation 2.70) is conducted in three locations in Bulgaria from 2016 to 2020. Refractive error is measured with an auto-refractor in the absence of cycloplegia, the visual acuity is assessed without refractive error correction. A paper-based preliminary questionnaire is used to collect data on previous eye examinations, prescribed optical vision correction, regularity of wearing corrective glasses and risk factors.Results: Children with myopic objective refraction ≤ -0.75 D and decimal visual acuity ≤ 0.8 on at least one of the eyes are 236 out of 1401 or 16.85%. The prevalence of myopia varies depending on age, geographical location, and school profile. The rate of myopic children in age group 6-10 is 14.2% compared to 19.9% in age group 11-15. The prevalence of myopic children in the urban populations is 31.4% (capital) and 19.9% (medium-sized town) respectively, and only 8.4% in the rural population. Our results show 53% increase of the prevalence of myopia in the age group 11-15 compared to a 2009 report. The analysis of data associated with health care coverage factors of all myopic pupils shows that 71.6% had a previous eye examination, 43.2% have prescription for corrective glasses, 27.5% wear their glasses regularly. Risk factors for higher odds of myopia are gender (female), age (adolescence), and parents with impaired vision. Residence in a small town and daily sport activities correspond to lower odds for myopia. The screen time (time in front of the screen calculated in hours per day) is self-reported and is not associated with increased odds of myopia when accounted for the other risk factors.Conclusions: The prevalence of myopia in this study is higher compared to previous studies in Bulgaria. Additional studies would be helpful in planning adequate prevention and vision care. [ABSTRACT FROM AUTHOR]

Background: The clinical and economic burden of type 2 diabetes mellitus on society is rising. Effective and efficient preventive measures may stop the increasing prevalence, given that type 2 diabetes mellitus is mainly a lifestyle-driven disease. The Feel4Diabetes-study aimed to tackle unhealthy lifestyle (unhealthy diet, lack of physical activity, sedentary behaviour, and excess weight) of families with a child in the first grades of elementary school. These schools were located in regions with a relatively low socio-economic status in Belgium, Bulgaria, Finland, Greece, Hungary and Spain. Special attention was paid to families with a high risk of developing type 2 diabetes mellitus. Methods: The aim of this paper is to describe the detailed methodology of the intervention's cost-effectiveness analysis. Based on the health economic evaluation of the Toybox-study, both a decision analytic part and a Markov model have been designed to assess the long-term (time horizon of 70 year with one-year cycles) intervention's value for money. Data sources used for the calculation of health state incidences, transition probabilities between health states, health state costs, and health state utilities are listed. Intervention-related costs were collected by questionnaires and diaries, and attributed to either all families or high risk families only. Conclusions: The optimal use of limited resources is pivotal. The future results of the health economic evaluation of the Feel4Diabetes-study will contribute to the efficient use of those resources. [ABSTRACT FROM AUTHOR]

Ethnic foods and beverages are cultural heritage. This review summarizes the available data about the manufacturing, flavouring, and colouring of the homemade Bulgarian ethnic alcoholic beverage rakia, including information from scientific and grey literature, published surveys, traditional old recipe books, and field observations and interviews with local producers of homemade rakia. Taking into consideration the scarce scientific evidence available on the subject, this study aims to contribute to the preservation of a valuable Bulgarian tradition and cultural heritage for future generations. A detailed description of the process of manufacturing homemade rakia is presented, and the role of this ancient technology in the extraction of bioactive compounds is discussed. Different aspects of the consumption of alcoholic beverages and their dual metabolic effects on human health are elucidated. The centuries-old knowledge about the preparation of the homemade beverage rakia, flavoured and coloured using arboreal species, is discussed as a basis for the development of low-alcohol or non-alcoholic functional beverages with high content of bioactive compounds with beneficial health effects. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to examine the Coronavirus disease 2019(COVID-19) vaccine policies disparities and effectiveness in Germany, Denmark and Bulgaria, with a view to providing lessons for global vaccination and response to possible outbreak risks. Methods: This study analyzed big data through public information on the official websites of the Ministries of Health of the European Union, Germany, Denmark and Bulgaria and the official websites of the World Health Organization. We systematically summarized the COVID-19 vaccine policies of the three countries, and selected the following six indicators for cross-cutting vaccination comparisons: COVID-19 vaccine doses administered per 100 people, COVID-19 vaccination rate, the share of people with fully vaccinated, the share of people only partly vaccinated, cumulative confirmed COVID-19 cases per million, cumulative confirmed COVID-19 deaths per million. Meanwhile, we selected the following four indicators for measuring the effectiveness of COVID-19 vaccine policy implementation: daily cases per million, daily deaths per million, the effective reproduction rate (Rt), the moving-average case fatality rate (CFR). Results: Although these three EU countries had the same start time for vaccination, and the COVID-19 vaccine supply was coordinated by the EU, there are still differences in vaccination priorities, vaccination types, and vaccine appointment methods. Compared to Germany and Denmark, Bulgaria had the least efficient vaccination efforts and the worst vaccination coverage, with a vaccination rate of just over 30% as of June 2023, and the maximum daily deaths per million since vaccination began in the country was more than three times that of the other two countries. From the perspective of implementation effect, vaccination has a certain effect on reducing infection rate and death rate, but the spread of new mutant strains obviously aggravates the severity of the epidemic and reduces the effectiveness of the vaccine. Among them, the spread of the Omicron mutant strain had the most serious impact on the three countries, showing an obvious epidemic peak. Conclusions: Expanding vaccination coverage has played a positive role in reducing COVID-19 infection and mortality rates and stabilizing Rt. Priority vaccination strategies targeting older people and at-risk groups have been shown to be effective in reducing COVID-19 case severity and mortality in the population. However, the emergence and spread of new variant strains, and the relaxation of epidemic prevention policies, still led to multiple outbreaks peaking. In addition, vaccine hesitancy, mistrust in government and ill-prepared health systems are hampering vaccination efforts. Among the notable ones are divergent types of responses to vaccine safety issue could fuel mistrust and hesitancy around vaccination. At this stage, it is also necessary to continue to include COVID-19 vaccination in priority vaccination plans and promote booster vaccination to prevent severe illness and death. Improving the fairness of vaccine distribution and reducing the degree of vaccine hesitancy are the focus of future vaccination work. [ABSTRACT FROM AUTHOR]

Background: Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest. Methods: DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries. Results: Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases – representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period – however, overall levels of inequality were low. Conclusions: The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access. [ABSTRACT FROM AUTHOR]

Aim: The aim of the present study is to evaluate the reduction of the distal teeth towards the medial ones in one functional dental group in southern Bulgarian population. Materials and methods: The study included 232 Bulgarians aged 20–40 years. Mesiodistal dimensions of the teeth were measured by Dentistry Sliding Vernier Caliper and analyzed with SPSS 23.0. Four interdental indices were calculated: inter-incisive, premolar, upper, and lower molar indices. Results: We found a decrease in the percentage ratio of the lateral to the central incisors of people from the Bulgarian population compared to those dating from the Eneolithic period on the territory of Bulgaria. Furthermore, we found a reduction in the percentage ratio of the upper and lower second molars compared to the first ones. The biggest reduction in the percentage ratio (more than 6%) was found in the lower second premolars compared to the first ones, which is characteristic for southern Bulgarians. Conclusion: There was a dental reduction in all the distal members compared to the medial ones participating in one morphological dental group. As a result, we think that interdental indices can be used for explaining historical, cultural, and biological macro and microevolutionary processes and thus for understanding the origin, formation, contacts, and migration pathways of the different populations leading to ethnic variation of humanity. Therefore, they can be a reliable source of information in physiological anthropology. [ABSTRACT FROM AUTHOR]

Background: The Complementary and Alternative Medicine (CAM) field in Europe has been a focus of research developments and public health policy changes for years. However, these processes are still in their infancy phase in Bulgaria. In this paper, homeopathy is the investigated CAM-modality at a Bulgarian context. The aim is threefold: 1) to outline the sociodemographic profile of the chronically ill adult patients (≥18 years old) who choose homeopathic medical treatment (HMT); 2) To identify the patients' sources and needs of information about homeopathy, and the reasons to use HMT; and 3) to measure health-related outcomes in patients who have visited homeopathic clinics to look for HMT of their chronic conditions.Methods: A cross-sectional observational multi-centered study (≥18 years old, n = 211) was conducted between June 2016 to Dec. 2017 in Bulgaria. Potentially eligible participants for the study were all chronically ill patients who had been receiving HMT for a year or more and had visited the homeopathic clinics for a follow up within the study period. The EQ-5D-3L instrument was applied with an additional questionnaire on sociodemographic and health related data.Results, Discussion and Conclusions: The study results outlined the country specific sociodemographic profile of the chronically ill homeopathic patients in Bulgaria: they are predominantly female, with higher education and at the age groups between 30 and 50. The EQ-5D-3L version, was applied to measure patients' health-related quality of life and to promote the use of a standardized generic instrument as a complementary and reliable scientific tool to assess the patient-reported outcomes of the homeopathic patients. Regarding the reasons of choice: the participants choose HMT because it is safe and mild, to avoid excessive antibiotic use, because the conventional treatment was not successful, etc. The study confirms the social demand for more scientific information about homeopathy. Participants stated that the medical universities' curriculum should keep pace with the modern CAM-developments. A key message is that the future of the successful chronic disease management is in the integration of the conventional and CAM-modalities and these processes should be facilitated through public health regulations, education and research. The presented study is a supportive action in this direction. [ABSTRACT FROM AUTHOR]

Background: In June 2020, severe symptoms of leaf mosaic and fruit malformation were observed on greenhouse-grown cucumber plants in Xizhou Township of Changhua County, Taiwan. An unknown virus, designated CX-2, was isolated from a diseased cucumber sample by single lesion isolation on Chenopodium quinoa leaves. Identification of CX-2 was performed. Moreover, the incidence of cucumber viruses in Taiwan was also investigated. Methods: Transmission electron microscopy was performed to examine virion morphology. The portable MinION sequencer released by Oxford Nanopore Technologies was used to detect viral sequences in dsRNA of CX-2-infected leaf tissue. The whole genome sequence of CX-2 was completed by Sanger sequencing and analyzed. Reverse transcription-polymerase chain reaction (RT-PCR) with species-specific primers and indirect enzyme-linked immunosorbent assay (ELISA) with anti-coat protein antisera were developed for virus detection in the field [see Additional file 1]. Results: Icosahedral particles about 30 nm in diameter were observed in the crud leaf sap of CX-2-infected C. quinoa plant. The complete genome sequence of CX-2 was determined as 4577 nt long and shared 97.0–97.2% of nucleotide identity with that of two cucumber Bulgarian latent virus (CBLV) isolates in Iran and Bulgaria. Therefore, CX-2 was renamed CBLV-TW. In 2020–2022 field surveys, melon yellow spot virus (MYSV) had the highest detection rate of 74.7%, followed by cucurbit chlorotic yellows virus (CCYV) (32.0%), papaya ringspot virus virus watermelon type (PRSV-W) (10.7%), squash leaf curl Philippines virus (SLCuPV) (9.3%), CBLV (8.0%) and watermelon silver mottle virus (WSMoV) (4.0%). Co-infection of CBLV and MYSV could be detected in field cucumbers. Conclusion: The emerging CBLV-TW was identified by nanopore sequencing. Whole genome sequence analysis revealed that CBLV-TW is closely related, but phylogenetically distinct, to two known CBLV isolates in Bulgaria and Iran. Detection methods including RT-PCR and indirect ELISA have been developed to detect CBLV and to investigate cucumber viruses in central Taiwan. The 2020–2022 field survey results showed that MYSV and CCYV were the main threats to cucumbers, with CBLV, SLCuPV and WSMoV were occasionally occurring. [ABSTRACT FROM AUTHOR]

Background: This study aimed to characterize recent Mycobacterium bovis/M. caprae isolates from Bulgaria by whole-genome sequencing (WGS) to gain a first insight into their molecular diversity, transmission, and position within the global phylogeography of this important zoonotic species. Results: The isolates were obtained from cattle in diverse locations of Bulgaria in 2015-2020 and were identified by microbiological and PCR assays. WGS data were used for phylogenetic analysis that also included M. bovis global dataset. Thirty-seven M. bovis/caprae isolates from Bulgaria were studied and 34 of them were SNP genotyped. The isolates were subdivided into 3 major phylogenetic groups. Type Mbovis-13 (Eu2 complex [western Europe and northern Africa]) included one isolate. Mbovis-37 type included 5 isolates outside of known clonal complexes. The Bulgarian M. caprae isolates formed a sub-group within the Mcaprae-27B cluster which also included 22 M. caprae isolates from Poland, Spain, Germany, and the Republic of Congo. The Bulgarian M. caprae isolates share their latest common ancestors with Spanish isolates. The Mbovis-37 group shares a distant common ancestor (pairwise distance 22-29 SNPs) with an isolate from Poland but was very distant (> 200 SNPs) from the rest of the tree. The Mbovis-13 group shares a common ancestor with two human isolates from Germany. Phylogeographically, both M. bovis clades had limited circulation in northeastern Bulgaria while the majority of the studied isolates (M. caprae) were from central and western provinces. A phylogenetic network-based analysis demonstrated that 11 Bulgarian isolates were separated by 1 to 6 SNPs within four clusters, mostly forming pairs of isolates. Conclusion: The obtained WGS analysis positioned the Bulgarian isolates within the global phylogeography of M. bovis/M. caprae. Hypothetically, the observed phylogenetic diversity may not have resulted from livestock trade routes, but instead may reflect the deeply rooted M. bovis/M. caprae phylogeography of Europe. A high level of genetic divergence between the majority of the studied isolates suggests limited active transmission of bTB in Bulgaria during the survey period. At the same time, a possibility of the endemic presence of circulating bTB strains in the form of the latent persistent disease cannot be ruled out. [ABSTRACT FROM AUTHOR]

Introduction: White spot lesions associated with orthodontic treatment are a common problem. Recent studies reported increased resistance to acid demineralization of enamel after sub-ablative CO2-laser irradiation in a combination with fluoride application. The aim of the study is to assess the efficacy of CO2-laser in combination with a fluoride varnish in the prevention, severity, and extent of white spot lesions during orthodontic treatment with fixed appliances.Methods and Analysis: This is a protocol for a randomized, split-mouth controlled, clinical trial. The participants will be children aged 12-18 years at high caries risk, requiring fixed orthodontic treatment. The vestibular surfaces of maxillary anterior teeth of eligible patients will be exposed to CO2-laser irradiation in combination with fluoride therapy and fluoride therapy alone followed by bonding of orthodontic brackets. The patients will be recalled 6 and 12 months post-irradiation. Outcome measures will be visual examination with International Caries Detection and Assessment System criteria and SoproLife fluorescence. Data will be analyzed by Student's t test for paired samples and proportional odds logistic regression model, p<0.05.Ethics and Dissemination: The study protocol has been approved by the Committee for Scientific Research Ethics, Medical University-Plovdiv, Bulgaria (Reference number P-605/27.03.2020, Protocol of approval No. 2/01.04.2021) and registered on a publicly accessible database. This research received institutional funding from the Medical University-Plovdiv, Bulgaria. The results will be presented through peer-reviewed publications and conference presentations.Trial Registration: ClinicalTrials.gov NCT04903275 . Registered on June 2021. [ABSTRACT FROM AUTHOR]

Background: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. Methods: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. Results: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care. Conclusions: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care. [ABSTRACT FROM AUTHOR]

Background: People travelling abroad tend to increase their use of alcohol and other drugs. In the present study we describe organized party activities in connection with young tourists' drinking, and the differences between young people travelling with and without organized party activities. Methods: We conducted ethnographic observations and a cross-sectional survey in Sunny Beach, Bulgaria. Results: The behaviour of the guides from two travel agencies strongly promoted heavy drinking, but discouraged illicit drug use. Even after controlling for several potential confounders, young people who travelled with such "party package travel agencies" were more likely to drink 12 or more units when going out. In univariate analyses, they were also more likely to get into fights, but were not more likely to seek medical assistance or medical assistance for an accident or an alcoholrelated problem. After controlling for confounders, the association between type of travel agency and getting into fights was no longer significant. Short-term consequences of drinking in the holiday resort did not differ between party package travellers and ordinary package travellers. Conclusion: There may be a small impact of party package travels on young people's drinking. Strategies could be developed used to minimise the harm associated with both party package travel and other kinds of travel where heavy substance use is likely to occur. [ABSTRACT FROM AUTHOR]

Background: Birds are major hosts for many tick species (Acari: Ixodidae, Argasidae), and their role is especially important in transporting ticks over large distances along their seasonal migratory routes. Accordingly, most studies across Europe focus on the importance of avian hosts in tick dispersal, and less emphasis is laid on resident birds and their role in supporting tick life cycles. Eurasian eagle owls (Bubo bubo) exemplify the latter, but all the few studies on their tick infestation were carried out in Western Europe and even those did not involve a large sample size and did not assess infestation prevalence in natural habitats. Methods: In this study, 320 ixodid ticks were collected from nestlings of Eurasian eagle owls during the period 2018–2020 in Bulgaria in south-eastern Europe. These ticks were analysed morphologically, and selected specimens molecularly based on cytochrome c oxidase subunit I (cox1) gene. The effects of environmental and habitat-related conditions and of the species of prey eaten by eagle owls on tick infestation were also evaluated. Results: The majority of ticks were identified as adults of Rhipicephalus turanicus (n = 296). In addition, 15 Hyalomma marginatum (three males, 11 nymphs and a larva), one female of Haemaphysalis erinacei and of Ha. punctata, and a nymph of Ixodes ricinus were found. Among R. turanicus, two distinct morphotypes were observed, but they do not form a monophyletic clade in the phylogenetic tree based on the mitochondrial gene cox1. We found a positive correlation between the total number of ticks on nestlings from a particular nest and the number of medium-sized to large prey mammals brought to the nestling owls. Also, the most important predictor for tick abundance was the effect of the extent of arable land (negative), while forests and grasslands contributed less, with no effect observed in case of urbanized areas and watercourses. Conclusions: The intensity of tick infestation can be high on nestling Eurasian eagle owls (mean intensity 16.59 ticks/nestling). In this study, five different tick species were recorded, among which R. turanicus dominated. Two male morphotypes of this tick species were found, but their morphological differences were not reflected by genetic diversity or phylogenetic clustering. The most important factor determining tick abundance was the land-use structure. [ABSTRACT FROM AUTHOR]

Objective: This study piloted a European technical protocol for conducting chronic hepatitis C prevalence surveys in the general population. The pilot study took place in the Bulgarian city of Stara Zagora in 2018, and results of setting up, conducting and evaluating the survey are presented. Results: A probability-based sample of the general adult population was drawn from the local population registry, stratified by age and sex. A sample size of 999 was calculated, and accounting for 50% non-response, 1998 registered invitation letters were sent. Venous blood samples and questionnaire data were collected by the Regional Health Inspectorate in Stara Zagora. Blood samples were tested for anti-HCV, and if reactive for RNA. 252 (21.6%) of the participants were included in the study. Mean age and sex distribution differed between the participants (55.9 years, 60.3% females) and the total sample (48.9 years, 53.4%). The weighted chronic HCV prevalence among participants was 0.9% [95% CI 0.2–4.2%]. The approach of only sending registered letters contributed to a low response rate, and more efforts are needed to reduce non-response, especially among men and younger age groups. Results of the evaluation were integrated in the final technical protocol. [ABSTRACT FROM AUTHOR]

Background: Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease characterized by frequent exacerbation phenotypes independent of disease stage. Increasing evidence shows that the microbiota plays a role in disease progression and severity, but long-term and international multicenter assessment of the variations in viral and bacterial communities as drivers of exacerbations are lacking.Methods: Two-hundred severe COPD patients from Europe and North America were followed longitudinally for 3 years. We performed nucleic acid detection for 20 respiratory viruses and 16S ribosomal RNA gene sequencing to evaluate the bacterial microbiota in 1179 sputum samples collected at stable, acute exacerbation and follow-up visits.Results: Similar viral and bacterial taxa were found in patients from the USA compared to Bulgaria and Czech Republic but their microbiome diversity was significantly different (P < 0.001) and did not impact exacerbation rates. Virus infection was strongly associated with exacerbation events (P < 5E-20). Human rhinovirus (13.1%), coronavirus (5.1%) and influenza virus (3.6%) constitute the top viral pathogens in triggering exacerbation. Moraxella and Haemophilus were 5-fold and 1.6-fold more likely to be the dominating microbiota during an exacerbation event. Presence of Proteobacteria such as Pseudomonas or Staphylococcus amongst others, were associated with exacerbation events (OR > 0.17; P < 0.02) but more strongly associated with exacerbation frequency (OR > 0.39; P < 4E-10), as confirmed by longitudinal variations and biotyping of the bacterial microbiota, and suggesting a role of the microbiota in sensitizing the lung.Conclusions: This study highlights bacterial taxa in lung sensitization and viral triggers in COPD exacerbations. It provides a global overview of the diverse targets for drug development and explores new microbiome analysis methods to guide future patient management applications. [ABSTRACT FROM AUTHOR]

Background: Premenstrual syndrome (PMS) and its more severe form premenstrual dysphoric disorder (PMDD) are highly prevalent conditions, but there seems to be ethnic and cultural variances in their distribution. Aims: To explore the prevalence of PMS/PMDD and their typical clinical features in a Bulgarian population. Materials and methods: This investigation was designed and executed as a cross-sectional descriptive study. Three hundred and five conveniently recruited females with no psychiatric history filled in a self-evaluation questionnaire based on DSM-IV tapping on different symptoms of PMS. The prevalence of the conditions was calculated. Results: 32.1% (N = 98) of the tested females (mean age 31.04 ± 6.31) suffered from PMS and 3.3% (N = 10) were diagnosed with PMDD. The leading symptoms in the sample were irritability, fatigue and changes in appetite, depressed mood, mood swings, and anxiety, and abdominal bloating, breast tension and tenderness. Most of the symptoms were moderately severe. Mild and moderate cases of PMS were near equally distributed and more frequent than severe ones. Conclusion: PMS is a common condition which is usually mildly expressed, but severe cases are not an exception. The clinical picture is dominated by almost equally distributed psychological and somatic symptoms. [ABSTRACT FROM AUTHOR]

Background: Parasites may actively seek for hosts and may use a number of adaptive strategies to promote their reproductive success and host colonization. These strategies will necessarily influence their host specificity and seasonality. Ticks are important ectoparasites of vertebrates, which (in addition to directly affecting their hosts) may transmit a number of pathogens. In Europe, three hard tick species (Ixodidae: Ixodes ariadnae, I. simplex and I. vespertilionis) and at least two soft tick species (Argasidae: Argas transgariepinus and A. vespertilionis) are specialized for bats. Methods: Here we report data on the host range of these ticks and the seasonality of tick infestation on wild caught bats in south-east Europe. We collected 1803 ticks from 30 species of bats living in underground shelters (caves and mines) from Romania and Bulgaria. On the basis of tick–host associations, we tested several hypotheses on host–parasite evolutionary adaptations regulating host specificity, seasonality and sympatric speciation. Results: We observed significant differences in host specificity and seasonality of abundance between the morphologically different bat specialist ticks (I. simplex and I. vespertilionis) likely caused by their host choice and their respective host-seeking behavior. The two highly generalist, but morphologically similar tick species (I. ariadnae and I. vespertilionis) showed temporal differences in occurrence and activity, thus exploiting significantly different host communities while occurring in geographical sympatry. Conclusions: We conclude that bat-specialist ticks show a wide range of adaptations to their hosts, with differences in specificity, seasonality of occurrence, the prevalence and intensity of infestation and all these contribute to a successful division of temporal niches of ticks sharing morphologically similar hosts occurring in geographical sympatry. [ABSTRACT FROM AUTHOR]

The article presents a study on regulatory barriers to equity in a health system in transition in Bulgaria. 50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria were conducted. The participants in the study reported a variety of regulatory barriers which undermined the principles of equity and as far as the health insurance system is concerned, solidarity.

Background: Patient satisfaction constitutes an important indicator for the quality of care. During the last years, Bulgaria changed its socialist health care system to a market-driven system. Despite the fact that the improvement of health care quality and patient satisfaction were put on top of the list of goals for the health care reforms, no studies of patient satisfaction with inpatient care have been conducted so far. Since cardiovascular diseases are amongst the major causes of death in Bulgaria, and strenuous efforts have been made to improve the quality of medical care of patients with acute coronary syndrome (ACS) during the last years, patient satisfaction in this group can be seen as an important example of the Bulgarian reforms. This study therefore investigates patient satisfaction of inpatients with ACS. Methods: We performed structured face-to-face interviews with all patients with ACS, residing in a representative Bulgarian region who were discharged from hospitals in this region between September 1st and December 31st, 2004. We surveyed their socio-demographic status, overall satisfaction, change in complaints, self-perceived health status, functional possibilities in activities of daily living, satisfaction with life and self-reported condition at admission. We used descriptive methods as well as t-tests, chi-square tests, and logit models for data analysis. Results: Face-to-face interviews were carried out in 394 cases, of which 53.6% were men and 46.4% were women. 24% of the patients were satisfied with inhospital treatment, 62% were satisfied to some extent, and 14% were unsatisfied. The overall satisfaction of patients with ACS was significantly associated (p < 0.05) with the type of hospital, the number of family members living together and the severity of the disease at admission. Patients treated in urban and middle-size rural hospitals, patients living together with three or more family members, and patients with more severe conditions at admission reported higher satisfaction scores. Conclusion: ACS patient satisfaction with inhospital treatment in Bulgaria shows much room for improvement. Information obtained from satisfaction studies could be used at decision-making and hospital-management levels for improving new strategies and structural changes in the Bulgarian health care system. [ABSTRACT FROM AUTHOR]

Background: The Bulgarian and Greek Medical Care systems have been reformated the last fifteen years. The aim of this study was an examination and comparison of the Bulgarian and Greek Medical Care Systems. Methods: This study was prepared by using all the published data related to both Bulgarian and Greek Medical Care systems. Besides, personal communications with related offices such as administration offices of hospitals and Ministries of Health were made. Results: In both countries, besides the compulsory insurance there is also additional voluntary insurance which is provided by private companies. The most important difference is the family doctor (specialist in general medicine) existing in Bulgaria. Every insured person needs a 'referral form' completed by the family doctor before visiting a hospital for medical attention (except emergencies). In contrast, in Greece an insured person can directly visit any hospital without needing any forms and independent of the severity of their health problem. An important disadvantage of the Greek health system is the low number of hospitals (139), in relation to population. In contrast, there are 211 hospitals in Bulgaria, although its population is lower than in Greece. Conclusion: In both Greek and Bulgarian health systems changes must be done to solve the problems related to informal payments, limited financing, large debts, lack of appropriate investment policy, lack of an objective method for the costing of medical activities and inefficient management. [ABSTRACT FROM AUTHOR]

Background: Haemophilias are the most common hereditary severe disorders of blood clotting. In families afflicted with heamophilia, genetic analysis provides opportunities to prevent recurrence of the disease. This study establishes a diagnostical strategy for carriership determination and prenatal diagnostics of haemophilia A in Bulgarian haemophilic population. Methods: A diagnostical strategy consisting of screening for most common mutations in the factor VIII gene and analysis of a panel of eight linked to the factor VIII gene locus polymorphisms was established. Results: Polymorphic analysis for carrier status determination of haemophilia A was successful in 30 families out of 32 (94%). Carrier status was determined in 25 of a total of 28 women at risk (89%). Fourteen prenatal diagnoses in women at high risk of having a haemophilia A - affected child were performed, resulting in 6 healthy boys and 5 girls. Conclusion: The compound approach proves to be a highly informative and cost-effective strategy for prevention of recurrence of haemophilia A in Bulgaria. DNA analysis facilitates carriership determination and subsequent prenatal diagnosis in the majority of Bulgarian families affected by haemophilia A. [ABSTRACT FROM AUTHOR]

Background: Bulgaria's official stroke mortality rates are higher for rural than urban areas. Official mortality data has indicated that these rates are amongst the highest in Europe. There has been a lack of studies measuring stroke incidence in urban and rural populations. Methods: We established intensive notification networks covering 37791 residents in Varna city and 18656 residents (55% of them village-dwellers), all aged 45 to 84, in 2 rural districts. From May 1, 2000 to April 30, 2001 frequent contact was maintained with notifiers and death registrations were scanned regularly. Suspected incident strokes were assessed by study neurologists within a median of 8 days from onset. Results: 742 events were referred for neurological assessment and 351 of these, which met the WHO criteria for stroke, were in persons aged 45 to 84 and were first ever in a lifetime. Incidence rates, standardised using the world standard weights for ages 45 to 84, were 909 (/100000/year) (95% CI 712-1105) and 597 (482-712) for rural and urban males and 667 (515-818) and 322 (248-395) for rural and urban females. Less than half were admitted to hospital (15% among rural females over 65). Twenty-eight day case fatality was 35% (123/351) overall and 48% (46/96) in village residents. The excess case fatality in the villages could not be explained by age or severity. Conclusions: Rural incidence rates were over twice those reported for western populations but the rate for urban females was similar to other western rates. The high level and marked heterogeneity in both stroke incidence and case fatality merit further investigation. [ABSTRACT FROM AUTHOR]

Background: Hearing loss (HL) affects 466 million people of all ages worldwide, with a rapidly increasing prevalence, and therefore requires appropriate public health policies. Multi-disciplinary approaches that make use of eHealth services can build the evidence to influence public policy. The European Union-funded project EVOTION developed a platform that is fed with real-time data from hearing aids, a smartphone, and additional clinical data and makes public health policy recommendations based on hypothetical public health policy-making models, a big data engine and decision support system. The present study aimed to evaluate this platform as a new tool to support policy-making for HL.Methods: A total of 23 key stakeholders in the United Kingdom, Croatia, Bulgaria and Poland evaluated the platform according to the Strengths, Weaknesses, Opportunities and Threats methodology.Results: There was consensus that the platform, with its advanced technology as well as the amount and variety of data that it can collect, has huge potential to inform commissioning decisions, public health regulations and affect healthcare as a whole. To achieve this, several limitations and external risks need to be addressed and mitigated. Differences between countries highlighted that the EVOTION tool should be used and managed according to local constraints to maximise success.Conclusion: Overall, the EVOTION platform can equip HL policy-makers with a novel data-driven tool that can support public health policy-making for HL in the future. [ABSTRACT FROM AUTHOR]

Background: Cystic echinococcosis (CE) is a neglected parasitic zoonosis prioritized by the WHO for control. Several studies have investigated potential risk factors for CE through questionnaires, mostly carried out on small samples, providing contrasting results. We present the analysis of risk factor questionnaires administered to participants to a large CE prevalence study conducted in Bulgaria, Romania and Turkey. Methods: A semi-structured questionnaire was administered to 24,687 people from rural Bulgaria, Romania and Turkey. CE cases were defined as individuals with abdominal CE cysts detected by ultrasound. Variables associated with CE at P < 0.20 in bivariate analysis were included into a multivariable logistic model, with a random effect to account for clustering at village level. Adjusted odds ratios (AOR) with 95% CI were used to describe the strength of associations. Data were weighted to reflect the relative distribution of the rural population in the study area by country, age group and sex. Results: Valid records from 22,027 people were analyzed. According to the main occupation in the past 20 years, "housewife" (AOR: 3.11; 95% CI: 1.51–6.41) and "retired" (AOR: 2.88; 95% CI: 1.09–7.65) showed significantly higher odds of being infected compared to non-agricultural workers. "Having relatives with CE" (AOR: 4.18; 95% CI: 1.77–9.88) was also associated with higher odds of infection. Interestingly, dog-related and food/water-related factors were not associated with infection. Conclusions: Our results point toward infection being acquired in a "domestic" rural environment and support the view that CE should be considered more a "soil-transmitted" than a "food-borne" infection. This result helps delineating the dynamics of infection transmission and has practical implications in the design of specific studies to shed light on actual sources of infection and inform control campaigns. [ABSTRACT FROM AUTHOR]

Background Temperament and character are definitions that describe human individuality. Interactions between temperament and character are sophisticated and they mould personality - phenomenon, which is unique for human beings. Temperament is the "virtual" structure that defines dynamics and speed of psychic processes: The temperament regulates what is announced and the character - what is the meaning. The meaning of life events and knowledge of life are modified by both. Actuality of modern groupings into temperamental traits is legalized by conception of H. Akiskal that linked temperamental structure and affective disorders. Materials and methods Aim Approbation of Bulgarian version of TEMPS-A (Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire). Tasks To investigate healthy population between 17 and 45 years. To identify specific biological predispositions which are predictors of personality and behavioral deviations. To identify dynamics of personality and temperamental structure during ontogenesis. Exclusion criteria 1. Clinical evidence of organic or toxic etiology of brain injury. 2. Mental retardation - mild and severe. 3. Linguistic or some other difficulties in communication that might interfere with adequate clinical assessment. 4. Substance dependence (alcohol and/or other substances) and substance related personal change that can disturb the homogeneity (?) of the group. 5. Delusional disorders, acute or other psychotic disorders. 6. Evidence of individual dysfunction caused by psychiatric disorder, for example psychosis Instruments • TEMPS-A - Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. • EPQ - Eysenck Personality Questionnaire. • Screening IPDE (IPDE-s) - International Personality Disorder Examination - screening Autoquestionnaire. • MPDO - diagnostic psychological inventory for personality features - A. E. Lichko modification personality diagnostic questionnaire. Results One of investigators translated original test and a professional translator who has never seen original text, made back-translation. We received full approval by the author. 523 healthy volunteers between 18-45 years old, take part in the study. Regarding test-retest (temporal) reliability - test was done again 45 days after first one. Our results demonstrate excellent correlations by test at all and by five dimensions separately. Analysis of the principal components with a Varimax rotation confirm that from the 110 Bulgarian items of the TEMPS-A we brought out five factors that were interpreted as representing the cyclothymic, depressive, irritable, hyperthymic, and anxious factors. Conclusions TEMPS-A showed a good reliability and validity (internal consistency) in a Bulgarian non-clinical population. It gives us a new challenge to understand affective disorders nature and opportunities to measure it. Such research is in progress. Limitations The study sample was relatively small. This is a preliminary report from an ongoing study. [ABSTRACT FROM AUTHOR]