Lozenetz Hospital

Background and Objectives: Various publications have compared outcomes among open (OPDs), laparoscopic (LPDs), and robotic pancreaticoduodenectomies (RPDs); however, the number of randomized controlled trials (RCTs) remains limited. This study aims to conduct a systematic review and analyze the outcomes between these approaches from randomized controlled trials. Materials and Methods: We performed a systematic literature search across PubMed/MedLine, Cochrane Library, ClinicalTrials.gov, and Google Scholar to identify relevant RCTs. The systematic review was conducted using the reporting items for systematic reviews and network meta-analyses guidelines (PRISMA-NMA) and registered in Prospero (CRD420251024475). For statistical analysis R software (version 4.3.2) was used. Results: Eight RCTs involving 1416 patients (706 OPDs, 600 LPDs, 110 RPDs) were included. LPD had a significantly longer operative time than OPD, while RPD showed no significant difference compared to OPD. Blood loss was reduced in both minimally invasive approaches. LPD showed a higher R0 resection rate and lower pancreatic fistula rate, whereas RPD had the lowest mortality. No significant differences were observed in major complications, reoperation, or readmission. LPD shortened hospital stay; RPD showed no difference. Conclusions: Although open pancreaticoduodenectomy remains a well-established standard, both laparoscopic and robotic approaches offer safe alternatives with distinct advantages. LPD is associated with shorter hospital stay and lower pancreatic fistula rates, whereas RPD demonstrates the lowest mortality. The lack of direct randomized comparisons between LPD and RPD highlights the need for further head-to-head trials.

Influenza poses a serious threat to both individual and public health. This study aimed to investigate the virological and epidemiological characteristics of influenza infections and to explore the genetic diversity of the circulating influenza viruses. In total, 1886 nasopharyngeal specimens from patients with acute respiratory illnesses were tested against 13 respiratory viruses using a multiplex real-time PCR. Whole-genome sequencing, phylogenetic, and amino acid analyses of representative influenza strains were performed. At least one respiratory virus was detected in 869 (46.1%) patients; 87 (4.6%) were co-infected with two or three viruses. Influenza A(H1N1)pdm09 was the most prevalent virus (16.1%), followed by rhinoviruses (8.1%) and RSV (6.7%). Hemagglutinin (HA) genes of the 74 influenza A(H1N1)pdm09 viruses were categorized in subclades C.1.8, C.1.9, and C.1 within clade 5a.2a and D1, D.2, and D.3 within clade 5a.2a.1. The A(H3N2) viruses analyzed belonged to clade 2a.3a.1, subclades J.2 and J.1. The sequenced B/Victoria lineage viruses fell into clade V1A.3a.2, subclades C.5.6 and C.5.7. Amino acid substitutions in most viral proteins were identified compared with the vaccine strains, including in the HA antigenic sites. This study demonstrated the dominant distribution of the influenza A(H1N1)pdm09 virus among the respiratory viruses studied and the genetic diversity of the circulating influenza viruses.

Introduction: Osteomyelitis can cause serious disability and even lethality. Its treatment requires a combination of surgical and conservative methods. Antimicrobial therapy is often initiated before microbiological test results are available. Empirical regimens are then used, which are not universal because of variations in causative agents according to geographical region and time periods. The lack of up-to-date information on these issues in Bulgaria is the impetus for the present study. Aim: The aim of this article is to conduct an epidemiological study and propose empirical antimicrobial therapy. Patients and Method s: A total of 58 patients between 19 and 86 years of age, with a history of infection from 2 weeks to 30 years and different localization, admitted to the Department of Orthopaedics and Traumatology of the Lozenets University Hospital (2019–2024). Results : Men were significantly more affected than women. The localization of the infection was predominantly in the tibia and hip region, and most rarely in the humerus and forearm bones. Among the comorbidities, the most prevalent were arterial hypertention, diabetes mellitus, and inferior paraplegia. S. aureus , Streptococcus agalactiae , and Enterococcus faecalis were mainly isolated from the osteomyelitis outbreak. S. aureus showed 100% susceptibility to vancomycin and 69% to moxifloxacin and rifampicin. Streptococcus agalactiae and Enterococcus faecalis were susceptible to a wide range of antibiotics, including vancomycin. Conclusion : Vancomycin was the most widely used antimicrobial agent in the study group and must be included in empiric therapy. It is recommended to combine it with moxifloxacin covering the Gram (–) spectrum, and in patients with orthopaedic implants its use with rifampicin, an antibiotic with proven activity against bacterial biofilm formation, is desirable.

Background:The treatment of patients with rheumatoid arthritis (RA) has become standardized and targeted in the past decades, using novel disease-modifying anti-rheumatic drugs (DMARDs: biologic (bDMARDs) and targeted synthetic (tsDMARDs)), which resulted in a significant improvement in the disease prognosis. However, treatment patterns might vary around the world according to different patient profiles, medical practices, and socioeconomic considerations.Objectives:To assess worldwide disparities in different DMARDs, with a focus on novel therapies, in patients with RA from the COVAD2 study, taking into account the geographic location and the country’s socioeconomic level.Methods:Data on RA patients was extracted from the COVAD2 database, an international multi-centre cross-sectional study based on a patient self-reported online study on patients with autoimmune diseases and controls from 110 countries. Sociodemographic data were collected, and regions of the world were considered in 5 categories: Africa, Asia, Europe, North America grouped with Oceania (due to the low number in the latter), and South America. The Human Development Index (HDI) was used to evaluate the country’s economic level. Pain, Patient-Reported Outcome Measurement Information System (PROMIS) scores, Physical function, and Fatigue 4a were recorded. Finally, DMARDs were categorized as corticosteroids, conventional synthetic (cs)DMARDs, Immunosuppressives, Hydroxychloroquine, bDMARDs (TNFi, IL1i, IL6i, IL12-23i, IL17i, IL23i, RTX, Belimumab, CTLA4Igi) and tsDMARDs (JAKi). The distribution of novel therapies (bDMARDs and tsDMARDs) was evaluated by continent and HDI. Factors associated with the novel therapies were identified using Chi-Square, Fisher exact test, and ANOVA as appropriate in a bivariate analysis, and significantly associated variables (p<0.05) were included in a multivariable binary logistic model.Results:At the time of the analysis, the COVAD2 database comprised 10739 participants, including 6390 patients with autoimmune rheumatic diseases and 2007 with RA. In patients with RA, the mean age was 51±14 years, disease duration was 12±10 years, 88% were females, 21% were in disease remission, and 32% had two or more comorbidities. Among all patients with RA, 39% were from Europe, 25% from Asia, 15% from North America and Oceania, 12% from South America and 9% from Africa, with significant differences in age, gender, disease duration, activity, multimorbidity and PROs among the continents. In parallel, 61% were from countries with very high HDI, 24% from high, 13% from moderate and 2% from low HDI.The use of novel therapies was reported in 30% of all patients with RA and was the highest in Europe (44%), followed by North America and Oceania (34%), South America (31%), Asia (12%), and Africa (5%) (p<0.001) (Table 1). Also, it increased with HDI (3% in low, 6% in Medium, 21% in high and 39% in very high HDI countries (p<0.001)). After adjusting on age, disease duration, gender, ethnicity, continent, HDI, pain, disease activity, basic multimorbidity, PROs, the use of novel therapies remained associated with the continent, the country’s HDI, and longer disease duration.Conclusion:In patients with RA from the COVAD2 international database, the use of novel DMARDs varied significantly across continents and increased significantly with the country’s economic level. These global disparities in RA treatment, beyond patients’ and disease’s characteristics, should be addressed to ensure equitable access to effective healthcare interventions around the world.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of Interests:None declared.

Despite the overall safety and efficacy of COVID-19 vaccinations, rare cases of systemic autoimmune diseases (SAIDs) have been reported post-vaccination. This study used a global survey to analyze SAIDs in susceptible individuals' post-vaccination. A cross-sectional study was conducted among participants with self-reported new-onset SAIDs using the COVID-19 Vaccination in Autoimmune Diseases (COVAD) 2 study dataset-a validated, patient-reported e-survey-to analyze the long-term safety of COVID-19 vaccines. Baseline characteristics of patients with new-onset SAIDs and vaccinated healthy controls (HCs) were compared after propensity score matching based on age and sex in a 1:4 ratio. Of 16 750 individuals, 74 (median age 52 years, 79.9% females, and 76.7% Caucasians) had new-onset SAID post-vaccination, mainly idiopathic inflammatory myopathies (IIMs) (n = 23, 31.51%), arthritis (n = 15; 20.53%), and polymyalgia rheumatica (PMR) (n = 12, 16.40%). Higher odds of new-onset SAIDs were noted among Caucasians (OR = 5.3; 95% CI = 2.9-9.7; p < .001) and Moderna vaccine recipients (OR = 2.7; 95% CI = 1.3-5.3; p = .004). New-onset SAIDs were associated with AID multimorbidity (OR = 1.4; 95% CI = 1.1-1.7; p < .001), mental health disorders (OR = 1.6; 95% CI = 1.3-1.9; p < .001), and mixed race (OR = 2.2; 95% CI = 1.2-4.2; p = .010), where those aged >60 years (OR = 0.6; 95% CI = 0.4-0.8; p = .007) and from high/medium human development index (HDI) countries (compared to very high HDI) reported fewer events than HCs. This study reports a low occurrence of new-onset SAIDs following COVID-19 vaccination, primarily IIMs, PMR, and inflammatory arthritis. Identified risk factors included pre-existing AID multimorbidity, mental health diseases, and mixed race. Revaccination was well tolerated by most patients; therefore, we recommend continuing COVID-19 vaccination in the general population. However, long-term studies are needed to understand the autoimmune phenomena arising post-vaccination.

Infections affecting the humerus are a serious therapeutic challenge, especially when they are spread along the entire length of the humerus and have a long evolution. Their origin can be both hematogenous and exogenous. Unsuccessfully treated osteomyelitis of the humerus can be the cause of severe disability, intoxication and even lead to amputation.&#x0D; The aim: To pay attention to the difficulties associated with the treatment of a rare localization of osteomyelitis affecting the entire humerus.&#x0D; Material and methods: One patient is presented, a 63-year-old man who underwent multiple operations for osteomyelitis of the humerus about 20 years ago.&#x0D; Results: The early postoperative period went smoothly. The surgical wound healed primarily, the bone infection was completely repaired, and the right upper extremity is in good functional condition, with no evidence of circulatory or neurological problems.&#x0D; Conclusion: The presented patient is a clear example that the key to the successful treatment of osteomyelitis is the correct choice of the main method, namely the method providing full revascularization of the bone or the replacement of the affected bone segment with autoosteoplastic material.&#x0D;

Among the countries in the European Union, Bulgaria reports the lowest immunization coverage. Gathering reliable information on the level of post-vaccine adverse events and making it publicly available might increase public confidence in vaccines and immunization strategies. The aim of our study is to analyze and summarize post-vaccination reactions among 100 pre-hospital care patients after the administration of the first and second doses of the SARS-CoV-2 vaccines. The reported adverse reactions found by us with both mRNA and adenoviral vector vaccines were mild and self-limiting, similar to the results reported by many other authors in different parts of the world. We hope that attitudes regarding vaccinations will change in favor of vaccines, precisely through the analysis of the results of post-vaccination side effects, proof of their harmlessness. Regarding vaccinations will change in favor of vaccines, precisely through the analysis of the results of post-vaccination side effects, proof of their harmlessness.

The plexiform fibrohistiocytic tumor is rare, typical for children and adolescents, affects more often the female sex and is most often localized in the upper limb-the region of the wrist joint and the hand. The tumor originates from the subcutaneous adipose tissue, but it is possible to involve the dermis and skeletal muscle. It is characterized by slow growth and sizes between 0.5 and 8 cm, with minimal or no cellular atypism. Three histological varieties have been described: fibrohistiocytic, fibroblastic, and mixed type, which occur with almost equal frequency. Aim: The aim of this article is to present an extremely rare pathohistologically large tumor atypical for the patient's gender, location and age, and address the surgical challenges of its removal. Result: After en bloc excision of the tumor formation, part of the surgical wound healed secondary. No recurrences were recorded. The pathohistological nature of the tumor is a prerequisite for a complete cure, but the removal of such giant soft tissue formations from the proximal and medial side of the lower leg is a real surgical challenge. The exposed large area of the tibia, with no soft tissue and periosteum, is difficult to cover by local skin plastic surgery, and at the same time it is extremely unsuitable for free plastic procedure.

Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases, including diabetes; hypertension; atherosclerosis; coronary artery disease and stroke; obstructive sleep apnea; depression; weight-related arthropathies and endometrial and breast cancer. A body weight 20% above ideal for age, gender and height is a severe health risk. Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet, increased physical activity, behavioral changes and drugs have failed. The two most common procedures currently used are sleeve gastrectomy and gastric bypass. This procedure has gained popularity recently and is generally considered safe and effective. Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved, more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures. This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.