Introduction: Progressive systemic sclerosis (PSS) is a connective tissue disorder with unknown etiology, characterized by increased collagen deposition leading to fibrosis, skin thickening and other pathological changes in organs. Females constitute at least two-thirds of all the cases. The disease commonly occurs in women aged 30-40 years. Other features of the disease include Raynaud’s phenomenon, telangiectasia, calcinosis, myositis, arthritis, tenosynovitis, renal failure, esophageal dysmotility, pulmonary fibrosis, and heart failure. Materials and Methods: A 71-year-old female was hospitalized with ischemic and cyanotic fingertips in the Department of Rheumatology, St. Marina University Hospital, Varna, Bulgaria. She complained of pain in both hip joints when walking, erythema in the region of the distal phalanges of the hands and feet with individual ulcerations on the fingertips. Raynaud’s phenomenon was positive. Other comorbidities that were included in her medical records were type two diabetes, hypertension, and past history of endometrial cancer. The physical exam revealed sclerodactyly, cutaneous sclerosis of hands and feet, and microstomia. Laboratory tests revealed high levels of very low-density lipoprotein (4.9) and high level of blood sugar (7.2). Immunology revealed high levels of antinuclear antibodies (+++), anti-centromere protein B (++), anti-Sjögren’s syndrome-A (Ro52) (+++). Results: The following medications were administered: methylprednisolone 40 mg intravenous, ranitidine 150 mg 2х1 per os, pulse therapy with cyclophosphamide amp 1000 mg in 500 mL saline, then followed by another bank of 500 mL saline, metoclopramide 10 mg - 1 ampoule intravenously, and heparin 2x500E intravenous. Conclusion: The occurrence of the disease in such an advanced age is unlikely, while the risk of diabetes and neoplasia increases exponentially with the age. The uniqueness of the case herein lies with its late presentation, which could easily be misinterpreted as a complication of her concomitant diseases.

Introduction: Anterior crossbite is a major aesthetic and functional concern to parents during the developmental stage of a child. Anterior crossbite is the lingual positioning of the maxillary anteri­or teeth in relationship to the mandibular anterior teeth. There are several methods for solving this problem. In this case report we present the treatment with a removable lingual plane. The aim of the following case report is to present the achieved good results after the early treatment of an anterior crossbite. Materials and Methods: This report describes the treatment of an 8-year-old girl in the Department of Orthodontics, Faculty of Dental medicine, Medical University - Varna. Diagnostic data was gathered from clinical photographs, cast models from intraoral impressions, cephalometric analysis based on lateral cephalograms and panoramic radiographs. Results: We established a crossbite of tooth 21 and laterodeviation. According to lateral cephalomet­ric analysis the patient has a retroclination of the upper central incisor on the left. There was suffi­cient mesiodistal width to achieve labial movement of the maxillary tooth. To align the maxillary an­terior central incisor and correct the crossbite, a removable acrylic appliance with posterior occlusal surfaces was used. A screw incorporated in the appliance was activated by 0.25 mm every 4 days for 12 days. After these 12 days the crossbite was corrected. Conclusion: There are many treatment options available for the correction of crossbites according to the number and site of the teeth/tooth involved, the stage of the dentition and its etiology. Based on the results presented here, a removable appliance with a screw may be considered the first choice of treatment to correct anterior dental crossbite of one incisor. This method is a safe, cost effective, rap­id and easy alternative for the treatment of an anterior crossbite.

Introduction: Imperforate hymen is a rare congenital anomaly with an incidence of 1:1000 to 1:10,000 newborns. The condition includes symptoms such as primary amenorrhea, recurrent cramping ab­dominal pain, urine retention and constipation. It is typically diagnosed in puberty when the second­ary sex characteristics have already been developed. The aim of this case report is to raise awareness about the late complications that often occur when misdiagnosed. Materials and Methods: 36-years old female is presented with a history of primary sterility. In 1997 she was admitted at the emergency room with an acute abdominal pain and abdominal distension. The ultrasound revealed fluid in the abdominal cavity. The patient underwent emergency operation. During the surgery a collection of coagulated blood was discovered in the lower pelvis. The left ova­ry, the left fallopian tube and a part of the right ovary were removed. One month following the sur­gery, the symptoms reoccurred. A gynecological exam revealed imperforate hymen, complicated with hematocolpos, hematometra and hematosalpinx. Hymenectomy and drainage of the menstrual blood were performed. In the following years the patient had a normal menstrual cycle. In 2017 a hystero­salpingography revealed adhesions in the right Fallopian tube. The patient underwent laparoscopic salpingotomia, as part of preparation for her in vitro fertilization. Results: The patient had suffered from primary sterility due to the misdiagnosed imperforate hymen which lead to the need of an in vitro fertilization as an only option. Conclusion: Imperforate hymen should be mostly suspected in pubertal girls, presenting with recur­ring cyclic abdominal pain, without menstrual bleeding. Early diagnosis is important, due to the pos­sibility of developing serious complications-infections, endometriosis, hydronephrosis, renal failure, infertility.

Introduction: While Addison`s disease may be thought of when considering autoimmune polyglandular syndrome in patients with Hashimoto Thyroiditis, secondary adrenal insufficiency is an even rarer finding. The diagnosis is further complicated by nonspecific signs and symptoms, such as hyponatraemia or fatigue, that may be attributed to other comorbidities, like heart failure. Materials and methods: A 63-year-old male patient presented with complaints of generalized weakness, weight loss (body mass index 15), lack of appetite and nausea. His medical history was extensive, including Hashimoto thyroiditis and advanced left-sided heart failure with pacemaker placement due to Sick Sinus Syndrome and hypertension stage III, amongst other diagnoses. Results: Initial examinations revealed hypoglycaemia (2.2 mmol/L) and hyponatraemia (118 mEq/L), with no other relevant abnormalities. Once adrenal insufficiency was considered, serum cortisol (46.98 nmol/L) and adrenocorticotropic hormone (7.13 pg/mL) were both found decreased. Synacthen test results were 91.32 nmol/L - 0 min, 281.09 nmol/L - 30 min, 390.3 nmol/L - 60 min, and urine cortisol was 552 mcg/24h. The remaining pituitary hormones were in normal range. Computed tomography (as magnetic resonance was contraindicated) failed to determine the cause and no hypothalamopituitary pathology was observed, although the possibility of a microadenoma could not be excluded. Therapy with methylprednisolone was instituted successfully. Conclusion: The pathophysiology of secondary adrenal insufficiency in this patient was most likely autoimmune. This case report represents an unusual diagnosis, which additionally highlights the various possible effects of adrenocorticotropic hormone deficiency and the complexity of the clinical picture that may be seen in patients with multiple autoimmune endocrine disorders and comorbidities.

Introduction: Sudden infant death syndrome (SIDS) is a term used to describe the sudden and un­identified death of an infant under one year of age. It is among the most common causes of postneo­natal infant deaths in economically advanced countries; yet little is known about SIDS in economi­cally disadvantaged countries, including Bulgaria. Materials and Methods: A systematic review of the literature for the period 1997-2017 included publi­cations from Medline, Pubmed, and Google Scholar. The initial search selected 79 articles published in English and Bulgarian of which 21 were included for the final review. Eligibility criteria for inclu­sion were year of publication, profile of the family and type of intervention with the goal of evaluat­ing its effectiveness. Effect size [ES] of the interventions measured the statistical significance of the findings. Results: Studies report that prone sleeping triples the risk of SIDS. Swaddling also showed to be relat­ed to SIDS death with an overall age-adjusted pooled odds ratio (OR) of swaddling of 1.58 (95% CI: 0.97-2.58). Among 22% of the deaths occurred when a parent was sleeping with their child. Econom­ically disadvantaged families and ethnic minority groups had higher prevalence of SIDS. Interven­tions aimed at reducing smoking among pregnant mothers have reduced the risk of SIDS. Addition­ally, hard bedding and pacifier use are found to significantly reduce the risk of SIDS. No evidence of SIDS cases was found for Bulgaria and other economically disadvantaged regions. Conclusion: Public health measures aimed at early and continuing involvement of expectant mothers in prenatal care are important not just to prevent SIDS, but to improve the health of infants. More re­search and data collection on factors associated to sudden infant deaths in less developing countries are needed to fully comprehend and compare trends in SIDS.

Introduction: The aim of present study is to determine the content of three methylxanthines in dif­ferent types of tea and coffee available on the Bulgarian market. The most important naturally oc­curring methylxanthines are caffeine, theophylline and theobromine (purine alkaloids), which are found in varying amounts in tea, coffee and other plants. Caffeine is the most widely used drug. Its main pharmaceutical applications are as a cardiac and respiratory stimulant. Theobromine is mild diuretic, stimulates and relaxes the smooth muscles of the bronchi. Theophylline has anti-inflamma­tory effects, stimulates the central nervous system, acting mainly on the medullary respiratory cen­tre. Materials and methods: Sample preparation procedure includes boiling water extraction, filtration and purification. High-Pressure Liquid Chromatography (HPLC) analysis was performed on column Synergi 4u Hydro-RP (250 x 4.6 um) with a mobile phase of acetonitrile: water = 90:10. Three meth­ylxanthines were monitored by ultraviolet (UV) detection at 274 nm. Results: Three purine alkaloids were quantified in almost all samples. The research shows a highest concentration of caffeine at about 35.0 mg/150 ml, whereas theophylline and theobromine values are around 5.0 mg/150 ml each. Conclusion: The statistical data observed that people from all over the world drink more than 2 bil­lion cups of coffee every day. Coffee is the second most traded product in the world after oil. In Bul­garia it is more consumed than tea. Worldwide, tea is the drink of choice from many people - over 3 billion cups per day. The HPLC method is appropriate for separation and quantification of caffeine, theobromine and theophylline. According to the European Food Safety Authority (EFSA) recom­mendation for caffeine daily intake (400 mg/day) three cups of analysed samples give the beneficial effects.

Introduction: Hemolytic-uremic syndrome (HUS) is a common cause of community-acquired acute kidney injury in young children. It is characterized by the triad of microangiopathic hemolytic ane­mia, thrombocytopenia, and renal insufficiency. The syndrome predominantly occurs in infants and children after prodromal diarrhea. HUS is classified into two main categories, depending on whether it is associated with Shiga-like toxin (Stx) or not and has clinical features in common with thrombot­ic thrombocytopenic purpura (TTP), rendering the differential diagnosis difficult. Materials and Methods: A case report of a 2-year-old child is discussed. Two days prior to hospital­ization the patient had diarrhea, vomiting and a sudden onset of weakness and lethargy. The physical examination revealed generalized edema, lack of rashes and no neurological deficit. Results: The laboratory tests showed normocytic normochromic anemia (hemoglobin 59 g/l), throm­bocytopenia (27N…10^9), elevations in serum blood, urea, nitrogen and creatinine. The results from the peripheral blood smear came back with anisocytosis, poikilocytosis and schistocytosis. Urinal­ysis showed proteinuria, leukocyturia and hematuria. Abdominal ultrasonography detected bilater­al hyperechoic renal parenchyma, as well as the presence of free fluid in the pelvis,. Immediate an­tibiotic treatment, infusion therapy and hemotransfusion were initiated. An infusion of furosemide was administered. Conclusion: With early recognition and intensive supportive care, the mortality for diarrhea-asso­ciated HUS is <5%. Although most of the patients recover renal function completely, there are risks of chronification of the disease. HUS is the most common cause of acute kidney injury in children. Knowing clinical symptomatology and course of action allows for a timely diagnosis and accurate treatment.

Introduction: Unconventional methods of treatment are those that favourably affect individual health trough non-traditional physical methods, non-medicinal products of organic or mineral origin, acu­puncture and others. According to the Law on Health, they can be practiced by people without med­ical education, who are registered by the Regional Health Inspections (RHIs). The aim of the paper is to explore consumer attitudes to the use of conventional physiotherapy procedures and unconven­tional methods to promote individual health. Methods and materials: A sociological method for collecting information and statistical methods for processing the results are used. A survey was conducted among 104 users of unconventional and con­ventional physiotherapeutic methods for treatment between 1st and 14th December 2017. The ques­tionnaire includes 29 closed and one open question. Results: Over 60% of the respondents, participated in the survey, have used unconventional methods. Among the unconventional methods used are reflexology (50.8%), ventusotherapy (31.1%), acupunc­ture (16.4%), and acupressure (11.5%). In regard with the conventional physiotherapeutic methods, the largest share has balneotherapy (46.4%), followed by physiotherapy (43.3%). The frequency of vis­its to centers for unconventional methods is different: several times per year - 48.5% of the respon­dents; only once per year - 37.9% and 9.1% once per month. Consumers prefer unconventional meth­ods mainly because of recommendations from family and friends. Many of the satisfied users visit­ing spa, balneology and eastern medicine centers would use the most of the services, if the NHIF cov­ers part of the price. Conclusions: In the recent years, more and more unconventional ancient methods to improve and protect health are used. Very often, consumers preferred these methods as a stand-alone alternative or in combination with traditional physical methods and procedures. According to the respondents, non-traditional and alternative methods for promoting individual health should be provided by phy­sicians, physiotherapists, kinesitherapists, and rehabilitators.

Introduction: Off-pump coronary artery bypass or «beating heart» surgery is a form of coronary ar­tery bypass graft (CABG) surgery performed without cardiopulmonary bypass as treatment for cor­onary artery disease. When a cardiac surgeon chooses the CABG procedure off-pump, also known as OPCAB (Off-pump Coronary Artery Bypass), the heart is still beating while the graft attachments are made to bypass a blockage. Using the OPCAB technique for multi-vessel myocardial revascular­ization in high-risk patients significantly reduces the incidence of perioperative myocardial infarc­tion and other major complications. Even though the OPCAB group includes a significantly higher proportion of older patients with poor Left Ventricle (LV) function and renal problems, the benefi­cial effect of OPCAB is evident. Materials and methods: The case report describes a 75-year old man with class III angina pectoris, class II chronic left heart failure, class III hypertension, dyslipidaemia and LV hypertrophy who has been suffering from chest pain, breathlessness and easy tiredness. After cardiac catheterization, the patient was diagnosed with three vessel coronary artery disease. Due to the patient`s comorbidities, his age and the higher perioperative risk of conventional CABG, the patient was considered as suit­able for OPCAB surgery in planned order. Results: Blood flow in the coronary arteries was restored with four grafts - Left Internal Mammary Artery (LIMA) to Left Anterior Descending coronary artery (LAD), Right Coronary Artery (RCA) to Posterior Descending Coronary Artery (Pd) to First Marginal Branch of the circumflex coronary artery (OM1) to Ramus Intermedius Artery (RIM) - free Right Internal Mammary Artery (RIMA) jump. Proximally the free RIMA is anastomosed terminal-laterally to in situ LIMA. Postoperatively no rhythm or conduction disorders have been registered. Conclusion: OPCAB has advantages in reducing postoperative complications such as: systemic in­flammatory response and myocardial, renal and cerebral injuries compared to on-pump coronary ar­tery bypass grafting.

Introduction: Unconventional treatment methods, as defined by law, include acupressure, acupunc­ture, iris and pulse diagnostics, diet, non-traditional physical methods of mechanical, thermal or magnetic treatment. These methods can be practiced by both medical and non-medical profession­als under special conditions. Their development and impact on public health depend on users` atti­tudes and providers` professionalism. However, most of the unconventional methods are not studied at the medical universities in Bulgaria. Therefore, the aim of the study is to research attitudes of fac­ulty members towards the use and development of unconventional healing methods. Materials and methods: A sociological survey was performed using a semi-structured questionnaire with 31 questions. Seventy-seven faculty members from 4 universities in Bulgaria took a part in the survey. Results: Nearly half of the respondents (46.1%) have used unconventional treatment services. Almost all of those who used such services were satisfied in general with the treatment they received. Major­ity of them (55.9%) experienced an improvement. The respondents declare that the hygiene and pro­fessionals` qualification of unconventional services providers could be improved. Fifty-four percent of the respondents acknowledge and accept the relevance of unconventional treatment methods. At the same time, the respondents declare that the unconventional methods should be applied by profes­sionals. Conclusion: Faculty members have a positive attitude towards the unconventional treatment meth­ods, applied by professionals. This may serve as a prerequisite for the introduction and development of academic courses as a step to the better control and quality of the unconventional treatment servic­es, provided to the public.