History of development of undergraduate public health education in Bulgaria.

OBJECTIVE: The study aims to present a historical review and analysis of the establishment and development of undergraduate public health (PH) education in Bulgaria from 1878 until 2019. METHODS: А search and selection of historical documents was performed, including laws, rules, regulations, government plans, programmes, scientific publications from periodical medical press, journals, specialized monographs, and books. A retrospective analysis of the normative documents related to the organization of the sanitation and public health activities, and to the provision of professional undergraduate education of the public health workforce in Bulgaria has been carried out. The required competences and tasks of the specialists exercising public health control services were extracted. RESULTS: The development in the public health educational activities were followed in three consecutive periods: the newly independent state (1878-1944); the socialist state (1945-1990); the democratizing state (1990-2019). The development of organized PH activities began after the liberation of Bulgaria in 1878. The historical analysis reveals a direct link between the major socioeconomic changes in the country and the organization of PH undergraduate education which passed through dynamic transformations. The professional education in the sphere of PH started with the training of feldshers, followed by sanitary feldsher and sanitary health inspectors performed in secondary vocational medical schools during the socialist period, reaching the stage of undergraduate university PH education provided by medical colleges associated with universities in the third period. CONCLUSION: Despite the continuous development in the organization of undergraduate PH education in Bulgaria, its content is still not fully compatible with the basic European PH services and actions. There is a growing need for wider standardization and integration of undergraduate PH education in the EU so that the specialty can reach the status of a regulated health profession similar to medicine, nursing, and others.

Trends in Stroke Burden in Central and Eastern Europe from 1990-2019.

INTRODUCTION: There has been wide recognition of the health divide between Western Europe and the former socialist countries from Central and Eastern Europe. However, these have not been assessed in terms of burden of disease, and the effect of stroke has not been fully elucidated, especially in terms of time trends. METHODS: The West-Eastern European stroke burden was analysed using data from the Global Burden of Stroke (GBD) Study 2019 in terms of disability-adjusted life years lost (DALYs) and years of life lost (YLL) over the period 1990-2019 by gender. Data were extracted on a regional (West, Central, and East Europe) and country level for the twenty former socialist countries from Central and East Europe according to GBD regional definitions. We focused on the trends of age-standardized stroke DALY rates across the three decades and compared them with the average rates for West Europe. MAIN FINDINGS: All Central and East European countries experienced a decline in all-cause disease burden between 1990 and 2019, and a gap was confirmed between the East, the Central, and the West European region for men but not for women. The age-standardized stroke DALY rates declined in the three European regions and in all twenty Central and East European countries but at a different pace. The stroke DALY rates among women exhibited the greatest decline in the West -59% (95% UI [-60; -57]) followed by the Central European region -48% (95% UI [-53; -42]) and lowest among women in East Europe -37% (95% UI [-43; -29]). The decline in men was even higher than among women -61% (95% UI [-63; -60]), while in Central Europe it was -43% (95% UI [-50; -37]) and in the East -25% (95% UI [-34; -14]), leading to widening of the gap between East, Central, and West Europe in relation to stroke burden. YLL represented more than 70% of stroke DALYs and more than 90% of DALYs for men in East European countries. CONCLUSIONS: The burden of stroke contributes to the European health gap through preventable premature stroke deaths. There are some very successful countries in stroke burden management from both Central (Slovenia, Czech Republic, and Hungary) and East Europe (Estonia), suggesting that closing the health gap between East and West is a realistic aim.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. AIMS AND OBJECTIVES: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. METHODS: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. RESULTS: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. CONCLUSION: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Cultural adaptation of a self-review tool for health promoting universities in Bulgaria.

Introduction: The Health Promoting University initiative is unknown in Bulgaria, and the health promotion potential of Bulgarian universities has not been studied. In order to examine it, a suitable instrument is needed. The UK Healthy Universities Network provides an accessible Self-Review-Tool (SRT). Aim: To present the process of cultural adaptation of the SRT in Bulgarian language. Methods: The standardized WHO methodology for cultural adaptation of instruments was followed in four stages: (1) Two language translations of the instrument into Bulgarian were made; (2) An expert Delphi discussion reached a consensus on specific health promoting (HP) terms, followed by a backward translation; (3) Pilot testing of the tool among university community representatives was conducted through a survey among a small sample, with independent responses to the SRT questionnaire followed by cognitive interviews; (4) Final revision of the instrument. Results: Ten public health experts reached a consensus on the name of the initiative and various HP terms. Ten other respondents pre-tested the tool. Difficulties in responding the SRT concerned the meaning of some HP terms, complex words, the system of answers, limited applicability of some statements. Changes were made to 61 of the total 68 elements in the SRT. Conclusion: All stages of the cultural adaptation were important for the final result. The adapted Bulgarian version of the SRT would be useful to Bulgarian universities that want to make a clear commitment to improving the health of their university community and the wider society.

Incidence, Risk Factors and Outcome of Bloodstream Infections in Patients After Hematopoietic Stem-Cell Transplantation: A Single Center Study.

The bloodstream infections (BSIs) are among the most common infectious complications after hematopoietic stem-cell transplantation (HSCT), often associated with high mortality rates. The aim of this study was to evaluate the incidence, risk factors and outcome of BSIs in HSCT recipients from the Transplantation Center of the University Hospital in Varna, Bulgaria during the period January 2019-December 2021. The role of patient- and transplantation-related variables was studied as potential risk factors for BSIs and survival after HSCT. Seventy-four patients were included in the study. The cumulative incidence of BSIs was 35%. The mean period of BSI onset after HSCT was 8 days. The Gram-positive bacteria were more commonly isolated as causative agents (52.3%). The mortality rate 30 days after the diagnosis of BSI was 23%. Fecal colonization with multidrug-resistant (MDR) bacteria (p = 0.005) and pre-transplant BSI (p = 0.05) were associated with significantly increased risk for post-HSCT BSIs. The overall 4-month survival was 86.5%. A statistical significance was found between the type of the underlying disease (acute leukemia and lymphoma, p = 0.043), previous HSCT (p = 0.001) and 4-month survival. This study confirms that the fecal colonization with MDR bacteria before transplantation and pre-transplant BSIs are independent risk factors for the occurrence of BSI in the early period after HSCT. Pre- and posttransplant monitoring of the patient fecal colonization status with MDR organisms, could contribute considerably to the prevention and successful management of the infectious complications in patients after HSCT.

Expression of matrix metalloproteinase-1, -9, -13, and tissue inhibitor of metalloproteinases-1 in basal cell carcinomas of the eyelid.

BACKGROUND: Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) function in the remodelling of the extracellular matrix in morphogenesis, angiogenesis, tissue repair, and tumor invasion. Elevated levels of distinct MMPs in tumor tissue are related to worse prognosis. However, no overall consistent pattern of expression in human cancer has been identified. The aim of the present study was to evaluate the expression of MMP-1, -9, -13 and TIMP-1 in tumor epithelial cells and surrounding connective tissue in primary basal cell carcinomas (BCC) of the eyelid, and to assess their role as prognostic markers for tumor recurrence. METHODS: Surgical specimens of 49 histologically proven primary BBCs of the eyelid of different histological subtypes were included. Immunohistological studies were performed using antibodies against MMP-1, MMP-9, MMP-13 and TIMP-1, and staining intensity was analyzed semi-quantitatively. RESULTS: MMP-1, -9, -13, and TIMP-1 were expressed at various intensities in epithelial tumor cells and surrounding stromal cells including fibroblasts, inflammatory cells, and vascular endothelial cells in all tumor subtypes. Staining was especially prominent at the invading edge of the BCC. A statistically significant correlation was seen between increased TIMP-1 expression in tumor and/or stromal cells with the presence of MMP-13 (p = 0.007 and p < 0.0001 respectively). Moreover, TIMP-1 expression in tumor and/or stroma was significantly associated with relapse (p = 0.012 and p = 0.042 respectively). CONCLUSION: MMP-9, MMP-13 and TIMP-1 expression may serve as a prognostic marker for early tumor invasiveness. Moreover, up-regulation of TIMP-1 in tumor and/or surrounding stromal cells may indicate an increased risk for BCC recurrence.

Perceived challenges to public health in Central and Eastern Europe: a qualitative analysis.

BACKGROUND: There is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries. METHODS: We invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis. RESULTS: Themes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify "best practices" of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries. CONCLUSIONS: To reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.

Nutrition Transition in Europe: East-West Dimensions in the Last 30 Years-A Narrative Review.

The current review aims to summarize published research on nutrition transition patterns (depicting changes in dietary consumption) in European populations over the last three decades (1990-2020), with a focus on East-West regional comparisons. Pubmed and Google-Scholar databases were searched for articles providing information on repeated dietary intakes in populations living in countries across Europe, published between January 1990 and July 2021. From the identified 18,031 articles, 62 were found eligible for review (17 from Eastern and 45 from Western European populations). Overall, both in Eastern and Western Europe, there have been pronounced changes in dietary consumption patterns over the last three decades characterized by reductions in average reported intakes of sugar, carbohydrates and saturated fats and increases in reported fruit and vegetable consumption. There has also been a tendency toward a reduction in traditional foods, such as fish, observed in some Mediterranean countries. Overall, these data suggests that European countries have undergone a nutrition transition toward adopting healthier dietary behaviors. These processes occurred already in the period 1990-2000 in many Western European, and in the last decades have been also spreading throughout Eastern European countries. Firm conclusions are hampered by the lack of standardized methodologies depicting changes in dietary intakes over time and the limited coverage of the full variety of European populations. Future studies based on standardized dietary assessment methods and representative for the whole range of populations across Europe are warranted to allow monitoring trends in nutrition transition within and among European countries.

Diabetic Retinopathy Screening and Registration in Europe-Narrative Review.

Diabetic retinopathy (DR) is a leading cause of preventable vision impairment and blindness in the European Region. Despite the fact that almost all European countries have some kind of prophylactic eye examination for people with diabetes, the examinations are not properly arranged and are not organized according to the principles of screening in medicine. In 2021, the current COVID-19 pandemic moved telemedicine to the forefront healthcare services. Due to that, a lot more patients could benefit from comfortable and faster access to ophthalmology specialist care. This study aimed to conduct a narrative literature review on current DR screening programs and registries in the European Union for the last 20 years. With the implementation of telemedicine in daily medical practice, performing screening programs became much more attainable. Remote assessment of retinal pictures simultaneously saves countries time, money, and other resources.

Incidence of Non-melanoma Eyelid Malignancies in Bulgaria (2000-2015).

PURPOSE: Malignant eyelid tumours are the most common malignancies in ophthalmic practice. We report here the incidence of non-melanoma eyelid malignancies in Bulgaria, for the period 2000-2015. METHODS: All cases coded with the International Classification of Diseases (ICD) code C 44.1, received from the Bulgarian National Cancer Registry, were used for estimating crude incidence rates by age and sex. In addition, directly age standardized incidence rates for non-melanoma eyelid malignancies are presented based on the European Standard population (year 2013) for Bulgaria and the region of Varna. RESULTS: Over the 16-year period there were 3,046 cases in total, of which 1,457 (47.8%) were among men. The age standardized rate (ASR) of non-melanoma eyelid malignancies in men was 2.9 per 100,000 (95% CI 2.79-3.11), in women it was 2.4 per 100,000 (95% CI 2.30-2.54), and the mean ASR was 2.6 per 100,000 (95% CI 2.53-2.73) for both sexes during the period. The ASR increased for women and for both sexes combined.The risk of eyelid malignancies was higher for men than for women with RR of 1.21 (95% CI 1.08-1.41) during the whole period. The risk was higher in women up to the age of 55 and over 55 years it was higher in men. CONCLUSION: We report results for the incidence of eyelid non-melanoma malignancies in a south-eastern European country, Bulgaria. They are comparable with earlier reports from other European countries.

Mapping the global evidence on nutrition transition: a scoping review protocol.

INTRODUCTION: Nutrition transition has emerged as an important concept in health research used to describe shifts in dietary consumption and energy expenditure that coincide with economic, demographic and epidemiological changes at a population level. Better understanding of the shifts in dietary patterns across populations and their drivers could possibly hold the key to prevention of diet-related disease risk. An increasing number of studies have reported on nutrition transition in populations around the world, however, global evidence has not been summarised. OBJECTIVE: This scoping review is aimed to identify, explore and map the literature on nutrition transition with a specific focus on dietary changes in populations across the world. The review would allow better clarification around the concept of nutrition transition, classification of published studies and provide a framework for further research. METHODS AND ANALYSIS: The scoping review will be designed based on the methodology by Arksey and O'Malley, refined by Levac et al. and developed in conjunction with guidance on conducting systematic scoping reviews by Peters et al. The main research question addressed by the scoping review will be: 'What is the evidence on nutrition transition defined based on dietary changes reported in general adult population across the world?' Electronic databases (PubMed, ScienceDirect and Web of Science), grey literature sources and the reference lists of key studies will be searched to identify studies appropriate for inclusion in the review. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Data will be abstracted into tables and logically organised according to items addressed in the specific research questions. ETHICS AND DISSEMINATION: Dissemination of results will be sought through a peer-reviewed publication, conference presentations and stakeholder meetings. The data used are from publicly available secondary sources, so no ethical review would be required for this study.

Developing and Translating a New Model for Teaching Empowerment Into Routine Chronic Care Management: An International Patient-Centered Project.

BACKGROUND: Health professional education has been criticized for not integrating patient expertise into professional curricula to develop professional skills in patient empowerment. OBJECTIVE: To develop and translate a new expert patient-centered model for teaching empowerment into professional education about routine chronic care management. METHODS: Eight Finnish patients (known as expert patients), 31 students, and 11 lecturers from 4 European countries participated in a new pilot intensive educational module. Thirteen focus groups, artefacts, and an online student evaluation were analyzed using a thematic analysis and triangulated using a meta-matrix. RESULTS: A patient-centered pedagogical model is presented, which describes 3 phases of empowerment: (1) preliminary work, (2) the elements of empowerment, and (3) the expected outcomes. These 3 phases were bound by 2 cross-cutting themes "time" and "enabling resources." CONCLUSION: Patient expertise was embedded into the new module curriculum. Using an example of care planning, and Pentland and Feldman's theory of routine organization, the results are translated into a patient-centered educational model for teaching empowerment to health profession students.

Public understanding of the causes of high stroke risk in northeast Bulgaria.

BACKGROUND: Knowledge of stroke risk factors is undocumented in Bulgaria. METHODS: 188 subjects in 2000 and 447 in 2003 were asked: 'Why do you think stroke is so common in this region?' RESULTS: Stress and poverty accounted for 69% of the first mentions in 2000 and 59% in 2003. There were no mentions of high blood pressure and no first mentions of smoking in 2000. High blood pressure appears only 10 times and smoking 12 times among 745 answers in 2003. CONCLUSION: Health education on the established causes of stroke is an urgent priority in Bulgaria.