S. Danev (Sofia, Bulgaria)

HISTORICAL PREREQUISITES

Most Western people are skeptical about the Balkans: they consider them a burning pot of unrest, poverty and conflict. Only few know that this region is the true birthplace of world civilization.

Recent DNA studies show that the prehistoric HOMO SAPIENS SAPIENS appeared in EAST AFRICA some 200 000 years ago. His grandchildren crossed the Red Sea and divided into three branches:

•  by 60 000 BC the WESTERN branch settled into the BALKANS and Southern Europe; its hallmark is a M-I68 mutation of the female X-chromosome;

•  by 50 000 BC the EASTERN branch crossed South Asia and a part of it settled in Australia; its hallmark is the M-9 mutation of the same chromosome;

•  by 40 000 BC the NORTHERN branch migrated to the Himalayas, China and Siberia; around 15 000 BC a part of it crossed the Behring strait to settle in North and South America, being marked by an M-3 mutation.

During the following centuries the Balkans became a crossroad of the various populations originating from these three branches. This resulted in an exceptional GENETIC, ETHNIC and PATHOLOGICAL HETEROGENEITY. After hosting 7 000 years BC the oldest world civilizations, such as Catal Hayuk (Anatolia) and the Varna Necropolis, the Balkans became the seat of the civilizations of Greece, Persia, Rome, Southern Asia, the Slavs, Protobulgarians, Celts, the Thracian states Illyria (present Albania), Dakia (present Romania), Misia and Skythia (parts of present Bulgaria, Serbia and Macedonia), the Ottomans, the crusaders, etc.

The marriage of these civilizations was encouraged by Alexander the Great, who gave birth to the silk road, Alexandria and to medical teachers like Hippocrates,

whose pupils included Demian and Cosma, Ibn Sina, etc. New data show that Demian and Cosma introduced the Mediterranean diet and lifestyle, that were lifesaving for patients like the Roman emperor Carin, who converted to Christianity after being cured, to the dismay of his generals who stabbed him and ordered his quack doctors to stone to death the two saint brothers.

About 900 AD Kliment and Naum (favorite pupils of Kyrill and Methodii) founded in Ohrid one of the oldest teaching schools. Their writings and the SHESTODNEV Textbook by Ioan Exarch enhanced the teaching of medicine in the monasteries of STUDENITZA (Serbia), HILENDAR and ZOGRAPH (Mount Athos – Khalkidhiki), RILA and BATCHKOVO (Bulgaria). During the Ottoman occupation the latter sheltered monks and healers from the Balkan countries and Russia, who organized there teaching centers and hospitals. The Serbian Hilendar

Monastery edited in the 16th century the famous MEDICAL CODEX with excellent chapters on the DIAGNOSTIC EXAMINATION OF URINE.

The history of European clinical chemistry is closely linked with the studies of Sir Robert Boyle, who already in 1684 anticipated the concept of REFERENCE VALUES.

Another pioneer of laboratory medicine – Sir Robert Hooke – devised in 1665 a high resolution microscope; without a laser, he made observations and drawings anticipating multiarray testing by CONFOCAL MICROSCOPY: he found that each facette of a fly's eye reflected the window panes of his laboratory!

The discoveries of the GARROD family were also remarkable: in 1850 Sir Alfred Garrod applied a gravimetric test for assaying blood uric acid as the hallmark of gout. In 1908 his son Archibald postulated the concept of “INBORN ERRORS OF METABOLISM” for alkaptonuria and 3 other rare genetic diseases. Today this concept is gaining a growing acceptance in McKusick's CATALOGUE, whose latest edition contains about 17 000 entries, including about 50 new genetic diseases and mutations prevailing in the Balkan region!

We should not skip the fantastic “workshop for biochemists”, founded by JUSTUS von LIEBIG, in Giessen (Germany), about 1850, who trained numerous future scientists, like Henry Bence Jones, who discovered the uroprotein bearing his name and coined the term CHEMICAL PATHOLOGY, and several Nobel Laureates (Otto Warburg, Emil Fischer, Heinrich Wieland, Hans Krebs, etc.).

During the last century clinical laboratory medicine progressed rapidly in most countries, including ours. By 1950–1960 the first clinical laboratory departments and national societies were founded in Bulgaria and Yugoslavia , followed by the remaining countries. The dramatic political and economic change on during the early nineties necessitated rapid reforms towards modern

European standards. To this purpose Sofia hosted in 1992 the FIRST IFCC COURSE FOR LABORATORY MANAGEMENT conducted by the British experts Prof. Peter Broughton (former IFCC secretary) and Prof. Harry Pandov (born in Sofia), who trained about 100 specialists from Albania, Bulgaria, Greece and Turkey on various GLP topics (AUTOMATION, QUALITY ASSURANCE, COST

POLICY, SAFETY, ACCREDITATION, etc. The successful two-week start in Sofia was followed by a cascade of courses in Plovdiv, Varna, Pleven and again Sofia.

The FINAL ASSESSMENT of the course was very positive owing to its relevant topics, top lecturers and excellent teamwork of a benevolent group of translators, hosts and tourist guides (Prof. Shipkov, S. Danev, N. Atanassov, T. Tzvetkova, etc.) aided by leading experts from Bulgaria (professors K. Tzatchev, D. Svinarov, A. Tzontcheva, E. Tzvetanova, etc.) and the other Balkan countries.

The climbing of SNEZANKA PEAK in the Rhodope resort PAMPOROVO was followed by vivid final discussions among all attendants and teachers in Sofia that gave rise to three crucial initiatives:

•  two-month training in Quality Assurance in Birmingham of Prof. Tzachev (Bulgaria) and Prof. Julien (Greece). On returning home, they established the national systems of Quality Assurance in Sofia and Athens .

•  Involvement of Yugoslavia, North Macedonia and Romania in support of the future Balkan Clinical Laboratory Federation (BCLF)

•  Inauguration of the BCLF.

In 1992 the Eighth Meeting of Yugoslav Clinical Biochemists chaired by Prof. Majkić-Singh and attended by representatives from Romania (Prof. Cojouharu) and Bulgaria (professors S. Danev, T. Shipkov and K. Tzatchev) gave full support to the founding of BCLP.

During the first National Meeting of the North Macedonian Clinical Biochemists in Ohrid in 1993, the same idea was instigated by professors Gruev, Hrisoho, Dzhekova, Traikovska, Dimitrov, etc.

In May 1993 Sofia hosted the First Inaugural BCLF Meeting, attended by 120 delegates from seven Balkan countries that adopted the SIX “COMMANDMENTS” of the BCLF Bylaws. In the ensuing years the “Yugoslav Journal of Clinical Biochemistry”, “ECLM” and “Clinical Chemistry” gave wide access to BCLF publications.

The FIRST BCLF MANDATE, hosted 1993–1996 in Bulgaria (president S. Danev, secretary K. Tzatchev), with its three meetings in Sofia, Istanbul and Struga witnessed a steady increase in the number of attendants from 120 to 390.

This early period enhanced the INTEGRATION OF into IFCC, which had a most successful start during the IFCC Meeting in Leipzig 1995, when Albania, Greece and North Macedonia became regular IFCC members, followed in 1996 by Turkey and Romania . We owe this great victory to the efforts of Prof. Gerard Siest and his IFCC board.

The Leipzig event was a grand day for BCLF and especially for its Yugoslav and Bulgarian members. It opened the doors to further initiatives of eurointegration:

- in 1996 BCLF became Associate Member of IFCC, EFCC and ECLM.

• In 1994–1996 the TEMPUS PROJECT on TEACHING AND TRAINING IN MOLECULAR BIOLOGY, coordinated by Bulgaria jointly with Belgium and Germany, involving 106 participants from Bulgaria, North Macedonia and Greece, bore rich fruits: establishment of three new laboratories in Sofia and Plovdiv, 18 joint projects, 25 fellowships. The project had a strong impact on molecular diagnosis of thalassemia, Balkan nephropathy, a set of new neuropathies met solely in our region, several myopathies, new mucoviscidosis haplotypes, and to meetings and teaching courses with about 50 lectures, etc.

•  TWINNING of Bulgaria with UK enhanced the study of iron deficiency and the profiling of urinary steroids, whereas twinning with INSTAND in Düsseldorf (Germany) boosted Quality Assurance and Accreditation.

Special tribute should be given to the companies sponsoring the trips of BCLF members to numerous sites, that helped to consolidate BCLF members, to establish new links of friendship by overcoming existing social and geographic differences.

FURTHER PROGRESS OF BCLF

During the SECOND BCLF MANDATE from 1996 to 1998, hosted by Greece (president Prof. O. Tsolas, secretary prof. K. Sepheriadis), the meetings in Budva (1996), Ioannina (1997) and Plovdiv (1998) witnessed further initiatives:

•  provision by Prof. Miras of PRIZES encouraging outstanding presentations from young scientists.

•  Satellite meetings on Free Radicals (Ioannina 1997) and Drug Monitoring (Plovdiv 1998) with top lectures by German, American, Canadian and Israeli experts.

•  Quality Assurance IFCC lectures by Prof. Reinauer, followed by fellowships in INSTAND – Düsseldorf.

During these meetings we enjoyed the marvels of BUDVA with its fantastic island ST. STEFAN, beloved by Claudia Schiffer and other eminent guests, as well as the hospitality of romantic Ioannina (highly esteemed by Lord Byron) and of Plovdiv with its 4 000 years of history.

New HI-TECH methods marking the start of “OMICS” were introduced:

•  DNA methods developed by Efremov (Skopje), Kremenski (Sofia) and Sepheriadis and Tsolas (Ioannina) boosted GENOMICS.

•  NMR methods developed by Bairaktari (Ioannina) and HPLC/MS by Svinarov and Kremenski (Sofia) boosted METABOLOMICS.

•  ETAAS of trace elements by Tzatchev (Sofia) and young scientists from Greece boosted METALLONOMICS.

•  Flow cytometry in hematology by Tzvetkova (Plovdiv), and capillary electrophoresis developed by Tzvetanova jointly with a CEEPUS team boosted cytomics and PROTEOMICS.

The THIRD BCLF MANDATE between 1999 and 2001 (president prof. T. Ozben) was marked by fruitful meetings in Antalya (1999), Sinaya (2000) and Ioannina (2001), whose hallmark was intensive TWINNING:

ACUTE CORONARY SYNDROME AND STROKE (Turkey – Greece – Yugoslavia);

RENAL PATHOLOGY (T. Gruev, North Macedonia → W. Guder, Germany);

TDM (D. Svinarov, Bulgaria → M. Oellerich, M. Shipkova, Germany) boosting pharmacogenetic and pharmacogenomic studies;

IRON DEFICIENCY ANEMIA (K. Tzatchev, B. Atanassova, Bulgaria → Peters, UK) gave rise to several fellowships and a PhD thesis.

LABORATORY MANAGEMENT and Accreditation (Albania → IFCC → Italy), coordinated by Prof. Mocarelly had a high impact on the rapid development of clinical laboratory medicine in Albania.

A new LABORATORY FOUNDATION between Germany (professors D. Seidel, M. Oellerich, E. Wieland, etc.) and Bulgaria (professors S. Danev, D. Svinarov, K. Tzatchev etc.) is boosting Hi-Tech methods.

In recognition for their scientific contributions, the Bulgarian National Academy, chaired by the late Prof. Tch. Natchev, awarded the title “Dr. Honoris Causa” to professors D. Seidel (Munich), M. Oellerich (Göttingen), Wolfson (Columbus, Ohio), and Efremov (Skopje).

We owe much to the IFCC presidents Prof. G. Siest, Prof. M. McQueen and Prof. M. Müller and to the EFCC presidents Prof. Palicka and Prof. Blaton, whose initiatives enhanced the further progress of BCLF.

The FOURTH BCLF MANDATE in North Macedonia 2002–2004 (president Prof. T. Gruev, secretary S. Traikovska) with its meetings in Ohrid (2002), Constanza (2003) and Belgrade (2004) boosted NOVEL MARKERS of stroke and hypertension (ADMA), ACS (CRP, troponins, adhesive and growth factors, BNP), osteoporosis, oxidative stress, nephropathology (nephrotoxins, cytokines), cancer (BRCA–1 and BRCA–2) etc. Prof. Gruev, whom i here since 1979, helped to integrate BCLF into EFCC, CEEPUS and the ALPO–ADRIA FOUNDATION.

The FIFTH BCLF MANDATE in Serbia (president Prof. Majkić-Singh, secretary S. Stanković)

had in 2005 a promising start at the Meeting in Tirana, where the hospitality and good organization by A. Bulo and her team were highly appreciated. The next Meeting in Sofia , in late September 2006, chaired by Pprof. Tzatchev, was a great success with its 480 participants from 19 countries! The meetings were supplemented each other by covering the crucial problems of total quality management, postgenomic aspects of atherosclerosis, stroke and cancer, drug resistant tuberculosis, and cancer multiarray testing, masspectrometry in pharmacogenetics, incretins in Diabetes, DNA mismatch repair in colonic cancer, etc.

These topics converge in many respects with the logo of PERSONALIZED MEDICINE formulated already in 1956 by ROGER WILLIAMS and reintroduced at the SANTORINI MEETING near the end of September 2006. Perhaps it is not by mere chance that the ideas of personalized medicine were given a simultaneous restart in two Balkan sites – the biblical Greek Santorini island and age-old Sofia. This opened the doors to unraveling the enigmas of genetic and epigenetic BIODIVERSITY, including the geographic and environmental bases of biochemical individuality and its pathological defects, especially in the Balkan region.

The personality of Prof. Majkić-Singh is an additional strong argument in favour of the further progress of BCLP. I have always admired her energy, devotion, competence and warm hospitality. It was she who urged me to shoot the wooden cannon in Belgrade and who made me learn the INDIVIDUAL DIFFERENCES between the Bulgarian and Serbian HORO dance.

SOME FUTURE TRENDS

The following 15th BCLF Meeting in Antalya, 2007, will surely reinforce the trends towards total quality management of most tests, personalized medicine by proteomic, pharmacogenetic and pharmacogenomic methods and the further search for “Balkan diseases''.

It is very difficult to predict the evolution of BCLF in the next decades. In all probability, it will develop under the logo of GLOBAL QUALITY MANAGEMENT (QM) with three main aspects:

I. ANALYTICAL QM involving three IN VITRO steps: PREANALYTICAL (robotics) → ANALYTIC (automation) → POSTANALYTIC (data processing and LIS). This will later lead to the validation of all tests including the “OMIC'' ones.

II. CELL QUALITY MANAGEMENT will proceed somewhat later, in three IN VIVO steps: DNA (repair, p35 control, etc.) → RNA (with emphasis on the RNA interference phenomena) → PROTEIN (with emphasis on the chaperones, as chief controllers of nascent peptides, their trafficking, folding, glycation, refolding and disposal).

III. QUALITY OF LIFE MANAGEMENT will involve: ENVIRONMENTAL QM (especially the global pollution and warming problems, that may transform the Balkans into a subtropic area, menacing with the reappearance of malaria, dengue and CHIKUNGUNYA disease) → QM of THERAPY AND PREVENTION (personalized strategies of lifestyle, dietary and drug treatment incl. TDM, ensuing into A BOOM of VACCINES and CELLULAR, PROTEIN AND GENETIC ENGINEERING METHODS).

The ultimate result of GLOBAL QM will be enhancement in the battle against cancer, severe infections (including HIV), arteriosclerosis, obesity, diabetes, Alzheimer and Parkinson disease, numerous genetic defects and the “BALKAN DISEASES''.

The battle against senescence aiming at LONGEVITY is of special importance for the Balkan region, as certain villages in Greece , Bulgaria , Turkey and Serbia were renowned for being populated with centagenerians. Hopefully, they will reappear in a better form, as this WATERSKIER, aged 100!

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