Anna Todorova

As pharmacy curricula expand to integrate clinical content alongside the basic pharmaceutical sciences, the demands placed on students grow accordingly. Satisfaction with education and perceived academic workload are the constructs most often used to gauge the consequences, but are usually studied separately. This review brings them together. Articles identified in PubMed/PMC and ScienceDirect were selected based on whether they addressed three key questions: what predicts satisfaction within pharmacy education; what the sources and effects of academic workload are; and how the two relate. Key themes identified include structural determinants of satisfaction over content volume; the divergence between objective workload volume and subjective experience; psychological need satisfaction as the primary driver of burnout; and the counterintuitive stress patterns in integrated pre-clinical versus clinical training. Satisfaction is generally high and depends more on the structures surrounding teaching than on content. Workload is a leading stressor, but the distinction that matters is between objective volume and subjective experience: test anxiety tracks the perception of course load rather than its size; workload and co-curricular variables expected to predict burnout have failed to do so, and perceived overload is associated with surface rather than deep approaches to learning. Psychological need satisfaction, not workload volume, predicts burnout. Evidence from integrated curricula then complicates the assumption that clinical content is what burdens students: pre-clinical students report higher stress than those on clinical rotations, and integrated programmes show no year-on-year escalation. For curriculum designers the implication is that how demands are distributed and framed matters more than how much content a programme carries.

Medication adherence is a critical determinant of treatment effectiveness; however, its measurement and integration into routine healthcare practice remain challenging in many healthcare systems. This study aimed to compare medication adherence measurement methods and examine the legal and regulatory frameworks governing adherence-related tools in North Macedonia, Romania, Serbia, and Bulgaria. A structured comparative, two-phase document review was conducted between January and April 2026. The first phase identified and compared medication adherence measurement methods reported in research and recognized within national healthcare systems. The second phase analyzed legislation, regulatory documents, and policy frameworks relevant to adherence-related tools, including digital technologies. Searches were performed in PubMed, Scopus, and Web of Science, together with official governmental, regulatory, and institutional websites. The final evidence base comprised 84 documents, including scientific publications, official legal and policy documents, and regulatory and institutional sources. Across North Macedonia, Romania, and Bulgaria, medication adherence monitoring was not systematically integrated into routine clinical practice, despite differences in digital health infrastructure and regulatory maturity. Traditional indirect methods, particularly prescription refill data and clinician assessment, were more consistently reported, whereas validated direct and digital adherence measurement approaches remained unevenly implemented. Regulatory frameworks differed substantially in scope, specificity, and formal recognition of adherence-related tools, reflecting varying levels of alignment with European digital health policies and contributing to fragmented implementation across healthcare systems. Although existing digital health infrastructure provides a foundation for systematic medication adherence monitoring, implementation remains fragmented because of limited interoperability, inconsistent regulatory support, and the absence of standardized national approaches. Strengthening regulatory guidance, harmonizing adherence measurement standards, integrating adherence indicators into routine healthcare information systems, and formally supporting pharmacist-led adherence services could support more consistent medication adherence monitoring and improve medication management across the healthcare systems of the four analyzed countries.

Regulation of medicinal products containing controlled substances varies considerably across Europe, despite a shared international and EU legal framework. A comparative normative analysis of national legislation in 10 European jurisdictions (nine EU Member States and the United Kingdom), structured around seven predefined criteria, ascertained four regulatory models: (1) Centralized–Procedural (France, Germany, Italy, and Greece); (2) Digitalized–Integrated (Belgium and Poland); (3) Harm-Reduction (Netherlands and Portugal); and (4) Institutional Accountability (United Kingdom and Ireland; Ireland shares features of Models 1 and 4). Substantial variation was observed in digitalization levels, document retention requirements (2–10 years), and destruction procedures. The findings highlight persistent regulatory fragmentation and underscore the need for minimum common standards for traceability and digitization while preserving national flexibility. The role of hospital pharmacists as a critical legal–clinical interface warrants explicit recognition in future harmonization efforts.

This study aims to assess medication adherence levels and identify the factors associated with it, among pregnant women in the city of Varna, Bulgaria. A pilot, observational, cross-sectional study was conducted among pregnant women at the Ambulatory Medical Centre for Specialised Care “Prof. Dr. Dimitar Stamatov”, Varna, Bulgaria. Medication adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). The study period was from 15 ^th July 2025 until 15 ^th October 2025. Overall, medication adherence was moderate, with a mean score of 5.92 (SD = 1.62), among the 50 pregnant women who participated in the study (mean age = 31.96; SD = 6.48). No significant associations were observed between adherence and age (r = 0.044, p = 0.760), educational level (t(48)= 0.445, p = 0.658), or trimester of pregnancy (t(48)= 0.901, p = 0.372). Adherence levels did not vary significantly across parity, although a slight, non-significant trend toward higher adherence was observed among multiparous women. Research on medication adherence during pregnancy is still limited, emphasizing the importance of further investigation to better understand adherence behaviours and their determinants in this vulnerable population.

Aim : This study aimed to evaluate pharmacists’ attitudes toward the medicines verification system and to identify key challenges associated with its implementation in routine pharmacy practice. Methods : A pilot cross-sectional study was conducted among 257 pharmacists practicing in community and hospital pharmacies in Bulgaria. Data were collected via an anonymous online questionnaire developed and administered through Google Forms. Descriptive and inferential statistical analyses were performed, including t -tests, ANOVA, Mann–Whitney U , Kruskal–Wallis tests, and Pearson correlation. Results : Most respondents reported a low frequency of technical (61.5%) and procedural (63.8%) alerts. However, attitudes toward the system were polarized, with similar proportions expressing positive (42.1%) and negative (43.1%) views. Verification frequency increased by 16.19 percentage points following a regulatory change related to the National Health Insurance Fund. Technical issues, particularly error resolution ( M = 3.74), were identified as the main barrier. Younger pharmacists and those with less professional experience demonstrated more positive attitudes ( p < 0.001), while pharmacy managers reported significantly more negative perceptions compared with staff pharmacists ( p = 0.025). Conclusion : Although the verification system is functionally integrated and regulatory compliance is high, its acceptance among pharmacists remains influenced by technical reliability, administrative burden, and professional characteristics. Targeted improvements in system performance and workflow integration are essential for enhancing long-term sustainability.

Expanding pharmacist roles in modern healthcare systems, together with the associated workload, creates a need to examine professional satisfaction and perceptions of overload. Professional well-being among pharmacists is shaped by a complex interaction of organizational, professional, and individual factors, providing a basis for investigating the relationships among job satisfaction, stress, perceived burnout, and health status. A direct anonymous survey was conducted using a semi-structured questionnaire among 127 Master of Pharmacy professionals in northeastern Bulgaria. Sociodemographic characteristics did not show a statistically significant effect. Positive correlations were found between satisfaction and remuneration ( ρ = 0.380), professional development ( ρ = 0.457), relationships with colleagues ( ρ = 0.393), and willingness to choose the profession again ( ρ = 0.410). Stress was associated with additional workload ( ρ = 0.352). A negative relationship was observed between satisfaction and perceived burnout ( ρ = -0.210), while a positive relationship was found between stress and perceived burnout ( ρ = 0.216). Physical activity was positively associated with health status ( ρ = 0.266). The results highlight the role of the organizational environment and psycho-emotional workload.

Introduction: Metformin exerts beneficial effects on glycaemic control by improving insulin sensitivity, which leads to inhibition of hepatic gluconeogenesis and glycogenolysis. Clinically, it is widely used in the management of type 2 diabetes mellitus and other insulin-resistant conditions. In recent years, its use during pregnancy has increased, particularly in improving maternal metabolic control. Aim: The aim of this article is to review and analyse current evidence on the efficacy, safety, and clinical applications of metformin use during pregnancy, focusing on maternal and neonatal outcomes, pharmacological considerations, and practical implications for clinical practice. Materials and Methods: A narrative review of the PubMed database was conducted using the following keywords: “metformin”, “pregnancy”, “gestational diabetes”, “type 2 diabetes”, “maternal outcomes”, “neonatal outcomes”, and “safety”. The initial search identified 175 articles. After screening titles and abstracts and application of the inclusion and exclusion criteria, 65 articles were included in the review. Results: In the context of pregnancy, metformin use has generated significant interest and debate. While traditional guidelines have favoured insulin for gestational diabetes mellitus (GDM), emerging evidence supports metformin as a viable alternative due to its efficacy, cost-effectiveness, and convenience. However, concerns persist regarding its transplacental passage, potential long-term effects on offspring, and variable efficacy across different patient profiles. Notably, randomised trials such as the Metformin in Gestational Diabetes (MiG), Metformin in Women with Type 2 Diabetes in Pregnancy (MiTY), and Metformin Plus Insulin for Preexisting Diabetes or Gestational Diabetes in Early Pregnancy (MOMPOD) studies and subsequent cohort follow-ups indicate that metformin can reduce maternal weight gain and neonatal complications without major safety concerns. Nonetheless, limitations include inconsistent glycaemic control in some patients and inconclusive data on long-term child development. Conclusion: Recent guidelines from the WHO, FDA, EMA, and NICE, along with the latest recommendations from leading diabetes associations and societies such as EASD, ADA, and ESE, reflect a cautiously evolving stance on metformin use during pregnancy, generally endorsing its use when insulin is unsuitable. While short-term safety appears acceptable, further longitudinal studies are needed to clarify its developmental impact on offspring. Overall, metformin remains a cornerstone in diabetes management with expanding potential, warranting nuanced consideration in pregnancy and beyond.

Introduction : The medicines verification system was introduced in the European Union to prevent the entry of falsified medicines into the legal supply chain. Bulgaria is an integral part of the European Medicines Verification System (EMVS), maintaining its national repository through the Bulgarian Medicines Verification Organization (BgMVO). Aim : To evaluate the effectiveness of the medicines verification system in Bulgaria by analyzing the degree of connectivity among end users and the frequency and structure of the generated alerts. Materials and methods : A documentary analysis was performed using official data from EMVO and BgMVO for 2024. The study focused on connectivity rates, the relative share of verified packs, and the distribution of alerts by type and origin. Results : By the end of 2024, 99.25% of the mandatory end-user locations in Bulgaria were integrated into the national system. The share of verified packs reached 85.26% in the last quarter of 2024, with an annual average of 82.33%. Generated alerts accounted for 0.062% of all scans, with 73.57% attributed to technical reasons and 26.43% attributed to procedural issues. Conclusion : Bulgaria demonstrates a high level of technical integration; however, a gap remains between connectivity and the actual frequency of verification and decommissioning. The alert structure shows a predominance of technical factors, suggesting a need for further optimization of software infrastructure and data management processes.

Digitalization and eHealth literacy are closely interconnected, as digital transformation in healthcare changes the way people access, understand, evaluate, and use online health information. In recent years, a validated instrument has been widely used to assess and measure these changes: the eHealth Literacy Scale (eHEALS). The aim of this study was to culturally and linguistically adapt the eHEALS questionnaire for use in the Bulgarian population. The study sample included 157 women (53%) and 140 men (47%). Most had completed higher education (68%), were employed (83%), and reported no chronic conditions (72%). The internal consistency of the Bulgarian version of the eHealth Literacy Scale (eHEALS) instrument was evaluated using Cronbach’s alpha. The 8-item version showed an alpha of 0.955, while the 10-item version achieved 0.938, demonstrating excellent reliability for both versions. In line with commonly accepted standards, alpha coefficients exceeding 0.90 indicate outstanding internal consistency, confirming that both scale formats are reliable tools for use in the Bulgarian population.

National legislative frameworks governing prescribing, pricing, reimbursement, and dispensing play a decisive role in shaping access to medicines. This study examines the financial availability of medicines in Bulgaria and North Macedonia through a comparative review of national pharmaceutical legislation, pricing mechanisms, reimbursement models, and digitalisation policies, assessed in relation to European Union standards. The findings indicate that access to medicines in both countries is shaped by the combined effects of multiple regulatory and financial instruments rather than by individual policy measures. Both systems apply strict control of prescribing and dispensing, external reference pricing, and positive reimbursement lists, reflecting alignment with international recommendations. However, significant differences in policy design lead to divergent access outcomes. Bulgaria’s more advanced digitalisation of prescribing and reimbursement, including mandatory electronic prescribing for selected therapeutic groups, enhances regulatory oversight and expenditure control but is associated with higher patient out-of-pocket expenditure, partly due to the application of the standard value-added tax on medicines. In contrast, North Macedonia combines lower taxation with capped patient co-payments, higher regulated pharmacy margins, and fixed pharmacy remuneration per prescription, contributing to improved financial affordability for patients while supporting pharmacy sustainability. Additional instruments, such as the Generics without Co-Payment List, further strengthen patient financial protection. The study provides comparative evidence relevant to pharmaceutical policy reforms and highlights the importance of balanced regulatory approaches that promote affordability, system sustainability, and equitable access to medicines.