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Alerji Pratiğinde Görülen Angioödemler
Abstract
Giriş: Anjiyoödem, sıvının interstisyel dokulara ekstravazasyonundan kaynaklanan, kendi kendini sınırlayan,
lokalize deri altı (veya submukozal) şişliktir. Anjiyoödem tek başına, ürtikerin eşlik ettiği ve anaflaksinin bir
bileşeni olarak ortaya çıkabilir. Anjioödem tipik olarak yüz, dudaklar, ağız, boğaz, larinks, uvula, ekstremiteler
ve genital bölge gibi gevşek bağ dokusu olan alanları etkiler. Anjiyoödem klinik olarak aşağıdaki özelliklerle
diğer ödem türlerinden ayırt edilebilir: Dakikalar ile saatler arasında başlar ve saatler ile birkaç gün içinde
kendiliğinden iyileşir. Asimetrik dağılım gösterir. Bazı anjiyoödem formlarına ürtiker ve diğer alerjik reaksiyon
veya anafilaksi belirti ve bulguları eşlik eder.
Amaç: Bu çalışmada biz günlük alerji pratiğinde sık rastlanan ve bazen de hayati tehtit edebilecek anafilaksi gibi
alerjik reaksiyonlara neden olan anjioödeme dikkat çekmeyi ve en sık sebep olan sık rastlanan alerjik durumları
sunmayı amaçladık.
Bulgular: 05.01.2015 ve 31.03.2015 tarihleri arasında Sağlık Bilimleri Üniversitesi Bursa Yüksek İhtisas Eğitim ve
Araştırma Hastanesi Alerji ve Klinik İmmunoloji polikliniğine müracaat eden ve 3506 hasta geriye dönük olarak
tarandı. Şikayetlerinde anjioödem tarifleyen 91 hasta belirlendi. Hastaların yaş ortalaması 43,9 idi. Hastaların
%34’ü (n=31) erkek, %66’sı (n=66) kadın idi. Hastaların 3’ünde anjioödeme hipertansiyon eşlik etmekteydi. 37
hastanın anjioödem yanında ürtikeri de mevcut idi. 2 hastamızda ek olarak ters gıda reaksiyonu vardı. 27
hastamızda sorumlu NSAİİ alerjisi idi. 1 hastada anjioödem nedeni polenlere bağlı mevsimsel alerjik rinit idi. 7
hastada allerjik astım ve anjioödem birlikteliği mevcuttu. 1 hastada alerjik rinit ürtiker anjioödem birlikte idi. 6
hastada anjioödemin sebebi antibiyotik alerjisi idi (Şekil 1).
Sonuç: Günlük poliklinik pratiğinde sık kullanılan antibiyotikler, NSAİİ ve sık rastlanılan astım, alerjik rinit,
ürtiker gibi alerjik hastalıkların anjioödeme neden olabileceği ve hatta anafilaktik şok gibi ölümcül sonuçlara
yol açabileceği her hekimin bilincinde olması gereken durumlardır.
Anahtar Kelimeler: Alerji, Anjioödem, Anafilaksi
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Background:
Little data exist regarding the practice of sodium management in acute neurologically injured patients. This study describes the practice variations, thresholds for treatment, and effectiveness of treatment in this population.
Methods:
This retrospective, multicenter, observational study identified 400 ICU patients, from 17 centers, admitted for ≥48 h with subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), intraparenchymal hemorrhage, or intracranial tumors between January 1, 2011 and July 31, 2012. Data collection included demographics, APACHE II, Glascow Coma Score (GCS), serum sodium (Na+), fluid rate and tonicity, use of sodium-altering therapies, intensive care unit (ICU) and hospital length of stay, and modified Rankin score upon discharge. Data were collected for the first 21 days of ICU admission or ICU discharge, whichever came first. Sodium trigger for treatment defined as the Na+ value prior to treatment with response defined as an increase of ≥4 mEq/L at 24 h.
Results:
Sodium-altering therapy was initiated in 34 % (137/400) of patients with 23 % (32/137) having Na(+) >135 mEq/L at time of treatment initiation. The most common indications for treatment were declining serum Na(+) (68/116, 59 %) and cerebral edema with mental status changes (21/116, 18 %). Median Na(+) treatment trigger was 133 mEq/L (IQR 129-139) with no difference between diagnoses. Incidence and treatment of hyponatremia was more common in SAH and TBI [SAH (49/106, 46 %), TBI (39/97, 40 %), ICH (27/102, 26 %), tumor (22/95, 23 %); p = 0.001]. The most common initial treatment was hypertonic saline (85/137, 62 %), followed by oral sodium chloride tablets (42/137, 31 %) and fluid restriction (15/137, 11 %). Among treated patients, 60 % had a response at 24 h. Treated patients had lower admission GCS (12 vs. 14, p = 0.02) and higher APACHE II scores (12 vs. 10, p = 0.001). There was no statistically significant difference in outcome when comparing treated and untreated patients.
Conclusion:
Sodium-altering therapy is commonly employed among neurologically injured patients. Hypertonic saline infusions were used first line in more than half of treated patients with the majority having a positive response at 24 h. Further studies are needed to evaluate the impact of various treatments on patient outcomes.
Background and Objectives: SGLT2 inhibitors are a new glucose-lowering therapy for type 2 diabetes. There are no recommendations for their use for patients fasting for Ramadan. Methods: We surveyed physicians regarding management of people with type 2 diabetes on SGLT2 inhibitors intending to fast for Ramadan. Results: Most of the responding 197 physicians had substantial experience with patients who fast for Ramadan, with 18.6% having 25-50% such patients, 18.2% having 50-75% and 23.6% having >75%. Most physicians were fully confident (49.4%) or fairly confident (34.4%) about diabetes management during Ramadan. Risks of hypoglycaemia (98.1%) and dehydration (83.1%) were identified more often than hyperglycaemias (67.5%), diabetic ketoacidosis (63.8%) and thromboembolic disease (45.2%). The majority felt that SGLT2 inhibitors were generally appropriate and safe during Ramadan but should be discontinued in selected patients (70.6%). Most respondents (92.2%) would advise taking an SGLT2 inhibitor with the first evening meal (Iftar), but 6.1% advised taking them before the last pre-dawn meal (Suhour). Taking extra clear fluids in the evening of Ramadan was recommended by the majority. Conclusions: This survey will help to inform interpretation of future studies towards the development of clinical guidelines for SGLT2 inhibitor use during Ramadan. The majority of physicians believe that SGLT2 inhibitors are generally safe for patients with diabetes who intend to observe Ramadan fasting, but should be discontinued for selected patients. We provide practical advice for physicians in this setting.
Background: During Ramadan, Muslims fast for prolonged periods, which might predispose patients with diabetes to an increased risk of hypoglycemia. Liraglutide is an incretin that has been associated with reduced risk of hypoglycemia. Objective: We aimed to assess the safety and efficacy of liraglutide as an add-on therapy to existing anti-diabetic agents during Ramadan. Patients and methods: Arab patients prescribed liraglutide within the 6 weeks before Ramadan 2014 were recruited to the study. Demographic information and HbA1c levels were recorded at baseline and again within 4 weeks after Ramadan. A telephone call was made to check the frequencies of hypoglycemia during Ramadan. Results: Of the total of 111 participants, 76 (68.5%) of the participants were female. The mean age was 52.6 ± 10.1. Seventy-seven percent of the patients were aged between 40-60 years. Eighteen patients (16.2%) developed hypoglycemia during Ramadan. None of them required assistance by medical personnel or were admitted to the accident and emergency department. One hundred and five (94.6%) of the participants were on insulin, sulfonylurea or both. Patients who had had diabetes for a longer time had significantly higher frequencies of hypoglycemia during Ramadan (p=0.05). Conclusion: Adding liraglutide to ongoing anti-diabetic agents did not increase the risk of hypoglycemia.Furthermore, hypoglycemic events were directly related to the duration of diabetes; the longer the duration of diabetes, the more hypoglycemic events the patient had.
Heart failure (HF) complicating myocardial infarction (MI) is common and may be present at admission or develop during the hospitalization. Among patients with MI, there is a strong relationship between degree of HF and mortality. The optimal management of the patient with HF complicating MI varies according to time since the onset of infarction. Medical therapy for HF after MI includes early (within 24 h) initiation of angiotensin-converting enzyme inhibitors and early (within 7 days) use of aldosterone antagonists. Alternatively, in patients with MI and ongoing HF, early use (<24 h) of beta-blockers is associated with an increased risk of cardiogenic shock and death. Long-term beta-blocker use after MI is associated with a reduced risk of reinfarction and death. Thus, it is critical to frequently re-evaluate beta-blocker eligibility among patients after MI with HF. Cardiogenic shock is an extreme presentation of HF after MI and is a leading cause of death in the MI setting. The only therapy proven to reduce mortality for patients with cardiogenic shock is early revascularization. Several studies are examining new approaches to mitigate the occurrence and adverse impact of post-MI HF. These studies are testing drugs for HF and diabetes and are evaluating mechanical support devices to bridge patients to recovery or transplantation.
Hyponatremia is a common water balance disorder that often poses a diagnostic or therapeutic challenge. Therefore, guidelines were developed by professional organizations, one from within the United States (2013) and one from within Europe (2014). This review discusses the diagnosis and treatment of hyponatremia, comparing the two guidelines and highlighting recent developments. Diagnostically, the initial step is to differentiate hypotonic from nonhypotonic hyponatremia. Hypotonic hyponatremia is further differentiated on the basis of urine osmolality, urine sodium level, and volume status. Recently identified parameters, including fractional uric acid excretion and plasma copeptin concentration, may further improve the diagnostic approach. The treatment for hyponatremia is chosen on the basis of duration and symptoms. For acute or severely symptomatic hyponatremia, both guidelines adopted the approach of giving a bolus of hypertonic saline. Although fluid restriction remains the first-line treatment for most forms of chronic hyponatremia, therapy to increase renal free water excretion is often necessary. Vasopressin receptor antagonists, urea, and loop diuretics serve this purpose, but received different recommendations in the two guidelines. Such discrepancies may relate to different interpretations of the limited evidence or differences in guideline methodology. Nevertheless, the development of guidelines has been important in advancing this evolving field.
Background:
beta-Blockade-induced benefit in heart failure (HF) could be related to baseline heart rate and treatment-induced heart rate reduction, but no such relationships have been demonstrated.
Methods and results:
In CIBIS II, we studied the relationships between baseline heart rate (BHR), heart rate changes at 2 months (HRC), nature of cardiac rhythm (sinus rhythm or atrial fibrillation), and outcomes (mortality and hospitalization for HF). Multivariate analysis of CIBIS II showed that in addition to beta-blocker treatment, BHR and HRC were both significantly related to survival and hospitalization for worsening HF, the lowest BHR and the greatest HRC being associated with best survival and reduction of hospital admissions. No interaction between the 3 variables was observed, meaning that on one hand, HRC-related improvement in survival was similar at all levels of BHR, and on the other hand, bisoprolol-induced benefit over placebo for survival was observed to a similar extent at any level of both BHR and HRC. Bisoprolol reduced mortality in patients with sinus rhythm (relative risk 0.58, P:<0.001) but not in patients with atrial fibrillation (relative risk 1.16, P:=NS). A similar result was observed for cardiovascular mortality and hospitalization for HF worsening.
Conclusions:
BHR and HRC are significantly related to prognosis in heart failure. beta-Blockade with bisoprolol further improves survival at any level of BHR and HRC and to a similar extent. The benefit of bisoprolol is questionable, however, in patients with atrial fibrillation.