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ISSN 2146-3069


Türk Toraks Derneği Adına Sahibi Dr. Sedat Altın Sorumlu Yazı İşleri Müdürü Dr. İbrahim Hikmet Fırat Bülten Yayın Kurulu (alfabetik sırayla) Dr. Aslı Görek Dilektaşlı, Dr. Hilal Altınöz, Dr. Osman Elbek, Dr. Ömer Araz Editörler Dr. Sedat Altın Türk Toraks Derneği Genel Başkanı Dr. Metin Akgün Türk Toraks Derneği Merkez Yönetim Kurulu Bülten ve İnternet Sorumlusu İmeceye Katkı Sunanlar (alfabetik sırayla) Dr. Abdullah Sayıner, Dr. Alev Gürgün, Dr. Ali Kılıçgün, Dr. Ali Kocabaş, Dr. Arzu Yorgancıoğlu, Dr. Aslı Görek Dilektaşlı, Dr. Burhan Söker, Dr. Deniz İnal İnce, Dr. Eda Uslu Tuğtepe, Dr. Elif Dağlı, Dr. Ender Levent, Dr. Esen Kıyan, Dr. Feyza Erkan, Dr. Göksel Kıter, Dr. Gül Dabak, Dr. Gülfer Okumuş, Dr. Gündeniz Altıay, Dr. Hilal Altınöz, Dr. Levent Elbeyli, Dr. Leyla Sağlam, Meagan Segal, Dr. Meltem Tor, Dr. Metin Akgün, Dr. Metin Görgüner, Dr. Münevver Erdinç, Dr. Muzaffer Metintaş, Dr. Oğuz Kılınç, Dr. Ömer Araz, Dr. Öner Dikensoy, Dr. Orhan Arseven, Dr. Oya İtil, Dr. Öznur Yıldız, Dr. Pınar Çelik, Dr. Salih Topçu, Dr. Sedat Altın, Serap Sarıtaşçı, Dr. Şule Akçay, Dr. Zeynep Aytemur.

Genel Başkan’dan Mektup

16. Kongre

Ön Kapak Fotoğrafı Meagan Segal AVES Kızılelma cad. 5/3 34096 Fındıkzade-İstanbul Tel: 0212 589 00 53 Fax: 0212 589 00 94 e-posta: info@avesyayincilik.com İletişim Adresi Türk Toraks Derneği Genel Merkezi Turan Güneş Bulvarı, Koyunlu Sitesi, No: 175/19 Oran-Ankara Tel: 0312 490 40 50 Fax: 0312 490 41 42 e-posta: toraks@toraks.org.tr web: www.toraks.org.tr

Hekime Şiddet

http://www.facebook.com/pages/Ankara/ Turk-Toraks-Derneği/168850906458728 http://www.twitter.com/#ToraksDernegi Yazılarınızı Bekliyoruz... Toraks Bülteni’nde yer almasını istediğiniz konuları, eleştirilerinizi, amatör çabalarınızı, sanatsal faaliyetlerinizi, yazı, şiir, resim ve çektiğiniz fotoğraflarınızı bize ileterek imeceye siz de katılabilirsiniz.

Akciğer Nakli


11. Genel Kurul’dan Notlar

15. Kongre’nin Ardından

Tütün Kontrolü

Türkiye’de Göğüs Hastalıkları Uzmanları


Editรถrโ€™den Mektup

Toraks Bรผlteni

Dr. Metin Akgรผn %ยOWHQYHยพQWHUQHW6RUXPOXVX DNJXQP#JPDLOFRP

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9


Toraks Bülteni

TÜRK TORAKS DERNEĞİ YENİ MERKEZ YÖNETİM KURULU (2012-2014) Genel Başkan Sedat Altın

1. Başkan Yardımcısı Feyza Erkan

2. Başkan Yardımcısı Arzu Yorgancıoğlu

Genel Sekreter Hikmet Fırat

Mali Sekreter Mustafa Demirel

Bilimsel Komite Başkanı Elif Dağlı

Okul Başkanı Oya İtil

Dış İlişkiler Sorumlusu Füsun Yıldız

Denetleme Kurulu Orhan Arseven Sadık Ardıç Ertürk Erdinç

Bülten ve İnternet Sorumlusu Metin Akgün

Etik Kurulu Ülkü Bayındır, Fuat Kalyoncu, Abdullah Sayıner, Zeki Kılıçaslan, Gül Öngen

Göğüs Cerrahi Temsilcisi Salih Topçu



Haziran 2012

Uzman Temsilcisi Eda Uslu Tuğtepe

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Genel Kurulโ€™dan Notlar

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Toraks Bรผlteni


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13


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14

Haziran 2012


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Toraks Bülteni 7RUDNV%OWHQL Akdeniz Şubesi

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Toraks Bülteni

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16

Haziran 2012


Yeni Uzman ve Asistan Komiteleri

Toraks Bรผlteni

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1 Mayıs’ta İstanbul: Erguvan Zamanı...

Fotoğraflar: Orhan Arseven


16. Kongre

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19


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Toraks Bรผlteni PDN ย]HUH WDP  NRQJUH\L Eย\ยN ELU EDรบDUร• LOH JHUoHNOHรบWLUPLรบWLU .RQJUHOHULQ KHU \|Qย LOH EX GHQOL QLWHOLNOL ROPDVร•Qร•Q QHGHQL NXรบNXVX]DUNDSODQGDEย\ยN|]YHULLOH\RรทXUXOPXรบ YH \DNODรบร•N ELU \ร•O VยUHQ \RรทXQ ELU HPHรทLQ ROPDVร•Gร•U <ร•OOร•N NRQJUHOHU RUJDQL]DV\RQ NRPLWHVLQLQ RUNHVWUD รบHIOLรทLQGH VDGHFH \|QHWLP NXUXOODUร• LOH GHรทLO oDOร•รบPD JUXSODUร•QGDQรบXEHOHUHX]PDQWHPVLOFLOLรทLQGHQ DVLVWDQ WHPVLOFLOLรทLQH NDGDU GHUQHรทLQ WยP ELULPOHUL LOH ELUOLNWH ย\HOHULQ VSRQVRUODUร•Q YH RUJDQL]DV\RQ ILUPDODUร•Qร•Q X\XPOX

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Haziran 2012

21


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TTD YAYINLANMIŞ KONGRE BİLDİRİSİ 2012: Birincilik Ödülü: Dr. Nur Dilek Bakan ve ark. İkincilik Ödülü: Dr. Sevim Bavbek ve ark. Üçüncülük Ödülü: Dr. Öner Dikensoy ve ark. TTD 2012 Actelion Pulmoner Vasküler Sistem Araştırma Ödülü: Dr. Nurdan Köktürk, Dr. Savaş Özsu

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17 Nisan 2012 ERSİN ASLAN’I KAYBETTİK...

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Toraks Bülteni


Toraks Bülteni

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ACI HABER: Sözün Bittiği Noktadayız Değerli Üyelerimiz, Gaziantep Avukat Cengiz Gökçek Devlet Hastanesi’nde görev yapan ve aynı zamanda Türk Toraks Derneği Çukurova Şube Üyesi olan Göğüs Cerrahisi Uzmanı Dr. Ersin Aslan, 17 Nisan 2012 günü ameliyattan çıktıktan sonra, on gün önce yaşamını yitiren bir hastasının 17 yaşındaki torunu tarafından bıçaklanarak saldırıya uğramıştır. Saldırı sonucu ağır yaralanan Aslan, ne yazık ki tüm çabalara rağmen kurtarılamamış ve yaşamını kaybetmiştir. Olay sonrası saldırgan yakalanmıştır. Sağlıkta Dönüşüm Programı ile birlikte hekime ve diğer sağlık çalışanlarına yönelik şiddet eylemlerinin arttığı artık hiç kimsenin reddedemediği bir hakikattir. Özellikle son beş yılda uygulanan politikalar sonucunda hekim emeğinin değersizleştirilmesi, popülist yaklaşımlarla hekimlerin ve sağlık çalışanlarının sağlıkta yaşanan aksamaların sorumluları olarak gösterilmesi ve bu çerçevede hekimlik mesleğini rencide edici yaklaşımların sergilenmesi artan şiddet olaylarının en önemli nedenleridir. Türk Toraks Derneği olarak üyemize yönelen şiddet eylemini kınıyor ve sürecin her aşamasında taraf olacağımızı kamuoyunun bilgisine sunuyoruz. Saygılarımızla. Türk Toraks Derneği Merkez Yönetim Kurulu

Değerli Türk Toraks Derneği Üyeleri,

Bugün Türk Toraks Derneği Üyesi, amacı sadece hastalarına daha iyi hizmet vermek olan Göğüs Cerrahisi Uzmanı Dr. Ersin Aslan’ı hunhar bir saldırı sonucu kaybettik. Evet, genç bir meslektaşımız, 4 aylık bir çocuk babası, hepimizin yüreğini sızlatan, arkasında acılı bir eş ve aile bırakan değerli bir insan, bu duygu yüklü cümleleri daha da uzatmak olanaklı. Bu saldırının son olmasını dilediğimizi veya genel geçer ifadeleri yazmamız inandırıcılığını ve etkisini çoktan yitirdi. Bundan daha fazlasını yapmamız gerekli. Özellikle Sayın Cumhurbaşkanı, Başbakan, Sağlık Bakanı ve Hükümet Üyeleri başta olmak üzere tüm ilgililere sesimizi duyurmak istiyoruz. Bu konuda bize acilen sahip çıkıldığını, bu olayın şiddetle kınandığını, gerekli önlemlerin alındığını ve halkımızın bilinçlendiğini göreceğimiz güne kadar tüm kamuoyunun dikkatini bu konunun üzerine çekecek, sesimizi duyurabileceğimiz ortak bir platformun acilen oluşturulması gerekmektedir. Hep beraber bu sefer hiç değilse bu konuda performansımız en üst seviyede olsun. Günlük uğraşılarımız bu büyük sorunun yanında önemsiz hale geliyor. Bunun aksine yaklaşım sergilemek yine münferit bir olay yanlış algısına yol açacaktır.

Saygılarımızla. Türk Toraks Derneği Sağlık Politikaları Çalışma Grubu YK

Haziran 2012

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Hekimlere solunum hastalÄąklarÄą alanÄąnda epidemiyolojik yaklaĹ&#x;ÄąmÄą tanÄątmak

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Solunum hastalÄąklarÄąnda temel epidemiyolojik ve klinik araĹ&#x;tÄąrmalarÄą yĂźrĂźtmek için gereken becerileri geliĹ&#x;tirmek

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Akademisyenler

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Bu kurslarla epidemiyoloji /klinik epidemiyolojiye ilgiyi arttÄąrmak, basit çalÄąĹ&#x;malarÄąn (Ă&#x2013;r: Arjantin Sigara AraĹ&#x;tÄąrmasÄą) gĂźcĂźnĂź gĂśstermek, insanlara soru sormalarÄą için araç olmak hedeflenmiĹ&#x;tir.

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Haziran 2012




ATSâ&#x20AC;&#x2122;den Notlar

Toraks BĂźlteni

Uyku apne kanser riskini artÄąrÄąyor

AÄ&#x;Äąr uyku apnesi olanlarda kansere baÄ&#x;lÄą ĂślĂźm riskinin arttÄąÄ&#x;ÄąnÄą ortaya koyan bir çalÄąĹ&#x;ma sunuldu (RR: 4,8, CI: 1,7-13,2, p<0,0052).

$EGXOODK6D\žQHU$OHY* UJ Q(VHQ.ž\DQ * OIHU2NXPXĂ&#x20AC;YH0HWLQ$NJ Qœ QNDWNžODUž\OD Kistik ďŹ broziste Ăśstrojenin prog-

Kanser taramasÄąnda dĂźĹ&#x;Ăźk doz BT

noza etkisi Ă&#x2013;strojenin kistik ďŹ brozisi olan kadÄąnlarda daha kĂśtĂź prognozla iliĹ&#x;kili olduÄ&#x;u ve bunun neden kistik ďŹ brozisli kadÄąnlarÄąn erkeklere gĂśre daha kĂśtĂź prognoza sahip olduklarÄąnÄą açĹklayabileceÄ&#x;i bildirildi.

Ă&#x2021;ocuk yaĹ&#x;ta sigara dumanÄąna maruz kalmanÄąn solunumsal etkileri BĂśyle bir iliĹ&#x;ki Ăśnceden dĂźĹ&#x;ĂźnĂźlmekteydi. Bu iliĹ&#x;kiyi ilk kez ortaya koyan çalÄąĹ&#x;ma sonuçlarÄąna gĂśre çocuk yaĹ&#x;ta sigara dumanÄąna maruz kalanlarda, yetiĹ&#x;kinlik dĂśneminde vizing (RR:1,9), persistan ĂśksĂźrĂźk (RR: 5,9) ve ßç aydan daha fazla sĂźren kronik ĂśksĂźrĂźk (RR: 2,3) semptomlarÄą daha fazla.

Statinlerin anti-inďŹ&#x201A;amauvar etkinliÄ&#x;i Statinlerin anti-inďŹ&#x201A;amatuvar etkilerine iliĹ&#x;kin çalÄąĹ&#x;malarÄąn verileri Ăśzetlendi. En az 2 yÄąl statin kullananlarda, tĂźm nedenlere baÄ&#x;lÄą mortalitenin %41 daha dĂźĹ&#x;Ăźk, akciÄ&#x;er sorununa baÄ&#x;lÄą mortalitenin %60 daha dĂźĹ&#x;Ăźk, kardiyovaskĂźler nedenli mortalitenin %45 daha dĂźĹ&#x;Ăźk bulunduÄ&#x;u; ayrÄąca mortalitenin

kateter ile talk plĂśrodezis Sigara içenlerde yÄąlda bir kez dĂźĹ&#x;Ăźk doz BT ile takip tartÄąĹ&#x;ÄąldÄą. ASCO ve ACCP ĂśncĂźlĂźÄ&#x;Ăźnde hazÄąrlanan rehberde (JAMA 2012), 55-74 yaĹ&#x; arasÄą, gĂźnde 30 paket/ yÄąlâ&#x20AC;&#x2122;dan fazla sigara içenlerde veya son 15 yÄąl içerisinde bÄąrakmÄąĹ&#x; olanlarda takip Ăśneriliyor. Ancak BT dozu, BT yorumlanmasÄą, vb. handikaplar nedeniyle, bu takibin sadece uzmanlaĹ&#x;mÄąĹ&#x; merkezlerde yapÄąlmasÄą gerektiÄ&#x;i vurgulandÄą.

BronĹ&#x;ektazide Ăśnleyici antibiyotik kullanÄąmÄą BronĹ&#x;ektazisi olan ve sÄąk alevlenme geçiren hastalarda Ăśnleyici antibiyotik tedavisi seçeneklerinin çok sÄąnÄąrlÄą olduÄ&#x;u; kistikďŹ broziste kullanÄąm için ruhsat almÄąĹ&#x; 8 inhale antibiyotik olmasÄąna karĹ&#x;Äąn, kistik ďŹ brozis dÄąĹ&#x;Äą bronĹ&#x;ektazilerde kullanÄąm için ruhsatlÄą ilaç bulunmadÄąÄ&#x;Äą bildirildi. Bu amaçla, gentamisin ampullerinnebĂźlizasyonla kullanÄąldÄąÄ&#x;Äąnda diÄ&#x;er inhale antibiyotiklere benzer etkinlik saÄ&#x;ladÄąÄ&#x;Äą belirtildi.

BronĹ&#x;ektazide tĂźberkĂźloz dÄąĹ&#x;Äą mikobakteri enfeksiyonlarÄą BronĹ&#x;ektazili hastalarda tĂźberkĂźloz dÄąĹ&#x;Äą mikobakteri enfeksiyonlarÄąna iliĹ&#x;kin A.B.D.â&#x20AC;&#x2122; de oluĹ&#x;turulan kayÄąt sisteminin verileri açĹklandÄą. Buna gĂśre: Erkek hastalarÄąn %61â&#x20AC;&#x2122;inde, kadÄąn hastalarÄąn %38â&#x20AC;&#x2122;inde izlem sĂźresi içinde en az bir kez tĂźberkĂźloz dÄąĹ&#x;Äą mikobakteri saptanmÄąĹ&#x;. BunlarÄąn %24â&#x20AC;&#x2122;Ăźnde hastalÄąk kriterleri saptanmÄąĹ&#x; (en az iki balgamda ya da bir BAL sÄąvÄąsÄą ĂśrneÄ&#x;inde Ăźreme ya da akciÄ&#x;er dokusunda patolojik kanÄąt), diÄ&#x;erleri kolonizasyon.

stabil dĂśnemde, hs-CRP dĂźzeyi> 3mg/L

HastalÄąk saptananlarÄąn bĂźyĂźk çoÄ&#x;unluÄ&#x;unda etken MAC, ikinci sÄąrada M. abscessus var.

olanlarda %77, <3mg/L olanlarda %24 daha dĂźĹ&#x;Ăźk olduÄ&#x;u gĂśzlendiÄ&#x;i bildirildi.

NTM enfeksiyonu sÄąklÄąÄ&#x;Äą giderek artÄąyor: Son 10 yÄąlda %8,2/yÄąl artÄąĹ&#x; gĂśzlenmiĹ&#x;. ArtÄąĹ&#x; kadÄąnlarda daha yĂźksek dĂźzeyde.



Haziran 2012

Malin plevral efĂźzyonda intraplevral

Bu konuda yapÄąlan ilk randomize kontrollĂź çalÄąĹ&#x;mada intraplevralkateter ile yapÄąlan talk plĂśrodezisindedispne kontrolĂźnĂźn daha iyi olduÄ&#x;u ve hastanede yatÄąĹ&#x; sĂźresinin kÄąsaldÄąÄ&#x;Äą vurgulandÄą.

KOAHâ&#x20AC;&#x2122;ta statin, ACE inhibitĂśrĂź veya anjiyotensin reseptĂśr blokeri kullanÄąmÄąnÄąn mortaliteye etkisi AÄ&#x;Äąr KOAHâ&#x20AC;&#x2122;lÄą uzun sĂźreli oksijen tedavisi alan 2249 hastada yapÄąlan retrospektif deÄ&#x;erlendirmede, mortalitenin, ACE inhibitĂśrĂź ya da anjiyotensin reseptĂśr blokeri kullananlarda %12, statin kullananlarda %14 daha dĂźĹ&#x;Ăźk, buna karĹ&#x;ÄąlÄąk, beta-bloker kullananlarda %14 daha yĂźksek olduÄ&#x;u belirtildi (ancak, oturumda, bu hastalarda eĹ&#x;lik eden kalp yetmezliÄ&#x;i ya da baĹ&#x;ka sorun olup olmadÄąÄ&#x;Äą belirtilmedi).

ECLIPSE çalÄąĹ&#x;masÄą: Sigara içimi ve KOAH ile biomarker iliĹ&#x;kisi ECLIPSE çalÄąĹ&#x;masÄąnÄąn havayolu yangÄąsÄąna iliĹ&#x;kin verileri açĹklandÄą. Ă&#x2021;alÄąĹ&#x;mada tĂźm hastalarda otuzdan fazla biomarker dĂźzeyleri ĂślçßlmĂźĹ&#x;. Sigara içmeyenlerin %77â&#x20AC;&#x2122;sinde tĂźm biomarkerâ&#x20AC;&#x2122;lar normal, %18 inde bir biomarker yĂźksek bulunmuĹ&#x;. Sigara içenlerin %42â&#x20AC;&#x2122;sinde tĂźm biomarkerâ&#x20AC;&#x2122;lar normal, %35â&#x20AC;&#x2122;inde bir, %16â&#x20AC;&#x2122;sÄąnda en az iki biomarkerâ&#x20AC;&#x2122;Äąn yĂźksek olduÄ&#x;u saptanmÄąĹ&#x;. KOAHâ&#x20AC;&#x2122;lÄą hastalarÄąn %30â&#x20AC;&#x2122;unda tĂźmĂź normal, %31â&#x20AC;&#x2122;inde bir, %19â&#x20AC;&#x2122;unda iki, %12â&#x20AC;&#x2122;sinde ßç, %6â&#x20AC;&#x2122;sÄąnda dĂśrt ya da daha fazla biomarker yĂźksek bulunmuĹ&#x;. SĂźrekli yangÄą bulgusu olan hastalarÄąn daha obez olduÄ&#x;u, daha sÄąklÄąkla aktif sigara kullandÄąÄ&#x;Äą, yaĹ&#x;am kalitelerinin belirgin olarak daha bozuk, FEV1 dĂźzeylerinin daha dĂźĹ&#x;Ăźk olduÄ&#x;u gĂśzlenmiĹ&#x;. BTâ&#x20AC;&#x2122; de amďŹ zem yaygÄąnlÄąÄ&#x;Äą diÄ&#x;er hastalarla aynÄą bulunmuĹ&#x;. Bu hastalarda mortalitenin (%13â&#x20AC;&#x2122;e %2) ve alevlenme sÄąklÄąÄ&#x;ÄąnÄąn daha yĂźksek (1,5/yÄąla karĹ&#x;Äąn 0,9/yÄąl) olduÄ&#x;u saptanmÄąĹ&#x;.


ATS’den Notlar

Toraks Bülteni Pnömokok tanısında üriner antijen

Soliter pulmoner nodülün malignite riski

Pnömokok için üriner antijen testinin pnömokoksikpnömonide tanı değerine ilişkin bir çalışmada, tanı konulan hastaların %40’ında tek tanı sağlayan yöntem olduğu, %8,6’sında tedavi değişikliğine yol açtığı gösterildi. Özellikle sağlık bakımı ile ilişkili pnömonide yararlı olabileceği; başlanan ampirik geniş spektrumlu tedavinin daraltılmasını sağlayabileceği savunuldu.

Soliter pulmoner nodüllere ilişkin ‘Mayo Clinic’ ve ‘Veterans Administration’ tarafından yapılan çalışmaların birleştirilmiş verileri aktarıldı. Malignite riskinin (OR), yaşın her yılı için 1,04, sigara öyküsü (aktif ya da bırakmış) varlığında 2,2-7,9, ekstratorasik kanser öyküsü varlığında 3,8, çaptaki her mm’likartış için 1,13, üst – orta zonlarda bulunması durumunda 2,2-3,3, spiküle kontur varlığında 2,8, ailede akciğer kanseri öyküsü varlığında 1,7 düzeyinde bulunduğu bildirildi.

Dispne nedenleri: 1) VENTİLASYONDA ARTIŞ: a. Pulmoner emboli, amfizem, egzersiz, CO2 değişiklikleri, metabolik asidoz, ağrı, anksiyete ve depresyon 2) MEKANİK CEVABIN BOZULMASI: a. KOAH, emboli, tümör basısı, obezite, torakotomi sonrası, AC fibozisi, konjesyon, nöromusküler hastalıklar, miyopati, elektrolit dengesizliği

Görüntüleme yöntemlerine bağlı radyasyon Görüntüleme yöntemlerine bağlı radyasyon maruziyetinin, standart toraksBT’de 4-6 mSv, düşük doz toraksBT’de 1-2 mSv, PA akciğer grafisinde 0,04 mSv düzeyinde olduğu, günlük yaşamdaki doğal radyasyon maruziyetinin ise 2,5-3,5 mSv/yıl düzeyinde olduğu anlatıldı.

Çapa göre değerlendirildiğinde, <5mm nodüllerde malignite riskinin %1, önceki BT’ de olmayan, yeni ortaya çıkmış <5mm nodüllerde %1,7-8,6, 5-10 mm nodüllerde %6-28, 11-20 mm nodüllerde %22-60, 21-30 mm nodüllerde %64-82 düzeyinde olduğu belirtildi.

Soliter pulmoner nodüllere yaklaşım Kanser riski yüksek, operablsoliter pulmoner nodüllerde tanı ve tedavi için torakotomi öneriliyor. Takipte düşük doz toraks BT kullanılmalı (Kanser riski doz bağımlı, özellikle kadınlar ve çocuklarda risk en yüksek düzeyde).

Obezite akciğer naklinde postoperatif mortaliteyi (özellikle yoğun bakımdaki mortaliteyi) artırıyor. Bekleme listesindeki obez hastalarda kilo verdirmeye önem verilmeli. Benzer şekilde yaş arttıkça postop mortalite de artıyor. Bu nedenle ileri yaştaki nakil adayları için seçici davranılmalı.

KOAH alevlenmelerini önlemede uzun süreli azitromisin kullanımı KOAH alevlenmelerinin önlenmesinde uzun süreli azitromisin kullanımının değerlendirildiği plasebokontrollu çalışmanın sonuçları değerlendirildi: Azitromisin kullanımının, ilk alevlenmeye dek geçen sürenin uzamasını (266’ya karşın 174 gün), daha fazla hastanın (%43’e %36) SGRQ skorunda en az 4 puan artış olmasını sağladığı bildirildi. Azitromisin uygulamasının, yaşlı hastalarda daha etkili, aktif sigara içenlerde daha az etkili bulunduğu belirtildi. İşitmede azalmanınazitromisinkullananlarda daha sık gözlendiği (%25’e%20), ama bu kaybın klinik açıdan anlamlı bulunmadığı, hastaların 1/3ünde azitromisine devam edilmesine karşın normal düzeye döndüğüne ilişkin veriler gösterildi. QT uzamasının her iki grupta benzer oranlarda(%29’a %33) görüldüğü; ancak, başlangıçta ya da çalışmanın 1. ayında QTc uzaması saptanan, istirahatte nabzı> 100/dk olan, kalp yetmezliği olan hastalar (risk grubundakiler) çalışma dışı bırakıldığı için, gerçek yaşamdaki oranların daha yüksek olabileceği ifade edildi.

1) Hava açlığı: Ventilasyon arttığında oluşan denge kusuru 2) Göğüste sıkışma hissi: Havayolu reseptörlerinin uyarılması ile ilgili 3) Eforla olan dispne: Motor uyarı ile ilişkili. Hava açlığı: ‘Yeterli hava alamıyorum, nefesim beni tatmin etmiyor, hava açlığı hissediyorum’. Nörofizyoloji: Beyin kökündeki solunum merkezlerinden gelen sinyallerle ortaya çıkıyor. Bu sinyaller hiperkapni, hipoksi veya egzersiz olabilir. Sağlıklı bireylerde egzersiz sırasında, kardiyopulmoner ya da nöromuskuler hastalıklarda daha erken dönemde ortaya çıkar. Örnekleri: Restriktif veobstrüktif AC hastalıkları, hipoksi, hiperkapni ve asidoz. Göğüste sıkışma hissi: Göğüs kafesi ya da akciğerlerde sıkışma hissi, bronkokonstrüksiyonun karakteristik özelliği, Nörofizyoloji: Hava açlığından daha az çalışılmış, intrapulmoner reseptörlerin uyarılmasına bağlı. Klasik olarak astım ataklarında ortaya çıkan bir bulgu. Mekanik ventilasyon solunum işini, dürtüsünü ortadan kaldırır ancak bronkokonstrüksiyon devam eder. Eforla olan dispne (solunum iş yükünde artış): Nefes alma eforunda artışı ifade eder. Solunumhasta için bir yük. Nörofizyoloji: Kas liflerinden gelen fiziksel yük duygusu ve motor dürtünün farkında olma olarak açıklanabilir. KOAH, Astım, solunum kas disfonksiyonlarında görülebilir.

HRCT’de kanser riski, buzlu cam opasitelerindesolid görünümden daha yüksek Subsantimetriknodüller (<8 mm) sık görülmektedir, malignite riski düşüktür. İdiyopatik pulmoner fibrosis gerçekten idiyopatik mi?

“Akademi-Endüstri İlişkileri” konulu ‘Presidential Lecture’dan seçmeler: Medikal alanda yatırım – ürün – kar oranları diğer alanlara göre daha kötü; örneğin, MSD firmasının araştırma-geliştirmeye ayırdığı bütçe Apple’ın 3 katı.

Akciğer naklinde obezite ve yaşın etkisi

Dispnenin nörofizyopatolojisi

Bulunan her 10,000 aday bileşikten yalnızca beşi klinik çalışma aşamasına gelmekte, bunlardan bir-ikisi kullanıma girmekte, süreç toplam 15-20 yıl kadar almaktadır. Halen NIH’in araştırmalara ayırdığı bütçe 29,4 milyar dolar ve ağırlıklı olarak temel araştırmalara gitmektedir. Endüstrinin ayırdığı bütçe ise 65,2 milyar dolar ve ağırlıklı olarak klinik araştırmalara gitmektedir.

İnterstisyel akciğer hastalıklarında idiyopatik pulmoner fibroziste, pulmoner fibrozis gerçekten idiyopatik mi sorusuna yanıt aranırken, çevresel etkenlerin çok iyi sorgulanması gerektiği üzerinde duruldu. Konuşmacılardan biri kendi kliniklerine İPF tanısı konularak başvuran 30 olguyu yeniden değerlendirmeye aldıklarında; bu olguların sadece ikisinin gerçek İPF olduğunu geriye kalan 28 olguda değişik etiyolojiler (özellikle çevresel kaynaklı) saptandığını ve bu etkenleri saptamada BAL analizinin çok önemli yer tuttuğunu belirtti. İnterstisyel akciğer hastalıkların tanısında (radyolojik olarak usual interstisyel pnömoni hariç) BAL’ın daha fazla kullanılmasının tanıda yaralı bilgiler sağlayacağı düşüncesi öne çıktı. Bu konuda ATS’nin 2012 Mayıs AJRCCM’de yayınlanan İnterstisyel akciğer hastalıklarında BAL’ın hücresel analizinin klinik yararı ile ilgili rehberi yol gösterici olabileceği belirtildi.

Akciğer nakli sonrası bronşiolitisobliterans:

Kemik iliği nakli sonrası bronşiolitis obliterans:

CMV infeksiyonu akciğer nakli sonrası sık ve BOS gelişiminden sorumlu. Bu nedenle CMV proflaksi süresini uzun tutmak (üç aydan uzun, valganciclovirle 12 ay gibi) BOS’u önlemede önemli. Dolaşımda flow-cytometry ile saptanan fibrosit (kemik iliğinden derivemezenkimal hücreler) düzeyi akciğer transplantasyonu sonrası BOS gelişimi ile korele. Bu açıdan bir marker olarak kullanılabilir. BOS riski tacrolimusdasiklosporine göre daha düşük (akut rejeksiyon açısından fark yokken). BOS’u önlemede ve tedavide azitromisin önemli (özellikle transplant sonrası BAL’danötrofilisi olanlarda).

Allojenikhematopoetik hücre transplantasyonunun nadir fakat fatal komplikasyonu. Kronik GVH hastalığının varlığı riski belirgin artırıyor. Transplant sonrası ilk 2 yılda saptanan geri irreverzibl havayolu obstrüksiyonu ile karakterizedir. Transplant öncesi bazal SFT ve transplant sonrası özellikle ilk bir yılda 3 ayda bir SFT yapılmalıdır. Başka organda GVH hastalığı olanlarda BO açısından daha da dikkatli olunmalıdır. FEV1’de %10’luk azalma uyarıcı olmalı. Etkin tedavi ?. Çalışmalar yetersiz ancak ilk seçenek yüksek doz steroid. İnhalesteroidlerin de tedaviye eklenmesi öneriliyor. Ekstrakorporalfotoferez denenebilir. Azitromisin tedavide önemli.

Haziran 2012

99


'Q\D6SLURPHWUL*Q(WNLQOLNOHUL Toraks Bülteni Toplumun ve yöneticilerin dikkatini akciğer sağlığına çekmek, farkındalık yaratmak ve hastalıkların erken tanısı için ‘’Spirometri’’ yi yaygınlaştırmak amacıyla, tüm dünya solunum derneklerinin ortak kararıyla, 27 Haziran 2012 tarihinde ilan ettikleri gün, ülkemizde, Forum of European Respiratory Societies (FERS) koordinasyonunda, Derneğimizce 10 Şube ve 17 Merkezde düzenlendi. Toplam 2530 kişiye spirometri uygulandı. Bu testlerden 235’inde patoloji saptanarak, erken tanı konan hastalar ileri tetkik için davet edildi. İlgili web sitesinde (wsd2012.org) sonuçlar görülmekte olup, Avrupa çerçevesinde ise 627 yerde toplam 30216 test yapıldığı belirtilmektedir. Ülkemizde bu güne destek veren tüm Şubelere, özveriyle hizmet eden tüm meslektaşlarımıza ve teknisyenlere, koşulsuz cömert desteği için Boehringer Ingelheim-Pfizer firmasına, cihaz desteği için Teknikel’e çok teşekkür ederiz.

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