Si può desiderare di provare un trattamento naturale disfunzione erettile come un diverso per i problemi di costruzione. Al giorno d oggi ci sono diverse terapie sul mercato, ma un trattamento naturale disfunzione erettile è stato confermato qualche ora e ora di nuovo per dare risultati efficienti e permanenti. Cos è la disfunzione sessuale? L incapacità di sviluppare o sostenere una costruzione abbastanza lungo per fare l amore è chiamato disfunzione erettile, ED https://farmacia-senzaricetta.it/ o (maschio) problemi di erezione. Tutti gli uomini possono avere problemi di costruzione di volta in volta e gli scienziati considerano ED essere presenti se si verificano problemi di costruzione almeno il 25% del tempo. Alcuni fatti duri: ED Può essere dovuto a problemi emotivi. Stress, pressione, giltiness, depressione, bassa autostima e ansia prestazioni può essere la causa dei vostri problemi di costruzione. La ricerca ha confermato che il 90 per cento della disfunzione erettile è fisica in origine, non emotiva. L impotenza colpisce la maggior parte degli uomini durante la loro vita e può essere dovuto a troppo colesterolo, problemi cardiaci, diabete, ipertensione, fumo o alcol. Alcuni rimedi possono essere la ragione. Le questioni legate al movimento sono collegate. Se ti occupi dei tuoi problemi di movimento, hai piu possibilita di risolvere questo problema. Qui ci sono 5 consigli facili su come aumentare la circolazione: 1. Mangia i pasti giusti. Questo ti rendera il flusso sanguigno ovvio. Una grande parte di rimanere sani e anche mantenere il flusso sanguigno ovvio è legato al vostro piano di alimentazione quotidiana e quello che si mangia. Una buona cura per la disfunzione erettile è mangiare un piano a basso contenuto di grassi e grande alimentazione di fibre. Mangiare fibre tutti i giorni e questo viene scoperto in prodotti cerealicoli cereali integrali, frutta e verdura. Evitare il più possibile pasti pronti o pasti non sani. 2. Wonder herbal rimedi. Molti rimedi vegetali per ED eseguire bene come possono migliorare il movimento. Hanno molto meno reazioni avverse rispetto ai farmaci convenzionali e si svolgono in modo efficiente per migliorare hardons e la forza, troppo. Erbe naturali come Ginkgo Biloba sono utilizzati come una strategia per ED. Gli specialisti di erboristeria credono anche che le spezie o le erbe come noce moscata, portano al movimento intorno al corpo, tra cui il pene. 3. Vitamine naturali vitali. Gli scienziati sanitari hanno scoperto che una mancanza di supplemento è tipico tra gli uomini con ED in particolare vitamina A. Se si ha una mancanza del nutriente ossido di zinco, Questo è stato confermato per portare alla disfunzione erettile. Queste inadeguatezze derivano dal fatto che molti valori nutrizionali in quello che mangiamo piano non sono sufficienti. Aggiungere al vostro fabbisogno di nutrienti aumenterà la circolazione del sistema e migliorare questa condizione. Gli integratori alimentari sono completamente naturali, quindi non dovrete preoccuparvi dei rischi di reazioni avverse. Inoltre, queste vitamine naturali sono utili per il vostro benessere over-all. Oltre a questi vantaggi benessere, disfunzione erettile vitamine naturali e integratori costano molto meno di farmaci rimedi. 4. Esercitare. Fai una mossa e non un tablet vibrante. Camminare farà di più per migliorare e sostenere hardons di qualsiasi altra compressa chimica nel lungo periodo. Il fitness fisico manterrà bassi livelli di pressione e mantenere grandi stadi di movimento. Andando per un 20-30 minuti di movimento rapido ogni giorno, può affrontare questo problema e può sostenere la vostra libido senza l uso di qualsiasi farmaco. 5. Sottolineare. Questo è il peggior attaccante per problemi di erezione. Scopri diversi metodi per riposare. Alcuni metodi tipici per riposare includono la lettura di un libro, la meditazione, un bagno rilassante o allenamenti di respirazione. Sto solo imparando alcuni semplici allenamenti di respirazione che possono migliorare significativamente il movimento nel reparto pantaloni. Una naturale disfunzione erettile soluzioni di trattamento stanno diventando sempre più popolare con gli uomini. Questi rimedi a base di erbe sono preferiti perché non hanno reazioni avverse e sono confermati essere efficiente come il farmaco. La maggior parte degli uomini combattere parlano dei loro problemi, in particolare la disfunzione erettile come c è poca discussione sui problemi di erezione. La verita e che ED ha un impatto su piu di dieci milioni di uomini solo negli Stati Uniti. Non siete soli e l aiuto è disponibile.
Doi:10.1016/j.pediatrneurol.2007.03.010
Clinical Profile of
defined by recent American Academy of Neurology–American Epilepsy Society guidelines, a newer antiepilep-tic drug is one approved by the U.S. Food and Drug
Oxcarbazepine-
Administration since 1990.) The oral suspension formula-tion was approved on May 25, 2001. Tablet and suspen-
Related Angioneurotic
sion formulations were approved on August 7, 2003, foruse as monotherapy in the treatment of partial seizures in
Edema: Case Report
children aged 4-16. Oxcarbazepine, a 10-keto analog ofcarbamazepine, is indicated for use as monotherapy oradjunctive therapy in the treatment of partial seizures in
and Review
adults and children (Ն4 years of age in the United Statesand Ն6 years of age in the European Union). Data fromthe manufacturer’s clinical development program indi-
James F. Knudsen, PhD, MD*,
cate that oxcarbazepine was well tolerated in children,
Charlene M. Flowers, RPh†,
with 10% (57/572) withdrawing from oxcarbazepine
Cindy Kortepeter, PharmD†, and
therapy due to adverse events, the most frequent being
Yasser Awaad, MD‡
Angioneurotic edema (angioedema and Quincke’s edema)
can be a life-threatening event. It is a vascular reactionoccurring in the skin and mucous membranes: essentially,
Oxcarbazepine, a carbamazepine analog, was ap-
anaphylaxis of the skin. This asymmetrical, nonpitting
proved for use as an antiepileptic agent in the United
edema may affect any part of the body but is usually
States in 2000. A search of the United States Food and
confined to the head and neck. Symptoms include facial
Drug Administration’s Adverse Event Reporting System
swelling (perioral and periorbital edema), dysphagia, full-
identified nine cases of oxcarbazepine-associated angio-
ness in the floor of the mouth, hoarseness, and muffled
edema in pediatric patients aged 16 years and younger.
voice Drooling occurs. Angioedema involving the
We describe in detail the first U.S. case report, of a
tongue and throat can be fatal due to asphyxia, stridor,
4½-year-old boy who experienced angioedema during
dyspnea, laryngeal edema, and other signs of acute airway
treatment with oxcarbazepine. The reporting rate for
obstruction can occur rapidly The mean duration from
angioedema was calculated to be 9.8 cases per 1,000,000
the onset of symptoms and presentation to the hospital has
pediatric patients. Oxcarbazepine-associated angioedema
been reported in one study of patients exposed to angio-
manifested by swelling of the face, eyes, lips, or tongue or
tensin-converting enzyme inhibitors to be 9 hours (range,
difficulty swallowing or breathing (or both) is a rare but
1-48 hours) Mortality may range from 25 to 30% and
potentially life-threatening reaction for which early rec-
results from rapidly progressive obstruction of the upper
ognition and management are vital. 2007 by Elsevier Inc. All rights reserved.
Angioedema may be hereditary or acquired, with the
overwhelming majority of cases induced by various pre-
Knudsen JF, Flowers CM, Kortepeter C, Awaad Y. Clinical
cipitating factors such as extreme temperature exposure,
profile of oxcarbazepine-related angioneurotic edema: case
trauma, food sensitivity, and exposure to such diverse
report and review. Pediatr Neurol 2007;37:134-137.
drugs as aspirin, indomethacin (and other nonsteroidalanti-inflammatory drugs), penicillin, and angiotensin-con-verting enzyme inhibitors
Introduction
The objectives of our study were as follows: 1) to
document U.S. reports of angioedema in pediatric patients
Oxcarbazepine is a newer aromatic antiepileptic agent,
treated with oxcarbazepine, 2) to present an illustrative
approved in the United States on January 14, 2000. (As
case of angioedema in a pediatric patient, and 3) to present
From the *Office of Drug Evaluation I, Division of Neurology
Products, and †Office of Surveillance and Epidemiology, Food and
Dr. Knudsen, Office of Drug Evaluation I; Division of Neurology
Drug Administration, Silver Spring, Maryland, and ‡Pediatric
Products; Food and Drug Administration, 10903 New Hampshire Ave.,
Neurology & Movement Disorders Program, Oakwood Healthcare
Building 22 Room 4336, Silver Spring, MD 20993-0002.
E-mail: [email protected] January 29, 2007; accepted March 23, 2007.
2007 by Elsevier Inc. All rights reserved.
doi:10.1016/j.pediatrneurol.2007.03.010 ● 0887-8994/07/$—see front matter
a systematic review of the medical literature for reports of
angioedema associated with exposure to oxcarbazepine inthe pediatric population and to calculate the U.S. reporting
Summary of Cases
rate of angioedema in pediatric patients 16 years of age
Our search of the Adverse Event Reporting System
database for reports of angioedema identified nine pediat-ric cases associated with oxcarbazepine use, four of which
occurred in the United States. Six of the nine reportsdocumented a serious outcome. A best representative case,
Patient Data Collection
that of a 4½-year-old boy, will be described in detail.
All cases of angioedema occurred in temporal relation-
Through the MedWatch program, the U.S. Food and Drug Adminis-
ship to oxcarbazepine therapy, although the time to onset
tration compiles and maintains an adverse event reports database for
of the angioedema varied considerably. In each case, the
drugs and biologic products used by humans. Reports from manufactur-
diagnosis of angioedema related to use of the drug was
ers associated with their products are required by law, and those fromhealth care professionals and consumers are voluntary. The reports are
deemed probable, possible, or not able to be excluded by
collected into an electronic database, referred to as the Adverse Event
the reporter. The duration from the initiation of drug use to
the onset of the event ranged from 30 minutes to 7 months.
We searched the Adverse Event Reporting System for reports of
Patient 1 (a 5-year-old boy with a swollen tongue and
angioedema in association with oxcarbazepine use from 2000, when the
pharynx) had been taking the drug for about 7 months
drug was approved in the United States, through November 15, 2006. Weused a broad search strategy to identify any report potentially related to
before the adverse event occurred 15 minutes after his last
angioedema using the following preferred terms: hypersensitivity, ana-
dose, whereas patient 4 (a 4½-year-old with dyspnea,
phylaxis, angioedema or other swelling-related terms such as face edema,
periorbital edema, and drooling) received only one dose
eyelid edema, laryngeal edema, mouth edema, periorbital edema, tongue
before he manifested symptoms 30 minutes later. He
edema, circumoral edema, and C1 esterase deficiency.
required hospitalization, whereas patient 1 did not.
Patient 2 had rash, angioedema, and fever after expo-
Literature Search
sure to oxcarbazepine. Patients 3 and 5-9 reported rash andangioedema only. Patients 1 and 7 mentioned a history of
We performed a literature search using MEDLINE, EMBASE,
angioedema and intolerance to antiepileptic drugs, respec-
TOXLINE, International Pharmaceutical Abstracts (IPA), and the Co-
tively. All patients recovered following cessation of ox-
chrane Library for the period 1980 through
carbazepine and in some instances following treatment
November 2006. The following subject heading terms were used in thesearch: oxcarbazepine, angioedema, anaphylaxis, and anaphylactoid
reaction. Bibliographies of review articles were searched for additionalinformation. Representative Case Report Reporting Rate
A 4½-year-old, 18.5-kg boy from Michigan with diag-
noses of hydrocephalus and seizure disorder presented
Data for this analysis included a cumulative total of unique patients
with acute onset of dyspnea and stridor 30 minutes after
aged 0-16 years receiving oxcarbazepine from January 2002 through
swallowing his first dose of an oral suspension of oxcar-
August 2006. Reporting rate calculations were made on the basis of
bazepine. There was an increase in the severity of his
domestic case counts divided by projected patient counts, which repre-
condition accompanied by facial swelling and drooling
sent the total number of unique patients who have filled a prescription ata retail pharmacy in the United States.
over the next 2 hours. His condition led to presentation to
With the Adverse Event Reporting System it is not possible to
calculate the absolute incidence of a drug-related side effect, because we
He had no history of cough, wheezing, sore throat,
know neither the actual number of patients who experienced the adverse
fever, or other complaints prior to the event. There was no
event (numerator) nor the actual number of patients exposed to the drug
history of atopy. The patient had not taken any other new
and duration of use (denominator). We can, however, estimate theincidence using a reporting rate.
drug or new food products, nor had he been exposed to
To approximate the extent of oxcarbazepine use in the pediatric age
insect stings, bites, or environmental triggers. He was up
group, we obtained an estimate of the total number of individual patients
to date on his immunizations. There was no family history
in the United States prescribed oxcarbazepine. The Verispan Total
Patient Tracker is a national-level projected
The patient was afebrile, tachycardic, and tachypneic on
audit designed to estimate the total number of unique patients by drugand therapeutic class usage in the retail outpatient setting. The Total
admission to the emergency department. The general
Patient Tracker derives its data from the Vector One Prescriber Extract
examination revealed a boy in moderate distress with
database (Medical Marketing Service, Wood Dale, IL), which integrates
audible inspiratory stridor. His pharynx was not erythem-
prescription activity from a variety of sources, including national retail
atous, and his tonsils were not enlarged. The chest x-ray
chains. mail order pharmacies, mass merchandisers, and pharmacy
findings were negative. The boy’s airway on anteroposte-
benefits mangers and their data systems. Vector One compiles more than2 billion prescription claims per year, which represents more than 160
rior lateral neck view showed subglottic narrowing and a
million patients tracked across time.
thickened epiglottis. No foreign body was found. The
Knudsen et al: Oxcarbazepine and Angioedema
patient’s temperature spiked to 38.3°C in the emergency
Discussion
department. Blood cultures were performed, showing nogrowth, and a complete blood count showed 22,000/mm3.
We describe the first U.S. reports of angioedema in
One dose of ceftriaxone was given intravenously. He was
pediatric patients treated with oxcarbazepine. Health care
given one racemic epinephrine nebulization without im-
practitioners should consider this potentially life-threaten-ing event as being possibly drug-induced. The case report
provement. He was given one dose each of dexamethasone
described in considerable detail is of a 4½-year-old boy
and diphenhydramine, with improvement of his respira-
who presented with sudden onset of difficult breathing,
tory stridor and less drooling. He was transferred to the
stridor, facial swelling, and drooling after swallowing 1
intensive care unit, where he was given dexamethasone
mL of oxcarbazepine suspension. It was the only drug the
intravenously every 6 hours and l-epinephrine nebuliza-
patient used before the onset of the adverse event. The
level of evidence, in addition to the temporal correlation
The child improved over a period of 2 hours. He had
between oxcarbazepine therapy and the development of
some stridor, but exhibited no retractions. When his vital
the adverse event, included the fact that other alternative
signs stabilized, he was transferred out of the intensive
causes such as food, insect stings and bites, epiglottis, and
care unit. Examination revealed an alert, active, and
C1 esterase inhibitor protein deficiency were excluded.
playful child with some mild periorbital puffiness, some
The patient had no history of atopy. There was no family
hoarseness, and no stridor. The boy continued to receive
history of allergic diatheses. Angioedema and rash have
dexamethasone intravenously every 6 hours and racemic
been reported in the literature in a 27-year-old Indian
epinephrine as needed. The boy was subsequently dis-
woman following treatment with carbamazepine a
charged and the parents were advised to use an epineph-
drug structurally related to oxcarbazepine.
rine autoinjector at home and to continue administering
Whereas the patient case we described here (patient 4)
prednisolone for the next 3 days. The boy’s parents were
was characterized by a rapid onset after one dose, another
instructed to follow up with his primary care physician in
case (patient 1) was not. This 5-year-old boy had been
3-5 days, and with his neurologist in 1-2 weeks for
taking oxcarbazepine for 7 months before the abrupt and
potentially life-threatening onset of symptoms of angio-edema ensued 15 minutes after dosing. These cases revealthat although adverse events may occur after the first dose,
Literature Review
they can occur at any time during treatment with the drug. It is unclear why some patients become symptomatic and
Our literature search identified one foreign report of
angioedema in a neonate exposed transplacentally to
A similar dilemma of variable latency of drug exposure
oxcarbazepine this incident was captured in our case
until the development of acute angioedema has been
series as patient 9. The patient’s mother was treated with
reported with angiotensin-converting enzyme inhibitors, in
1050 mg/day oxcarbazepine for epilepsy for an unknown
which angioedema is a well-documented but still fre-
period of time. The neonate was reported to have eyelid
quently unrecognized side effect occurring in 0.1-0.7% ofpatients In one report that highlighted the potential
edema, a feeding problem, and disproportionate head-to-
risks of angioedema in children, two children with sys-
trunk size. We found no other foreign or domestic litera-
temic lupus erythematosus developed acute angioedema
ture reports of angioedema, anaphylaxis, anaphylactoid
after months of treatment with enalapril The duration
reactions in individuals of any age exposed to oxcarbaz-
of angiotensin-converting enzyme inhibitor use prior to
the onset of angioedema may vary from months to years,but is more commonly observed in patients whose use ofthe drug was more recent The median duration of
Calculation of U.S. Reporting Rate
angiotensin-converting enzyme inhibitor therapy beforeangioedema onset was 12 months (range, 1 day to 13
According to data from the Verispan Total Patient
Tracker for the period January 1, 2002, to August 31,
Given the nature of the spontaneous reporting system,
2006, ϳ1,622,717 patients of any age had a prescription
an exact incidence rate for angioedema-like symptoms in
filled for oxcarbazepine in an outpatient retail pharmacy
the pediatric population exposed to oxcarbazepine cannot
setting in the United States. Approximately 25% (407,391;
be calculated. Underestimates of the true incidence of
95% confidence interval, 405,944-408,839) of those pa-
adverse events are widely recognized in a passive surveil-
tients were between 0 and 16 years of age. Therefore, with
lance program. The proportion of serious adverse events
a case count of 4 and a projected patient count of 407,391
reported to the Food and Drug Administration is reported
in the United States, the calculated reporting rate for
to range from Ͻ1 to 10% Consequently, underre-
angioedema in pediatric patients in the United States is 9.8
porting of angioedema in pediatric patients exposed to
oxcarbazepine seems likely. We calculated a U.S. report-
ing rate for angioedema in a pediatric population exposed
Frank MM, Gelfand JA, Atkinson JP. Hereditary angioedema:
to oxcarbazepine to be 9.8 cases per 1,000,000 pediatric
the clinical syndrome and its management. Ann Intern Med 1976;84:
patients. To put this in some perspective, Slater et al.
Chiu AG, Newkirk KA, Davidson BJ, Burningham AR, Krowiak
reported 138 cases consistent with the diagnosis of angio-
EJ, Deeb ZE. Angiotensin-converting enzyme inhibitor-induced angio-
edema from the overall controlled and marketed experi-
edema: a multicenter review and an algorithm for airway management.
ence using enalapril in more than 1.2 million patients of
Ann Otol Rhinol Laryngol 2001;110:834-40. Sondhi D, Lippmann M, Murali G. Airway compromise due to
Angioedema associated with the use of oxcarbazepine is
angiotensin-converting enzyme inhibitor-induced angioedema: clinicalexperience at a large community teaching hospital. Chest 2004;126:
a rare but potentially life-threatening reaction. Angio-
edema may have a considerable impact on patient safety
Seidman MD, Lewandowski CA, Sarpa JR, Potesta E,
and treatment decisions. Early recognition and discontin-
Schweitzer VG. Angioedema related to angiotensin-converting enzyme
uation of the offending agent, in this case oxcarbazepine,
inhibitors. Otolaryngol Head Neck Surg 1990;102:727-31.
remain the primary therapy Management of the
Lindhout D, Omtzigt JG. Teratogenic effects of antiepileptic
drugs: implications for the management of epilepsy in women of
edema should be according to its clinical presentation.
childbearing age. Epilepsia 1994;35(Suppl 4):S19-28.
Patients should be advised to immediately report signs
Elias A, Madhusoodanan S, Pudukkadan D, Antony JT. Angio-
and symptoms suggesting angioedema (swelling of the
edema and maculopapular eruptions associated with carbamazepine
face, eyes, lips, or tongue, or difficulty swallowing or
administrations. CNS Spectr 2006;11:352-4.
breathing) and to stop taking the drug until they have
Israili ZH, Hall WD. Cough and angioneurotic edema associated
with angiotensin-converting enzyme inhibitor therapy: a review of the
consulted their physician. It is recommended that pa-
literature and pathophysiology. Ann Intern Med 1992;117:234-42.
tients presenting with angioedema be tested for C1
Sabroe RA, Black AK. Angiotensin-converting enzyme (ACE)
inhibitor function and for C4, C3, and C1q antigens, to
inhibitors and angio-oedema. Br J Dermatol 1997;136:153-8.
exclude the possibility of hereditary angioedema or
Assadi FK, Wang HE, Lawless S, McKay CP, Hopp L, Fattori
D. Angiotensin converting enzyme inhibitor-induced angioedema: areport of two cases. Pediatr Nephrol 1999;13:917-9. Zingale LC, Beltrami L, Zanichelli A, et al. Angioedema
without urticaria: a large clinical survey. CMAJ 2006;175:1065-70.
The views and opinions expressed herein are those of the authors and
La Grenade L, Graham DJ, Nourjah P. Underreporting of
do not represent those of the Food and Drug Administration or the
hemorrhagic stroke associated with phenylpropanolamine. JAMA 2001;
Slater EE, Merrill DD, Guess HA, et al. Clinical profile of
angioedema associated with angiotensin converting-enzyme inhibition. References Bourgeois BF, D’Souza J. Long-term safety and tolerability of Byrd JB, Adam A, Brown NJ. Angiotensin-converting enzyme
oxcarbazepine in children: a review of clinical experience. Epilepsy
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In vitro effect of medicinal plants used to treat erectile dysfunction on smooth muscle relaxation and human sperm N.C. Rakuambo, J.J.M. Meyer, A. Hussein, C. Huyser, S.P. Mdlalose and T.G. Raidani Abstract Chloroform and ethanol extracts of root bark of Securidaca longepedunculata , Wrightia natalensis and Rhoicissus tridentata were investigated for their in vitro activity on
LEARNING STYLES OF ITE STUDENTS Puah Keng Hai M/ASC/CC Abstract This paper presents a study on the relationship between learning styles and GPA (Grade Point Average). Accordingly to Kolb’s Model, students’ learning styles can be classified as Accommodating, Converging, Diverging and Assimilating. This study on a group of 291 ITE students revealed that those who employed