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Casian A, Sangle SR, D'Cruz DP. New use for an old treatment: Hydroxychloroquine as a potential treatment for systemic vasculitis. Autoimmun Rev 2018; 17:660-664. [DOI: 10.1016/j.autrev.2018.01.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/09/2018] [Indexed: 12/20/2022]
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Pedrosa M, Prieto-García A, Sala-Cunill A, Baeza ML, Cabañas R, Campos A, Cimbollek S, Gómez-Traseira C, González Quevedo T, Guilarte M, Jurado-Palomo J, Lobera T, López-Serrano MC, Marcos C, Piñero-Saavedra M, Prior N, Sáenz de San Pedro B, Ferrer M, Barceló JM, Daschner A, Echechipía M, Garcés M, Iriarte P, Jáuregui I, Lázaro M, Quiñones M, Veleiro B, Villareal O. Management of angioedema without urticaria in the emergency department. Ann Med 2014; 46:607-18. [PMID: 25580506 DOI: 10.3109/07853890.2014.949300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.
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Affiliation(s)
- Maria Pedrosa
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain.
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Melamed J, Ahuja-Malik A. A case of transient acquired C1 inhibitor deficiency. Ann Allergy Asthma Immunol 2014; 113:116-7. [PMID: 24950848 DOI: 10.1016/j.anai.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/09/2014] [Accepted: 05/11/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Julian Melamed
- Division of Allergy, Lowell General Hospital, Lowell, Massachusetts.
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Farkas H, Veszeli N, Csuka D, Temesszentandrási G, Tóth F, Kőszegi L, Varga L. Management of pregnancies in a hereditary angioedema patient after treatment with attenuated androgens since childhood. J OBSTET GYNAECOL 2014; 35:89-90. [DOI: 10.3109/01443615.2014.925860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aygören‐Pürsün E, Martinez Saguer I, Kreuz W, Klingebiel T, Schwabe D. Risk of angioedema following invasive or surgical procedures in HAE type I and II--the natural history. Allergy 2013; 68:1034-9. [PMID: 23968383 PMCID: PMC4223932 DOI: 10.1111/all.12186] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 01/28/2023]
Abstract
Background Hereditary angioedema (HAE), caused by deficiency in C1-inhibitor (C1-INH), leads to unpredictable edema of subcutaneous tissues with potentially fatal complications. As surgery can be a trigger for edema episodes, current guidelines recommend preoperative prophylaxis with C1-INH or attenuated androgens in patients with HAE undergoing surgery. However, the risk of an HAE attack in patients without prophylaxis has not been quantified. Objectives This analysis examined rates of perioperative edema in patients with HAE not receiving prophylaxis. Methods This was a retrospective analysis of records of randomly selected patients with HAE type I or II treated at the Frankfurt Comprehensive Care Centre. These were examined for information about surgical procedures and the presence of perioperative angioedema. Results A total of 331 patients were included; 247 underwent 700 invasive procedures. Of these procedures, 335 were conducted in 144 patients who had not received prophylaxis at the time of surgery. Categories representing significant numbers of procedures were abdominal (n = 113), ENT (n = 71), and gynecological (n = 58) procedures. The rate of documented angioedema without prophylaxis across all procedures was 5.7%; in 24.8% of procedures, the presence of perioperative angioedema could not be excluded, leading to a maximum potential risk of 30.5%. Predictors of perioperative angioedema could not be identified. Conclusion The risk of perioperative angioedema in patients with HAE type I or II without prophylaxis undergoing surgical procedures ranged from 5.7% to 30.5% (CI 3.5–35.7%). The unpredictability of HAE episodes supports current international treatment recommendations to consider short-term prophylaxis for all HAE patients undergoing surgery.
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Affiliation(s)
- E. Aygören‐Pürsün
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - I. Martinez Saguer
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - W. Kreuz
- Internationales Forschungsinstitut für Gerinnungsstörungen und Immundefekte Mörfelden‐Walldorf Germany
| | - T. Klingebiel
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - D. Schwabe
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
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Abstract
Hereditary Angioedema (HAE) is a rare disease and for this reason proper diagnosis and appropriate therapy are often unknown or not available for physicians and other health care providers. For this reason we convened a group of specialists that focus upon HAE from around the world to develop not only a consensus on diagnosis and management of HAE, but to also provide evidence based grades, strength of evidence and classification for the consensus. Since both consensus and evidence grading were adhered to the document meets criteria as a guideline. The outcome of the guideline is to improve diagnosis and management of patients with HAE throughout the world and to help initiate uniform care and availability of therapies to all with the diagnosis no matter where the residence of the individual with HAE exists.
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Varga L, Farkas H. rhC1INH: a new drug for the treatment of attacks in hereditary angioedema caused by C1-inhibitor deficiency. Expert Rev Clin Immunol 2011; 7:143-53. [PMID: 21426252 DOI: 10.1586/eci.11.5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recombinant human C1 esterase inhibitor (rhC1INH) (Ruconest(®), Pharming) is a new drug developed for the relief of symptoms occurring in patients with angioedema due to C1-inhibitor deficiency. Pertinent results have already been published elsewhere; this article summarizes the progress made since then. Similar to the purified C1-inhibitor derived from human plasma, the therapeutic efficacy of rhC1INH results from its ability to block the actions of enzymes belonging to the overactivated bradykinin-forming pathway, at multiple locations. During clinical trials into the management of acute edema, a total of 190 subjects received recombinant C1-inhibitor by intravenous infusion on 714 occasions altogether. Dose-ranging efficacy studies established 50 U/kg as the recommended dose, and demonstrated the effectiveness of this agent in all localizations of hereditary angioedema attacks. Studies into the safety of rhC1INH based on 300 administrations to healthy subjects or hereditary angioedema patients followed-up for 90 days have not detected the formation of autoantibodies against rhC1INH or IgE antibodies directed against rabbit proteins, even after repeated administration on multiple occasions. These findings met favorable appraisal by the EMA, which granted European marketing authorization for rhC1INH. Pharming is expected to file a biological licence with the US FDA by the end of 2010 to obtain marketing approval in the USA. The launch of rhC1INH onto the pharmaceutical market may represent an important progress in the management of hereditary angioedema patients.
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Affiliation(s)
- Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University Budapest, H-1125 Kútvölgyi street 4, Budapest, Hungary.
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[Facial edema as an earlier presenting sign of giant cell arteritis. Possible relationship with angioedema]. Z Rheumatol 2011; 70:160-2. [PMID: 21312024 DOI: 10.1007/s00393-010-0702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Giant cell arteritis (GCA) is a chronic granulomatous vasculitis of unknown etiology occurring in the elderly. New-onset headache, scalp tenderness, jaw claudication, temporal artery abnormalities on physical examination, visual symptoms and associated polymyalgia rheumatica represent the most typical and frequent features of the disease. However, facial edema is being more commonly recognized as a presenting symptom that may herald the disease. We present a case with facial edema as initial symptom and discuss if this rare symptom of GCA is due to hereditary or acquired angioedema.
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Farkas H. Pediatric hereditary angioedema due to C1-inhibitor deficiency. Allergy Asthma Clin Immunol 2010; 6:18. [PMID: 20667121 PMCID: PMC2920237 DOI: 10.1186/1710-1492-6-18] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 07/28/2010] [Indexed: 12/03/2022] Open
Abstract
Hereditary angioedema (HAE) resulting from the deficiency of the C1 inhibitor (C1-INH) is a rare, life-threatening disorder. It is characterized by attacks of angioedema involving the skin and/or the mucosa of the upper airways, as well as the intestinal mucosa. In approximately 50 per cent of cases, clinical manifestations may appear during childhood. The complex management of HAE in pediatric patients is in many respects different from the management of adults. Establishing the diagnosis early, preferably before the onset of clinical symptoms, is essential in cases with a positive family history. Complement studies usually afford accurate diagnosis, whereas molecular genetics tests may prove helpful in uncertain cases. Appropriate therapy, supported by counselling, suitable modification of lifestyle, and avoidance of triggering factors (which primarily include mechanical trauma, mental stress and airway infections in children) may spare the patient unnecessary surgery and may prevent mortality. Prompt control of edematous attacks, short-term prophylaxis and intermittent therapy are recommended as the primary means for the management of pediatric cases. Medicinal products currently used for the treatment of children with hereditary angioedema include antifibrinolytics, attenuated androgens, and C1-INH replacement therapy. Current guidelines favour antifibrinolytics for long-term prophylaxis because of their favorable safety profile but efficacy may be lacking. Attenuated androgens administered in the lowest effective dose are another option. C1-INH replacement therapy is also an effective and safe agent for children. Regular monitoring and follow-up of patients are necessary.
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Affiliation(s)
- Henriette Farkas
- 3rd Department of Internal Medicine, Faculty of Medicine, Semmelweis University, H-1125 Budapest, Kútvölgyi út 4, Hungary.
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Varga L, Farkas H. Treatment of type I and II hereditary angioedema with Rhucin, a recombinant human C1 inhibitor. Expert Rev Clin Immunol 2010; 4:653-61. [PMID: 20477114 DOI: 10.1586/1744666x.4.6.653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hereditary and acquired angioedema are of outstanding clinical importance, as edematous attacks associated with these conditions can thrust afflicted patients into mortal danger. Currently, C1 inhibitor concentrate - a human blood product - is available as a replacement therapy. In view of the limited number of donors, as well as the risk of transmission of blood-borne infections, it is a reasonable expectation to develop a therapeutic alternative based on recombinant technology, which would eliminate all these shortcomings. Pharming (Leiden, The Netherlands) has developed Rhucin, a recombinant human C1 inhibitor, as a proprietary product, which is currently being evaluated in Phase III clinical trials. Ongoing studies conducted within the framework of the development program are almost complete and their interim findings are reassuring. This should facilitate successful regulatory approval in the near future, which is indispensable in order to make Rhucin available for patients with hereditary angioedema or other disorders amenable to C1 inhibitor replacement.
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Affiliation(s)
- Lilian Varga
- 3rd Department of Internal Medicine, Semmelweis University Budapest, H-1125 Kútvölgyi Street 4, Budapest, Hungary.
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Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol 2009; 155:367-77. [PMID: 19220828 DOI: 10.1111/j.1365-2249.2008.03845.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Angio-oedema is a common reason for attendance at the accident and emergency department and for referral to immunology/allergy clinics. Causative factors should always be sought, but a large proportion of patients have the idiopathic form of the disease. A minority of patients represent a diagnostic and treatment challenge. Failure to identify the more unusual causes of angio-oedema may result in life-threatening situations. Common and rare causes of angio-oedema will be discussed in this article, as well as the diagnostic and treatment pathways for the management of these patients. A comprehensive history and close monitoring of response to treatment are the most cost-effective diagnostic and treatment tools.
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Affiliation(s)
- S Grigoriadou
- Barts and The London NHS Trust, Royal London Hospital, London, UK
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Bernstein IL. Hereditary angioedema: a current state-of-the-art review, II: historical perspective of non-histamine-induced angioedema. Ann Allergy Asthma Immunol 2008; 100:S2-6. [PMID: 18220145 DOI: 10.1016/s1081-1206(10)60579-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review the evolution of our understanding of hereditary angioedema (HAE) from the first historical reference to the present day. DATA SOURCES MEDLINE and PubMed were searched using the following keywords: history of HAE, C1 inhibitor, complements system, genetics of HAE, mechanisms of HAE, and treatment of HAE. STUDY SELECTION Information was selected that outlines the advances made in complementology, the first report of HAE, and subsequent studies that elucidated the underlying mechanisms of this disease, leading to current therapy of this orphan disease. RESULTS Generational research efforts in HAE have focused on the following: (1) several new clinical presentations, (2) acquired forms of non-histamine-induced angioedema, (3) the genetic basis for the inherited forms, (4) the effects of C1 inhibitor on contact phases of coagulation-fibrinolytic pathways, and (5) various therapies for short- and long-term control of the disease. CONCLUSION The progress made in understanding the pathogenesis and treatment of HAE is an excellent example of the "bench to the bedside" paradigm involving the collaboration between clinicians and researchers.
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Affiliation(s)
- I Leonard Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, University of Cincinnati College of Medicine, Ohio 45267-0563, USA.
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Copeland B, Aljitawi O, Fitzgerald SM, Chi DS, Krishnaswamy G. A patient with facial and neck swelling, dyspnea, and dysphagia. Ann Allergy Asthma Immunol 2006; 95:510-7. [PMID: 16400888 DOI: 10.1016/s1081-1206(10)61011-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Billy Copeland
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee 37614-1709, USA
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Abstract
OBJECTIVE To search for anaphylatoxin activity in plasma during episodes of erythema marginatum, and to evaluate the histology of erythema marginatum by electron microscopy and immunohistologic techniques. METHODS Plasma samples were studied for C5a activity by granulocyte aggregation, and C3 conversion by immunoelectrophoresis. A skin biopsy of erythema marginatum was done, and the tissue stained with a rabbit antibody to bradykinin. RESULTS No plasma anaphylatoxin was found. Dense deposits of bradykinin were discovered in stromal tissue and lining endothelial cells. CONCLUSIONS Bradykinin may be important in the causality of the erythema marginatum associated with hereditary angioedema.
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Affiliation(s)
- John C Starr
- Division of Allergy & Immunology, Department of Pathology, Scott & White, Scott, Sherwood, TX, USA.
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Agostoni A, Aygören-Pürsün E, Binkley KE, Blanch A, Bork K, Bouillet L, Bucher C, Castaldo AJ, Cicardi M, Davis AE, De Carolis C, Drouet C, Duponchel C, Farkas H, Fáy K, Fekete B, Fischer B, Fontana L, Füst G, Giacomelli R, Gröner A, Hack CE, Harmat G, Jakenfelds J, Juers M, Kalmár L, Kaposi PN, Karádi I, Kitzinger A, Kollár T, Kreuz W, Lakatos P, Longhurst HJ, Lopez-Trascasa M, Martinez-Saguer I, Monnier N, Nagy I, Németh E, Nielsen EW, Nuijens JH, O'grady C, Pappalardo E, Penna V, Perricone C, Perricone R, Rauch U, Roche O, Rusicke E, Späth PJ, Szendei G, Takács E, Tordai A, Truedsson L, Varga L, Visy B, Williams K, Zanichelli A, Zingale L. Hereditary and acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond. J Allergy Clin Immunol 2004; 114:S51-131. [PMID: 15356535 PMCID: PMC7119155 DOI: 10.1016/j.jaci.2004.06.047] [Citation(s) in RCA: 437] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 06/24/2004] [Accepted: 06/24/2004] [Indexed: 01/13/2023]
Abstract
Hereditary angioedema (HAE), a rare but life-threatening condition, manifests as acute attacks of facial, laryngeal, genital, or peripheral swelling or abdominal pain secondary to intra-abdominal edema. Resulting from mutations affecting C1 esterase inhibitor (C1-INH), inhibitor of the first complement system component, attacks are not histamine-mediated and do not respond to antihistamines or corticosteroids. Low awareness and resemblance to other disorders often delay diagnosis; despite availability of C1-INH replacement in some countries, no approved, safe acute attack therapy exists in the United States. The biennial C1 Esterase Inhibitor Deficiency Workshops resulted from a European initiative for better knowledge and treatment of HAE and related diseases. This supplement contains work presented at the third workshop and expanded content toward a definitive picture of angioedema in the absence of allergy. Most notably, it includes cumulative genetic investigations; multinational laboratory diagnosis recommendations; current pathogenesis hypotheses; suggested prophylaxis and acute attack treatment, including home treatment; future treatment options; and analysis of patient subpopulations, including pediatric patients and patients whose angioedema worsened during pregnancy or hormone administration. Causes and management of acquired angioedema and a new type of angioedema with normal C1-INH are also discussed. Collaborative patient and physician efforts, crucial in rare diseases, are emphasized. This supplement seeks to raise awareness and aid diagnosis of HAE, optimize treatment for all patients, and provide a platform for further research in this rare, partially understood disorder.
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Key Words
- aae
- acquired angioedema
- angioedema
- c1 esterase inhibitor
- c1-inh
- hae
- hane
- hano
- hereditary angioedema
- hereditary angioneurotic edema
- angioneurotic edema
- chemically induced angioedema
- human serping1 protein
- aae, acquired angioedema
- aaee, (italian) voluntary association for the study, therapy, and fight against hereditary angioedema
- ace, angiotensin-converting enzyme
- app, aminopeptidase p
- at2, angiotensin ii
- b19v, parvovirus b19
- bmd, bone mineral density
- bvdv, bovine viral diarrhea virus
- c1, first component of the complement cascade
- c1-inh, c1 esterase inhibitor
- c1nh, murine c1 esterase inhibitor gene
- c1nh, human c1 esterase inhibitor gene
- c2, second component of the complement cascade
- c3, third component of the complement cascade
- c4, fourth component of the complement cascade
- c5, fifth component of the complement cascade
- ccm, chemical cleavage of mismatches
- ch50, total hemolytic complement, 50% cell lysis
- cmax, maximum concentration
- cpmp, committee for proprietary medicinal products
- cpv, canine parvovirus
- dhplc, denaturing hplc
- ff, (ovarian) follicular fluid
- ffp, fresh frozen plasma
- hae, hereditary angioedema
- hae-i, hereditary angioedema type i
- hae-ii, hereditary angioedema type ii
- haea, us hae association
- hav, hepatitis a virus
- hbsag, hepatitis b surface antigen
- hbv, hepatitis b virus
- hcv, hepatitis c virus
- hk, high molecular weight kininogen
- hrt, hormone replacement therapy
- huvs, hypocomplementemic urticaria-vasculitis syndrome
- lh, luteinizing hormone
- masp, mannose-binding protein associated serine protease
- mbl, mannan-binding lectin
- mfo, multifollicular ovary
- mgus, monoclonal gammopathies of undetermined significance
- mr, molecular mass
- nat, nucleic acid amplification technique
- nep, neutral endopeptidase
- oc, oral contraceptive
- omim, online mendelian inheritance in man (database)
- pco, polycystic ovary
- pct, primary care trust
- prehaeat, novel methods for predicting, preventing, and treating attacks in patients with hereditary angioedema
- prv, pseudorabies virus
- rhc1-inh, recombinant human c1 esterase inhibitor
- rtpa, recombinant tissue-type plasminogen activator
- shbg, sex hormone binding globulin
- ssca, single-stranded conformational analysis
- tpa, tissue-type plasminogen activator
- uk, united kingdom
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Abstract
The Hungarian HAE Center was established in 1994, in Budapest. Assignments of the Center include diagnostic work-up of patients with angioedema; developing national guidelines for the recognition, treatment of patients with HAE; maintaining the registry, patient education, supply patients with info-card and C1-INH concentrate, follow-up of patients, telephone 'hot-line' service, under- and postgraduate education as well as pursues scientific activities. Established in 1996, the Hungarian HAE Patients' Association a foundation to support HAE patients; and a Hungarian HAE website. Hungarian HAE Working Group is the main organizer of the European C1-INH Deficiency Workshops to be held at two-year intervals from 1999.
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Affiliation(s)
- Henriette Farkas
- Allergy and Angiooedema Outpatients Clinic, Kútvölgyi Clinical Center, Semmelweis University, Kútvölgyi út 4, H-1125 Budapest, Hungary.
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