enver bi sikimi alamazdı.
fatih sultan mehmet ömrü yetseydi bütün avrupayı kolonize edebilirdi.
1. viyana değil de 2. viyana başarılı olabilirdi ama merzifonlu kara eşşek yüzünden alınamadı
Tarih ihtimaller üzerine yazılmaz ama ya olsaydı?
Tarihin kırılma anları bunlar. Ömürleri ve vizyonları kendilerinden sonrakilerde devam etseydi hepsi alınırdı....
Never in my life have I been prouder to be Australian than when I heard a pub full of people erupt into cheers after seeing a 10 year old Turkish boy crying in the crowd.
Kayda geçmesi için not düşüyorum:
Dünya Kupası, evimden arabayla birkaç saatlik sürüş mesafesinde düzenlenecek. Buna rağmen Türkiye’nin oynayacağı hiçbir maçı stadyumda izlemeyeceğim.
Futbol izlemek bana göre boş bir uğraş.
Türk futbolu ise bunun da ötesinde daha da boş bir iştir.
videonun tamamını izleyin, adam sağlıklı dediğiniz haldeyken nefes alamıyordu otururken. şu haliyle hem fiziken hem zihnen gençleşmiş görünüyor videonun genelinde. millet yine bir yerlerinden sallıyor farklı zamanlardan ve açılardan çekilmiş 2 fotoya bakarak.
NT-proBNP
🧠 Core physiology
NT-proBNP is released from LV myocardium due to:
• Increased wall stress from volume or pressure overload
• Hypoxia and ischemia
• Neurohormonal activation like Angiotensin II and Endothelin
👉 It reflects hemodynamic stress, not just heart failure
⚙️ Biochemical pathway
Pre-proBNP (134 AA) → proBNP (108 AA) → cleaved into:
• BNP (32 AA) → biologically active, causes natriuresis and vasodilation
• NT-proBNP (76 AA) → inactive but clinically measurable
👉 NT-proBNP is more useful because of stability
⏱️ Kinetics and clearance
• BNP half-life ~20 minutes
• NT-proBNP half-life 90–120 minutes
• BNP cleared by receptors and enzymes
• NT-proBNP cleared exclusively by kidneys
👉 NT-proBNP reflects sustained cardiac stress over ~12 hours
📊 BNP vs NT-proBNP clinical relevance
• BNP affected by neprilysin inhibition
• NT-proBNP unaffected
• BNP less stable in vitro
• NT-proBNP highly stable
👉 In modern practice, NT-proBNP is preferred
🚨 Acute dyspnea: Rule OUT HF
NT-proBNP < 300 pg/mL
• Negative predictive value ~99%
• Effectively excludes acute decompensated HF
👉 Shift focus to pulmonary or systemic causes
2: Rule IN HF using age-adjusted cutoffs
“45-90-18 rule”
• Age <50 → >450 pg/mL
• Age 50–75 → >900 pg/mL
• Age >75 → >1800 pg/mL
👉 Aging myocardium and declining GFR increase baseline levels
🏥 Chronic outpatient setting
NT-proBNP < 125 pg/mL
• Rules out chronic HF in stable patients with mild symptoms
⚠️ Critical concept
NT-proBNP is NOT HF specific
👉 It is a marker of myocardial strain
👉 Always interpret with clinical context, echo, volume status
🚩 Causes of falsely elevated NT-proBNP
Think CARSS
• CKD → reduced renal clearance
• Age → baseline elevation
• Rhythm → AF and tachyarrhythmias
• Sepsis → cytokine-mediated myocardial depression
• Strain → RV strain like PE, PAH
Also seen in:
• Acute coronary syndrome
• Critical illness
👉 Elevated value ≠ always LV failure
📉 Causes of falsely low NT-proBNP
• Obesity → increased peptide clearance
• Flash pulmonary edema → delay in release 2–4 hours
• HFpEF → less wall stretch compared to dilated ventricles
• Constrictive pericarditis or tamponade → restricted stretch
• Severe mitral stenosis → LV underfilled
👉 Normal value does not completely exclude HF
💡 High-yield bedside pearl
Obesity halving rule
• Reduce diagnostic cutoffs by ~50%
• Example: 450 becomes ~225
👉 Prevents missing HF in obese patients
💊 ARNI paradigm shift
Sacubitril inhibits neprilysin
→ BNP breakdown blocked → falsely elevated BNP
👉 BNP becomes unreliable
✅ NT-proBNP must be used for diagnosis and monitoring
💊 Sacubitril/Valsartan dosing
• Starting dose: 24/26 mg or 49/51 mg PO BD
• Target dose: 97/103 mg PO BD
⚠️ Absolute rule
• 36-hour washout after ACE inhibitor
Monitoring
• Hypotension most common
• Hyperkalemia risk
• Creatinine rise up to 30% acceptable
📉 Prognostic and discharge utility
Track admission to discharge change
👉 Target ≥30% reduction
If not achieved
• Persistent subclinical congestion
• High 30-day readmission and mortality
👉 Action
• Continue IV diuresis
• Plan early follow-up within 72 hours
👉 Always correlate with clinical exam, echo, IVC, response to diuretics
🔚 Final takeaways
• <300 pg/mL rules OUT acute HF
• Always apply age-adjusted rule-IN
• Interpret in clinical context, not isolation
• Use NT-proBNP in ARNI patients
• Aim ≥30% reduction before discharge
This is not just a lab value.
It is a dynamic tool for diagnosis, monitoring, and prognosis
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Lübnan’ın demografik haritası onun ebediyen bir fail state olmaktan kurtulamayacağını gösteriyor.
Fransız mandasında iken Lübnan Suriye’nin bir parçasıydı. Fransa bu bölgeyi terk ederken Lübnan ile Suriyeyi ayırıp öyle çekildi.
Lübnan’ın 2022’den beri resmi Cumhurbaşkanı yok. Başbakanı da yok. Ordusu yok.
Ülke kaderine terk edilmiş vaziyette.