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Erectile Dysfunction — NEJM

Erectile Dysfunction — NEJM
Erectile dysfunction is defined as the inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse.1 It has been estimated to ...

Care must be exercised to provide adequate cardiac filling without causing substantial overload to the already stressed right ventricle. Anecdotal reports of Bortezomib have suggested this agent may have additional efficacy over Rituximab, but randomized trials have not yet confirmed its utility. Despite its success in achieving these goals, the universal use of induction therapy was nonetheless limited due to mixed reports that it may have increased the risk for infection and post-transplant lymphoproliferative disease (PTLD). Of these, standard pediatric monitoring would include all except assessment of pulmonary arterial wedge pressure (PAWP) and cardiac output via Swan-Ganz catheters due to concerns of catheter size and maintaining appropriate catheter position especially in smaller recipients. Although there is currently no universally accepted desensitization protocol, multiple agents have been used including oral methotrexate, cyclophosphamide and mycophenolate mofetil.

No increased risk of infection or PTLD has been documented after ATG administration in several recent reports [ Use of novel interleukin-2 receptor antagonists (IL-2Ra) has increased over the last several years (Table ]. The ISHLT guidelines recommend peri-operative antibiotic prophylaxis against skin flora, particularly Staphylococcus aureus, and, if donor infection is confirmed, additional targeted therapy against the potentially transmittable donor organism should be strongly considered [ Up to 7% of children may develop a peri-operative fungal infection following transplant [ ]. The recent ISHLT guidelines recommend initiating treatment with oral or IV ganciclovir or valganciclovir for CMV+ or CMV-mismatched pediatric recipients [ Despite evolving immune therapies, rejection continues to be a major source of morbidity and mortality in the immediate post-operative period. This infection type is often localized, but disseminated disease can occur and is associated with an increased risk of death during the first year post-transplant [ ]. In addition, the opsinization of CD-3+ T-cells can lead to the release of multiple cytokines causing headache, nausea, vomiting, fever, chest pain, and dyspnea from pulmonary edema, collectively termed “cytokine release syndrome” [ ].

Induction immunosuppression for transplants performed January 2001–June 2009. Recipient congenital heart disease, pre-transplant mechanical support, increasing donor ischemic time, anoxia-mediated donor death, prolonged donor resuscitation time, and increasing donor:recipient weight ratio have all been associated with increased graft failure risk [ ], while donor blood type O+ and donor hyperdynamic systolic function are protective [ ]. The mechanism of RV failure in the immediate post-OHT period is multifactorial. Given this risk, particular attention must be paid to adequate control of the post-operative PA pressures. Often, iNO is continued for several days post-operatively when RV failure is a concern [ ]. Initiation of antifungal prophylaxis with nystatin or clotrimazole is recommended after extubation [ Pneumocystis jiroveci infection has been reported in approximately 4% of adult heart transplant recipients and presents with acute and potentially fatal systemic illness [ ]. Endomyocardial biopsy (EMB) is the gold standard for diagnosis [ ]. Tjang and colleagues reported a single center series of 116 patients post-transplant and found that recipient age 210 minutes were associated with increased 30-day mortality. Hyperacute (pre-formed antibody mediated) rejection may also be an etiology for cases of profound hemodynamic instability [ ] and often requires aggressive therapies including mechanical circulatory support and plasmapheresis for reversal. For patients in whom avoidance was not tolerated or attempted, steroid withdrawal has been consistently and successfully implemented over the last decade as a strategy to decrease the adverse late-effects of steroids.

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No difference was identified in probability of infection based on induction (i. Tjang and colleagues reported a single center series of 116 patients post-transplant and found that recipient age 210 minutes were associated with increased 30-day mortality. Successful desensitization after use of these drugs was generally poor, and more recently, clinicians have implemented strategies using Rituximab and IVIg. Individual transplant physicians dose these agents to target total lymphocyte counts of 0. Nitric oxide may be started intra-operatively when significant RV dysfunction or failure is first recognized, and some centers empirically treat all patients with pulmonary vasodilators prior to weaning from cardiopulmonary bypass as recent studies have shown this strategy decreases the incidence of post-operative right heart failure [ ].

Both preparations lead to production of polyclonal antibodies against multiple human antigens including immune cell surface receptors and HLA antigens expressed on T-lymphocytes [ ]. In infants, more than 50% of deaths in the first post-transplant month have been attributed to primary graft failure [ ]. There are two currently available forms utilized in pediatric transplantation: basiliximab (Simulect, Novartis, New Jersey, USA), a chimeric mouse/human antibody, and daclizumab (Zenapax, Roche Pharmaceuticals, New Jersey, USA), a humanized (>90% human, 1 month post-transplant) or recurrent rejection [ ]. Recombinant factor VII may be useful for refractory bleeding [ ]. When inhaled, it preferentially dilates local vascular beds in well ventilated areas of the lung and has been effective in treating primary pulmonary hypertension in adults [ ].

The catecholamine stores of the newly transplanted heart are often depleted necessitating exogenous catechol supplementation [ ]. Injection of the polyclonal sera into humans leads to antibodies coating recipient immune cells, which results in rapid depletion of recipient T-lymphocytes via opsinization, phagocytic, and natural killer cell mechanisms [ ]. There have been fewer confirmed infections in pediatric patients, but because of its virulence in immunosuppressed patients, current recommendations are for 3-24 months of post-transplant prophylaxis with trimethoprim/sulfamethoxazole, aerosolized pentamidine isethionate, pyrimethamine or dapsone (with or without trimethoprim) in patients with sulfa allergies [ Cytomegalovirus (CMV) infection is the most common infectious agent identified after pediatric transplant, and the incidence in post-transplant patients who have not received CMV prophylaxis is 60-90% [ ]. In this group, production of anti-HLA antibody may occur during use of a ventricular assist device, prior blood transfusions (especially platelets), or following implantation of cryopreserved homografts which are used in many surgical reconstructions [ ]. IVIg is first administered to bind and remove circulating anti-HLA antibodies. This technique enables the recipient center to remotely predict the risk of accepting a given donor since Luminex technology allows quantitative identification of potential donor-specific antibodies. This contrasts with a 20% risk of RV failure in patients without increased PVR [ ]. Roche and colleagues (2008) similarly found low rates of cellular rejection in their ABOi patient cohort (n=21) [ ]. Recipient congenital heart disease, pre-transplant mechanical support, increasing donor ischemic time, anoxia-mediated donor death, prolonged donor resuscitation time, and increasing donor:recipient weight ratio have all been associated with increased graft failure risk [ ], while donor blood type O+ and donor hyperdynamic systolic function are protective [ ]. Over the last decade, treatment with pulmonary vasoactive substances has been used as first-line therapy or in conjunction with the above-listed maneuvers.

Poster Presentations - Arteriosclerosis, Thrombosis, and Vascular ...

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