Parenteral administration of ivermectin in a patient with disseminated strongyloidiasis.

We report the case of a 23-year-old Caribbean man with disseminated strongyloidiasis (co-infected with human T cell lymphotropic virus I/II)), severe hypoalbuminemia, and a paralytic ileus. Subcutaneous ivermectin (200 microg/kg) was administered daily for 14 days because of the inability to effectively administer oral albendazole and oral ivermectin. Three hours after the third daily dose of oral ivermectin, the serum ivermectin concentration was only 0.8 ng/mL, but it increased several fold to 5.8 ng/mL 16 hours after the first dose of subcutaneous ivermectin. During the course of subcutaneous treatment, ivermectin clearance was higher than expected (46.0 L/hour, normal = 31.8 L/hour). This is likely the result of severe hypoalbuminemia since ivermectin is highly protein bound. The ability to achieve adequate levels of ivermectin after oral administration in patients with disseminated strongyloidiasis may be impaired, highlighting the need for alternative routes of administration of ivermectin in these patients.

Use of a composite Biomer-butyl rubber/Biomer material to prevent transdiaphragmatic water permeation during long-term, electrically-actuated left ventricular assist device (LVAD) pumping.

The pumping diaphragm of the Texas Heart Institute (THI) E-Type ALVAD must perform the dual functions of providing a flexible blood interface and isolating the electrical actuator from adjacent fluids. Thus, protection is required against fluid leakage and moisture diffusion to prevent corrosion and damage to electrical actuator components. Average diffusion rates up to 1 ml per day through currently used elastomeric diaphragm materials have been measured during static in-vitro and in-vivo tests. To circumvent this problem, an improved pumping diaphragm has been recently developed for use with the electrically-actuated THI E-Type ALVAD. This trilaminar diaphragm consists of a composite Biomer and butyl rubber design. A.010 inch layer of butyl rubber (characterized by an extremely low diffusion rate for water, approximately 0 ml per day) is positioned between two Biomer layers (.020 and.010 inches in thickness). Initial invitro and in-vivo studies, in calves, indicate that this composite diaphragm provides an excellent barrier to water permeation, without sacrificing biocompatibility or structural integrity under conditions of chronic flexure.

Transascending aortic intraaortic balloon insertion with delayed sternal closure: A retrospective analysis.

Intraaortic balloon pumping (IABP) is an established therapeutic adjunct in the treatment of postcardiotomy/infarction low cardiac output states. Although the common femoral or iliac arteries are the preferred sites for balloon insertion, severe arterial occlusive disease may preclude entry by these methods. To circumvent this problem, alternative methods of insertion utilizing transthoracic approaches have evolved. In our institution, direct (transaortic) IABP insertion, combined with delayed sternal closure to avoid cardiac compression and possible tamponade, was performed in 28 adult postcardiotomy patients (mean age 60.4 +/- 3 years). The severity of generalized atherosclerosis was reflected in an overall survival rate of 28.6%. Retrospective analyses of the clinical courses of these patients revealed that the transaortic approach allowed utilization of larger and more effective balloons. Successful insertion of 30 and 40 ml balloons was accomplished in 27 of 28 (96%) of these patients, and one patient with a hypoplastic aorta required a 20 ml balloon. There were no complications directly attributable to this alternative site of balloon insertion, and tamponade was avoided. Delayed sternal closure was accomplished within 48 to 96 hours. We concluded that when severe peripheral vascular occlusive disease prevents insertion of intraaortic balloons via the femoral or iliac arteries in patients with low cardiac output, the alternative transaortic approach is indicated. Combined with delayed sternal closure in patients with postcardiotomy dilatation, additional benefits accrue.