Symptomatic zinc deficiency in a one-year-old child precipitated by changing from formula to cow's milk.

The case of a one-year-old girl with symptomatic zinc deficiency is presented. She had been misdiagnosed as having impetigo and/or candidiasis and had been treated with topical antifungal agents and both oral and topical antibiotic agents without success during the four months before she presented. Zinc replacement led to rapid improvement. Her nutritional history suggests that weaning from formula to cow's milk precipitated her eruption. The clinical findings, differential diagnosis, and treatment of zinc deficiency are reviewed.

Electrical control of gastric emptying in denervated and reinnervated canine stomach: a pilot study.

Gastric emptying of solids is abnormally slow after vagotomy. To determine whether it was possible to accelerate emptying by electrical stimulation either of the gastric wall directly or of a "foreign" nerve brought in to reinnervate the stomach, eight dogs underwent truncal vagotomy (TV); five of the dogs received intercostal nerve muscle pedicle (NMP) implants. Gastric atony was demonstrated postoperatively in all animals up to 4 months later by means of radiological contrast studies. After allowing time for neurotization to occur (mean 78 days), the cervical vagi were stimulated to confirm that TV was complete. Gastric peristalsis, intraluminal pressures, and emptying were assessed during stimulation of the NMPs and of the gastric wall, followed by sacrifice for histologic study. Neither reinnervation alone nor stimulation of the NMPs improved emptying. Although viable somatic nerve was found in the gastric wall, nerve sprouting was not. By contrast, stimulation of the gastric wall with trains of pulses (20 Hz, 2-10 ms, 2-5 mA) evoked peristalsis in all animals. We conclude that somatic nerve tissue cannot produce functional reinnervation of a visceral organ; however, direct muscular stimulation can accelerate gastric emptying after TV.

An artificial myotatic reflex: a potential avenue to fine motor control.

When a striated muscle becomes paralyzed, not only its motor function, but its sensory innervation may be impaired. Methods of rehabilitation have previously focused only on motor innervation, although striated muscles are submitted to self-regulation of length and tension. Indeed, reinnervated muscle may not contract appropriately unless sensory information is available, nor is it known whether sensory receptors are included in the reinnervation process. We hypothesized that the myotatic reflex (MR) would be absent in the event these sensory organs are not reinnervated, and that an artificial myotatic reflex (AMR) would be useful in reestablishing fine motor control. The strap muscles were exposed in six anesthetized rabbits. The MR was verified by stretching an intact sternohyoid muscle. Next, loss of the reflex was documented after the ipsilateral ansa hypoglossi was divided, and a crossover nerve-muscle pedicle (NMP) was brought in from the opposite sternothyroid. After 3 months, the MR was still absent; however, stretch of the contralateral sternohyoid produced a reflex response on the reinnervated side. A strain gauge sutured to the reinnervated muscle was linked to an electronic modulator so that stretch induced electric stimulation of the NMP and contraction (the AMR). We conclude that (1) proprioception is not reestablished in the reinnervated muscle; (2) by contrast, sensory information from the muscle of origin of the NMP is conveyed to the reinnervated side; and (3) the AMR offers promise toward more sophisticated control of paralyzed (i.e., facial, laryngeal) musculature.

Contractile response to electrical stimulation of the small intestine in anesthetized and awake dogs.

To test whether small bowel contraction can be induced by electrostimulation similar to in vitro results in anesthetized and awake animals, five dogs had stainless steel electrodes implanted on the serosal surface of the jejunum and ileum. Fifty milliamperes of 500-microseconds 910-Hz currents induced a 50-80-mm Hg pressure increase in the jejunum with a threshold of 25 mA. Transverse stimulation was studied long-term in two dogs. The mean pressure change for 500-microseconds 910-Hz 25-mA stimulation in 10 studies was 26 mm Hg (0-75). The thresholds ranged between 15 mA and currents not tolerated by the animal. For 200-microseconds 1.67-kHz 30-mA stimulation, the mean pressure change was 28 mm Hg (0-75 mm Hg, n = 16). On 10 occasions, the pressure increased further after termination of the stimulus (off response), with a mean of 48 mm Hg (10-85). Electrical currents elicit a mechanical response in the small intestine of the intact animal, which resembles the in vitro observations. Currents necessary to evoke contractions in the physiologic range are tolerated by the trained animal.

Excitation thresholds for nerve pedicles: a preliminary report.

Ongoing interest in the rehabilitation of paralyzed musculature in the head and neck has focused on the electronic stimulation of nerve-muscle pedicles that have been reimplanted into the incapacitated effector(s). Despite visual and histochemical evidence of reinnervation, it is still not known whether the excitability of a nerve-muscle pedicle (or for that matter a direct nerve implant) is equivalent to or better than that of reinnervated or normal muscle. Such information is necessary for the eventual construction of an implantable stimulator. Eighteen rabbits were anesthetized with intramuscular xylazine and ketamine and the ansa hypoglossi nerve was cut on one side. A crossover nerve-muscle pedicle was brought in from the opposite sternothyroid muscle to the sternohyoid in nine animals; the other nine received a direct nerve implant. After a minimum neurotization period of 3 months and reexploration, an electrical stimulator capable of delivering square wave pulses of variable amplitude and width was used to determine the thresholds of contraction of the nerve pedicles, an intact motor nerve of similar size, a normal muscle, and the reinnervated strap in 16 evaluable rabbits. Strength duration curves were established. The data indicate that thresholds for nerve pedicles are equivalent to those of normal nerves and are significantly lower than those of muscle.

Electrical pulse train and single pulse stimulation of the small intestine: acute and chronic studies in the dog.

In vitro tests have shown that electric currents may lead either to relaxation or contraction of the bowel wall. Because voluntary changes of the intestinal motility could be useful in the treatment of intestinal disorders, we investigated the reactions elicited by electrostimulation of the small intestine in the intact animal. Stimulating electrodes, electroenteromyogram electrodes, and pressure monitoring tubes were used to instrument a 5-cm segment of the proximal jejunum in five dogs in acute studies and in two dogs in chronic studies. Single pulses of 200 ms elicited a pulsatile pressure increase of 10-35 mm Hg. Pulse train stimulation was followed by a more complex reaction. Trains of 500-microseconds, 910-Hz pulses at 30 mA evoked a 50-80 mm Hg pressure increase, 1-ms, 10-Hz trains caused an initial relaxation, followed by a pressure increase during stimulation and a further pressure increase after termination of the burst. These reactions were similar to those observed by Campbell working with colon in vitro. The chronic fasted animals reacted to 500 microseconds, 910-Hz, 25-mA stimulation with a mean pressure increase of 26 mm Hg (n = 10) and to 200-microseconds, 1.67-kHz, 30 mA stimulation with 28 mm Hg (n = 16). In the fasted animals a pressure increase during stimulation predominated (Campbell type I), whereas in the fed animal an additional off response after termination of the stimulation was the most common type of reaction (Campbell type II). Initial relaxation (Campbell type III) could be elicited by 1-ms, 10-Hz trains.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrostimulation of ileum and jejunum reservoirs in an acute and chronic experiment]. / Elektrostimulation von Ileum und Jejunumreservoiren im akuten und chronischen Experiment.

Voluntary control of the motility of intestinal reservoirs may be used to improve evacuation and continence. In 4 dogs a U-shaped jejunum pouch and in another 4 an ileum pouch was constructed and instrumented with stimulating and EMG electrodes and pressure lines. In the acute experiments jejunum pouch stimulation with 200 microseconds 1.67 kHz 30 mA increased the intrapouch pressure by 38 +/- 4 mm Hg (n = 6) and 500 microseconds 910 Hz 25 mA by 60 +/- 5 mm Hg (n = 3). The pressure increase in the awake animals was consistently lower (200 microseconds 4 +/- 6 mm Hg, n = 9; 500 microseconds 25 +/- 17, n = 11). The ileum pouch responded with a 37 +/- 10 mm Hg pressure increase (n = 9) to 50 ms 6 Hz 20 mA pulse trains. Ileum pouches could not be stimulated in the awake animal due to contraction of the abdominal wall. Electrostimulation may be used to contract and evacuate intestinal reservoirs but additional drug therapy or autonomic nerve stimulation will be necessary to lower the thresholds especially for ileum stimulation in the awake animal.

Biological performance of TiNi shape memory alloy vascular ring prostheses: a two year study.

A method was developed for the noninvasive insertion of a vascular ring prostheses aimed at preserving arterial patency and preventing restenosis following angioplasty. Using a specially designed 7F catheter 22 nitinol (TiNi) wire prostheses (I.D. 5 mm; 0.25 mm thickness) were torsion reduced in diameter and inserted under fluoroscopy into both carotid (n = 2) and iliac-femoral arteries (n = 20) of dogs. Aspirin (650 mg BID) and Persantin (200 mg BID) were given for only 30 days postoperatively. Angiography of all rings at 1, 6, 12 months exhibited excellent biocompatibility and long term patency 91% (20/22) as reported in Trans ASAIO 32:30, 1986. Four rings inserted in the right and left common iliac arteries and femoral artery were followed for up to 2 years and exhibited 100% patency. Angiography demonstrated that the anchorage of the prostheses was stable and the lumen was uniformly covered by a thin neointimal layer of endothelial like cells. The prostheses were patent with no evidence of thrombosis or inflammation. In view of the problem of recurrent stenosis occurring during the healing period after balloon angioplasty (PTA or PTCA), this approach may lead to a new means of clinical intervention in atherosclerosis.

Electrical control of intestinal reservoirs in a chronic dog model.

Pouches constructed from small intestine are used to replace reservoir function after extirpative surgery of the colon. Such pouches empty in an involuntary and uncontrolled fashion. To see whether emptying could be voluntarily controlled, ileal and jejunal reservoirs were constructed in eight dogs under general anesthesia. Four pairs of stainless steel electrodes were attached to the serosa at 5 cm intervals, and the pouches were intubated for pressure measurements with 1.67 mm polyethylene catheters. All lines were brought subcutaneously to the neck where they were maintained under a protective jacket. One to four weeks later, the pouches were stimulated with trains of square wave pulses at frequencies between 3 Hz and 1.67 KHz. The pouches were injected with contrast, and the results were monitored by fluoroscopy. Intrapouch pressure increases as high as 80 mmHg were seen after stimulation at 3 Hz, 100 msec and 6 Hz, 50 msec (10 to 25 mA) and emptying was induced. Pressure increases were also seen after stimulation with 330 Hz, 1 msec and 10 Hz, 1 msec pulse trains, but emptying was not documented. Abdominal wall contraction during stimulation was a problem but could be inhibited by interposing an insulating silastic sheet. The conclusion was made that it is possible to electrically induce emptying of intestinal reservoirs in a chronic dog model.

New horizons in dynamic rehabilitation of paralyzed laryngeal functions.

Bilateral vocal cord paralysis can result in inspiratory difficulty, while stroke can impair swallowing and be followed by severe aspiration. Ideally, these mutually exclusive functions must be rehabilitated dynamically. The principle of the artificial reflex arc (ARA) entails appropriate pick-up information, which is then sent to a modulator that in turn synchronously stimulates the impaired effector. In vocal cord paralysis (six dogs), respiratory information has been picked up via tracheal strain gauges and transthoracic impedance electrodes, producing an analog voltage proportional to respective changes during inspiration. A trigger and a stimulator circuit were used to drive an electrode placed around a nerve-muscle pedicle previously implanted into the posterior cricoarytenoid muscle. Two msec square waves with 1.8 V amplitude and 50 Hz frequency resulted in frank vocal cord abduction synchronous with inspiratory flow. Conversely, vocal fold closure can be paced from information originating from strain gauges placed on the hypopharynx (four dogs). Stretch stimulating deglutition resulted in controlled output of a constant current stimulator driving an electrode passed around both recurrent laryngeal nerves. An adjustable stimulus from 0 to 20 mA at 25 Hz produced tetanic closure of the vocal folds. This might offer promise for electronic control of the transplanted larynx.

Development of an epicardial circulatory assist device.

The overall purpose of this project was to develop a circulatory assist device that could be used as a bridge to heart transplantation. Although heart muscle damage was one of the disadvantages with the original epicardial assist devices, as long as no bleeding occurs, such trauma would be of secondary importance in this particular application. The development of the proposed epicardial circulatory assist device (ECAD) was evolutionary in nature, with the second prototype design based on the lessons learned from that of the first. In vivo results from both phases of the project are reported. ECAD prototype 1 (ECAD-1) was composed of a flexible outer housing and two driving balloons. Fixation to the heart was adjustable for various heart sizes using Velcro fasteners. The design of the ECAD prototype 2 (ECAD-2) was based on the results of ECAD-1. Fixation to the heart was accomplished by suturing the outer housing onto the heart along the anterior descending artery and at the posterior atrioventricular groove. Each device was tested in five dogs. ECAD-1 was able to maintain the systemic circulation for 5 hours. However, unstable fixation and myocardial damage due to rubbing were the major problems. ECAD-2 passive effects on natural heart filling were acceptable. Under conditions of severe heart failure, a flow of more than 85% of control was obtained with a driving rate of 90-110 beats/min and 30% systole. The longest pumping was conducted for 8 hours. The ECAD was demonstrated to be a device useful in assisting the failing heart for short periods. Proper design will play a fundamental role in successful extended use.

Voluntary control of an ileal pouch by coordinated electrical stimulation. A pilot study in the dog.

Ileal reservoirs were constructed in four dogs under general anesthesia and stimulated by means of a constant current generator that produced pulse trains at frequencies between 6 Hz and 1.67 kHz. Stimulation at 6 Hz with 50 ms pulses between amplitudes of 15 and 25 mA uniformly produced pouch contraction and reservoir emptying. Stimulation at other frequencies did not cause pouch emptying although pressure increases were sometimes observed. Such electrical stimulation may be useful for voluntary control of intestinal reservoirs when used as replacement for urinary bladder or colon. The mechanism by which the intestinal contraction is produced appears to be different than that produced by slow wave pacing.

A technique to model the nasal airway for aerodynamic study.

This article presents a new technique for creation of a model that can be used to study the aerodynamics of the nasal airway. The model is employed to determine parameters used to calculate nasal resistance and modified to compare various types of nasal obstruction. It quantitatively compares the importance of septal deviation, turbinate size, and nasopharyngeal port size to airflow. A new parameter of nasal resistance is introduced.

A simple method for extended heart-lung preservation by autoperfusion.

A modification of Robicsek's autoperfusing heart-lung preparation preserved normal structure in the canine lung for 8 hrs and in the heart for 12 hrs. Applicable to both heart and heart-lung transplantation, the system would permit a safe extension of preservation time limits.

Volume compensation for left ventricle assist systems (LVAS): 18 month in vivo evaluation.

The smooth surface cycled chambers, both Biomer and silicone rubber, developed thick tissue capsules and exhibited persistent active tissue reactions at the diaphragm-capsule interface. Textured surface chambers (dacron velour), both the cycled and control, developed a thin, stable capsule, with no active tissue reaction. Textured surface chambers have been explanted and examined after 210 and 494 days. One experiment is continuing, approaching 2 yrs in vivo with good performance. Although the number of textured surface compliance chamber studies as yet is limited, the dramatic improvement in performance and tissue response between the smooth and textured surface studies demonstrates the biological feasibility of this method of variable volume compensation for use in completely intracorporeal LVAS.

Promising results with a new textured surface intrathoracic variable volume device for LVAS.

The smooth surface cycled chambers, both Biomer and silicone rubber, developed thick tissue capsules and exhibited persistent acute tissue reaction at the interface. The silicone rubber noncycled chambers either developed no capsule or a very thin capsule without the acute inflammation observed with the cycled side. The dacron velour surface chambers, both the cycled and noncycled, developed a thin, stable capsule, with no acute inflammation. The cycled dacron velour surface chambers have achieved almost one year with acceptable performance and are continuing at this time. These results with the textured surface compliance chambers compare favorably with the smooth surface series. Although the number of studies as yet is limited, the performance of the textured series compliance chambers shows promise for the application of the compliance chamber for use with totally implantable blood pump systems.