PACEMAKER: April 1996
Deaf patient receives UIHC's first auditory
brain stem implant
The brain stem project is one of the first results of a new
philosophy of vision and program investment enabled by the convening
of the UIHC and College of Medicine into the UI Clinical Enterprise.
Recognizing that financial resources are limited, the Clinical
Program Development process identifies and provides broad support for
promising clinical initiatives.
The brain stem implant program was one of the first approved under
the Clinical Enterprise "new vision" philosophy in July 1995.
Building on more than a decade of clinical expertise developed in
cochlear implants, with 11 years of continuous funding from the
National Institutes of Health, the brain stem project is now
implemented.
41-year-old deaf man from Coralville, Iowa, is the first
University of Iowa Hospitals and Clinics patient to receive an
innovative brain stem operation that could enable him to again
experience sound.
Mukunda Kantamneni, a senior programmer analyst in the Department
of Otolaryngology-Head and Neck Surgery, received an auditory brain
stem implant April 5, 1996, in a 14-hour procedure performed by Bruce
Gantz, MD, Professor and Head of the Department of Otolaryngology,
and Arnold Menezes, MD, Professor and Vice Chair in the Division of
Neurosurgery, Department of Surgery.
Although Kantamneni is deaf, UIHC physicians hope the special
electronic device they implanted into his left brain stem nucleus
will eventually enable him to hear sounds that, with training, he can
interpret as words.
Auditory brain stem implants function similarly to cochlear
implants, electronic devices used by some deaf people. However,
cochlear implants can only benefit deaf people who have healthy
auditory nerves (nerves that connect the inner ear with the brain).
Patients lacking functional auditory nerves may benefit from auditory
implants, which were developed at the House Ear Institute in Los
Angeles. Clinical trials are now ongoing in five centers in the
United States, three in Europe, and one in Australia. Fewer than 50
implants have been placed to date.
The University of Iowa became a trial center because of its
world-class expertise in cochlear implant research and development.
Other specialists involved with the brain stem project include
Otolaryngologist/Speech Pathologist Paul Abbas, PhD; Associate
Research Scientist Carolyn Brown, PhD; and Otolaryngologist Jay
Rubinstein, MD, PhD, whose electrophysiology monitorings are
essential for correct placement of electrodes in the brain stem
during surgery.
Early trials indicate that many deaf patients with non-functioning
auditory nerves may benefit from auditory brain stem implants.
"It's too soon to say whether Mukunda will actually hear sound
with this implant, although we certainly expect that he will," Dr.
Gantz says. "We won't see the first indications of improvement for a
few weeks, and he won't realize maximum benefit from the implant for
at least a year."
Kantamneni has been deaf for approximately 15 years because of
neurofibromatosis II, which causes tumors to grow on his hearing
nerve. Although surgeons elsewhere removed those tumors in previous
operations, they eventually grew back. Untreated, the tumors can
continue to grow, compress the brain, and cause death.
Drs. Gantz and Menezes removed one such tumor as part of the
implant procedure, which requires an 8-inch incision behind the ear
and removal of skull bone about the circumference of a baseball for
access to the tumor and brain stem.
Auditory brain stem implant technology includes four major
components:
- A microphone worn by the recipient on the outer ear, and
connected by wire to a speech processor;
- The speech processor (which transforms acoustic information into a
digital signal) worn by the recipient in a pocket or on a belt and
connected by wire to a tiny transmitter;
- The transmitter, worn behind the ear and connected through the skin
to a decoding chip;
- The decoding chip, attached by wire to an internal coil, which
connects to an electrode placed on the brain stem nucleus.
"This device delivers different frequencies of information to the
brain, enabling the recipient to hear a variety of sounds," Dr. Gantz
says. "A few recipients can actually talk on the telephone."
Brain stem implant technology is one approach to enabling deaf
people to hear sounds. Dr. Gantz and another group of UI researchers,
including Neurosurgeon Matthew Howard, MD, are investigating another
new hearing technology for implantation into the auditory cortex, or
hearing portion of the brain (Pacemaker, February 1996).
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Multidisciplinary team treats complex airway
obstruction
The 15 years Paul Seddon worked at a radiator shop in Centerville,
Iowa, was largely a labor of love.
He seldom missed work, and enjoyed being around cars of all types,
including demolition derby cars and old cars in need of restoration.
Unfortunately, emphysema disabled him at age 45, forcing him to
give up his job. As his condition worsened, he required a lung
transplant at the University of Iowa Hospitals and Clinics.
Last November, Seddon developed bilateral bronchial stenosis. In
effect, his airways became so narrow that he couldn't clear them by
coughing. Seddon subsequently became one of a growing number of
patients who benefits from the expertise of the UIHC's
multidisciplinary Adult Airway Team.
These patients experience conditions ranging from benign airway
obstructions caused by trauma or inflammatory disease, to
malignancies resulting from lung cancer or secondary deposits from
breast cancer.
In Seddon's case, team members cleared the right bronchial tube
with balloon dilatation, in which a bronchoscope-guided balloon was
inserted through the tube and inflated, opening the bronchial airway.
Balloon dilatation also cleared Seddon's left side bronchial tube
obstruction, but the narrowing returned. The Adult Airway Team solved
this problem by implanting a silicone sleeve to hold the airway open
and restore near-normal breathing.
"It helped me quite a bit at a time when I needed it," says
Seddon, 49, who lives in Mystic, Iowa, with his wife, Joyce.
Pulmonary disease specialist Geoffrey McLennan, MD, Associate
Professor in the Department of Internal Medicine, leads the Adult
Airway Team, which specializes in resolving complex breathing
problems in patients like Seddon.
"Patients with benign and malignant obstructions of the trachea
and the main bronchi can be helped if they get the right kind of
health care," Dr. McLennan says. "These patients often present
complex treatment challenges, largely because they may have a very
compromised airway, making it difficult to administer anesthesia. A
range of treatment options is offered by different specialties, and
several new procedures have been introduced, with Kurt Wolf in
Respiratory Therapy being especially helpful."
Dr. McLennan says the Adult Airway Team performs a full range of
upper airway procedures, depending on each patient's specific
condition. These include:
- Balloon dilatation of the type received by Paul Seddon;
- Stent implants, either silicone or wire mesh;
- Treatment with a carbon dioxide laser or Nd:YAG laser;
- Brachytherapy (radiation delivered by a radioactive implant placed
next to a cancer that is partly obstructing an airway);
- Surgical reconstruction of the airway in complex cases.
In addition to Dr. McLennan, other members of the
multidisciplinary Adult Airway Team include Otolaryngologist Scott
Graham, MD; Thoracic Surgeon Kemp Kernstine; Radiation Oncologist
Fred Doornbos, MD; Interventional Radiologist Elvira Lang, MD;
Physiologist Eric Hoffman, PhD, and Pulmonologist Steve Hempel, MD.
"The key to effective treatment for all airway patients is proper
evaluation of the problem, which is why we provide a complete
multidisciplinary service," Dr. McLennan says. "If you correctly
identify the problem and apply the correct solution, you get good
results. If not, you can traumatize the condition and worsen the
problem."
An exciting new aspect of upper airway care involves a
sophisticated, 3-dimensional imaging system developed by Dr. Hoffman
and colleagues in the Division of Physiologic Imaging, Department of
Radiology.
"We're actually one of the few institutions anywhere that offers
this evaluative process and the range of procedures for airway care,"
Dr. McLennan says. "This new imaging software enables us to
accurately measure and anatomically assess the airways so that we can
pre-plan effective treatment with a minimum patient risk."
Questions about the UIHC's Adult Airway Team may be addressed to
Dr. McLennan at (319) 356-3603, or any other team member.
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Outpatient diabetes program teaches
self-management skills
The cold, complex realities of diabetes took 19-year-old Amy Stark
by surprise.
"I always thought diabetes meant you couldn't eat sugar any more
and you gave yourself insulin shots," says Stark, a University of
Iowa sophomore from Cedar Falls. "I'm finding out it's a lot more
than that."
Stark's insight came during her first day at a new Outpatient
Diabetes Self-Management Education Program at the University of Iowa
Hospitals and Clinics. Stark enrolled in the program shortly after
learning that diabetes was causing her blurred vision.
"I guess I was kind of frustrated by the diagnosis, but I didn't
know very much and I was kind of curious, too," she says. "Now I'm
learning a lot about what it really means to be diabetic."
The UIHC's Outpatient Diabetes Self-Management Education Program,
coordinated by Advanced Practice Nurse Vicki Kraus, ARNP, CDE, began
10 months ago. Kraus says the program meets the American Diabetes
Association's instructional standards.
"Most of our program staff are Certified Diabetes Educators," says
Kraus, noting that nine staff nurses with diabetes expertise,
together with full-time diabetes dietitian Sydne Carlson, RD, LD,
CDE, teach the program's classes.
The program's physician liaison is John MacIndoe, MD, Associate
Professor in the Department of Internal Medicine. He and eight other
endocrinologists provide physician support.
"In the interest of patient safety, a UIHC primary care physician
is available to participants while they attend the program," Dr.
MacIndoe says. "Patients who do not already have a UIHC physician are
asked to visit briefly with one of our endocrinologists before
starting the program."
The UIHC's Diabetes Education Program dates to 1982, when Drs.
Robert Hardin and Joseph C. Brown launched an inpatient program for
diabetes patients.
Kraus says, "Beginning in late 1994, it became very clear that we
had to make the program more accessible to outpatients. We reduced
the four-day program to three, with a two-day option. Because
insurance companies frequently do not pay for patient education
services, the charges were reduced so more people could afford to pay
for the program out-of-pocket."
The current fee for the three-day program is $175, while the
two-day program is $125. Family members may attend free.
"We think this is very reasonable for what people get," Kraus
says. "It's really a very wise investment in the future, an
opportunity to learn or sharpen the skills necessary for diabetes
self-care."
A noon meal is served each day of the program. This meal is
optional for all participants and involves a modest additional fee,
but is highly recommended as a dietary educational tool.
Carlson writes food choices on the blackboard, then guides and
supports patients with their food choices. Choosing a small dessert
portion is acceptable, for instance, but affects other food choices
because of its carbohydrate and fat content.
"This noon meal service is one of the unique aspects of our
education program," Carlson says. "It's a very effective way to teach
patients with diabetes how to make appropriate food choices."
The UIHC's diabetes education program serves patients with all
types of diabetes. The two-day course teaches self-management skills
essential for all persons with diabetes. The three-day course
provides more in-depth information and assistance in developing
problem-solving and coping skills.
For more information contact Vicki Kraus at (319) 356-1616 and ask
for pager 5260.
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Surgeons complete first UIHC small bowel
transplant
Debbra L. Taft says she cried uncontrollably after learning that
doctors had located a donor organ that would permit her to receive a
small bowel transplant.
"I was in my car on the way to pay our light bill when the beeper
went off," says the 41-year-old resident of Albion, Iowa. "It was a
signal from Stacey Abel (a transplant coordinator at the University
of Iowa Hospitals and Clinics) that they'd found a donor organ. I
think I hit every red light on my way to a phone."
Taft, who required the operation because of a near-fatal auto
accident in May 1991, underwent the procedure on April 5, 1996. It
was the first such transplant performed at the University of Iowa
Hospitals and Clinics.
Transplant surgeons Youmin Wu, MD, Maureen Martin, MD, and
Ferdinand Ukah, MD, and transplant hepatologists Michael Voight, MD,
and Donald Hillebrand, MD, used the small bowel from a teen-age
donor.
UIHC transplant teams also transplanted the donor's heart and
liver to other patients, while other tissues, including a cornea,
were also used. In addition, the donor's kidneys were a perfect match
for patients elsewhere, bringing to five the number of people
benefiting from the donated organs.
"Everything went extremely well," Dr. Martin says. "We're very
pleased to get our small bowel program off to a successful start."
Dr. Wu says small bowel transplants present more complications
than most other transplant procedures. "Fewer than 200 small bowel
transplant procedures have been performed worldwide, so it's still
relatively new," he says. "We still have much to learn about
long-term patient survival, but considerable progress has been made
the past few years. For Debbra, as for most patients, the first
couple of months of recovery will be especially critical."
Patients requiring small bowel transplantation have short bowel
syndrome, in which they lack a complete small intestine. Some
children experience short bowel syndrome because of other conditions,
while people of any age can experience infections, diseases, or
accidents that cause it.
Taft's accident, which occurred on Highway 30 near Marshalltown,
cost her segments of her large and small bowel, her gallbladder,
appendix, and spleen. She also sustained two broken legs, a broken
right wrist and gashes in her right knee and left ankle. As part of
the life-saving care she received at the Marshalltown Medical &
Surgical Center, doctors transfused 42 units of blood into her
system.
"I wasn't supposed to make it," she says. "My bowel was dying so
they had to go back into surgery to remove all but 18 inches of the
small bowel and 5 feet of large intestine," she said. "That's why I
needed the transplant."
Since most people have 25 feet of bowel, Taft's abdominal organs
for digesting food were severely compromised. Until the transplant,
she had been required to perform nightly, time-consuming intravenous
(IV) feedings. "I could eat food," she says, "but my system didn't
absorb enough nutrition to keep me alive without artificial
feedings."
The IV feedings also led to serious infections that kept Taft
hospitalized off and on the past three years. Doctors also ran out of
line sites in the body, severely limiting their ability to get IV
nutrition into her system. During the past year alone, she was
hospitalized seven times.
After learning a donor organ had been found, Taft drove to Iowa
City in a three-car family caravan that included her husband, John.
"You never know how you're going to handle it until it happens,"
John says. "I guess you could say I was excited and a little bit
scared."
In addition to transplantation of the small bowel alone, as in
Taft's case, transplant surgeons also perform two other types of
small bowel procedures. One is transplantation of the small bowel and
liver for patients who suffer liver damage from IV nutrition, and
another is the multivisceral transplant in which surgeons transplant
the stomach, intestine, large bowel, liver, pancreas, and sometimes
kidney.
Dr. Martin recruited Dr. Wu to help develop a multi-organ
transplant program at Iowa. He spearheaded the early experience in
small bowel transplant procedures in the mid-1980s while at the
University of Pittsburgh, where approximately half of all the
procedures have been performed to date.
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Experts believe organ donor paradox can be
resolved
Sixteen years later, Joe Liddell still regards the car crash that
killed his teen-age daughter as more than a tragedy. It was also a
lost opportunity.
"We were so caught up in the tragedy of the moment we never
thought about Becky being an organ donor," Joe says. "It never
crossed our minds, and no one asked."
Becky Liddell died on August 14, 1980, from injuries sustained in
a car crash on Highway 30 near Mount Vernon. She received treatment
in the same hospital where her mother, now deceased, worked as a
nurse.
"Becky would have liked that ... being an organ donor," Joe says.
"She would have liked to see her organs going on and helping someone
else. My wife used to talk about that once in awhile, how we would
have supported it."
Joe Liddell's lament reflects the reality of organ donation in
Iowa, according to a new survey conducted by Sheldon F. Kurtz and
Michael J. Saks at the University of Iowa College of Law and
sponsored by the Iowa Statewide Organ Procurement Organization.
Entitled "The Transplant Paradox: Overwhelming Public Support for
Organ Donation vs. Under-Supply of Organs," the survey shows that 96
percent of Iowans strongly desire to be organ donors.
Eighty-four percent of those surveyed said that if they lost a
child, they would agree to donate that child's organs to someone in
need.
"The critical thing is, someone has to ask," Kurtz says. "If
they're asked, the odds are overwhelming the families will concur."
The statistically valid Iowa Organ Procurement Study asked 834
Iowans a range of questions on organ procurement issues. The results
provide ample evidence of overwhelming support for organ donation.
Unfortunately, based on national statistics and personal
observation, surviving family members aren't being asked often enough
to assure a steady donor organ supply, according to Lawrence
Hunsicker, MD, a transplant specialist at the University of Iowa
Hospitals and Clinics and Secretary of the United Network for Organ
Sharing.
"Last year, the state of Iowa had only 45 cadaver organ donors,
and 70 the year before that," he says. "Statistically, these just
aren't big enough numbers, even if you assume a standard 25 percent
non-consent rate. It's clear we're not getting all the organ donors
we should."
This organ donor shortage, both national and statewide, translates
into lost hope for patients needing organ transplants. Every year,
hundreds die waiting for organ transplants.
Dr. Hunsicker, among others, believes the status quo can be
changed, but not without a concerted effort by the entire medical
community. It begins, he says, with acknowledge-ment that an organ
procurement problem exists, and that something should be done about
it.
"We're certainly not criticizing anyone," he says. "Virtually all
doctors support the concept of organ donation in principle. However,
doctors are trained to provide patient care, and that's their entire
focus. They're not focused on organ donation at the time of death.
There's a sense of, 'I've done everything I can, but it failed and
that's the end of it.' This is understandable. It's human nature."
The change Dr. Hunsicker envisions parallels what the medical
community does for cardiopulmonary resuscitation training.
"We don't all expect to use CPR, but we all know we must be
certified just the same," he says. "It's part of our profession.
Maybe we need a similar institutional commitment to an explicit
method of putting the organ donor question before each doctor when a
patient dies."
Such a commitment might involve a short addition to the
certificate doctors must sign when patients die.
Dr. Hunsicker adds that the actual asking of families should be
done by trained organ procurement specialists. "This takes the onus
off the doctor, and gets it into the hands of people trained to
handle this very sensitive situation. Doctors really shouldn't have
to do it, because many of them aren't comfortable with it."
In addition, he believes doctors would benefit from improved organ
procurement education. "A lot of times even doctors aren't sure what
makes a good donor," he says. "They need more information. It needs
to be known that, 'Yes, the 60-year-old woman with diabetes can be an
organ donor.'"
The medical community should also take a voluntary organ donor
audit after every death, Dr. Hunsicker says. This would permit annual
audit reviews to identify where organ procurement breakdowns occur.
"There's no question we can do better," Dr. Hunsicker says, adding
that by their very nature, Iowans are generous.
"They're givers," he says. "There's also room to accommodate the
25 percent who aren't sure about organ donation. And this state's
Organ Procurement Organization ranks right up there with the best.
Somehow, we simply need to bring all this together to get the
referral patterns for organ donation working, and working right."
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Son's achievements turn mom's anger to praise
of UIHC physician
If courage were the sole measure of success on the high school
wrestling mat, Keith Nollen would have a mantel full of first-place
trophies.
Instead, the 17-year-old senior at Mediapolis High School proudly
accepts his fifth place finish in the 1996 Class 2A tourney
sectionals as the crowning achievement of his high school career.
For Nollen, his family, and friends, that fifth place finish ranks
as a benchmark victory-a living testament to his indomitable spirit.
Because of cancer, Nollen has only his right leg. Every sweaty
practice session, every "in-your-face" match throughout his four-year
high school career was fought with a two-and-one-half-pound Styrofoam
rubber protective device on his left leg.
Nollen's challenge to succeed at anything in life-let alone
wrestling-began at age five when he was diagnosed with osteosarcoma,
or bone cancer of the leg. Because his tumor was unusually aggressive
and did not respond well to drug therapies, the only possible method
of saving his life was to amputate above the knee.
Marsha Nollen recalls her anger when Joseph Buckwalter, an
orthopaedic surgeon at the University of Iowa Hospitals and Clinics,
told her that despite the amputation, her son could do anything in
life he wanted.
"When he told me that, I thought he was crazy," she says. "I
thought, 'How can you cut off this little boy's leg and think it
won't affect him?' But it hasn't. Keith's done everything he's wanted
to do."
Marsha, in fact, was so thrilled with her son's achievements-seven
match wins during his senior season in addition to the fifth place
finish-that she penned a letter of gratitude to Dr. Buckwalter.
"You were right," she wrote. "He's a great kid. Thanks for all
you've done for him." Meanwhile, Keith Nollen doesn't think any great
fuss should be made over his wrestling achievements.
"I really don't think anything of it," he says. "I've been
wrestling since the fourth grade, so everybody's used to it. I don't
see this as a handicap at all. It's just another minor setback."
Nollen's wrestling coach, Dan Cummings, says Keith's "never-quit"
attitude kept him competitive in a physically demanding sport.
"His only effective strategy was to wrestle his opponent on the
mat, rather than on his feet," he says. "If he could get an opponent
on the mat and get his cradle, Keith was really tough. The problem
was getting to that point. He didn't win a lot of matches, but he
sure did a lot for us as a competitor."
Wrestling wasn't the only sport in which Nollen used his
considerable strength. He competed three straight years as a
weightlifter in the Iowa Games, an annual competition for amateur
athletes. He finished first for two consecutive years, competing
initially as a 123-pounder and then as a 132-pounder, before
finishing third last year as a 148-pounder.
Marsha Nollen notes that her son wears a "200 percent" T-shirt,
indicating he can bench press twice his body weight. "He's only the
second in school history to achieve this," she says proudly.
Nollen plans to attend the University of Northern Iowa, where he
intends to major in physical education.
Dr. Buckwalter describes Nollen as a wonderful example of how
hardships of bone cancer or other disabling illnesses do not have to
become overwhelming obstacles. "It doesn't always work out so well,
but Keith serves as an inspirational example of what can be done when
people make up their minds to succeed, no matter what."
