Archive for January, 2017

Partnerships That Foster The Exchange Of Healthcare Professionals

Mr. Nizar Mamdani, Executive Director, International Healthcare Services, Nebraska Medicine


The University of Nebraska Medical Center/ Nebraska Medicine’s International Healthcare Services (“UNMC”) is a renowned leader in patient care excellence in the United States and is internationally recognized for its innovative programs. It has world-class experts in patient-care, research, education, training and management to enhance patient-care delivery around the world. UNMC has established 124 collaborative partnerships in 44 countries. The diverse array of global partnerships touches patients around the world.

Nizar Mamdani, Executive Director of the International Healthcare Services, experienced first hand how extraordinary the healthcare delivery in cancer care and bone marrow transplantation is at UNMC. His wife, Nancy, was a Non-Hodgkin’s patient at UNMC. “I recognized the importance for international patients to be the ultimate beneficiaries from UNMC’s advanced treatment programs”, says Mamdani. He started UNMC’s International Healthcare department and the “No-Cost” healthcare training/observation programs for international healthcare professionals.


“No-Cost training programs work fairly simply. Healthcare professionals participate in a two-week, observership with UNMC’s experts. They receive free housing, meals, local transportation, and priceless training. The rewards of such training programs are returned many times over, because the patients, in their own countries, are the ultimate beneficiaries of our training programs”, says Mamdani. Hundreds of healthcare professionals have participated in UNMC’s No-Cost programs while 54 UNMC specialists visited 24 partner institutions for training.

Abdalla Bajawi, a trainee in Pathology from King Fahd Specialized Hospital, Dammam, Saudi Arabia said, “We are so impressed with advanced technology and the state-of-the-art medical advancement here. I’m training in HBLC and will transfer the knowledge to my colleagues when I go back”.

“The relationships Nizar describes are having a strong impact, according to Dr. James Armitage, a world-renowned hematologist at UNMC. “Anytime you can interact with colleagues around the world to the betterment of patients is excellent.”

For more information contact: nmamdani@nebraskamed.com; www.unmc.edu/international


Fostering Educational Collaboration in Neurology at UNMC

The Department of Neurological Sciences at University of Nebraska Medical Center/Nebraska Medicine (UNMC), offers highly specialized and individually customized Neurology Preceptorship programs in Parkinson’s, Huntington, Botulinum Toxin Chemo-denervation, Movement Disorders, Deep Brain Stimulation surgery and continuous Levodopa infusion pump therapy. Participation by international healthcare professionals in such program experiences help enhance their skills in specific sub-specialties.

UNMC has a proven track record in clinical services, medical education, biomedical research, and international outreach. Danish Bhatti MD, Director of UNMC says, “Our primary focus has always been to provide exceptional educational opportunities and extraordinary patient care at all levels. Our Neurology Preceptorship program is yet another example to fulfill a strong need of sub-specialty training exposure for practicing international Neurologists”.

UNMC’s one to three month’s Neurology Preceptorship programs are designed for fully-trained international neurologists in active practice, who are interested in advancing knowledge in cutting-edge technology and current guidelines/practices in their area(s) of interest.

“With rapid advancements in all Neurological sub-specialties, our Preceptorship programs enhance experiences in Movement Disorders, Stroke, Neuro-Critical Care, Epilepsy, Neuromuscular Medicine, Multiple Sclerosis, Neuro-Immunology, Inpatient Neurology (Neuro-Hospitalist) and other sub-specialties.” says Dr Bhatti. “Research is also a vital part of the department’s activities, including clinical and translational research for neurologic disorders such as Alzheimer’s, Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis, Parkinson’s, Peripheral Neuropathy and Stroke”.

Nizar Mamdani, executive director and founder of the International Healthcare Services says, “Dr. Bhatti is an inspiring and remarkable example of the caliber of specialists and researchers working tirelessly to help provide better Neurology treatment and educational opportunities. Through collaborative strategic partnerships with 122 institutions in 44 countries, we continue to provide innovative educational and treatment options, as well as specialized tele-pathology and second opinion consultation services for Neurology, Cancercare and Transplantation patients around the world,” says Mamdani. Contact: nmamdani@nebraskamed.com; www.unmc.edu/international; +1-402-559-3656.

Oxygen Under Pressure – a future adjunct option for refractory wounds

By Dr. Lon W. Keim


Imagine being at risk of losing one of your feet.

That’s what a mother of seven from Kuwait with advanced diabetes mellitus recently faced before coming to Nebraska Medicine and the University of Nebraska Medical Center, through the assistance of the Office of International Healthcare Services.

She presented with a problem wound involving her right foot, now threatened by potential amputation. Her management was further complicated by the need of dialysis three times per week for her end stage renal disease.

Years ago Dr. Jefferson Davis and Dr. Thomas Hunt coined the term “problem wounds,” which they defined as wounds which simply do not heal as they should.

Through their experience and research they determined that a common denominator of problem wounds is tissue hypoxia or oxygen deprivation. Tissue hypoxia is commonly a result of three factors: inadequate oxygen in the blood, insufficient regional blood flow, or most often – focal oxygen demand exceeds delivery. That is the metabolic demands of the wound exceed oxygen delivery from the available blood supply.

Accordingly, the body’s inherent defense mechanisms – the ability to fight infection, generate new blood vessels, build tissue, create strength, provide coverage – are forced to function in an oxygen deficient environment. Thus a problem wound, like the one the woman from Kuwait experienced, is created.

Re-establishment of local regional blood flow through vascular enhancement procedures such as arthrectomies, angioplasties, stent placement, and bypass procedures is the essential cornerstone of initial management.

Hyperbaric Oxygen Therapy (HBO) also has been found to be a useful adjunct in selected patients who tissue oxygenation is not improved to accepted levels by revascularization procedures The patient is entirely enclosed in a monoplace chamber  and breathes 100 percent oxygen at pressures greater than  1.0 atmospheric pressure absolute (ATA).

With increased pressure, the amount of oxygen physically dissolved in the blood is increased. This increased oxygen pressure in plasma enhances diffusion from existing vasculature and improves regional wound tissue oxygen tensions.

The increased oxygen tension will not make a normal wound heal faster, but allows an otherwise compromised wound to heal through improved white cell function, enhanced antibiotic effectiveness, promotion of micro-vessel growth and collagen formation. It should be emphasized that HBO is not a substitute for adequate debridement or appropriate antibiotics, adequate nutrition, or local wound care.

Prior to coming to Nebraska, the mother from Kuwait had been evaluated by clinicians in Europe who believed nothing further could be done with amputation being the next most likely course of action.  She was subsequently referred to Nebraska Medicine where vascular surgeons were able to improve her distal vascular circulation through angioplasties and stent placement.

Subsequent transcutaneous oxygen assessment confirmed marginal tissue oxygen tensions that reversed with Hyperbaric Oxygen Therapy, thereby justifying further treatment with HBO. While continuing her dialysis three times a week, through a series of HBO treatments at 2.4 ATA  for 90 minutes each, local wound care, and pressure off loading, her wound oxygen tensions improved, allowing her wound to heal to a degree it was believed she could be safely discharged and return to Kuwait with her limb intact.

It should be emphasized that her recovery was the result of a team effort that included: skilled surgeons, gifted interventional radiologists, talented infectious disease expertise, attentive nurses, ongoing dialysis support, pressure off loading, aggressive nutritional support, and hyperbaric oxygen therapy.

The Hyperbaric Unit at Nebraska Medicine is equipped with four monoplace chambers capable of treating patients at pressures up to 3.0 ATA. The unit is staffed by hyperbaric trained critical care nurses, and is located immediately adjacent to an ICU. As such, the Nebraska Medicine specialists are capable of both treating walk-in outpatients as well as those requiring intensive critical care support. Although available 24/7 for emergent conditions, the unit routinely runs four shifts a day, with the majority of patients treated once daily five days a week.

HBO is viewed as the primary treatment for only three conditions: (1) acute carbon monoxide intoxication, (2) decompression sickness (bends), and air emboli (air bubbles within the vascular system).

For all other conditions, HBO is viewed as adjunctive therapy to the traditionally accepted mandates of care: adequate debridement and wound care, pressure off loading, edema control, nutrition, wound care, appropriate antibiotics, etc.

The following conditions have been approved and are endorsed by the Undersea and Hyperbaric Medicine Society (UHMS) as appropriate for treatment with HBO: (1) Clostridial myonecrosis – gas gangrene, (2) Necrotizing Soft Tissue Infections, (3) Refractory Chronic Osteomyelitis, (4) Compromised Flaps & Grafts, (5) Diabetes Mellitus – with lower extremity problem wounds refractory to conventional management for > 30 days, Wagner III-IV, (6) Delayed Radiation Injury – to Soft Tissues and Bone including radiation cystitis, radiation caries, colorectal radiation enteritis, or any chronic non-resolving chronic wound within a prior area of radiation, (7) Crush Injury – Skeletal Muscle Compartment Syndromes, (8) Intracranial Abscess, (9) Idiopathic Sudden Sensorineural Hearing Loss, (10) Exceptional Blood Loss Anemia, and (11) Thermal Burns.

The risks and side effects associated with HBO therapy are few. They include: confinement anxiety; barotrauma to the ears sinuses and potentially the lungs; fire (controlled by rigid adherence to strict safety protocols), rare oxygen induced seizures; and occasional transient reversible changes in vision. All in all, it is extremely well tolerated with minimum risks.

Multiple Myeloma 2016: where do we stand?

Multiple myeloma (MM) is the second most common hematologic malignancy in the United States, with rising incidence and prevalence, and is fast becoming an expanding health care burden globally. At a median age of 69, it may manifest differently, however, detrimental effects of abnormal plasma cells invariably involve the bone marrow, skeleton, kidneys, electrolytes and may predispose patients to infections by impairing immunity.

Though considered incurable, the field of MM, the survival of patients has more than doubled over the past decade.

Muhamed Baljevic, M.D., a multiple myeloma specialist and his team at the University of Nebraska Medical Center/Nebraska Medicine (UNMC) have been providing the latest treatment option include the use of cornerstone agents such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs), and their combinations. Daratumumab and elotuzumab recently became the first monoclonal antibodies to join the therapeutic armamentarium against MM.

Unfortunately, despite tremendous advances and ever increasing degrees of response, disease usually relapses, with decreasing remission durations upon each additional treatment.

On the brighter side, small molecules and an array of antibodies against other surface antigens and immune checkpoints are already part of early phase development in humans. The present appears to suggest chemo-immuno approaches as the future standard in the front-line setting, for both transplant eligible and transplant unfit patients. Consolidation therapy with Bi-specific T-cell engagers (BiTE), vaccine and checkpoint immunologic approaches also promise to push the boundaries of short and long-term outcomes.

Nizar Mamdani, executive director of UNMC’s International Healthcare says, “Dr. Baljevic and his expert team are remarkable examples of the caliber of specialists and researchers working tirelessly to help provide better treatment options”.

“Through collaborative strategic partnerships with 124 institutions in 44 countries, we continue to provide innovative treatment options, as well as specialized tele-pathology and second opinion consultation services for cancer care, neurology and transplantation patients around the world.”

UNMC also provides no-cost, training and educational programs. “Through our customized training programs, we facilitate patients around the globe to be the ultimate beneficiaries of the most advanced treatment options and empower them to receive the latest treatments in their own home countries,” says Mamdani.