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Forgoing Partnerships that foster the exchange of healthcare professionals

MEH

Middle East Health Magazine-January 2016

Renowned as a leader in health care delivery in the United States and internationally recognized for excellence, The University of Nebraska Medical Center/ Nebraska Medicine’s International Healthcare Services (UNMC) has established a unique model for world-class clinical experts in patient care, research, education, training, management and advanced technology to enhance patient-care delivery around the world. UNMC leverages the academic and medical hospital’s core competencies, intellectual capital and management expertise to create innovative services and collaborative partnerships and to provide “No-Cost” Training and research opportunities to healthcare providers around the world.

UNMC’s achievements reach far beyond the boundaries of the heartland in North America. Its leadership and excellence in health care has extended internationally with its footprints in 122 collaborative partnerships in 44 countries. The diverse array of global partnerships touch  patients in Delhi, Jeddah, Cairo, Kuwait, Nairobi, Cape Town, Madrid, Mexico, Beijing, Tokyo and Rio. This is a clear affirmation of UNMC’s strong commitment to create and nurture outstanding sustainable relationships and programs throughout the world.

U.S. News and World Report named UNMC as one of Best Hospitals in North America. UNMC attracts the best US and international healthcare professionals and researchers to work in a global environment that promotes the best patient care and treatment options that can leap over geographical boundaries to reach global patients in need.

Medical Expertise Shared Around the World

Established international presence and research driven experiences have allowed UNMC the ability to leverage and successfully operate under changing and challenging international healthcare delivery systems. UNMC continues to successfully grow, collaborate and expand its international programs.

Fifteen years ago, Nizar Mamdani, Executive Director of the International Healthcare Services, experienced first hand how extraordinary and world-renowned the healthcare delivery in cancer care and bone marrow transplantation is at UNMC, as his wife, Nancy, was a Non-Hodgkin’s patient at UNMC. “I realized the importance for international patients to be the ultimate beneficiaries from UNMC’s advanced treatment programs in cancer care and transplantation. I wanted to start a global “No-Cost” healthcare training program for healthcare professionals” says Mamdani. “Today, our selfless programs provide healthcare professionals the unique opportunity to learn from world-renowned doctors and nurses in cancer care, transplantation, neurology and 36 other subspecialties”.

During his first overseas visit fifteen years ago, it became clear to Mamdani that most international physicians were very well educated and trained, but the support staff needed training in specialized treatment programs. His No-Cost training programs have focused around that basic premise of providing allied health and nursing staff with customized training.

Healthcare professionals participate in a 15 to 21-day, No-Cost collegial observership and become familiar with US and internationally renowned physicians. UNMC’s training programs work fairly simply. A partner institution sends specialists, nurses and other allied health professional team for training. While at UNMC, they receive free housing, meals, local transportation, and priceless training. It’s an investment, Mamdani says, that is returned many times over, because the international patients, in their own countries, are the ultimate beneficiaries of these training programs. 187 healthcare professionals from 28 countries have participated in No-Cost programs at UNMC and 52 UNMC specialists have visited 23 international partner institutions to provide training.

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

Dr. Grande from Spain stated “UNMC’s clinical floors are run like a caring and innovative enterprise, every international doctor will immensely benefit from this collaborative experience. This is the best education and life-changing experience in the world, with the free tuition and paid living expenses”.

Borderless Medicine Delivery

UNMC’s individualized Tele-Medicine programs provide global healthcare solutions to cross geographic limitations and high costs in travel. Patients are touched through individualized Tele-Health, Tele-Pathology and Tele-Educational programs. These programs provide a collegial opportunity to electronically access and collaborate with UNMC’s experiences and proven treatment options for their patients. UNMC utilizes state-of-the art technology, web based software, “real-time” interactive diagnosis, tele-pathology and electronic consultation.

“On-line uploading of patient’s reports and past medical history, pathology slides x-rays and other radiological images also provide a medium for statistical data and the exchange of medical research, educational information and patient outcomes”, says Mamdani.

UNMC is inviting healthcare and research institutions as well as healthcare professionals and researchers to collaborate in its international research and patient care programs to help improve treatment options in cancer and other life-threatening illnesses.

For more information visit www.unmc.edu/international and contact oihs@nebraskamed.com.


 

Oxygen Under Pressure – a future adjunct option for refractory wounds

MEH

Middle East Health Magazine-November 2015
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.

For additional information, please contact Nizar Mamdani, Executive Director, International Healthcare Services at Nebraska Medicine at +1 (402) 559-3656 or via email at nmamdani@nebraskamed.com.  Visit our website at www.unmc.edu/international.


 

The Cardiovascular Program at the University of Nebraska Medical Center

MEH

Middle East Health Magazine-January 2015

A hidden gem exists in the middle of the United States, the Cardiovascular Program at the University of Nebraska Medical Center/Nebraska Medicine. In the past decade this program has grown into a comprehensive cardiovascular program worthy of international recognition. The Division is composed of six Sections: Interventional and Structural Heart Disease, Advanced Heart Failure and Transplantation, Consultative Cardiology, Electrophysiology, Imaging, and Adult Congenital Heart Disease.

The Interventional and Structural Heart Disease program is lead by Dr. Gregory Pavlides.  Before moving to Nebraska, Dr. Pavlides was the Director of the Onassis Heart Hospital in Athens and one of Europe’s leading interventional cardiologist. He brings extensive experience in transaortic valve replacement and decades of experience in valvuloplasty.  Dr. Brian Lowes leads the advanced heart failure and transplant program.  Over the past decade the program has grown to be one of the largest advanced heart failure programs in the United States.  This year we will perform 40 transplants and 75 LVADs.  Dr. Lowe’s research interest is coupling next generation DNA sequencing with clinical research and personalized medicine.

The consultative cardiology program brings over 100 years of clinical experience with a broad international exposure.  Dr. Ward Chambers, the Executive Director of International Health and Medical Education for UNMC has set-up programs and partnerships in the Middle East and Asia.  Additionally, the consultative program has launched an innovative prevention and telemedicine program to better engage patients in their care.  The electrophysiology program provides comprehensive advanced ablation therapies for all types of SVT and VT including epicardial mapping and ablation.

The cardiovascular imaging program is lead by Dr. Tom Porter.  Dr. Porter is an international leader in perfusion imaging, therapeutic imaging and cardiac magnetic resonance imaging.  He is joined by Drs. Samer Sayyed, Shikar Saxena and Haree Vongooru to provide world-class multi-modality imaging.

A recent but important addition to this program has been the adult congenital heart disease program.  Over 50% of all patients with congenital heart deformities are now adults and their management requires special expertise.  The program is led by Dr. Shane Tsai, who is board certified in Pediatrics, Medicine, Pediatric Cardiology, Adult Cardiology as well as Cardiac Electrophysiology. He is joined by Dr. Angela Yetman, a noted researcher in connective tissue disorders and Dr. Jonathan Cramer who holds joint imaging appointments in Medicine, Pediatrics and Radiology.

The Cardiology Program is complemented by a superb Cardiovascular Surgery team lead by Dr. Mike Moulton.  Their outcomes are among the best in the Country and their expertise ranges for surgery for adults with congenital heart disease, to heart and lung transplantation (launching in 2015) to advanced valve surgery. Joining Dr. Moulton are Drs. Kim Duncan, John Um and Aleem Siddique.
Equally important to UNMC’s clinical care is research and education.  The cardiology fellowship consists of four fellows per year for general cardiology as well as advanced programs in interventional cardiology, advanced imaging, electrophysiology and heart failure/transplantation.  Their research expertise spans genetics, inflammation, imaging and informatics.  The Cardiovascular Biobank contains blood and tissue samples that are linked to the program’s Cardiovascular Quality, Outcomes and Research database that allows them to perform research from protein function to population-based therapeutics.
In summary, the Cardiovascular Program at UNMC provides a world-class patient experience in the Heartlands of the United States.

Nizar Mamdani, executive director of Nebraska Medicine’s International Healthcare says: “Our healthcare professionals and researchers are great examples of the caliber of specialists and researchers working tirelessly to help provide the best head and neck surgical oncology treatment options. Through strategic collaborations with 123 institutions in 44 countries, Nebraska provides innovative treatment options for cancer care and transplantation to patients around the world”. Nebraska also provides customized training and educational programs for specialists, nurses and allied healthcare professionals. Contact: nmamdani@nebraskamed.com; www.unmc.edu/international


 

Centers of excellence in head and neck surgical oncology promise improved survival and quality of life
– The University of Nebraska experience

MEH

Middle East Health Magazine-November 2014

The head and neck surgical oncology program at the University of Nebraska Medical Center/Nebraska Medicine (Nebraska) has evolved into a center of excellence that provides comprehensive care to patients affected by head and neck cancer. With over 25 years of experience, the program is one of the highest volume teams in North America. Interdisciplinary care revolves around collaboration between fellowship-trained physicians in head and neck surgical oncology, reconstructive surgery, robotics, medical oncology, radiation oncology, endocrinology, and head and neck pathology, with wide recognition for their clinical expertise, teaching and leadership roles. Dedicated support services provide ongoing care for speech and swallowing rehabilitation, dental oncology, social support and seamless transition to survivorship.

Head and neck cancer affects over half a million individuals globally every year. A majority of these cases are related to tobacco and alcohol use, although human papilloma virus associated oropharyngeal carcinomas have recently demonstrated a dramatic increase in incidence. Care of patients diagnosed with head and neck malignancy often require collaboration between multiple specialty physicians and allied health care professionals to ensure optimization of patient outcomes related to survival and quality of life.

There is increasing evidence that high volume centers that focus on specialized care of head and neck cancer patients have improved outcomes. Such programs rely on care protocols based on best practice models, established network of supportive services, and continued skill improvement in focus areas to provide superior care, better survival and quality of survivorship. The effect of high institutional volume on improved outcomes is not limited to head and neck surgical oncology, and has been demonstrated reliably in areas like esophageal, bariatric and pancreatic surgery.

Several patient centered specialized care pathways have been developed in Nebraska for patients with malignancies affecting the upper aerodigestive tract, skull base and thyroid gland.  These pathways have resulted in significant improvements in patient outcomes, including reduction in length of hospital stay, shorter and less frequent intensive care unit stay and reduced cost of care.

The efficient delivery of care allows the program to support academic training programs for clinicians, the opportunities to develop meaningful clinical and laboratory research, and use established scientific principles for outcomes improvement. For example, the recognition of depression as a major determinant of the adverse quality of life, for patients with advanced head and neck cancer receiving non-surgical therapy, resulted from the experience gained at Nebraska program. Nebraska researchers further identified the role of prophylactic use of anti-depressants in mitigating depression and improving quality of life parameters in such patients even after cessation of therapy. The potential positive impact of these findings on a large number of patients worldwide, who are at high risk for treatment related depression and self harm, are substantial.

A robust clinical program supports a head and neck cancer registry and tissue bank that advances our understanding of specific molecular markers that determine behavior of head and neck squamous cell carcinoma. UNMC researchers’ work on the expression of MUC 1 & MUC 4 and their adverse prognostic implications in head and neck mucosal malignancies offers hope for development of novel therapeutic agents in the future.

In addition to continued excellence in oncologic care, the program offers unique opportunities for dissemination of knowledge and shared expertise with partners on a worldwide basis, through training programs, continued medical education opportunities and the ability to provide clinical decision support through remote tumor boards.

As leaders in head and neck cancer care, Nebraska continues to expand its efforts at improving survival and quality of care outcomes for its patients through innovative use of care pathways, research with real world applications, advanced clinical training programs and opportunities for collaboration with head and neck clinicians and researchers across the globe.

Nizar Mamdani, executive director of the Nebraska’s International Healthcare says, “Our healthcare professionals and researchers are great examples of the caliber of specialists and researchers working tirelessly to help provide the best head and neck surgical oncology treatment options. Through strategic collaborations with 123 institutions in 44 countries, Nebraska provides innovative treatment options for cancercare and transplantation to patients around the world”. Nebraska also provides customized training and educational programs for specialists, nurses and allied healthcare professionals. Contact nmamdani@nebraskamed.com.  www.unmc.edu/international


 

The Nebraska Medical Center offers Advanced Treatment Options in Ocular Imaging Technology – Diagnosis and Management of Primary Intraocular Lymphoma

MEH

Middle East Health Magazine-January 2014

Serious Medicine. Extraordinary Care.
That has always been the motto for the University of Nebraska Medical Center/The Nebraska Medical Center (“TNMC”). And certainly the specialists and researchers at TNMC are doing everything to maintain such reputation in the area of uveitis and intraocular lymphoma.

In 1929, Percival Bailey first coined the term primary central nervous system lymphoma (PCNSL). Since the entry of PCNSL into the world of medical literature, countless medical advances regarding its pathogenesis, diagnosis, and prognosis have resulted.

Yet, during the past eight decades , PCNSL is still bound to a harrowing prognosis, as relapsing CNS lymphoma has one-year overall survival of 25-40%. PCNSL is the second most common intracranial mass lesion. It is highly prevalent in the human immunodeficiency virus (HIV)-infected population—a population which continues to expand in the Middle Eastern and North African regions.

However, advances in the diagnosis of one subset of PCNSL— primary intraocular lymphoma (PIOL)— are proving to be pivotal to the early detection of eyes with PIOL and allowing the physician to preserve sight in such eyes by initiating early therapy. PIOL is a rare non-Hodgkin’s lymphoma, which consists of large B-cells. While PIOL may represent a mere 1% of the non-Hodgkin’s lymphomas, 1% of intracranial tumors, and less than 1% of intraocular tumors, 60-80% of PIOL cases eventually develop CNS involvement.

“The diagnosis of PIOL itself was considered to be very difficult for a long time due to its masquerading features and low incidence,” explains Quan Dong Nguyen, MD, MSc, McGaw Memorial Endowed Chair in Ophthalmology, Inaugural Director of the Truhlsen Eye Institute (TEI). “Chief patient complaints typically consist of blurred vision and floaters without painful or red eyes; however, clinical manifestation varies among patients. PIOL also masquerades as infectious, non-infectious, or idiopathic inflammation of the eye and often even responds to corticosteroid therapy, thus contributing to the diagnostic challenge,” Dr. Nguyen expands further.

However, several advanced imaging techniques are now being utilized to help diagnose and follow patients with PIOL.  “We are employing most if not all of them, even those techniques in development” says Yasir J. Sepah, MBBS, Director at TNMC. There are several techniques that have been used to evaluate patients with suspected PIOL.  Fluorescein angiography is useful for monitoring the changes in the size of hypofluorescent lesions. Indocyanine green angiography also reveals hypofluorescent lesions, although it is not as sensitive as fluorescein angiography. “Now, spectral-domain optical coherence tomography (SD-OCT) may be employed to assess the degree of lymphoma infiltration. SD-OCT findings of distorted retinal layers and hyper-reflective signals in the forms of bands and nodules have recently been reported by our team and may further help in early identification of eyes with PIOL, especially in cases where there is no CNS involvement. The Figure illustrates the course of a patient with PIOL managed by Dr. Nguyen. The diagnosis was missed by two comprehensive ophthalmologists and two retina specialists before Dr. Nguyen established the critical findings which led the patient not only able to learn of the diagnosis of PIOL but also subsequently of CNS lymphoma.  Such proper diagnoses have certainly saved the patient’s sight and also life.  We have conducted extensive research on this subject and have published various seminal scientific papers in this area.  And, we apply what we have learned from the OIRRC to the patients who are being examined at TEI, providing those who are suspected to have PIOL or those with atypical uveitis with the most comprehensive evaluation,” states Dr. Sepah.
Although treatment is individualized for each case of PIOL, systemic methotrexate and rituximab are currently considered to be first-line therapy. The affected eyes may be radiated in addition to systemic and intravitreal chemotherapy.

Improvement with local and intrathecal chemotherapy has also been reported. In some patients, autologous stem cell transplant following high-dose chemotherapy has been shown to be effective.

PIOL is a highly malignant neoplastic disease with poor prognosis. “To improve the outcome, early diagnosis and appropriate treatments with careful monitoring are necessary,” emphasizes Diana V. Do, MD, Vice Chair for Education and Director at TNMC “The masquerading features and low incidence of PIOL make the diagnosis quite challenging,” Dr. Do reiterates.

Nizar Mamdani, executive director of the TNMC’s International Healthcare says, “Our researchers and specialists are great examples of the caliber of specialists and researchers working tirelessly to help provide better lymphoma treatment options. Through strategic collaborations in 44 countries, we provide innovative treatment options for cancercare and transplantation to patients around the world”, says Mamdani. TNMC also provides customized training and educational programs for specialists, nurses and allied healthcare professionals. Contact nmamdani@nebraskamed.com.  www.unmc.edu/international

Figure: Longitudinal wide-angle color fundus photographs (P200 Tx, Optos, Inc.) on the left and spectral domain optical coherence tomography (OCT, Spectralis, Heidelberg Engineering, Inc.) on the right of a patient with primary intraocular lymphoma. (A) First day of presentation: fluid in the retina is circled on the OCT. Arrowheads indicate hyper-reflective signals on the retina (photoreceptor layer, PRL, and retinal pigment epithelium, RPE, layer). OCT scan was performed before the diagnostic vitrectomy. Color fundus image is from Day 14 following vitrectomy. (B) Day 19: the arrows indicate intraretinal fluids on the OCT. Lesions on the PRL and RPE are pointed. (C) Day 77: hyper-reflective signals on the RPE pointed by the arrowheads on the OCT have arguably thickened. Hyper-reflective signals are also seen in the inner retina. An arrowhead points to an example in the inner nuclear layer of the retina.

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