A Study Looking at the Teaching of Peripheral Arterial Disease to Medical Personnel in Nepal: How well are we doing and how might we be able to improve?

Background There is currently no data showing the prevalence of peripheral arterial disease in Nepal, although they have a high incidence of risk factors in their population such as diabetes, hypertension, and high volume of smoke inhalation. Objective To quantify a gap in medical education curriculum in Nepal as it pertains to medical trainees that have a lack of exposure to peripheral arterial disease (PAD) in a clinical setting as well as improve lecture quality on peripheral arterial disease. Method A survey was sent out to 615 medical trainees in Nepal with a survey completion rate of 44%. The results indicate that both medical students and intern doctors feel most confident in their ability to diagnose peripheral arterial disease and comfortable ordering a workup for peripheral arterial disease when their education includes both a dedicated lecture and care of a patient. Result The self-reported ability to diagnose peripheral arterial disease increased in medical students from 21.9% in the lecture only group to 44.4% in the group who had both lecture and cared for a patient. The current curriculum at the Kathmandu University School of Medical Sciences only allows two hours in the medical school to cover all vascular topics and is taught with a traditional PowerPoint method. Conclusion To improve this area of curriculum, we recommend increasing the allotted time for lectures as well as demonstrate on live patients the evaluation for peripheral arterial disease.

Addressing Vascular Disease in Nepal: Perspectives of a US/Nepal Collaboration.

Vascular surgery is a separate domain in surgery, and is still in its infancy in Nepal, but is ready for big strides. Following trends of western world, vascular disease is on a rise in Nepal, growing the demands of vascular surgeons. I have been closely following the development of vascular surgery in Nepal by being involved with many of my vascular surgical colleagues and friends in Nepal, especially in Dhulikhel and Kathmandu. Of the various subdivisions in vascular surgery, creating vascular access for patients with end stage renal disease is a highly specialized field. The declaration that the Nepal government would pay for dialysis has suddenly paved the way for interest and demand in this field. My visits to Nepal have focused on addressing the need of growth in vascular access and managing associated complications such as aneurysms, swollen arms, decreased flow in the fistulas, and failure of fistulas to mature. Organising skill oriented hands on courses in simulation labs help with understanding and mastering the skills needed. Similarly surgery for peripheral arterial disease, in the form of peripheral bypass and endovascular repairs, is a promising area for growth in Nepal. There already seems to be heavy interest in management of venous diseases in Nepal backed by the fact that most of the recent modalities for the treatment are already well established in Nepal. Aortic surgery is being done only in a few centers focused at Kathmandu and mostly in association with cardiac surgical facilities.

Catechol-based layer-by-layer assembly of composite coatings: a versatile platform to hierarchical nano-materials.

Inspired by the marine mussel's ability to adhere to surfaces underwater, an aqueous catechol-based dip coating platform was developed. Using a catechol-functionalized polyacrylamide binder in combination with inorganic nanoparticles enables the facile fabrication of robust composite coatings via a layer-by-layer process. This modular assembly of well-defined building blocks provides a versatile alternative to electrostatic driven approaches with layer thickness and refractive indices being readily tunable. The platform nature of this approach enables the fabrication of hierarchically ordered nano-materials such as Bragg stacks.

Rare bleeding disorders are associated with depression and anxiety.

Thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenia (ITP) and acquired haemophilia are very rare haemorrhagic disorders (1) associated with surgery, hospitalization (2) and death being reported (3). Despite the rapid development of interventional techniques, therapeutic options for patients with these illnesses remain limited. We suppose that depression and anxiety disorders appear more frequently than in the normal population in patients with rare haemorrhagic disorders.

Oxigenación por membrana extracorpórea como rescate de la insuficiencia cardiovascular y respiratoria en niños. Experiencia del Hospital Universitario Austral / Oxygenation by membrane extracorporeal as a rescue cardiovascular insufficiency and Respiratory in children. Experience of the Austral University Hospital

Introducción: La circulación de membrana extracorpórea consiste en el uso de una bomba de circulación extracorpórea con intercambio gaseoso, de forma prolongada, para proveer soporte vital temporario. Brinda soporte circulatorio, oxigena y remueve dióxido de carbono sin las complicaciones que puede generar la ventilación mecánica convencional. Diseño: Descriptivo, retrospectivo, observacional. Población: Se revisaron los registros clínicos de pacientes pediátricos y neonatos con diagnóstico de patología respiratoria y cardiovascular (0-192 meses) ingresados en ECMO entre el 1 de octubre de 2008 y el 30 de septiembre de 2013. Criterios de inclusión: edad gestacional >34 semanas y >2 kg), sin coagulopatía grave ni hemorragia cerebral grados III o IV, con enfermedad cardíaca reversible, enfermedad respiratoria con hipoxemia o hipercapnia , resistentes al mayor soporte mecánico ventilatorio disponible. Resultados: Ingresaron en ECMO 16 pacientes (mediana de la edad 24 meses, 0-192), 10 niñas y 6 niños. Cuatro ingresados por causas respiratorias y 12, por causas cardiovasculares. La mortalidad por ECMO respiratorio fue del 25% (1/4), cardiovascular 75% (10/12). El PIM de ingreso en la UCIP tuvo una mediana de 3 (1-10). La mediana de estadía en ECMO fue de 7 días (rango 3-16), la de estadía en UCIP-UCIN fue de 22 días (3-120) y en el hospital, de 40 (3-300).Cuatro pacientes recibieron canulación venovenosa y los restantes 12, arteriovenosa. El índice de oxigenación medio de ingreso fue de 26 (DE ± 4); mediana de presión media de la vía aérea, 22 (rango 19-35); media de PartO2 43 (DE ± 8) y la media de PCO2 53 (DE ± 5). El índice Pa/Fi al ingreso tuvo una mediana de 42 (rango 32-74). Conclusión: El ECMO es una herramienta útil para el rescate de pacientes con falla cardíaca e insuficiencia respiratoria, pues permite sostener al paciente, evitando los efectos nocivos de la ventilación mecánica convencional (cuando no se puede mantener la estrategia de protección pulmonar) y de altas dosis de drogas vasoactivas. No obstante, el desarrollo de programas costo- efectivos de ECMO en nuestro país plantea un escenario difícil.(AU)

Introduction: Extracorporeal membrane circulation (ECMO) is the use of cardiopulmonary bypass with prolonged gas exchange to provide temporary life support. The ECMO offers circulatory support, oxygenates and removes carbon dioxide without the complications that can generate conventional mechanical ventilation. Design: Descriptive, retrospective, observational. Population: Clinical records of pediatric and neonatal patients diagnosed with respiratory and cardiovascular disease (0-192 months) admitted to ECMO from October 10, 2008 to September 30, 2013 were reviewed. Inclusion criteria: gestational age >34 weeks and >2 kg, absence of severe coagulopathy and cerebral hemorrhage grade III or IV, with reversible heart disease, respiratory disease with hypoxemia and/or hypercapnia refractory to the most ventilatory mechanical support available. Results: Sixteen children with a median age of 24 months (0-192) (10 girls and 6 boys) were admitted to ECMO. Four children were admitted due to respiratory illness and 12 for cardiovascular disease. Mortality from respiratory ECMO was 25% (1/4), cardiovascular 75% (10/12). PIM at the PICU admissions had a median of 3 (1-10). Median ECMO stay was 7 days (range 3-16), median PICU-NICU stay 22 days (3-120) and hospital stay 40 (3-300). The kind of cannulation was veno-venous (4), and arteriovenous (12). Mean oxygenation index at admission, 26 (SD ± SD 4); median average pressure of air, 22 (range 19-35); average PartO2, 43 (SD ± 8) and mean PCO2 53 (SD ± 5). Median Pa/Fi index at admission, 42 (range 32-74 ). Conclusions: The ECMO is a useful tool for the rescue of patients with heart failure and respiratory failure, avoiding the deleterious effects of conventional mechanical ventilation (when it is not possible to maintain lung protective strategy) and high doses vasoactive drug. However the development of cost-effective ECMO programs in our country poses a difficult scenario.(AU)

Saturated ablation in metal hydrides and acceleration of protons and deuterons to keV energies with a soft-x-ray laser.

Studies of materials under extreme conditions have relevance to a broad area of research, including planetary physics, fusion research, materials science, and structural biology with x-ray lasers. We study such extreme conditions and experimentally probe the interaction between ultrashort soft x-ray pulses and solid targets (metals and their deuterides) at the FLASH free-electron laser where power densities exceeding 10(17) W/cm(2) were reached. Time-of-flight ion spectrometry and crater analysis were used to characterize the interaction. The results show the onset of saturation in the ablation process at power densities above 10(16) W/cm(2). This effect can be linked to a transiently induced x-ray transparency in the solid by the femtosecond x-ray pulse at high power densities. The measured kinetic energies of protons and deuterons ejected from the surface reach several keV and concur with predictions from plasma-expansion models. Simulations of the interactions were performed with a nonlocal thermodynamic equilibrium code with radiation transfer. These calculations return critical depths similar to the observed crater depths and capture the transient surface transparency at higher power densities.

Damage mechanisms of MoN/SiN multilayer optics for next-generation pulsed XUV light sources.

We investigated the damage mechanism of MoN/SiN multilayer XUV optics under two extreme conditions: thermal annealing and irradiation with single shot intense XUV pulses from the free-electron laser facility in Hamburg - FLASH. The damage was studied "post-mortem" by means of X-ray diffraction, interference-polarizing optical microscopy, atomic force microscopy, and scanning transmission electron microscopy. Although the timescale of the damage processes and the damage threshold temperatures were different (in the case of annealing it was the dissociation temperature of Mo2N and in the case of XUV irradiation it was the melting temperature of MoN) the main damage mechanism is very similar: molecular dissociation and the formation of N2, leading to bubbles inside the multilayer structure.

Single shot damage mechanism of Mo/Si multilayer optics under intense pulsed XUV-exposure.

We investigated single shot damage of Mo/Si multilayer coatings exposed to the intense fs XUV radiation at the Free-electron LASer facility in Hamburg - FLASH. The interaction process was studied in situ by XUV reflectometry, time resolved optical microscopy, and "post-mortem" by interference-polarizing optical microscopy (with Nomarski contrast), atomic force microscopy, and scanning transmission electron microcopy. An ultrafast molybdenum silicide formation due to enhanced atomic diffusion in melted silicon has been determined to be the key process in the damage mechanism. The influence of the energy diffusion on the damage process was estimated. The results are of significance for the design of multilayer optics for a new generation of pulsed (from atto- to nanosecond) XUV sources.

Spot size characterization of focused non-Gaussian X-ray laser beams.

We present a new technique for the characterization of non-Gaussian laser beams which cannot be described by an analytical formula. As a generalization of the beam spot area we apply and refine the definition of so called effective area (A(eff)) [1] in order to avoid using the full-width at half maximum (FWHM) parameter which is inappropriate for non-Gaussian beams. Furthermore, we demonstrate a practical utilization of our technique for a femtosecond soft X-ray free-electron laser. The ablative imprints in poly(methyl methacrylate) - PMMA and amorphous carbon (a-C) are used to characterize the spatial beam profile and to determine the effective area. Two procedures of the effective area determination are presented in this work. An F-scan method, newly developed in this paper, appears to be a good candidate for the spatial beam diagnostics applicable to lasers of various kinds.

Soft x-ray free electron laser microfocus for exploring matter under extreme conditions.

We have focused a beam (BL3) of FLASH (Free-electron LASer in Hamburg: lambda = 13.5 nm, pulse length 15 fs, pulse energy 10-40 microJ, 5 Hz) using a fine polished off-axis parabola having a focal length of 270 mm and coated with a Mo/Si multilayer with an initial reflectivity of 67% at 13.5 nm. The OAP was mounted and aligned with a picomotor controlled six-axis gimbal. Beam imprints on poly(methyl methacrylate) - PMMA were used to measure focus and the focused beam was used to create isochoric heating of various slab targets. Results show the focal spot has a diameter of < or =1 microm. Observations were correlated with simulations of best focus to provide further relevant information.

Lamotrigine in the prophylactic treatment of migraine aura--a pilot study.

The aim of this study was to evaluate the efficacy of lamotrigine, a glutamate antagonist blocking voltage-sensitive sodium channels, in the prophylaxis of migraine aura symptoms. Glutamate is one of the main neurotransmitters involved in the development of cortical spreading depression. The study was conducted as an open longitudinal trial over 7 months, with a treatment phase of 4 months and a post-treatment period of 3 months. Thirteen patients suffering from migraine with aura and 2 patients with aura but without migraine were enrolled and treated with lamotrigine. The dose was gradually increased in steps of 25 mg up to 100 mg per day, depending on the patient's aura symptoms. Aura symptoms were reduced from baseline (an average of 1.3 aura episodes per month) to month 4 (0.1, p < 0.001). High statistical significance was also observed with regard to aura duration (23 min at baseline vs 4 min at 4 months, p < 0.001). In all 15 cases, increases in aura frequency (on average sevenfold, p < 0.001) and aura duration (minutes; on average more than threefold, p < 0.001) were evident following cessation of treatment. A number of mild to moderate adverse events without any medical consequences occurred. The study outcome suggests that lamotrigine is effective in preventing migraine aura symptoms and in influencing migraine headache frequency.

Acetabular fractures.

Trauma injuries to the acetabulum and the associated pelvic region are second only to head injuries in mortality and morbidity for surgical patients. Surgeons in the past avoided exposing and stabilizing complex fractures of the acetabulum because of the intricate anatomy of the pelvic region. Recent advances in surgical techniques have increased the use of open reduction internal fixation of acetabular fractures. Early internal fixation of acetabular fractures allows rapid mobilization of severely injured patients and provides trauma patients optimal, long-term, functional results.

Zonisamide for add-on treatment of refractory partial epilepsy: a European double-blind trial.

The new antiepileptic drug zonisamide was evaluated in a European multicenter parallel-group double-blind trial as add-on treatment for 139 patients with refractory partial epilepsy. During treatment with zonisamide complex partial seizures decreased by 27.7% compared to placebo (P < 0.05) and the median rate dropped from 12/month to 7.1/month with no changes in the placebo group (P < 0.007). During the 12-week double-blind phase a 50% reduction of all seizures was recorded in 29.9% of the patients treated with zonisamide vs. 9.4% during placebo. Complete remission was observed during treatment with zonisamide in 6.2%. The plasma concentrations of the concomitant antiepileptic drugs did not change markedly when zonisamide was added. Adverse events, mostly fatigue, somnolence, dizziness and ataxia, occurred in 59.2% of the patients compared to 27.9% during placebo. Zonisamide was withdrawn in two patients due to adverse events. Kidney stones were not observed nor any relevant clinical chemistry or hematological changes. Zonisamide is an effective antiepileptic drug for add-on treatment of refractory partial epilepsy.

[Stability after capsular ligament surgery of the knee joint]. / Stabilität nach Kapselbandoperationen am Kniegelenk.

Post-operative checks of 57 cases of anterio-medial knee instability (II and III degree) were carried out over a period of 1-4 years after operation. "Subjective knee stability" was documented on three levels in a questionnaire as not "giving way". "Objective knee stability" was evaluated by measuring 30 degree anterior drawer displacement using the KT 1000 instrument. Strength of the thigh muscles of both legs for different power parameters under isokinetic load was measured with the Cybex II instrument system. No significant correlation between subjective perception of knee instability and instrumented measured anterior drawer displacement could be shown in a T-test. Individuals with higher "objective stability" or higher "subjective stability" level had both generally stronger tight muscle parameters, specially for knee extension. Most of our interest had the group of individuals assumed "subjective stable" but having quite a large anterior drawer displacement phenomena like ACL deficit knee. This group is characterized by higher 10 degree power parameters for knee extension and flexion and lower H/Q-quotient. This is supposed to be indication to functional adaptation of the neuro-muscular system to altered biomechanic situation after ACL disruption or reconstruction. Electromyographic studies should follow to test this hypothesis.

[Glandular metaplasia and primary adenocarcinoma of the urethra]. / Glanduläre Metaplasie und primäres Adenokarzinom der Urethra.

This is a case report of a 67-year-old woman who had a mucinous adenocarcinoma of the urethra: she died 3 years after the clinical symptoms started owing to progression of the tumor. The tumor developed from a glandular metaplasia, which has to be regarded as a premalignant lesion. Problems of the diagnosis, including the differential diagnosis, are discussed.

[Restricted motion after surgery of the capsular ligament of the knee joint, with special reference to stability of the ligament and muscle status in isokinetic stress]. / Bewegungseinschränkung nach Kapselband-Operation am Kniegelenk, unter Berücksichtigung der Bandstabilität und der muskulären Situation bei isokinetischer Belastung.

Post-operative checks of 57 cases of anterio-medial knee instability (II and III degree) were carried out over a period of 1-4 years after operation. On a questionnaire subjective feelings, complaints, and changes in living and sport habits, were documented. Thus a parameter for the functional result of treatment was created. Knee stability was evaluated by measurement of 30 degree anterior drawer displacement using the Medmetric corp. ligament measuring instrument KT1000. Strength of the thigh muscles of both legs for different power parameters under isokinetic load was measured with the Cybex II instrument system. In 51 cases a correlation between the movement deficit and the following parameters was assumed and tested by comparing the mean values in a T-test: side comparison of the anterior drawer phenomenon, power parameters of the thigh muscles for knee extension and flexion, score for the functional result. In case of extension deficit of the knee, it could be shown that the tension of the reconstructed crucial ligaments, which is expressed in the measured value of the anterior drawer displacement, is not as important from a causal point of view as has been supposed. Extension deficit had no obvious negative effects on the power development of the thigh muscle. However, movement restriction caused significant negative effects on functional result-score.

External carotid endarterectomy in the treatment of symptomatic patients with internal carotid artery occlusion.

In patients with internal carotid artery (ICA) occlusion, the external carotid artery (ECA) can be both a source of collateral flow and a pathway for emboli. We identified 11 patients with ICA occlusion and ipsilateral ECA stenosis who underwent ECA endarterectomy to determine its role in treating extracranial cerebrovascular disease. Follow-up ranged from 1-65 months, with a mean of 27 months. Seven of eight patients with unilateral disease remained symptom free. The eighth patient had recurrent symptoms that were subsequently diagnosed as hemi-Parkinsonism. Two of three patients with bilateral occlusive disease had developed non-hemispheric symptoms at 12 and 24 months, respectively; the third remains asymptomatic after extracranial-intracranial bypass. None of the seven patients who presented with amaurosis fugax had recurrent visual symptoms. ECA endarterectomy is a safe and effective operation in treating symptomatic patients with ICA occlusion, especially those with transient monocular blindness or unilateral occlusive disease. It is less effective in those patients who have diffuse bilateral occlusive disease.

[Treatment of coronary heart disease with the beta-1-receptor blocker celiprolol in a long-term study over a 12-month period]. / Behandlung der koronaren Herzkrankheit mit dem Beta-1-Rezeptorenblocker-Celiprolol in einer Langzeitstudie über 12 Monate.

In the present study, the beta-receptor-blocker Celiprolol was tested for its antianginal effects during an observation period of 12 months; 29 patients, both male and female, with definite coronary heart diseases, were subjected to this study. In general Celiprolol was well accepted by the patients, the dosage being 200 mg every morning. Regarding intensity and frequency, the side effects were negligible. It was possible to lower the intensity and frequency of angina attacks considerably during the treatment with Celiprolol. Exercise examinations were carried out at prescribed intervals and showed an increase in pain free working capacity and a decrease in the hypoxic ST-depression on the ECG, also to a considerable extent. The indication for the use of Celiprolol in long-term treatment of coronary heart disease was impressingly confirmed.