Background: The University of Global Health Equity (UGHE) is a new medical school in Rwanda that aims to train new physicians with competencies in global health delivery for Africa. As part of an effort to deliver high-quality, preclinical medical education, UGHE has implemented a low-cost, modular digital curricular platform called ScholarRx Bricks, which has already been well evaluated in the USA. We aim to test whether Rwandan medical students will find the Bricks to be an acceptable curricular resource. Methods: Bricks are self-contained, integrated basic science learning units consisting of learning objectives, illustrated narrative text, and interactive self-assessment items delivered through a web browser. The Bricks have been assigned as flipped classroom pre-work in a course that includes integrated topics in anatomy, histology, embryology, biochemistry, and physiology. Students are in the first year of a 6-year MBBS programme. We used a Kirkpatrick programme evaluation model to measure student use and satisfaction (level 1 outcome). We also conducted a student focus group for qualitative feedback. Findings: We included responses from all 27 students, all of whom had used the Bricks in some capacity in the course; 18 students (67%) agreed that the Bricks were a helpful resource, and 19 (70%) would recommend the Bricks to other students. Key themes that arose from qualitative questions and the focus group were that the Bricks provided detailed and useful information for the course, and were valued as a curricular resource, but that information was often viewed as too advanced for this foundational stage of the medical school programme. Interpretation: The Bricks appeared to be generally well accepted by Rwandan medical students and may be a viable, low-cost curricular option in Africa. We identified potential adjustments that may improve the learner experience. Funding: ScholarRx provided in-kind support access to the Bricks.

Diabetes is an independent risk factor for atrial fibrillation (AF). Frequently, it is part of the metabolic syndrome cluster, which includes obesity and hypertension that are independently associated with AF. The risk appears to be higher with longer duration of diabetes and inadequate glycemic control. Patients with diabetes and AF have a substantially increased risk of death and serious cardiovascular complications compared with those in sinus rhythm. Conversely, good metabolic control appears to be associated with maintenance of rhythm after successful therapeutic conversion to sinus rhythm by catheter ablation or electrical cardioconversion of AF. AF puts patients with type 2 diabetes at a high risk of cardiovascular complications and death, which could be successfully addressed by new classes of antidiabetic agents such as incretin analogues or sglt-2 inhibitors. Thus, a diagnostic strategy that addresses the increased risk for AF is urgently recommended, in addition to diabetes monitoring in routine outpatient practice. In order to prevent thromboembolic complications, which frequently determine the prognosis for this patient population, appropriate anticoagulation remains the mainstay of therapy, whereas the prognostic value of reinstalling sinus rhythm awaits further evidence.

Clinique. Le cancer du pancréas (CP) est l’un des cancers les plus agressifs avec près de 80 % des patients présentant une maladie métastatique au diagnostic. La chimiothérapie à base de fluoropyrimidine (Folfirinox) est l’un des traitements standards de première ligne métastatique. Ce protocole est le plus efficace mais également le plus toxique. L’impact de la CC du patient, incluant la sarcopénie, spécifiquement dans le CP avancé reste débattu. L’objectif de notre étude était donc d’évaluer l’impact de différents paramètres de CC sur le pronostic du CP et la toxicité du Folfirinox (FOX). Tous les patients traités par FOX en première ligne d’un CP avancé entre 2007 et 2015 dans notre centre de lutte contre le cancer ont été rétrospectivement analysés. La CC a été évaluée par coupe scanner au niveau de la troisième vertèbre lombaire. Les images ont été analysées avec le logiciel ImageJ (NIH, USA). La sarcopénie était définie par l’index musculaire squelettique (IMS) (< 52,4 cm2/m2 pour les hommes et 38,5 cm2/m2 pour les femmes). Les index du muscle psoas (IMP), du tissu adipeux viscéral (IAV), sous-cutané (IASC) et intramusculaire étaient évalués. Satistiques : Kaplan–Meier et Cox pour comparer les effets des paramètres de CC sur les survies globale et sans progression. Tests du Chi2 et Fisher Exact pour la toxicité de la chimiothérapie. Les données de 137 patients ont été extraites : 91 avaient un scanner abdominal disponible et ont été inclus. L’âge moyen (± SD) était de 60,7 (± 9,2) ans. La maladie était localisée dans 42 % des cas et métastatique dans 58 %. IMS moyen : H, 48,63 (± 7,03) cm2/m2, F, 36,92 (± 6,00) cm2/m2. La prévalence de la sarcopénie était de 64 % (n = 58). En analyse multivariée, ni la sarcopénie ni les autres paramètres de CC (hormis l’index de tissu adipeux intrapsoas) n’étaient significativement associés à la survie globale ou à la survie sans progression. En revanche, le performans status (HR = 0,42 [0,20 ;0,85], p = 0,015), la chirurgie du primitif (HR= 0,55 [0,32 ;0,93], p = 0,03), la présence de métastases hépatiques (HR = 2,62 [1,59 ;4,32], p < 0,001) ainsi que l’index de tissu adipeux intrapsoas (HR = 0,52 [0,29 ;0,95], p = 0,03) étaient des facteurs indépendants prédictifs de la mortalité. Les patients ayant un IMS faible (<37,3 cm2/m2, n = 22) avaient plus de vomissement que ceux ayant un IMS haut (54 % vs 24 %, p = 0,016). Les patients avec un IASC et IAV élevé (> 24,6 cm2/m2 n = 63, > 21,8 cm2/m2 n = 62, respectivement) avaient significativement plus de toxicité hématologique ≥ grade 3 (35 % vs 5 %, p = 0,009 ; 34 % vs 9 %, p = 0,028, respectivement). Cette étude ne met pas en évidence de lien entre les paramètres de CC et la survie chez les patients avec CP localement avancé ou métastatique. En revanche, un IMS bas, un IASC ou IAV haut est associé à une toxicité de la chimiothérapie plus sévère. Cela mérite des études complémentaires, notamment pour savoir si une intervention nutritionnelle ciblée pourrait améliorer la tolérance de la chimiothérapie de ces patients.

Background: The pfm Nit-Occlud Lê VSD coil (pfm medical, Cologne, Germany) was developed for closure of perimembranous and muscular ventricular septal defects and received a CE-mark in August 2010. Long-term outcome data of the initial approval study are presented including 93 patients with perimembranous and muscular ventricular septal defects (VSD). Patient inclusion and procedures were performed in six tertiary clinical centers in Germany and Israel from October 13th 2006 to July 21st 2011, the last follow-up visit was performed on June 26th 2016. A set of Objective Performance Criteria (OPC) according to the multi-organization Advisory Panel to FDA for Pediatric Cardiovascular Devices for PDAs were established to evaluate efficacy and safety of the device under investigation.

Die Zahl erwachsener Patienten mit angeborenen Herzfehlern (EMAH) wird in Deutschland auf ca. 280.000 geschätzt und ist damit größer als die der Kinder mit angeborenen Herzfehlern (AHF). Kardiovaskuläre Rest- und Folgezustände bei fast allen EMAH erfordern die lebenslange Nachsorge. Trotzdem werden schätzungsweise mehr als 200.000 EMAH nicht von zertifizierten Spezialisten behandelt. Dies ist besonders kritisch, da viele Ärzte der Basisversorgung keine spezifischen Kenntnisse über die Probleme dieser teils sehr komplexen Anomalien haben. Auch können bei vorerst benignen Anomalien mit zunehmendem Patientenalter relevante Probleme auftreten, selbst nach frühzeitig durchgeführter Therapie. Typisches Beispiel ist die pulmonalarterielle Hypertonie bei primären Links-rechts-Shunt-Vitien. Unzureichende Verlaufskontrolle und Nachsorge können sich negativ auf Morbidität und Mortalität der Betroffenen auswirken. Frühzeitige präventive Maßnahmen werden möglicherweise nicht rechtzeitig eingeleitet. Kardiale Hauptprobleme der EMAH betreffen Herzinsuffizienz, -rhythmusstörungen, Endokarditiden und pulmonalvaskuläre Erkrankungen. Mit zunehmendem Alter stellen kardiale oder nichtkardiale Komorbiditäten weitere Probleme dar. Diese manifestieren sich oft anders als bei erworbenen Herzerkrankungen. Dort etablierte Therapieregime lassen sich nicht unbedingt auf AHF übertragen. Treten bei EMAH Probleme neu auf, wenden sie sich zumeist primär an ihren Haus- oder Allgemeinarzt. Trotz überwiegend fehlender spezifischer Kenntnisse zu EMAH stellt dieser die Weichen für die adäquate Diagnostik, Behandlung und prophylaktische Maßnahmen. Daher muss der Hausarzt wissen, welcher (Kinder-) Kardiologe mit entsprechender EMAH-Erfahrung für das gemeinsame Patientenmanagement infrage kommt.

The residues enriched in putrescible materials and those with a high content of organic fraction produce large environmental impacts and other problems associated with the productive sector where they are generated. Colombia has a high biomass potential susceptible to be energetically valorized through biological processes achieving two functions: treatment and energy production. Anaerobic digestion is established as a technology with worldwide applications inside the circular biobased economy concept (cradle to cradle). Nevertheless, most of the studies related to technologies like anaerobic digestion have been concentrated on residues from industrialized countries. Considering the variability of residues composition depending on the level of development of a country, it is necessary to assess the biomethanation potential of biomass produced by different productive sectors in Colombia. In this study, a biomethanation potential assessment of organic residues (Organic Fraction of Municipal Solid Wastes, swine manure, cocoa husks and pods, residues from the bottled fruit drinks industry and rice stovers) from different productive sectors in Colombia was carried out. The biochemical methane potential (BMP) of each residue and its mixtures was carried out in a system which consisted in a battery of batch reactors (250 and 120 mL bottles) equipped with gasometers. To keep mesophilic conditions, an immersion thermostated bath was used. For all mixtures, an optimum C/N ratio of 20-30 was fixed based on the previous physicochemical characterization of the employed residues. The batch digestion process was evaluated until the total stoppage of gas production. The results indicate that the best mixture in terms of biogas production is the one containing cocoa, fruits and swine manure (C/N = 24), reporting a cumulative specific gas production around 497 mL CH4/g VS. However, this result was lower than the sum of the ones reported by BMP for each individual substrate.

Fear of death (FoD) is an exceptionally stressful symptom of ST-elevation myocardial infarction (STEMI), which received little scientific attention in recent years. We aimed to describe the prevalence and factors contributing to FoD among STEMI patients and assess the impact of FoD on prehospital delay.

Bei einem kardiochirurgischen Eingriff können Herz und Nieren durch die Ischämie und Reperfusion geschädigt werden. Die präoperative Konditionierung soll die Ischämietoleranz des Herzmuskels verbessern – der Nutzen ist allerdings umstritten. In einer deutschen Studie von Meybohm et al. senkte das Verfahren die Komplikationsrate nicht.

The relationship between atrial fibrillation and diabetes mellitus type 2 is controversial, and various studies have demonstrated conflicting results. However, the majority of larger prospective studies published during recent years demonstrated a positive correlation. After multivariate adjustment diabetes increased the risk for atrial fibrillation at least two fold. This combination is associated with substantially increased risks of death and cardiovascular events (stroke and heart failure). Atrial fibrillation in patients with diabetes mellitus type 2 identifies individuals who are likely to obtain greater benefits from glycemic control and anticoagulants as well as antihypertensive therapy.

After showing four quasi-periodic outbursts spaced by similar to 1 yr from 2009 to 2012, the hyper luminous X-ray source ESO 243-49 HLX-1, currently the best intermediate mass black hole (IMBH) candidate, showed an outburst in 2013 delayed by more than a month. In Lasota et al., we proposed that the X-ray light curve is the result of enhanced mass transfer episodes at periapsis from a donor star orbiting the IMBH in a highly eccentric orbit. In this scenario, the delay can be explained only if the orbital parameters can change suddenly from orbit to orbit. To investigate this, we ran Newtonian smooth particle hydrodynamical simulations starting with an incoming donor approaching an IMBH on a parabolic orbit. We survey a large parameter space by varying the star-to-black hole mass ratio (10(-5)-10(-3)) and the periapsis separation r(p) from 2.2 to 2.7r(t) with r(t), the tidal radius. To model the donor, we choose several polytropes (Gamma = 5/2, n = 3/2, Gamma = 3/2, n = 2, Gamma = 5/3, n = 2, and G = 5/3, n = 3). Once the system is formed, the orbital period decreases until reaching a minimum that may be shallow. Then, the period tends to increase over several periapsis passages due to tidal effects and increasing mass transfer, leading ultimately to the ejection of the donor. We show that the development of stochastic fluctuations inside the donor by adding or removing orbital energy from the system could lead to sudden changes in the orbital period from orbit to orbit with the appropriate order of magnitude to that which has been observed for HLX-1. We also show that given the constraints on the black hole (BH) mass (M-BH > 10(4) M-circle dot) and assuming that the HLX-1 system is currently near a minimum in period of similar to 1 yr, the donor has to be a white dwarf or a stripped giant core. We predict that if HLX-1 is indeed emerging from a minimum in orbital period, then the period would generally increase with each passage, although substantial stochastic fluctuations can be superposed on this trend.

„Sapere aude!“ (Habe Mut, dich deines eigenen Verstands zu bedienen!), forderte Kant. Chirurgische Exzellenz fordert diesen Gebrauch des Verstands, weil die Individualität der konkreten Behandlungssituation die Anwendung starrer Regel ausschließt. Diese Individualität ergibt sich v. a. aus dem Willen des Patienten. In Anlehnung an Clausewitz sind es aber 3 Tendenzen, die als eigenständige Kräfte die Individualität der Behandlungssituation begründen. Die 1. Tendenz besteht in der Gewaltsamkeit, die als Todesdrohung der Erkrankung das Handlungsfeld unter die Wirkung menschlicher Gefühle stellt. Die 2. Tendenz besteht in der Unsicherheit, die jede Entscheidung zum Kalkül der Wahrscheinlichkeit macht. Die 3. Tendenz besteht in der Politik, die die Medizin zum Instrument ihres Willens macht. Strategisches Denken versteht die Auseinandersetzung mit diesen Tendenzen als ergebnisoffenen Prozess. Dieser Denkstil ist eine hochwirksame Methode, mit der der Chirurg individuelle Zwecke des Patienten mit medizinischer Rationalität verbindet. Strategisches Denken ist damit die Lehre zur Individualisierung ärztlicher Vorgehensweisen und weist den Weg zu chirurgischer Exzellenz.

There are exiting new developments in several areas of atrial fibrillation (AF) management. This paper summarizes the results of two studies carried out within the atrial fibrillation network (AFNET) and provides some information about ongoing "Mega-Studies" dealing with optimized management of AF. The Flecainide Short-Long trial (Flec SL) was embedded within the AFNET and was designed to compare short- and long-term therapy with flecainide following successful cardioversion. Although sufficiently powered, the trial failed to demonstrate non inferiority of short-term as compared to long term antiarrhythmic therapy for prevention of recurrent AF after cardioversion. However, in a post-hoc Landmark analysis beginning at the time point of withdrawel of short-term therapy, long-term drug therapy was superior to short-term therapy. The "Angiotensin II-Antagonist in paroxysmal atrial fibrillation (ANTIPAF)-Trial was a prospective, randomized double-blind placebo controlled trial, which was also conducted by the German AFNET. The ANTIPAF-study enrolled patients with paroxysmal atrial fibrillation without significant heart disease. Compared to placebo Olmesartan had no effect on the cumulative incidence of AF recurrence or AF burden. In the same way Olmesartan did not influence the cumulative incidence of persistent AF. It is likely that a "comprehensive approach for rhythm control therapy of AF" can help to improve outcome in patients with AF. This concept of "early and comprehensive rhythm control therapy" for reducing relevant outcomes in AF patients will be tested in future controlled trials, including the EAST trial (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial).