The World Health Report –Health systems Empowering Citizens and Improving Performance

Background: Oman is a Middle Eastern country bordering the Arabian Sea, Sea of Oman and the Persian Gulf. It has a population of about four million people, about 50% of whom are expatriates. The WHO report is the first international assessment of Oman’s health system (HS). More, the WHO report is the first-ever comprehensive assessment of the world’s health systems. Purpose of the study: To discuss the WHO report assessment of Oman’s health system. In addition, we will explore how a small country with relatively a young health system could, achieve such a high ranking where others with high financial capacity and well mature health system fail to achieve a goo ranking by the WHO standard. Methods: The study utilises WHO report that relies on the following major components: (1) goal attainment (effectiveness), (2) health expenditures per-capita, and (3) efficiency and the overall level of health performance. Its analysis identifies the key outcomes in terms of three main goals for HS: to improve health; to improve the responsiveness of the HS to people’s legitimate expectations of being treated with dignity and autonomy and due care; and to encourage, the third component, the HS to be fairly financed. Results: Oman was ranked highly by the WHO report. Its success is very impressive compared to many countries that are well advanced and have a better health finance system. WHO used five performance indicators to measure HS in 191 member states, it finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan. Conclusions, brief summary and potential implications: This highly innovative study has been criticised for its choice of objectives and advocate a case for omitting the equity of financing from the list and replacing it with an index of access, both financial and geographical. The weights attached to the system objectives have not been validated. However, it is highly unlikely that a single set of weights or a single set of objectives can be obtained which are valid reflections of the aspirations of every country in the world. Key words: World Health Organization, health report, health system, Oman, health system, effectiveness, health expenditures, efficiency, health performance, dignity and autonomy

Effectiveness of EMLA Cream in the Management of Arterio-Venous Fistula Needle Insertion Pain in Haemodialysis Patients

This systematic review is conducted to assess the effectiveness of EMLA-cream in the management of Arterio-Venous Fistula-AVF needle insertion pain in adult haemodialysis-HD patients compared with other alternative interventions. The main search was conducted in November 2020 and was updated on 5th December 2020. In the search strategy, keywords and synonyms were used, and multiple databases were searched with no date limitation to ensure a comprehensive search that would allocate all studies relevant to the review, and to minimize location bias. The following databases were explored: Joanna Briggs Institute (JBI), the International Prospective Register of Systematic Reviews (PROSPERO), Cochrane Library, and the Campbell Collaboration Library of Systematic Reviews. The keywords “EMLA cream”, “Arterio-Venous Fistula needle pain” and “hemodialysis patients” or “haemodialysis patient” were used for a scoping search in Google Scholar, whereas in the databases were ((“EMLA”) OR (“eutectic mixture of local anesthetic*) AND Arteriovenous*) OR “fistula needle* fistula cannula* and (“h#emodialysis patient OR * dialysis patient)). A total of 209 studies were found in this search and were filtered. Initially, any duplicated studies were removed, leaving 89 studies that were relevant to the inclusion and exclusion criteria. Two studies were included from the hand search. There were no studies identified in the grey literature or backward and forward chaining search. Following this initial filtration, the titles and abstracts of the remaining studies were reviewed and 76 were excluded. The full text of 15 studies was read in full and nine were excluded for the following reasons: three studies were focused on mixed participants, six studies used other interventions and one study was a duplicate paper with the same author and different title. Five studies were taken forward for critical appraisal. EMLA-cream is an effective management strategy in reducing AVF needle insertion pain among adult HD-patients. However, despite the positive effect of EMLA cream in reducing HD needle insertion pain, with fewer side effects, the findings should be considered with caution, as there are some limitations, and further research is required. Keywords: EMLA; Pain; Dialysis; Arterio-Venous Fistul

Post-Infarction Ventricular Septal Defect: A quarter century experience

Objectives: Post-infarction ventricular septal defect (VSD) is one of the known complications after acute myocardial infarction. This study investigated the clinical results after surgical repair of VSD. Methods: This retrospective study included all patients undergoing surgical repair of VSD from 1996 to 2020 in Oman. Results: Out of a total of 75 patients, 62.5% were men, with a mean age of 59 years. The mean follow-up was 17.2 (7.5) years. Of the 75 patients, 34 (45.3%) patients died within 30 days. Total survival was 41.3% at 5 years, while the 10-year survival rate was 33.3%. Outcomes and predictors for 30 days mortality were the number of concomitant coronary involvement and anastomoses performed, residual postoperative shunt and postoperative dialysis. Conclusion: Even with surgical repair, early mortality of post-infarction septal defect is still considerably high. Early repair and the anatomically posterior rupture are predictors of early mortality. In patients surviving the immediate postoperative period, long-term survival is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt. Keywords: Post Infarction Heart Rupture; Ventricular Septal Rupture; Coronary Artery Bypass Grafting; Mortality; Oman

Mycophenolate Induced Colitis: One-year Post-kidney Transplantation

The incidence of end-stage kidney disease (ESKD) has been increasing over the past few years as a direct result of the growing percentages of individuals with metabolic syndrome. From 2001 to 2015 there were 2805 individuals diagnosed with ESKD in Oman with a growing number of patients undergoing renal transplant as the gold standard management of renal replacement therapy. Mycophenolate mofetil (MMF) is one of the most frequently used medications as a part of immunosuppressive medications in renal transplant specifically and solid organ transplant generally. We are reporting a case of MMF-induced colitis in a young female patient that underwent a living-related kidney transplant. She presented with a three-month history of watery non-bloody and afebrile diarrhea. Investigations confirmed the diagnosis of MMF-induced colitis. Histopathological examination of colonic biopsies obtained during the colonoscopy procedure showed mildly increased crypt apoptosis, mild architectural disarray, and focal crypt attenuation; features consistent with MMF-induced colitis. The patient was treated by stopping the causative agent and replacing it with another immunosuppressive medication, which led to complete resolution of the symptoms on follow-up appointments. In this case report, we highlighted the underlying mechanism, pathogenesis, and clinical features of MMF-induced colitis

BIRTHWEIGHT AND SUSCEPTIBILITY TO CHRONIC DISEASE

The thesis examines the relationship of birthweight to risk factors and markers, such as proteinuria and glomerular filtration rate, for chronic disease in postnatal life. It made use of the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). The AusDiab study is a cross sectional study where baseline data on 11,247 participants were collected in 1999-2000. Participants were recruited from a stratified sample of Australians aged ≥ 25 years, residing in 42 randomly selected urban and non-urban areas (Census Collector Districts) of the six states of Australia and the Northern Territory. The AusDiab study collected an enormous amount of clinical and laboratory data. During the 2004-05 follow-up AusDiab survey, questions about birthweight were included. Participants were asked to state their birthweight, the likely accuracy of the stated birthweight and the source of their stated birthweight. Four hundred and twelve chronic kidney disease (CKD) patients were approached, and 339 agreed to participate in the study. The patients completed the same questionnaire. Medical records were reviewed to check the diagnoses, causes of kidney trouble and SCr levels. Two control subjects, matched for gender and age, were selected for each CKD patient from participants in the AusDiab study who reported their birthweight. Among 7,157 AusDiab participants who responded to the questionnaire, 4,502 reported their birthweights, with a mean (standard deviation) of 3.4 (0.7) kg. The benefit and disadvantages of these data are discussed in chapter three. The data were analysed for the relationship between birthweight and adult body size and composition, disorders of glucose regulation, blood pressure, lipid abnormalities, cardiovascular diseases and glomerular filtration rate. Low birthweight was associated with smaller body build and lower lean mass and total body water in both females and males. In addition low birthweight was associated with central obesity and higher body fat percentage in females, even after taking into account current physical activity and socioeconomic status. Fasting plasma glucose, post load glucose and glycosylated haemoglobin were strongly and inversely correlated with birthweight. In those with low birthweight (< 2.5 kg), the risks for having impaired fasting glucose, impaired glucose tolerance, diabetes and all abnormalities combined were increased by 1.75, 2.22, 2.76 and 2.28 for females and by 1.40, 1.32, 1.98 and 1.49 for males compared to those with normal birthweight (≥ 2.5 kg), respectively. Low birthweight individuals were at higher risk for having high blood pressure ≥ 140/90 mmHg and ≥ 130/85 mmHg compared to those with normal birthweight. People with low birthweight showed a trend towards increased risk for high cholesterol (≥ 5.5 mmol/l) compared to those of normal birthweight. Females with low birthweight had increased risk for high low density lipoprotein cholesterol (≥ 3.5 mmol/l) and triglyceride levels (≥ 1.7 mmol/l) when compared to those with normal birthweight. Males with low birthweight exhibited increased risk for low levels of high density lipoprotein cholesterol

Quality of Life and Health-related Quality of Life in Patients with End-stage Kidney Disease Undergoing Hemodialysis: A Literature Review

Measurements of quality are intended to drive improvements in care and provide accountability regarding costs and quality. Quality of life (QoL) and health-related QoL (HRQoL) comprise personal perceptions, health, and socioenvironmental dimensions. This structured integrative review aimed to present and analyze the nature and significance of the predictors of QoL and HRQoL in patients with end-stage kidney disease (ESKD). The articles found through searching the main databases were assessed for sample size, design, and methodological limitations. The revised Wilson–Cleary conceptual framework of HRQoL and the World Health Organization's definition of QoL guided this review. Forty-five articles were selected (36 were observational or cross-sectional studies; nine were prospective). These articles reported a range of factors related to QoL and HRQoL characterized as physical, mental, socioeconomic, biological, and symptomatic. Few studies considered spiritual beliefs and cultural beliefs. There was a lack of consistency in the use of measures of QoL and HRQoL in ESKD. The most validated measures of HRQoL and QoL identified were the Short-Form 36 v2, the QoL Index – Dialysis, the Hospital, Anxiety, and Depression Scale, the Fatigue Severity Scale, the Itch Scale, the Spiritual Well-being Scale, and the Schedule for the Evaluation of QoL – Direct Weighting. Most studies were conducted in developed countries, with only two from the Middle East. The possible measures of QoL and HRQoL are health status, disease-specific, symptom-specific, spiritual, and individualized QoL measures. This set of measures is expected to capture the patients' own perceptions concerning their QoL and HRQoL

Commercial Kidney Transplantation: Attitude, Knowledge, Perception, and Experience of Recipients

Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant. Methods: A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. Results: One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program. Discussion: The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from deceased sources. All western ethical arguments turn out to become of vital importance in developing countries, because transplantation is the cheapest renal replacement therapy. However, it must be emphasized that commercial transplants should not be an alternative to building a national transplant initiative. The national diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program and to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation

Birth weight, gestational age, and blood pressure: Early life management strategy and population health perspective

The incidence of hypertension (HTN) is rising worldwide with an estimated prevalence of 22%, 7.5 million deaths (12.8%). It is a major risk factor for coronary heart diseases and hemorrhagic strokes. In Oman, the crude prevalence of HTN was 33.1%, whereas the age-adjusted prevalence was 38.3%. Among Gulf Cooperation Countries, 47.2% of the individuals were hypertensive, and women were more likely to have HTN than men. Similarly, the prevalence of low-birth-weight (LBW) is also rising globally with the more prevalent incidence in developing countries reaching almost a rate just lower than 20.0/100 births. In Oman, the prevalence of LBW was 4.2% in 1980, which doubled (8.1%) in 2000 and has shown a slow but steady increase reaching 10.2% in 2013. LBW term is the most commonly used surrogate measure of intrauterine growth retardation and has been related to increased cardiovascular mortality, due to increased risk of cardiovascular risk factors, including blood pressure (BP), diabetes, cholesterol level, and other risk factors. The epidemiologic evidence clearly points to an inverse association between birth weight and many hemodynamic cardiovascular risk markers. Possible mechanisms operating in fetal life that might determine BP include the structural development of resistance arteries, the setting of hormone levels, and nephron endowment. Retarded fetal growth leads to permanently reduced cell numbers in the kidney. Patients with high BP had almost 50% less number of glomeruli compared to that of the normotensive individuals, and subsequent accelerated growth may lead to excessive metabolic demand on this limited cell mass. It is not merely a reduced nephron number that is responsible for HTN, but compensatory maladaptive changes that occur internally when nephrogenesis is compromised. The likelihood of an adverse outcome is greatly amplified in those born with LBW who later develop obesity or an increased ponderal index