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

Cells of the synovium in rheumatoid arthritis. Dendritic cells

Dendritic cells are the major antigen-presenting and antigen-priming cells of the immune system. We review the antigen-presenting and proinflammatory roles played by dendritic cells in the initiation of rheumatoid arthritis (RA) and atherosclerosis, which complicates RA. Various signals that promote the activation of NF-κB and the secretion of TNF and IL-1 drive the maturation of dendritic cells to prime self-specific responses, and drive the perpetuation of synovial inflammation. These signals may include genetic factors, infection, cigarette smoking, immunostimulatory DNA and oxidized low-density lipoprotein, with major involvement of autoantibodies. We propose that the pathogenesis of RA and atherosclerosis is intimately linked, with the vascular disease of RA driven by similar and simultaneous triggers to NF-κB

Inflammation predicts accelerated brachial arterial wall changes in patients with recent-onset rheumatoid arthritis

Introduction Patients with recent-onset rheumatoid arthritis (RA) have impaired brachial artery endothelial function compared with controls matched for age, sex and cardiovascular risk factors. The present study examined endothelium-dependent (flow-mediated dilatation (FMD)) and independent (glyceryl trinitrate (GTN)-mediated dilatation (GMD)) structural responses in early RA patients, and determined progress over one year

Atherosclerotic disease is increased in recent-onset rheumatoid arthritis: a critical role for inflammation

Rheumatoid arthritis (RA) patients have increased mortality and morbidity as a result of cardiovascular and cerebrovascular disease. What is not clear, however, is either how early accelerated atherosclerosis begins in RA or how soon risk factors must be rigorously controlled. Furthermore, given the strong relationship of vascular disease to RA mortality and of inflammation to the accelerated atherosclerosis associated with RA, it is important to evaluate indices that could serially and noninvasively quantify atherosclerotic disease in RA patients. The carotid intima-media thickness (cIMT) and plaque, measured by ultrasound, correlate closely with direct measurement of the local and systemic atherosclerotic burden. To investigate the presence of subclinical atherosclerosis in the early stages of RA, the cIMT and plaque were measured using carotid duplex scanning in 40 RA patients with disease duration < 12 months and in 40 control subjects matched for age, sex and established cardiovascular risk factors. Patients with RA had significantly higher average cIMT values and more plaque than the control group (cIMT 0.64 ± 0.13 mm versus 0.58 ± 0.09 mm, respectively; P = 0.03). In RA patients, the cIMT was predicted by age and C-reactive protein level at first presentation to the clinic (R2 = 0.64). C-reactive protein was associated with age of disease onset and history of smoking. Since inflammation has been shown to predate onset of clinical RA, the accelerated atherogenic process related to inflammation may precede RA symptom onset

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

Determinants of the Median Nerve Cross Sectional Area in Rheumatoid Arthritis Patients

BACKGROUND: Rheumatoid arthritis (RA) is a widely recognized cause of carpal tunnel syndrome (CTS). Others stated that CTS is overestimated in RA. CTS is associated with increase in the thickness of the median nerve. This study aims to establish the determinants of the median nerve cross sectional area (MNCSA) in RA patients with no CTS. METHODS: Ultrasound measurements were performed in 120 RA patients (240 hands)without symptoms or diagnosis/previous diagnosis of CTS. Eachmedian nerve was measured three times, and the mean value was used for analyses. RESULTS: MNCSA was 9.79plusmn2.6 mm2 (range 1.5-22.25). MNCSA was positively associated with the age of participants (p=0.03, CI:0.00-0.08), body mass index (BMI) (p=0.04, CI:0.00-0.21), uric acid level (p=0.033, CI:0.00-0.01), and urine microalbumin (p=0.04, CI:0.00-0.01). RA clinical characteristics and inflammatory markers showed no significant relation to the MNCSA. CONCLUSION:MNCSA in RA is affected by age, BMI, serum uric acid and microalbumin level

Rheumatoid arthritis: links with cardiovascular disease and the receptor for advanced glycation end products

Cardiovascular (CV) disease is increased in patients with chronic inflammatory disease, including rheumatoid arthritis (RA). Furthermore it has become clear at a pathophysiological level, that atherosclerosis has striking similarities with autoimmune disease. This realization has come at a time of paradigm shift in how rheumatologists manage RA, with the availability of biological agents targeting key inflammatory cytokines. This review will focus on the possible causes of increased vascular disease in RA, including the role of traditional CV risk factors. Mechanisms potentially at play, such as C-reactive protein (CRP), altered coagulation, and cyclooxygenase (COX) -2 inhibitors will be covered in brief. The Receptor for Advanced Glycation End Products (RAGE) has been identified as a candidate molecule influencing response to ongoing inflammation and autoimmunity. There will be a focus on the role of RAGE in CV disease and RA. As has been the case with many novel molecules, functional polymorphisms are thought to alter disease expression and assist us in coming to terms with the biological activities of the parent molecule. The review will conclude with a discussion of the potential role of the RAGE Glycine 82 Serine polymorphis