Health system performance assessment and reforms, Oman.

Problem: To prioritize key areas of action and investment for the next strategic cycle of national development plans (2026-2031) in Oman, we needed a holistic view of the country's health system and its main deficiencies and inefficiencies. Approach: Informed by the World Health Organization framework, our team of seven national health ministry staff and two international experts conducted a rapid health system performance assessment. We used already available data to identify system bottlenecks and their potential root causes, verifying our findings with key informant interviews. Local setting: Oman's 4.9 million population is relatively young (average age 28 years) but ageing, with a mounting burden of chronic diseases. While health-care services are free for Omani nationals, more than 1.5 million expatriates rely on out-of-pocket payments for health-care services. Strengthening primary health care, improving the quality of care, providing financial protection, and ensuring that public and private health-care providers operate within the same legal and procedural framework are recognized as key national priorities. Relevant changes: Our assessment highlighted the need to extend health service coverage to the whole population, strengthen private health-care sector governance, improve health education, increase financial investment, and expand the country's capacity for data collection and analysis. Lessons learnt: The assessment framework allowed us to identify areas where information is lacking and use already available data to analyse multiple health outcomes. As well as identifying issues that need to be addressed during the next policy development cycle, our findings have contributed towards the preparation of a more extensive assessment.

Towards a green hospital approach in Oman: A case study of quantifying an environmental impact.

INTRODUCTION: The environmental impact of hospitals and healthcare providers practices is substantial, although often unnoticed and infrequently tracked. A green and healthy hospital is one that promotes public health by continuously monitoring and reducing its environmental impact. METHODS: We adopted a descriptive case study design with a multi-dimensional evaluation and monitoring of carbon emission equivalence (CO2e) using two examples from a tertiary care hospital practice in Oman. One example (1) was related to inhalation anaesthetic gases (IAG) consumption and the second example (2) was related to estimation of telemedicine clinics (TMCs) CO2e travel-related savings. RESULTS: The cumulative consumption of three different (1) IAG over three years (2019, 2020, 2021) was generated with estimated CO2e for each year for sevoflurane, isoflurane and desflurane. Desflurane had the lowest consumption with a yearly cumulative consumption of 6000 mL, 1500 mL, and 3000 mL for the years 2019, 2020 and 2021. The (2) TMCs during the first two years of the COVID-19 pandemic travel related CO2e savings were in the range of 12.65-3483.1 tonnes. In the second year of launching this service it doubled to a range of 24-6610.5 tonnes of CO2e savings. CONCLUSION: A green and healthy hospital approach of tracking and monitoring environmental impact of healthcare providers practices is critical for health planning and management of the environmental policy. This case study illustrated the importance of closely tracking hospital-based practices from an environmental perspective towards a green hospital approach.

Agile Teams and Lean Methods in a Tertiary Care Hospital During COVID-19 Pandemic.

Objectives: To share the experience of Agile Teams using Lean Method to facilitate improvement projects during the COVID-19 pandemic. Methods: A tertiary hospital in Oman mobilized agile teams using lean methods to streamline the workflow during the early stages of COVID-19 pandemic in year 2020. Results: The collaborative network generated by the agile teams increased interdepartmental engagement within the hospital and trimmed workflows, thus improving patient care despite the pandemic. Conclusions: Agile teams using lean methods demonstrably enhance collaboration and efficiency in healthcare, leading to improved patient care.

Ivacaftor in Omani children with cystic fibrosis caused by p.Ser549Arg CFTR mutation.

Background: Cystic fibrosis (CF) is a multisystemic chronic disease caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) protein. These mutations are classified in to six classes. Ivacaftor is a CFTR potentiator which partially restores the CFTR function for class III mutations. In Oman, p.Ser549Arg (class III) is the most common mutation (65% of cases). Our study prospectively evaluated the tolerance and clinical efficacy of ivacaftor. Methods: A prospective observational study was conducted at the Royal Hospital, Oman. All children aged 6-18 years who are followed and carry at least one copy of the p.Ser549Arg mutation were started on Ivacaftor and included in the study. Data collected included weight, height, forced expiratory volume in first second (FEV1), sweat chloride concentration, stool elastase level and liver enzymes at baseline and at 12, 24, 36, and 48 weeks after initiation of treatment. The number of CF pulmonary exacerbations one year before and during treatment were compared. Results: Twenty one children were started on Ivacaftor (90% homozygous for p.Ser549Arg). The mean age was 10.8 (SD ±3.5) years. When compared to baseline, FEV1 significantly improved by a mean of 10.8 (SD ±13.5) percentage points (pp) and 14.3 (SD ±7.5) pp at 12 and 48 weeks respectively. The sweat chloride level significantly dropped from a mean of 107 (SD ±8.5) mmol/l to 38.5 (SD ±22.3) mmol/l at 12 weeks and remained low. The Body Mass Index (BMI) improved by a mean of 1.37 (SD ±1.3) kg/m 2 and 1.9 (SD ±1.35) kg/m 2 at 24 and 48 weeks of treatment respectively. The number of admissions the year before and during treatment reduced significantly from a mean of 2.2 (SD± 1.9) to 0.7 (SD ±1) admission per year. Two children developed transaminitis. Conclusion: Ivacaftor is well tolerated and resulted in a significant improvement in FEV1, BMI and sweat chloride level in children with p.Ser549Arg CFTR mutation.

Oman's COVID-19 publication trends: A cross-sectional bibliometric study.

Public health crises, such as the COVID-19 pandemic led researchers and clinicians to stretch their capacities in conducting, writing, reviewing, and publishing a wealth of pandemic-related research. Oman scholars, researchers, and clinicians are no different in their quest for rapid dissemination of relevant scientific knowledge, which is of paramount importance nationally and internationally. Given the intense international interest in COVID-19 research. The study aim is to describe the COVID-19 research output in Oman in relation to publication type, journal impact factor, collaboration, author affiliation and compared it with national scholarly output over the decade. Study Design: We carried out a bibliometric cross-sectional study. Methods: We included all Oman COVID-19 publications for the period February 14 and 25, February 2021. Data retrieved using search engines PubMed, Google Scholar and Directory of Open Access Journals. Results: The COVID-19 publications search generated 210 articles. There were 36.7% review articles and 30% original articles. Of note, 2.4% randomized controlled trials articles were produced during the search period, 1.4% systematic and meta-analysis articles. The 85.7% of the publications were in journals with defined impact factor (IF) and 89.4% of articles with IF < 5. There was 53.8% international collaboration. Conclusion: The need to increase research published in journals with high impact factors and there was a high international collaboration in reviews and report articles, which may require building national research capacity.

Prevalence and Characteristics of Cystic Fibrosis in Omani Children: A Multi-center Cross-sectional Study.

Objectives: To describe the demographic distribution of cystic fibrosis (CF) in Omani children, estimate the national prevalence, and provide updated mutational panels of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Methods: We conducted a retrospective cross-sectional study of all CF patients who had been diagnosed and followed-up at Sultan Qaboos University Hospital and Royal Hospital in Oman between 2006 and 2020. Data were collected from electronic hospital records and telephone interviews. Results: A total of 227 patients with CF were included in the study. Geographical clusters of the disease were identified in the governorates of Al-Batinah, A'Dhahirah, and A'Dakhiliyah. Parental consanguinity and family history of CF were present in 68.3% and 69.6% of the patients, respectively. The most common CFTR mutation was p.Ser549Arg (52.0%), followed by p.Phe508del (12.3%), and c.2988+1G>A (4.4%). Three novel CFTR mutations were identified, viz., Leu88TyrFs*, p.Asp192Val, and c.4242+1G>C. Conclusions: The estimated prevalence of CF in Oman is 10.3 per 100 000 individuals. Premarital genetic counseling and preimplantation genetic testing are recommended in CF-prevalent regions.

Biological and clinical manifestations of juvenile Huntington's disease: a retrospective analysis.

BACKGROUND: Huntington's disease is a rare, neurodegenerative disease caused by an expanded CAG repeat mutation in the huntingtin gene. Compared with adult-onset Huntington's disease, juvenile Huntington's disease (onset ≤20 years) is even rarer and has not been studied extensively. We aimed to further characterise juvenile Huntington's disease by examining the effect of CAG repeat size on disease presentation, progression, and survival. METHODS: We did a retrospective analysis of patients with juvenile Huntington's disease aged 20 years or younger, according to the length of their CAG repeat and who had disabling psychiatric symptoms (with motor symptoms) or motor symptoms alone, and of patients with adult-onset Huntington's disease manifesting aged 30-60 years with 40 or more CAG repeats, from the REGISTRY and ENROLL-HD platforms and from two institutional databases (Lega Italiana Ricerca Huntington Foundation and the Instituto Neurociencias de Buenos Aires and the Sanatorio de la Trinidad Mitre). Patients with psychiatric but no motor symptoms were excluded. We compared symptoms at onset and longitudinally in patients with juvenile Huntington's disease with highly expanded (HE subgroup) or low expansion (LE subgroup) mutations, grouped by hierarchical clustering analysis. We also compared disease progression (longitudinal change in Unified Huntington's Disease Rating Scale-Total Motor Score) and survival of patients with juvenile and adult-onset Huntington's disease. FINDINGS: We extracted medical records from 580 patients entered into the studies or databases between June 23, 2004, and March 31, 2018, of whom 36 patients met our definition of juvenile Huntington's disease and 197 for adult-onset Huntington's disease. According to caregiver reports, gait disturbance was more often a first presenting symptom in the HE subgroup (eight [80%] of 10 patients) than in the LE subgroup (seven [27%] of 26 patients; p=0·0071), whereas loss of hand dexterity was more common in the LE subgroup (11 [42%] of 26 patients) than in the HE subgroup (0 [0%] of 10 patients; p=0·0160). Compared with the LE subgroup, development delay (0 [0%] in the LE subgroup vs nine [90%] in the HE subgroup; p<0·0001), severe gait impairment (nine [35%] in the LE subgroup vs nine [90%] in the HE subgroup; p=0·0072), and seizures (three [11%] in the LE subgroup vs eight [80%] in the HE subgroup; p<0·0001) prevailed over time in the HE subgroup. Disease progression was more rapid in juvenile Huntington's disease (n=14) than in adult-onset Huntington's disease (n=52; generalised estimating equation model, p=0·0003). Of 121 deceased patients, median survival was shorter in the juvenile Huntington's disease (n=17) cohort than in adult-onset Huntington's disease (n=104) cohort (hazard ratio 2·18 [95% CI 1·08-4·40]; p=0·002). INTERPRETATION: Patients with HE juvenile Huntington's disease differ clinically from patients with LE juvenile Huntington's disease or adult-onset Huntington's disease, suggesting reclassification of this particularly aggressive form of Huntington's disease might be required. FUNDING: Lega Italiana Ricerca Huntington Foundation and IRCCS Ospedale Casa Sollievo della Sofferenza.

Serum KL-6 and surfactant proteins A and D in pediatric interstitial lung disease.

OBJECTIVE: To determine if serum KL-6, surfactant protein A (SP-A), and surfactant protein D (SP-D) levels are elevated in pediatric interstitial lung disease (ILD) and associated with pulmonary function and disease severity score. METHODS: Serum KL-6, SP-A, and SP-D levels were measured by enzyme-linked immunosorbent assay in 10 children with ILD and in 10 healthy volunteers. In the ILD group, FEV1 percentage of predicted, FVC percentage of predicted, and ILD disease severity score were measured and correlated with serum KL-6, SP-A, and SP-D levels. RESULTS: For the ILD and control groups, respectively, mean serum KL-6 was 4,523 U/mL and 206 U/mL (p = 0.007), mean serum SP-A was 133 ng/mL and 21 ng/mL (p = 0.003), and mean serum SP-D was 304 ng/mL and 75 ng/mL (p = 0.004). There was an inverse relationship between SP-A and FVC (p = 0.05), and between SP-D and FEV1 (p = 0.05). There was a direct relationship between SP-D and ILD score (p = 0.05). CONCLUSIONS: Serum KL-6, SP-D and SP-D levels are elevated in children with ILD. SP-A and SP-D levels appear to correlate with some measures of disease severity.

Mucinous cystadenocarcinoma of the pancreas in an adolescent with cystic fibrosis.

Epidemiologic studies indicate that the overall risk of malignancy among patients with cystic fibrosis (CF) is similar to that of the general population. However, these studies and a number of case reports suggest that patients with CF may be at increased risk for the development of specific gastrointestinal cancers. Tumors of the esophagus, stomach, small and large bowels, liver and biliary tracts, and pancreas have been described. Previous reports of pancreatic cancers among patients with CF have included only adenocarcinoma in adults. This is the first description of a mucinous cystadenocarcinoma of the pancreas in an adolescent with CF. The tumor developed within a pancreatic cyst that had been initially identified 13 years before resection. Our report highlights the increased risk of pancreatic malignancy among patients who have CF and illustrates the premalignant potential of pancreatic cysts in this at-risk population. Further, it reinforces the need for careful surveillance and suggests a role for more aggressive diagnostic and therapeutic interventions for patients with atypical findings on pancreatic imaging studies.