Recommendations to improve opioid use disorder outcomes in countries of the Middle East

Background: Progress has been made in treatment of opioid use disorder (OUD) in the Middle East; current clinical practice often differs from standards of care elsewhere.

Aim: describe treatment approaches in selected countries to inform recommendations for improving care.

Methods: Evidence describing approaches to OUD care was collected and analyzed in a structured, comparative manner. Recommendations were developed based on experts’ clinical experience in the region.

Results: Care differs across countries assessed: Egypt, KSA, UAE, Oman, Kuwait, and Bahrain. Detoxification programs are the common treatment approach in Egypt, KSA, Oman, and Bahrain; integrated programs with opioid agonist therapy (OAT): UAE, Kuwait. Fear of misuse and diversion risk commonly limits access to OAT. Problems with sourcing medicines may limit treatment options. There is limited data on treatment needs or provision. Recommendations: develop effective policy and expert-led consensus on best practice for OUD in the region including integrated treatment programs, provide support for specialists and centers, include innovative medication choices with low diversion risk, promote collaborative work, coordinate data collection, and sharing.

Conclusions: There is important unmet need for OUD in the region and opportunity to improve services through collaboration to support change. Therapy options with reduced diversion risk may address barriers to care.     

Measurement of range of movement in the lumbar spine—what methods are valid? A systematic review

Objectives

To examine the validity of low-tech procedures used in routine clinical practice to determine the range of movement of the lumbar spine in comparison to the ‘gold’ standard of measurement.

Data sources

AMED, CINAHL, Embase, OVID Medline, The Cochrane Library, Spine and other relevant journals.

Review methods

A search of electronic databases (January 2006) was complemented by hand searching reference lists of identified studies and journals, plus consultation with recognised experts to identify English language studies designed to evaluate the validity of low-tech procedures used to determine range of movement of the lumbar spine in adult human subjects presenting with non-specific low back pain.

Results

Four relevant studies were identified for analysis. Three studies investigated the use of the double-inclinometer method and one study investigated the modified-modified Schober test. The appraisal was performed using the modified QUADAS tool. The studies were considered heterogeneous and thus qualitative analysis was undertaken. This indicated limited positive evidence that the double-inclinometer method is valid for measuring total lumbar range of movement, conflicting evidence for double-inclinometer measurement of lumbar flexion range, limited evidence that the modified-modified Schober test is not valid for measurement of lumbar flexion range and limited evidence that the double-inclinometer method is not valid for measuring lumbar extension range.

Conclusion

There is little evidence to support the use of current methods of range of movement measurement in the lumbar spine. If range of movement is to continue to be used during routine clinical practice to assess spinal function, degree of impairment and response to therapeutic input there is a need for scientific evidence on the validity of these procedures.     

Primary health care in Saudi Arabia: applying global aspects of health for all, locally

Primary health care in Saudi Arabia: applying global aspects of health for all, locally This paper describes the application of primary health care principles in the Islamic Kingdom of Saudi Arabia. It arose from a doctoral supervisory experience on a joint programme for women students, operating between a British and Saudi Arabian University. The research looked at nutritional advice given by diploma-level nurses to pregnant women attending primary health care centres in Saudi Arabia. The supervisor supported research that drew on internationally recognized trends in nursing research (the reflexive learner) whilst attending to local requirements and conventions of the culture. The student was encouraged explicitly to site the research within the framework of Islamic teaching and Saudi culture. The Qur'an was used as an overarching framework within which the tenets of primary health care were explored. This was seen to be crucial in addressing World Health Organisation and the International Council of Nurses' views on contextualizing nursing for the greatest benefit of the population. This was of particular relevance in Saudi Arabia where research carried out in the community by women is novel, and as yet there are no nurse theorists from within Saudi culture.     

Severe haemolysis after an ABO unmatched kidney transplant - a nonsecretor transplanted from a donor with high anti-A titre

A case of severe haemolysis following an ABO unmatched renal transplant is reported in a group A nonsecretor who received a kidney from a group O living related donor. Following the haemolytic episode, group A donor units were incompatible and the patient was transfused with group O blood. Serological investigation of the recipient revealed anti-A present in the serum and on the red cells. Investigation of the donor revealed the presence of high-titre anti-A. The association of such high-titre donor antibody with haemolysis in ABO unmatched grafts has not been reported before. We discuss the risk factors for developing haemolysis in an ABO unmatched organ transplant and explore the possible relevance of such high donor antibody titre to recipients who are nonsecretors.     

The immunocompromised adult patient and surgery

The current state of perioperative management of the immunocompromised patient rests at an uncomfortable transition between understanding that management decisions have an important impact on patient well-being and awaiting clear guidance to best practices. It is not clear that the concept of physiological reserve that has served clinicians so well in areas such as cardiovascular risk stratification and management will be easily applied to assessing risk and optimizing treatment with regard to the immunocompromised patient. For example, it seems logical that somehow minimizing typical perioperative suppression of cell-mediated immunity could benefit patients with cancer and AIDS, because we conceptualize this aspect of immune dysfunction to be paramount in such patients. But an issue such as this that seems somewhat straightforward is actually unanswered. The delicate and intricate interplay of the initial inflammatory response to injury with the later cell-mediated responses allows neither the discrete manipulation of our simplified model of the immune response nor simple measurement of the outcomes of therapeutic efforts. With the added complexities of variable patient responses, presumably on the basis of factors such as individual genome, procedure variations, differences in medication effects, and issues not even yet considered, anesthetic care tailored to the individual patient is not yet a reality.As the work of clarifying these issues continues, the clinician must first fall back to basic principles. The terrible cost of surgical infection both financially and in human suffering mandate that every patient receive meticulous attention to avoiding infection. The immunocompromised patient should further be assessed for degree of suppression, nutritional status, and either maintenance of routine medications or the necessity of perioperative alterations or supplementation. As outlined in the discussions above, such considerations will range from HAART in the HIV infected patient, to chemotherapy and radiotherapy history in the cancer patient, to immunosuppressives in the transplanted patient and the treatment of autoimmune disease.Regarding specific medications or techniques, the current understanding of available data is that pain control attenuates most phases of the immune response by decreasing the neuroendocrine response. There appear to be increased risks such as infection in neuroaxial anesthesia and preexisting neuropathy in the patient who has received certain chemotherapeutic agents. The risks and benefits of procedures therefore may both be altered in the immunocompromised patient, and the relative benefit must be considered uniquely in each case and in partnership with the patient. Certain anesthetic medications have, with varying scientific basis and clinical applicability, become known as immunosuppressive. Again, it must be remembered from the earlier discussion that some degree of suppression of the early pro-inflammatory response is often beneficial, whereas augmentation of the later compensatory depression may have grave consequences, usually of infectious etiology in this high-risk group. It is difficult to recommend the absolute inclusion or exclusion of any particular medication or technique at this time in the management of immunosuppressed patients.The questions that remain to be answered are many. A better understanding of the immune response to injury itself appears to be emerging with developing animal models, discovery of measurable immune-mediators, and characterization of the response to injury in the clinical setting. The effects of medications used in the perioperative period, and the wide variabilities between patients and situations, need to be elucidated. Finally, with the escalating introduction and utilization of minimally invasive surgery and percutaneous interventional procedures, these interventions must be critically assessed for the risk-benefit balance of decreased tissue injury and disruption versus the effectiveness of the procedures they replace. With such progress, it is to be hoped that patients will not be simply considered “immunosuppressed”. Assessing a patient's immunologic profile and then managing the patient as dictated by that profile and within the impact of the particular procedure(s) of the perioperative period will represent the next level of sophistication in dealing with this patient population.