Heather McLeod

Alterations in Porcine Gastric Mucin during the Development of Experimental Ulceration

Bile duct ligation in the pig results in ulceration of the pars oesophagea (oesophagogastric junction) within 48 h with 100% reproducibility. This work describes novel observations made during development of such ulcers using an endoscope introduced at intervals postoperatively via a Thomas gastric cannula. Macroscopic and histological changes were recorded and compared with quantitative and qualitative changes in crude mucus scrapings and purified mucins. Crude mucus scrapings of the cardiac gland region had a higher protein content in the ulcerated states than in the normals. After bile duct ligation, the (degraded) mucin glycopeptide/total protein ratio was higher in partially purified mucus from pre-ulcerated and ulcerated stomachs as compared with normal samples. The quantity of purified mucin was less in samples from ulcerated stomachs, and the N-acetylgalactosamine and fucose contents were also decreased. It is possible that these changes resulted in the failure of the mucus barrier and the development of oesophagogastric junction ulceration.

Risk equalisation in voluntary health insurance markets: A three country comparison

The paper summarises the conclusions for health policy from the experience of three countries who have introduced risk equalisation subsidies, in their voluntary health insurance (VHI) markets. The countries chosen are Australia, Ireland and South Africa. All of these countries have developed VHI markets and have progressed towards introducing risk equalisation. The objective of such subsidies is primarily to make VHI affordable while encouraging efficiency in health care production. The paper presents a conceptual framework to understand and compare risk equalisation subsidies in VHI markets. The paper outlines how such subsidies are organised in each of the countries and identifies problems that arise in their implementation. We conclude that the objectives of risk equalisation, in VHI markets are no different to those in countries with mandatory insurance systems. We find that the introduction of risk equalisation subsidies is complex and that countries seeking to introduce risk equalisation in VHI markets must carefully consider how such subsidies advance their overall health policy goals. Furthermore, we conclude that such subsidies must be structured correctly as otherwise incentives exist for risk selection which may threaten affordability and efficiency. Our overall conclusion is that also in voluntary health insurance markets risk equalisation has a role in meeting the related public policy objectives of risk solidarity and affordability, and without it these objectives are severely undermined.

Private-sector caesarean sections in perspective

Extracted from text ... SAJOG 66 September 2005, Vol. 11, No. 3 In a recent issue of the Journal, 1 views were expressed that our national private sector caesarean section (CS) rate is too high at over 60%, and government and/or funders are likely to intervene unless doctors begin to self-regulate by developing appropriate protocols and guidelines. This is not a new issue for South Africa or for medically insured populations around the world, and the sheer volume of literature on the subject of high CS rates indicates that it is unlikely one will reach consensus on a national target CS rate simply by ..

Risk equalisation and voluntary health insurance: The South Africa experience

South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. The paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.

Steady growth in antiretroviral treatment provision by disease management and community treatment programmes.

To the Editor: Although access to highly active antiretroviral treatment (HAART) in the South African public health sector is closely monitored,1 much remains unknown regarding the numbers of HIV-positive individuals receiving HAART outside the public health sector. Access to HAART in the private health sector is probably considerably better than in the public health sector, as private sector patients can often afford the costs of HAART, and many are beneficiaries of medical schemes, which are required to provide HAART to eligible beneficiaries as a prescribed minimum benefit. An investigation conducted in 2005 found that by the middle of 2005, at least 50 000 South Africans were receiving HAART through disease management programmes (DMPs), workplace treatment programmes (all of which are administered by DMPs) or community treatment programmes.2 This investigation was repeated in 2006, with the objective of estimating the numbers of people receiving HAART by mid-2006 and the rate of growth in numbers on treatment between 2005 and 2006.

Extraction, isolation, and SDS-PAGE analysis of purified gastric mucin in a patient with Menetrier's disease

Menetriers disease is a rare condition characterized by marked proliferation of gastric mucosa with variable mucus secretion and achlorhydria. Although crude mucus secretion and gastric aspirates have been evaluated in this disease for output of dry matter, hexosamine, fucose, protein content, and transforming growth factor α activity, we report for the first time the isolation, purification, and gel electrophoresis of mucin from crude mucus scrapings. The fragmentation pattern of mucin in Menetriers disease demonstrated less large polymeric mucin than the control. There was also a band of ∼55–65 kd Mr on polyacrylamide gel electrophoresis similar to that found in gastric carcinoma or peptic ulcer, but absent in the control specimens.

Sucralfate in the prevention of porcine experimental peptic ulceration

Sucralfate is the first drug to be shown to prevent ulceration in bile duct-ligated pigs. Usually such ulceration is uniformly fatal. Seven pigs in each of four groups in this study received only saline, or sucralfate (1 g every six hours), famotidine (40 mg per day), or misoprostol (200 micrograms every six hours). A Foley catheter was placed into a gastrectomy after bile duct ligation. Similar groups of sham-operated pigs were also prepared. After 48 hours, all saline-, famotidine-, or misoprostol-treated pigs showed severe macroscopic ulceration, whereas only two of those treated with sucralfate showed minimal macroscopic ulceration. Until now, only highly selective vagotomy has reduced ulceration caused by bile duct ligation. The present results suggest that acid inhibition is not the only important factor in healing bile duct ligation-induced peptic ulceration.

Large cell lymphoma: correlation of HIV status and prognosis with differentiation profiles assessed by immunophenotyping.

Diffuse large B cell lymphoma (DLBCL) and plasmablastic lymphoma (PBL) represent aggressive non-Hodgkin lymphomas, particularly in the setting of HIV infection. Since the introduction of highly active antiretroviral therapy (HAART), recent studies have documented improved survival outcome in patients with AIDS-related lymphomas. This study contributes a South African perspective by correlating the HIV status and prognosis of DLBCL and PBL with differentiation profiles assessed by immunophenotyping. Analysis of the morphologic, immunophenotypic and clinicopathologic features of 52 cases of DLBCL and 9 cases of de novo PBL was performed. The overall survival of patients with PBL was poorer than that of DLBCL (logrank p value 0.002). Despite HAART, the overall survival with DLBCL and HIV infection was significantly poorer than HIV negative patients with DLBCL (p value <0.001). Profound immunosuppression was evident in the HIV positive group as the mean CD4 count was 151 cells/mm3 in DLBCL and 61 cells/mm3 in PBL. HIV positive patients were significantly younger at presentation with greater likelihood of extranodal lymphoma. When Hans’ and Muris’ algorithmic stratification of DLBCL were applied, no statistical significance was demonstrated (p values 0.188 and 0.399 respectively). However, when Bcl-2 expression occurred in germinal center-type DLBCL (Hans’ defined), improved survival was conferred by the germinal center immunophenotype (p value 0.007). The study demonstrates that DLBCL and PBL have significant potential for aggressive behaviour and poor outcome in the setting of profound immunosuppression due to HIV infection. Further studies are required to assess the effect of targeted-immunotherapy (Rituximab) in combination with recent amendment of the South African national antiretroviral treatment guidelines which has created tremendous potential for improved survival in patients with AIDS-related non-Hodgkin B-cell lymphomas.

The role of risk equalization in moving from voluntary private health insurance to mandatory coverage: the experience in South Africa

OBJECTIVE The South African health system has long been characterised by extreme inequalities in the allocation of financial and human resources. Voluntary private health insurance, delivered through medical schemes, accounts for some 60% of total expenditure but serves only the 14.8% of the population with higher incomes. A plan was articulated in 1994 to move to a National Health Insurance system with risk-adjusted payments to competing health funds, income cross-subsidies and mandatory membership for all those in employment, leading over time to universal coverage. This chapter describes the core institutional mechanism envisaged for a National Health Insurance system, the Risk Equalisation Fund (REF). A key issue that has emerged is the appropriate sequencing of the reforms and the impact on workers of possible trajectories is considered. METHODOLOGY The design and functioning of the REF is described and the impact on competing health insurance funds is illustrated. Using a reference family earning at different income levels, the impact on worker of various trajectories of reform is demonstrated. FINDINGS Risk equalization is a critical institutional component in moving towards a system of social or national health insurance in competitive markets, but the sequence of its implementation needs to be carefully considered. The adverse impact of risk equalization on low-income workers in the absence of income cross-subsidies and mandatory membership is considerable. IMPLICATIONS FOR POLICY The South African experience of risk equalization is of interest as it attempts to introduce more solidarity into a small but highly competitive private insurance market. The methodology for considering the impact of reforms provides policymakers and politicians with a clearer understanding of the consequences of reform.

The effect of administration of FK506 on delayed regeneration in flushed partially hepatectomized livers

It has been shown previously that liver regeneration after partial hepatectomy in rats is delayed if the liver is subjected to either concurrent ischaemia, flushing with cold solution, or grafting. We have shown recently that treatment with CsA preoperatively overcomes the suppressive effect of flushing and returns the regenerative response to a normal time scale. The present study was designed to investigate whether administration of FK506 would also return the observed delayed regenerative response to normal. Long-Evans rats weighing 250-350 g were subjected to standard 68% partial hepatectomy. Group 1 had no further treatment; in group 2, the liver remnant was flushed with 10 ml cold (4 degrees C) Ringers lactate solution, and in group 3, FK506 (1 mg/kg/day) was administered by intramuscular injection for 3 days before the partial hepatectomy and flushing as in group 2; a final dose was given after completion of the procedures. Animals were killed in sets of 6 per group at 4, 24, 48, 72, and 96 hr after surgery and blood samples were taken for measurement of plasma aspartate amino-transferase. Liver biopsies were analyzed for measurement of thymidine kinase and ornithine decarboxylase activity and for counting of mitotic figures. While the highest recorded thymidine kinase activity occurred in group 1 at 24 hr, this was delayed to 48 hr in both group 2 and 3 and counts remained high up to 96 hr in group 3. Mitotic indices were only significantly elevated (compared with group 1 at 96 hr), while ornithine decarboxylase activity did not correlate with these changes being significantly lower than in groups 2 and 3 at 4 hr and in group 3 also at 24 hr. Plasma aspartate aminotransferase was also significantly higher in group 3. It is concluded that the administration of FK506 preoperatively to rats subjected to partial hepatectomy and flushing did not restore the delayed regenerative response to normal but enhanced the response (as measured by thymidine kinase but not by mitotic indices) which commenced at 48 hr and was still present at 96 hr.