Operationalizing universal health coverage in Nigeria through social health insurance

Nigeria faces challenges that delay progress toward the attainment of the national government''s declared goal of universal health coverage (UHC). One such challenge is system-wide inequities resulting from lack of financial protection for the health care needs of the vast majority of Nigerians. Only a small proportion of Nigerians have prepaid health care. In this paper, we draw on existing evidence to suggest steps toward reforming health care financing in Nigeria to achieve UHC through social health insurance. This article sets out to demonstrate that a viable path to UHC through expanding social health insurance exists in Nigeria. We argue that encouraging the states which are semi-autonomous federating units to setup and manage their own insurance schemes presents a unique opportunity for rapidly scaling up prepaid coverage for Nigerians. We show that Nigeria''s federal structure which prescribes a sharing of responsibilities for health care among the three tiers of government presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this governance structure to impair progress toward UHC, it should be leveraged to accelerate the process by supporting the states to establish and manage their own insurance funds while encouraging integration with the National Health Insurance Scheme.     

Gastrointestinal motility problems in critical care: A clinical perspective

Advances in surgery, anesthesia and intensive care have led to a dramatic increase in the number of patients who spend time in our intensive care units (ICU). Gastrointestinal (GI) motility disorders are common complications in the intensive care setting and are predictors of increased mortality and length of the stay in the ICU. Several risk factors for developing GI motility problems in the ICU setting have been identified and include sepsis, being on mechanical ventilation and the use of vasopressors, opioids or anticholinergic medications. Our focus is on the most common clinical manifestations of GI motor dysfunction in the ICU patient: gastroesophageal reflux, gastroparesis, ileus and acute pseudo‐obstruction of the colon.     

Laparoscopic Appendectomy in Women Without Identifiable Pathology Undergoing Laparoscopy for Chronic Pelvic Pain

Objectives:

To assess the effectiveness of appendectomy in women undergoing laparoscopy for chronic pelvic pain without identifiable pathology.

Methods:

This retrospective cohort study included women aged 15 to 50 years who underwent laparoscopic surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women who underwent appendectomy and women who had not undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by subsequent mailed questionnaire.

Results:

Women who underwent appendectomy (n = 19) were significantly more likely to report improvement in pain at 6-week follow-up than women who did not undergo appendectomy (n = 76) (93% vs 16%; P < .001). Thirty-six patients (38%) responded to the questionnaire at a median of 4.2 years after surgery, when the median change (improvement) in reported pain was greater in the appendectomy group than in the nonappendectomy group.

Conclusion:

Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who are undergoing laparoscopy.     

Hepatitis C virus genotypes in Saudi Arabia

Hepatitis C virus genotypes have been associated with specific geographical areas and in many cases with specific mode of transmission. In developed countries, genotype determination has formed a part of the management of patients with hepatitis C virus seropositivity and liver diseases due to hepatitis C virus. The epidemiology of hepatitis C virus has been shown to be changing rapidly in many countries due to population movement and different life-styles; hence the distribution of the genotypes is being monitored closely in many countries. In the Kingdom of Saudi Arabia, there are only a handful of publications recording the hepatitis C virus genotypes in various population groups. These studies have been carried out mainly in Riyadh (Central province) and Jeddah (Western province). There are no studies emanating from the Eastern or Northern provinces. According to these studies, the most prevalent genotype in the Western Province and probably in the whole Kingdom of Saudi Arabia was genotype 4, followed by genotypes 1a and 1b. Genotypes 1, 2a,/2b, 3 and 6 are very rare in the Kingdom of Saudi Arabia. Genotype 5 was identified exclusively in the Western province and nowhere else. Genotypes 1b and 4 were associated with different histological grades of liver disease. Mixed infections with more than one genotype were observed in some studies. More detailed epidemiological studies of hepatitis C virus infections are needed in the Kingdom of Saudi Arabia to gain more insight into a possible type/subtype-specific pathogenesis of hepatitis C virus in the different regions of the Kingdom of Saudi Arabia as well as the distribution of the genotypes in the various localities.     

Meningococcal carriage among local inhabitants during the pilgrimage 2000-2001

The first international outbreak of Neisseria meningitidis serogroup W135 occurred in 2000, in direct association with the annual Hajj in Saudi Arabia. In anticipation of the following Hajj, we conducted a survey of oropharyngeal carriage rates of N. meningitidis both pre- and post-pilgrimage in the King Khalid National Guard Hospital (KKNGH) employees preparing to attend the Hajj. These KKNGH employees were native to the Mecca-Jeddah area. Pre-Hajj throat cultures were obtained 1 week prior to Hajj, and post-Hajj cultures within 10 days after completing the Hajj pilgrimage. A total of 327 throat culture samples were collected from 218 persons. Overall meningococcal carriage rate was found to be 4.7%. Serogroup W135 accounted for 40% of all recovered pre-Hajj strains of N. meningitidis. Only one post-Hajj sample was positive for N. meningitidis W135. This high rate of colonization with N. meningitidis serogroup W135 indicates this strain predominates amongst the population indigenous to the Mecca-Jeddah area. This 'nidus' of N. meningitidis W135 is a potential reservoir for future outbreaks. More worrying, there is real risk of future W135 endemicity in this vulnerable local population. These preliminary findings warrant larger surveillance studies examining both transmission and carrier rate acquisition of N. meningitidis in the Mecca-Jeddah area. These vital data are needed to curb further epidemic outbreaks during future Hajj pilgrimages.     

The impact of topiramate (Topamax®) therapy on the development of aggressive and/or agitated behavior

The use of topiramate therapy to control the neuropsychiatric and behavioral disturbances in individuals with mental and/or developmental disabilities with co-occurring psychiatric disturbances has become a standard of practice in many long-term care assisted living facilities. With increased utilization of this anticonvulsant, there has been a rise in the number documented cases of agitation and/or aggressive behavior associated with topiramate therapy. It is the purpose of this article to explore the current literature documenting the connection between topiramate utilization and the development of aggressive and/or agitated behavior.     

Low CD4 cells and viral co-infection increase the risk of VaIN: Use of SCCA1 and Ki67 as diagno-prognostic biomarkers

This study evaluated the correlation of SCCA1, Ki67 and CD4 cell expressions and classified vaginal smears in individuals co-infected with Human immunodeficiency virus (HIV), Herpes simplex virus 2 (HSV2), Epstein Barr virus (EBV) and Human Papilloma virus (HPV). This crossectional study included 173 participants within the age range of 20–70 years. Vaginal smears were stained by Papanicolaou technique and classified into high-grade squamous cell intraepithelial lesion (HSIL), low-grade squamous intraepithelial lesion (LSIL), atypical squamous cells of undetermined significance (ASCUS) and negative for intraepithelial lesion (NIL). Presence of immunoglobulin M and G antibodies for EBV, HIV, HPV and HSV2, and SCCA1 and Ki67 antigens were determined by ELISA method. Result showed that biomarkers SCCA1 had higher sensitivity (87.5%) to vaginal lesions when compared with Ki67 which had a sensitivity of 70.8% (p?>?.01). Assays revealed viral co-infections of 96.0% and 16.8% in smears positive and negative for vaginal lesions, respectively (p?<?.01) with HIV, HSV2 and EBV as the most prevalent type of co-infection (36%). The findings of this study suggest that low CD4 cells and viral co-infection could increase the risk of developing vaginal lesions. This study also suggests that SCCA1 and Ki67 could be used as diagnostic and prognostic biomarkers for vaginal intraepithelial neoplasia (VaIN).     

Parameters of glucose metabolism and the aging brain: a magnetization transfer imaging study of brain macro- and micro-structure in older adults without diabetes

Given the concurrent, escalating epidemic of diabetes mellitus and neurodegenerative diseases, two age-related disorders, we aimed to understand the relation between parameters of glucose metabolism and indices of pathology in the aging brain. From the Leiden Longevity Study, 132 participants (mean age 66 years) underwent a 2-h oral glucose tolerance test to assess glucose tolerance (fasted and area under the curve (AUC) glucose), insulin sensitivity (fasted and AUC insulin and homeostatic model assessment of insulin sensitivity (HOMA-IS)) and insulin secretion (insulinogenic index). 3-T brain MRI was used to detect macro-structural damage (atrophy, white matter hyper-intensities, infarcts and/or micro-bleeds) and magnetization transfer imaging (MTI) to detect loss of micro-structural homogeneity that remains otherwise invisible on conventional MRI. Macro-structurally, higher fasted glucose was significantly associated with white matter atrophy (P = 0.028). Micro-structurally, decreased magnetization transfer ratio (MTR) peak height in gray matter was associated with higher fasted insulin (P = 0.010), AUC_insulin (P = 0.001), insulinogenic index (P = 0.008) and lower HOMA-IS index (P < 0.001). Similar significant associations were found for white matter. Thus, while higher glucose was associated with macro-structural damage, impaired insulin action was associated more strongly with reduced micro-structural brain parenchymal homogeneity. These findings offer some insight into the association between different parameters of glucose metabolism (impairment of which is characteristic of diabetes mellitus) and brain aging.