Who gets what? Utilization of health services in Indonesia

An evaluation of health service utilization patterns was carried out in five rural districts and a number of urban areas in Indonesia. The study was part of a larger effort to develop economically-related information about the health care services. Utilization levels were then related to such selected population variables as distance from health facilities, insurance status and income. The annual contact rate, curative plus preventive, with all public sector facilities was found to be 0.8 per capita. The geographic catchment areas of the facilities were also found to be very limited. The insured population (civil servants and their families) used services about four times more frequently, on average, than did the rest of the population. In one provincial study, the top 9 per cent of income earners made up one-third of all hospital inpatients, one-half of all hospital outpatients, and one-quarter of all health centre visitors. The implications of these results for equity and efficiency are discussed.

Loss of polyneuronal innervation and establishment of a topographical map in the glutaeus muscle of Bufo marinus during generation of secondary muscle cells

The development of synaptic connections to the toad (Bufo marinus) glutaeus magnus from segmental nerves 8 (N8) and 9 (N9) was determined in the postmetamorphic period. Three different-size toads were studied: small (0.3-2.0 g), medium-size (5-15 g) and large (greater than 20 g). The number of cells in the glutaeus increased about 9-fold during development; this involved the appearance and subsequent maturation of secondary fibres throughout the muscle. The glutaeus in small toads, which consisted almost entirely of primary fibres, was innervated to a similar extent by N8 and N9 as assessed by tetanic contraction measurements. During late development there was a progressive increase in the percentage of the muscle innervated by N9 and a decrease in the percentage innervated by N8. This change in the segmental innervation was accompanied by changes in the innervation of the ventral glutaeus as assessed by intracellular recording. In small toads this surface of the muscle was innervated predominantly by N8, with N9 frequently appearing as a low-efficacy terminal on dually innervated fibres. With further development there was a progressive reduction in the percentage of dually innervated fibres and a concomitant decrease in the percentage innervation of the entire ventral glutaeus by N8. These results suggest that the topographical projection is established by the initial distribution of N9 terminals on the primary fibres of the muscle. The multiple innervation of newly generated fibres and the on-going process of terminal elimination results in N9 terminals, many of which were initially weak, preserving their position in the muscle. This occurs at the expense of N8 terminals, whose relative incidence declines during development. The competitive advantage of N9 motoneurones may be due to their greater capacity to lay down axon collaterals and preferentially innervate newly generated fibres; alternatively N9 terminals may displace N8 terminals, which were initially more efficacious, from dually innervated fibres. Secondary muscle fibres generated throughout the muscle are thus incorporated into an increasingly precise topographical map.

Evaluation of high-dose versus standard FAC chemotherapy for advanced breast cancer in protected environment units: a prospective randomized study

Fifty-nine evaluable patients under 65 years of age with measurable metastatic breast cancer and without prior chemotherapy were randomly assigned to treatment with fluorouracil, Adriamycin (Adria Laboratories, Columbus, OH), and cyclophosphamide (FAC) at standard or high doses (100% to 260% higher than standard FAC) following a dose escalation schedule. Patients randomized to the high-dose FAC received the first three cycles of therapy within a protected environment. Subsequent cycles for this group were administered at standard doses of FAC in an ambulatory setting, the same as for the control group. After reaching 450 mg/m2 of Adriamycin, patients in both groups continued treatment with cyclophosphamide, methotrexate, and fluorouracil until there was disease progression. Analysis of pretreatment patient characteristics showed an even distribution for most known pretreatment factors, although the control group had slightly (but nonsignificantly) more favorable prognostic characteristics. Fourteen patients (24%) achieved a complete remission (CR) and 32 (54%) achieved a partial remission (PR), for an overall major response rate of 78%. There were no differences in overall, CR, or PR rates between the high-dose FAC and control groups. The median response durations were 11 and 10 months for the protected environment and control groups, respectively, and the median survival was 20 months for both groups. Hematologic, gastrointestinal (GI), and infection-related complications were significantly more frequent and severe in the group treated with high-dose chemotherapy. Stomatitis, diarrhea, and skin toxicity were dose-limiting. However, there were no treatment-related deaths. High-dose induction combination chemotherapy with the agents used in this study failed to increase the response rate or survival duration, and resulted in a substantial increase in toxicity.

Comparison of electrocardiography and thallium-201 myocardial scintigraphy for the detection of ergonovine-induced coronary artery spasm: angiographic correlation

This study was performed to determine the sensitivity of thallium imaging vs ECG monitoring for detecting coronary artery spasm noninvasively following intravenous ergonovine administration as compared to simultaneous coronary angiography. Thirty-two patients with insignificant coronary artery disease and chest pain underwent 12-lead ECG monitoring, thallium imaging, and coronary arteriography following the administration of 0.05, 0.1, 0.2, and 0.3 mg of ergonovine given 5 minutes apart or until chest pain occurred. One minute following the last dose of ergonovine, 2.5 mCi of thallium-201 was injected intravenously, and a final ECG was recorded and repeat coronary arteriography performed. Within 10 minutes following the injection of thallium, imaging was performed in the 40-degree and 70-degree left anterior oblique and anterior projections. The ECG, thallium study, and coronary arteriogram were read blindly and results were compared. The ECG, angiogram, and thallium study were read as positive if the following occurred, respectively: greater than or equal to 1 mm ST segment elevation, depression, or T wave reversal; greater than 50% vessel narrowing,; and reversible perfusion defect. Five patients were excluded from analysis because of either catheter-induced spasm, suboptimal thallium studies, or protocol violations. Of the 27 patients included for analysis, six had chest pain, five had a positive angiogram, five had a positive thallium study, and one had a positive ECG. The sensitivity of thallium vs ECG monitoring was 80% vs 25%, and the accuracy was 92% vs 80%. We conclude that thallium imaging greatly increases the noninvasive detection of ergonovine-induced coronary spasm as compared with the ECG with no loss of accuracy.

An autopsy study of rheumatic heart disease. Part I. Valvular involvement and Aschoff bodies

Autopsy study of 60 cases of rheumatic heart disease is presented, demonstrating an increased incidence of panvalvulitis in our series. The presence of Aschoff bodies is correlated with the clinical and laboratory parameters of activity and their significance is discussed.

A pharmacological study of group I muscle afferent terminals and synaptic excitation in the intermediate nucleus and Clarke's column of the cat spinal cord

When administered microelectrophoretically GABA and piperidine-4-sulphonic acid depolarized the central terminations of muscle group Ia and Ib afferent fibres in the lumbar intermediate nucleus and Clarke's column of cats anaesthetised with pentobarbitone sodium. Both this depolarization, and primary afferent depolarization, generated by impulses in other primary afferent fibres which produce prolonged bicuculline-sensitive inhibition of the firing of group I afferent fibre-excited interneurones in the intermediate nucleus and cells in Clarke's column, are reduced by microelectrophoretic bicuculline methochloride. Systemically administered (+/-)-baclofen hydrochloride (maximum dose 8 mg kg-1) depressed the monosynaptic excitation of Clarke's column neurones by impulses in muscle and cutaneous afferent fibres. Microelectrophoretically administered (-)-baclofen reduced the bicuculline-sensitive primary afferent depolarization of group I terminations without, however, reducing the depolarizing action of GABA or piperidine-4-sulphonic acid. The depression by (-)-baclofen of the group I monosynaptic excitation of intermediate nucleus neurones is not reduced by concentrations of bicuculline methochloride adequate to suppress prolonged inhibition of these neurones.

Evaluation of histological appearance of tissues removed by cavitron ultrasonic surgical aspirator (CUSA)

Histological appearances of the tissue fragments obtained by cavitron ultrasonic surgical aspirator (CUSA) were studied in 25 cases to determine whether the aspirated tissue could be used for diagnosis. It was found that a definite diagnosis could be made on the tissue removed by this method.

A neurophysiological analysis of the effect of kainic acid on nerve fibres and terminals in the cat spinal cord

Kainic acid was administered micro-electrophoretically in relatively small amounts (approx. 0.15 nmol) near gastrocnemius motoneurones in the spinal cord of cats anaesthetized with sodium pentobarbitone. After initial excitation, extracellularly recorded orthodromic and antidromic field potentials were reduced. Such neurophysiological evidence for motoneuronal damage or death persisted for 5 h, the longest period of observation. At the site of administration, the terminations of gastrocnemius group Ia afferent fibres were electrically inexcitable for approximately 1 h. Subsequently, the number and excitability of these terminations appeared to be normal, as were the depolarizing actions at bicuculline-sensitive receptors of micro-electrophoretic piperidine-4-sulphonic acid and of gamma-aminobutyric acid (GABA) released at axoaxonic synapses on these terminations. Central myelinated and non-myelinated fibres and terminals of muscle group Ia afferent fibres, and the synaptic release of GABA on these terminals at axo-axonic synapses formed by certain spinal interneurones, thus appear to be relatively insensitive to kainic acid administered in amounts which damage or destroy motoneurones.

Mycopathology of cerebral mycosis

Seven cases of cerebral mycosis have been studied with respect to the pattern of distribution of the various cerebral fungi and the spectrum of histopathological changes. It has been found that aspergillosis is the most prevalent pathogen in our region unlike in the western world where candidosis dominates the picture. The relevant literature is discussed.

Glycine antagonism by RU 5135

In the spinal cord of the pentobarbitone-anaesthetised cat, microelectrophoretic RU 5135, a steroid derivative, was a potent strychnine-like glycine antagonist, having less effect on the inhibition by GABA of neuronal firing.

The differential effects of baclofen on segmental and descending excitation of spinal interneurones in the cat

Intravenous baclofen (1-6.25 mg kg-1) substantially reduced the monosynaptic excitation of neurones in the intermediate nucleus of the cat spinal cord by impulses in group I extensor muscle primary afferent fibres, but had little or no effect on excitation by stimulating fibres of the ipsilateral dorsolateral funiculus or the contralateral red nucleus. Relatively low concentrations of baclofen thus appear not to influence the release of excitatory transmitter from the terminals of rubrospinal, corticospinal and long descending propriospinal fibres, in contrast to the reduction of the release of primary afferent transmitters.

Securinine alkaloids: a new class of GABA receptor antagonist

Experiments were undertaken to determine the site of action of securinine and related convulsant indolizidines. All of these compounds induced tonic seizures in mice, with CD50 values ranging from 11 to 87 mg/kg. The CD50 for bicuculline was found to be 8 mg/kg. Equilibrium binding assays revealed that securinine and dihydrosecurinine inhibit [3H]GABA binding to rat brain membranes with an IC50 of approximately 50 microM, which is some 7 times less potent than bicuculline. Allosecurinine and virosecurinine have IC50 values greater than 1 mM. Both dihydrosecurinine and securinine inhibited GABA-stimulated benzodiazepine binding in rat brain membranes, though they were somewhat weaker than bicuculline in this respect. Other binding assays revealed that securinine and its analogs were inactive as inhibitors of bicuculline-insensitive GABA binding, benzodiazepine, cholinergic muscarinic, and beta-adrenergic receptor binding. In addition, while thiocyanate ion increased the apparent binding potency of bicuculline 10-fold, it had little effect on that of securinine. Extracellular electrophysiological studies on neurons in the cat spinal cord indicated that securinine and dihydrosecurinine blocked the inhibitory action of GABA while having no effect on that of glycine. Allo- and virosecurinine were much less active as GABA receptor antagonists in this test. These results suggest that, like bicuculline, securinine and dihydrosecurinine are selective antagonists of GABA recognition sites on mammalian central neurons.

The effect of GABA on lumbar terminations of rubrospinal neurons in the cat spinal cord

Although GABA and piperidine-4-sulphonic acid depolarize I a afferent terminations in the cat spinal cord by activation of bicuculline-sensitive GABA receptors, no evidence was obtained for a bicuculline-sensitive alteration by either gabamimetic of the electrical threshold of rubrospinal terminations in the spinal intermediate nucleus. The terminal axonal arborizations in the spinal cord of neurons in the red nucleus thus do not have GABA receptors similar to those on the cell bodies. The results are discussed in relation to the depolarizing action of GABA on some central neurons, and on neurons with peripheral cell bodies, and to probable differences in the intracellular chloride content of neurons having peripheral or central cell bodies, and thus of different embryological origin. A presynaptic depolarizing inhibitory process mediated by GABA appears to be confined to the terminals of primary afferent fibres in the mammalian central nervous system.