How should Malaysia respond to its ageing society?

As Malaysia ages its health and social care systems will have to adapt to a changing pattern of disease and dependency. Improved public health measures extend life expectancy at the relative expense of increased prevalence of currently incurable conditions such as dementia and Parkinson's disease. In this article we discuss how these demographic changes will impact and suggest possible means of coping with the altered epidemiology of disease and disability. Malaysia will need to swiftly develop sufficient expertise in acute Geriatric Medicine, rehabilitation of older people; the management of long-term conditions in older people with multiple complex problems within Primary Care; as well as an infrastructure for home and institutional care.

Respiratory dysfunction in Parkinson's disease.

Respiratory dysfunction has been associated with Parkinson's disease since it was first described in 1817. The respiratory symptoms observed in Parkinson's disease patients vary greatly. Most patients remain asymptomatic, whereas others present with acute shortness of breath and even stridor. In August 2016, an electronic literature search was conducted using PubMed and Google Scholar. Results were screened and studies reporting on respiratory dysfunction associated with Parkinson's disease were included. Respiratory dysfunction is due to a combination of factors including restrictive changes, upper airway obstruction, abnormal ventilatory drive and response to medications. Much debate surrounds the mechanism underlying respiratory dysfunction in Parkinson's disease, its prevalence and the effect of levodopa on respiration. It is clear from this review that larger studies, comparing patients of similar disease duration and severity using the same pulmonary function parameters, are required to provide a better understanding of the pathophysiology underlying respiratory dysfunction in Parkinson's disease.

Pharmacokinetics of tacrine hydrochloride in Alzheimer's disease.

The clinical pharmacokinetics of tacrine hydrochloride have been characterized in patients who have Alzheimer's disease. Serum concentrations of the drug and of its probable metabolite were monitored in eight patients after a 25 mg oral dose, in six patients after a 50 mg oral dose, in four patients after repeated administration of 50 mg, and in two patients after a small intravenous dose. Urinary excretion of drug and metabolite for 24 hours was measured in one of the patients who received a small intravenous dose. The serum half-life was 1.59 +/- 0.15 hours (mean +/- SEM) after the 25 mg dose, 2.14 +/- 0.24 hours after the 50 mg dose, and 2.91 +/- 0.39 hours after continuous treatment. After intravenous administration, clearance was above 600 ml/min in both patients, and oral bioavailability was calculated at below 5%. Urine recovery was less than 3% of the dose. The low bioavailability of tacrine hydrochloride is partly explained by presystemic metabolism.

Propagule size and the relative success of exotic ungulate and bird introductions to New Zealand.

We investigated factors affecting the success of 14 species of ungulates introduced to New Zealand around 1851-1926. The 11 successful species had a shorter maximum life span and were introduced in greater numbers than the three unsuccessful species. Because introduction effort was confounded with other life-history traits, we examined whether independent introductions of the same species were more likely to succeed when a greater number of individuals were introduced. For the six species with introductions that both succeeded and failed, successful introductions always involved an equal or greater number of individuals than unsuccessful introductions of the same species. For all independent introductions, there was a highly significant relationship between the number of individuals introduced and introduction success. When data for ungulate and bird introductions to New Zealand were combined, a variable categorizing species as ungulate or bird was a highly significant predictor of introduction success, after variation in introduction effort was controlled. For a given number of individuals introduced, ungulates were much more likely to succeed than birds.

Evidence by spectral karyotyping that 8q11.2 is nonrandomly involved in lipoblastoma.

We report two cases of lipoblastoma with chromosome 8-related aberrations, ie, a 92,XXYY,t(7;8Xp22;q11.2)x2 [8]/46,XY[16] in Case 1 and a 46,XY,-8,-13,add(16) (q22),+mar, +r [cp13]/46,XY[7] in Case 2. Using spectral karyotyping and fluorescence in situ hybridization techniques, the karyotype of Case 2 was redesignated as 46,XY, r(8), del(13)(q12), der(16)ins(16;8)(q22; q24q11.2)[cp13]/46,XY[7]. This report delineates a new chromosome rearrangement, ie, der(16)ins(16;8)(q22; q24q11.2) in lipoblastoma, and also confirms the t(7; 8)(p22;q11.2), reported only once previously, as a recurrent translocation involved in such a tumor. These findings provide valuable information for clinical molecular cytogenetic diagnosis of lipoblastoma. Furthermore, this report highlights the value of cytogenetic and molecular cytogenetic analysis in differential diagnosis of childhood adipose tissue tumors and adds to the number of lipoblastomas reported with chromosomal abnormalities at 8q11.2.

Hemodynamic comparison of primary venous or arteriolar dilatation and the subsequent effect of furosemide in left ventricular failure after acute myocardial infarction.

The hemodynamic effect of venous dilatation (intravenous isosorbide dinitrate [ISDN]) and arteriolar dilatation (intravenous hydralazine), both as firstline treatment and then combined with intravenous furosemide, were evaluated in a randomized, between-group comparison in 20 men with severe acute left-sided cardiac failure after myocardial infarction (MI). Both ISDN (50 to 200 micrograms/kg/hour) (Group 1) and hydralazine (0.15 mg/kg) (Group 2) reduced systemic arterial pressure (p less than 0.05) and vascular resistance (p less than 0.05). Pulmonary artery occluded pressure was reduced (p less than 0.01) only by ISDN, whereas heart rate (p less than 0.01), cardiac output (p less than 0.01) and stroke volume (p less than 0.05) were increased only after hydralazine. After ISDN, furosemide (1 mg/kg) decreased left-sided cardiac filling pressure by 1 mm Hg (p greater than 0.05), whereas after hydralazine, furosemide in a similar dose reduced pulmonary artery occluded pressure by 5 mm Hg (p less than 0.01). In both groups of patients, furosemide transiently increased systemic arterial pressure (p less than 0.05). Cardiac output was reduced (p less than 0.05) and systemic vascular resistance increased (p less than 0.05) in Group 1 patients after furosemide. Similar changes in both variables in Group 2 patients did not attain statistical significance. In conclusion, ISDN-induced venous dilatation is preferable to primary arteriolar dilatation by hydralazine as first-line treatment in acute left-sided cardiac failure. However, hydralazine and furosemide in combination were equally effective in reducing pulmonary artery occluded pressure and increasing cardiac output. The influences of each regimen on prognosis await further investigation.

Nitrendipine and renal tubular function in human volunteers.

Nine normotensive, water-loaded subjects received 10 mg oral nitrendipine, and eight subjects received placebo in a double-blind randomized manner. Urine and plasma were collected at fixed time points for 1 hour before and for 4 hours after drug administration for biochemical measurements. Glomerular filtration rate was measured by inulin clearance and effective renal blood flow was measured by para-amino hippurate clearance. Absolute sodium excretion increased by 25.9% from 0.27 +/- 0.03 mmol/min to 0.34 +/- 0.02 mmol/min (P = .02), and fractional sodium excretion increased by 32.3% from 18.9 +/- 3.0% to 25.0 +/- 1.9% (P = .03) after nitrendipine, but both were unchanged after placebo. There was no change in inulin clearance, para-amino hippurate clearance, urine volume, or fractional excretion of uric acid, which made an effect on glomerular filtration, renal blood flow, or proximal tubular function an unlikely explanation of the natriuresis. Fractional excretion of magnesium increased after both placebo and nitrendipine administration, from 5.0 +/- 0.6% to 6.8 +/- 0.7% (P = .027) and 5.7 +/- 0.8% to 8.8 +/- 1.0% (P = .006), respectively. Fractional excretion of phosphate also increased after both placebo and nitrendipine, from 9.5 +/- 2.3% to 12.9 +/- 3.9% (P = .05) and 9.7 +/- 1.7% to 14.2 +/- 1.9% (P = .002), respectively. These changes are likely to be due to the effects of the water load rather than due to a drug effect. There was no change in clearance of solute free water, which made a direct effect on the loop of Henle or cortical diluting segment unlikely.(ABSTRACT TRUNCATED AT 250 WORDS)

Developing quality indicators for older adults: transfer from the USA to the UK is feasible.

BACKGROUND: Measurement of the quality of health care is essential for quality improvement, and patients are an underused source of data about quality of care. We describe the adaptation of a set of USA quality indicators for use in patient interview surveys in England, to measure the extent to which older patients receive a broad range of effective health care interventions in both primary and secondary care. METHOD: One hundred and nineteen quality indicators covering 16 clinical areas, based on a set of indicators for the care of vulnerable elderly patients in the USA, were reviewed by a panel of 10 clinical experts in England. A modified version of the RAND/UCLA appropriateness method was used and panel members were supplied with literature reviews summarising the evidence base for each quality indicator. The indicators were sent for comment before the panel meeting to UK charitable organisations for older people. RESULTS: The panel rated 102 of the 119 indicators (86%) as valid for use in England; 17 (14%) were rejected as invalid. All 58 indicators about treatment or continuity and follow up were rated as valid compared with just over half (13 of 24) of the indicators about screening. CONCLUSIONS: These 102 indicators are suitable for use in patient interview surveys, including the English Longitudinal Study of Ageing (ELSA). The systematic measurement of quality of care at the population level and identification of gaps in quality is essential for quality improvement. There is potential for transfer of quality indicators between countries, at least for the health care of older people.

Pulsed discharge detector: theory and applications.

The pulsed discharge detector (PDD) is a significant advancement in gas chromatography (GC) detector design which can be operated in three different modes: pulsed discharge helium ionization (He-PDPID), pulsed discharge electron capture (PDECD) and helium ionization emission (PDED). The He-PDPID can detect permanent gases, volatile inorganics and other compounds which give little or no response with the flame ionization detector (FID) and has significantly better limits of detection (minimum detectable quantities (MDQs) in low picogram range) than can be achieved with a thermal conductivity detector (typically not lower than 1 ng). The PDECD has similar or better sensitivity (MDQs of 10(-15) to 10(-12) g) than radioactive source ECD but does not require licensing, wipe tests and other administrative or safety requirements which have increased over security concerns. The PDED shows promise as an extremely selective and sensitive elemental detector but a commercial unit is not presently available. In this report, the theory of operation, applications of the PDD and the practical aspects of using this novel detector are presented.

Determination of butyltin, methyltin and tetraalkyltin in marine food products with gas chromatography-atomic absorption spectrometry.

Extraction methods were developed for the determination of butyltin, methyltin and tetraalkyltin in marine food products. Alkyltins were complexed with either diphenylthiocarbazone (dithizone) or tropolone from enzymatically hydrolysed samples. Tetraalkyltins were extracted with hexane. Butyl or methyl derivatives of the alkyltins were made by Grignard reaction for analysis by gas chromatography-atomic absorption spectrometry. Many of the examined marine food products contained ppb levels of alkyltins. Tetramethyltin and tetraethyltin levels were less than the method detection limits of 0.8 and 0.7 ng/g (as Sn), respectively.

The determination of organotin compounds in edible oils by gas chromatography-atomic absorption spectrometry.

An extraction method for butyl-, cyclohexyl-, octyl- and phenyltin compounds from edible oils was developed using 0.05% tropolone in 0.04M HCl/methanol. Cooling the methanol extracts in a dry ice/methanol bath removed approximately 64% of nonvolatile coextractives without affecting recoveries. Methyl derivatives formed by Grignard reaction were quantitated by gas chromatography-atomic absorption spectrometry. Edible oils sold in poly(vinyl chloride) containers had ng/g levels of dioctyl- and monooctyltin. GCMS confirmed the presence of octyltin and did not detect any other organotin compounds in the extracts.

Oral (gavage), in utero and postnatal exposure of Sprague-Dawley rats to low doses of tributyltin chloride. Part 1: Toxicology, histopathology and clinical chemistry.

Tributyltin (TBT) is a biocide that contaminates foods, especially shellfish. TBT is an endocrine disrupter in several marine species and is neurotoxic and immunotoxic in mammals. We have examined the effects of exposure to low doses of tributyltin chloride (TBTC) from day 8 of gestation until adulthood. Pregnant rats were gavaged daily with 0, 0.025, 0.25 or 2.5 mg TBTC/kg body weight from day 8 of gestation until weaning. Stomach contents of suckling pups contained undetectable levels of TBT and dibutyltin (DBT) levels were detectable only in the highest TBTC dose used, indicating negligible lactational transfer to pups. Post weaning, pups were gavaged daily with the same dose of TBTC administered to their mothers and sacrificed on post-natal days (PND) 30 (males and females), 60 (females) and 90 (males). TBTC had no effects on dams' body weights, food consumption, litter size, sex ratio or survival of pups to weaning. However, all doses of TBTC significantly affected parameters of the growth profile of the pups (mean body weights, average slope, curvature) and the ratio of weekly food consumption to weekly body weight gain indicated enhanced food conversion to body mass in females but a decreased conversion in males. Liver, spleen and thymus weights were also affected by TBTC. In male pups dosed at 2.5 mg/kg/day, reduced serum thyroxine levels were evident, indicating that the thyroid is a target for TBTC toxicity. No histopathological lesions were seen in the liver but elevated serum alanine aminotransferase, gamma-glutamyl transferase and amylase indicated hepatotoxicity. Significant decreases in liver weights in female pups exposed to 0.025 mg/kg/day TBTC were observed at PND 60. Decreases in spleen and thymus weights also pointed towards toxic effects of TBTC on the immune system. The 0.025 mg/kg/day TBTC should have been a no affect dose and yet this dose caused significant effects on growth profiles, decreased liver weights and elevated serum GGT levels in females.

Effects of herbicides on two submersed aquatic macrophytes, Potamogeton pectinatus L. and Myriophyllum sibiricum Komarov, in a prairie wetland.

Clopyralid, picloram, 2,4-D and a mixture of 2,4-D plus picloram, (Tordon 202C) were added to the water of 1 m square enclosures in a prairie wetland in Saskatchewan, Canada to produce concentrations of 0.01 and 0.1 mg active ingredient litre(-1). Effects on the submersed macrophytes, Potamogeton pectinatus and Myriophyllum sibiricum, were monitored by taking repeated measurements of plant weight, flower and tuber production and inspecting for injuries at 30 and 60 days after application. Clopyralid did not inhibit weight gain (growth) in either species, but stimulated growth and flowering by M. sibiricum at 0.01 mg litre(-1) and tuber production by P. pectinatus at both rates. The low rate of 2,4-D stimulated flowering by M. sibiricum and tuber production by P. pectinatus, whereas the high rate inhibited growth of M. sibiricum and injured both species. Picloram did not affect growth of either species, but injured M. sibiricum at both concentrations and inhibited flowering at 0.1 mg litre(-1). Tordon 202C at 0.1 mg litre(-1) caused reduced growth and flowering in M. sibiricum and injured both species; 0.01 mg litre(-1) also injured M. sibiricum. Mortality resulted only from Tordon 202C and 2,4-D. Field data are lacking to assess the extent to which submerged macrophytes in prairie ponds are exposed to harmful concentrations of herbicide from aerial spraying, drift from ground application, runoff or wind erosion of soil.

Organochlorine contaminants and eggshell thinning in grebes from prairie Canada.

Eggs of five species of grebe were collected from Manitoba, Saskatchewan and Alberta during 1982-1987: red-necked (Podiceps grisegena), horned (P. auritus), eared (P. caspicus), western (Aechmophorus occidentalis) and pied-billed (Podilymbus podiceps). DDE and PCBs were present in all samples analyzed, whereas dieldrin, mirex and oxychlordane were occasionally present at low levels. Mercury was present at low levels in all samples for which it was analyzed. Red-necked grebes nesting in Manitoba had the highest contaminant levels and, assuming that contaminant burdens were accumulated principally on the wintering grounds, the mean PCB:DDE ratio (3.1) indicated that these birds and those from sites in central and eastern Saskatchewan probably wintered on the Atlantic coast. Overall low contaminant levels and a low mean PCB:DDE ratio (1.4) in the eggs of red-necked grebes breeding in Alberta and western Saskatchewan suggested that these birds wintered on the Pacific coast. A similar pattern was apparent in horned and eared grebes. Concentrations of DDE and PCB were both significantly correlated with Ratcliffe index (shell thickness), and were strongly correlated with each other. Ratcliffe indices were determined for historical collections of red-necked grebe eggs. Eggshell thickness of grebes nesting in Manitoba declined significantly during the years following the introduction of DDT (post-1947) and has only recovered partially since it was banned in 1972. The Alberta-breeding population did not appear to have undergone any significant decrease in shell thickness.

The effects of intestinal Escherichia coli 263, intravenous infusion of Escherichia coli 263 culture filtrate and iron dextran supplementation on iron metabolism in the young pig.

An experiment using 32 pigs in a 2(3) factorial arrangement of treatments was used to determine the effects on the (1) level of iron dextran supplementation, (2) iv infusion of an Escherichia coli 263 culture filtrate and (3) presence of E. coli 263 in a ligated intestinal segment, on the ability of the young pig to limit systemic Fe availability. Iron dextran was administered im 3 d postpartum. Culture filtrate was infused iv, E. coli were injected into ligated intestines and blood sampling was started at 14 d postpartum. Blood was taken every 2 h for 22 h, after which pigs were euthanized and livers, spleens and kidneys were removed. Pigs receiving 400 mg of iron dextran (HiFe) exhibited greater serum Fe (SFe) and lower total Fe-binding capacity (TIBC) than pigs injected with 100 mg Fe (LoFe). The effects of the E. coli culture filtrate infusion appeared to be associated with endotoxin-induced circulatory shock. The presence of E. coli in the intestine increased TIBC in LoFe pigs, but not in HiFe pigs. The increase in TIBC coincided with the time of maximal fluid secretion into the intestine. Intestinal E. coli also caused an increase in liver Fe content, particularly in HiFe pigs. These data suggest that intestinal E. coli can cause a shift of Fe from the plasma to the reticuloendothelial system, and pigs receiving high supplemental dosages of Fe are less able to limit the availability of Fe to microorganisms.

The effect of an adaptation period to soybean oil additions in the diets of young pigs.

Utilization of soybean oil (SBO) in swine starter diets and the effect of an adaptation period to SBO on performance was studied in two 4-wk experiments with pigs initially 4 to 5 wk of age. One trial was extended an additional 4 wk and apparent DE was measured during the 4th wk postweaning. Corn-soybean meal-based diets were used in which SBO was substituted for cornstarch at 2, 4 and 6% of the diet in Exp. 1 and at 3 and 6% of the diet in Exp. 2. In Exp. 2, SBO was added either initially (adaptation) or after 2 wk (no adaptation). In Exp. 1 daily gain and efficiency of feed utilization were improved (P less than .05) by adding SBO during wk 3 and 4, but not earlier. Feed intake was not affected by treatment. In Exp. 2, for the initial 4-wk postweaning period, there was no effect of SBO addition on growth rate; feed intake was depressed (P less than .05) when SBO was added at wk 3, and efficiency of feed utilization was improved (P less than .05) for pigs fed SBO without an adaptation period. The primary improvements in performance occurred in the 3rd and 4th wk postweaning, with a tendency for pigs to perform better without an adaptation period. During wk 4, pigs adapted to SBO consumed more (P less than .05) feed but tended to be less efficient (P less than .10) than nonadapted pigs. With or without adaptation, apparent DE was unaffected by SBO additions. Regardless of adaptation period, SBO additions depressed feed intake (P less than .05) and improved efficiency of feed utilization (P less than .01) for the 5- to 8-wk growing phase. In conclusion, adding SBO the first 2 wk postweaning did not improve performance; an adaptation period was not necessary for a performance response from added SBO.

Improving the documentation and appropriateness of cardiopulmonary resuscitation decisions.

A criterion based audit was undertaken, over a 3 year period, to review the appropriateness of the decision to undertake cardiopulmonary resuscitation (CPR) and the recording of resuscitation status in a 112 bedded department of medicine for the elderly. Resuscitation status was not recorded in either nursing or medical notes of patients undergoing CPR during the first two 12 month audit periods, and was recorded in 71% in the final 12 month audit period. The auditors agreed in 91% of cases that CPR was either appropriate or inappropriate. In the third year of audit 40% of decisions to resuscitate were judged inappropriate.

Digital imaging of cephalometric radiography, Part 1: Advantages and limitations of digital imaging.

Digital imaging has several potential advantages over traditional cephalometry. These include storage, transmission, and enhancement of images, reduced exposure to radiation for patients, and the possibility of automated cephalometric analysis. This paper outlines some of these advantages, discusses the limitations of digital imaging and suggests possible future developments.

Digital imaging of cephalometric radiographs, Part 2: Image quality.

The aim of this study was to compare the diagnostic quality of conventional cephalometric radiographs with that of digital image counterparts. The random error associated with angular and linear measurements recorded on the digital images was greater than on the conventional radiographs. In addition, there was a systematic error producing statistically significant differences in the majority of angular and linear measurements between the digital images and the conventional radiographs. The errors that occurred with some measurements were of sufficient magnitude to be of clinical significance, particularly in a cephalometric situation where a high degree of accuracy is required. It is therefore suggested that, for digital imaging of cephalometric radiographs, a pixel matrix larger than 512 x 512 with more than 64 gray levels is required to maintain the diagnostic quality of the original radiograph.