Vitamin D status and clinical implications in the adult population of Malaysia: a position paper by the Malaysian Vitamin D Special Interest Group

PURPOSE

Vitamin D deficiency and insufficiency is common among populations globally, and in Asia and Malaysia. The purpose of this Position Paper is to propose recommendations for both clinicians and non-clinicians to promote vitamin D sufficiency in Malaysian adults. Formation of a national multisector, multidisciplinary alliance is also proposed to progress initiatives relating to safe sun exposure, adequate vitamin D intake through food fortification, and vitamin D supplementation for high-risk groups.

METHODS

Literature reviews were undertaken to inform summaries of the following: vitamin D status globally and in Asian and Malaysian populations, vitamin D status among individuals with common medical conditions, and current recommendations to achieve vitamin D sufficiency through sun exposure, food intake and supplementation. Recommendations were based on the findings of the literature reviews, recent European guidance on vitamin D supplementation, the 2018 road map for action on vitamin D in low- and middle-income countries, and research recommendations proposed by the Malaysian Ministry of Health in 2017.

RESULTS

Recommendations on assessment of vitamin D in the adult Malaysian population include using serum or plasma 25-hydroxyvitamin D concentration as a biomarker, widespread participation by Malaysian laboratories in the Vitamin D Standardization Program, adoption of the US Endocrine Society definitions of vitamin D deficiency and insufficiency, and development of a comprehensive nationwide vitamin D status study. Specific high-risk groups are identified for vitamin D assessment and recommendations relating to loading doses and ongoing management are also made.

CONCLUSION

This Position Paper provides individual clinicians and national stakeholder organisations with clear recommendations to achieve vitamin D sufficiency in the adult population of Malaysia.

A Cross-sectional Study to Assess Beta-Cell Function in Individuals with Recently Diagnosed Young-Onset Type 2 Diabetes Mellitus and Its' Complications

Objective

The primary objective was to assess beta-cell function of recently-diagnosed young-onset type 2 diabetes mellitus (T2DM) individuals using basal and stimulated C-peptide levels. The secondary objective was to examine the association between C-peptide with metabolic factors and diabetes complications.

Methodology

A cross-sectional study was conducted for young-onset T2DM individuals aged 18-35 years with a disease duration of not more than 5 years. Plasma C-peptide was measured before and after intravenous glucagon injection. Demographic data, medical history and complications were obtained from medical records and clinical assessment. Continuous data were expressed as median and interquartile range (IQR). Categorical variables were described as frequency or percentage. Multivariable linear regression analysis was used to determine factors associated with C-peptide levels.

Results

113 participants with young-onset T2DM with a median (IQR) age of 29.0 (9.5) years and 24 (36) months were included in this study. The median (IQR) basal and stimulated C-peptide was 619 (655) pmol/L and 1231 (1024) pmol/L. Adequate beta-cell function was present in 78-86% of the participants based on the basal and stimulated C-peptide levels. We found hypertension, obesity and diabetic kidney disease (DKD) to be independently associated with higher C-peptide levels. In contrast, females, smokers, those on insulin therapy and with longer duration of disease had lower C-peptide levels.

Conclusion

Most recently diagnosed young-onset T2DM have adequate beta-cell function. Elevated C-peptide levels associated with obesity, hypertension and diabetic kidney disease suggest insulin resistance as the key driving factor for complications.

Practical Guidance on Basal Insulin Initiation and Titration in Asia: A Delphi-Based Consensus

The global health burden of diabetes is on the rise and has affected more than half a billion people worldwide, particularly in Southeast Asia, North Africa, Africa, and the Western Pacific, Middle East, and South and Central America regions of the International Diabetes Federation (IDF). Despite many new treatments being available for the management of diabetes, glycemic control remains suboptimal in Asia, compared to the rest of the world. Delay in timely insulin initiation and inadequate titration of insulin are regarded to be some of the important reasons for inadequate glycemic control. Additionally, Asian populations have a distinct phenotype, including a younger age of onset and higher glycemic excursions, suggestive of a lower beta-cell function, as compared to non-Asians. Although there are multiple local and international guidelines on insulin initiation and titration, some of these guidelines can be complex. There is an unmet need for guideline recommendations on basal insulin initiation and titration to be simplified and customized for the Asian population with type 2 diabetes mellitus (T2DM). A unified approach would increase adoption of basal insulin initiation by primary care and family medicine physicians, which in turn would help reduce the inertia to insulin initiation. With this background, a consensus-seeking meeting was conducted with 14 experts from seven Asian countries to delineate appropriate practices for insulin initiation and titration in the Asian context. The key objective was to propose a simple insulin titration algorithm, specific for the Asian population, to improve glycemic control and optimize therapeutic outcomes of people with T2DM on basal insulin. Following a detailed review of literature and current guidelines, and potential barriers to insulin initiation and titration, the experts proposed a simplified insulin titration algorithm based on both physician- and patient-led components. The consensus recommendations of the experts related to basal insulin initiation and titration have been summarized in this article, along with the proposed titration algorithm for optimizing glycemic control in the Asian population with T2DM.

Management of prediabetes in Malaysian population: An experts' opinion

INTRODUCTION

Prediabetes, typically defined as blood glucose levels above normal but below diabetes thresholds, denotes a risk state that confers a high chance of developing diabetes. Asians, particularly the Southeast Asian population, may have a higher genetic predisposition to diabetes and increased exposure to environmental and social risk factors. Malaysia alone was home to 3.4 million people with diabetes in 2017; the figure is estimated to reach 6.1 million by 2045. Developing strategies for early interventions to treat prediabetes and preventing the development of overt diabetes and subsequent cardiovascular and microvascular complications are therefore important.

METHODS

An expert panel comprising regional experts was convened in Kuala Lumpur, for a one-day meeting, to develop a document on prediabetes management in Malaysia. The expert panel comprised renowned subject-matter experts and specialists in diabetes and endocrinology, primary-care physicians, as well as academicians with relevant expertise.

RESULTS

Fifteen key clinical statements were proposed. The expert panel reached agreements on several important issues related to the management of prediabetes providing recommendations on the screening, diagnosis, lifestyle and pharmacological management of prediabetes. The expert panel also proposed changes in forthcoming clinical practice guidelines and suggested that the government should advocate early screening, detection, and intensive management of prediabetes.

CONCLUSION

This document provides a comprehensive approach to the management of prediabetes in Malaysia in their daily activities and offer help in improving government policies and the decision-making process.

Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature

Hypopituitarism is a rare presentation of Burkitt's lymphoma (BL). The purpose of this report is to present a case of BL presenting with panhypopituitarism and to review other case reports of lymphoma presenting with pituitary dysfunction to highlight the distinguishing features of these cases from other benign aetiologies of pituitary dysfunction such as non-functioning pituitary adenomas. We reviewed a total of 11 cases of lymphoma presenting with pituitary dysfunction published from 1998 to 2013 including the present case. The demographics, clinical presentations, laboratory features, radiological findings, histological diagnosis, treatment administered and outcomes were described. Of the total number of patients, 45.5% of the cases had diffuse large B-cell lymphoma while 27.3% had BL. Anterior pituitary dysfunction was more common than posterior pituitary dysfunction at presentation. The other common associated presenting symptoms were painful ophthalmoplegia, cranial nerve palsies and constitutional symptoms. Hypothalamic–pituitary abnormalities were often demonstrated radiologically to be associated with cavernous sinus and/or stalk involvement. All patients who completed immunochemotherapy responded haematologically. Pituitary dysfunction also improved in most cases although the recovery tended to be partial. In conclusion, a high index of suspicion of underlying malignancy, such as lymphoma, should be present in patients presenting with acute pituitary dysfunction associated with painful ophthalmoplegia, rapidly evolving neurological features, radiological features atypical of a pituitary adenoma and constitutional symptoms. An early diagnosis is essential as prompt initiation of definitive therapy will induce disease remission and recovery of pituitary dysfunction.

Rhinolith in the fossa of Rosenmuller--a hidden stone

This is a case report of an 80-year-old woman who presented to the ENT services with multiple non-specific upper aerodigestive tract symptoms. Despite extensive investigation and treatment, her symptoms remained unalleviated with significant impact on the psychological morbidity. During a routine flexible nasoendoscopy for worsening globus pharnygis, a mass was noted in the right Rosenmüller's fossa, where the Eustachian tube leaves the lateral wall of the nasopharynx. A CT scan showed this to be a 10 mm calcified entity within the right Eustachian tube. It was subsequently removed under local anaesthesia providing much relief to the patient. Histology showed this mass to be a rhinolith.

Dopamine-secreting phaeochromocytomas and paragangliomas: clinical features and management

Most functional phaeochromocytomas/paragangliomas produce noradrenaline and/or adrenaline. Those that produce dopamine are rare. We describe the distinguishing clinical features of dopamine-secreting phaeochromocytomas and paragangliomas from those that secrete noradrenaline/adrenaline and the impact on their management. We present a case of a dopamine-secreting paraganglioma from our institution and review 14 case reports of dopamine-secreting phaeochromocytomas/paragangliomas published between 1984 and 2008. As observed in the literature, 80% of the tumours were extra-adrenal. Most patients presented with non-specific symptoms or mass effect without the classical presentation of catecholamine excess. The majority were diagnosed with urinary or plasma dopamine. Five patients had malignant tumours and 12 patients underwent surgical resection of the primary tumours. Unlike noradrenaline/adrenaline-secreting phaeochromocytomas/paragangliomas, dopamine-secreting tumours lack a classical presentation, are extra-adrenal and have a higher malignant potential. A routine inclusion of urinary or plasma dopamine as part of catecholamine screening in all suspected phaeochromocytomas and paragangliomas is recommended.

Effect of polyaramid fiber reinforcement on the strength of 3 denture base polymethyl methacrylate resins

PURPOSE

The interactive effects of synthetic polyaramid reinforcement fibers on the transverse strength of intact and repaired heat-polymerized denture base acrylic resins were investigated.

MATERIALS AND METHODS

Three polymethylmethacrylate (PMMA) polymers were tested: Acron MC (GC International Corp, Scottsdale, AZ), Lucitone 199 (Dentsply International Inc, York, PA), and Microlon (The Hygienic Corp, Akron, OH). With each polymer, there were 2 controls and 4 experimental groups (n = 9 per group). The treatment groups were intact heat-polymerized PMMA control, PMMA with unreinforced repair, PMMA with polyaramid reinforced repair, intact polyaramid reinforced heat-polymerized PMMA control, polyaramid reinforced PMMA with unreinforced repair, and polyaramid reinforced PMMA with polyaramid reinforced repair. The transverse fracture strengths of the samples were measured with a 3-point bending test on a Zwick Universal Testing Machine (Zwick of America, Inc, East Windsor, CT).

RESULTS

The highest mean strength at fracture was recorded with intact polyaramid reinforced heat-polymerized PMMA controls for all resins. Analysis of variance showed significant differences in transverse strength (p < .05) by experimental group, by material, and by interaction of group and material. Tukey HSD (honestly significant difference) Multiple Comparisons Test (alpha = 0.05) showed that intact polyaramid reinforced heat-polymerized PMMA controls were significantly stronger than intact heat-polymerized PMMA controls and all the other treatment groups. Use of polyaramid reinforcement in repair of unreinforced PMMA or polyaramid reinforced PMMA did not result in significantly increased transverse strength.

CONCLUSIONS

Polyaramid reinforcement significantly increased the transverse strength of intact heat-polymerized PMMA. Polyaramid fibers did not significantly increase strength to reinforce PMMA repairs.

An epidemiological survey of methicillin-resistant Staphylococcus aureus in a tertiary referral hospital

Over a 30-month period from July 1995 to December 1997, new detections of methicillin-resistant Staphylococcus aureus (MRSA) were prospectively studied in a tertiary referral hospital. The aims of the study were to determine the incidence of colonization of patients admitted to each of the hospital's 39 clinical units and ascertain where each patient had become colonized. Epidemiological information (time to detection, ward movement, admission to other hospitals, data on MRSA isolations in hospital wards) and phage typing were used by the hospital's infection control unit to make this determination. Routine containment procedures included cohorting, flagging and triclosan body washes. Surveillance cultures were collected infrequently. Patients known to be colonized with MRSA were excluded from orthopaedic and haematology wards. During the study period, 995 patients were found to be newly colonized. The incidence of colonization varied from nil to 72 per 1000 admissions, being highest in the main intensive care unit and in services which frequently used that unit. The incidence of colonization in elective orthopaedic surgery (< 1 per 1000) and haematology (3 per 1000) was very low. Determining the place where patients acquired MRSA was made difficult by the high frequency of endemic phage types and frequent patient transfer between wards. Epidemiological data suggested that the main intensive care unit and surgical wards nursing patients with colorectal, urological and vascular diseases were the places where most patients became colonized. MRSA was never acquired by patients nursed in wards which practised an exclusion policy towards patients known to be colonized with MRSA. Our data suggest that in tertiary referral hospitals, where MRSA is not only endemic but frequently imported from other hospitals, it is possible to establish areas where MRSA is never acquired.

Fluoride release and antibacterial properties of new-generation tooth-colored restoratives

The aim of this study was to compare the amounts and pattern of fluoride release and antibacterial properties of new-generation restoratives over a 35-day period. Materials evaluated included fluoride-releasing composites (Tetric, Experimental X), compomers (Dyract, Compoglass), and a resin-modified glass-ionomer cement (Fuji II LC). A conventional glass ionomer (Fuji II Cap) was used as a control for fluoride-release testing. Five samples of each restorative material were evaluated for daily fluoride release over a 35-day period by means of ion chromatography. Ranking of materials from least to greatest total fluoride release over 35 days was as follows: Tetric < Experimental X < Dyract < Fuji II LC < Compoglass < Fuji II Cap. Fuji II Cap had significantly greater fluoride release than all other materials evaluated. Fuji II Cap, Fuji II LC, and Compoglass had similar patterns of fluoride release characterized by a high initial release that was many times that released later. The fluoride-releasing composites evaluated stopped releasing fluoride by day 14. Antibacterial testing was conducted using the agar diffusion inhibitory test. Five samples of each restorative were assessed at baseline and weekly intervals up to 35 days. The microorganisms used were Lactobacillus casei, Streptococcus mutans, and Streptococcus sobrinus. IRM, a zinc oxide/eugenol cement, was used as the baseline control. None of the restorative materials evaluated affected the growth of L casei, S sobrinus, or S mutans at all time periods including baseline, where fluoride was detected in the agar beneath the specimen disks. There was no correlation noted between fluoride-release potential and antibacterial properties.

Hippocampal atrophy correlates with severe cognitive impairment in elderly patients with suspected normal pressure hydrocephalus

Measurements of hippocampal formation atrophy using MRI have been useful in distinguishing demented patients with a diagnosis of probable Alzheimer's disease from cognitively normal controls. To determine whether there is a similar relationship between hippocampal size and dementia in elderly patients suspected of normal pressure hydrocephalus (NPH), the authors obtained mini-mental status examination (MMSE) scores and MRI measurements of hippocampal size and CSF volume on 16 elderly patients whose severe ventriculomegaly and unexplained gait impairment made NPH a probable diagnosis. Hippocampal size correlated strongly with MMSE score (r = 0.75, p < 0.001); no significant MMSE correlation was found for ventricular CSF volume or extra-ventricular/ventricular CSF ratio. It was concluded that hippocampal atrophy is associated with severe cognitive dysfunction in many elderly patients with a diagnosis of NPH. As a hypothesis for further investigation, the detection of such atrophy may help identify cases where the presence of a pathology of Alzheimer's disease complicates the diagnosis of NPH.

Visual system toxicity following intra-arterial chemotherapy

We studied the effects of intra-arterial chemotherapy on the visual system of 29 consecutive patients with gliomas. As expected, infra-ophthalmic carotid infusion of cisplatin or carmustine (BCNU) was associated with clinically apparent anterior visual pathway lesions. Electroretinography revealed retinal dysfunction in patients without clinical abnormalities. Supra-ophthalmic carotid infusion of cisplatin or BCNU caused no retinal or optic nerve lesions. Electroretinography was abnormal in only one of these patients. Our results indicated that BCNU and cisplatin cause ischemic damage and are toxic to both retinal and neural tissue in patients with gliomas.

Deprenyl in the treatment of symptom fluctuations in advanced Parkinson's disease

Deprenyl, a selective inhibitor of monoamine oxidase, type B, which is free of the "tyramine effect," may ameliorate symptom fluctuations in advanced Parkinson's disease (PD). We randomized 96 patients with marked symptom fluctuations at three centers to receive either deprenyl 5 mg b.i.d. or placebo in parallel fashion in addition to a previously optimized levodopa/carbidopa (Sinemet) regimen. Disability was recorded hourly at home by patients 3 days weekly during the 2-week baseline and the 6-week treatment period. Disability during the "on" state was assessed each week by examination. Mean hourly self-assessment of gait improved in 28 of 50 patients (56%) receiving deprenyl (mean degree of improvement 0.25 points on a 0-2 scale) and in 14 of 46 (30.4%) taking placebo (mean 0.15). Mean hourly overall symptom control improved in 29 (58%) taking deprenyl (mean 0.34) and in 12 (26.1%) taking placebo (mean 0.15) (p less than 0.01 for each parameter). No significant improvement occurred in the objective quality of the "on" state with deprenyl. Mean daily Sinemet dosage decreases were 17% in the deprenyl group and 7% in the placebo group. Adverse effects included nausea, light-headedness, dyskinesias, and hallucinations, all of which abated after the Sinemet dose was reduced. We conclude that deprenyl is of moderate benefit in a majority of patients with symptom fluctuations complicating PD and is generally well tolerated.

Longitudinal CT study of parenchymal brain changes in glioma survivors

We reviewed the serial CT studies obtained between 1974 and 1986 of 31 patients with malignant glioma who survived for 2 to 11 years after surgical removal of their tumors. In all cases surgery was followed by radiation therapy to the head (6000 rad) and chemotherapy. Patients were divided into two age groups: those under age 40 (n = 13) and those over age 40 (n = 18). By 2 years all patients in the older group developed evidence of leukoencephalopathy characterized by periventricular zones of decreased attenuation. Only 58% of the younger group showed evidence of white matter changes at this point. All patients from both age groups who survived for 4 years developed leukoencephalopathy. The severity of leukoencephalopathy from 6 months after surgery and beyond was always greater in the older group. All patients developed cerebral atrophy as evidenced by sulcal dilatation and ventricular enlargement. Atrophy was progressive beginning with the first postirradiation scan, and was always more severe in the older patients. A significant difference was found in the clinical status of the two age groups as determined by the mental status score and the Karnofsky scale. Despite progressive brain changes, survivors under age 40 maintained a nearly normal mental status and Karnofsky scores until their death, whereas survivors over age 40 showed progressive clinical decline.

Supraophthalmic intracarotid infusion of BCNU for malignant glioma

We treated five patients with 11 supraophthalmic infusions of BCNU at 200 mg/m2 every 2 months. All three patients with residual tumors showed marked CT response after one infusion. Two patients with bilateral tumors had no response on the contralateral side. All four evaluable cases showed evidence of BCNU neurotoxicity. CT findings superficially resembled tumor recurrence, but white matter changes, nonspecific gyral enhancement, and delayed calcification were more indicative of neurotoxicity. There were no procedure-related complications. One autopsy suggested that direct parenchymal damage might be responsible for delayed neurotoxicity. Supraophthalmic BCNU infusion, at this dosage, is too toxic for cerebral tissue.

Acanthosis nigricans-like hyperpigmentation secondary to triazinate therapy

Cutaneous hyperpigmentation resembling acanthosis nigricans developed in two patients with malignant brain tumors following chemotherapy with triazinate (Baker's Antifol), a folic acid antagonist. In both cases, the eruption resolved after the cessation of drug administration and reappeared after the reinstitution of triazinate therapy. A skin biopsy specimen from one patient showed microscopic changes consistent with those found in acanthosis nigricans. The other patient had a decreased serum folate level that returned to normal as the hyperpigmentation resolved. Folate may have a role in triazinate-induced acanthosislike hyperpigmentation.

CT prognostic criteria of survival after malignant glioma surgery

The serial pre- and postoperative computed tomographic (CT) scans of 115 patients entered in the Cooperative Brain Tumor Study between 1975 and 1982 were analyzed in order to define CT prognostic criteria and to test the hypothesis that radical glioma surgery prolongs patient survival. The CT parameters of mass size, associated edema, and intensity of enhancement were quantitated on all scans. Clinical parameters evaluated included gender, age, length of survival, and useful (Karnofsky greater than 30) survival. Data analyses indicated postoperative residual tumor burden was inversely related to length of survival (p less than 0.01). Postoperative associated edema and intensity of image enhancement were also of prognostic value and showed an inverse relation to survival. Younger patients proved more likely than older patients to attain long-term survival. Residual tumor burden of less than 45 mm diameter on postoperative CT scans was associated with 70% chance of long-term survival. These findings support the radical surgical management of glioma.

Long term survival among patients with malignant brain tumors

Eight of 57 patients (14%) with malignant astrocytomas lived at least 2 years. The mean survival time was 143 weeks (range, 104 to 250 weeks). All of the patients were treated with operation, radiation, and chemotherapy. Four of the 8 patients died because of tumor recurrence, 1 died from a second primary tumor, 2 died of cases unrelated to the tumor, and 1 is still alive. Diffuse cortical dysfunction associated with cortical atrophy that could not be related to tumor regrowth and was not explained by focal deficits, psychotic of depressive thought disorders, metabolic or endocrine abnormalities, or hydrocephalus developed in the 3 longest-surviving patients. The diffuse dysfunction was initially apparent only through psychometric testing, but eventually became so disabling as to result in 2 of the 3 patients retiring from work. Although small, but gratifying, gains have been made in the treatment of patients with malignant brain tumors, accompanying these gains have been problems of a magnitude that is only now beginning to be appreciated.

Long-term efficacy of bromocriptine in Parkinson disease

Twenty-eight patients with Parkinson disease (PD) were treated with bromocriptine for at least 2 years (mean, 2.8 years; range, 2 to 5 years). All of them had first been treated with levodopa (alone or combined with carbidopa, as Sinemet) for 7.4 years (range, 1 to 10 years). At the time bromocriptine was started, all were showing increasing disability. In these patients, attempts to increase levodopa resulted in adverse effects, and attempts to decrease levodopa resulted in increased parkinsonism. Bromocriptine (mean daily dose, 56 mg) was added to levodopa and resulted in improvement of at least one stage (Hoehn and Yahr scale) in 21 of the patients. After 2 years, five of these patients continue to maintain this improvement. The remaining patients, although there has been deterioration, maintain some of their original improvement. Bromocriptine, when added to levodopa, results in improvement that is maintained, in part, for at least 2 years. The ratio of bromocriptine to levodopa has to be periodically readjusted.

Treatment of Parkinson's disease with dopamine agonists: a review

Bromocriptine and lergotrile were administered to 81 patients with Parkinson disease (PD) and increasing disability despite optimal treatment with levodopa (secondary levodopa failures). Sixty-six patients were treated with bromocriptine and 53 patients were treated with lergotrile. Both groups had significantly decreased rigidity, tremor, bradykinesia and gait disturbance upon addition of bromocriptine or lergotrile to levodopa. Twenty-five patients improved at least one-stage on bromocriptine, and 21 improved at least one-stage on lergotrile. The mean dose of bromocriptine was 47 mg, and the mean dose of lergotrile was 49 mg, permitting a 10% reduction in levodopa. Bromocriptine was discontinued in 29 of 66 patients because of adverse effects, including mental changes (14 patients) and involuntary movements (9 patients). Lergotrile was discontinued in 33 of 53 patients because of adverse effects including hepatotoxicity (11 patients) and mental changes (12 patients). The results of treatment with bromocriptine or lergotrile were comparable, with patients either responding or not. Bromocriptine will shortly be available for use in PD. Lergotrile, because of the hepatotoxicity, will not.