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To characterize the clinical features, neurological examination findings, diagnostic imaging results, histopathological findings, and outcome following transsphenoidal hypophysectomy (TSH) in dogs with nonfunctional sellar masses (NFSM).Multi-institutional retrospective study.Medical records of dogs that underwent TSH for a NFSM were reviewed for clinical signs, physical and neurological examination findings, diagnostic imaging results, endocrine testing, surgery reports, and outcome. Magnetic resonance (MR) imaging was rereviewed, and tumors were classified using the previously described system according to pituitary tumor extension and vascular involvement. Owners of dogs that survived to discharge were contacted.The majority of dogs presented for mentation change (12/15). The mean pituitary to brain ratio (P/B ratio) was 1.05 (0.6-1.4). Eight dogs had a tumor imaging classification of 5B. Eleven dogs were diagnosed with a nonfunctional pituitary adenoma (NFPA). Perioperative mortality was 33% (5/15). The median survival for all dogs was 232 days (0-1658). When dogs that did not survive to discharge were excluded, the median survival time was 708 days. Seven of 10 dogs that survived the perioperative period received adjunctive therapy. Owner assessment of outcome was excellent (6/7) to good (1/7).The common presenting complaint for dogs with large NFSM causing mass effect was mentation changes. Dogs with NFPA that survived to discharge and received adjunctive therapy had good to excellent outcomes.Transsphenoidal debulking with adjunctive therapy can be considered for the treatment of NFSM causing clinical signs of mass effect in dogs. Successful long-term outcomes are possible.

To describe the development and implementation of a small animal hemovigilance program at a university veterinary teaching hospital.Retrospective observational descriptive study performed between October 2014 and March 2019.University teaching hospital.Dogs and cats receiving blood product transfusions .None. A hemovigilance working group composed of veterinary specialists in clinical pathology, internal medicine, and emergency and critical care was established. This group developed evidence-based definitions of transfusion reactions, reaction classification systems, and a transfusion reaction reporting form. The reporting form contained sections for patient information, transfusion information, administration details, and reaction details. Reaction events were classified by reaction type, severity grade, and imputability to the transfusion. Following implementation of the hemovigilance program, transfusion reaction data were collected and examined for the period spanning October 2014 and March 2019. During the study period, 718 canine transfusions (4 whole blood, 400 packed RBC [pRBC], 300 fresh frozen plasma [FFP], 7 platelet rich plasma, and 7 cryoprecipitate) and 124 feline transfusions (5 whole blood, 95 pRBC, and 24 FFP) were administered. There were 32 total reactions (27 canine and 5 feline), with the most common reaction being febrile nonhemolytic transfusion reactions (19/32; 59%). The incidence rate of transfusion reactions was found to be 3.8% in dogs and 4.0% in cats. For the confirmed reactions, classification criteria for case definition, reaction severity grade, and imputability were able to be determined and recorded. This allowed targeted interventions to be implemented in order to potentially reduce future reactions.A hemovigilance program can be instituted successfully in a veterinary hospital setting and once developed, standardized reporting tools could be utilized by multiple hospitals and provide the basis for more widespread reaction reporting in veterinary medicine.

Objective To describe a complex case involving the management of a dog with von Willebrand disease (vWD), active ehrlichiosis infection, nonregenerative anemia, and blood type incompatibility related to the Dal antigen. Case summary A 13-week-oldintact male Doberman Pinscher weighing 7.2 kg was presented to the emergency service for a previous hemorrhaging event and progressive nonregenerative anemia. The dog had received a fresh whole blood transfusion 8 days prior to presentation due to severe anemia. Upon presentation, the puppy was tachycardic, and his mucous membranes were pale. A CBC revealed a nonregenerative anemia with a PCV of 0.11 L/L (11%). von Willebrand factor deficiency was suspected and later confirmed. The dog's blood type was dog erythrocyte antigen (DEA) 1 positive, but cross-matching to 4 RBC units, both DEA 1 positive and negative, failed to yield any compatible units. Antibody against a possible Dal RBC antigen was suspected, and 11 blood donors (Dalmatians and Dobermans) were cross-matched to find 2 compatible donors. After an uneventful fresh whole blood transfusion, a bone marrow biopsy revealed a hypocellular bone marrow and erythroid hypoplasia. A SNAP4DxPlus test and subsequent polymerase chain reaction (PCR) testing were positive for Ehrlichia ewingii and E. canis. Treatment with doxycycline was started, and the PCV was 0.17 L/L (17%) at discharge. At the 1-week follow-up, the PCV was 0.24 L/L (24%), and the puppy was doing well. New or unique information provided This is a unique case of a dog presenting with several challenging disorders, including vWD resulting in hemorrhage, ehrlichiosis potentially contributing to a nonregenerative anemia, and a blood type incompatibility due to the Dal antigen. Doberman Pinschers have a high prevalence of vWD- and Dal-negative phenotype, which emphasizes the value of cross-matching and the recognition of antigen prevalence in specific breeds.

OBJECTIVE: To develop and assess the instructional efficacy of an online learning module on transfusion reactions in small animals and to evaluate participants’ satisfaction of the module. DESIGN: Randomized controlled trial. SETTING: University teaching hospital. SUBJECTS: A total of 55, fourth‐year veterinary students, 27 in a treatment group that received the learning module plus standard rotation training and 28 in a control group (no module) who received only standard training INTERVENTIONS: Students received a pretest on transfusion reactions followed by administration of a transfusion reaction learning module covering recognition, treatment, prevention, case examples, and self‐assessment questions for 6 common transfusion reactions. Students also received a module satisfaction survey, a post‐test at 2 weeks post‐module, and a retention test at 6 weeks post‐module. MEASUREMENTS AND MAIN RESULTS: Previous transfusion medicine exposure did not affect pretest scores and there was no difference in pretest scores between groups. The module group scored higher on the post‐test (P < 0.001) and retention test (P = 0.002) than the control group. Mean post‐test scores were 74.4% and 57.7% and mean retention test scores were 80.6% and 56.5% for the module and control groups, respectively. The module group scored higher on posttest and retention questions involving reaction recognition (P < 0.001). Students were overall very satisfied with the module with an average score of 4.8 (1‐5). CONCLUSIONS: A transfusion reaction instructional module can be delivered successfully to veterinary students on an ICU‐based clinical rotation. Students taking the module scored significantly better on post‐assessments up to 6 weeks after module administration as compared to students receiving only conventional clinical rotation training.

Pituitary glands from 141 feline autopsy cases were reviewed histologically. Adenoma and hyperplasia were the most common lesions at 13 cases each. Pituitary adenoma was more likely than hyperplasia to be associated with clinical evidence of endocrinopathy or an intracranial mass ( P < .001). A histochemical and immunohistochemical panel was applied to 44 autopsy- or hypophysectomy-derived pituitary adenomas in 43 cats from 2 diagnostic laboratories. Adenomas were differentiated from hyperplasia by the presence of disrupted reticulin fibers. One cat had a double (somatotroph and melanotroph) adenoma. Twenty somatotroph adenomas consisted of periodic acid-Schiff (PAS)-negative acidophils that expressed growth hormone; 16/20 had hypersomatotropism; 17/20 had diabetes mellitus. Eleven melanotroph adenomas consisted of PAS-positive basophils or chromophobes that expressed melanocyte-stimulating and adrenocorticotrophic hormones; 5/11 had hypercortisolism; 6/11 had diabetes mellitus. Eleven gonadotroph adenomas consisted of PAS-negative chromophobes that expressed follicle-stimulating and/or luteinizing hormones. Two thyrotroph adenomas consisted of PAS-negative basophils or chromophobes that expressed thyroid-stimulating hormone. Pituitary-dependent disease was not recognized in cats with gonadotroph or thyrotroph adenomas. The Ki-67 proliferation index in hypophysectomy specimens was lower in somatotroph than in melanotroph adenomas. Fourteen cats with hypophysectomy-treated somatotroph or melanotroph adenoma had an 899-day median survival time versus 173 days in 17 nonsurgical cases. After adjusting for age, adenoma size and type, hypophysectomized cats had an overall better survival time than nonsurgical cases ( P = .029). The study results underscore the value of hypophysectomy and trophic hormone immunohistochemistry in the treatment and classification of feline pituitary adenomas.

Medical management is currently the most common treatment for pituitary-dependent hyperadrenocorticism and hypersomatotropism/acromegaly in veterinary medicine. Medical management does not provide a cure for either disease process, and rarely is pituitary imaging a part of initial diagnostics. Early pituitary imaging in animals with clinically functional pituitary tumors provides a baseline assessment, allows monitoring of tumor changes, and permits radiation and surgical planning. Surgery is the only treatment for pituitary tumors that has curative intent and allows for a definitive diagnosis. Surgical removal of pituitary tumors via transsphenoidal hypophysectomy is an effective treatment for clinical pituitary tumors in patients exhibiting endocrine abnormalities associated with pituitary-dependent hyperadrenocorticism and hypersomatotropism. Surgery, however, is rarely pursued until patients have failed medical management, and often not until they are showing neurologic signs, making surgical success challenging. It is well documented that dogs surgically treated when the pituitary mass is small have a lower mortality, a lower recurrence rate, and a longer survival than those with larger pituitary masses. Providing owners with the option of early pituitary imaging in addition to medical, surgical, and radiation treatment options should be the standard of care for animals diagnosed with pituitary-dependent hyperadrenocorticism or hypersomatotropism.

Hypophysectomy specimens from 16 dogs with pituitary adenoma were evaluated with periodic acid-Schiff (PAS), reticulin, and immunohistochemistry for adrenocorticotrophic hormone (ACTH), melanocyte stimulating hormone (MSH), growth hormone (GH), and Ki-67. The reticulin network was obliterated in all adenomas. One adenoma expressed ACTH and GH. Eight corticotroph adenomas were basophilic to chromophobic, and PAS- and ACTH-positive. Seven melanotroph adenomas were distinguished from corticotroph adenomas by expression of MSH. Pituitary-dependent hypercortisolism was diagnosed in 5 of 8 dogs with corticotroph and 4 of 7 with melanotroph adenoma. Pituitary height/brain area (P/B) ratio was elevated in all dogs. Previous canine hypophysectomy studies suggested that melanotroph adenomas were larger and carried a worse prognosis than corticotroph adenomas; however, in this study, corticotroph adenomas in comparison to melanotroph adenomas were larger (median P/B ratio: 1.06 versus 0.76), more proliferative (median Ki-67 index: 9.47% versus 1.99%), and associated with shorter survival (median: 300 versus 793 days). Recommended immunohistochemistry for PAS-positive pituitary adenomas includes ACTH and MSH to distinguish corticotrophs from melanotrophs and Ki-67 for proliferation index.

Objectives To determine whether the prevalence of cognitive limitation (CL) among Americans ages 55 to 69 years changed between 1998 and 2014, and to assess the trends in socioeconomic disparities in CL among groups defined by race/ethnicity, education, income, and wealth. Method Logistic regression using 1998-2014 data from the biennial Health and Retirement Study, a nationally representative data set. CL is defined as a score of 0-11 on a 27-point cognitive battery of items focused on memory. Socioeconomic status (SES) measures are classified as quartiles. Results In models controlling for age, gender, and previous cognitive testing, we find no significant change over time in the overall prevalence of CL, widening disparities in limitation by income and, in some cases, wealth, and improvements among non-Hispanic whites but not other racial/ethnic groups. Discussion Among people 55-69, rates of CL are many times higher for groups with lower SES than those with higher SES, and recent trends show little indication that the gaps are narrowing.

OBJECTIVE To assess effects of major abdominal surgery on serum cortisol and aldosterone and plasma canine ACTH (cACTH) concentrations. ANIMALS 39 healthy dogs undergoing laparotomy during veterinary student surgical laboratories. PROCEDURES Blood samples were obtained before and at completion of surgery. Serum cortisol and aldosterone and plasma cACTH concentrations were measured by use of validated radioimmunoassays. Changes in concentrations (postoperative concentration minus preoperative concentration) were calculated. Data were analyzed by use of the Wilcoxon signed rank test, Pearson correlation analysis, and Mann-Whitney rank sum test. RESULTS Cortisol, aldosterone, and cACTH concentrations increased significantly from before to after surgery. Although cortisol and aldosterone concentrations increased in almost all dogs, cACTH concentrations decreased in 6 of 32 (19%) dogs. All dogs had preoperative cortisol concentrations within the reference range, but 24 of 39 (62%) dogs had postoperative concentrations above the reference range. A correlation between the change in cACTH concentration and the change in cortisol concentration was not detected. CONCLUSIONS AND CLINICAL RELEVANCE Laparotomy caused a significant increase in serum cortisol and aldosterone concentrations. In most dogs, but not all dogs, plasma cACTH concentrations increased. Lack of correlation between the change in cACTH concentration and the change in cortisol concentration suggested that increased postoperative cortisol concentrations may have been attributable to ACTH-independent mechanisms, an early ACTH increase that caused a sustained cortisol release, or decreased cortisol clearance. Further studies are indicated to evaluate the effects of various anesthetic protocols and minimally invasive surgical techniques on the stress response.

To optimize the histologic evaluation of hypophysectomy specimens, sections of 207 canine pituitary glands (196 postmortem, 11 hypophysectomy specimens) were reviewed. Adenohypophyseal proliferation was the most common (n = 79) lesion. Proliferative lesions were sparsely to densely granulated; the granules were usually basophilic to chromophobic and periodic acid-Schiff-positive. Adenohypophyseal proliferation was classified as hyperplasia (n = 40) if ≤2 mm diameter with intact reticulin network, as microadenoma (n = 22) for 1–5 mm homogeneous nodules with lost reticulin network, or as macroadenoma (n = 17) for larger tumors. Craniopharyngeal duct cysts were common incidental lesions and the only lesion in 15 dogs. Uncommon diagnoses included lymphoma (n = 4), hemorrhagic necrosis (n = 4), metastatic carcinoma (n = 3), hypophysitis (n = 3), ependymoma (n = 2), craniopharyngioma (n = 2), and 1 case each of metastatic melanoma, pituicytoma, gliomatosis, germ cell tumor, meningioma, and atrophy. The pituitary histologic diagnosis was associated with hyperadrenocorticism (HAC; P < .001) and adrenocortical histologic diagnosis ( P = .025). Both HAC and adrenocortical hyperplasia showed a positive trend with the degree of adenohypophyseal proliferation. The association of adrenocortical hyperplasia with HAC was not significant ( P = .077). Dogs with adenohypophyseal proliferations were older than dogs with normal pituitary glands ( P < .05). Brachycephalic breeds were overrepresented among dogs with pituitary macroadenoma or craniopharyngeal duct cysts, but the association was not statistically significant ( P = .076). Adenohypophyseal hyperplasia was more common than adenoma among postmortem specimens, but was unexpected in >80% of cases. Pituitary macroadenoma was the most common diagnosis in hypophysectomy specimens.

Objectives The disablement process can be viewed conceptually as a progression from disease to impairment to functional limitation and finally disability (frequently operationalized as activity limitation). This article assesses the extent to which early phases of the process are associated with individual-level disability trajectories by age. Method We use data from seven waves of the Health and Retirement Study, 1998 to 2010, to investigate for individuals aged 65-84 years how baseline sociodemographic characteristics and self-reported disease, pain, and functional limitation (physical, cognitive, or sensory) are related to the dynamics of limitations in activities of daily living (ADLs). Our modeling approach jointly estimates multiperiod trajectories of ADL limitation and mortality and yields estimates of the number of, shapes of, and factors associated with the most common trajectories. Results Individual probability of ADL limitation can best be described by three common trajectories. In comparison with disease, pain, and functional limitation, sociodemographic characteristics have weak associations with trajectory group membership. Notably, neither sex nor education is strongly associated with group membership in multivariate models. Discussion The analysis confirms the importance of the early phases of the disablement process and their relationships with subsequent trajectories of activity limitation.

Transsphenoidal surgery is an option for dogs and cats with functional and nonfunctional pituitary masses or other sellar and parasellar masses. An adrenocorticotropic hormone-secreting tumor causing Cushing disease is the most common clinically relevant pituitary tumor in dogs, and the most common pituitary tumor seen in cats is a growth hormone-secreting tumor causing acromegaly. Transsphenoidal surgery can lead to rapid resolution of clinical signs and provide a cure for these patients. Because of the risks associated with this surgery, it should only be attempted by a cohesive pituitary surgery group with a sophisticated medical and surgical team.

OBJECTIVE To determine the accuracy of locating the pituitary fossa with the Brainsight neuronavigation system by determining the mean target error of the rostral (tuberculum sellae) and caudal (dorsum sellae) margins of the pituitary fossa. STUDY DESIGN Experimental cadaveric study. ANIMALS Ten canine cadavers. METHODS Computed tomography (CT) and MRI were performed on each cadaver with fiducials in place. Images were saved to the neuronavigation computer and used to plan the drilling approach. The cadavers were placed in the surgical head clamp of the Brainsight system and positioned for a transsphenoidal approach. On the basis of the planning, 2 localization points were drilled, 1 each at the rostral and caudal margins of the pituitary fossa, and CT was repeated. Error was assessed from the difference in millimeters between the targets identified during Brainsight planning and the actual location of the 2 points drilled on each cadaver skull as identified by postdrilling CT. RESULTS The rostral and caudal margins of the pituitary fossa provided 2 target points per cadaver. The median target error (interquartile range) for all target sites (n = 20) was 3.533 mm (range, 2.013-4.745). CONCLUSION This stereotactic system allowed the surgeon to locate the rostral and caudal margins of the pituitary fossa with clinically acceptable accuracy and confidence. CLINICAL SIGNIFICANCE Using the Brainsight neuronavigation system for localization during transsphenoidal hypophysectomy may decrease morbidity and surgical time.

China has the world's largest oldest-old population, but information on trends in late-life disability is lacking. We use data from the Chinese Longitudinal Healthy Longevity Survey for 1998 to 2008 to determine whether prevalence of limitations with physical functions and daily activities has changed recently among the Chinese population aged 80 to 105 and, if so, to investigate the factors associated with the change. We find that prevalence of need for assistance with activities of daily living and inability to independently conduct instrumental activities of daily living declined substantially. Males did not experience improvement in ability to carry out underlying physical functions over the same period, but females did. Variables associated with trends in one or more of these outcomes were adequacy of medical care as a child, childhood hunger, father's occupation in agriculture, main occupation before age 60 in agriculture, adequacy of current medical care, and body weight.

Objectives Identify common trajectories of physical functional limitation and mortality among Taiwanese 50 and older as they age, link these to underlying transitions in onset, recovery, and mortality, and assess associations between trajectories and a set of risk factors. Method Longitudinal data from 4 waves of the Survey of Health and Living Status of the Middle-Aged and Elderly in Taiwan, collected between 1996 and 2007, are analyzed using a summary measure indicating difficulty with one or more of 7 physical functions. A group-based trajectory model identifies common trajectories. Shorter term transition probabilities that underlie multiperiod trajectories are examined. Multinomial regression associates risk factors with trajectory group membership. Results Best fitting the data is a model with 3 groups characterized as early, mid, and late onset of limitation. Roughly half the population follows the trajectory of mid onset and a quarter each of the other 2. Females and those least educated are most likely to belong to the early-onset group. Discussion The analysis advances understanding of late-life functioning by focusing on the heterogeneity of functional limitation experience, appropriately accounting for the relation between functional limitation and mortality and linking long-term patterns with short-term changes in functional limitation.

Background Maximal aldosterone secretion in healthy dogs occurs 30 minutes postadrenocorticotropin (ACTH; 5 μg/kg IV) stimulation. The effect of trilostane and mitotane on aldosterone at that time is unknown. Objectives To assess the effect of trilostane and mitotane in dogs with pituitary-dependent hyperadrenocorticism on aldosterone secretory reserve. To determine if aldosterone concentration correlates with electrolyte concentrations. Animals Serum collected from 79 client-owned dogs and 33 stored samples. Methods Client-owned dogs had ACTH stimulation tests with cortisol concentrations measured at 0 and 60 minutes and aldosterone concentrations measured at 0, 30, and 60 minutes. Stored samples had aldosterone concentrations measured at 0 and 60 minutes. Ten historical clinically healthy controls were included. All had basal sodium and potassium concentrations measured. Results The aldosterone concentrations in the mitotane- and trilostane-treated dogs at 30 and 60 minutes post-ACTH were significantly lower than in clinically healthy dogs; no significant difference was detected in aldosterone concentration between 30 and 60 minutes in treated dogs. However, a significantly higher percentage of dogs had decreased aldosterone secretory reserve detected at 30 minutes than at 60 minutes. At 30 minutes, decreased secretory reserve was detected in 49% and 78% of trilostane- and mitotane-treated dogs, respectively. No correlation was detected between aldosterone and serum electrolyte concentrations. Conclusions and Clinical Importance Decreased aldosterone secretory reserve is common in trilostane- and mitotane-treated dogs; it cannot be predicted by measurement of serum electrolyte concentrations. Aldosterone concentration at 30 minutes post-ACTH stimulation identifies more dogs with decreased aldosterone secretory reserve than conventional testing at 60 minutes.

Objective To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). Etiology Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. Diagnosis Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. Summary Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.

Objective To review the current literature in reference to the pathophysiology and diagnostic modalities available for acute traumatic coagulopathy (ATC) in relationship to traumatic hemorrhagic shock. Etiology Posttraumatic hemorrhage is responsible for one of the leading causes of preventable human deaths worldwide. Acute traumatic coagulopathy is an endogenous hypocoagulable condition that has been observed during the immediate (< 1 hour) posttraumatic period. Phenotypically, ATC manifests as a state of systemic hypocoagulability and hyperfibrinolysis. Although different functional mechanisms have been proposed for causing ATC, it is universally thought to be a manifestation of severe tissue injury, shock-induced hypoperfusion, systemic inflammation, and endothelial damage. Excessive activation of the thrombin-thrombomodulin activated Protein C pathway, catecholamine-induced endothelial damage as well as disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype are all hypotheses that have been proposed in attempts to explain the functional mechanism of ATC. Diagnosis An accurate and reliable test remains to be validated for ATC. Traditional coagulation assays (activated partial thromboplastin times and prothrombin times) along with platelet count and fibrinogen concentrations have been used more commonly. Viscoelastic tests (thromboelastography and rotational thromboelastometry) are currently being investigated as a more predictive modality for identifying and guiding therapy for ATC. Therapy Damage control resuscitation and hemostatic resuscitation are gaining favor as the optimal resuscitative strategies for hemorrhagic shock and ATC. Antifibrinolytics may also play a role when hyperfibrinolysis is present. Prognosis Massive hemorrhage accounts for 30–56% of prehospital posttraumatic deaths in people, with coagulopathic hemorrhage remaining one of the major causes of preventable deaths within the first 24 hours posttrauma. Ten to twenty-five percent of human trauma patients experience ATC, which has been shown to prolong hemorrhage, deter resuscitative efforts, promote sepsis, and increase mortality by at least 4-fold. Prognosis in veterinary patients is not currently known.

Background Lowering the cosyntropin dose needed for ACTH stimulation would make the test more economical. Objectives To compare the cortisol response to 1 and 5 μg/kg cosyntropin IV in dogs being screened for hyperadrenocorticism (HAC) and in dogs receiving trilostane or mitotane for pituitary-dependent HAC. Animals Healthy dogs (n = 10); client-owned dogs suspected of having HAC (n = 39) or being treated for pituitary-dependent HAC with mitotane (n = 12) or trilostane (n = 15). Procedures In this prospective study, healthy dogs had consecutive ACTH stimulation tests to ensure 2 tests could be performed in sequence. For the first test, cosyntropin (1 μg/kg IV) was administered; the second test was initiated 4 hours after the start of the first (5 μg/kg cosyntropin IV). Dogs suspected of having HAC or being treated with mitotane were tested as the healthy dogs. Dogs receiving trilostane treatment were tested on consecutive days at the same time post pill using the low dose on day 1. Results In dogs being treated with mitotane or trilostane, the 2 doses were pharmacodynamically equivalent (90% confidence interval, 85.1–108.2%; P = 0.014). However, in dogs suspected of having HAC, the doses were not pharmacodynamically equivalent (90% confidence interval, 73.2–92.8%; P = 0.37); furthermore, in 23% of the dogs, clinical interpretation of test results was different between the doses. Conclusions and Clinical Relevance For dogs suspected of having HAC, 5 μg/kg cosyntropin IV is still recommended for ACTH stimulation testing. For dogs receiving mitotane or trilostane treatment, a dose of 1 μg/kg cosyntropin IV can be used.

Objectives This study examines changes in functional and activity limitations 1998–2012 for individuals 55–69. Methods Logistic models are used to estimate trends in limitations in vision, hearing, physical and cognitive functioning, IADLs, and ADLs. Additional models assess the extent to which trends are associated with and differ by education, smoking, and BMI. Results Changes in prevalence of limitations in vision, hearing, cognitive functioning, and ADLs are not statistically significant. Limitations in physical functioning declined by 0.37% per year. IADL limitations increased by 1.33% per year, but most of the increase occurred between 2008 and 2010/2012, and are associated with economic hardship during the Great Recession. Increases in education are especially beneficially associated with trends in limitations, but reductions in smoking also appear to be advantageous for some outcomes. Increases in BMI are associated with trends in physical functioning, IADL, and ADL limitation. Discussion For Americans 55–69, functional and activity limitations were largely unchanged 1998–2012. Our results suggest that if educational attainment had not increased, most functional and activity limitations potentially could have worsened substantially. Future change in educational attainment is not expected to be so positive. Continued monitoring of trends in activity limitations might well include greater focus on the explanatory roles of environmental factors, including economic circumstances.

This article updates trends from five national U.S. surveys to determine whether the prevalence of activity limitations among the older population continued to decline in the first decade of the twenty-first century. Findings across studies suggest that personal care and domestic activity limitations may have continued to decline for those ages 85 and older from 2000 to 2008, but generally were flat since 2000 for those ages 65–84. Modest increases were observed for the 55- to 64-year-old group approaching late life, although prevalence remained low for this age group. Inclusion of the institutional population is important for assessing trends among those ages 85 and older in particular.

Objective To review current human and veterinary protocols for platelet transfusion triggers, available platelet transfusion products to support veterinary thrombocytopenic patients, and the advantages and disadvantages of each product. Data Sources Data from human and veterinary literature. Human Data Synthesis Prophylactic and therapeutic platelet transfusions are instrumental in managing human patients with thrombocytopenia. The platelet transfusion products used in human medicine consist of platelet concentrates, derived from pooled random donor platelets, or single-donor apheresis platelets. Historically, platelet transfusions in human medicine have been prophylactic in nature; however, recent research suggests changing from a prophylactic transfusion strategy to a therapeutic transfusion strategy may be safe for most patients. The optimal platelet transfusion trigger and the use of prophylactic verses therapeutic platelet transfusions are ever changing in human medicine. Veterinary Data Synthesis There have been many advances in platelet transfusion products, but fresh whole blood remains the most commonly used platelet transfusion product in veterinary medicine. New products such as lyophilized platelets and cryopreserved platelets offer the benefits of long shelf life, immediate availability, and higher concentration of platelets at smaller doses. Veterinary platelet transfusion guidelines are mostly extrapolated from human literature because data on veterinary platelet transfusions are lacking. Conclusions In veterinary medicine the most commonly available product for platelet transfusions is fresh whole blood, because of availability of blood donors and lack of a cost effective easily obtainable alternative. Cryopreserved and lyophilized platelets are promising new products being used in the treatment of hemorrhaging patients with thrombocytopenia. These products offer increased platelet concentrations at decreased volumes, longer storage shelf life, and decreased exposure to whole blood products. With the development of newer readily available products, platelet transfusion parameters, to include dose, platelet count trigger, presence of disease, and clinical signs, should be further evaluated in veterinary medicine.

Objective To examine the safety and feasibility of using lyophilized platelets (LYO) and fresh platelet concentrate (FRESH) in bleeding thrombocytopenic dogs. Design Preliminary prospective randomized clinical trial. Setting Two private referral centers and 3 university teaching hospitals. Animals Thirty-seven dogs with a complaint of hemorrhage associated with thrombocytopenia (platelet count 15%, and that had received neither vincristine nor platelet-containing transfusions within 72 h of enrollment were studied. Interventions Animals were randomized to receive LYOor FRESH, dosed according to weight. Physical examination, complete blood counts, and coagulation testing (prothrombin time and activated partial thromboplastin time) were performed at enrollment. Physical examinations were also performed immediately post transfusion, and at 1 and 24 h after transfusion. Complete blood counts were repeated immediately post transfusion and at 24 h. Collected data included bleeding score (BLS), response to transfusion, adverse reactions, hospitalization time, need for additional transfusions, survival to discharge, and 28-d survival. Measurements and Main Results Twenty-two dogs received LYOand 15 received FRESH. There was no difference between groups in age, weight, BLS, platelet count, white blood cell count, hematocrit, or presence of melena. There was no difference between groups in transfusion reaction rates, the need for additional transfusions, 24-h BLS, hospitalization time, survival to discharge, or 28-d survival. Conclusions Transfusion of LYO was feasible and associated with a low transfusion reaction rate in this limited study of thrombocytopenic canine patients presenting with mild-to-severe hemorrhage. LYOwere easy to use and provided storage advantages over FRESH. Further study of this product, including examination of efficacy and platelet life span, is warranted.

BackgroundRecently, late-life disability rates have declined in several countries of the Organisation for Economic Co-operation, but no national-level trend analysis for England has been available. The authors provide such analysis, including measures both early and late in the disablement process, and the authors investigate the extent to which temporal trends are associated with population changes in socioeconomic position (SEP).MethodsThe authors fit logistic models of trends in self-reports and nurse measures of 16 health indicators, based on cross-sectional data from those aged 65 years and older from the 1992 to 2007 Health Survey for England.ResultsOverall, prevalence rates of limitations in seeing, hearing and usual activities declined (pConclusionsRecent trends in late-life health and functioning in England have been mixed. A better understanding of which specific activities pose challenges, how the environment in which activities are conducted influences functioning and the causes of relatively worse trends for some SEP groups is needed.

This analysis offers the first strong evidence of trends in late-life disability in an emerging economy. For the population of Taiwan aged 65 and older, consistent measures of limitations in seeing, hearing, physical functions, instrumental activities of daily living (IADLs), and activities of daily living (ADLs) were available for three to six survey waves, depending on the outcome, from 1989 to 2007. Limitations in seeing, hearing, and IADLs declined substantially, but trends were mixed for physical functions and flat for ADLs. The remarkable reduction in difficulty telephoning, an IADL, may reflect changes in telecommunications infrastructure and highlights the roles of environment and technology in disability outcomes. Trends for urban residents were more advantageous than those for rural residents for seeing and hearing, but less so for physical functions and IADLs. Were it not for the substantial increase in educational attainment, trends in all outcomes would have been less favourable.

Objective—To determine the lowest dose of cosyntropin on a per body weight basis that would produce maximal cortisol and aldosterone secretion and the ideal timing of blood sample collection after ACTH stimulation in healthy cats. Design—Randomized crossover trial. Animals—7 adult sexually intact male purpose-bred cats. Procedures—Each cat received saline (0.9% NaCl) solution (control) and 5 doses (125 μg/cat and 10, 5, 2.5, and 1 μg/kg [4.54, 2.27, 1.14, and 0.45 μg/lb]) of cosyntropin IV with a 2-week washout period between treatments. Blood samples were obtained before (baseline) and at 15, 30, 45, 60, 75, and 90 minutes after administration of saline solution or cosyntropin. Results—Serum cortisol and aldosterone concentration increased significantly, compared with baseline values, after administration of all cosyntropin doses. Lower doses of cosyntropin resulted in an adrenocortical response equivalent to the traditional dose of 125 μg/cat. The lowest doses of cosyntropin that stimulated a maximal cortisol and aldosterone response were 5 and 2.5 μg/kg, respectively. Lower doses of cosyntropin resulted in a shorter interval between IV administration of cosyntropin and peak serum cortisol and aldosterone concentrations. Conclusions and Clinical Relevance—Low-dose ACTH stimulation testing with IV administration of cosyntropin at 5 μg/kg followed by blood sample collection at 60 to 75 minutes resulted in concurrent peak serum cortisol and aldosterone concentrations that were equivalent to those achieved following administration of cosyntropin at 125 μg/cat, the standard dose currently used.

The decline in late-life disability prevalence in the United States was one of the most important developments in the well-being of older Americans in the 1980s and 1990s, but there is no guarantee that it will continue into the future. We review the past literature on trends in disability and other health indicators and then estimate the most recent trends in biomarkers and limitations for both the population aged 65 and older and those aged 40 to 64, the future elderly. We then investigate the extent to which trends in education, smoking, and obesity can account for recent trends in limitations and discuss how these three factors might influence future prospects for late-life health. We find that improvements in the health of the older population generally have continued into the first decade of the twenty-first century. The recent increase in the proportion of the younger population needing help with activities of daily living is concerning, as is the doubling of obesity in the last few decades. However, the increase in obesity has recently paused, and favorable trends in education and smoking are encouraging.

At the time of publication of the 1994 National Research Council’s Demography of Aging, the expert contributors to that volume were hungry for more information (Martin and Preston 1994). Over the last 15 years, population researchers focusing on aging have made great strides in describing the status and experiences of older people, especially in the United States, identifying factors influencing those outcomes, and understanding the societal consequences of aging. A particularly important development has been the growth in the availability of survey data. For example, at the time of writing the 1994 book, the Health and Retirement Study (HRS) had only recently started. Another key development has been the growth of interdisciplinarity in the study of the demography of aging. Certainly the US National Institute on Aging’s fostering of aging centers has been critical. But individual scholars also have recognized that they can learn from other disciplines. Most social scientists have learned some biology, and many economists in particular have learned some psychology. Overall, there has been an enormous increase in our knowledge about the older population and the process of population aging. Of course, there is much more to be done in the description and modeling of aging. To highlight just a few areas, we need to know more about individual trajectories in outcomes over multiple periods, trends in outcomes at the population level over time and their explanations, disparities in outcomes, and cross-national comparisons. At the same time, we need to begin to move on. In other domains of population research (e.g., fertility), besides describing the demographic process and investigating both the determinants and the consequences of the phenomenon, a major focus has been the design and evaluation of policies and programs that may influence determinants and mitigate consequences. But thus far in the demography of aging in the United States, except perhaps for work on Social Security, policy and program development has not been a major focus of population researchers. Albert Hermalin made this point in his 1993 presidential address at the annual meeting of the Population Association of America (Hermalin 1993). In his intriguingly titled talk, “Fertility and family planning among the elderly in Taiwan,” he highlighted the integral role of family planning program research in the broader study of fertility and argued for the considerable potential of population experts to evaluate programs designed for the elderly. In the following commentary, I build on Hermalin’s suggestion by illustrating the potential role of demographers in working on interventions in two domains critical for the older population: saving and disability. My focus is on the United States, where as a result of analysis of the HRS and other surveys, we now know much more about the dimensions of these issues among the elderly, and we can potentially use that information to design interventions that improve outcomes.

THE consequences of declines in mortality for the health and functioning of the nation's older adults have been the subject of much interest over the last quarter century. Indeed, spurred by Manton, Corder, and Stallard's (1993) analysis of the National Long Term Care Survey, a vast literature has developed that explicitly focuses on trends in health and disability in late life. Although initially there was disagreement, a consensus has emerged among researchers in the field that there have been improvements in most measures of late-life functioning (see, e.g., Crimmins, 2004; Cutler, 2001; Freedman, Martin, & Schoeni, 2002; Freedman et al., 2004; Kramarow, Lubitz, Lentzner, & Gorina, 2007; Manton, Gu, & Lamb, 2006; Waidmann & Liu, 2000). A recent report by the Institute of Medicine on the future of disability in America (Field & Jette, 2007) suggests that despite these improvements, the numbers of adults with disabilities will likely swell in the coming years as the large Baby Boom generation—those born during the years 1946–1964—reaches the ages associated with the highest rates of morbidity and disability. Undoubtedly, such a trend would have important implications for the provision of medical and social services, for the ability of future older adults to participate fully in society, including the workplace, and more generally for their quality of life. However, although the number of adults reaching older ages and thus experiencing elevated risks for debilitating conditions will certainly grow, there is debate about whether the Baby Boom cohort will enter later life with better or worse age-specific rates of morbidity and disability than earlier cohorts. Only a handful of studies have taken up the question of trends in health and functioning of the adult population in the decades approaching retirement, and results have been conflicting. One study, using data from the National Health Interview Survey (NHIS), found from 1984 to 1996 an increase in the prevalence of needing help with personal care and routine household activities among adults aged 40–49 and 50–59 years, although the rates of such disability were very low (Lakdawalla, Bhattacharya, & Goldman, 2004). Another study, by Zack, Moriarty, Stroup, Ford, and Mokdad (2004), using data from the Behavioral Risk Factor Surveillance System (BRFSS), found an increase from 1993 to 2001 in the proportion of those aged 35–44, 45–54, and 55–64 years who reported poor or fair health. A third study, which relied on data from the Health and Retirement Study (HRS), suggested worse health and functioning among people aged 51–56 years in 2004 compared with 1992 (Soldo, Mitchell, Tfaily, & McCabe, 2007). However, Weir (2007) concluded from his analysis of the same cohorts using a different recode of the HRS data that although early Baby Boomers were more likely to report poor or fair health than the cohort born 12 years earlier, objectively their overall health and functioning were similar. Other recent analyses of health trends among the middle-aged adult population have been more positive. Using the NHIS, Martin, Schoeni, Freedman, and Andreski (2007) found a downward trend from 1982 to 2003 in reports of poor or fair health among adults aged 40–49 and 50–59 years. Mortality rates among adults also have continued to decline in recent decades (National Center for Health Statistics, 2007). Several lessons have emerged from studying late-life health and functioning trends that are relevant to this new and growing literature focused on adults under age 65 years. First, trends are best assessed over a relatively long time horizon with multiple observations (Freedman et al., 2002); given annual variation, two data points may not necessarily constitute a trend (Crimmins, 1996). Second, different measures may move in different directions (Crimmins, 1996, 2004). For example, despite declines in most measures of late-life disability, reports of many chronic conditions among older adults have increased in recent decades (Crimmins, 2004; Crimmins & Saito, 2000; Freedman & Martin, 2000; Freedman, Martin, Schoeni, & Cornman, 2007). There are many reasons for such divergences, not the least of which is that no single indicator is a pure measure of health. For example, self-reports of chronic diseases may be influenced by access to health care, which in turn is a function of socioeconomic status. Moreover, indicators of functioning reflect the gap between an individual's capacity and the environment in which activities are carried out. Accordingly, breadth of measurement is important before drawing conclusions about the health and functioning of a cohort. Third, care must be taken to ensure that methodological threats to validity—such as low response rates, use of screening questions, changes in question wording, changes in response rates, or omission of important groups such as the institutionalized population—do not bias conclusions (Freedman et al., 2002). In this paper, we heed these lessons and expand on existing studies by assessing trends in mortality and multiple nonclinical indicators of health and functioning (including general health status, health conditions, physical functional limitations, and need for help with daily activities); by using annual data spanning from one to more than two decades, depending on the measure; and by covering the full age range of the Baby Boom. Our goal is to investigate whether the health and functioning of Baby Boomers are better or worse than those of previous cohorts in middle age.

Disability prevalence rates have declined dramatically among older Americans during the past quarter century (Freedman, Martin, and Schoeni 2002; Freedman et al. 2004; Manton, Gu, and Lamb 2006; Waidmann and Liu 2000). If these rates continue to fall, a greater number of older Americans could remain economically and socially active, and fewer would need medical and long-term care (Cutler 2001; Lubitz et al. 2001; Singer and Manton 1998). Despite these implications for policy and society, however, there currently is very little evidence indicating why these declines have occurred (Freedman 2006). The reason may be that disability in late life is affected by a complex set of biological, medical, behavioral, economic, social, and environmental determinants throughout the life course. Determining the reasons for the declines in late-life disability is more than an academic exercise. Because the first baby boomers will turn sixty-five in 2011, it is imperative that we understand the prospects for additional reductions in disability rates. An understanding of past trends can help improve predictions of future changes in disability and can also give policymakers and clinicians an idea of the costs of achieving these reductions and where in the disablement process any interventions might be most effective. Understanding this decline also would enable us to determine the likely effects of competing factors influencing health and disability. For example, although millions of people with specific diseases and conditions have clearly benefited from medical advances, health care tends to account for only a relatively small variation in a population's health (McGinnis, Williams-Russo, and Knickman 2002). Accordingly, economic, social, and environmental factors have long been recognized as major determinants of a population's health (McKeown 1979; McKinlay and McKinlay 1977; Preston 1977). In this article, therefore, we take a broad perspective that integrates medical, behavioral, economic, social, and environmental factors throughout the life course, assessing the extent to which each accounts for the drop in disability rates. Unfortunately, no single available data source covers the breadth of possible explanations. Largely because of this limitation, the decline in disability rates cannot be explained with a single monolithic study design that produces precise results based on a handful of coefficient estimates. Moreover, even when data are available and individual-level factors are identified as likely influences, changes in these factors may themselves be driven by other, more basic causes, such as changes in social and economic policies. Furthermore, our confidence that the estimates represent true causal effects, as opposed to a simple accounting for the trends, varies with the factors considered. We thus address these challenges by piecing together evidence from a variety of sources, some more convincing and some less, some based on original analyses and some drawn from other scientists' work. Before assessing the evidence, we begin by briefly describing the trends in disability that we are trying to explain. We focus on changes at the level of the U.S. population during the last two to three decades, which have been the focus of most of, but not all (Costa 2002), the recent work on old-age disability trends. The facts of these trends are more broadly accepted for this period, and the data available for assessing the causes are richer. We then describe a framework for understanding the diverse factors that may influence disability and hence account for these trends. With this framework as our guide, we consider the empirical evidence that supports or refutes the particular factors. Finally, we synthesize the evidence, dismissing some factors and pointing to others as explaining the remarkable declines in late-life disability.

Objective: To review the occurrence and etiologies of hypocalcemia in septic human and veterinary patients. Data sources: A thorough search was conducted using CAB abstracts and MEDLINE and the keywords hypocalcemia, ionized calcium, sepsis, and procalcitonin (proCT). Human data synthesis: Ionized hypocalcemia (iHCa) is a common finding in septic human patients. The cause is unknown but is likely multifactorial. Low ionized calcium (iCa2+) concentrations coincide with increased severity of illness and increased mortality. Recent studies show that iHCa has a strong correlation with elevated calcitonin precursor concentrations. Veterinary data synthesis: There is a paucity of publications in the veterinary literature pertaining to iHCa in septic animals. Experimental models of sepsis indicate that iHCa exists in animals. iHCa has also been investigated in horses with enterocolitis and endotoxemia. Prospective studies are needed to determine the prevalence of iHCa among septic small animals, and to determine whether iHCa correlates with increased mortality and severity of disease. Indications for the treatment of iHCa in septic small animals also need to be investigated. Conclusions: iHCa is well documented in septic human patients, but little is known about iHCa in septic veterinary patients. Future veterinary studies should focus on documenting the presence of iHCa in septic patients and steps should be taken to determine the cause. proCT concentrations may show promise for predicting sepsis and mortality in critically ill veterinary patients.

Rapid population aging is occurring in many parts of the developing world. Age structures are shifting from a relative concentration of younger to older individuals. Formal and informal health care needs across the developing world are changing concurrently. Therefore, population aging has enormous implications for health and social policy. This essay, which serves as an introduction to a special issue of Journal of Cross-Cultural Gerontology, highlights several critical research topics that require attention due to their implications for the health of individuals living in developing countries that are experiencing population aging. These include: population health levels, trends, and individual health transitions; influences of socioeconomic status on health and the consequences of rapidly changing socioeconomic structures for population health; and comparative studies on health and aging. Comparative research, in particular, has been underdeveloped and underutilized, but has great potential for providing insights into health determinants as well as the uniformity versus variation of the aging experience across societies. The remaining four papers that make up this special issue deal with these research topics and together highlight the complexity that exists in assessing individual and population health trends in developing countries that are undergoing population aging.

In societies in which families are highly integrated, the education of family members may be linked to survival. Such may be the case in Taiwan, where there are large gaps in levels of education across generations and high levels of resource transfers between family members. This study employs 14 years of longitudinal data from Taiwan to examine the combined effects of the education of older adults and their adult children on the mortality outcomes of older adults. We use nested Gompertz hazard models to evaluate the importance of the education of an older adult and his or her highest-educated child after controlling for socioeconomic, demographic, and health characteristics at baseline. To gain further insight, we fit additional models based on the sample stratified by whether older adults report serious diseases at baseline. The results indicate that the educational levels of both older adults and children are associated with older adult mortality, but children’s education appears more important when we examine the mortality of only those older adults who already report a serious disease. This finding suggests that there may be different roles for education in the onset versus the progression of a health problem that may lead to death.

Objective: To evaluate the hypothalamic–pituitary–adrenal (HPA) axis in MDR1-1D (dogs with the MDR1 mutation associated with ivermectin sensitivity) and MDR1 wildtype dogs. Design: Prospective study. Setting: Institutional vivarium. Animals: Seven healthy Collie dogs. Measurements: MDR1 genotyping was used for allocation of dogs to 1 of 2 groups: dogs homozygous for the wildtype MDR1 allele (MDR1 wildtype) and those homozygous for the MDR1-1D mutation (MDR1 mutant). Blood samples were obtained for determination of cortisol and adrenocorticotropin hormone (ACTH) concentrations under basal conditions, before and after ACTH administration, and before and after dexamethasone administration. Main results: Significant differences were identified between the MDR1 mutant and MDR1 wildtype groups. Basal plasma cortisol concentrations and cortisol concentrations after ACTH administration were significantly lower in MDR1 mutant dogs as compared with MDR1 wildtype dogs. Plasma ACTH concentrations after dexamethasone administration were significantly lower in MDR1 mutant dogs as compared with MDR1 wildtype dogs. Conclusions: Results suggest that P-glycoprotein (P-gp) plays a role in regulation of the HPA axis. Furthermore, it appears that the HPA axis in MDR1 mutant dogs that lack P-gp is suppressed compared with MDR1 wildtype dogs. This finding may explain some clinical observations in breeds known to harbor the MDR1 mutation including Collies, Shelties, Australian Shepherds, and others. There is a clinical impression that many of these dogs have worse outcomes in response to stress and, at times, respond poorly to appropriate therapy. HPA axis suppression, secondary to the MDR1 mutation, could result in a relative adrenal insufficiency (RAI) state during times of stress or illness. Further studies are required to determine the relationship between the MDR1 genotype and RAI.

Objective: To present a case of clinical hypocalcemia in a critically ill septic dog. Case summary: A 12-year old, female spayed English sheepdog presented in septic shock 5 days following hemilaminectomy surgery. Streptococcus canis was cultured from the incision site. Seven days after surgery, muscle tremors were noted and a subsequent low serum ionized calcium level was measured and treated. Intensive monitoring, fluid therapy, and antibiotic treatment were continued because of the sepsis and hypocalcemia, but the dog was euthanized 2 weeks after surgery. New or unique information provided: Low serum ionized calcium levels are a common finding in critically ill human patients, especially in cases of sepsis, pancreatitis, and rhabdomyolysis. In veterinary patients, sepsis or streptococcal infections are not commonly thought of as a contributing factor for hypocalcemia. Potential mechanisms of low serum ionized calcium levels in critically ill patients include intracellular accumulation of calcium ions, altered sensitivity and function of the parathyroid gland, alterations in Vitamin D levels or activity, renal loss of calcium, and severe hypomagnesemia. Pro-inflammatory cytokines and calcitonin have also been proposed to contribute to low ionized calcium in the critically ill. Many veterinarians rely on total calcium levels instead of serum ionized calcium levels to assess critical patients and may be missing the development of hypocalcemia. Serum ionized calcium levels are recommended over total calcium levels to evaluate critically ill veterinary patients.

Relationships among socio-demographic characteristics general assessments of health and old-age mortality are well established in developed countries. There is also an increasing focus on the connection between early-life experiences and latelife health. This paper tests these and other associations using representative survey data from Taiwan on the population aged 60 and older in 1989 1993 and 1996 that have been linked to data on deaths between 1989 and 1999 from a national death registry. The study also explores the possible influence of Taiwan’s Universal Health Insurance Program instituted in 1995 and whether or not the survival of some groups of older people may have been differentially enhanced. Mortality is modeled using Gompertz regression. Multiple survey waves are employed to construct time-varying covariates. Some results verify findings of past studies; others are new. Effects of education are attenuated after the introduction of some health indicators. Functional and global assessments of health have stronger associations with mortality than do self-reports of health behaviors or particular chronic conditions such as diabetes. Mainlanders have higher survival than others. The survival of older adults with the greatest number and severity of functional limitations improved over the 1990s suggesting a possible beneficial influence of the insurance program. (authors)

Objective: To review the effects of critical illness on hypothalamic–pituitary–adrenal (HPA) function in human and veterinary medicine. Data sources: Data from human and veterinary literature was reviewed. Human data synthesis: Relative adrenal insufficiency (RAI) appears to be common in critically ill human patients with sepsis or septic shock. Hypotension that is refractory to fluid therapy and requires vasopressors is the most common presentation of RAI in the human intensive care unit (ICU). Many investigators now advocate the use of a low-dose adrenocorticotropin hormone stimulation test to diagnose RAI. It is important to evaluate for the presence of adrenal dysfunction, because current data suggest that treatment with ‘stress’ or low doses of glucocorticoids (200–300 mg hydrocortisone daily) may improve patient outcome in humans. Veterinary data synthesis: There is a paucity of controlled studies in the veterinary literature regarding the effects of critical illness on HPA function. The results of these studies are varied. However, research models of sepsis and hemorrhagic shock suggest the existence of RAI in animals. Prospective clinical studies are needed to further examine pituitary–adrenal response to severe illness in veterinary patients, and to determine if there are therapeutic options, including glucocorticoid administration, which will improve patient outcome in animals. Conclusions: RAI is well documented in critically ill human patients, yet little is known about adrenal dysfunction in veterinary critically ill patients. A small number of studies suggest that RAI may exist in certain subpopulations of veterinary patients. The syndrome of RAI could be considered as a differential diagnosis in seriously ill veterinary patients that fail to respond to appropriate therapy, especially when hypotension refractory to fluid and vasopressor therapy is encountered. This disorder may represent a previously unidentified syndrome in critically ill veterinary patients with important therapeutic implications.

Background The medication appropriateness index (MAI) has demonstrated reliability in selected outpatient clinics where medical data were easily accessible from medical charts. However, its use in the community setting where patient data may be limited has not been examined. Objective To evaluate the usefulness of a modified MAI for use in the community pharmacy setting by testing interrater reliability using 3 different rating schemes. Methods Two raters evaluated 160 medications for 32 elderly ambulatory patients. Patient information was acquired using community pharmacist-collected medication histories. A summated MAI score, percent agreement, κ, positive agreement, negative agreement, and intraclass correlation coefficient were calculated for each criterion using 3 scoring schemes. A paired samples t-test (95% CI) was used to test interrater reliability. Results The κ statistics were >0.75 for indication and effectiveness, but good (0.41–0.66) for the remaining criteria using the Hanlon scoring scheme. The intraclass coefficients (0.82, 0.86, 0.87) and overall κ (0.65, 0.66, 0.61) were similar for the 3 schemes. Conclusions This study suggests that the modified MAI has the potential to detect medication appropriateness and inappropriateness in the community pharmacy setting; however, it is not without limitations. Because the MAI has the most clinimetric and psychometric data available, the instrument should be studied further to increase its reliability and generalizability.

Background Iatrogenic hypothyroidism (IH) after treatment of hyperthyroidism can impair renal function. No study compared the efficacy of measurement of serum free thyroxine by equilibrium dialysis (fT4ed) or thyroid-stimulating hormone (TSH) concentrations for monitoring cats receiving methimazole. Objectives To (1) compare the ability of total T4 and fT4ed concentrations in conjunction with TSH to define thyroid function in hyperthyroid cats receiving methimazole, (2) determine the prevalence of IH in cats receiving methimazole, and (3) examine the relationship between thyroid axis hormones and serum creatinine concentration. Animals One hundred and twenty-five serum samples from hyperthyroid cats receiving methimazole and total T4 concentrations ≤3.9 μg/dL. Methods Total T4, fT4ed, and TSH concentrations were measured to evaluate thyroid status and serum creatinine concentration was measured to assess renal function. A low total T4 or fT4ed concentration in combination with an increased TSH concentration defined IH. Results Forty-one cats (33%) had increased TSH concentrations. Of cats with total T4 and fT4ed concentrations below the reference range, 68% and 73%, respectively, had TSH concentrations above the reference range. Only 18% of cats with a normal TSH concentration had an increased serum creatinine concentrations as compared to 39% of those with increased TSH concentrations (P

Populations in South Asia, although less aged than other populations of Asia and the West, are aging rapidly. This paper presents demographic, social, and economic characteristics of the elderly in Bangladesh, India, Nepal, Pakistan, and Sri Lanka, and reviews evidence on whether or not the family situation and status of the elderly have changed in recent decades. There is not strong evidence that the status of the elderly has declined nor that it was uniformly high in the past, but there is indication that economic power has long been an important determinant of status. The paper concludes with a discussion of how future elderly may be different from today's, the limits on developing programs for the elderly in countries at relatively low levels of economic development, and the need for additional research on the elderly of South Asia.

Objectives. This study explored whether improvements in cognitive functioning occurred during the 1990s among older Americans and investigated several possible explanations for such changes. Methods. Using the 1993 Asset and Health Dynamics of the Oldest Old study ( N 5 7,443) and 1998 Health and Retirement Survey ( N 5 7,624), this study examined aggregate changes in the proportion of the noninstitutionalized population aged 70 and older with severe cognitive impairment. Impairment was measured for self-respondents using a modified version of the Telephone Interview Cognitive Screen; for proxy respondents, ratings of memory and judgment were used. Logistic regression was used to investigate potential explanations for aggregate changes. Results. The percentage of older Americans with severe cognitive impairment declined from 6.1% in 1993 to 3.6% in 1998 ( p , .001). The decline was statistically significant among self-respondents but not among those with proxy interviews. Improvements between 1993 and 1998 were not explained by shifts in demographic and socioeconomic factors or by changes in the prevalence of stroke, vision, or hearing impairments. Discussion. As a group, older persons, especially those well into their 80s, appear to have better cognitive functioning today than they did in the early 1990s.

Using the Survey of Income and Program Participation, we document the importance of education in accounting for declines in functional limitations among older Americans from 1984 to 1993. Of the eight demographic and socioeconomic variables considered, education is most important in accounting for recent trends. The relationship between educational attainment and functioning has not changed measurably, but educational attainment has increased greatly during this period. Our analysis suggests, all else being equal, that future changes in education will continue to contribute to improvements in functioning, although at a reduced rate.

Hypercalcemia and hypermagnesemia occur infrequently in small animal patients. Specific clinical signs usually do not accompany these electrolyte disorders, and their presence is often recognized only after reviewing serum chemistry profile results. The etiologies, clinical signs, and therapies for each electrolyte disorder are discussed in this article. Treatment of these disorders is aimed at correcting the underlying disease process and enhancing the removal of calcium or magnesium from the body. In severe cases, rescue therapies and resuscitative measures are required to stabilize the patient.