Here - American Geriatrics Society

P OSTER
A BSTRACTS
have inherent procoagulant effect by itself. Prior to this admission,
our patient’s blood findings were only mildly abnormal. When he was
stable and on treatment for the DVT/PE, his blood findings reverted
to their previous levels. We believe this case demonstrates that even
mild elevations of blood elements should be investigated to rule out a
myeloproliferative syndrome in the context of thrombosis, and further
molecular testing might be warranted in some patients whose
blood counts are mildly, but consistently abnormal. Myeloproliferative
disorders, especially those that are JAK2 positive, should be considered
in the differential diagnosis of acquired hypercoagulation
syndromes.
A143
JAK2 positive Polycythemia Vera in a patient with sleep apnea.
Competing causes for erythrocytosis.
R. Lands, S. Y. Bae. Department of Medicine, University of Tennessee,
Knoxville, TN.
In the course of having blood work in her health maintenance, a
75-year-old woman was found to have an elevated hemoglobin. She
was not hypertensive, but had been treated for hyperlipidemia for
several years. She had a left body stroke about a year prior to the
clinic visit from which there was no residual and for which she was
taking aspirin. She had never smoked cigarettes. She complained of
fatigue and daytime sleepiness. Her husband noted that she snored,
but he had not observed apnea. She did not complain of restless legs.
Oxygen saturation was 98% on room air. The tongue was of normal
size. There was no abdominal organomegaly.
CBC demonstrated a hemoglobin of 17mg/dL and hematocrit of
50%. The white blood cell count and platelet counts were normal although
the platelets were quite large. The bone marrow demonstrated
panhyperplasia. Megakaryocytes were increased with prominent
pleomorphism. There was no increase in reticulin. JAK-2 V617F
was found to be present in a population of cells tested. BCR/ABL
was absent. Erythropoietin was 31mIU/ML (4.2-27.8), and the CT abdomen
demonstrated an enlarged spleen. She was placed on hydroxyurea
and one phlebotomy was performed.
In the interim, she reluctantly accepted a referral to a sleep specialist.
Sleep studies demonstrated mild to moderate sleep apnea. She
was prescribed C-PAP and quickly noted a remarkable improvement
in her fatigue and in her daytime somnolence. Furthermore, her hemoglobin
dropped into the low normal range, more than expected
from just one phlebotomy. The hydroxyurea and the phlebotomies
were discontinued. She has been compliant with her C-PAP has not
required resumption of hydroxyurea or phlebotomy in one year.
Discussion: With a hemoglobin greater than 16.5mg/dL and the
presence of JAK2, the patient met WHO diagnostic criteria for Polycythemia
Vera. The history of cerebrovascular accident and
splenomegaly further support a diagnosis of the myeloproliferative
syndrome. The inappropriately high normal erythropoietin level together
with the rapid improvement in her hemoglobin after treatment
for sleep apnea suggest that the predominate cause of her erythrocytosis
at the time of diagnosis was due to her sleep apnea. Myeloproliferative
syndromes may be quite subtle in their presentation and may
accompany other diseases that mask and delay their diagnosis.
A144
Calcium Supplement May be Associated with Optimal Responses to
Vitamin D Supplementation in Adults.
V. Heh, 1 C. Forman, 2 J. Gau. 2 1. Office of Research and Grants, Ohio
University Heritage College of Osteopathic Medicine, Athens, OH; 2.
Geriatric Medicine, OU-HCOM, Athens, OH.
Background: Deficiency of vitamin D is a common problem in
adult patients. There are efforts in aggressively treating these patients
as benefits have been shown in reducing the risk of falls and fractures.
Clinical observation suggests that some patients receiving a high-dose
supplement may not have achieved an optimal serum 25-hydroxy
(OH) vitamin D levels with months of therapy. The objective of this
study is to characterize factors that may be associated with patients’
responses to vitamin D supplementation. This characterization is
based on the existence of possible unobserved groups, also called latent
classes.
Methods: Medical records of a geriatric clinic population who
had baseline and follow-up serum 25(OH)D levels during the period
of January 2007 and June 2011 were reviewed. All patients received
vitamin D supplements to achieve levels above 30 ng/mL. Forty-one
adults receiving an average daily dose more than 3,300 IU per day.
These patients were sub-divided into two groups reflecting ideal (i.e.,
> 40 ng/mL; N=24) and suboptimal levels (N=17) of serum 25(OH)D
on the follow-up measurements.A cut-off value of 40 ng/mL was used.
Results: The two groups, ideal respondents and suboptimal respondents
to high dose regimens, were similar in age, gender, weight,
BMI measures, baseline 25(OH)D and serum calcium levels, average
daily dose (5,500 [1,800] vs. 5,100 [1,200] IU; p=0.44), and duration of
therapy (11.9 [7.3] vs. 8.6 [5.3] months; p=0.11). However, those patients
who had ideal levels of follow-up 25(OH)D had significantly
higher baseline serum albumin levels (mean =4.1 gm/dL, SD=0.4 vs.
mean =3.7 gm/dL, SD=0.4, p=0.026); were about 6 times more likely
to be on calcium supplements (12 [50%] vs. 2 [12%], p=0.018, Fisher’s
exact test). The suboptimal respondents were about 3 times more
likely to use oral laxatives; 9(64%) vs. 5(21%), p=0.048. After adjusting
for height, weight, and use of oral laxatives, calcium supplement
was associated with a better response to high dose supplementation.
Limitations of this study: small sample size, unknown compliance
with supplements, and not a controlled clinical trial study.
CONCLUSIONS: Calcium supplement may be associated with
patients’ responses to vitamin D regimens. Nutrition status and better
study design will need to be included in the future study.
A145 Encore Presentation
Nontuberculous mycobacterial infections in elderly patients with
rheumatological diseases.
V. Nagaraja, 1 J. Terriquez, 2 J. Lisse, 3 S. Hoover. 2 1. Arizona Center on
Aging, University of Arizona, Tucson, AZ; 2. Infectious Diseases,
University of Arizona, Tucson, AZ; 3. Rheumatology, University of
Arizona, Tucson, AZ.
Background: Non-tuberculous mycobacterial (NTM) infections
are frequently identified in elderly patients with rheumatologic disease.
Management of these infections can be challenging. The aim of
this study was to describe the management and outcomes of cases of
NTM infections in patients with any form of rheumatologic disease.
Methods: A retrospective chart review of inpatient and outpatient
records was performed at two health-care facilities. ICD-9 diagnostic
codes were used to identify patients with NTM infection. Patients
with any pre-existent rheumatologic disease were included in
the study. The review focused on rheumatologic disease, its treatment,
other co-morbidities, the NTM infection and its treatment, and impact
of the infection on the rheumatologic disease management.
Results: Of 339 patients with NTM infection, 11 with rheumatologic
disease were identified. Ten were females. The median age at the
time of diagnosis of the infection was 67 years. Eight cases were pulmonary
and 3 were extrapulmonary. 5/11 patients had radiologically
pre-existent bronchiectasis. There were patients with rheumatoid
arthritis(5), systemic lupus erythematosus(2), polymyalgia rheumatic(1),
scleroderma(1), polymyositis(1) and sarcoidosis(1). Patients
were on one of the following medications for a significant period of
time: prednisone, methotrexate, and anti-tumor necrosis factor (TNF)
agents. In 4/9 cases who were on immunosuppressive therapy, the implicated
medication was discontinued. In 3/9 it was continued, and in
2/9 it was restarted after a brief discontinuation. Mycobacterium
avium complex was the commonest species isolated. Treatment for
AGS 2012 ANNUAL MEETING
S65