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Vitamin D Deficiency as a Risk Factor for Pain: Prevalence in the Setting of Advanced Malignancy (413-C)
Vol. 43 No. 2 February 2012
Schedule With Abstracts
Adrenal Insufficiency as a Possible Contributor to Pain in Adults With Sickle Cell Disease (SCD) (413-B) Lawrence Solomon, MD, Yale University School of Medicine, New Haven, CT. (Solomon has disclosed no relevant financial relationships.) Objectives 1. Recognize the relationship between adrenal insufficiency and pain. 2. Discuss the frequency of adrenal insufficiency in adult sickle cell patients at baseline and during painful vaso-occlusive crises. Background. Inflammation may play a major role in pain due to vaso-occlusive crises (VOC) in SCD patients and brief courses of high dose steroid therapy are beneficial in this setting. Less well understood are chronic pain syndromes experienced by many SCD patients. Significantly, adrenal insufficiency may cause both musculoskeletal pain and increased pain sensitivity. Research objective. To determine the incidence of adrenal insufficiency in SCD. Method. A retrospective review was performed of SCD patients seen during a 4-year period. Adrenal insufficiency was defined as either a random serum cortisol value < 7 mcg/dl or a urine free cortisol < 4 mcg/24 hours. Result. Serum cortisol values were obtained on 61 occasions in 37 patients and one patient had a 24 hr urine cortisol determination. Adrenal insufficiency was present on 41 occasions overall (66%) including 28 events during 40 hospitalizations for VOC (70%) and 6 events during 22 outpatient visits (27%). Low serum cortisol values were present on at least 1 occasion in 24 of the 38 individuals (63%). When only morning cortisol values were considered (4 am-8 am), values were low in 13 of 20 determinations (65%) and were actually # 3 mcg/dl on 8 occasions (40%). Cosyntropin stimulation tests were performed in 16 patients with adrenal insufficiency and increases at 1 hr to $ 18 mcg/dl occurred on 10 occasions (63%). Increased eosinophil counts (> 500/mm3) were present during 18 of 27 events when cortisol values were low (65%) but on only 6 of 20 occasions when cortisol values were normal (30%; x2 ¼ 6.1815; p < .02).
379
Conclusion. Adrenal insufficiency is common in adult SCD patients, functionally significant and usually, but not always, due to impaired hypothalamic-pituitary function. Implications for research, policy, or practice. Further studies are needed to determine the clinical role of hypocortisolism in both VOC and in the chronic pain syndromes often seen in adult SCD patients.
Vitamin D Deficiency as a Risk Factor for Pain: Prevalence in the Setting of Advanced Malignancy (413-C) Lawrence Solomon, MD, Yale University School of Medicine, New Haven, CT. Leslie Blatt, MBA MSN APRN, Yale New Haven Hospital, New Haven, CT. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the relationship between vitamin D deficiency and pain. 2. Recognize the frequency of vitamin D deficiency in patients with advanced malignancy. Background. Vitamin D deficiency has been associated with musculoskeletal pain and an increased risk of osteonecrosis during bisphosphonate therapy, but information on vitamin D deficiency in cancer patients is limited. Research objective. To determine the prevalence of vitamin D deficiency in patients with pain and advanced malignancy. Method. A retrospective review of 25-hydroxy vitamin D levels in subjects with advanced malignancy seen for pain management during a 4-year period. Deficiency was defined as severe (# 10 ng/ml); moderate (11-20 ng/ml); possible (21-30 ng/ml); or absent (> 30 ng/ml). Result. Vitamin D values were obtained in 260 patients including 96 patients with bone metastases identified on imaging studies (37%). Deficiency was identified as severe in 55 subjects (21%), moderate in 113 subjects (43%), possible in 52 subjects (20%), and absent in only 21 subjects (8%). Subjects with known bone metastases also had a 64% incidence of moderate-to-severe vitamin D deficiency and only 6% of these subjects had adequate vitamin D levels. PTH values, obtained in 23 patients with normal or low creatinine and calcium values, were increased (> 25
380
Schedule With Abstracts
pg/ml) in 11 of 16 patients with moderate-severe deficiency (69%); 4 of 6 patients with possible deficiency (67%); and in the only subject with a normal vitamin D level studied. Conclusion. The vast majority of patients with advanced malignancy have evidence of functional vitamin D deficiency which is often severe even in subjects with bone metastases who are likely to be on calcium supplements. Moreover, even a normal vitamin D level may be associated with an increased PTH value. Implications for research, policy, or practice. Studies are needed in patients with advanced malignancies to (a) define optimum vitamin D levels and the doses of vitamin D supplements needed to achieve these levels and (b) determine the role of vitamin D therapy in improving pain management and decreasing the incidence of bisphosphonate-induced osteonecrosis.
Decisional Aides to Train Non-psychiatrists in Evidence-Based Use of Antipsychotics for Dementia (414-A) Michelle Weckmann, MD, University of Iowa, Iowa City, IA. Ryan Carnahan, PharmD MS BCPP, University of Iowa College of Public Health, Iowa City, IA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. List three appropriate targets for antipsychotic use in patients with dementia. 2. Discuss how to use and access the clinical decision aides and education materials to assist with prescribing antipsychotics to patients with dementia. Background. Behavioral disturbances in dementia pose significant challenges to healthcare providers and family caregivers and can be especially troubling as a person nears the end of life. Atypical antipsychotics have been the mainstay of treatment for a number of years. However, recent evidence has shown that they may have limited effectiveness, increase the risk of mortality, and increase the risk of cerebrovascular events among users with dementia. Despite these warnings, antipsychotic use remains common. Training providers to understand other aspects of care that impact behavioral disturbances, as well as appropriate antipsychotic
Vol. 43 No. 2 February 2012
selection and use, may improve antipsychotic utilization patterns and, as a result, the safety and quality of life of people with dementia. Research objective. Develop innovative ways of reaching out to clinicians who may lack access to local expert consultation with geriatric psychiatrists, psychopharmacologists, or other specialists. Method. We formed a collaboration between the University of Iowa Older Adults Center for Education and Research on Therapeutics, the Iowa Geriatric Education Center, the Iowa Foundation for Medical Care, and Iowa Health Systems to adapt and disseminate the AHRQ comparative effectiveness research review and summary guide within a comprehensive program to guide providers in the care of patients with dementia and behavioral disturbances. Result. We designed and modified numerous adaption products, including a series of casebased presentations targeted towards clinicians and direct care providers (electronic formats); decisional aides to guide providers in caring for patients with dementia and behavioral disturbances (print, web, and personal digital assistant formats); and products for patient families including a guide to facilitate shared decision. Conclusion. We believe these adaption products are a useful way to educate primary care providers and nursing home staff on evidence based antipsychotic use for behavioral control in dementia. Implications for research, policy, or practice. Our purpose is to inform and share the developed adaption products to improve the care of patients with dementia.
How Elderly Patients and Nephrologists Discuss the Trajectory of Kidney Disease (414-B) Jane Schell, MD, Duke University, Durham, NC. Karen Steinhauser, PhD, Duke University/ Durham VA Medical Center, Durham, NC. James Tulsky, MD, Duke University/Durham VA Medical Center, Durham, NC. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the growth of an aging nephrology population.
Schedule With Abstracts
Adrenal Insufficiency as a Possible Contributor to Pain in Adults With Sickle Cell Disease (SCD) (413-B) Lawrence Solomon, MD, Yale University School of Medicine, New Haven, CT. (Solomon has disclosed no relevant financial relationships.) Objectives 1. Recognize the relationship between adrenal insufficiency and pain. 2. Discuss the frequency of adrenal insufficiency in adult sickle cell patients at baseline and during painful vaso-occlusive crises. Background. Inflammation may play a major role in pain due to vaso-occlusive crises (VOC) in SCD patients and brief courses of high dose steroid therapy are beneficial in this setting. Less well understood are chronic pain syndromes experienced by many SCD patients. Significantly, adrenal insufficiency may cause both musculoskeletal pain and increased pain sensitivity. Research objective. To determine the incidence of adrenal insufficiency in SCD. Method. A retrospective review was performed of SCD patients seen during a 4-year period. Adrenal insufficiency was defined as either a random serum cortisol value < 7 mcg/dl or a urine free cortisol < 4 mcg/24 hours. Result. Serum cortisol values were obtained on 61 occasions in 37 patients and one patient had a 24 hr urine cortisol determination. Adrenal insufficiency was present on 41 occasions overall (66%) including 28 events during 40 hospitalizations for VOC (70%) and 6 events during 22 outpatient visits (27%). Low serum cortisol values were present on at least 1 occasion in 24 of the 38 individuals (63%). When only morning cortisol values were considered (4 am-8 am), values were low in 13 of 20 determinations (65%) and were actually # 3 mcg/dl on 8 occasions (40%). Cosyntropin stimulation tests were performed in 16 patients with adrenal insufficiency and increases at 1 hr to $ 18 mcg/dl occurred on 10 occasions (63%). Increased eosinophil counts (> 500/mm3) were present during 18 of 27 events when cortisol values were low (65%) but on only 6 of 20 occasions when cortisol values were normal (30%; x2 ¼ 6.1815; p < .02).
379
Conclusion. Adrenal insufficiency is common in adult SCD patients, functionally significant and usually, but not always, due to impaired hypothalamic-pituitary function. Implications for research, policy, or practice. Further studies are needed to determine the clinical role of hypocortisolism in both VOC and in the chronic pain syndromes often seen in adult SCD patients.
Vitamin D Deficiency as a Risk Factor for Pain: Prevalence in the Setting of Advanced Malignancy (413-C) Lawrence Solomon, MD, Yale University School of Medicine, New Haven, CT. Leslie Blatt, MBA MSN APRN, Yale New Haven Hospital, New Haven, CT. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the relationship between vitamin D deficiency and pain. 2. Recognize the frequency of vitamin D deficiency in patients with advanced malignancy. Background. Vitamin D deficiency has been associated with musculoskeletal pain and an increased risk of osteonecrosis during bisphosphonate therapy, but information on vitamin D deficiency in cancer patients is limited. Research objective. To determine the prevalence of vitamin D deficiency in patients with pain and advanced malignancy. Method. A retrospective review of 25-hydroxy vitamin D levels in subjects with advanced malignancy seen for pain management during a 4-year period. Deficiency was defined as severe (# 10 ng/ml); moderate (11-20 ng/ml); possible (21-30 ng/ml); or absent (> 30 ng/ml). Result. Vitamin D values were obtained in 260 patients including 96 patients with bone metastases identified on imaging studies (37%). Deficiency was identified as severe in 55 subjects (21%), moderate in 113 subjects (43%), possible in 52 subjects (20%), and absent in only 21 subjects (8%). Subjects with known bone metastases also had a 64% incidence of moderate-to-severe vitamin D deficiency and only 6% of these subjects had adequate vitamin D levels. PTH values, obtained in 23 patients with normal or low creatinine and calcium values, were increased (> 25
380
Schedule With Abstracts
pg/ml) in 11 of 16 patients with moderate-severe deficiency (69%); 4 of 6 patients with possible deficiency (67%); and in the only subject with a normal vitamin D level studied. Conclusion. The vast majority of patients with advanced malignancy have evidence of functional vitamin D deficiency which is often severe even in subjects with bone metastases who are likely to be on calcium supplements. Moreover, even a normal vitamin D level may be associated with an increased PTH value. Implications for research, policy, or practice. Studies are needed in patients with advanced malignancies to (a) define optimum vitamin D levels and the doses of vitamin D supplements needed to achieve these levels and (b) determine the role of vitamin D therapy in improving pain management and decreasing the incidence of bisphosphonate-induced osteonecrosis.
Decisional Aides to Train Non-psychiatrists in Evidence-Based Use of Antipsychotics for Dementia (414-A) Michelle Weckmann, MD, University of Iowa, Iowa City, IA. Ryan Carnahan, PharmD MS BCPP, University of Iowa College of Public Health, Iowa City, IA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. List three appropriate targets for antipsychotic use in patients with dementia. 2. Discuss how to use and access the clinical decision aides and education materials to assist with prescribing antipsychotics to patients with dementia. Background. Behavioral disturbances in dementia pose significant challenges to healthcare providers and family caregivers and can be especially troubling as a person nears the end of life. Atypical antipsychotics have been the mainstay of treatment for a number of years. However, recent evidence has shown that they may have limited effectiveness, increase the risk of mortality, and increase the risk of cerebrovascular events among users with dementia. Despite these warnings, antipsychotic use remains common. Training providers to understand other aspects of care that impact behavioral disturbances, as well as appropriate antipsychotic
Vol. 43 No. 2 February 2012
selection and use, may improve antipsychotic utilization patterns and, as a result, the safety and quality of life of people with dementia. Research objective. Develop innovative ways of reaching out to clinicians who may lack access to local expert consultation with geriatric psychiatrists, psychopharmacologists, or other specialists. Method. We formed a collaboration between the University of Iowa Older Adults Center for Education and Research on Therapeutics, the Iowa Geriatric Education Center, the Iowa Foundation for Medical Care, and Iowa Health Systems to adapt and disseminate the AHRQ comparative effectiveness research review and summary guide within a comprehensive program to guide providers in the care of patients with dementia and behavioral disturbances. Result. We designed and modified numerous adaption products, including a series of casebased presentations targeted towards clinicians and direct care providers (electronic formats); decisional aides to guide providers in caring for patients with dementia and behavioral disturbances (print, web, and personal digital assistant formats); and products for patient families including a guide to facilitate shared decision. Conclusion. We believe these adaption products are a useful way to educate primary care providers and nursing home staff on evidence based antipsychotic use for behavioral control in dementia. Implications for research, policy, or practice. Our purpose is to inform and share the developed adaption products to improve the care of patients with dementia.
How Elderly Patients and Nephrologists Discuss the Trajectory of Kidney Disease (414-B) Jane Schell, MD, Duke University, Durham, NC. Karen Steinhauser, PhD, Duke University/ Durham VA Medical Center, Durham, NC. James Tulsky, MD, Duke University/Durham VA Medical Center, Durham, NC. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the growth of an aging nephrology population.