ABSTRACTS

CLINICAL MEDICINEA case of Calcium Pyrophosphate Dihydrate (CPPD) deposition diseasepresented with acute migratory arthritis

Presenting Author(s): Ashkan Javaheri, MD, Eastern Virginia Medical SchoolAuthor(s): Ashkan Javaheri, MD; and Thomas R. Grant, MD

Introduction/Objective: The deposition of calcium pyrophosphate dehydrate(CPPD) crystals in articular tissues is common in elderly, affecting 10 to 15%of people 65 to 75 years old and 30 to 60% of those more than 85 years old.These deposits may be asymptomatic or associated with acute attacks of monoor oligoarthritis (pseudogout) or chronic arthropathy. The various clinicalpatterns of CPPD in elderly with multiple coexisting degenerative bonediseases make the diagnosis challenging. We report a case of CPPD present-ing with migratory arthritis and radiculopathy.Design/Methodology: Case Report.Results: 69 year old female, with diabetes type 2, hyperlipidemia, asthma,HTN, and anemia presented with severe pain at right posterior shoulder andlateral chest with some shortness of breath and wheezing. She was worked upfor cardiac causes of pain and treated for asthma exacerbation and dischargedhome. Three weeks later she came back with fever, leukocytosis, elevatedESR and right hip pain radiating to the lateral leg. Imaging of right hip andlumbosacral showed small joint effusion, sclerotic bone lesion in right femurand iliac bones, and L4-L5 spondylolisthesis. Patient’s symptoms improvedsignificantly on NSAIDs and LS corset. Three days later, she presented to theER with painful, inflamed left knee. ANA and RF were both negative. Kneex-ray showed degenerative changes with chondrocalcinosis. Arthrocentesisrevealed CPPD crystals and 38,000/cu mm WBC. The patient responded tooral colchicine, NSAIDs, and short-term systemic corticosteroid.Conclusion/Discussion: The prevalence of CPPD disease increases with age.It can present as asymptomatic disease, pseudogout, pseudo-rheumatoid ar-thritis, pseudo-osteoarthritis, or pseudo-neuropathic joint disease. Most casesin elderly are idiopathic. Familial or metabolic causes are seen in youngerpatients. Pseudogout is the third most frequent cause of acute arthritis inelderly. Knee is most commonly involved, followed by shoulder, wrist, andankle. Precipitating factors are advanced age, trauma, hyperparathyroidism,surgery, diabetes, gout, or osteoarthritis. Arthrocentesis with presence ofpositive bifringent intracellular CPPD crystals in synovial fluid establishes thediagnosis with or without chondrocalcinosis on X-ray. Other inflammatoryarthritis including RA, gout, and septic arthritis should also be considered.NSAIDs, colchicine, and intra-articular or systemic corticosteroids are themainstays of treatment. This case is an example of an unusual presentation ofpseudogout with migratory arthritis. Acute shoulder and hip involvementwere more likely due to pseudogout. CPPD deposition of longitudinal liga-ment of lower spine can cause radiculopathy and there are several case reportsof spondylolisthesis with pseudogout in the literature. In elders with under-lying articular disorders, diagnosis of pseudogout is challenging. Recognitionof this inflammatory process is important and proper medical managementgreatly improves function and quality of life in elders.Disclosures: All authors have stated that there are no disclosures to be madethat are pertinent to this abstract.

A quality improvement project to reduce falls and injuries in a NursingHome (NH) in Singapore

Presenting Author(s): David H. Yong, MBBS, Changi General HospitalAuthor(s): David H. Yong, MBBS; Monica Rajis, RN; and Lina Ma

Introduction/Objective: Falls in NH are serious events and are audited. Aprevious audit in this NH in 2003/04 had recorded significant rates of fallsand injuries. This was a quality improvement project to try and reduce theseevents.Design/Methodology: Medical and nursing leadership backed by adminis-trative support, staff enthusiasm instilled through teamwork and usingestablished multipronged strategies. These strategies included a fall team

with ‘fall champions’; staff education; provision of resources on falls;design of a fall reporting form and an evaluation and managementguideline; exercises; hip protectors; fall screening; environmental modi-fications; identification of fall risk and recurrent fallers; postfall wardaudit; prescribing calcium and alendronate.Results:

2003/04(pre)

2005/06(post)

%change

no. of falls 60 62 �3.3Fall rate (fall per bed year) 0.3 0.35 �16.7% falls sent out to A&E 29 18.3 �33.3% of falls with injuries 67.7 45.9 �33.3% of falls with fractures 8 5 �37.5no. of hip fractures 4 2 �50

Conclusion/Discussion: A multicomponent program in this NH did notreduce falls but is effective in reducing injuries (by up to a third ) and hipfractures( by half). However it is not clear which intervention(s) or combi-nations work best or are most cost-effective.Disclosures: All authors have stated that there are no disclosures to be madethat are pertinent to this abstract.

An evaluation of the process of erythropoietic stimulating agent use inthe anemia of chronic kidney disease in LTC

Presenting Author(s): Mario Cornacchione, DO, CMD, UMDNJ-SOMAuthor(s): Mario Cornacchione, DO, CMD; Domminick Trombetta, PharmD;Maria Humphrey, PharmD Student; and Michael Silla, PharmD Student

Introduction/Objective: To determine whether prescriber evaluation, treat-ment and laboratory follow-up of residents with anemia of CKD followed themanufacturer guidelines for the administration of the erythropoietic(EPS)agents. In addition the involvement of the consultant pharmacist in theprocess was evaluated.Design/Methodology: Retrospective cohort study of 1000 residents in 6 LTCfacilities. Inclusion Criteria: CKD(abbreviated MDRD � 60 ml/min/m2),erythropoietic agent therapy for at least four months from July 05-06. Exclu-sion Criteria: Residents on EPS agents for �four months, for causes otherthan CKD, treated from period other than July 05-06. 19 residents metinclusion criteria and had complete data analysis. Partial data was analyzedfrom five residents who were on an EPS agent for �four months but met allother inclusion criteria. The data from these residents was separated from thecomplete data of residents meeting all of the inclusion criteria. Primary areasanalyzed: initial dosage appropriate, dosage adjusted appropriately based onresident response, and/or following therapy holds, Hgb within 2.5% of targetrange (10.725–12.3 g/dl), Hgb within 5% of target range (10.45-12.6 g/dl),Hgb drawn at manufacturer recommended intervals(MRI) upon initiation,Hgb drawn at MRI once in target range, target Hgb stated by prescriber orpharmacist, iron supplementation and iron studies, pharmacist dosage andlaboratory recommendations (Hgb and/or iron), and physician response torecommendation.Results: Of the 1,000 residents,41(4.1%) were on an EPS agent. Duringmaintenance phase of therapy dosage was adjusted appropriately according tothe package insert in 7/19 (37%)residents. Hgb was within 2.5% of the targetrange in 5/18 residents (28%) and within 5% in 6/18 residents (33%). In15/19 residents(79%), iron supplementation, and 9/19(47%) iron studieswere performed at some point during EPS agent therapy. However ironstudies were performed at recommended intervals in only 2/19 resi-dents(11%). Pharmacist recommendations for dosage and laboratory find-ings occurred in 7/19 residents(37%) with a prescriber response in 9/11residents(82%).Conclusion/Discussion: There appear to be significant process issues sur-rounding the use of EPS agents in the LTC setting. A significant percentage

POSTER ABSTRACTS B3