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This case brings MALA to attention, underlining the need

for thoughtful metformin use and details the seriousness of MALA in a

very elderly patient, focusing on the need of high clinical suspicion to

improve outcomes.


Cancer: one of the most prevalent diseases in geriatric population

M. Semedo


, R. Mendes


, E. Cunha




Hospital de São João, Porto,



Departamento de Medicina Molecular, Universidade de

Santiago de Compostela, Santiago de Compostela, Spain


Heavy metals and cancer are a subject widely spoken

and studied given to their level of exposure by the entire population,

mainly people of an advanced age. Despite being awell-known theme,

we still do not know the mechanisms related to cancer presence

and contact with heavy metals. For this reason, we investigated the

possibility of the presence of heavy metals in samples from renal

carcinoma tissue and renal adjacent tissue, in patients that do radical

or partial nephrectomy. This study was approved by the local ethics

committee of Centro Hospitalar de S. João, E.P.E. and patient consent

was obtained from all participants.


The collected samples were processed and observed by

using Scanning ElectronMicroscopy coupledwith X-RayMicroanalysis

(SEM-XRM), with the aim of comparing qualitatively and semi-

quantitatively the existence of heavy metals.


The results obtained in this study showed there was a

significant difference between the amount of heavy metals present in

samples of tumor tissue and adjacent tissue, used as a control. The

tumor tissue was found to have a sequestering of some types of metal,

contrary to what happened with control tissue.


With these results, we can suggest that heavy metals

play a role in the oncogenic pathway of renal cell carcinoma. It is

necessary to question if the presence of heavy metals in tumor tissue is

a cause or a consequence of carcinogenesis phenomenon or if these

metals can be used as biomarkers with a diagnosis or prognosis

interest for geriatric population.


Use of central nervous system active medications in patients with


s disease or Parkinsonism

J. Barnes


, A. Michael




Neurology Specialist Pharmacist, Dudley CCG,

NHS, Dudley,


Consultant Geriatrician, Russells Hall Hospital, Dudley, UK


Patients with Parkinson

s disease (PD) are frequently

prescribed CNS active drugs, many of which have side effects and

wide spectrum of drug interactions. Antimuscarinics can lead to

confusion. Tricyclic and related antidepressants have varying degrees

of antimuscarinic side effects and cardiotoxicity. There is increased

CNS toxicity when SSRIs or Tricyclic Antidepressants are given

concomitantly with Selegiline or Rasagiline. There is risk of extrapyr-

amidal side effects when antipsychotics are given with amantadine.

Opioids can cause Confusion, hallucinations and muscle rigidity. And

Antipsychotics antagonize the effect of PD dopaminergic drugs. Most

CNS active drugs also increase the risk of falling.


To study the use of CNS active drugs in patients with PD or



Prospective study of CNS active drugs

use in 200 consecutive

patients attending PD clinic in a UK teaching hospital. Patients


and electronic records were reviewed. Data were collected on excel

and descriptive statistics were used.


200 patients were included; 115 males and 85 females with

mean age of 73 and 72 years respectively. 88% of patients had PD, 10%

had secondary Parkinsonism and 2% had Parkinson

s plus syndrome.

33% of patients had 1 or 2 falls in the previous 6 months, 18% had 3 or

more falls.

28% of patients were on Antimuscarinics, 20% were on antidepres-

sants, 11% on opioids, 5% on sedatives and 3% on antipsychotics .


Many patients with PD or Parkinsonism are on many CNS

active drugs. Patient

drug and drug

drug interactions should be

meticulously considered before prescribing. The indication, dose and

risk/benefit should be regularly reviewed and dose adjusted or the

drug stopped.


Resistant hypocalcemia with denosumab therapy

C. Michael, A. McGrath.

The Christie NHS Foundation Trust, Dudley Group

of Hospitals Foundation Trust

Case report:

A 73-year old patient had non-traumatic right hip

fracture while being on alendronate and daily calcium 1200 mg and

colecalciferol 800 units. Her past medical history includes auto-

immune pancreatitis, ileojejunostomy, biliary stricture and chronic

kidney disease. She also had L1 vertebral fracture. Shewas onwarfarin,

bisoprolol, amlodipine, citalopram, creon, and ferrous sulphate. She is

a non-smoker and occasionally drinks alcohol. DEXA scan showed

osteoporosis of the lumber spine with a T score of

2.7 at L1 and

osteopenia of the left hip with a T score of

2.4. Alendronate was

stopped and she was started on Denosumab 60mg subcutaneously

every six months. Calcium level before initiation of Denusumab was

normal. She also continued on daily calcium 1200 mg and colecalci-

ferol 800units. Three years later she attended A&E on two occasions

with hypocalcaemia related symptoms. Despite calcium and vitamin D

treatment her corrected calcium level was still low at 1.71 and

1.96 mmol/L. Phosphate and alkaline phosphatase were normal. Her

total 25-hydroxy-vitamin D level was insufficient at 29 nmol/L. Her

chronic kidney disease was stable with urea of 16.8 mmol/L and

Creatinine was 170 umol/L. Her magnesium level was normal.


The most common cause of hypocalcaemia is vitamin D

deficiency (1). Other causes include: malnutrition, malabsorption,

chronic kidney disease and hypoparathyroidism. Bone resorption

inhibitors such as Denosumab and bisphosphonates may induce

hypocalcaemia in patients with pre-existing vitamin D deficiency. In

patients with hypomagnesaemia, hypocalcaemia is difficult to correct

without magnesium repletion first (2) because serum magnesium is

essential for the synthesis and release of parathyroid hormone (3).

In this case, the patient had pancreatic insufficiency, biliary stricture

and short bowel syndrome due to ileojejunostomy. All can lead to

malabsorption of vitamin D, calcium and magnesium. Denosumab

therapy is likely to have exaggerated the hypocalcaemia and exposed

the vitamin D deficiency.


Calcium and vitamin D should be assessed and optimized

before initiating Denosumab therapy. Monitoring of calcium and

vitamin D levels is recommended throughout treatment, especially in

patients predisposed to hypocalcaemia or vitamin D deficiency.


1. Holick MF. Vitamin D deficiency.

N Engl J Med


2. Cooper MS, Gittoes NJ. Diagnosis and management of hypocal-


Brit Med J



3. Anast CS, Winnacker JL, Forte LR, Burns TW. Impaired release of

parathyroid hormone in magnesium deficiency.

J Clin Endocrinol




Medication review starts from the front door: the success of STOPP/

START criteria in frail elderly patients in the emergency


L. Mieiro


, O. Kayode


, F. Hayat


, S. Mason


, D. Webbe


, S. Green




Department of Medicine for Elderly People, Whipps Cross University

Hospital, Barts Health NHS Trust,


Forest Assessment Unit, Whipps Cross

University Hospital, Barts Health NHS Trust,


Pharmacy Department,

Whipps Cross University Hospital, Barts Health NHS Trust, London, United



Polypharmacy and potentially inappropriate medication

(PIM) are common problems in frail elderly patients. STOPP/START tool

is validated for in- and outpatients. Medication review should be part

of Comprehensive Geriatric Assessment delivered in Emergency

Poster presentations / European Geriatric Medicine 7S1 (2016) S29