Lisa Chodirker, MD, FRCPC, Clinical Fellow, Division of Hematology/Oncology, Odette Cancer Centre*, Sunnybrook Health Sciences Centre, Toronto, ON.
Rena Buckstein, MD, FRCPC, Co-director of MDS research programs, Division of Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON.

Myelodysplastic syndromes (MDS) are among the most common hematological malignancies in Western countries, with a median age at diagnosis of 74. They are a stem cell disorder characterized by cellular dysplasia, cytopenias, and an increased risk of transformation to acute myeloid leukemia. Disease trajectory is commonly determined by the international and world prognostic scoring systems (International Prognostic Scoring System and the World Health Organization [WHO] classification–based prognostic scoring system) and the WHO classification. Some patients have an indolent disease course, while others experience a rapid deterioration and short overall survival. For many years, the mainstay of therapy was supportive care with blood transfusions and hematopoietic growth factors. Fortunately, novel effective agents including lenalidomide, hypomethylating agents, and oral iron chelators have emerged over the past 5–10 years that improve transfusion dependence and may alter the natural history of the disease. These new therapeutic options offer new hope for individuals with MDS and bolster the role for the investigation of unexplained cytopenias in the older patient.
Key words: myelodysplastic syndrome, erythropoietin, anemia, red blood cell transfusions, stem cell disorder.

Cinzia Maraldi, MD, Department of Clinicial and Experimental Medicine, Division of Internal Medicine, Gerontology, and Geriatrics, University of Ferrara, Ferrrara, Italy; Department of Aging and Geriatric Research, College of Medicine, Institute on Aging, University of Florida, Gainesville, FL, USA.
Marco Pahor, MD, Department of Aging and Geriatric Research, College of Medicine, Institute on Aging, University of Florida; Geriatric Research, Education and Clinical Center (GRECC), Malcolm Randall Veteran’s Affairs Medical Center, Gainesville, FL, USA.

Maintaining independence is one of the major goals in geriatric care, and identification of modifiable conditions that may promote the onset and progression of disability is of paramount importance in the clinical approach to the older patient. Anemia is key among those factors that may affect physical function in older adults. It is a common condition that appears to predict the onset of functional decline and disability in older adults. Early diagnosis of anemia and identification of its underlying causes is important not only in order to prevent the condition from worsening but also to prevent its associated poor health outcomes.
Key words: anemia, aging, disability, hemoglobin, functional decline.

Please read "A Case of Iron Deficiency Anemia: Commentary" below

Anna Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD, USA.

Mr. WH is a 72-year-old-man who presented in April 2004 with a hematocrit of 21%. His previous hematocrit was 34% in February 2004. He complained of bright red blood per rectum and rectal pain secondary to external hemorrhoids. Mr. H was admitted with a presumed gastrointestinal bleed.
Mr. H’s past medical history is significant for bovine aortic valve prosthesis in 1997 secondary to aortic stenosis, Addison’s disease, hypocalcemia, seizure disorder, B12 deficiency, colon cancer with partial colon resection, and small bowel obstruction due to adhesions. Mr. H had chronic diarrhea secondary to bowel surgeries. His last colonoscopy was in 1997 and it revealed hemorrhoids. An esophagogastroduodenoscopy done at the time showed duodenitis.
The patient’s medications on hospital admission were as follows: calcium carbonate 500mg three times a day, vitamin B12 1000mcg I.M. monthly, divalproex sodium 750mg twice a day, hydrocortisone 25mg every 12 hours, vitamin D 100,000 IU every three months, phenobarbital 30mg every 12 hours, lasix 20mg by mouth daily, and potassium chloride 20m.e.q. daily. He has no known drug allergies.

Scott R.A. Walsh PhD, MD, Division of Dermatology, Department of Medicine, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto Medical School, Toronto, Ontario.

Dermatitis herpetiformis (DH) is a pruritic and chronic autoimmune blistering skin disease associated with varying degrees of gluten-induced enteropathy. Associated symptomatic celiac disease (CD) occurs in a minority of patients, but the pathogenesis of both diseases shares several features. In addition to some features of enteropathy, patients with DH also form specific antibodies to epidermal transglutaminase not typically found in patients with only CD. Although incidence is highest in middle age, because it is a life-long condition its prevalence is highest in the older population. Chronic complications of DH, including gastrointestinal lymphomas, are more likely to present in the geriatric group. Similarly, common comorbid disease associations including pernicious anemia, splenic atrophy and thyroid disease should be routinely assessed in this population. Long-term treatment of DH requires strict adherence to a gluten-free diet. Symptomatic treatment of this skin disease commonly uses dapsone to inhibit neutrophil accumulation and disease expression. Older patients may be more susceptible to toxic side effects of dapsone metabolites, and both careful patient selection and close monitoring should be undertaken with dapsone treatment.

Key words: dermatitis herpetiformis, autoimmunity, anemia, comorbidities, dapsone.

Durhane Wong-Rieger, PhD, President, Anemia Institute for Research & Education.

Anemia affects tens of thousands of Canadians, including many older people. While some types of anemia are relatively easy to diagnose and treat, complications such as chronic disease or complex medication regimes can often interfere with diagnosis and management of this condition.

The Anemia Institute for Research & Education (AIRE) is the first and only nonprofit organization in the world committed entirely to generating and sharing knowledge about anemia. AIRE supports patients in understanding anemia, its causes, effects and the available treatment options. The Institute partners with numerous patient and professional groups to facilitate patient education on anemia and blood safety and supply. Furthermore, through a yearly research grant competition, AIRE sponsors numerous anemia research studies. All in all, the Anemia Institute is working hard to ensure that anemia is treated seriously.

For Physicians: Anemia Guidelines for Primary Care
In a 2001 survey of family physicians across Canada, 90% of doctors indicated their interest in clinical practice guidelines on anemia for family practice. The Anemia Institute responded, initiating the development of Anemia Guidelines for Primary Care with MUMS Guidelines Clearinghouse (Medication Use Management Services), to be published in May 2003. The Anemia Guidelines is the fifth book in the Orange Book guideline series published by MUMS. This easy to use, peer-reviewed and fully-referenced book provides diagnostic and treatment guidelines for the full range of anemia conditions (see Table 1 for a selection of topics covered).

A limited number of complimentary copies of the Anemia Guidelines is available from AIRE. To order, please visit www.anemiainstitute.org and go to the Healthcare Professionals section.

For Your Patient: Anemia Educational Tools
The Anemia Institute's series of patient leaflets covers the most common types of anemia. Patient Educational Leaflets include:

• What is Anemia?
• What is Hemoglobin?
• Anemia & Nutrition
• Anemia & Iron Deficiency
• Anemia & Cancer
• Anemia & Kidney Disease
• Anemia & Surgery
• Anemia & Hepatitis C
• Anemia & HIV/AIDS
• Anemia & Children and Teens.

Anemia Awareness Week is the Institute's yearly campaign to raise awareness of anemia among the general public. This takes place each year during the last week of March. In March 2003, the public were invited to visit numerous hemoglobin screening clinics and anemia display booths in pharmacies and hospitals across Canada. Similar events are planned for Anemia Awareness Week next year, March 22&endash;26, 2004.

Research & Development Fund
The Anemia Institute Research & Development Fund supports research initiatives through a yearly, peer-reviewed grant competition. Projects currently funded include:

• the role of anemia and red blood cell substitutes in traumatic brain injury;
• new strategies to treat post-transplant anemia;
• anemia among the inner city homeless.

More information on the AIRE research grant process, including funding priorities and application procedures, can be found on the Internet at www.anemia-institute.org.

Richard A. Wells, MD, DPhil, FRCP(C), Assistant Professor of Medicine, University of Toronto; Staff Physician, Leukaemia Group, Princess Margaret Hospital; Scientist, Ontario Cancer Institute, Toronto, ON.

In myelodysplastic syndrome (MDS), genetic mutations in bone marrow stem cells result in production of defective blood cells. These defective cells fail to meet the intrinsic "quality control" standards of the bone marrow and are not released into the circulation, leading to anemia, leukopenia or thrombocytopenia. In some, but not all, patients with MDS, there also is a greatly increased risk of development of acute myelogenous leukemia. Until very recently, therapeutic options in MDS were extremely limited. This article reviews recent advances in risk-based classification of MDS, and describes new therapies that promise to revolutionize our approach to patients with this disorder.
Key words: myelodysplastic syndrome, bone marrow, anemia, acute myelogenous leukemia.

Fritz Francois, MD, Gerald A. Villanueva, MD, Edmund J. Bini, MD, FACP, FACG, Division of Gastroenterology, VA New York Harbor Healthcare System, Bellevue Hospital, and NYU School of Medicine, New York, NY.

Iron deficiency anemia is the most common cause of anemia encountered in clinical practice. In elderly patients, iron deficiency anemia is most commonly due to gastrointestinal blood loss, but also can be caused by poor iron intake or malabsorption of iron. Therefore, a careful evaluation of the gastrointestinal tract is warranted in all elderly patients with iron deficiency anemia. Upper endoscopy and colonoscopy can detect clinically important lesions in up to 44-84% of patients. In those who do not have a cause of iron deficiency anemia identified by endoscopy, the prognosis is excellent. Treatment includes iron supplementation and careful monitoring of hemoglobin levels.
Key words: iron deficiency, anemia, endoscopy, gastrointestinal bleeding, iron malabsorption.

Jeffrey Kwong, BSc

Anemia, a common problem in the elderly, warrants thorough investigation. Among those aged 85 years and older, the prevalence of the disorder ranges between 27% and 40% in men and between 16% and 21% in women.^1,2 Anemia has been defined by the World Health Organization as a hemoglobin concentration below 120 g/L in women and below 130 g/L in men.³ This definition was recently confirmed to be clinically relevant in the elderly, with increased risk of mortality (especially from malignant and infectious causes) linked to lower hemoglobin concentrations.⁴ Thus, it is important not to dismiss anemia as a normal aspect of aging, and to make efforts to determine and treat the underlying cause.