Association of admission serum levels of vitamin D, calcium, Phosphate, magnesium and parathormone with clinical outcomes in neurosurgical ICU patients

Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review

Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.

Biochemical spectrum of parathyroid hormone disorders in patients attending Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Objectives

This study intends to determine the association of parathormone with vitamin D and other biochemical parameters (calcium and phosphate) and evaluate the relationship between low vitamin D and parathormone levels.

Methods

A hospital-based cross-sectional study was conducted among 310 study participants over the period of 1 year. Patients who underwent laboratory investigations for vitamin D, parathormone, calcium, and phosphate in the Clinical Biochemistry Laboratory at the Institute of Medicine, Tribhuvan University Teaching Hospital were included. Serum intact parathyroid hormone, vitamin D, calcium, and phosphate were measured in Abbott Architect (ci4100) integrated system autoanalyzer.

Results

Among the 310 study participants, 177 (57%) were males and 43% were females. The mean age of the patient was 47.09 ± 19.01 years. High intact parathyroid hormone (>68 pg/ml) was observed in 73% of the patients. Low vitamin D (<20 ng/ml) was present in 30.2% of the patients. The findings from our study depict that there is a negative significant correlation between intact parathyroid hormone levels, vitamin D, and calcium levels and a positive correlation between intact parathyroid hormone and phosphate levels (p < 0.001).

Conclusions

The findings from our study illustrate that there is a swapping drift in the profile of hyperparathyroidism in the Nepalese population. We report the presence of hyperparathyroidism in the middle age group than in the older age group contradictory to that reported in the literature.

Lower mean phosphate independently predicts mortality in critically ill patients: Results from a prospective cohort study

PURPOSE

To evaluate lower mean phosphate as a prognostic tool in critically ill patients.

METHODS

This is a prospective single-center cohort study including adult patients (> 18 years) with a length of intensive care unit (ICU) stay of at least 24 h. Phosphatemia was evaluated within 1 h of ICU admission and once daily. Mean phosphate, calculated by the simple arithmetic mean of daily phosphate measurements, was proposed and tested. Standard severity scores were applied. Multivariate and survival analyses were performed.

RESULTS

A total of 317 patients were included, of whom 111 (35%) presented hypophosphatemia. Hypophosphatemia associated with surgical conditions, nutritional therapy, hypovitaminosis D, hyperparathyroidism, mechanical ventilation (need and duration), and ICU and hospital length of stay were evaluated. Admission APACHE II and SOFA (ICU days 1, 3, and 7) scores and ICU and in-hospital mortality were greater in the hypophosphatemia group than control group. Higher APACHE II (RR: 1.1; 95%CI: 1.01-1.2; p = 0.045) and lower mean phosphate (RR: 0.02; 95%CI: 0.001-0.09; p = 0.044) independently predicted ICU and in-hospital mortality.

CONCLUSIONS

Hypophosphatemia is frequent in the ICU, and was associated with unfavorable outcomes. This study introduces the importance of longitudinal monitoring of phosphate levels, since lower mean phosphate is an independent predictor of mortality in critically ill patients.

Association between Vitamin D Levels and Mortality in Sepsis Patients Admitted to an Intensive Care at General Hospital Dr. M. Djamil, West Sumatera, Indonesia

BACKGROUND: Vitamin D deficiency is associated with an increased risk and progression of the disease, especially sepsis. Low serum Vitamin D levels when patients enter the Intensive Care Unit (ICU) can affect patient care outcomes. AIM: This study aims to determine the relationship between Vitamin D levels and sepsis patients’ treatment outcomes in the Intensive Care Unit. METHODS: We analyzed 80 sepsis patients admitted from July 2022 to September 2022. This study used a cohort design. Sampling and collection were carried out from July 2022 to September 2022 in the Intensive Care Unit of Dr. M. Djamil Hospital, Padang. This study was conducted on 40 case samples and 40 control samples. The relationship between Vitamin D levels and treatment outcomes for sepsis patients was analyzed using the Chi-Square/Fisher Exact Test. RESULTS: Patients with the most Vitamin D deficiency were women (77.5%), obese (57.5%), with the most comorbid Chronic Kidney Injury (12.5%), the mean APACHE II score was 21, and SOFA score of 7. Patients with non-deficiency Vitamin D most was male (7%), obese (52.5%), with the most comorbid Cardiovascular Disease (15.0%), the mean APACHE II score was 19, and SOFA score of 5. In 40 patients with Vitamin D deficiency, 24 patients (57.1%) non-survived, and 16 patients (42.1%) survived (RR = 1.833). CONCLUSION: Vitamin D deficiency increases the risk of death in septic patients, so further intervention is needed.

A Novel U-Shaped Association Between Serum Magnesium on Admission and 28-Day In-hospital All-Cause Mortality in the Pediatric Intensive Care Unit

Objective

Our purpose is to evaluate whether serum magnesium when entering the ICU is related to 28-day in-hospital all-cause mortality in the pediatric ICU.

Methods

We used the PIC database to conduct a retrospective analysis to investigate the first-time serum magnesium levels of 10,033 critically ill children admitted to the pediatric ICU, and analyzed association between serum magnesium and all-cause mortality. Smoothing spline plots, subgroup analysis and segmented multivariate logistic regression analysis were conducted to estimate the relative risk between serum magnesium and all-cause mortality. The shape of the curve was used to describe the relationship between magnesium and 28-day in-hospital mortality.

Results

There is a non-linear relationship between serum magnesium and 28-day in-hospital all-cause mortality. The U-type relationship between serum magnesium and all-cause mortality was observed. The optimal range of serum magnesium with the lowest risk of mortality was 0.74–0.93 mmol/L. As the serum magnesium level reaches the turning point (0.74 mmol/L), the risk of death decreases by 60% for every 0.1 mmol/L increase in serum magnesium; when the serum magnesium level exceeds 0.93, an increase of 0.1 mmol/L increases the risk of death by 38 %.

Conclusion

Serum magnesium has a U-shaped relationship with 28-day in-hospital all-cause mortality. Both low and high serum magnesium can increase the risk of death. The best serum magnesium range when the risk of death is the lowest is 0.74–0.93 mmol/L.

Ionized Blood Magnesium in Sick Children: An Overlooked Electrolyte

INTRODUCTION

Magnesium is a less frequently monitored electrolyte in critically ill patients. Hypomagnesemia is associated with increased need for mechanical ventilation, mortality and prolonged ICU stay. The present study was undertaken to identify the proportion of children with abnormal magnesium levels and correlate it with disease outcome.

METHODS

This observational study included children aged 1 month to 12 years hospitalized at the emergency room. Heparinized blood was collected for determination of ionized magnesium, ionized calcium, sodium, potassium and lactate using Stat Profile Prime Plus (Nova Biomedical, Waltham, MA, USA). Clinical outcomes for duration of hospitalization, and death or discharge were recorded.

RESULTS

A total of 154 (102 males) children with median (IQR) age of 11 (4, 49.75) months were enrolled. Sixty one (39.6%) had ionized magnesium levels below 0.42 mmol/l, 63 (40.9%) had normal levels and 30 (19.4%) had hypermagnesemia (>0.59 mmol/l). Hypomagnesemia was associated with hypocalcemia (p < 0.001), hyponatremia (p < 0.001) and hypokalemia (p < 0.02). A higher proportion of children with hypermagnesemia required ventilation than hypomagnesemia (26% vs. 9%) and succumbed (35% vs. 20%), respectively; p > 0.05. Ninety-three (60.3%) had hypocalcemia and 10 (6.5%) children had hypercalcemia. There was good correlation between ionized calcium and magnesium values (r = 0.72, p < 0.001).

CONCLUSION

Both hypomagnesemia and hypermagnesemia were seen in critically ill children. Patients with hypomagnesemia had significantly higher proportion of other electrolyte abnormalities.

Prevalence of Vitamin D Deficiency and Associated Factors in Critically Ill Patients: A Multicenter Observational Study

Background: Vitamin D deficiency is common in the general population worldwide, and the prevalence and severity of vitamin D deficiency increase in critically ill patients. The prevalence of vitamin D deficiency in a community-based cohort in Northern Taiwan was 22.4%. This multicenter cohort study investigated the prevalence of vitamin D deficiency and associated factors in critically ill patients in Northern Taiwan. Methods: Critically ill patients were enrolled and divided into five groups according to their length of stay at intensive care units (ICUs) during enrolment as follows: group 1, <2 days with expected short ICU stay; group 2, <2 days with expected long ICU stay; group 3, 3-7 days; group 4, 8-14 days; and group 5, 15-28 days. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25(OH)D) level < 20 ng/ml, and severe vitamin D deficiency was defined as a 25(OH)D level < 12 ng/ml. The primary analysis was the prevalence of vitamin D deficiency. The exploratory analyses were serial follow-up vitamin D levels in group 2, associated factors for vitamin D deficiency, and the effect of vitamin D deficiency on clinical outcomes in critically ill patients. Results: The prevalence of vitamin D deficiency was 59% [95% confidence interval (CI) 55-62%], and the prevalence of severe vitamin D deficiency was 18% (95% CI 15-21%). The median vitamin D level for all enrolled critically ill patients was 18.3 (13.7-23.9) ng/ml. In group 2, the median vitamin D levels were <20 ng/ml during the serial follow-up. According to the multivariable analysis, young age, female gender, low albumin level, high parathyroid hormone (PTH) level, and high sequential organ failure assessment (SOFA) score were significantly associated risk factors for vitamin D deficiency. Patients with vitamin D deficiency had longer ventilator use duration and length of ICU stay. However, the 28- and 90-day mortality rate were not associated with vitamin D deficiency. Conclusions: This study demonstrated that the prevalence of vitamin D deficiency is high in critically ill patients. Age, gender, albumin level, PTH level, and SOFA score were significantly associated with vitamin D deficiency in these patients.

Effect of Application of Different Exercise Intensities on Vitamin D and Parathormone in Children with Down's Syndrome

BACKGROUND

Children with Down's syndrome are more liable to vitamin D deficiency. Treating this deficiency with supplements is associated with the risk of intoxication.

AIM

The study is aimed at comparing the effect of two exercise intensities on the modulation of vitamin D and parathormone levels in children with DS.

METHODS

Forty-four DS male children aged from 8 to 12 years participated in the study. They were assigned randomly into two equal groups. Group I received high-intensity treadmill aerobic exercises, and group II received moderate-intensity T-AE, three times per week for three months. The blood samples were collected from both groups before the intervention, after one month of intervention, then after three months of intervention to assess serum 25(OH)D and PTH levels.

RESULTS

Repeated measure MANOVA revealed that the high-intensity T-AE induced a significant increase in 25(OH)D after one month and after three months while it significantly decreased PTH only after three months. Moderate-intensity T-AE had a nonsignificant effect on both hormones.

CONCLUSION

The current study concluded that the high-intensity T-AE improved both vitamin D and parathormone serum levels after three months of intervention.

Insights into the possible impact of COVID-19 on the endocrine system

The novel 2019 coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly transmissible and pathogenic coronavirus. Because of the novelty of the COVID-19 pandemic, few data are available on the impact of the SARS-CoV-2 on the different endocrine glands. Previous studies of severe acute respiratory syndrome (SARS) have shown a harmful effect on endocrine function. Notably, the angiotensin-converting enzyme-2 receptor, which is the entry route of coronaviruses to the host cell, is widely expressed in the endocrine organs including testis, endocrine pancreas, thyroid, and adrenal, and pituitary glands. Clinical and biochemical manifestations have been recorded in COVID-19 patients resulting in changes in endocrine activities, which were also recorded during the SARS outbreak in 2003. This review aims to explore the impact of SARS-CoV-2 infection on the function of endocrine glands, based on the latest research in the field.

Hypophosphatemia in critically ill adults and children - A systematic review

BACKGROUND & AIMS

Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments.

METHODS

A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies.

RESULTS

For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak.

CONCLUSIONS

Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.

Efficacy of high-dose versus low-dose vitamin D supplementation on serum levels of inflammatory factors and mortality rate in severe traumatic brain injury patients: study protocol for a randomized placebo-controlled trial

Background

Traumatic brain injury (TBI) is the most common trauma worldwide and is a leading cause of injury-related death and disability. Inflammation is initiated as a result of the TBI, which is in association with severity of illness and mortality in brain trauma patients, especially in subdural hemorrhage and epidural hemorrhage cases. A high percentage of adults admitted to the intensive care unit with TBI are diagnosed with vitamin D deficiency; this deficiency may induce impaired immune responses and increase the risk of infections. Vitamin D intervention has been shown to modulate pro- and anti-inflammatory cytokines in non-critically ill patients, but to date, there is no substantial data on the effectiveness of vitamin D for the improvement of immune function in traumatic brain injury patients.

Methods/design

A randomized clinical trial (RCT) will be performed on 74 Iranian adults 18–65 years old with brain trauma and will be treated daily with vitamin D supplements (100,000 IU oral drop) or a similar placebo (1000 IU) for 5 days.

Discussion

If this randomized clinical trial demonstrates reductions in inflammatory cytokines, it would provide evidence for a multicenter clinical trial to evaluate the efficacy of vitamin D supplementation in neurocritically ill patients. Since vitamin D supplements are inexpensive and safe, this clinical trial could have the potential to improve clinical outcomes in traumatic brain injury patients through reduction of inflammation and infection-associated morbidity and mortality rates.

Trial registration

Iranian Registry of Clinical Trials, IRCT20180619040151N3. Registered on 10 August 2019.

COVID-19: the endocrine opportunity in a pandemic

The 2019 Coronavirus disease (COVID-19) pandemic has disrupted the social, economical and medical system worldwide. Although it is strictly an infectious disease, its intricate bidirectional relationship with various non-communicable metabolic diseases and endocrinological factors has been observed. While diabetes, hypertension, obesity have been found to be independent risk factors for COVID-19 disease severity and mortality, more inclination towards sedentary lifestyle, psychosocial stress at this critical time may be the harbingers of metabolic syndrome. Thus, endocrinologists have a great opportunity to play their role to combat this pandemic. This paper examines how various endocrinological disorders influence the dynamics of COVID-19 and vice versa. Moreover, it also intends to review the clinical guidelines to be adopted in practice of endocrinology in this trying time.

Vitamin D deficiency is endemic in neurosurgical patients and is associated with a longer length of inpatient stay

INTRODUCTION

Vitamin D deficiency is common in spinal surgery and critical care. Hypovitaminosis D may impact on outcomes in cranial neurosurgical care and play roles in underlying disease processes.

METHODS

A prospective observational cohort study was performed. All emergency cranial neurosurgical ward admissions from 1st January to 10th May 2017 were screened for inclusion (n = 406). Patients already receiving vitamin D supplementation, spinal patients and elective admissions were excluded. Admission vitamin D levels were checked for all remaining patients (n = 95). Patients with vitamin D <30 nmol/L were defined as "deficient" and those 30-50 nmol/L as "inadequate." All patients with levels <50 nmol/L were replaced, as per local guidelines. Descriptive analyses of the cohorts were undertaken, with multivariate regression used to assess the effect of vitamin D on length of stay, inpatient morbidity and mortality.

RESULTS

The median age of participants was 61 years (n = 95; 57% male, 43% female). The median vitamin D level was 23 nmol/L (deficient). 84% (n = 80) of patients had low vitamin D levels, with 61% (n = 58) classed as deficient (<30 nmol/L). Vitamin D deficiency rates were similar in those aged below 65 years (86%; n = 38/44) and those above 65 years (82%; n = 42/51). Deficient vitamin D level was associated with longer hospital stay (P = .03), and this relationship persisted after adjusting for potential confounders such as age, sex and preadmission Charlson co-morbidity index. No statistically significant association was seen with vitamin D status and inpatient morbidity or mortality.

CONCLUSIONS

Vitamin D deficiency is common in cranial neurosurgical patients, even in predefined low-risk groups (age <65). Lower vitamin D level was associated with longer length of stay. This study supports the need for: (a) further investigation into the roles of vitamin D in neurosurgical pathologies and management and (b) an appropriately powered, randomised investigation into the impact of vitamin D status upon neurosurgical diagnoses and complications.

Association of intestinal permeability with admission vitamin D deficiency in patients who are critically ill

Emerging data have led to the hypothesis that vitamin D plays a role in promoting epithelial barrier dysfunction. Therefore, intestinal permeability becomes a significant determiner in the future of patients hospitalized in intensive care unit (ICU). The relationship between vitamin D and intestinal permeability remains unclear in patients who are critically ill. The aim of the study is to document the relationship between the admission vitamin D deficiency and markers of intestinal permeability in the critical care setting. This was a single-center, observational, prospective study in the general ICU of a university-affiliated hospital. A sample of 144 ICU-hospitalized adult patients was recruited between January and May 2018. The admission serum 25-hydroxyvitamin D levels were measured and categorized as <20 and ≥20 ng/dL, respectively. Moreover, the admission plasma endotoxin and zonulin concentrations as markers of intestinal permeability were determined in stringent conditions. The association between markers of intestinal permeability and 25-hydroxyvitamin D levels was assessed adjusting for potential confounders through an estimation of a binary logistic regression model. Our results showed that median plasma endotoxin and zonulin decreased with increasing serum levels of vitamin D categories (p=0.001) in the overall study population. Multivariate binary logistic regression analyses showed a significant association between the plasma endotoxin (OR 0.12, 95% CI 0.03 to 0.52) and zonulin (OR 0.91, 95% CI 0.87 to 0.99) levels with serum levels of vitamin D categories in the overall population. Our finding suggests a relationship between vitamin D deficiency and early alterations in intestinal permeability. Thus, evaluating vitamin D levels in patients who are critically ill may be warranted.

Effect of Vitamin D Supplementation on Postcraniotomy Pain After Brain Tumor Surgery: A Randomized Clinical Trial

OBJECTIVE

To determine the effect of vitamin D supplementation on postoperative pain and analgesic requirement in brain tumor surgery.

METHODS

A total of 60 patients with vitamin D serum levels ≤20 ng/dL were randomly assigned to 2 groups equally. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D before surgery.

RESULTS

Preoperative serum level of vitamin D was 15.9 ± 3.8 ng/dL and 14.5 ± 3.6 ng/dL in the study and control groups, respectively (P = 0.13). Serum level of vitamin D on day 5 of surgery was 22.5 ± 4.3 and 13.7 ± 3.8 in the study and control groups, respectively (P < 0.001). A percentage of 50% had pain scores >4 on the first postoperative day, which decreased with time. The median (interquartile range) of the visual analogue scale score during the 3 postoperative days was 3 (5), 3 (5), 1 (3), and 5 (7), 2 (5), 1 (3) in the study and control groups, respectively, with no significant difference. There was no difference in analgesic consumption between the 2 groups. Analysis through the generalized estimating equation model indicated that patients who had received vitamin D for a longer time before the operative time had an insignificantly less pain score.

CONCLUSIONS

On the basis of the study results, one half of our patients reported moderate-to-severe pain scores on the first day after surgery. The pain in the study group was insignificantly less than that in the control group, but it seems that chronic high level of vitamin D may lead to promising results.