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Siglin J, Restrepo D. A Break in the Case: an Exercise in Clinical Reasoning. J Gen Intern Med 2024; 39:1515-1518. [PMID: 38499722 PMCID: PMC11169111 DOI: 10.1007/s11606-023-08572-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/05/2023] [Indexed: 03/20/2024]
Affiliation(s)
- Jonathan Siglin
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Gray 730, Boston, MA, 02114, USA.
| | - Daniel Restrepo
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Gray 730, Boston, MA, 02114, USA
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2
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Shabpiray H, Khan S, Hersi J, Khorsand Askari M. Uncommon Scurvy Manifestation: Solitary Skin Lesion in an Alcoholic Case. Cureus 2024; 16:e57652. [PMID: 38707091 PMCID: PMC11070115 DOI: 10.7759/cureus.57652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 05/07/2024] Open
Abstract
Scurvy, characterized by vitamin C deficiency, typically manifests with various symptoms, most commonly skin lesions. However, the presentation of a solitary skin lesion is considered atypical. An elderly patient with a history of heavy alcohol consumption presented with a small skin lesion that developed rapidly into a solitary open wound without any preceding trauma. Laboratory analysis revealed severe vitamin C deficiency (<5 μmol/L). The patient showed significant improvement following high-dose vitamin C replacement therapy. This case underscores the potential for scurvy to present with a solitary lower body wound devoid of typical symptoms. It highlights the importance of prompt consideration of vitamin C replacement therapy, particularly in high-risk groups such as alcoholics, by healthcare providers.
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Affiliation(s)
| | - Saira Khan
- Medicine, University of Toledo, Toledo, USA
| | - Jama Hersi
- Medicine, University of Toledo, Toledo, USA
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3
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Hemilä H, de Man AME. Vitamin C deficiency can lead to pulmonary hypertension: a systematic review of case reports. BMC Pulm Med 2024; 24:140. [PMID: 38504249 PMCID: PMC10949735 DOI: 10.1186/s12890-024-02941-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/01/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In the early literature, unintentional vitamin C deficiency in humans was associated with heart failure. Experimental vitamin C deficiency in guinea pigs caused enlargement of the heart. The purpose of this study was to collect and analyze case reports on vitamin C and pulmonary hypertension. METHODS We searched Pubmed and Scopus for case studies in which vitamin C deficiency was considered to be the cause of pulmonary hypertension. We selected reports in which pulmonary hypertension was diagnosed by echocardiography or catheterization, for any age, sex, or dosage of vitamin C. We extracted quantitative data for our analysis. We used the mean pulmonary artery pressure (mPAP) as the outcome of primary interest. RESULTS We identified 32 case reports, 21 of which were published in the last 5 years. Dyspnea was reported in 69%, edema in 53% and fatigue in 28% of the patients. Vitamin C plasma levels, measured in 27 cases, were undetectable in 24 and very low in 3 cases. Diet was poor in 30 cases and 17 cases had neuropsychiatric disorders. Right ventricular enlargement was reported in 24 cases. During periods of vitamin C deficiency, the median mPAP was 48 mmHg (range 29-77 mmHg; N = 28). After the start of vitamin C administration, the median mPAP was 20 mmHg (range 12-33 mmHg; N = 18). For the latter 18 cases, mPAP was 2.4-fold (median) higher during vitamin C deficiency. Pulmonary vascular resistance (PVR) during vitamin C deficiency was reported for 9 cases, ranging from 4.1 to 41 Wood units. PVR was 9-fold (median; N = 5) higher during vitamin C deficiency than during vitamin C administration. In 8 cases, there was direct evidence that the cases were pulmonary artery hypertension (PAH). Probably the majority of the remaining cases were also PAH. CONCLUSIONS The cases analyzed in our study indicate that pulmonary hypertension can be one explanation for the reported heart failure of scurvy patients in the early literature. It would seem sensible to measure plasma vitamin C levels of patients with PH and examine the effects of vitamin C administration.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, POB 41, Helsinki, FI-00014, Finland.
| | - Angelique M E de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
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4
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Gajate L, de la Hoz I, Espiño M, Martin Gonzalez MDC, Fernandez Martin C, Martín-Grande A, Parise Roux D, Pastor O, Villahoz J, Rodriguez-Gandía MÁ, Nuño Vazquez J. Intravenous Ascorbic Acid for the Prevention of Postreperfusion Syndrome in Orthotopic Liver Transplantation: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e50091. [PMID: 38100226 PMCID: PMC10757222 DOI: 10.2196/50091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Liver transplantation is the last therapeutic option for patients with end-stage liver disease. Postreperfusion syndrome (PRS), defined as a fall in mean arterial pressure of more than 30% within the first 5 minutes after reperfusion of at least 1 minute, can occur in liver transplantation as a deep hemodynamic instability with associated hyperfibrinolysis immediately after reperfusion of the new graft. Its incidence has remained unchanged since it was first described in 1987. PRS is related to ischemia-reperfusion (I/R) injury, whose pathophysiology involves the release of several mediators from both the donor and the recipient. The antioxidant effect of ascorbic acid has been studied in resuscitating patients with septic shock and burns. Even today, there are publications with conflicting results, and there is a need for further studies to confirm or rule out the usefulness of this drug in this group of patients. The addition of ascorbic acid to preservation solutions used in solid organ transplantation is under investigation to harness its antioxidant effect and mitigate I/R injury. Since PRS could be considered a manifestation of I/R injury, we believe that the possible beneficial effect of ascorbic acid on the occurrence of PRS should be investigated. OBJECTIVE The aim of this randomized controlled trial is to assess the benefits of ascorbic acid over saline in the development of PRS in adult liver transplantation. METHODS We plan to conduct a single-center randomized controlled trial at the Hospital Universitario Ramón y Cajal in Spain. A total of 70 participants aged 18 years or older undergoing liver transplantation will be randomized to receive either ascorbic acid or saline. The primary outcome will be the difference between groups in the incidence of PRS. The randomized controlled trial will be conducted under conditions of respect for fundamental human rights and ethical principles governing biomedical research involving human participants and in accordance with the international recommendations contained in the Declaration of Helsinki and its subsequent revisions. RESULTS The enrollment process began in 2020. A total of 35 patients have been recruited so far. Data cleaning and analysis are expected to occur in the first months of 2024. Results are expected around the middle of 2024. CONCLUSIONS We believe that this study could be particularly relevant because it will be the first to analyze the clinical effect of ascorbic acid in liver transplantation. Moreover, we believe that this study fills an important gap in the knowledge of the potential benefits of ascorbic acid in the field of liver transplantation, particularly in relation to PRS. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database 2020-000123-39; https://tinyurl.com/2cfzddw8; ClinicalTrials.gov NCT05754242; https://tinyurl.com/346vw7sm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50091.
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Affiliation(s)
- Luis Gajate
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Inés de la Hoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mercedes Espiño
- Department of Immunology, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Maria Del Carmen Martin Gonzalez
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Cristina Fernandez Martin
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Ascensión Martín-Grande
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Diego Parise Roux
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Oscar Pastor
- Department of Biochemistry, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Judith Villahoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Miguel Ángel Rodriguez-Gandía
- Department of Digestive Diseases, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Javier Nuño Vazquez
- Department of Liver Surgery, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
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5
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Kinlin LM, Weinstein M. Scurvy: old disease, new lessons. Paediatr Int Child Health 2023; 43:83-94. [PMID: 37795755 DOI: 10.1080/20469047.2023.2262787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
Scurvy, the condition associated with severe vitamin C deficiency, is believed to be one of the oldest diseases in human history. It was particularly prevalent during the Age of Sail, when long sea voyages without access to fresh food resulted in an epidemic which claimed millions of lives; however, scurvy has existed across time and geography, occurring whenever and wherever diets are devoid of vitamin C. Young children, specifically, were affected by the emergence of 'infantile scurvy' in the 19th century owing to the use of heated milk and manufactured infant foods of poor nutritional quality. Scurvy continues to occur in at-risk groups. In children and youths, it is primarily observed in the context of autism spectrum disorder and feeding problems such as a limited food repertoire and high-frequency single food intake. Diagnosis may be delayed and invasive testing undertaken owing to clinicians' lack of familiarity with the disease, or the mistaken assumption that it is exclusively a disease of the past. The aetiology, clinical manifestations and treatment of scurvy are described. Its long history and current epidemiology are also reviewed, demonstrating that scurvy is very much a disease of the present. It is suggested that future efforts should focus on (i) anticipatory guidance and early nutritional intervention, informed by an understanding of scurvy's epidemiology, with the aim of preventing the disease in those at risk, and (ii) prompt recognition and treatment to minimise morbidity and healthcare costs.Abbreviations: ASD: autism spectrum disorder.
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Affiliation(s)
- Laura M Kinlin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Weinstein
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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6
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Hemilä H, Chalker E, de Man AME. Vitamin C May Improve Left Ventricular Ejection Fraction: A Meta-Analysis. Front Cardiovasc Med 2022; 9:789729. [PMID: 35282368 PMCID: PMC8913583 DOI: 10.3389/fcvm.2022.789729] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/21/2022] [Indexed: 01/02/2023] Open
Abstract
Background Vitamin C deprivation can lead to fatigue, dyspnea, oedema and chest pain, which are also symptoms of heart failure (HF). In animal studies vitamin C has improved contractility and mechanical efficiency of the heart. Compared with healthy people, patients with HF have lower vitamin C levels, which are not explained by differences in dietary intake levels, and more severe HF seems to be associated with lower plasma vitamin C levels. This meta-analysis looks at the effect of vitamin C on left ventricular ejection fraction (LVEF). Methods We searched for trials reporting the effects of vitamin C on LVEF. We assessed the quality of the trials, and pooled selected trials using the inverse variance, fixed effect options. We used meta-regression to examine the association between the effect of vitamin C on LVEF level and the baseline LVEF level. Results We identified 15 trials, three of which were excluded from our meta-analysis. In six cardiac trials with 246 patients, vitamin C increased LVEF on average by 12.0% (95% CI 8.1–15.9%; P < 0.001). In six non-cardiac trials including 177 participants, vitamin C increased LVEF on average by 5.3% (95% CI 2.0–8.5%; P = 0.001). In meta-regression analysis we found that the effect of vitamin C was larger in trials with the lowest baseline LVEF levels with P = 0.001 for the test of slope. The meta-regression line crossed the null effect level at a baseline LVEF level close to 70%, with progressively greater benefit from vitamin C with lower LVEF levels. Some of the included trials had methodological limitations. In a sensitivity analysis including only the four most methodologically sound cardiac trials, the effect of vitamin C was not substantially changed. Conclusions In this meta-analysis, vitamin C increased LVEF in both cardiac and non-cardiac patients, with a strong negative association between the size of the vitamin C effect and the baseline LVEF. Further research on vitamin C and HF should be carried out, particularly in patients who have low LVEF together with low vitamin C intake or low plasma levels. Different dosages and different routes of administration should be compared.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
- *Correspondence: Harri Hemilä
| | - Elizabeth Chalker
- Biological Data Science Institute, Australian National University, Canberra, ACT, Australia
| | - Angelique M. E. de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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7
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Abstract
Scurvy is a rare disease which can manifest in a variety of presentations. Classically, scurvy is associated with poor dentition and bleeding diatheses. Rarely, scurvy can present with life-threatening hemodynamical instability. Herein, we report the case of a 69-year-old female with a history of hypertension and depression who presented with four months of weakness and a 20-pound weight loss. Her presentation was complicated by lower extremity bruising and myalgias over the last three weeks. The patient’s blood pressure in the emergency department was 86/54 mmHg. On further examination, she had poor dentition and extensive ecchymoses in different stages of resolution over her posterior thighs and calves. The patient was also noted to have perifollicular hemorrhages. An ascorbic acid level was checked and the result was 0.0 mg/dL (normal range: 0.4 to 2.0 mg/dL). During her admission, she slowly improved with a provided diet and multivitamins. Her blood pressure consistently remained over 120/65 mmHg. The patient was advised to adjust her diet and take supplemental ascorbic acid. On a follow-up visit two weeks later, the patient endorsed an improvement in pain and exercise tolerance and was noted to have marked improvement in skin findings. Ascorbic acid is an essential piece of multiple biochemical pathways. Humans are required to attain ascorbic acid from their diet. People who consume diets lacking in ascorbic acid develop scurvy.
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Affiliation(s)
- Jason M Thomas
- Internal Medicine, Wright Patterson Air Force Base/Wright State University, Dayton, USA
| | - Kathryn M Burtson
- Internal Medicine, Wright Patterson Air Force Base/Wright State University, Dayton, USA
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8
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Esteves A, Teixeira da Silva F, Carvalho J, Felgueiras P, Laranjeira P. Scurvy, Starvation, and Flea Infestation - A Case Report From 21st Century Europe. Cureus 2021; 13:e13158. [PMID: 33728161 PMCID: PMC7935234 DOI: 10.7759/cureus.13158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Scurvy is a disease caused by vitamin C deficiency, historically associated with long sea voyages, periods of famine and war. Currently, it is often misdiagnosed and underreported, as physicians tend to consider it a disease of the past. We present the case of a 79-year-old female who was admitted to the Emergency Department complaining of pruritus. The patient lived alone and in poor hygiene conditions. Diet was scarce. One week before admission she was in contact with flea-ridden stray dogs. Sometime later she noted several fleas and multiple pruritic small papules, crusts, and excoriations on her torso, limbs, palms, soles, and scalp. Physical examination showed the patient to be pale, emaciated, and poorly groomed. Laboratory analysis showed microcytic anemia. Flea bites were treated with oral antihistamines and prednisolone. Follow-up one month later showed weight gain and partial resolution of skin lesions. However, multiple small ecchymosis on both lower and upper limbs, and occasional perifollicular petechias on her lower extremities, were noted. Additional workup showed undetectable serum vitamin C levels. A diagnosis of scurvy was made. The patient was treated with 1000 mg per day of oral vitamin C for one month leading to complete recovery. We present this case to remind that early recognition of vitamin C deficiency and appropriate supplementation are essential in patients with scurvy. Physicians should be aware of classic signs, symptoms, and social factors associated with this forgotten disease.
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Affiliation(s)
- Alexandra Esteves
- Internal Medicine, Unidade Local de Saúde do Alto Minho, Viana do Castelo, PRT
| | | | - José Carvalho
- Internal Medicine, Unidade Local de Saúde do Alto Minho, Viana do Castelo, PRT
| | - Paula Felgueiras
- Internal Medicine, Unidade Local de Saúde do Alto Minho, Viana do Castelo, PRT
| | - Paulo Laranjeira
- Department of Safety, Health and Environment, School of Management and Technology, Polytechnic Institute of Porto, Porto, PRT
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9
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Montalto M, Porceddu E, Pero E, Lupascu A, Gallo A, De Simone C, Nucera E, Aruanno A, Giarretta I, Pola R, Landolfi R. Scurvy: A Disease not to be Forgotten. Nutr Clin Pract 2020; 36:1063-1067. [PMID: 33368529 DOI: 10.1002/ncp.10616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
An 18-year-old man presented to our hospital with muscular pain, diffuse petechiae, spontaneous thigh ecchymosis, edema and pain of the right knee, bilateral pretibial subcutaneous nodules, and gingival hypertrophy and hemorrhage. His history was positive for a mixed anxiety-depressive disorder and a restrictive diet caused by self-diagnosed food allergies. Skin lesions appeared like hyperkeratotic papules with coiled hairs and perifollicular hemorrhages. A diagnosis of scurvy was made upon demonstration of low serum levels of ascorbic acid. An allergy evaluation found cross-reactivity between pollens and food, related to the presence of panallergens. Moreover, we found that our patient was also affected by celiac disease. In conclusion, scurvy should be considered in the differential diagnosis of patients with petechiae and ecchymosis, especially when food restriction, malabsorption, or psychiatric disorders are present.
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Affiliation(s)
- Massimo Montalto
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Enrica Porceddu
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Erika Pero
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Lupascu
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonella Gallo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Clara De Simone
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Eleonora Nucera
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Arianna Aruanno
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Igor Giarretta
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Roberto Pola
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Raffaele Landolfi
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
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10
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Benarroch EE. What is the role of ascorbic acid in norepinephrine synthesis and orthostatic hypotension? Neurology 2020; 95:913-916. [DOI: 10.1212/wnl.0000000000010960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 11/15/2022] Open
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11
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Hemilä H, Chalker E. Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis. Nutrients 2019; 11:E708. [PMID: 30934660 PMCID: PMC6521194 DOI: 10.3390/nu11040708] [Citation(s) in RCA: 155] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
A number of controlled trials have previously found that in some contexts, vitamin C can have beneficial effects on blood pressure, infections, bronchoconstriction, atrial fibrillation, and acute kidney injury. However, the practical significance of these effects is not clear. The purpose of this meta-analysis was to evaluate whether vitamin C has an effect on the practical outcomes: length of stay in the intensive care unit (ICU) and duration of mechanical ventilation. We identified 18 relevant controlled trials with a total of 2004 patients, 13 of which investigated patients undergoing elective cardiac surgery. We carried out the meta-analysis using the inverse variance, fixed effect options, using the ratio of means scale. In 12 trials with 1766 patients, vitamin C reduced the length of ICU stay on average by 7.8% (95% CI: 4.2% to 11.2%; p = 0.00003). In six trials, orally administered vitamin C in doses of 1⁻3 g/day (weighted mean 2.0 g/day) reduced the length of ICU stay by 8.6% (p = 0.003). In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2% (95% CI 7.7% to 27%; p = 0.001). Given the insignificant cost of vitamin C, even an 8% reduction in ICU stay is worth exploring. The effects of vitamin C on ICU patients should be investigated in more detail.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, POB 41, FI-00014 Helsinki, Finland.
| | - Elizabeth Chalker
- School of Public Health, University of Sydney, Sydney 2006, Australia.
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12
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Bennett SE, Schmitt WP, Stanford FC, Baron JM. Case 22-2018: A 64-Year-Old Man with Progressive Leg Weakness, Recurrent Falls, and Anemia. N Engl J Med 2018; 379:282-289. [PMID: 30021092 PMCID: PMC6060279 DOI: 10.1056/nejmcpc1802826] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Susan E Bennett
- From the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - William P Schmitt
- From the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Fatima C Stanford
- From the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
| | - Jason M Baron
- From the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Massachusetts General Hospital, and the Departments of Medicine (S.E.B., W.P.S., F.C.S.), Pediatrics (F.C.S.), and Pathology (J.M.B.), Harvard Medical School - both in Boston
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13
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Alhenc-Gelas F. A New Player in Circulatory Adaptation to Orthostatism: Better to Play With Than Without Him. Circ Res 2018; 122:802-803. [PMID: 29700080 DOI: 10.1161/circresaha.118.312749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor's requirement in septic shock. J Res Pharm Pract 2016; 5:94-100. [PMID: 27162802 PMCID: PMC4843590 DOI: 10.4103/2279-042x.179569] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: Effects of ascorbic acid on hemodynamic parameters of septic shock were evaluated in nonsurgical critically ill patients in limited previous studies. In this study, the effect of high-dose ascorbic acid on vasopressor drug requirement was evaluated in surgical critically ill patients with septic shock. Methods: Patients with septic shock who required a vasopressor drug to maintain mean arterial pressure >65 mmHg were assigned to receive either 25 mg/kg intravenous ascorbic acid every 6 h or matching placebo for 72 h. Vasopressor dose and duration were considered as the primary outcomes. Duration of Intensive Care Unit (ICU) stay and 28-day mortality has been defined as secondary outcomes. Findings: During the study period, 28 patients (14 in each group) completed the trial. Mean dose of norepinephrine during the study period (7.44 ± 3.65 vs. 13.79 ± 6.48 mcg/min, P = 0.004) and duration of norepinephrine administration (49.64 ± 25.67 vs. 71.57 ± 1.60 h, P = 0.007) were significantly lower in the ascorbic acid than the placebo group. No statistically significant difference was detected between the groups regarding the length of ICU stay. However, 28-day mortality was significantly lower in the ascorbic acid than the placebo group (14.28% vs. 64.28%, respectively; P = 0.009). Conclusion: High-dose ascorbic acid may be considered as an effective and safe adjuvant therapy in surgical critically ill patients with septic shock. The most effective dose of ascorbic acid and the best time for its administration should be determined in future studies.
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Affiliation(s)
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Ramezani
- Department of Intensive Care Unit, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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15
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Robitaille L, Hoffer LJ. A simple method for plasma total vitamin C analysis suitable for routine clinical laboratory use. Nutr J 2016; 15:40. [PMID: 27102999 PMCID: PMC4839128 DOI: 10.1186/s12937-016-0158-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/13/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In-hospital hypovitaminosis C is highly prevalent but almost completely unrecognized. Medical awareness of this potentially important disorder is hindered by the inability of most hospital laboratories to determine plasma vitamin C concentrations. The availability of a simple, reliable method for analyzing plasma vitamin C could increase opportunities for routine plasma vitamin C analysis in clinical medicine. METHODS Plasma vitamin C can be analyzed by high performance liquid chromatography (HPLC) with electrochemical (EC) or ultraviolet (UV) light detection. We modified existing UV-HPLC methods for plasma total vitamin C analysis (the sum of ascorbic and dehydroascorbic acid) to develop a simple, constant-low-pH sample reduction procedure followed by isocratic reverse-phase HPLC separation using a purely aqueous low-pH non-buffered mobile phase. Although EC-HPLC is widely recommended over UV-HPLC for plasma total vitamin C analysis, the two methods have never been directly compared. We formally compared the simplified UV-HPLC method with EC-HPLC in 80 consecutive clinical samples. RESULTS The simplified UV-HPLC method was less expensive, easier to set up, required fewer reagents and no pH adjustments, and demonstrated greater sample stability than many existing methods for plasma vitamin C analysis. When compared with the gold-standard EC-HPLC method in 80 consecutive clinical samples exhibiting a wide range of plasma vitamin C concentrations, it performed equivalently. CONCLUSION The easy set up, simplicity and sensitivity of the plasma vitamin C analysis method described here could make it practical in a normally equipped hospital laboratory. Unlike any prior UV-HPLC method for plasma total vitamin C analysis, it was rigorously compared with the gold-standard EC-HPLC method and performed equivalently. Adoption of this method could increase the availability of plasma vitamin C analysis in clinical medicine.
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Affiliation(s)
- Line Robitaille
- Lady Davis Institute for Medical Research and Department of Medicine, McGill University and Jewish General Hospital, 3755 Cote Sainte Catherine, Montreal, QC H3T 1E2 Canada
| | - L. John Hoffer
- Lady Davis Institute for Medical Research and Department of Medicine, McGill University and Jewish General Hospital, 3755 Cote Sainte Catherine, Montreal, QC H3T 1E2 Canada
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16
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Carr AC, Shaw GM, Fowler AA, Natarajan R. Ascorbate-dependent vasopressor synthesis: a rationale for vitamin C administration in severe sepsis and septic shock? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:418. [PMID: 26612352 PMCID: PMC4661979 DOI: 10.1186/s13054-015-1131-2] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Severe systemic inflammatory response to infection results in severe sepsis and septic shock, which are the leading causes of death in critically ill patients. Septic shock is characterised by refractory hypotension and is typically managed by fluid resuscitation and administration of catecholamine vasopressors such as norepinephrine. Vasopressin can also be administered to raise mean arterial pressure or decrease the norepinephrine dose. Endogenous norepinephrine and vasopressin are synthesised by the copper-containing enzymes dopamine β-hydroxylase and peptidylglycine α-amidating monooxygenase, respectively. Both of these enzymes require ascorbate as a cofactor for optimal activity. Patients with severe sepsis present with hypovitaminosis C, and pre-clinical and clinical studies have indicated that administration of high-dose ascorbate decreases the levels of pro-inflammatory biomarkers, attenuates organ dysfunction and improves haemodynamic parameters. It is conceivable that administration of ascorbate to septic patients with hypovitaminosis C could improve endogenous vasopressor synthesis and thus ameliorate the requirement for exogenously administered vasopressors. Ascorbate-dependent vasopressor synthesis represents a currently underexplored biochemical mechanism by which ascorbate could act as an adjuvant therapy for severe sepsis and septic shock.
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Affiliation(s)
- Anitra C Carr
- Department of Pathology, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand.
| | - Geoffrey M Shaw
- Department of Intensive Care Medicine, Christchurch Hospital, Private Bag 4710, Christchurch, 8011, New Zealand.
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Box 980050, Richmond, VA, 23298, USA.
| | - Ramesh Natarajan
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Box 980050, Richmond, VA, 23298, USA.
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