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Orford NR, Bone A, Kotowicz MA, Bailey M, Pasco JA, Maiden M, Kakho N, Cattigan C, Nichonghaile M, Jones C, Hodgson C, Nair P, Center J, Bellomo R. A pilot feasibility randomised controlled trial of bone antiresorptive agents on bone turnover markers in critically ill women. Sci Rep 2024; 14:2071. [PMID: 38267490 PMCID: PMC10810087 DOI: 10.1038/s41598-024-52607-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/21/2024] [Indexed: 01/26/2024] Open
Abstract
Critical illness is associated with increased bone turnover, loss of bone density, and increased risk of fragility fractures. The impact of bone antiresorptive agents in this population is not established. This trial examined the efficacy, feasibility, and safety of antiresorptive agents administered to critically ill women aged fifty years or greater. Women aged 50 years or greater admitted to an intensive care unit for at least 24 h were randomised to receive an antiresorptive agent (zoledronic acid or denosumab) or placebo, during critical illness and six months later (denosumab only). Bone turnover markers and bone mineral density (BMD) were monitored for 1 year. We studied 18 patients over 35 months before stopping the study due to the COVID-19 pandemic. Antiresorptive medications decreased the bone turnover marker type 1 cross-linked c-telopeptide (CTX) from day 0 to 28 by 43% (± 40%), compared to an increase of 26% (± 55%) observed with placebo (absolute difference - 69%, 95% CI - 127% to - 11%), p = 0.03). Mixed linear modelling revealed differences in the month after trial drug administration between the groups in serum CTX, alkaline phosphatase, parathyroid hormone, and phosphate. Change in BMD between antiresorptive and placebo groups was not statistically analysed due to small numbers. No serious adverse events were recorded. In critically ill women aged 50-years and over, antiresorptive agents suppressed bone resorption markers without serious adverse events. However, recruitment was slow. Further phase 2 trials examining the efficacy of these agents are warranted and should address barriers to enrolment.Trial registration: ACTRN12617000545369, registered 18th April 2017.
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Affiliation(s)
- Neil R Orford
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia.
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine (SPPHPM), Monash University, Melbourne, Australia.
- IMPACT-Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia.
- Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Allison Bone
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine (SPPHPM), Monash University, Melbourne, Australia
| | - Mark A Kotowicz
- IMPACT-Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia
- Department of Medicine-Western Health, The University of Melbourne, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine (SPPHPM), Monash University, Melbourne, Australia
| | - Julie A Pasco
- IMPACT-Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia
- Department of Medicine-Western Health, The University of Melbourne, Melbourne, Australia
| | - Matthew Maiden
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Nima Kakho
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Claire Cattigan
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Martina Nichonghaile
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Claire Jones
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine (SPPHPM), Monash University, Melbourne, Australia
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
| | - Jacqueline Center
- Intensive Care Unit, St Vincent's Hospital Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine (SPPHPM), Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
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Kim T, Kim H. Pathophysiology and Therapeutic Management of Bone Loss in Patients with Critical Illness. Pharmaceuticals (Basel) 2023; 16:1718. [PMID: 38139844 PMCID: PMC10747168 DOI: 10.3390/ph16121718] [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: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Patients with critical illnesses are at higher risk of comorbidities, which can include bone mineral density loss, bone turnover marker increase, and fragility fractures. Patients admitted to intensive care units (ICUs) have a higher risk of bone fractures. Since hypermetabolism is a characteristic of ICU patients, such patients are often rapidly affected by systemic deterioration, which often results in systemic wasting disease. Major risk factors for ICU-related bone loss include physical restraint, inflammation, neuroendocrine stress, malnutrition, and medications. A medical history of critical illness should be acknowledged as a risk factor for impaired bone metabolism. Bone loss associated with ICU admission should be recognized as a key component of post-intensive care syndrome, and further research that focuses on treatment protocols and prevention strategies is required. Studies aimed at maintaining gut integrity have emphasized protein administration and nutrition, while research is ongoing to evaluate the therapeutic benefits of anti-resorptive agents and physical therapy. This review examines both current and innovative clinical strategies that are used for identifying risk factors of bone loss. It provides an overview of perioperative outcomes and discusses the emerging novel treatment modalities. Furthermore, the review presents future directions in the treatment of ICU-related bone loss.
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Affiliation(s)
- Taejin Kim
- Department of Urology, CHA University Ilsan Medical Center, CHA University School of Medicine, Goyang-si 10414, Republic of Korea;
| | - Hyojin Kim
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si 14353, Republic of Korea
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Elamir YM, Amir H, Lim S, Rana YP, Lopez CG, Feliciano NV, Omar A, Grist WP, Via MA. A randomized pilot study using calcitriol in hospitalized COVID-19 patients. Bone 2022; 154:116175. [PMID: 34508882 PMCID: PMC8425676 DOI: 10.1016/j.bone.2021.116175] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/01/2021] [Accepted: 09/03/2021] [Indexed: 12/24/2022]
Abstract
The systemic illness associated with SARS-CoV-2 infection results in hospitalization rate of 380.3 hospitalizations per 100,000 population, overwhelming health care systems. Vitamin D regulates expression of approximately 11,000 genes spanning many physiologic functions that include regulation of both innate and adaptive immune function. We investigate potential benefit of calcitriol therapy given to patients hospitalized with COVID-19. This was an open label, randomized clinical trial of calcitriol or no treatment given to hospitalized adult patients with COVID-19. Subjects were randomly assigned treatment with calcitriol 0.5 μg daily for 14 days or hospital discharge; or no treatment (1:1) at time of enrollment. We enrolled 50 consecutive patients, 25 per trial arm. The change in peripheral arterial oxygen saturation to the inspired fraction of oxygen (SaO2/FIO2 ratio) was calculated on admission and discharge between the groups. The control group had an average increase of +13.2 (±127.7) on discharge and the calcitriol group had an increase of +91.04 (±119.08) (p = .0305), suggesting an improvement in oxygenation among subjects who received calcitriol. Additionally, 12 patients in the control group required oxygen supplementation on admission and 21 of them were discharged on room air. 14 subjects needed oxygen supplementation in the calcitriol group on admission while all 25 were discharged on room air. Other clinical markers showed the average length of stay was 9.24 (±9.4) in the control group compared to 5.5 (±3.9) days in the calcitriol group (p = .14). The need for ICU transfer was 8 in the control group and 5 in the calcitriol group. There were 3 deaths and 4 readmissions in the control group and 0 deaths and 2 readmissions in the calcitriol group. This pilot study illustrates improvement in oxygenation among hospitalized patients with COVID-19 treated with calcitriol and suggests the need for a larger randomized trial.
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Affiliation(s)
- Yasmine M Elamir
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America
| | - Hajira Amir
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America.
| | - Steven Lim
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | - Yesha Patel Rana
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | | | | | - Ali Omar
- Division of Internal Medicine at Mount Sinai Beth Israel, United States of America
| | - William Paul Grist
- Division of Pulmonary and Critical Care Medicine at St Joseph's University Medical Center, United States of America
| | - Michael A Via
- Division of Endocrinology Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai Beth Israel, Mount Sinai Morningside, Mount Sinai West, United States of America
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Tseitkin B, Mårtensson J, Eastwood GM, Brown A, Ancona P, Lucchetta L, Iwashyna TJ, Robbins R, Bellomo R. Nature and impact of in-hospital complications associated with persistent critical illness. CRIT CARE RESUSC 2020; 22:378-387. [PMID: 38046870 PMCID: PMC10692497 DOI: 10.51893/2020.4.oa11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Persistent critical illness (PerCI) is defined as an intensive care unit (ICU) admission lasting ≥ 10 days. The in-hospital complications associated with its development are poorly understood. Aims: To test whether PerCI is associated with a greater prevalence, rate and specific types of in-hospital complications. Methods: Single-centre, retrospective, observational case-control study. Results: We studied 1200 patients admitted to a tertiary ICU from 2010 to 2015. Median ICU length of stay was 16 days (interquartile range [IQR], 12-23) for PerCI patients v 2.3 days (IQR, 1.1-3.7) for controls, and median hospital length of stay was 41 days (IQR, 22-75) v 8 days (IQR, 4-17) respectively. A greater proportion of PerCI patients received acute renal replacement therapy (37% v 6.8%) or underwent reintubation (17% v 1%) and/or tracheostomy (36% v 0.6%); P < 0.0001. Despite these complications, PerCI patients had similar hospital mortality (29% v 27%; P = 0.53). PerCI patients experienced a greater absolute number of complications (12.1 v 4.0 complications per patient; P < 0.0001) but had fewer exposure-adjusted complications (202 v 272 complications per 1000 hospital bed-days; P < 0.001) and a particularly high overall prevalence of specific complications. Conclusions: PerCI patients experience a higher prevalence, but not a higher rate, of exposure-adjusted complications. Some of these complications appear amenable to prevention, helping to define intervention targets in patients at risk of PerCI. Funding: Austin Hospital Intensive Care Trust Fund.
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Affiliation(s)
- Boris Tseitkin
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alastair Brown
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, Catholic University of the Sacred Heart, “A. Gemelli” University Hospital, Rome, Italy
| | - Luca Lucchetta
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Raymond Robbins
- Department of Administrative Informatics, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, VIC, Australia
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Holmes WL, Maish GO, Minard G, Croce MA, Dickerson RN. Hypercalcemia Without Hypervitaminosis D During Cholecalciferol Supplementation in Critically Ill Patients. Nutr Clin Pract 2019; 35:933-941. [PMID: 31605425 DOI: 10.1002/ncp.10407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Vitamin D deficiency during critical illness has been associated with worsened outcomes. Because most critically ill patients with severe traumatic injuries are vitamin D deficient, we investigated the efficacy and safety of cholecalciferol therapy for these patients. METHODS Fifty-three patients (>17 years of age) admitted to the trauma intensive care unit who had a serum 25-hydroxy vitamin D (25-OH vit D) concentration <20 ng/mL were given 10,000 IU of cholecalciferol daily. Efficacy was defined as achievement of a 25-OH vit D of 30-79.9 ng/mL. Safety was evaluated by the presence of hypercalcemia (serum ionized calcium [iCa] >1.32 mmol/L) or hypervitaminosis D (25-OH vit D >79.9 nmol/L). Patients were monitored for 2 weeks during cholecalciferol therapy. RESULTS Twenty-four patients (45%) achieved target 25-OH vit D. No patients experienced hypervitaminosis D. Hypercalcemia occurred in 40% (n = 21) of patients; 2 patients experienced an iCa >1.49 nmol/L. 25-OH vit D was significantly greater for those who developed hypercalcemia (37.2 + 11.2 vs 28.4 + 5.6 ng/mL, respectively, P < 0.001) by the second week of cholecalciferol. Of 24 patients who achieved target 25-OH vit D, 14 (58%) experienced hypercalcemia in contrast to 24% of patients (7 out of 29) who did not achieve target 25-OH vit D (P = 0.024). CONCLUSIONS Cholecalciferol normalized serum 25-OH vit D concentrations in less than half of patients yet was associated with a substantial proportion of patients with hypercalcemia without hypervitaminosis D.
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Affiliation(s)
- Whitney L Holmes
- Department of Pharmacy, Regional One Health, Memphis, Tennessee, USA
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin A Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Ibrahim A, Cutinha D, Ayton A. What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa? EVIDENCE-BASED MENTAL HEALTH 2019; 22:77-82. [PMID: 31003978 PMCID: PMC10270425 DOI: 10.1136/ebmental-2018-300064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 11/04/2022]
Abstract
Bed rest is commonly used on medical and paediatric wards as part of nursing management of the physically compromised patient with severe anorexia nervosa. The aim of this study was to review the evidence base of bed rest as an intervention in the management of severe anorexia nervosa. We searched MEDLINE, PubMed, Embase, PsychInfo, CINAHL, HMIC, AMED, HBE, BNI and guidelines written in English until April 2018 using the following terms: bed rest and anorexia nervosa. After exclusion of duplicates, three guidelines and eight articles were included. The papers were methodologically heterogeneous, and therefore, quantitative summary was not possible. There have been no randomised controlled trials to compare the benefits and harms of bed rest as the focus of intervention in the treatment of anorexia nervosa. Several papers showed that patients have a strong preference for less restrictive approaches. These are also less intensive in nursing time. Negative physical consequences were described in a number of studies: these included lower heart rate, impaired bone turn over and increased risk of infection. We found no evidence to support bed rest in hospital treatment of anorexia nervosa. The risks associated with bed rest are significant and include both physical and psychological harm, and these can be avoided by early mobilisation. Given the established complications of bed rest in other critically ill patient populations, it is difficult to recommend the enforcement of bed rest for patients with anorexia nervosa. Future research should focus on safe early mobilisation, which would reduce complications and improve patient satisfaction.
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Affiliation(s)
- Ali Ibrahim
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, London, UK
| | - Darren Cutinha
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, London, UK
| | - Agnes Ayton
- Cotswold House, Oxford Health NHS Foundation Trust Adult Mental Health Services, Oxford, Oxfordshire, UK
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Obesity attenuates serum 25-hydroxyvitamin D response to cholecalciferol therapy in critically ill patients. Nutrition 2019; 63-64:120-125. [PMID: 30939386 DOI: 10.1016/j.nut.2019.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/20/2019] [Accepted: 01/25/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The presence of obesity may confound cholecalciferol dosing in vitamin D-deficient patients owing to potentially decreased bioavailability. The aim of this retrospective study was to evaluate cholecalciferol therapy in vitamin D-deficient, critically ill trauma patients with and without obesity. METHODS Adult patients with severe traumatic injuries who had a serum 25-hydroxyvitamin D (25-OH vit D) <50nmol/L were prescribed 10 000 IU of liquid cholecalciferol daily. Efficacy was defined as achievement of a 25-OH vit D of 75 to 200nmol/L. Safety was evaluated by the presence of hypercalcemia (serum ionized calcium >1.32 mmol/L). Fifty-three patients (18 obese, 35 non-obese) were identified for study. RESULTS Despite similar baseline concentrations (36 ± 7 versus 37 ± 7 nmol/L; P = NS), 25-OH vit D response was attenuated for those with obesity after 1 and 2 wk of cholecalciferol therapy (51 ± 18 versus 66 ± 27nmol/L, P < 0.01; 68 ± 19 versus 92 ± 25nmol/L, P < 0.01, respectively). Patients with obesity also tended to experience less hypercalcemia (22% versus 49% of patients, respectively) post-cholecalciferol therapy. CONCLUSION Obesity alters the response to cholecalciferol therapy in critically ill patients with severe traumatic injuries.
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Su N, Yang J, Xie Y, Du X, Chen H, Zhou H, Chen L. Bone function, dysfunction and its role in diseases including critical illness. Int J Biol Sci 2019; 15:776-787. [PMID: 30906209 PMCID: PMC6429025 DOI: 10.7150/ijbs.27063] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
The skeleton is one of the largest organs in the human body. In addition to its conventional functions such as support, movement and protection, the skeleton also contributes to whole body homeostasis and maintenance of multiple important non-bone organs/systems (extraskeletal functions). Both conventional and extraskeletal functions of the skeleton are defined as bone function. Bone-derived factors (BDFs) are key players regulating bone function. In some pathophysiological situations, including diseases affecting bone and/or other organs/systems, the disorders of bone itself and the subsequently impaired functions of extraskeletal organs/systems caused by abnormal bone (impaired extraskeletal functions of bone) are defined as bone dysfunction. In critical illness, which is a health status characterized by the dysfunction or severe damage of one or multiple important organs or systems, the skeleton shows rapid bone loss resulting from bone hyper-resorption and impaired osteoblast function. In addition, the dysfunctions of the skeleton itself are also closely related to the severity and prognosis of critical illness. Therefore, we propose that there is bone dysfunction in critical illness. Some methods to inhibit osteoclast activity or promote osteoblast function by the treatment of bisphosphonates or PTH1-34 benefit the outcome of critical illness, which indicates that enhancing bone function may be a potential novel strategy to improve prognosis of diseases including critical illness.
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Affiliation(s)
- Nan Su
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Jing Yang
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Yangli Xie
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Xiaolan Du
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Hangang Chen
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
| | - Hong Zhou
- Bone Research Program, ANZAC Research Institute, The University of Sydney, Hospital Road, Sydney, NSW 2139, Australia
| | - Lin Chen
- Center of Bone Metabolism and Repair, State Key Laboratory of Trauma, Burns and Combined Injury, Trauma Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, China
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Abstract
Improved survival after critical illness has led to recognition of impaired recovery following critical illness as a major public health problem. A consistent association between critical illness and accelerated bone loss has been described, including changes in bone turnover markers, bone mineral density, and fragility fracture rate. An association between accelerated bone turnover and increased mortality after critical illness is probable. Assessment of the effect of antifracture agents on fracture rate and mortality in the high-risk population of postmenopausal women with prolonged ventilation is warranted.
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Affiliation(s)
- Neil R Orford
- University Hospital Geelong, Barwon Health, Bellerine St, Geelong, VIC 3220, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia; School of Medicine, Deakin University, 75 Pigdons Rd, Geelong, VIC 3216, Australia.
| | - Julie A Pasco
- University Hospital Geelong, Barwon Health, Bellerine St, Geelong, VIC 3220, Australia; School of Medicine, Deakin University, 75 Pigdons Rd, Geelong, VIC 3216, Australia; Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Wellington Rd, Clayton, VIC 3800, Australia; Department of Medicine, Melbourne Medical School-Western Campus, The University of Melbourne, McKechnie St, St Albans, VIC 3021, Australia
| | - Mark A Kotowicz
- University Hospital Geelong, Barwon Health, Bellerine St, Geelong, VIC 3220, Australia; School of Medicine, Deakin University, 75 Pigdons Rd, Geelong, VIC 3216, Australia; Department of Medicine, Melbourne Medical School-Western Campus, The University of Melbourne, McKechnie St, St Albans, VIC 3021, Australia
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Orford NR, Bailey M, Bellomo R, Pasco JA, Cooper DJ, Kotowicz MA. Changes in bone mineral density in women before critical illness: a matched control nested cohort study. Arch Osteoporos 2018; 13:119. [PMID: 30397732 DOI: 10.1007/s11657-018-0533-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 10/19/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED The contribution of premorbid bone health to accelerated bone loss following critical illness is unknown. This study compared bone density in women before critical illness to women who did not become critically ill. Overall bone density was similar, although femoral neck bone mass increased immediately prior to critical illness. PURPOSE The relative contribution of acute and chronic factors to accelerated loss of bone mineral density (BMD) following critical illness is unknown. This study compared the BMD trajectory of women before critical illness to the BMD trajectory of women who did not become critically ill. METHODS This prospective, nested, age- and medication-matched, case-control study compared trajectory of BMD in women in the Geelong Osteoporosis study (GOS) requiring admission to an Australian Intensive Care Unit (ICU) between June 1998 and March 2016, to women not admitted to ICU. The main outcome was age and medication use adjusted change in BMD. RESULTS A total of 52 women, with a mean age of 77 ± 9 years were admitted to ICU, predominantly post-surgery (75%), during the study period. A greater age-adjusted annual rate of decline was observed for pre-ICU women compared to no-ICU women for AP spine BMD (-0.010 ± 0.002 g/cm2 vs -0.005 ± 0.002 g/cm2, p = 0.01) over the 15-year study period. In participants with multiple BMDs 2 years before critical illness, a significantly greater increase in femoral neck BMD compared to age- and medication-matched controls was observed (difference in BMD, ICU vs no-ICU = 0.037 ± 0.013 g/cm2, p = 0.006). CONCLUSION In a cohort of women with predominantly surgical ICU admission, bone health prior to critical illness was comparable to age- and medication-matched controls, with a relative increase in femoral neck bone mass immediately prior to critical illness. These findings suggest critical illness-related bone loss cannot be entirely explained as a continuation of pre-morbid bone trajectory.
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Affiliation(s)
- Neil R Orford
- Intensive Care, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia.
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia.
- School of Medicine, Deakin University, Geelong, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Julie A Pasco
- School of Medicine, Deakin University, Geelong, Australia
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
- Department of Medicine, Melbourne Medical School-Western Campus, The University of Melbourne, St Albans, Australia
| | - David J Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine (DEPM), Monash University, Melbourne, Australia
| | - Mark A Kotowicz
- School of Medicine, Deakin University, Geelong, Australia
- Department of Medicine, Melbourne Medical School-Western Campus, The University of Melbourne, St Albans, Australia
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Li W, Cheng X, Guo L, Li H, Sun C, Cui X, Zhang Q, Song G. Association between serum 25-hydroxyvitamin D concentration and pulmonary infection in children. Medicine (Baltimore) 2018; 97:e9060. [PMID: 29505508 PMCID: PMC5943122 DOI: 10.1097/md.0000000000009060] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
We assessed the relationship between serum 25-hydroxyvitamin D (25(OH)D) level and community-acquired pneumonia (CAP) among Chinese children.This observational study examined children aged 3 days to 14 years (n = 1582) from the Capital Institute of Pediatrics in 2009 to 2011. There were 797 children in the CAP group and 785 controls. The CAP group was divided into 2 groups: a pneumonia group and pneumonia-induced sepsis group. The serum 25(OH)D level was estimated using micro whole blood chemiluminescence.The average serum 25(OH)D level in all samples was 25.32 ± 14.07 ng/mL, with the CAP group showing a lower value than the control group (P < .001). There were also significant differences between the pneumonia group and pneumonia-induced sepsis group (P < .001). In the pneumonia-induced sepsis group, significant differences in serum 25(OH)D levels were observed in children who received mechanical ventilation or presenting with multiple organ dysfunction (P < .01).All serum 25(OH)D levels in the pneumonia group and pneumonia-induced sepsis group were below normal levels, particularly in the sepsis group. A lower serum 25(OH)D level was associated with more serious symptoms in CAP children. Children with low serum 25(OH)D levels may be at higher risk of receiving mechanical ventilation and presenting with multiple organ dysfunction. These findings suggest that vitamin D supplements are beneficial for the treatment and prevention of CAP.
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Affiliation(s)
- Wei Li
- Department of ICU, Affiliated Children's Hospital of Capital Institute of Pediatrics
| | - Xianfen Cheng
- Department of Central Laboratory of Capital Institute of Pediatrics
| | - Linying Guo
- Department of ICU, Affiliated Children's Hospital of Capital Institute of Pediatrics
| | - Hongri Li
- Department of ICU, Affiliated Children's Hospital of Capital Institute of Pediatrics
| | - Chunrong Sun
- Department of Central Laboratory of Capital Institute of Pediatrics
| | - Xiaodai Cui
- Department of Central Laboratory of Capital Institute of Pediatrics
| | - Qi Zhang
- Department of Pediatrics, China-Japan Friendship Hospital District, Chaoyang District, Beijing, China
| | - Guowei Song
- Department of Central Laboratory of Capital Institute of Pediatrics
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Abstract
OBJECTIVES Survivors of critical illness have an increased prevalence of bone fractures. However, early changes in bone strength, and their relationship to structural changes, have not been described. We aimed to characterize early changes in bone functional properties in critical illness and their relationship to changes in bone structure, using a sepsis rodent model. DESIGN Experimental study. SETTING Animal research laboratory. SUBJECTS Adult Sprague-Dawley rats. INTERVENTIONS Forty Sprague-Dawley rats were randomized to cecal ligation and puncture or sham surgery. Twenty rodents (10 cecal ligation and puncture, 10 sham) were killed at 24 hours, and 20 more at 96 hours. MEASUREMENTS AND MAIN RESULTS Femoral bones were harvested for strength testing, microCT imaging, histologic analysis, and multifrequency scanning probe microscopy. Fracture loads at the femoral neck were significantly reduced for cecal ligation and puncture-exposed rodents at 24 hours (83.39 ± 10.1 vs 103.1 ± 17.6 N; p = 0.014) and 96 hours (81.60 ± 14.2 vs 95.66 ± 14.3 N; p = 0.047). Using multifrequency scanning probe microscopy, collagen elastic modulus was lower in cecal ligation and puncture-exposed rats at 24 hours (1.37 ± 0.2 vs 6.13 ± 0.3 GPa; p = 0.001) and 96 hours (5.57 ± 0.5 vs 6.13 ± 0.3 GPa; p = 0.006). Bone mineral elastic modulus was similar at 24 hours but reduced in cecal ligation and puncture-exposed rodents at 96 hours (75.34 ± 13.2 vs 134.4 ± 8.2 GPa; p < 0.001). There were no bone architectural or bone mineral density differences by microCT. Similarly, histologic analysis demonstrated no difference in collagen and elastin staining, and C-X-C chemokine receptor type 4, nuclear factor kappa beta, and tartrate-resistant acid phosphatase immunostaining. CONCLUSIONS In a rodent sepsis model, trabecular bone strength is functionally reduced within 24 hours and is associated with a reduction in collagen and mineral elastic modulus. This is likely to be the result of altered biomechanical properties, rather than increased bone mineral turnover. These data offer both mechanistic insights and may potentially guide development of therapeutic interventions.
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Schwetz V, Schnedl C, Urbanic-Purkart T, Trummer C, Dimai HP, Fahrleitner-Pammer A, Putz-Bankuti C, Christopher KB, Obermayer-Pietsch B, Pieber TR, Dobnig H, Amrein K. Effect of vitamin D3 on bone turnover markers in critical illness: post hoc analysis from the VITdAL-ICU study. Osteoporos Int 2017; 28:3347-3354. [PMID: 28842727 PMCID: PMC5684305 DOI: 10.1007/s00198-017-4190-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/02/2017] [Indexed: 12/21/2022]
Abstract
UNLABELLED In this post hoc analysis of the VITdAL-ICU study, an RCT in critically ill adults with 25-hydroxyvitamin D levels ≤20 ng/ml, vitamin D3 did not have a significant effect on β-Crosslaps and osteocalcin. INTRODUCTION Observational studies have shown accelerated bone loss in ICU survivors. A reversible contributor is vitamin D deficiency. In a post hoc analysis of the VITdAL-ICU study, we evaluated the effect of high-dose vitamin D3 on the bone turnover markers (BTM) β-Crosslaps (CTX) and osteocalcin (OC). METHODS The VITdAL-ICU study was a randomized, double-blind, placebo-controlled trial in critically ill adults with 25-hydroxyvitamin D levels ≤20 ng/ml who received placebo or high-dose vitamin D3 (a loading dose of 540,000 IU and starting 1 month after the loading dose five monthly maintenance doses of 90,000 IU). In this analysis on 289 survivors (209 telephone, 80 personal follow-up visits), BTM were analyzed on days 0, 3, 7, 28, and 180; self-reported falls and fractures were assessed. Bone mineral density (BMD) was measured after 6 months. RESULTS At baseline, CTX was elevated; OC was low in both groups-after 6 months, both had returned to normal. There were no differences between groups concerning BTM, BMD, falls, or fractures. In linear mixed effects models, CTX and OC showed a significant change over time (p < 0.001, respectively), but there was no difference between the vitamin D and placebo group (p = 0.688 and p = 0.972, respectively). CONCLUSIONS Vitamin D supplementation did not have a significant effect on BTM. Further studies should assess the effectiveness of vitamin D on musculoskeletal outcomes in ICU survivors.
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Affiliation(s)
- V Schwetz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - C Schnedl
- Klinikum Klagenfurt am Wörthersee, Institute for Diagnostic and Interventional Radiology, Carinthia, Austria
| | - T Urbanic-Purkart
- Department of Neurology, Division of General Neurology, Medical University of Graz, Graz, Styria, Austria
| | - C Trummer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - H P Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - A Fahrleitner-Pammer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - C Putz-Bankuti
- Department of Internal Medicine, LKH Hörgas-Enzenbach, Gratwein-Straßengel, Styria, Austria
| | - K B Christopher
- The Nathan E. Hellman Memorial Laboratory, Division of Renal Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - B Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - T R Pieber
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - H Dobnig
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
- Schilddrüsen|Endokrinologie|Osteoporose, Institut Dobnig GmbH, Graz, Styria, Austria
| | - K Amrein
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria.
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Evans DJW, Lewis SR, Smith AF. Pharmacological interventions for preventing bone density loss in critically ill people. Hippokratia 2017. [DOI: 10.1002/14651858.cd012716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- David JW Evans
- Lancaster University; Lancaster Health Hub; Lancaster UK LA1 4YG
| | - Sharon R Lewis
- Royal Lancaster Infirmary; Patient Safety Research Department; Pointer Court 1, Ashton Road Lancaster UK LA1 4RP
| | - Andrew F Smith
- Royal Lancaster Infirmary; Department of Anaesthesia; Ashton Road Lancaster Lancashire UK LA1 4RP
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Abstract
OBJECTIVES The origin of systemic inflammatory response syndrome and multiple organ dysfunction syndrome is poorly understood but remains a fundamental concern in the ICU. This paper provides a critical appraisal on whether bone failure may represent an unrecognized component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome. DATA SOURCES, DATA SELECTION, AND DATA EXTRACTION Search of the PubMed database and manual review of selected articles investigating bone pathophysiology in critical illness. DATA SYNTHESIS Bone hyperresorption is highly prevalent among critically ill patients. Bone breakdown releases numerous systemically active cytokines and bone-sequestered toxins, with the capacity to fuel inflammatory hypercytokinaemia and metabolic toxaemia. Anti-resorptive medication inhibits bone break down and preadmission anti-resorptive use is associated with superior survival among critically ill patients. CONCLUSIONS We propose that hyperresorptive bone failure is an unrecognised component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome that is causal to critical illness progression. If this hypothesis is valid, bone preservative strategies could reduce the risk of osteoporosis/fractures among ICU survivors, as well as decreasing critical illness mortality.
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Surviving physiological stress: Can insights into human adaptation to austere environments be applied to the critical care unit? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.1016/j.tacc.2016.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Evaluation of Bone Metabolism in Critically Ill Patients Using CTx and PINP. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1951707. [PMID: 28025639 PMCID: PMC5153473 DOI: 10.1155/2016/1951707] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/11/2016] [Accepted: 11/15/2016] [Indexed: 11/18/2022]
Abstract
Background. Prolonged immobilization, nutritional and vitamin D deficiency, and specific drug administration may lead to significant bone resorption. Methods and Patients. We prospectively evaluated critically ill patients admitted to the ICU for at least 10 days. Demographics, APACHE II, SOFA scores, length of stay (LOS), and drug administration were recorded. Blood collections were performed at baseline and on a weekly basis for five consecutive weeks. Serum levels of PINP, β-CTx, iPTH, and 25(OH)vitamin D were measured at each time-point. Results. We enrolled 28 patients of mean age 67.4 ± 2.3 years, mean APACHE II 22.2 ± 0.9, SOFA 10.1 ± 0.6, and LOS 31.6 ± 5.7 days. Nineteen patients were receiving low molecular weight heparin, 17 nor-epinephrine and low dose hydrocortisone, 18 transfusions, and 3 phenytoin. 25(OH)vitamin D serum levels were very low in all patients at all time-points; iPTH serum levels were increased at baseline tending to normalize on 5th week; β-CTx serum levels were significantly increased compared to baseline on 2nd week (peak values), whereas PINP levels were increased significantly after the 4th week. Conclusions. Our data show that critically ill patients had a pattern of hypovitaminosis D, increased iPTH, hypocalcaemia, and BTMs compatible with altered bone metabolism.
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18
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Relevance of serum sclerostin concentrations in critically ill patients. J Crit Care 2016; 37:38-44. [PMID: 27621111 DOI: 10.1016/j.jcrc.2016.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 07/26/2016] [Accepted: 08/17/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Sclerostin is a negative regulator of bone metabolism and associated with chronic morbidities. We investigated circulating sclerostin in critically ill patients. METHODS A total of 264 patients (170 with sepsis) were studied prospectively upon admission to the medical intensive care unit (ICU) and on day 7. Patients' survival was followed for up to 3 years. RESULTS Sclerostin serum levels were significantly elevated in critically ill patients at ICU admission compared with 99 healthy controls. Unlike in healthy controls, sclerostin did not depend on sex or age of ICU patients. Sclerostin was associated with disease severity, independent of the presence of sepsis. Sclerostin levels increased during the first week of treatment at the ICU but were not a predictor of mortality. Sclerostin was elevated in patients with preexisting chronic kidney disease or liver cirrhosis, but was not related to diabetes, obesity, or cardiovascular disease. Circulating sclerostin in ICU patients correlated with biomarkers reflecting renal, hepatic and cardiac dysfunction, and biomarkers reflecting bone metabolism. CONCLUSION Serum sclerostin concentrations are significantly elevated in critically ill patients, linked to renal or hepatic organ failure, and associated with bone resorption markers, supporting its value as a potential tool for the assessment of ICU-related metabolic bone disease.
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Orford NR, Lane SE, Bailey M, Pasco JA, Cattigan C, Elderkin T, Brennan-Olsen SL, Bellomo R, Cooper DJ, Kotowicz MA. Changes in Bone Mineral Density in the Year after Critical Illness. Am J Respir Crit Care Med 2016; 193:736-44. [PMID: 26559667 DOI: 10.1164/rccm.201508-1514oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Critical illness may be associated with increased bone turnover and loss of bone mineral density (BMD). Prospective evidence describing long-term changes in BMD after critical illness is needed to further define this relationship. OBJECTIVES To measure the change in BMD and bone turnover markers (BTMs) in subjects 1 year after critical illness compared with population-based control subjects. METHODS We studied adult patients admitted to a tertiary intensive care unit (ICU) who required mechanical ventilation for at least 24 hours. We measured clinical characteristics, BTMs, and BMD during admission and 1 year after ICU discharge. We compared change in BMD to age- and sex-matched control subjects from the Geelong Osteoporosis Study. MEASUREMENTS AND MAIN RESULTS Sixty-six patients completed BMD testing. BMD decreased significantly in the year after critical illness at both femoral neck and anterior-posterior spine sites. The annual decrease was significantly greater in the ICU cohort compared with matched control subjects (anterior-posterior spine, -1.59%; 95% confidence interval, -2.18 to -1.01; P < 0.001; femoral neck, -1.20%; 95% confidence interval, -1.69 to -0.70; P < 0.001). There was a significant increase in 10-year fracture risk for major fractures (4.85 ± 5.25 vs. 5.50 ± 5.52; P < 0.001) and hip fractures (1.57 ± 2.40 vs. 1.79 ± 2.69; P = 0.001). The pattern of bone resorption markers was consistent with accelerated bone turnover. CONCLUSIONS Critically ill individuals experience a significantly greater decrease in BMD in the year after admission compared with population-based control subjects. Their bone turnover biomarker pattern is consistent with an increased rate of bone loss.
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Affiliation(s)
- Neil R Orford
- 1 Intensive Care Unit, University Hospital Geelong.,3 School of Medicine, Deakin University, and.,2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen E Lane
- 3 School of Medicine, Deakin University, and.,4 Biostatistics Unit, Barwon Health, Geelong, Australia
| | - Michael Bailey
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julie A Pasco
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,6 Barwon Health, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Claire Cattigan
- 1 Intensive Care Unit, University Hospital Geelong.,3 School of Medicine, Deakin University, and
| | | | - Sharon L Brennan-Olsen
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia.,8 Australian Institute for Musculoskeletal Science and Epidemiology Unit for Healthy Ageing, School of Medicine, University of Melbourne, Melbourne, Australia; and.,9 Institute for Health and Ageing, Australian Catholic University, Melbourne, Australia
| | - Rinaldo Bellomo
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - David J Cooper
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark A Kotowicz
- 5 Epi-Centre for Healthy Ageing, School of Medicine, Deakin University, Geelong, Australia.,6 Barwon Health, Geelong, Australia.,7 Department of Medicine, The University of Melbourne, Melbourne, Australia
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Schulman RC, Moshier EL, Rho L, Casey MF, Godbold JH, Zaidi M, Mechanick JI. INTRAVENOUS PAMIDRONATE IS ASSOCIATED WITH REDUCED MORTALITY IN PATIENTS WITH CHRONIC CRITICAL ILLNESS. Endocr Pract 2016; 22:799-808. [PMID: 26919649 DOI: 10.4158/ep151050.or] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Chronic critical illness (CCI), characterized by prolonged mechanical ventilation and tracheostomy, commonly manifests with elevated bone resorption, which has previously been shown to abate after treatment with intravenous (IV) bisphosphonates. Our study assessed the impact of pamidronate administration on clinical outcomes in a CCI cohort. METHODS A retrospective case series was performed on 148 patients admitted to The Mount Sinai Hospital Respiratory Care Unit (RCU) from 2009-2010. We identified patients with CCI who did (n = 30) or did not (n = 118) receive IV pamidronate (30 to 90 mg). Both groups included patients with normal and abnormal renal function. Pamidronate was administered for elevated urine or serum N-telopeptide, hypercalciuria, or hypercalcemia. RESULTS RCU and 1-year mortality were significantly lower in the pamidronate group (0 and 20%, respectively) compared to nonreceivers (19 and 56%, respectively) (P = .0077 and P = .0004, respectively). After adjusting for differences in baseline creatinine, estimated glomerular filtration rate, and serum calcium, the association with reduced mortality remained significant at 1 year (P = .0132) and with borderline significance for RCU mortality (P = .0911). Creatinine was significantly lower 7 days following pamidronate administration (P = .0025), with no significant difference at 14 days compared to baseline. Pamidronate receivers showed a greater increase in albumin during the RCU stay (2.49 to 3.23 g/dL), compared to nonreceivers (2.43 to 2.64 g/dL) (P = .0007). Pamidronate administration was associated with a significantly reduced rate of hypoglycemia compared to RCU patients not receiving pamidronate (0.09 versus 0.12; P = .0071). CONCLUSION Pamidronate use in a CCI population is associated with reduced mortality, lower hypoglycemia rates, improved albumin, and stable renal function. ABBREVIATIONS BMI = body mass index CCI = chronic critical illness CI = confidence interval CKD = chronic kidney disease CTx = C-telopeptide eGFR = estimated glomerular filtration rate ICU = intensive care unit IV = intravenous NTx = N-telopeptide PMV = prolonged mechanical ventilation RCU = respiratory care unit.
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Cheng HH, Carmona F, McDavitt E, Wigmore D, Perez-Rossello JM, Gordon CM, Pigula FA, Laussen PC, Rajagopal SK. Fractures Related to Metabolic Bone Disease in Children with Congenital Heart Disease. CONGENIT HEART DIS 2015; 11:80-6. [PMID: 26302998 DOI: 10.1111/chd.12293] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Critically ill children with congenital heart disease (CHD) are at risk for metabolic bone disease (MBD) and bone fractures. Our objective was to characterize a cohort of CHD patients with fractures and describe a Fragile Bone Protocol (FBP) developed to reduce fractures. DESIGN/SETTING Patients who developed fractures in the Cardiac Intensive Care Unit (CICU) of Boston Children's Hospital from 3/2008 to 6/2014 were identified via quality improvement and radiology databases. The FBP (initiated July 2011) systematically identifies patients at risk for MBD and prescribes special handling precautions. RESULTS Twenty-three fractures were identified in 15 children. Median age at fracture identification was 6.2 months, with a median duration of hospitalization before fracture diagnosis of 2.7 months. Six patients (40%) had single ventricle CHD. Hyperparathyroidism and low 25-OH vitamin D levels were present in 77% and 40% of those tested, respectively. Compared with patients not diagnosed with fractures, fracture patients had increased exposure to possible risk factors for MBD and had elevated parathyroid and decreased calcitriol levels.Six patients (40%) did not survive to hospital discharge, compared with an overall CICU mortality rate of 2.6% (P < .01). The fracture case rate before implementation of the FBP was 2.6 cases/1000 admissions and was 0.7/1000 after implementation of the FBP (P = .04). CONCLUSIONS Critically ill CHD patients are at risk for fractures. They represent a complex group who frequently has hyperparathyroidism and decreased calcitriol levels, and each may predispose to fractures. FBPs consisting of identification and careful patient handling should be considered in at-risk patients.
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Affiliation(s)
- Henry H Cheng
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA
| | - Fabio Carmona
- Department of Pediatric Intensive Care, Hospital das Clinicas of Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Erica McDavitt
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA
| | - Daniel Wigmore
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA
| | - Jeannette M Perez-Rossello
- Department of Radiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Radiology, Harvard Medical School, Boston, Mass, USA
| | - Catherine M Gordon
- Department of Medicine, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA.,Department of Adolescent Medicine and Endocrinology, Hasbro Children's Hospital and Albert Medical School, Brown University, Providence, RI, USA
| | - Frank A Pigula
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass, USA.,Department of Surgery, Harvard Medical School, Boston, Mass, USA
| | - Peter C Laussen
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Satish K Rajagopal
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
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Dickerson RN, Berry SC, Ziebarth JD, Swanson JM, Maish GO, Minard G, Brown RO. Dose-response effect of ergocalciferol therapy on serum 25-hydroxyvitamin D concentration during critical illness. Nutrition 2015. [PMID: 26213135 DOI: 10.1016/j.nut.2015.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the dose-response relationship between ergocalciferol therapy and serum 25-hydroxyvitamin D concentrations in enterally fed, critically ill patients with traumatic injuries. METHODS A retrospective cohort of critically ill patients with traumatic injuries and vitamin D deficiency (25-OH vitamin D <50 nmol/L) were given either 50 000 IU of liquid ergocalciferol weekly, twice weekly, or three times weekly while in the intensive care unit (ICU). Serum 25-OH vitamin D and ionized calcium concentrations were monitored weekly. Ergocalciferol therapy was stopped when the serum 25-OH vitamin D was >75 nmol/L, if the patient experienced hypercalcemia (ionized calcium >1.34 mmol/L), when the patient was discharged from the ICU, or if enteral nutrition was discontinued. RESULTS Sixty-five patients (16, 18, and 31 per dosage group) were examined. One (6%), two (11%), and eight (26%) patients achieved normal 25-OH vitamin D concentrations after 2 to 4 wk of ergocalciferol therapy for each dosage group, respectively (P < 0.001). Serum 25-OH vitamin D concentrations improved from 36 ± 6, 40 ± 7, and 37 ± 6 nmol/L to 50 ± 15, 54 ± 21, and 62 ± 17 nmol/L, respectively, after 2 wk of ergocalciferol therapy (P < 0.001) Two (13%), one (6%), and seven (23%) patients developed hypercalcemia for each dosage group, respectively (P = NS). CONCLUSIONS Ergocalciferol therapy improved baseline serum 25-OH vitamin D concentrations but was inadequate for consistently achieving normal serum concentrations of 25-OH vitamin D during critical illness. The trend in increasing appearance of mild hypercalcemia for the highest dosage group is concerning.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Scott C Berry
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jamie D Ziebarth
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joseph M Swanson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - George O Maish
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rex O Brown
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
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Orford N, Cattigan C, Brennan SL, Kotowicz M, Pasco J, Cooper DJ. The association between critical illness and changes in bone turnover in adults: a systematic review. Osteoporos Int 2014; 25:2335-46. [PMID: 24803332 DOI: 10.1007/s00198-014-2734-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/22/2014] [Indexed: 01/11/2023]
Abstract
SUMMARY Critical illness may lead to altered bone turnover and associated adverse health outcomes. This systematic review found moderate evidence for a positive association between critical illness and increased bone turnover. Prospective cohort studies that identify the extent and risk factors for critical illness related bone loss are required. INTRODUCTION Intensive care patients face health issues that extend beyond their critical illness and result in significant morbidity and mortality. Critical illness may result in altered bone turnover due to associated immobilisation, inflammation, exposure to medications that effect bone and calcium metabolism, and endocrine dysfunction. The aim of this study was to synthesise the existing evidence for altered bone turnover in adults admitted to intensive care. METHODS A literature search using MEDLINE and EMBASE was performed from 1965 to March 2013. Reviewed studies investigated the relationship between critical illness and evidence of altered bone turnover (bone turnover markers, bone mineral density, or fracture). Studies were rated upon their methodological quality, and a best-evidence synthesis was used to summarise the results. RESULTS Four cohort and seven case-control studies were identified for inclusion, of which five studies were rated as being of higher methodological quality. Ten of the studies measured bone turnover markers, and one study fracture rate. Findings were consistent across studies, and best-evidence analysis resulted in a conclusion that moderate evidence exists for an association between critical illness requiring admission to intensive care and altered bone turnover. CONCLUSION A positive association between critical illness requiring intensive care admission and bone turnover exists, although data are limited, and the risk factors and the nature of the relationship are not yet understood. Prospective cohort studies that identify risk factors and extent of critical illness related bone turnover changes are required.
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Affiliation(s)
- N Orford
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia,
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Joshi A, Bhadade R, Varthakavi PK, DeSouza R, Bhagwat NM, Chadha MD. Vitamin D deficiency is associated with increased mortality in critically ill patients especially in those requiring ventilatory support. Indian J Endocrinol Metab 2014; 18:511-515. [PMID: 25143908 PMCID: PMC4138907 DOI: 10.4103/2230-8210.137504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Vitamin D (VitD) classically recognized for its role in the musculoskeletal system, has been implicated in myriad of conditions such as diabetes, immune dysfunction, cancers, heart disease, metabolic syndrome, etc. We studied the role of VitD in acute care setting and its correlation with mortality. MATERIALS AND METHODS A total of 85 consecutive consenting patients admitted in medical intensive care unit of tertiary care hospital who fulfilled the inclusion criteria were included. All patients were evaluated clinically, and blood samples were collected for hemogram, biochemical investigations including serum calcium, phosphorus, alkaline phosphatase, magnesium, along with 25(OH) VitD, 1,25(OH) VitD and intact parathormone levels. Simplified acute physiology score (SAPS II) was calculated for all patients. RESULTS VitD was deficient (<30 ng/ml) in 27 patients (32%). The overall mortality was more in VitD deficient group as compared to VitD sufficient group (74 vs. 41%; P < 0.05). The actual mortality in VitD deficient group was higher than the mortality predicted by SAPS II score (50 vs. 74%; P < 0.0507). VitD deficiency was also associated with more mortality among those requiring ventilator support (95% vs. 40%; P < 0.05) as well as with higher blood glucose (124.5 ± 29.7 vs. 94.8 ± 19.8: P < 0.01) levels. CONCLUSION VitD deficiency was associated with increased mortality, poor ventilator outcomes, and increased blood glucose in critically ill patients.
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Affiliation(s)
- Ameya Joshi
- Department of Endocrinology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Rakesh Bhadade
- Department of Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Premlata K. Varthakavi
- Department of Endocrinology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Rosmarie DeSouza
- Department of Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Nikhil M. Bhagwat
- Department of Endocrinology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Manoj D. Chadha
- Department of Endocrinology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
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Çekmez F, Aydemir G, Yildirim S, Bulut Ö, Tunç T, Kul M, İnce E, Çoban A. Diagnostic Value of 25-Hydroxyvitamin D Level and New Cytokines in Neonatal Sepsis. EUR J INFLAMM 2014. [DOI: 10.1177/1721727x1401200209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to evaluate diagnostic value of 25-hydroxyvitamin D level, Upar, IL-33 and ST2 in comparison with C-reactive protein, TNF-α and Interleukin-6 in neonatal sepsis. A total of 106 term babies were included 20 of whom were the control group. We used only data of high probable sepsis with blood culture positive infants, therefore 46 infants were excluded. Blood was collected from infants from the first day of sepsis (1.value) and 48–72 hours later (2.value). There were significant differences between the controls and sepsis (1.value) for 25-hydroxyvitamin D levels (35±19ng/ml and 69±7.5ng/ml, p=0.01), for IL-33 levels (90±34 ng/ml and 412±170 ng/ml, p=0.01), for sST2 levels (453±44 ng/ml and 4120±2720ng/ml, p=0.01), for sUpar levels (2.1±1.3 ng/ml and 11.4 ± 5.2 ng/ml, p=0.01), respectively. There were significant differences between sepsis (1.value) and sepsis (2.value.) with reference to 25-hydroxyvitamin D, IL-33, sST2, and suPAR levels, respectively. In the light of these results, it may be suggested that 25-hydroxyvitamin D level, upar, IL-33 and ST2 can be used as an acute phase reactant like C-reactive protein, TNF-α and Interleukin-6 in diagnosis of neonatal sepsis.
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Affiliation(s)
- F. Çekmez
- Department of Pediatrics, Division of Neonatology, GATA Medical Faculty, Istanbul, Turkey
| | - G. Aydemir
- Department of Pediatrics, Division of Neonatology, GATA Medical Faculty, Istanbul, Turkey
| | - S. Yildirim
- Department of Pediatrics, Division of Neonatology, Istanbul Medical Faculty, Turkey
| | - Ö. Bulut
- Department of Pediatrics, Division of Neonatology, Istanbul Medical Faculty, Turkey
| | - T. Tunç
- Department of Pediatrics, Division of Neonatology, GATA Medical Faculty, Ankara, Turkey
| | - M. Kul
- Department of Pediatrics, Division of Neonatology, GATA Medical Faculty, Istanbul, Turkey
| | - E.Z. İnce
- Department of Pediatrics, Division of Neonatology, Istanbul Medical Faculty, Turkey
| | - A. Çoban
- Department of Pediatrics, Division of Neonatology, Istanbul Medical Faculty, Turkey
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26
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Stokes CS, Krawczyk M, Reichel C, Lammert F, Grünhage F. Vitamin D deficiency is associated with mortality in patients with advanced liver cirrhosis. Eur J Clin Invest 2014; 44:176-83. [PMID: 24236541 DOI: 10.1111/eci.12205] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 11/10/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic liver disease is the fifth most common cause of mortality in Europe. Recently, vitamin D deficiency has been associated with an increased risk of mortality in the general population. As patients with advanced liver disease frequently exhibit vitamin D deficiency, we assessed for a possible association of vitamin D deficiency with survival in a cohort of patients with advanced liver disease. METHODS Sixty-five patients with liver cirrhosis (median age, 58 years; range, 19-76 years; 66% male; Child-Pugh stage C, 46%) were included in our prospective single-centre survival study. Serum 25-hydroxyvitamin D concentrations were measured by chemiluminescence immunoassay. The optimal cut-off was determined using receiver operating characteristic (ROC) and Kaplan-Meier analysis. Chi-square statistics and multivariate binary logistic regression analysis were also conducted. RESULTS Median serum vitamin D levels were 8·2 ng/mL (range <4·0-95·8 ng/mL). Overall, 48% of patients (31/65) died during a 24-month follow-up period. ROC analysis determined a vitamin D level of 6·0 ng/mL as optimal cut-off for discriminating survivors from nonsurvivors. Kaplan-Meier analysis of survival confirmed low vitamin D levels as significant predictor of death (P = 0·012). Finally, multivariate analysis identified low vitamin D levels (OR = 6·3; 95% CI, 1·2-31·2; P = 0·012) and MELD scores (OR = 1·4; 95% CI, 1·2-1·7; P < 0·001) as independent predictors of survival. CONCLUSION Low vitamin D levels are associated with increased mortality in patients with advanced liver disease. Thus, serum levels of vitamin D might represent a critical marker of survival in advanced liver cirrhosis.
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Affiliation(s)
- Caroline S Stokes
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
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27
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Aydemir G, Cekmez F, Kalkan G, Fidanci M, Kaya G, Karaoglu A, Meral C, Arzıman İ, Karademir F, Ayar G, Gunduz RC, Suleymanoglu S. High Serum 25-Hydroxyvitamin D Levels Are Associated with Pediatric Sepsis. TOHOKU J EXP MED 2014; 234:295-8. [DOI: 10.1620/tjem.234.295] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | | | | | - Guven Kaya
- Department of Pediatrics, GMMA Medical Faculty
| | | | - Cihan Meral
- Department of Pediatrics, GMMA Medical Faculty
| | | | | | - Ganime Ayar
- Pediatric Service, Ankara Childrens Hematology Oncology Education and Research Hospital, Pediatric Intensive Care Unit
| | - Ramiz Coskun Gunduz
- Pediatric Service, Ankara Childrens Hematology Oncology Education and Research Hospital, Pediatric Intensive Care Unit
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28
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Raimundo M, Crichton S, Lei K, Sanderson B, Smith J, Brooks J, Ng J, Lemmich Smith J, McKenzie C, Beale R, Dickie H, Ostermann M. Maintaining normal levels of ionized calcium during citrate-based renal replacement therapy is associated with stable parathyroid hormone levels. Nephron Clin Pract 2013; 124:124-31. [PMID: 24192818 DOI: 10.1159/000355860] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Citrate is an effective anticoagulant during continuous renal replacement therapy (CRRT). Previous studies showed raised parathyroid hormone (PTH) levels when aiming for serum ionized calcium [Cai] between 0.8 and 1.1 mmol/l. Our objective was to assess whether citrate-based CRRT with physiologic target systemic [Ca(i)] between 1.12 and 1.20 mmol/l could maintain stable PTH levels. METHODS Measurement of intact PTH (PTHi) in 30 consecutive critically ill patients treated with citrate-based CRRT. RESULTS Thirty patients [mean age: 70.4 (SD 11.3) years; 56.7% males] were enrolled. Mean serum [Ca(i)] was 1.16 mmol/l (SD 0.09), 1.13 mmol/l (SD 0.09), 1.17 mmol/l (SD 0.05) and 1.16 mmol/l (SD 0.04) at baseline, 12, 24 and 48 h, respectively (p = 0.29). Median PTHi levels (interquartile range) at baseline, 12, 24 and 48 h were 66.5 (43-111), 109 (59.5-151.5), 88.5 (47-133) and 85 pg/ml (53-140), respectively. The differences between baseline and 12 h and across all time points were statistically not significant (p = 0.16 and p = 0.49, respectively). In a mixed-effects model, each 0.1 mmol/l increase in serum [Ca(i)] was associated with a 31.2% decrease in PTHi (p < 0.001). Results were unchanged after adjustment for age, gender, magnesium, phosphate, arterial pH and time spent on CRRT. CONCLUSIONS Maintaining systemic [Ca(i)] within the physiologic range was associated with stable PTHi levels.
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Affiliation(s)
- Mário Raimundo
- Department of Critical Care, Guy's and St Thomas' Foundation Hospital, King's Health Partners, King's College London, London, UK
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29
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Zerem A, Mimouni FB, Picard E, Shahroor S. Bone ultrasound velocity in pediatric intensive care unit: a pilot study. Crit Ultrasound J 2013; 5:8. [PMID: 24172205 PMCID: PMC4228487 DOI: 10.1186/2036-7902-5-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 10/11/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Bone loss has been documented in adults in intensive care wards. Children admitted to pediatric intensive care units (PICU) are also exposed to many potential risk factors for bone loss such as immobilization, catabolic state, and nutritional depletion. Quantitative ultrasound technique that measures speed of sound (SOS) correlates with bone mineral density (BMD) and strength. Herein is a clinical prospective longitudinal, observational pilot study to evaluate early bone changes that occur during the first few days of PICU admission. METHODS Children are hospitalized in a pediatric intensive under general anesthesia and muscle paralysis. Bone SOS at the mid-shaft tibia was measured on the first day of hospitalization and on days 2 to 3 thereafter. RESULTS Nineteen children were studied. Bone SOS decreased during the first 3 days of hospitalization from 3,297 ± 315 to 3,260 ± 311 m/min (p < 0.05). The decrease was approximately 1% of the original SOS over the first 2 to 3 days of admission. CONCLUSION There is a significant decrease in bone strength after 3 days in pediatric patients admitted to an intensive care department. Longitudinal studies of a larger group of children are necessary to determine the clinical meaning of the results and to possibly evaluate preventive approaches.
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Affiliation(s)
- Ayelet Zerem
- Pediatric Intensive Care Unit, Shaare Zedek Medical Center, affiliated to The Hebrew University School of Medicine and Pediatric department, Jerusalem 91031, Israel
| | - Francis B Mimouni
- Tel Aviv Medical Center, the Sackler School of Medicine, Tel Aviv 69978, Israel
| | - Elie Picard
- Pediatric Pulmonary Unit, Shaare Zedek Medical Center, affiliated to The Hebrew University School of Medicine and Pediatric department, Jerusalem 91031, Israel
| | - Sarit Shahroor
- Pediatric Intensive Care Unit, Shaare Zedek Medical Center, affiliated to The Hebrew University School of Medicine and Pediatric department, Jerusalem 91031, Israel
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Abstract
PURPOSE OF REVIEW The pleotropic effects of vitamin D on chronic diseases have received significant attention; however, its role in acute illness is less understood. The purpose of this review is to summarize the current evidence regarding the role of vitamin D in acute stress and critical illness. RECENT FINDINGS 25-Hydroxyvitamin D levels may affect risk of developing acute illnesses (e.g. respiratory infections), and low concentrations are associated with unfavorable outcomes during critical care. Inflammatory changes alone do not explain the observed deterioration in vitamin D status following acute stress. Hemodilution, interstitial extravasation, decreased synthesis of binding proteins, and renal wasting of 25-hydroxyvitamin D, all appear to play a more significant role in the regulation of vitamin D status during critical illness. SUMMARY Single-point assessments of 25-hydroxyvitamin D following acute stress may provide an inaccurate assessment of vitamin D status. In such cases, measurement of binding proteins and free vitamin D metabolites may be essential to create a more realistic approximation of vitamin D status. Variations in patient responses to acute stress and critical illness may depend not only on the degree of systemic vitamin D insufficiency, but also on the individual tissue requirements.
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Affiliation(s)
- Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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31
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Watkins RR, Yamshchikov AV, Lemonovich TL, Salata RA. The role of vitamin D deficiency in sepsis and potential therapeutic implications. J Infect 2011; 63:321-6. [DOI: 10.1016/j.jinf.2011.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 06/28/2011] [Accepted: 07/03/2011] [Indexed: 01/26/2023]
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Abstract
Vitamin D deficiency is highly prevalent and has been associated with a diverse range of chronic medical conditions in the general population. In contrast, the prevalence, pathogenesis and significance of vitamin D deficiency have received little attention in acute medicine. Vitamin D deficiency is seldom considered and rarely corrected adequately, if at all, in critically ill patients. Recent recognition of the extra-skeletal, pleiotropic actions of vitamin D in immunity, epithelial function and metabolic regulation may underlie the previously under-recognized contribution of vitamin D deficiency to typical co-morbidities in critically ill patients, including sepsis, systemic inflammatory response syndrome and metabolic dysfunction. Improved understanding of vitamin D metabolism and regulation in critical illness may allow therapeutic exploitation of vitamin D to improve outcome in critically ill patients.
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Affiliation(s)
- Paul Lee
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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33
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Abstract
OBJECTIVES To describe the incident fracture rate in survivors of critical illness and to compare fracture risk with population-matched control subjects. DESIGN Retrospective longitudinal case-cohort study. SETTING A tertiary adult intensive care unit in Australia. PATIENTS All patients ventilated admitted to intensive care and requiring mechanical ventilation for ≥48 hrs between January 1998 and December 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New fractures were identified in the study population for the postintensive care unit period (intensive care unit discharge to January 2008). The incident fracture rate and age-adjusted fracture risk of the female intensive care unit population were compared with the general population adult females derived from the Geelong Osteoporosis Study. Over the 8-yr period, a total of 739 patients (258 women, 481 men) were identified. After a median follow-up of 3.7 yrs (interquartile range, 2.0-5.9 yrs) for women and 4.0 yrs (interquartile range, 2.1-6.1 yrs) for men, incident fracture rates (95% confidence interval) per 100 patient years were 3.84 (2.58-5.09) for females 2.41 (1.73-3.09) for males. Compared with an age-matched random population-based sample of women, elderly women were at increased risk for sustaining an osteoporosis-related fracture after critical illness (hazard ratio, 1.65; 95% confidence interval, 1.08-2.52; p = .02). CONCLUSIONS The increase in fracture risk observed in postintensive care unit older females suggests an association between critical illness and subsequent skeletal morbidity. The explanation for this association is not explored in this study and includes the effects of pre-existing patient factors and/or direct effects of critical illness. Prospective research evaluating risk factors, the relationship between critical illness and bone turnover, the extent and duration of bone loss, and the associated morbidity in this population is warranted.
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34
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Doley J, Mallampalli A, Sandberg M. Nutrition management for the patient requiring prolonged mechanical ventilation. Nutr Clin Pract 2011; 26:232-41. [PMID: 21586408 DOI: 10.1177/0884533611405536] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Patients requiring prolonged mechanical ventilation are often medically complex and present with a wide range of pulmonary conditions, including neuromuscular diseases, chronic pulmonary diseases, and chronic critical illness. These patients present the nutrition support professional with many challenges. However, accurate nutrition assessment, timely and effective nutrition interventions, and careful monitoring will help patients meet their medical and nutrition goals.
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35
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Via MA, Potenza MV, Hollander J, Liu X, Peng Y, Li J, Sun L, Zaidi M, Mechanick JI. Intravenous Ibandronate Acutely Reduces Bone Hyperresorption in Chronic Critical Illness. J Intensive Care Med 2011; 27:312-8. [DOI: 10.1177/0885066611402156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael A. Via
- Division of Endocrinology and Metabolism, Albert Einstein College of Medicine, Beth Israel Medical Center, New York, NY, USA
| | | | - Jason Hollander
- Princeton Endocrinology, Princeton, New Jersey, Princeton, NJ, USA
| | - Xuan Liu
- The Mount Sinai Bone Program, Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
| | - Yuanzhen Peng
- The Mount Sinai Bone Program, Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
| | - Jianhua Li
- The Mount Sinai Bone Program, Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
| | - Li Sun
- Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
| | - Mone Zaidi
- The Mount Sinai Bone Program, Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
| | - Jeffrey I. Mechanick
- Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, NY, USA
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37
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Bellar A, Kunkler K, Burkett M. Understanding, recognizing, and managing chronic critical illness syndrome. ACTA ACUST UNITED AC 2011; 21:571-8. [PMID: 19900217 DOI: 10.1111/j.1745-7599.2009.00451.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE No evidence-based guidelines exist for the care of patients with chronic critical illness syndrome (CCIS), a growing population of patients being cared for by nurse practitioners (NPs). The purpose of this article is to provide NPs with a beginning physiological framework, allostasis, to guide their understanding and management of patients with CCIS. DATA SOURCES Scientific publications, related clinical guidelines. CONCLUSIONS Patients with CCIS are a distinct group of critically ill patients whose care needs are different from those of patients who are acutely critically ill. These patients demonstrate widespread tissue and organ damage. The widespread tissue and organ damage results in a syndrome of interrelated elements, which include neuroendocrine problems, severe malnutrition, wounds, infections, bone loss, polyneuropathy and myopathy, delirium and depression, and suffering. IMPLICATIONS FOR PRACTICE In caring for patients with CCIS, NPs need to focus on treating the elements of the syndrome as a cohort of interrelated elements and on re-establishing normalcy for the patient.
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Affiliation(s)
- Ann Bellar
- College of Health Professions, University of Detroit Mercy, Detroit, Michigan, USA.
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38
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Via MA, Gallagher EJ, Mechanick JI. Bone physiology and therapeutics in chronic critical illness. Ann N Y Acad Sci 2010; 1211:85-94. [PMID: 21062297 DOI: 10.1111/j.1749-6632.2010.05807.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Modern medical practices allow patients to survive acute insults and be sustained by machinery and medicines for extended periods of time. We define chronic critical illness as a later stage of prolonged critical illness that requires tracheotomy. These patients have persistent elevations of inflammatory cytokines, diminished hypothalamic-pituitary function, hypercatabolism, immobilization, and malnutrition. The measurement of bone turnover markers reveals markedly enhanced osteoclastic bone resorption that is uncoupled from osteoblastic bone formation. We review the mechanisms by which these factors contribute to the metabolic bone disease of chronic critical illness and suggest potential therapeutics.
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Affiliation(s)
- Michael A Via
- Division of Endocrinology and Metabolism, Beth Israel Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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39
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Abstract
With evolving interest in multiscalar biological systems one could assume that reductionist approaches may not fully describe biological complexity. Instead, tools such as mathematical modeling, network analysis, and other multiplexed clinical- and research-oriented tests enable rapid analyses of high-throughput data parsed at the genomic, proteomic, metabolomic, and physiomic levels. A physiomic-level approach allows for recursive horizontal and vertical integration of subsystem coupling across and within spatiotemporal scales. Additionally, this methodology recognizes previously ignored subsystems and the strong, nonintuitively obvious and indirect connections among physiological events that potentially account for the uncertainties in medicine. In this review, we flip the reductionist research paradigm and review the concept of systems biology and its applications to bone pathophysiology. Specifically, a bone-centric physiome model is presented that incorporates systemic-level processes with their respective therapeutic implications.
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Affiliation(s)
- Aaron J Weiss
- Division of Endocrinology, Diabetes, and Bone Disease, Mount Sinai School of Medicine, New York, New York, USA
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40
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Abstract
Homeostatic bone remodeling depends on precise regulation of osteoblast-osteoclast coupling through intricate endocrine, immune, neuronal, and mechanical factors. The osteoblast-osteoclast model of bone physiology with layers of regulatory complexity can be investigated as a component of a local skeletal subsystem or as a part of a complete whole-body system. In this review, we flip the traditional investigative paradigm of scientific experimentation ("bottom-top research") to a "top-bottom" approach using systems biology. We first establish the intricacies of the two-cell model at the molecular signaling level. We then provide, on a systems level, an integrative physiologic approach involving many recognized organ-level subsystems having direct and/or indirect effects on bone remodeling. Lastly, a hypothetical model of bone remodeling based on frequency and amplitude regulatory mechanisms is presented. It is hoped that by providing a thorough model of skeletal homeostasis, future progress can be made in researching and treating skeletal morbidities.
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Affiliation(s)
- Aaron J Weiss
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA
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41
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Krishnan A, Ochola J, Mundy J, Jones M, Kruger P, Duncan E, Venkatesh B. Acute fluid shifts influence the assessment of serum vitamin D status in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R216. [PMID: 21110839 PMCID: PMC3219984 DOI: 10.1186/cc9341] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/09/2010] [Accepted: 11/26/2010] [Indexed: 11/30/2022]
Abstract
Introduction Recent reports have highlighted the prevalence of vitamin D deficiency and suggested an association with excess mortality in critically ill patients. Serum vitamin D concentrations in these studies were measured following resuscitation. It is unclear whether aggressive fluid resuscitation independently influences serum vitamin D. Methods Nineteen patients undergoing cardiopulmonary bypass were studied. Serum 25(OH)D3, 1α,25(OH)2D3, parathyroid hormone, C-reactive protein (CRP), and ionised calcium were measured at five defined timepoints: T1 - baseline, T2 - 5 minutes after onset of cardiopulmonary bypass (CPB) (time of maximal fluid effect), T3 - on return to the intensive care unit, T4 - 24 hrs after surgery and T5 - 5 days after surgery. Linear mixed models were used to compare measures at T2-T5 with baseline measures. Results Acute fluid loading resulted in a 35% reduction in 25(OH)D3 (59 ± 16 to 38 ± 14 nmol/L, P < 0.0001) and a 45% reduction in 1α,25(OH)2D3 (99 ± 40 to 54 ± 22 pmol/L P < 0.0001) and i(Ca) (P < 0.01), with elevation in parathyroid hormone (P < 0.0001). Serum 25(OH)D3 returned to baseline only at T5 while 1α,25(OH)2D3 demonstrated an overshoot above baseline at T5 (P < 0.0001). There was a delayed rise in CRP at T4 and T5; this was not associated with a reduction in vitamin D levels at these time points. Conclusions Hemodilution significantly lowers serum 25(OH)D3 and 1α,25(OH)2D3, which may take up to 24 hours to resolve. Moreover, delayed overshoot of 1α,25(OH)2D3 needs consideration. We urge caution in interpreting serum vitamin D in critically ill patients in the context of major resuscitation, and would advocate repeating the measurement once the effects of the resuscitation have abated.
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Affiliation(s)
- Anand Krishnan
- Intensive Care Unit, Princess Alexandra Hospital, University of Queensland, Ipswich Road, Woolloongabba, QLD 4102, Australia
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42
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Mata-Granados JM, Vargas-Vasserot J, Ferreiro-Vera C, Luque de Castro MD, Pavón RG, Quesada Gómez JM. Evaluation of vitamin D endocrine system (VDES) status and response to treatment of patients in intensive care units (ICUs) using an on-line SPE-LC-MS/MS method. J Steroid Biochem Mol Biol 2010; 121:452-5. [PMID: 20399267 DOI: 10.1016/j.jsbmb.2010.03.078] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 03/19/2010] [Accepted: 03/26/2010] [Indexed: 01/05/2023]
Abstract
Vitamin D deficiency is recognized as one of the most common chronic medical conditions in the world. Vitamin deficiency has been associated with increased mortality. The aim of the study here presented was to evaluate the vitamin D endocrine system (VDES) status in healthy blood donors and critically ill patients baseline and in response to treatment during a week with two doses of 1.5 mg of 25-hydroxyvitamin D3 and 2 microg calcitriol (1,25(OH)2D3) IV on alternate days, by monitoring levels in serum of major vitamin D metabolites in critically ill patients. Group 1: healthy blood donors (control group) (n=92), and group 2: critically ill subjects from an intensive care unit (ICU) (n=33). Critically ill patients were divided into three groups: group A (n=12) is the control group; group B (n=11), administration PO 1,5 mg of 25(OH)D3, in days 0 and 4 of treatment; and group C (n=11), administration IV of 2 microg 1,25(OH)2D3 on alternate days. Baseline serum levels of vitamin D2 and 25(OH)D2 were not detected. Vitamin D3 (9.8 vs 26.0 nM) (p<0.05), 25(OH)D3 (13.3 vs 52.3 nM) (p<0.001), and 1,25(OH)2D3 (53.8 vs 120.5 pM) (p<0.01) serum levels were significantly lower in critically ill subjects than in healthy donors. After treatment in group B: 25OHD3 increased to 46.0+/-16.5 ng/ml (p<0.0001) (22.2%<75 nM, 11.1% <50 nM). 1,25(OH)2D3 increased to 121.8+/-61.8 pM<0.01 whereas were slightly decreased in the other groups during the study. 24,25(OH)2D3 serum levels were increased in patients treated with calcitriol 8.5+/-5.3 vs 24.8+/-16.3 nM (p<0.05) while the levels kept stable in group A patients. In summary, critically ill patients have a severe vitamin D deficiency, which can be easily corrected by administration of high doses of 25OHD (PO). The VDES functional deficiency could be probably also corrected through administration of calcitriol (IV). Both treatments could produce an improvement in the general health and probably a reduction in overall mortality risk of the critically ill patients.
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Affiliation(s)
- J M Mata-Granados
- Department of I+D+i, Sanyres Group, University of Córdoba, Mineral Metabolism Unit, Hospital Reina Sofia, E-14004 Córdoba, Spain
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Krishnan A, Ochola J, Venkatesh B. Vitamin D in Critical Illness. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
OBJECTIVE To describe a new aspect of critical care termed intensive metabolic support. METHODS We performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data. RESULTS Intensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness. CONCLUSIONS Intensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness.
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Affiliation(s)
- Corey Scurlock
- Cardiothoracic Surgical Intensive Care Unit, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Jeng L, Yamshchikov AV, Judd SE, Blumberg HM, Martin GS, Ziegler TR, Tangpricha V. Alterations in vitamin D status and anti-microbial peptide levels in patients in the intensive care unit with sepsis. J Transl Med 2009; 7:28. [PMID: 19389235 PMCID: PMC2684740 DOI: 10.1186/1479-5876-7-28] [Citation(s) in RCA: 302] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Accepted: 04/23/2009] [Indexed: 11/15/2022] Open
Abstract
Background Vitamin D insufficiency is common in hospitalized patients. Recent evidence suggests that vitamin D may enhance the innate immune response by induction of cathelicidin (LL-37), an endogenous antimicrobial peptide produced by macrophages and neutrophils. Thus, the relationship between vitamin D status and LL-37 production may be of importance for host immunity, but little data is available on this subject, especially in the setting of human sepsis syndrome and other critical illness. Methods Plasma concentrations of 25-hydroxyvitamin D (25(OH)D), vitamin D binding protein (DBP) and LL-37 in critically ill adult subjects admitted to intensive care units (ICUs) with sepsis and without sepsis were compared to healthy controls. Results Critically ill subjects had significantly lower plasma 25(OH)D concentrations compared to healthy controls. Mean plasma LL-37 levels were significantly lower in critically ill subjects compared to healthy controls. Vitamin D binding protein levels in plasma were significantly lower in critically ill subjects with sepsis compared to critically ill subjects without sepsis. There was a significant positive association between circulating 25(OH)D and LL-37 levels. Conclusion This study demonstrates an association between critical illness and lower 25(OH)D and DBP levels in critically ill patients as compared to healthy controls. It also establishes a positive association between vitamin D status and plasma LL-37, which suggests that systemic LL-37 levels may be regulated by vitamin D status. Optimal vitamin D status may be important for innate immunity especially in the setting of sepsis. Further invention studies to examine this association are warranted.
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Affiliation(s)
- Leo Jeng
- Division of Endocrinology, Diabetes & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the elements of critical illness that predispose to rapid and severe bone loss and illustrate how potent nitrogen containing intravenous bisphosphonates can mitigate this potentially serious disease. RECENT FINDINGS Recent studies confirm that inflammatory cytokines, immobilization, and hormonal irregularities incite osteoclast-mediated bone resorption. Bisphosphonates are antiresorptive agents and well suited to treat this bone loss. Intravenous bisphosphonates have long been considered safe, but recent evidence has raised concerns in regard to such serious side effects as atrial fibrillation, osteonecrosis of the jaw, and 'frozen bone'. SUMMARY Metabolic bone disease in the ICU is potentially a devastating consequence of critical illness. Screening with biochemical markers of bone turnover may allow identification of those most likely to have fracture after ICU discharge. Intravenous bisphosphonates are safe and very effective at preventing osteoporotic fracture in other populations. There is likely a subset of individuals who remain critically ill for a prolonged period of time that may benefit from an intravenous infusion of a potent aminobisphosphonate.
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Ball C. Improving rehabilitation following transfer from ICU. Intensive Crit Care Nurs 2008; 24:209-10. [PMID: 18472264 DOI: 10.1016/j.iccn.2008.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 04/01/2008] [Indexed: 11/30/2022]
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van der Voort PHJ, Postma SR, Kingma WP, Boerma EC, de Heide LJM, Bakker AJ. An observational study on the effects of nadroparin-based and citrate-based continuous venovenous hemofiltration on calcium metabolism. Blood Purif 2007; 25:267-73. [PMID: 17446700 DOI: 10.1159/000101853] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Accepted: 02/14/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND To study calcium homeostasis during citrate-based compared to nadroparin-based CVVH in critically-ill patients with acute renal failure. METHODS 11 patients were observed during citrate anticoagulation, 9 with nadroparin and 10 controls. Citrate was chosen for patients with active or at risk for bleeding. RESULTS The controls had, at 24 h, a median serum iCa of 1.1 mmol/l, the citrate group 0.87 mmol/l and the nadroparin group 1.1 mmol/l (citrate vs. control p = 0.001, citrate vs. nadroparin p = 0.002). At 48 h, iCa was not significantly different anymore. Ca balance was negative for the citrate group in contrast to the nadroparin group (p = 0.012). Median serum PTH was higher (30.0 pmol/l vs. 6.5 pmol/l, p = 0.003) in the citrate group. CONCLUSION With a relative low target-serum-iCa (0.8-0.9 mmol/l) citrate CVVH-treated patients had a negative daily calcium balance and a temporarily lower iCa level resulting in an enhanced PTH response in comparison to nadroparin.
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Abstract
Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. Nutrition support in this stage is unproven and may ultimately prove detrimental. As critical illness progresses, there is no evolutionary precedent, and man owes his life to modern critical care medicine. It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.
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Affiliation(s)
- Jason M Hollander
- Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai of Medicine, New York, NY 10128, USA.
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