A prospective analysis of hypovitaminosis D and mortality in 400 patients in the neurocritical care setting

Vitamin D Supplementation in Functional Recovery of Subjects with Severe Acquired Brain Injury: A Pilot Controlled Randomized Study

Low vitamin D (VD) has been associated with poor clinical course in several neurological diseases. Supplementation has been suggested to improve outcomes. Severe acquired brain injury (sABI) subjects have low VD levels and disabling conditions requiring rehabilitation. The aim of the present study was to evaluate if VD supplementation produced a better clinical course and a better functional outcome in sABI during rehabilitation. A randomized single-blind study was performed. sABI subjects were randomized to the VD supplementation group (VDsG) (initial dose of 50.000 UI and 1.000 daily) and usual care control group (CG). Disability Rating Scale (DRS), Glasgow Outcome Scale (GOS), and Level of Cognitive Functioning (LCF) were used in assessing disability. A total of 73 subjects (42 M and 31 F; mean age 53.2 ± 15.7) were randomized: 36 (21 M and 15 F; mean age 57.52 ± 14.88) to VDsG and 37 (20 M and 17 F; mean age 48.28 ± 17.47) to CG. Both groups significantly improved after rehabilitation, and no between-group difference was observed. The mean score values for DRS, GOS, and LCF in VDsG were 18.83 ± 4.27 and 9.42 ± 5.83; 2.89 ± 0.32 and 3.78 ± 0.80; and 4.81 ± 1.70 and 7.53 ± 1.28, at admission and discharge, respectively. Likewise, mean values for DRS, GOS, and LCF in CG were 18.57 ± 4.80 and 9.84 ± 6.34; 2.84 ± 0.37 and 3.81 ± 0.94; and 4.97 ± 2.01 and 7.41 ± 1.32, respectively. VD supplementation did not improve functional outcomes in sABI during rehabilitation treatment.

Intrathecal Injection of Tigecycline and Polymyxin B in the Treatment of Extensively Drug-Resistant Intracranial Acinetobacter baumannii Infection: A Case Report and Review of the Literature

Purpose

Intracranial infection after neurosurgery is one of the most serious complications, especially extensively drug-resistant (XDR) Acinetobacter baumannii (A. baumannii) seriously affects the prognosis of patients. At present, there is little experience in the treatment of this infection and limited effective treatment options, like tigecycline or polymyxin B. Therefore, this report aims to describe the efficacy of tigecycline combined with polymyxin B by intrathecal (ITH) injection in the treatment of XDR intracranial infection with A. baumannii.

Methods

We report a case of intracranial infection with XDR A. baumannii after ventricular drainage, treated by daily ITH and intravenous (IV) tigecycline, combined with polymyxin B ITH route. Moreover, tigecycline and polymyxin B treatments for XDR intracranial infection with A. baumannii that were reported in the literature were also reviewed and summarized.

Results

The white blood cells (WBCs) of the patient’s cerebrospinal fluid dropped to normal, and the symptoms of intracranial infection disappeared. The patient finally obtained good clinical results and transferred to the local hospital.

Conclusion

The polymyxin B ITH route is an ideal treatment strategy for XDR A. baumannii. The IV plus ITH tigecycline may be an effective treatment option. However, more researches should be conducted to confirm our observation.

Vitamin D supplementation and the outcomes of critically ill adult patients: a systematic review and meta-analysis of randomized controlled trials

This meta-analysis assessed the association between vitamin D supplementation and the outcomes of critically ill adult patients. A literature search was conducted using the PubMed, Web of Science, EBSCO, Cochrane Library, Ovid MEDLINE, and Embase databases until March 21, 2020. We only included randomized controlled trials (RCTs) comparing the efficacy of vitamin D supplementation with placebo in critically ill adult patients. The primary outcome was their 28-day mortality. Overall, 9 RCTs with 1867 patients were included. In the pooled analysis of the 9 RCTs, no significant difference was observed in 28-day mortality between the vitamin D supplementation and placebo groups (20.4% vs 21.7%, OR, 0.73; 95% CI, 0.46–1.15; I² = 51%). This result did not change as per the method of vitamin D supplementation (enteral route only: 19.9% vs 18.2%, OR, 1.19; 95% CI, 0.88–1.57; I² = 10%; intramuscular or intravenous injection route: 25.6% vs 40.8%, OR, 0.48; 95% CI, 0.21–1.06; I² = 19%) or daily dose (high dose: 20.9% vs 19.8%, OR, 0.83; 95% CI, 0.51–1.36; I² = 53%; low dose: 15.6% vs 21.3%, OR, 0.74; 95% CI, 0.32–1.68; I² = 0%). No significant difference was observed between the vitamin D supplementation and placebo groups regarding the length of ICU stay (standard mean difference [SMD], − 0.30; 95% CI, − 0.61 to 0.01; I² = 60%), length of hospital stay (SMD, − 0.17; 95% CI, − 041 to 0.08; I² = 65%), and duration of mechanical ventilation (SMD, − 0.41; 95% CI, − 081 to 0.00; I² = 72%). In conclusion, this meta-analysis suggested that the administration of vitamin D did not provide additional advantages over placebo for critically ill patients. However, additional studies are needed to confirm our findings.

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

Background

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

Methods/design

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

Discussion

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

Trial registration

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

Magnesium: The overlooked electrolyte in blood cancers?

Magnesium is an important element that has essential roles in the regulation of cell growth, division, and differentiation. Mounting evidence in the literature suggests an association between hypomagnesemia and all-cause mortality. In addition, epidemiologic studies have demonstrated that a diet poor in magnesium increases the risk of developing cancer, highlighting its importance in the field of hematology and oncology. In solid malignancies, hypomagnesemia at diagnosis portends a worse prognosis. However, little is known about prognosis in patients with hypomagnesemia and blood cancers in general; lymphoma more specifically. Hypomagnesemia has been associated with a higher viral load of the Epstein Barr virus, a virus associated with a multitude of hematologic malignancies. The role of magnesium in the immune system has been further elucidated in studies of patients with a rare primary immunodeficiency known as XMEN disease (X-linked immunodeficiency with Magnesium defect, Epstein-Barr virus (EBV) infection, and Neoplasia disease). These patients have a mutation in the MAGT1 gene, which codes for a magnesium transporter. The mutation leads to impaired T cell activation and an increased risk of developing hematologic malignancies. In this review we discuss the relevance of magnesium as an electrolyte, current measurement techniques, and the known data related to cause and prognosis of blood cancers. The goal is to use these data to stimulate additional high-quality and well powered studies to further investigate the role of magnesium in preventing cancer and improving outcomes of patients with malignancy and concomitant magnesium deficiency.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perceptions of overlapping surgery in neurosurgery based on practice volume: A multi-institutional survey

OBJECTIVE

Overlapping surgery, accepted by many as two distinct operations occurring at the same time but without coincident critical portions, has been said to improve patient access to surgical care. With recent controversy, some are opposed to this practice due to concerns regarding its safety. In this manuscript, we sought to investigate the perceptions of overlapping surgery among neurosurgical leadership and the association of these perceptions with neurosurgical case volume.

PATIENTS AND METHODS

We conducted a self-administered survey of neurosurgery department chair and residency program directors of institutions participating in the Vizient Clinical Database/Resource (CDB/RM), an administrative database of 117 United States (US) medical centers and their 300 affiliated hospitals. We queried participants regarding yearly departmental case-volume, frequency of overlapping surgery in daily practice and the degree of overlapping they find acceptable.

RESULTS

Of the 236 surveys disseminated, a total of 70 responses were received with a response rate of 29.7.%, which is comparable to previously reported response rates among neurosurgeons and other physicians. Our respondents consisted of 43 of 165 chairs (26.1.%) and 27 of 66 program directors (40.0.%) representing 64 unique hospitals/institutions out of 216 (29.6.%). Based on the responses to question involving case volume, we divided our responders into high volume hospitals (HVH) (n = 44; > 2000 cases per year) and low volume hospitals (LVH) (N = 26). More HVH were found to have frequent occurrence of overlapping surgery (50% weekly and 20.9.% daily vs LVH's 26.9.% weekly and 3.8.% daily, p = 0.003) and considered two overlapping surgeries without overlap of critical portion as acceptable (38.6.% vs 26.9.%, p = 0.10).

CONCLUSIONS

Our survey results showed that neurosurgical departments with high-volume practices were more likely to practice overlapping surgery on a regular basis and to view it as an acceptable practice. The association between overlapping surgery and the volume-outcome relationship should be further evaluated.

The effect of supplementation of vitamin D in neurocritical care patients: RandomizEd Clinical TrIal oF hYpovitaminosis D (RECTIFY)

OBJECTIVE

Hypovitaminosis D is prevalent in neurocritical care patients, but the potential to improve patient outcome by replenishing vitamin D has not been investigated. This single-center, double-blinded, placebo-controlled, randomized (1:1) clinical trial was designed to assess the effect on patient outcome of vitamin D supplementation in neurocritical care patients with hypovitaminosis D.

METHODS

From October 2016 until April 2018, emergently admitted neurocritical care patients with vitamin D deficiency (≤ 20 ng/ml) were randomized to receive vitamin D3 (cholecalciferol, 540,000 IU) (n = 134) or placebo (n = 133). Hospital length of stay (LOS) was the primary outcome; secondary outcomes included intensive care unit (ICU) LOS, repeat vitamin D levels, patient complications, and patient disposition. Exploratory analysis evaluated specific subgroups of patients by LOS, Glasgow Coma Scale (GCS) score, and Simplified Acute Physiology Score (SAPS II).

RESULTS

Two-hundred seventy-four patients were randomized (intent-to-treat) and 267 were administered treatment within 48 hours of admission (as-treated; 61.2% of planned recruitment) and monitored. The mean age of as-treated patients was 54.0 ± 17.2 years (56.9% male, 77.2% white). After interim analysis suggested a low conditional power for outcome difference (predictive power 0.12), the trial was halted. For as-treated patients, no significant difference in hospital LOS (10.4 ± 14.5 days vs 9.1 ± 7.9 days, p = 0.4; mean difference 1.3, 95% CI -1.5 to 4.1) or ICU LOS (5.8 ± 7.5 days vs 5.4 ± 6.4 days, p = 0.4; mean difference 0.4, 95% CI -1.3 to 2.1) was seen between vitamin D3 and placebo groups, respectively. Vitamin D3 supplementation significantly improved repeat serum levels compared with placebo (20.8 ± 9.3 ng/ml vs 12.8 ± 4.8 ng/ml, p < 0.001) without adverse side effects. No subgroups were identified by exclusion of LOS outliers or segregation by GCS score, SAPS II, or severe vitamin D deficiency (≤ 10 ng/ml).

CONCLUSIONS

Despite studies showing that vitamin D can predict prognosis, supplementation in vitamin D-deficient neurocritical care patients did not result in appreciable improvement in outcomes and likely does not play a role in acute clinical recovery.Clinical trial registration no.: NCT02881957 (clinicaltrials.gov).

Association of Overlapping Neurosurgery With Patient Outcomes at a Large Academic Medical Center

BACKGROUND

Limited data exist on the safety of overlapping surgery, a practice that has recently received widespread attention.

OBJECTIVE

To examine the association of overlapping neurosurgery with patient outcomes.

METHODS

A total of 3038 routinely scheduled, elective neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. Procedures were categorized into any overlap or no overlap and further subcategorized into beginning overlap (first 50% of procedure only), end overlap (last 50% of procedure only), and middle overlap (overlap at the midpoint).

RESULTS

A total of 1030 (33.9%) procedures had any overlap, whereas 278 (9.2%) had beginning overlap, 190 (6.3%) had end overlap, and 476 (15.7%) had middle overlap. Compared with no overlap patients, patients with any overlap had lower American Society of Anesthesiologists scores (P = .0018), less prior surgery (P < .0001), and less prior neurosurgery (P < .0001), though they tended to be older (P < .0001) and more likely in-patients (P = .0038). Any-overlap patients had decreased overall mortality (2.8% vs 4.5%; P = .025), 30- to 90-d readmission rate (3.1% vs 5.5%; P = .0034), 30- to 90-d reoperation rate (1.0% vs 2.0%; P = .03), 30- to 90-d emergency room (ER) visit rate (2.1% vs 3.7%; P = .018), and future surgery on index admission (2.8% vs 7.3%; P < .0001). Multiple regression analysis validated noninferior outcomes for overlapping surgery, except for the association of increased future surgery on index admission with middle overlap (odds ratio 3.99; 95% confidence interval [1.91, 8.33]).

CONCLUSION

Overlapping neurosurgery is associated with noninferior patient outcomes that may be driven by surgeon selection of healthier patients, regardless of specific overlap timing.

Association of Surgical Overlap during Wound Closure with Patient Outcomes among Neurological Surgery Patients at a Large Academic Medical Center

BACKGROUND

Several studies have explored the effect of overlapping surgery on patient outcomes, but impact of surgical overlap during wound closure has not been studied.

OBJECTIVE

To examine the association of overlap during wound closure and suture time overlap (STO) with patient outcomes in a heterogeneous neurosurgical population.

METHODS

Over 4 yr (7/2013-7/2017), 1 7689 neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. STO was defined as all surgeries for which an overlapping surgery occurred, exclusively, during wound closure of the index case being studied. We excluded nonelective cases and overlapping surgeries that involved overlap during surgical portions of the case other than wound closure. Tests of independence and Wilcoxon tests were used for statistical analysis.

RESULTS

Patients with STO had a shortened length of hospital stay (100.6 vs 135.1 h; P < .0001), reduced deaths in follow-up (1.59% vs 5.45%; P = .0004), and lower 30- to 90-d readmission rates (3.64% vs 7.47%; P = .0026). Patients with STO had no increase in revision surgery. Patients with STO had longer wound closure times (26.5 vs 23.9 min; P < .0001) but shorter total surgical times (nonclosure surgical time 101.8 vs 133.3 min; P < .0001; and total surgical time 128.3 vs 157.1 min; P < .0001).

CONCLUSION

Surgical overlap during wound closure (STO) is associated with improved or at least noninferior patient outcomes, as it pertains to readmissions and wound revisions.

Vitamin D in acutely ill patients

Objective To investigate 25(OH)D₃ levels and their relationship to survival in a cohort of acutely ill patients on admission to an intensive care unit. Methods This study enrolled acutely ill patients at admission to an intensive care unit and a group of sex- and age-matched healthy control subjects. The 25(OH)D₃ levels were measured using an enzyme immunoassay. C-reactive protein and procalcitonin levels were also measured using immunoassays. Results A total of 50 acutely ill patients and 50 healthy control subjects were enrolled in the study. The mean ± SEM 25(OH)D₃ levels were significantly lower in the acutely ill patients compared with the control group (11.74 ± 0.88 ng/ml versus 24.66 ± 1.60 ng/ml, respectively). The 25(OH)D₃ levels were not related to survival. An inverse relationship was observed between 25(OH)D₃ levels and C-reactive protein levels. A weak inverse relationship was also observed between 25(OH)D₃ levels and procalcitonin levels. Conclusions The 25(OH)D₃ levels were decreased in acutely ill patients admitted to an intensive care unit compared with healthy control subjects. 25(OH)D₃ levels may be inversely related to C-reactive protein and procalcitonin levels.

Effect of calcitriol on in vitro whole blood cytokine production in critically ill dogs

Hypovitaminosis D has been identified as a predictor of mortality in human beings, dogs, cats and foals. However, the immunomodulatory effects of vitamin D in critically ill dogs has not been evaluated. The aim of this study was to evaluate the effect of calcitriol on cytokine production from whole blood collected from critically ill dogs in vitro. Twelve critically ill dogs admitted to a veterinary intensive care unit (ICU) were enrolled in a prospective cohort study. Whole blood from these dogs was incubated with calcitriol (2×10^-7M) or ethanol (control) for 24h. Subsequent to this incubation, lipopolysaccharide (LPS)-stimulated whole blood production of tumor necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 were measured using a canine-specific multiplex assay. Calcitriol significantly increased LPS-stimulated whole blood production of IL-10 and decreased TNF-α production without significantly altering IL-6 production. There was no significant difference in whole blood cytokine production capacity between survivors and non-survivors at the time of discharge from the ICU or 30days after discharge. These data suggests that calcitriol induces an anti-inflammatory phenotype in vitro in whole blood from critically ill dogs.

Serum vitamin D concentrations in hospitalized critically ill dogs

Hypovitaminosis D has been extensively documented in critically ill humans. However, whether or not critically ill dogs have alterations in vitamin D concentrations remains unconfirmed. The primary aims of our study were to compare serum 25-hydroxycholecalciferol [25(OH)D] concentrations in critically ill dogs with healthy control dogs, determine the prognostic utility of serum 25(OH)D concentration as a biomarker in critically ill dogs, and to assess if serum 25(OH)D concentrations in critically ill dogs are associated with length of stay in the intensive care unit or illness severity. Serum concentrations of 25(OH)D together with a range of other clinical, biochemical, and hematological parameters, were measured in 99 dogs within 24 hours of admission to the Intensive Care Unit (ICU). Critically ill dogs (P = 0.001) and dogs with sepsis (P = 0.002) had significantly lower serum 25(OH)D concentrations compared to healthy control dogs. In addition, serum 25(OH)D concentration was an independent predictor of in-hospital and 30 day survival. Using a cut-off of 33 ng/mL, serum 25(OH)D concentrations had excellent sensitivity (0.94; 95% CI, 0.71–1.00), but poor specificity (0.41; 95% CI, 0.31–0.53) for detection of survival. Serum 25(OH)D concentrations were inversely associated with acute patient physiologic and laboratory evaluation (APPLE) fast score but were not associated with ICU length of stay. Hospitalized dogs with critical illness have decreased serum 25(OH)D concentrations compared to healthy dogs and can be used to predict survival in this cohort.

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

To evaluate the association of admission serum levels of 25(OH)D, parathormone and the related electrolytes with severity of illness and clinical outcomes in neurosurgical critically ill patients, serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate, along with APACHE II score were measured for 210 patients upon admission. Mean serum 25(OH)D was 21.1 ± 7.4 ng/mL. 25(OH)D deficiency (less than 20 ng/dL) and elevated serum parathormone level were found in 47.6% and 38% of patients respectively. Hypocalcaemia, hypophosphatemia, hypomagnesaemia and hypermagnesaemia were found in 29.5%, %63.8, 41.9% and 27.6% of patients respectively. The APACHE II score was significantly correlated with serum levels of 25(OH)D, parathormone, calcium, and phosphate. Multivariate regression analysis adjusted by other risk factors showed that among all clinical outcomes, admission hypovitaminosis D was associated with longer duration of ICU stay and a high admission of parathormone was associated with in ICU mortality. We concluded that disorders of admission serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate are related to the presence of multiple causal factors such as severity of disease and are not independently associated with clinical outcomes. Most often they are normalize spontaneously with resolution of the disease process.

Vitamin D status and 3-month Glasgow Outcome Scale scores in patients in neurocritical care: prospective analysis of 497 patients

OBJECTIVE Vitamin D deficiency has been associated with a variety of negative outcomes in critically ill patients, but little focused study on the effects of hypovitaminosis D has been performed in the neurocritical care population. In this study, the authors examined the effect of vitamin D deficiency on 3-month outcomes after discharge from a neurocritical care unit (NCCU). METHODS The authors prospectively analyzed 25-hydroxy vitamin D levels in patients admitted to the NCCU of a quaternary care center over a 6-month period. Glasgow Outcome Scale (GOS) scores were used to evaluate their 3-month outcome, and univariate and multivariate logistic regression was used to evaluate the effects of vitamin D deficiency. RESULTS Four hundred ninety-seven patients met the inclusion criteria. In the binomial logistic regression model, patients without vitamin D deficiency (> 20 ng/dl) were significantly more likely to have a 3-month GOS score of 4 or 5 than those who were vitamin D deficient (OR 1.768 [95% CI 1.095-2.852]). Patients with a higher Simplified Acute Physiology Score (SAPS II) (OR 0.925 [95% CI 0.910-0.940]) and those admitted for stroke (OR 0.409 [95% CI 0.209-0.803]) or those with an "other" diagnosis (OR 0.409 [95% CI 0.217-0.772]) were significantly more likely to have a 3-month GOS score of 3 or less. CONCLUSIONS Vitamin D deficiency is associated with worse 3-month postdischarge GOS scores in patients admitted to an NCCU. Additional study is needed to determine the role of vitamin D supplementation in the NCCU population.