A randomized pilot study using calcitriol in hospitalized COVID-19 patients

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.

BROWN TUMORS SECONDARY TO PARATHYROID CARCINOMA MASQUERADING AS SKELETAL METASTASES ON 18F-FDG PET/CT: A CASE REPORT

Objective

Brown tumors develop as skeletal manifestations of hyperparathyroidism. Increased osteoclast activity leads to accumulation of highly active giant cells and to excess cortical bone resorption, producing fibrous cysts. Though most often reported in patients with parathyroid adenomas, brown tumors secondary to parathyroid carcinoma create a clinical dilemma. Increased signal uptake on 2-deoxy-2-(fluorine-18)fluoro-D-glucose positron emission tomography (¹⁸F-FDG PET)/computed tomography (CT) seen within brown tumors may be indistinguishable from bone metastases. We report a case of parathyroid carcinoma in a 38-year-old man presenting with osteolytic bone lesions on ¹⁸F-FDG PET/CT that were diagnosed as brown tumors by biopsy.

Methods

We describe the patient history, presentation, diagnostic studies, and treatment.

Results

We report a case of a 38-year-old man diagnosed with parathyroid carcinoma with associated hypercalcemia and elevated parathyroid hormone levels who had undergone 3 surgical resections for local recurrences and had persistent hypercalcemia. He was found to have multiple osteolytic lesions throughout his skeleton on ¹⁸F-FDG PET/CT imaging 2 months after diagnosis. Biopsy of a right scapula lesion confirmed a brown tumor.

Conclusion

The role of ¹⁸F-FDG PET/CT in management of parathyroid carcinoma has not been systematically evaluated. Skeletal manifestations of parathyroid carcinoma may be present in this imaging modality. Clinicians should consider the possibility of brown tumors in patients with parathyroid carcinoma who undergo ¹⁸F-FDG PET/CT imaging.

Nutritional and Micronutrient Care of Bariatric Surgery Patients: Current Evidence Update

PURPOSE OF REVIEW

The continued success of bariatric surgery to treat obesity and obesity-associated metabolic conditions creates a need for a strong understanding of clinical nutrition both before and after these procedures.

RECENT FINDINGS

Surgically induced alteration of gastrointestinal physiology can affect the nutrition of individuals, especially among those who have undergone malabsorptive procedures. While uncommon, a subset of patients may develop protein-calorie malnutrition. In these cases, nutrition support should be tailored to the severity of malnutrition. Among all patients who undergo bariatric surgery, high rates of micronutrient deficiencies have been observed. To mitigate these deficiencies, empiric supplementation with multivitamins, calcium citrate, and vitamin D is generally recommended. Periodic surveillance should be performed for commonly deficient micronutrients, including thiamin (B1), folate (B9), cobalamin (B12), iron, and vitamin D. Following Roux-en-Y gastric bypass, serum levels of copper and zinc should also be monitored. In addition, lipid-soluble vitamins should be monitored following biliopancreatic diversion with/without duodenal switch.

Nutrition in Type 2 Diabetes and the Metabolic Syndrome

For individuals at risk for type 2 diabetes mellitus or the metabolic syndrome, adherence to an idealized dietary pattern can drastically alter the risk and course of these chronic conditions. Target levels of carbohydrate intake should approximate 30% of consumed calories. Healthy food choices should include copious fruits, vegetables, and nuts while minimizing foods with high glycemic indices, especially processed foods.

Previous gastric bypass surgery complicating total thyroidectomy

Hypocalcemia is a well-known complication of total thyroidectomy. Patients who have previously undergone gastric bypass surgery may be at increased risk of hypocalcemia due to gastrointestinal malabsorption, secondary hyperparathyroidism, and an underlying vitamin D deficiency. We present the case of a 58-year-old woman who underwent a total thyroidectomy for the follicular variant of papillary thyroid carcinoma. Her history included Roux-en-Y gastric bypass surgery. Following the thyroid surgery, she developed postoperative hypocalcemia that required large doses of oral calcium carbonate (7.5 g/day), oral calcitriol (up to 4 μg/day), intravenous calcium gluconate (2.0 g/day), calcium citrate (2.0 g/day), and ergocalciferol (50,000 IU/day). Her serum calcium levels remained normal on this regimen after hospital discharge despite persistent hypoparathyroidism. Bariatric surgery patients who undergo thyroid surgery require aggressive supplementation to maintain normal serum calcium levels. Preoperative supplementation with calcium and vitamin D is strongly recommended.

Obesity as a Disease

In recent years, obesity and related medical conditions have become leading public health concerns worldwide. Policy measures to combat or prevent obesity have been instated in a number of countries, with varying degrees of success. To stress the importance of obesity as a health issue, many professional health organizations, including the American Medical Association, have defined obesity itself as a disease. While this may be somewhat controversial, the high risk of comorbid conditions in obese individuals, the significant changes from healthy physiology that are present in the obese state, and the need for further public policies to address the public health threat and economic impact of obesity in the population are strong supporting arguments to label obesity as a disease.

Impaired postoperative hyperglycemic stress response associated with increased mortality in patients in the cardiothoracic surgery intensive care unit

OBJECTIVE

To describe the association of tight glycemic control with intensive insulin therapy and clinical outcome among patients in the cardiothoracic surgery intensive care unit.

METHODS

All patients who underwent cardiothoracic surgery and were admitted to the cardiothoracic surgery intensive care unit between September 13, 2007, and November 1, 2007, were enrolled. Clinical and metabolic data were prospectively collected. All patients received intensive insulin therapy using a nurse-driven dynamic protocol targeting blood glucose values of 80 to 110 mg/dL. Four stages of critical illness were defined as follows: acute critical illness (intensive care unit days 0-2), prolonged acute critical illness (intensive care unit 3 or more days), chronic critical illness (tracheotomy performed), and recovery (liberated from ventilator).

RESULTS

One hundred fourteen patients were enrolled. Seventy-three (64%) recovered during acute critical illness, 26 (23%) recovered during prolonged acute critical illness, and 15 (13%) progressed to chronic critical illness. All 6 deaths were among patients in chronic critical illness. Admission blood glucose and average blood glucose values for the first 12 hours were lower in patients who developed chronic critical illness and died and were higher in patients who developed chronic critical illness and survived (P = .007 and P = .007, respectively). Severe hypoglycemia (blood glucose <40 mg/dL) occurred once (0.03% of all measurements). Lower initial blood glucose values, which reflect an impaired stress response immediately after surgery, were associated with increased mortality, and a significant delay in achieving tight glycemic control with intensive insulin therapy was associated with prolonged intensive care unit course, but no increase in mortality.

CONCLUSION

The study findings suggest that acute postoperative hyperglycemia and its prompt correction with intensive insulin therapy are associated with favorable outcomes in patients in the cardiothoracic surgery intensive care unit.

Inpatient enteral and parenteral [corrected] nutrition for patients with diabetes

Both glycemic control and adequate nutrition support impact the clinical outcome of hospitalized patients. Providing nutrition to malnourished patients using the enteral or parenteral route may increase the risk of hyperglycemia, especially in patients with diabetes. Hyperglycemia can be managed through the use of enteral tube feeds with reduced carbohydrate content or limiting the carbohydrate concentration in parenteral formulas. Judicious use of insulin or other glucose-lowering medications synchronized with appropriate nutrition support allows for optimal inpatient glycemic control.

Bone physiology and therapeutics in chronic critical illness

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.

Bromocriptine approved as the first medication to target dopamine activity to improve glycemic control in patients with type 2 diabetes

Type 2 diabetes mellitus (T2DM) continues to rise in prevalence in the United States and worldwide. Despite advances in medical treatments for T2DM, many patients remain uncontrolled. By targeting centrally mediated pathways of glucose metabolism, bromocriptine represents a novel therapeutic option in T2DM. Several small clinical trials demonstrate improvements in insulin resistance and glycemic control. After the submission of data from four recent, large clinical trials, the US Food and Drug Administration has approved the use of bromocriptine in T2DM. We review the available data from these four trials and other published studies. Bromocriptine is a promising therapy for diabetes patients and demonstrates modest improvements in glycemic control.