Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission?

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.

A Case of Severe Neonatal Hypocalcemia Treated With Continuous Enteral Calcium

Background/Objective

Hypocalcemia is a common, treatable cause of neonatal seizures. The rapid repletion of calcium is essential for restoring normal calcium homeostasis and resolving seizure activity. The accepted approach to administer calcium to a hypocalcemic newborn is via peripheral or central intravenous (IV) access.

Case Report

We discuss a case of a 2-week-old infant who presented with hypocalcemia and status epilepticus. The etiology was determined to be neonatal hypoparathyroidism secondary to maternal hyperparathyroidism. Following an initial dose of IV calcium gluconate, the seizure activity abated. However, stable peripheral intravenous access could not be maintained. After weighing the risks and benefits of placing a central venous line for calcium replacement, it was decided to use continuous nasogastric calcium carbonate at a rate of 125 mg of elemental calcium/kg/d. Ionized calcium levels were used to guide the course of the therapy. The infant remained seizure-free and was discharged on day 5 on a treatment regimen that included elemental calcium carbonate, calcitriol, and cholecalciferol. He remained seizure free since discharge and all medications were discontinued by 8 weeks of age.

Discussion

Continuous enteral calcium is an effective alternate therapy for restoration of calcium homeostasis in a neonate presenting with hypocalcemic seizures in the intensive care unit (ICU).

Conclusion

We propose that continuous enteral calcium be considered as an alternative approach for calcium repletion in neonatal hypocalcemic seizures, one that avoids the potential complications of peripheral or central IV calcium administration.

Severe Vitamin D Deficiency in Youth with Autism Spectrum Disorder During the COVID-19 Pandemic

BACKGROUND

Decrease in sunlight exposure during periods of social distancing during the COVID-19 pandemic increased the risk of severe manifestations of vitamin D deficiency (VDD) in a particular "high-risk" population. Our objective was to highlight the importance of vitamin D screening in youth with autism spectrum disorder (ASD) and restrictive eating.

CASE PRESENTATION

We describe 3 adolescent male patients with ASD who developed severe manifestations of VDD and hypocalcemia in late 2020 during the COVID-19 pandemic. All spent less time outdoors than in prior years because of isolation at home during the pandemic. Presenting symptoms included seizures and atraumatic fractures. All 3 were found to have hypocalcemia and severe VDD. Limited sun exposure because of isolation indoors during the COVID-19 pandemic was a likely contributing factor to the severity of VDD. All 3 were treated with intravenous calcium acutely, followed by oral calcium and vitamin D. Laboratory tests performed post-treatment showed biochemical resolution of hypocalcemia and VDD.

CONCLUSION

These cases highlight the importance of screening "at-risk" youth for VDD. Clinicians should be cognizant that children and adolescents with ASD and restricted eating can have severe manifestations of hypocalcemia and VDD. Decreased sun exposure because of isolating indoors during the COVID-19 pandemic increased their risk for this.

New-onset Adrenal Insufficiency Presenting with Adrenal Shock in a Pediatric Patient

This case report describes new-onset adrenal insufficiency and adrenal shock in an 11-year-old male complaining of two weeks of malaise and weight loss. He was lethargic and pale in appearance. Work-up revealed hypoglycemia and hyponatremia without evidence for an infectious process. He was transported via a pediatric critical care transport team to a regional pediatric intensive care unit (PICU). He required intravenous fluids and vasopressors prior to arrival in the PICU. He had generalized weakness, and hyperpigmentation of his face and extremities. Adrenal insufficiency was suspected, and glucocorticoid administration led to improvement. Cortisol level was undetectable. At time of discharge, he was prescribed daily glucocorticoid and mineralocorticoid replacement, along with a stress dose glucocorticoid plan.

MON-260 Simple Febrile Seizure vs Hypocalcemic Seizure: Complicated Case of an 11-Month-Old

Background Hypocalcemia in young children can be an incidental finding, however, it may also present as spasms or seizures. Simple febrile seizures (SFS) are common benign convulsive events in children younger than 5 years. We present a case of an infant who presented with fever, seizures, and unresponsiveness and was found to have low calcium and Vitamin D levels. Case This 11-month-old African American female, born full term, was found unresponsive by parents at home after 2 days of URI symptoms and fever. She had upward eye rolling and stiffening of upper extremities and parents started CPR. On EMS arrival, the patient was responsive but weak. In the ER, she was febrile (103F), tachycardic, and alert. Physical examination was unremarkable except for nasal congestion. No frontal bossing, widening of wrist joint or long bone deformities were noted. On dietary history, patient was exclusively breastfed until 6 months of age. Upon presentation, she was on stage 1 food and expressed breast milk, but no other dairy products or vitamin supplements. Laboratory workup showed a normal CBC, serum calcium 4.8 mg/dl (9-11 mg/dl), ionized calcium 2.9 mg/dl (4.9-5.5mg/dl), phosphorus 3.6 mg/dl (4-6.5 mg/dl), 25 hydroxy-vitamin D <3.4 ng/ml (20-100 ng/ml), Vitamin D 1,25 (OH)₂ 25.8 pg/ml (16 - 65 pg/ml), alkaline phosphatase 625U/l (150-420 U/l) and PTH 281 pg/ml (15-65 pg/ml). Distal fraying at radial and ulnar physis were seen on X-ray. EKG showed prolonged QT interval of 466ms (370 - 440ms). After receiving an IV calcium bolus in the ER, she was admitted to the PICU for cardiac monitoring and IV calcium infusions. High dose oral Vitamin D (5000 IU daily) was given. She had no further seizure episodes. She was discharged home on oral calcium and Vitamin D after her calcium levels and QT interval had normalized. All her laboratory parameters improved on outpatient follow up. Conclusion Nutritional rickets in infants can be missed due to its non-specific clinical manifestations and recommendations that do not include chemistry panels on routine health visits. Our patient was initially assessed as SFS with her classic clinical presentation. Even though the AAP suggests no benefit of routine blood studies in SFS¹, in our patient, it was vital in identifying and treating the underlying hypocalcemia, which could have contributed to the seizure. With this case we want to highlight the morbidity associated with undiagnosed infantile rickets. Nutritional rickets needs to be considered in young children presenting with seizures, especially in those who are exclusively breastfed and are coming from high-risk populations. 1. Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure. Pediatrics Feb 2011, 127 (2) 389-394

Adult immunization-Need of the hour

Immunization is the process or the act of making individuals immune, which is usually done during childhood. Everyone is aware about immunization during childhood, however, very few know about adult immunization. This led us to review the adult immunization literature for the preventive strategies through various vaccination protocols. Adults do require vaccination protocols with booster doses for hepatitis B, Shingles, communicable diseases, traveler's diseases, etc. In this context, this article revises much of the available adult immunization literature and presents comprehensive guidelines. This article will increase the awareness regarding the importance of vaccination for adults to prevent a variety of conditions prevalent in our country as well as epidemics. The article comprehensively provides insights into the available vaccination and preventive strategy of human papilloma virus (HPV), hepatitis, and human immunodeficiency virus (HIV) infection in this part of the review. We strongly recommend all the health care professionals to educate their co-professionals and the public to use the benefits of adult immunization. It is the need of the hour and reduces the burden of treatment and increases productivity.