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Zavala S, Pape KO, Walroth TA, Reger M, Hoyte B, Thomas W, Adams B, Hill DM. Vitamin D Deficiency Is Associated With Increased Length of Stay After Acute Burn Injury: A Multicenter Analysis. J Burn Care Res 2024; 45:728-732. [PMID: 38141248 DOI: 10.1093/jbcr/irad201] [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: 08/02/2023] [Indexed: 12/25/2023]
Abstract
In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis and infectious complications. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). This was a multicenter retrospective study of adult patients at 7 burn centers admitted over a 3.5-year period, who had a 25-hydroxyvitamin D concentration drawn within the first 7 days of injury. Of 1147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, P < .001), acute kidney injury (AKI) requiring renal replacement therapy (7.3 vs 1.7%, P = .009), more days requiring vasopressors (mean 1.24 vs 0.58 days, P = .008), and fewer ventilator-free days of the first 28 days (mean 22.9 vs 25.1, P < .001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, vitamin D deficiency was associated with longer LOS. In conclusion, patients with thermal injuries and vitamin D deficiency on admission have increased LOS and worsened clinical outcomes when compared with patients with nondeficient vitamin D concentrations.
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Affiliation(s)
- Sarah Zavala
- Department of Pharmacy, Jesse Brown VA Medical Center, Chicago, IL 60612, USA
| | - Kate O Pape
- Department of Pharmacy, University of Iowa Health Care, Iowa City, IA 52245, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN 46202, USA
| | - Melissa Reger
- Department of Pharmacy, Community Regional Medical Center, Fresno, CA 93721, USA
| | - Brittany Hoyte
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Wendy Thomas
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Beatrice Adams
- Department of Pharmacy, Tampa General Hospital, Tampa, FL 33606, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
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Klein GL. Is calcium a link between inflammatory bone resorption and heart disease? eLife 2022; 11:83841. [PMID: 36580074 PMCID: PMC9799968 DOI: 10.7554/elife.83841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/08/2022] [Indexed: 12/30/2022] Open
Abstract
Several epidemiologic studies associate bone-resorbing chronic inflammatory conditions with increased risk of atherosclerotic heart disease. These include post-menopausal osteoporosis, spinal cord injury, rheumatoid arthritis, and osteoarthritis. Additional studies have noted that the use of anti-resorptive agents following hip fracture, during rheumatoid arthritis, and prior to intensive care management have resulted in reduced overall mortality and mortality from cardiovascular disorders. The careful study of burn patients has allowed us to detect that children and adolescents have a mechanism that protects them from the entry of calcium into the circulation following inflammatory bone resorption. That is, they respond to pro-inflammatory cytokines by up-regulating the parathyroid calcium-sensing receptor (CaSR) with consequent development of hypocalcemic hypoparathyroidism and hypercalciuria. As extracellular calcium appears to exacerbate and/or prolong the inflammatory response, this responsiveness of the CaSR to inflammatory cytokines may be the factor that reduces cardiovascular morbidity and mortality. In adults with chronic inflammatory conditions, the ability of the CaSR to respond to pro-inflammatory cytokines is lost, suggesting that the calcium that enters the circulation following inflammatory bone resorption may persist in the circulation, entering the small coronary blood vessels and favoring the formation of coronary artery calcification, inflammation, and consequent cardiovascular disease.
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Affiliation(s)
- Gordon L Klein
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at GalvestonGalvestonUnited States
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Garner KM, Zavala S, Pape KO, Walroth T, Reger M, Thomas W, Hoyte B, Adams B, Hill DM. A multicenter study analyzing the association of vitamin D deficiency and replacement with infectious outcomes in patients with burn injuries. Burns 2021; 48:1319-1324. [PMID: 34903417 DOI: 10.1016/j.burns.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/02/2022]
Abstract
Vitamin D (25OHD) deficiency is associated with poor outcomes in intensive care populations. The primary objective of this 7-center study was to determine if 25OHD deficiency is associated with infectious outcomes in adult burn patients. Generalized linear mixed modeling was used to control for center effect, percent total body surface area burn (% TBSA), age, and presence of inhalation injury. A total of 1147 patients were initially included (admitted January 2016 through August 2019). After exclusions, 234 (56.8%) in the deficient (25OHD < 20 ng/mL) and 178 in the non-deficient group (25OHD ≥ 20 ng/mL) remained, surpassing a priori power requirements. The non-deficient group had their concentration drawn earlier (p < 0.001), were more likely to be male (p = 0.006), Caucasian (p < 0.001), have lower body mass index (p = 0.009), lower % TBSA (p = 0.002), and taking a 25OHD supplement prior to admission (p < 0.001). Deficient patients were more likely to have an infectious outcome (52.1% vs 36.0%, p = 0.002), acute kidney injury with renal replacement therapy (p = 0.009), less ventilator free days in the first 28 days (p < 0.001), and vasopressors (p = 0.01). After controlling for center, % TBSA, age, and inhalation injury the best model also included presence of deficiency (OR 2.425 [CI 1.206-4.876]), days until 25OHD supplement initiation (OR 1.139 [CI 1.035-1.252]), and choice of cholecalciferol over ergocalciferol (OR 2.112 [CI 1.151-3.877]). To the authors' knowledge, this is the first multicenter study to evaluate the relationship between 25OHD and infectious complications in burn patients.
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Affiliation(s)
- Katelyn M Garner
- Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA
| | - Sarah Zavala
- Clinical Pharmacist, Department of Pharmacy, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Kate O Pape
- Clinical Pharmacist, Department of Pharmacy, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Todd Walroth
- Clinical Pharmacist, Department of Pharmacy Services, Eskenazi Health, 640 Eskenazi Avenue, Indianapolis, IN 46202, USA
| | - Melissa Reger
- Clinical Pharmacist, Pharmacy Department, Community Regional Medical Center, 2823 Fresno Street, Fresno, CA 93721, USA
| | - Wendy Thomas
- Clinical Pharmacist, Pharmacy Department, Spectrum Health, 100 Michigan Street Northeast, Grand Rapids, MI 49503, USA
| | - Brittany Hoyte
- Clinical Pharmacist, Pharmacy Department, Spectrum Health, 100 Michigan Street Northeast, Grand Rapids, MI 49503, USA
| | - Beatrice Adams
- Clinical Pharmacist, Pharmacy Department, Tampa General Hospital, 1 Tampa Circle, Tampa, FL 33606, USA
| | - David M Hill
- Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA.
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Sobouti B, Dahmardehei M, Fallah S, Karrobi M, Ghavami Y, Vaghardoost R. Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study. Curr Med Mycol 2020; 6:33-41. [PMID: 33834141 PMCID: PMC8018818 DOI: 10.18502/cmm.6.3.4663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background and Purpose : Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients. Materials and Methods: Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group. Results: A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results,
C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that
candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral
nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia. Conclusion: Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors.
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Affiliation(s)
- Behnam Sobouti
- Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Dahmardehei
- Department of Plastic Surgery, Burn Research Center, Motahari Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Fallah
- Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Karrobi
- Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Yaser Ghavami
- Department of Plastic Surgery, Burn Research Center, Motahari Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Vaghardoost
- Department of Plastic Surgery, Burn Research Center, Motahari Hospital, Iran University of Medical Sciences, Tehran, Iran
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Vitamin D in burn-injured patients. Burns 2019; 45:32-41. [PMID: 29776863 DOI: 10.1016/j.burns.2018.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/06/2018] [Accepted: 04/24/2018] [Indexed: 12/25/2022]
Abstract
Recently, many studies have demonstrated pleotropic effects of vitamin D, including immune modulation and cardiovascular system activity. Sufficient vitamin D concentrations and supplementation of vitamin D may be of benefit in burn-injured patients. Low 25(OH)D has been observed in nearly all pediatric and most adult burn patients. Vitamin D has primarily been studied in pediatric burn patients, focusing on bone marker measurements and the incidence of fractures. The preferred vitamin D dose, formulation, and route of administration remain unknown, and there is limited data on the impact of vitamin D status on clinical outcomes. Further research should focus on determining optimal monitoring strategies, supplementation regimens and clinical outcomes like mortality, length of stay and incidence of sepsis.
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High Prevalence of Vitamin D Deficiency among Iranian Population: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF MEDICAL SCIENCES 2018; 43:125-139. [PMID: 29749981 PMCID: PMC5936844 DOI: pmid/29749981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevention and correction of vitamin D deficiency requires a precise depiction of the current situation and identification of risk factors in each region. The present study attempted to determine these entities using a systematic review and meta-analysis in Iran. METHODS Articles published online in Persian and English between 2000 and November 1, 2016, were reviewed. This was carried out using national databases such as SID, IranMedex, Magiran, and IranDoc and international databases such as PubMed, Google Scholar, and Scopus. The heterogeneity index among the studies was determined using the Cochran (Q) and I2 test. Based on the heterogeneity results, the random-effect model was applied to estimate the prevalence of vitamin D deficiency. In addition, meta-regression analysis was used to determine heterogeneity-suspected factors, and the Egger test was applied to identify publication bias. RESULTS The meta-analysis of 48 studies identified 18531 individuals with vitamin D deficiency. According to the random-effect model, the prevalence of vitamin D deficiency among male, female, and pregnant women was estimated to be 45.64% (95% CI: 29.63 to 61.65), 61.90% (95% CI: 48.85 to 74.96), and 60.45% (95% CI: 23.73 to 97.16), respectively. The results of the meta-regression analysis indicated that the prevalence of vitamin D deficiency was significantly different in various geographical regions (β=4.4; P=0.023). CONCLUSION The results obtained showed a significant prevalence of vitamin D deficiency among the Iranian population, a condition to be addressed by appropriate planning.
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Klein GL, Benjamin DA, Herndon DN. Calcemic response to burns differs between adults and children: A review of the literature. Osteoporos Sarcopenia 2017; 3:170-173. [PMID: 30775526 PMCID: PMC6372815 DOI: 10.1016/j.afos.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/06/2017] [Accepted: 10/09/2017] [Indexed: 10/30/2022] Open
Abstract
Objectives The calcemic and parathyroid hormone (PTH) responses to severe burn injury appear to differ between children and adults. In our limited studies children exhibited hypocalcemic hypoparathyroidism consistent with up-regulation of the parathyroid calcium-sensing receptor (CaSR) while adults did not, suggesting a developmental cutoff in cytokine-mediated up-regulation of the CaSR. This difference may be clinically important as published studies indicate that extracellular calcium (Ca) may stimulate the inflammatory response. The aim of this study was to examine the existing literature on burns to see if the differences between pediatric and adult calcemic and PTH responses to burn supported our findings providing stronger evidence to support this developmental difference. Methods We reviewed the National Library of Medicine database using the terms burns, PTH and ionized calcium and found 9 articles from 8 different medical centers; one was eliminated due to mixing of adults and children. Results There were 245 burn patients reported from the literature, 178 pediatric and 67 adults. The data are mostly consistent with our reported findings. Of the 10 pediatric patients with severe burns that we studied, mean ionized Ca concentration was below the lower limit of normal of 1.10 mM. The 67 adult burn patients reported in the literature had a mean blood ionized Ca concentration that was within the adult normal range or was lower than normal but with secondary hyperparathyroidism. Moreover, serum PTH concentrations were uniformly low in the 178 children in the burn literature but normal or mildly elevated in the 67 adults. Conclusions These results support the hypothesis that the difference between pediatric and adult victims is consistent with an age-related CaSR response to cytokine stimulation and may be consistent with a lower level of inflammation in children. Ionized Ca and PTH might serve as possible therapeutic targets to lower the inflammatory response in burn victims.
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Affiliation(s)
- Gordon L Klein
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA.,Shriners Hospital for Children, Galveston, TX, USA
| | - Debra A Benjamin
- Shriners Hospital for Children, Galveston, TX, USA.,Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - David N Herndon
- Shriners Hospital for Children, Galveston, TX, USA.,Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
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