Hypovitaminosis D and Bone Mineral Metabolism and Bone Density in Hyperthyroidism

Little is known about the impact of concomitant vitamin D deficiency on bone mineral density in hyperthyroidism. Therefore, we evaluated bone mineral measures in vitamin D–deficient and sufficient patients with hyperthyroidism. Thirty newly diagnosed consecutive patients with hyperthyroidism were included. Blood samples were used for measurement of calcium, phosphate, alkaline phosphatase, 25-hydroxy vitamin D [25(OH) D], and parathyroid hormone (PTH). Bone mineral density (BMD) was measured at the hip, spine, and forearm. The patients were divided into vitamin D–deficient (<25 nmol/L) and vitamin D–sufficient groups (≥25 nmol/L). Eight (26.6%) patients had 25(OH) D levels less than 25 nmol/L, with mean ± standard deviation (SD) level of 16.5 ± 3.2 (vitamin D–deficient group 1), and the remainder had a mean ± SD of 46.0 ± 13.5 nmol/L (vitamin D–sufficient group 2). Serum-intact PTH levels were significantly higher in group 1 compared with those in group 2 (31.2 ± 16.3 vs 18.0 ± 13.1 pg/mL; p = 0.041). In the vitamin D–deficient group, the mean BMD T-scores were in the osteoporotic range at hip and forearm (?2.65 ± 1.13 and ?3.04 ± 1.3) and in the osteopenia range at lumbar spine (?1.83 ± 1.71). However, in vitamin D–sufficient group, the mean BMD T-scores were in the osteopenia range (?1.64 ± 1.0, ?1.27 ± 1.6, and ?1.60 ± 0.7) at hip, forearm, and lumbar spine, respectively. The mean BMD Z-scores were also significantly lower in vitamin D–deficient group compared with those in vitamin D–sufficient group. Finally, BMD values (gm/cm²) at the hip and forearm were significantly lower in the vitamin D–deficient group compared with those in the vitamin D–sufficient group. In conclusion, hyperthyroid patients with concomitant vitamin D deficiency had lower BMD compared with vitamin D–sufficient patients.     

High-dose oral vitamin D3 supplementation in rheumatology patients with severe vitamin D3 deficiency

ObjectivesRecent large trials indicate that adherence associated with a daily regimen of vitamin D is low and limits anti-fracture efficacy with vitamin D supplementation. The aim of this report is to describe changes of 25-hydroxyvitamin D (25(OH)D) serum concentrations achieved with a single oral dose of 300 000 IU vitamin D3.MethodsOver a course of 4 months, we identified 33 elderly with severe vitamin D deficiency (25(OH)D < 25 nmol/l) on admission to acute care. Patients were admitted for musculoskeletal pain, bone disease, or gait abnormalities. The mean age was 80.5 years (SD ± 6.1). All patients were treated with a single oral dose of 300 000 IU D3 in combination with 500–1000 mg calcium supplements per day depending on their dietary calcium intake.ResultsBaseline mean 25(OH)D serum concentrations were 15 nmol/l (SD ± 5.5). Mean 25(OH)D serum concentrations increased to 81.4 nmol/l (SD ± 29.7) at 3 months (29 patients) and were still 69.0 nmol/l (SD ± 17.9) at 6 months (26 patients). Mean serum calcium levels were 2.24 mmol/l (SD ± 0.11) at baseline, 2.28 mmol/l (SD ± 0.18) at 3 months, and 2.28 mmol/l (SD ± 0.13) at 6 months. Two patients with mild hypercalcemia (2.69 mmol/l) at 3 months had normal values at 6 months.ConclusionBased on our observations, a single oral dose of 300 000 IU vitamin D3 raises mean 25(OH)D serum concentrations to the target mean of above 75 nmol/l at 3 months and a mean level of 69 nmol/l at 6 months. As calcium absorption is enhanced with higher 25(OH)D serum concentrations, calcium supplementation may need downward adjustment with this regimen to avoid mild hypercalcemia.     

25 hydroxyvitamin D serum levels influence adequate response to bisphosphonate treatment in postmenopausal osteoporosis

It remains unclear whether vitamin D sufficiency optimizes response to bisphosphonate (BP) treatment in postmenopausal osteoporosis. We evaluated the role and possible mechanisms of vitamin D in adequate response to standard BP treatment for postmenopausal osteoporosis.MethodsWe included 120 postmenopausal osteoporotic women (aged 68 ± 8 years) receiving BP (alendronate or risedronate) at their annual follow-up, performing complete anamnesis, including treatment adherence, use of vitamin D supplements, and previous falls and fractures during the last year. We analyzed the evolution of bone mineral density (BMD) during this period and serum PTH and 25 hydroxyvitamin D (25(OH)D) and urinary NTx levels. Patients were classified as inadequate responders to antiosteoporotic treatment based on BMD loss > 2% and/or the presence of fragility fractures during the last year.ResultsThirty percent of patients showed inadequate response to BP treatment, with significantly lower levels of 25(OH)D (22.4 ± 1.3 vs. 26.6 ± 0.3 ng/ml, p = 0.01), a higher frequency of 25(OH)D levels < 30 ng/ml (91% vs. 69%, p = 0.019) and higher urinary NTx values (42.2 ± 3.9 vs. 30.9 ± 2.3 nM/mM, p = 0.01). Patients with 25(OH)D > 30 ng/ml had a greater significant increase in lumbar BMD than women with values < 30 ng/ml (3.6% vs. 0.8%, p < 0.05). The probability of inadequate response was 4-fold higher in patients with 25(OH)D < 30 (OR, 4.42; 95% CI, 1.22–15.97, p = 0.02).ConclusionsInadequate response to BP treatment is frequent in postmenopausal women with osteoporosis as is vitamin D insufficiency, despite vitamin D supplementation. Maintenance of 25(OH)D levels > 30 ng/ml is especially indicated for adequate response to BP treatment.     

Single high-dose oral vitamin D3 (stoss) therapy — A solution to vitamin D deficiency in children with cystic fibrosis?

ObjectivesTo determine the safety and efficacy of stoss therapy on vitamin D levels over a 12 month period in children with cystic fibrosis and vitamin D deficiency (< 75 nmol/L).Study designRetrospective chart review of 142 paediatric CF patients from 2007 till 2011.ResultsThirty eight children received stoss therapy and 37 children with vitamin D deficiency were not treated and served as a control group. The stoss treated group had a significant and sustained increase in 25-hydroxyvitamin D levels measured at 1, 3, 6 and 12 months post treatment compared to controls (94.82 ± 41.0 nmol/L, p = 0.001; 81.54 ± 24.6 nmol/L, p = 0.001; 92.18 ± 36.5 nmol/L, p = 0.008 and 64.6 ± 20.0 nmol/L, p = 0.006 respectively). At 12 months post intervention, the mean difference in vitamin D levels from baseline between the stoss treated group and controls was significant at 15 nmol/L compared to 5 nmol/L (p = 0.038).ConclusionStoss therapy effectively achieves and maintains levels of 25-hydroxyvitamin D greater than 75 nmol/L over 12 months.     

Strong relationship between vitamin D status and bone mineral density in anorexia nervosa

BackgroundAnorexia nervosa (AN) is associated with impaired bone health and low bone mineral density (BMD) as a consequence of an inadequate peak bone mass in adolescence and bone loss in young adulthood. The vitamin D status with its implications for bone health in patients affected by AN has only been examined previously in small studies.ObjectiveTo evaluate the prevalence of vitamin D deficiency and test the hypothesis that patients with AN and vitamin D deficiency might have worse bone metabolism and lower bone density as compared with AN with adequate vitamin D repletion.DesignWe analysed the vitamin D status and bone metabolism in a large cohort (n = 89) of untreated patients affected by AN, with amenorrhoea.ResultsVitamin D deficiency is widespread in untreated patients with AN: 16.9% had 25OH vitamin D levels below 12 ng/ml, 36% below 20 ng/ml and 58.4% below 30 ng/ml. PTH values were higher and BMD at both femoral sites were lower in patients with vitamin D < 20 ng/ml. Progressively higher values of BMD were observed by 4 ranks of 25 OH vitamin D values (severe deficiency: < 12 ng/ml, deficiency: ≥ 12 ng/ml and < 20 ng/ml, insufficiency: ≥ 20 and < 30 ng/ml and normal: ≥ 30 ng/ml). In patients with severe vitamin D deficiency BMD at the hip were significantly lower than that measured in groups with values over 20 ng/ml (p < 0.001 for trend). The level of significance did not change for values adjusted for BMI or body weight.ConclusionWe found a strong relationship between vitamin D status and hip BMD values with additional benefits for those with 25OHD levels above 20 ng/ml. Our results support the design of a randomized placebo-controlled clinical trial on the effect of vitamin D on BMD in patients with AN. The second point, whether 25OHD should be above 20 or 30 ng/ml remains a discussion point.     

Vitamin D insufficiency: evaluation of an oral standardized supplementation using 100,000 IU vials of cholecalciferol, depending on initial serum level of 25OH vitamin D

ObjectivesThere is no protocol of vitamin D supplementation used worldwide due to a great disparity of vitamin D supplements available in different countries. The aim of this study was to evaluate the efficiency of the protocol most often used in France to correct vitamin D deficiency defined by a serum 25-hydroxy vitamin D (25OHD) level of less than 30 ng/mL.MethodsThis was a pragmatic multicentric study of vitamin D supplementation in 257 osteopenic/osteoporotic, vitamin D deficient patients who received 100,000 UI vitamin D3 vials every two weeks according to their initial serum 25OHD level (four vials when 25OHD less than 10 ng/mL, three when 25OHD was 10–19 ng/mL, two when 25OHD was 20–29 ng/mL). Blood samples were obtained at baseline, one (M1), two (M2), and three months (M3), after the end of the supplementation protocol.ResultsAt M1, 198/257 (77%) patients had a serum 25OHD level more than 30 ng/mL. Eighty-five percent of those with a BMI less than 25 kg/m² had a 25OHD concentration more than 30 ng/mL, whereas only 66% of those with a BMI more than 25 had a level more than 30 ng/mL. At M2 and M3, 25OHD levels decreased significantly with 55% and 46% having still a level more than 30 ng/mL respectively, without any significant difference according to the initial 25OHD level.ConclusionThis protocol was effective in rising serum 25OHD of most vitamin D insufficient patients with a BMI less than 25 kg/m², but not in overweight patients. As almost one half of our patients had a serum 25OHD level less than 30 ng/mL at M2, we suggest that regular doses should be started quite soon after this initial supplementation.     

High prevalence of vitamin D deficiency among middle-aged and elderly individuals in northwestern China: Its relationship to osteoporosis and lifestyle factors

PurposeVitamin D deficiency has reached epidemic proportions; this deficiency has been associated with osteoporosis and certain lifestyle factors in adults. This relationship is not well documented among the Lanzhou population in northwest China. This study sought to determine the prevalence of vitamin D deficiency and its risk factors in addition to its relationship with osteoporosis in a Chinese population living in Lanzhou.MethodsThis cross-sectional study involved 2942 men and 7158 women aged 40–75 years who were randomly selected from 3 communities in the Lanzhou urban district and examined medically. Levels of 25-hydroxy-vitamin D [25(OH)D] and other parameters were measured according to detailed inclusion criteria. Vitamin D deficiency was defined as serum 25(OH)D levels below 20 ng/mL. Calcaneus bone mineral density (BMD) was measured by quantitative ultrasound (QUS).ResultsThe prevalence of vitamin D deficiency (25(OH)D levels < 20 ng/mL) was present in 75.2% of the entire study population. Vitamin D deficiency was more prevalent in women (79.7%) than in men (64%; P < 0.001). Multiple logistic regression analysis revealed that the significant predictors of vitamin D deficiency included coronary heart disease (CHD), obesity, dyslipidemia, older age, female sex, and smoking (all P < 0.05), whereas tea intake, moderate physical activity, milk intake, vitamin D supplementation and sun exposure were protective (all P < 0.05). No significant difference in calcaneus BMD measured by QUS was noted between subjects with < 20 ng/mL and ≥ 20 ng/mL vitamin D levels (0.53 ± 0.13 vs. 0.54 ± 0.13; P = 0.089). The risk of having osteoporosis did not increase when vitamin D levels decreased from ≥ 20 ng/mL to < 20 ng/mL after multiple adjustments (OR = 1.00; 95% CI 0.85–1.16; P = 0.357).ConclusionsVitamin D deficiency is prevalent in the middle-aged and elderly northwestern Chinese population and is largely attributed to CHD, obesity, dyslipidemia, older age, female sex, and smoking. Reduced 25(OH)D levels are not associated with an increased osteoporosis risk.     

Functional hypoparathyroidism in postmenopausal women with fragility fracture

IntroductionSecondary hyperparathyroidism sometimes is lacking despite authentic vitamin D insufficiency (VDI) and the concept of functional hypoparathyroidism with a protective role on bone status has been proposed. Therefore, we tested the hypothesis that its prevalence was very low in a population of women with a peripheral fragility fracture.MethodsWe conducted our study in postmenopausal women, admitted for such a fracture in our Fracture Liaison Service. All had bone mineral density (BMD), biochemical assessment and a medical visit.ResultsTwo hundred and thirty seven women (72.9 ± 11.6-year-old) were included and 90.4% had VDI (25[OH]D ≤ 30 ng/mL). Yet, 87.9% of the latter had normal PTH levels less or equal to 64 ng/L. In this population with VDI (n = 214), we found no PTH plateau level related to 25(OH)D. Since a recent study reported an increase in the risk of fracture only when 25(OH)D was below 15 ng/mL, we then used this value as a new threshold. We observed a significant difference in hip BMD between patients with 25(OH)D either less or equal to or greater than 15 ng/mL. However, 81.2% of the formers were still with normal PTH with no difference in BMD whether PTH level was above or within normal range.ConclusionIn a population of postmenopausal women with a fragility fracture, we found that 25(OH)D less or equal to 15 ng/mL was associated with significantly lower hip BMD. Even using this low threshold, we found a high prevalence of functional hypoparathyroidism and it was not associated with any difference in hip or spine BMD. Overall, our results do not support the hypothesis of a protective effect of this biological profile.     

Fractures and handicap in an adult population: A clinical study

ObjectiveTo evaluate the bone status of ambulatory patients with physical and mental handicaps before a program of fracture prevention.MethodsWe recruited 58 walking adults. We retrospectively collected the past episodes of fractures, essentially peripheral, and epilepsy. The serum calcium, albumin, 25-hydroxyvitamin D, parathormone, CTX-1 and P1NP levels were prospectively measured in 36 consecutive patients. Each patient received daily calcium and vitamin D. The vertebral status has been not evaluated.ResultsTwenty-one patients had presented at least one fracture. Thirty nine per cent of the fractures were minor (nasal bone, hands, feet). The age of patients with fractures was significantly higher than patients without fracture (46 versus 40 years, respectively; p = 0.04). Patients with fractures had a significantly increased S-P1NP (63.5 ng/ml ± 32.0 versus 41.9 ng/ml ± 20.0, respectively; p = 0.02).Nineteen patients suffered from epilepsy. We listed 23 fractures among 9 patients treated by phenobarbital and 8 fractures, which tended to be less severe among 5 patients epileptics without this drug. Minor fracture was often followed by severe fracture in case of phenobarbital treatment. This treatment was associated with a significantly lower serum calcium level (2.16 mmol/l ± 0.05, versus epileptic patients without phenobarbital 2.32 mmol/l ± 0.08, p < 0.0004).ConclusionsThe presence of a fracture, even minor, must encourage to improve the preventive and curative measures among patients with handicaps.     

Relationship between vitamin D deficiency and bone fragility in sickle cell disease: A cohort study of 56 adults

BackgroundRecent studies suggest that patients with sickle cell disease (SCD) have profound vitamin D (VD) deficiency. Limited data exist on the effect of VD deficiency on bone fragility in these patients.ObjectivesTo assess the prevalence of VD deficiency in adults with SCD and its consequences on bone metabolism and fragility.MethodsThis prospective study included 56 SCD adult patients (mean age 29.8 ± 9.5 years), in a clinically steady state. Clinical and laboratory data were recorded. Bone mineral density (BMD) was measured using dual X-ray absorptiometry. Fracture history, BMD, avascular osteonecrosis, H-shaped vertebra and markers of mineral metabolism were compared between two groups of patients presenting very low (≤ 6 ng/mL, n = 26) (group 1) and low (> 6 ng/mL, n = 26) (group 2) 25(OH)D concentration, respectively.ResultsMedian 25(OH)D concentration was 6 ng/mL. VD deficiency (25(OH)D < 10 ng/mL) was found in 42 out of 56 patients (75%) and secondary hyperparathyroidism in 40 (71.4%). History of fracture was documented in 17 patients (30.3%), osteopenia and/or osteoporosis in 39.6% of patients. Overall, patients of group 1 were more likely to have sustained a fracture (42.8%) compared to patients of group 2 (17.8%) (p = 0.04). These patients had also lower body mass index and significantly higher parathyroid hormone, C-terminal telopeptides of type I-collagen and bone-specific alkaline phosphatase serum levels. There was no difference between group for BMD, avascular osteonecrosis history, H-shaped vertebra, and disease severity markers.ConclusionThis study suggests that VD deficiency is a key feature in SCD-bone disease. It is highly prevalent and associated with hyperparathyroidism, bone resorption markers, and history of fracture. The optimal supplementation regimen remains to be determined.     

Impact of vitamin D supplementation on markers of bone mineral metabolism in term infants

25-Hydroxyvitamin D (25OHD) may influence bone turnover. We compared the dynamics of bone markers in 30 infants on vitamin D supplementation (? 550 IU/day) with different degrees of hypovitaminosis D (25OHD < 11 ng/ml — deficiency vs. ≥ 11 < 20 ng/ml — insufficiency). Baseline and follow-up (after 10 weeks), 25OHD, 1,25-dihydroxyvitamin D (1,25(OH)₂D), alkaline phosphatase (ALP), PTH, osteocalcin (OC), N-terminal propeptide of type I procollagen (PINP), C-terminal telopeptide of type I collagen (CTX), and amino-terminal propeptide of C-type natriuretic peptide (NT-proCNP) were measured. None of the newborns had craniotabes, hypocalcemia or hyperparathyroidism. The median (Q1;Q3) 25OHD increased from a baseline of 8.45 (7;11.9) ng/ml to 54.6 (34.7;67.3) ng/ml (p < 0.001). The baseline 25OHD negatively correlated with total increment of 25OHD (r = ? 0.54; p = 0.002). There were changes in ALP (241 vs. 331 IU; p < 0.001), 1,25(OH)₂D (48 vs. 95.5 pg/ml, p < 0.001), OC (88.8 vs. 159.1 ng/ml, p < 0.001), PINP (3886 vs. 2409 ng/ml; p < 0.001), CTX (1.6 vs. 1.1 ng/ml; p < 0.001), and NT-proCNP (75.1 vs. 35.1 pmol/l; p < 0.001). Vitamin D deficient infants at baseline, compared to the insufficient group, revealed significantly higher percentage changes for 25OHD (745% vs. 167%, p < 0.0001), OC (113% vs. 40%, p < 0.05) and 1,25(OH)₂D (95% vs. 58%, p < 0.05). Conclusions: Vitamin D supplements had little to no impact on markers of bone turnover in term infants in the first few months of life, with the exception of osteocalcin. Ten weeks of cholecalciferol supplementation at a dose of 550 IU/day led to a marked increase of 25OHD concentration. The magnitude of 25OHD increment was inversely related to vitamin D status at baseline. Irrespective of the severity of vitamin D deficiency, a secondary hyperparathyroidism with elevated iPTH, ALP, phosphaturia or hypophosphatemia was not observed in the studied neonates.     

Prevalence and risk factors of low bone mineral density and 25-hydroxyvitamin D status in young healthy epileptic adult patients in a tropical Asian country taking antiepileptic drug

PurposeAntiepileptic drugs have been reported to reduce bone mineral density (BMD) in several countries with varying prevalence but in studies with small sample size and inadequate assessment of confounders, and rarely including young adults. We sought to determine the prevalence, vitamin D status and risk factors for low BMD in young adult epileptic patients in a tropical setting.MethodsWe prospectively examined left femoral neck and spine with dual-energy X-ray absorption. Demographic data, basic laboratory studies, history of clinical epilepsy, parathyroid hormone and vitamin D level were obtained.ResultsOne hundred and twenty three patients were included. The mean (± SD) T-score was ? 0.31 ± 1.24 at the spine and ? 0.19 ± 1.11 at the left femoral neck. 36% had osteopenia and 4.1% had osteoporosis at either site. Four patients had vitamin D deficiency. Vitamin D levels were not correlated with BMD. Twenty-five patients had vitamin D insufficiency. Multivariate logistic regression analysis identified low body mass index (BMI) and male sex as risk factors for low BMD at the spine and low BMI and duration of treatment as risk factors for low BMD at the left femoral neck.ConclusionChronic use of antiepileptic drug (AED) in young adult patients is associated with low BMD.     

Vitamin D deficiency promotes growth of MCF-7 human breast cancer in a rodent model of osteosclerotic bone metastasis

IntroductionBreast cancer metastases to bone are common in advanced stage disease. We have recently demonstrated that vitamin D deficiency enhances breast cancer growth in an osteolytic mouse model of breast cancer metastasis. In this study, we examined the effects of vitamin D deficiency on tumor growth in an osteosclerotic model of intra-skeletal breast cancer in mice.MethodsThe effects of 1,25-dihydroxyvitamin D₃ [1,25(OH)₂D₃] on proliferation and apoptosis of MCF-7 breast cancer cells, and changes in the expression of genes within the vitamin D metabolic pathway (VDR, 1α- and 24-hydroxylase) were examined in vitro. MCF-7 breast cancer cells were injected intra-tibially into vitamin D deficient and vitamin D sufficient mice co-treated with and without osteoprotegerin (OPG). The development of tumor-related lesions was monitored via serial X-ray analysis. Tumor burden and indices of proliferation and apoptosis were determined by histology along with markers of bone turnover and serum intact PTH levels.ResultsIn vitro, MCF-7 cells expressed critical genes for vitamin D signalling and metabolism. Treatment with 1,25(OH)₂D₃ inhibited cell growth and proliferation, and increased apoptosis. In vivo, osteosclerotic lesions developed faster and were larger at endpoint in the tibiae of vitamin D deficient mice compared to vitamin D sufficient mice (1.49 ± 0.08 mm² versus 1.68 ± 0.15 mm², P < 0.05). Tumor area was increased by 55.8% in vitamin D deficient mice (0.81 ± 0.13 mm² versus 0.52 ± 0.11 mm² in vitamin D sufficient mice). OPG treatment inhibited bone turnover and caused an increase in PTH levels, while tumor burden was reduced by 90.4% in vitamin D sufficient mice and by 92.6% in vitamin D deficient mice. Tumor mitotic activity was increased in the tibiae of vitamin D deficient mice and apoptosis was decreased, consistent with faster growth.ConclusionVitamin D deficiency enhances both the growth of tumors and the tumor-induced osteosclerotic changes in the tibiae of mice following intratibial implantation of MCF-7 cells. Enhancement of tumor growth appears dependent on increased bone resorption rather than increased bone formation induced by these tumors.     

Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery

BackgroundTo evaluate the adequacy of supplementation to correct preoperative vitamin D deficiency in adult patients during the year after Roux-en-Y gastric bypass (RYGB) surgery.MethodsThe medical records were reviewed and the preoperative and 12-month postoperative serum 25-hydroxyvitamin D [25(OH)D] levels were compared in patients who underwent RYGB from 2002 to 2004. The serum 25(OH)D levels were defined as being optimal (≥80 nmol/L), suboptimal (50–79 nmol/L), or deficient (<50 nmol/L). Patients with deficient 25(OH)D levels were prescribed 50,000 IU ergocalciferol weekly. The remaining patients averaged 710 IU supplemental vitamin D intake daily.ResultsThe mean patient age was 43.8 ± 10.7 years, and the mean preoperative body mass index was 51.8 ± 9.8 kg/m². Of the 95 patients with baseline and 12-month 25(OH)D levels, 89% were women. The mean preoperative 25(OH)D level was 49.7 ± 26.5 nmol/L; 34% had suboptimal 25(OH)D levels and 54% had deficient levels before surgery. Twelve months after surgery, those receiving 50,000 IU weekly (n = 40) had a mean 25(OH)D level of 69.2 ± 22.2 nmol/L; 63% had suboptimal and 8% deficient levels. Those taking 710 IU daily (n = 55) had a mean 25(OH)D level of 85.5 ± 33.0 nmol/L; 44% had suboptimal and 6% deficient levels.ConclusionVitamin D deficiency is prevalent in RYGB patients before surgery. The vitamin D status improved markedly after RYGB surgery with either 710 IU vitamin D daily or 50,000 IU weekly. Current supplementation practices do not appear to optimize the serum 25(OH)D levels and need to be more closely examined.     

Vitamin D levels in 577 consecutive elective foot & ankle surgery patients

BackgroundVitamin D deficiency is a global concern impacting upon large communities and certain disease populations. It can adversely affect the outcome of orthopaedic operations. We aimed to perform an audit of the Vitamin D status of patients in two centres in the United Kingdom undergoing elective foot and ankle surgery.MethodsSerum 25-hydroxyvitamin-D (vitamin D) levels were obtained prospectively in 577 consecutive elective patients undergoing elective foot and ankle surgery between October 2014 and March 2017 (29 months). Variables including age, gender, ethnicity, location, season, month and procedure type were recorded.Results577 patients were included over the study period. 62.0% were female. Mean age was 53.2 (median 54.5, range 16.7–86.6). 300 patients were treated in Northampton and 277 in Leicester. The serum 25-hydroxyvitamin-D levels for the patient group were normally distributed. The mean was 52.3 nmol/L (SD 28.0; range 7.5–175) and the median 47.5 nmol/L. 21.7% were grossly deficient, 31.9% deficient, 28.9% insufficient and 17.5% within normal range. Age, gender and procedure type did not statistically affect vitamin D levels (p = 0.5, t-test). Ethnicity, location and Winter season did affect Vitamin D levels (p < 0.05). August was the most significant month with levels significantly higher than January, February, March, April, June, November and December (p < 0.05, one-way ANOVA).ConclusionsOnly 1 in 5.7 patients had a normal Vitamin D level and 1 in 4.6 were grossly deficient. Ethnicity and patient location significantly affected Vitamin D results. Summer months were noted to demonstrate significantly the highest levels and August the highest. We did not find that age or gender affected Vitamin D levels in our cohort.     

Assessment of hand trabecular bone texture with high resolution direct digital radiograph in rheumatoid arthritis: a case control study

ObjectivesRheumatoid arthritis is characterized by an early inflammatory related periarticular osteopenia. A new high resolution direct digital X-ray device has been recently developed to provide bone texture analysis which is designed to assess changes in trabecular bone architecture. For the first time, we have evaluated trabecular bone texture impairment in rheumatoid arthritis patients compared to healthy controls.MethodsIn this cross-sectional study, the reproducibility was assessed by three separate digital X-rays of the right hand, with repositioning in 14 late rheumatoid arthritis patients and 14 healthy subjects. Then, trabecular bone texture of the MCP2 and MCP3 from patients enrolled in a prospective cohort of 78 rheumatoid arthritis patients was compared with that of 50 healthy subjects, using three texture parameters: Hmean, co-occurrence and run-length.ResultsThe coefficients of variation of the high resolution direct digital X-ray measurements ranged from 0.5 to 1.8%. Only the Hmean parameter was significantly decreased in rheumatoid arthritis patients compared to healthy subjects at MCP2 (0.637 ± 0.040 vs 0.654 ± 0.032, P < 0.05) and at MCP3 (0.646 ± 0.044 vs 0.665 ± 0.037, P < 0.05). This reduction was significantly correlated to disease activity.ConclusionsThis study demonstrated both the good reproducibility of the high resolution digital X-ray measurements and the trabecular bone texture impairment at MCP joints in rheumatoid arthritis patients. In addition to provide a high resolution hand radiograph, this technique may represent an interesting tool to easily quantify periarticular osteopenia with a low radiation dose.     

Plasma levels of soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) in familial Mediterranean fever

AimsTo assess the levels of soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) in patients with familial Mediterranean fever (FMF).MethodsPlasma levels of sVEGFR-1 were investigated in 33 FMF patients in an attack-free period (mean age 30.8 years; males/females 10/23), in 15 patients with acute FMF attack (mean age 32.7 years; males/females 7/8), and 19 healthy controls (mean age 32 years; males/females 11/8). Levels of sVEGFR-1 were also compared among patients who were receiving colchicine and those who were not.ResultsPlasma sVEGFR-1 levels were 3.49 ± 1.10, 3.53 ± 1.02, and 0.37 ± 0.28 ng/ml for FMF patients in the attack-free period, FMF patients with acute attack, and healthy controls, respectively. Plasma sVEGFR-1 levels were significantly higher in FMF patients with and without acute attack compared to the control group (p < 0.05). sVEGFR-1 levels were not statistically significant between patients with acute attack and attack-free FMF patients (p > 0.05). The plasma levels of sVEGFR-1 were also comparable in colchicine treated and untreated patients.ConclusionOur data suggest that sVEGFR-1 may have a role in the ongoing inflammatory cascade in FMF.     

The increasing burden of phlebotomy in the development of anaemia and need for blood transfusion amongst trauma patients

BackgroundDiagnostic laboratory tests are an integral part of the management of trauma patients, however, may be responsible for significant iatrogenic blood loss. The purpose of this study was to examine how phlebotomy practises have changed over time, and to assess the impact of these practises on patient outcomes.MethodsA continuous series of injured patients admitted to a level I trauma centre (March–April 2004) was compared to the same period in 2009. All diagnostic tests and blood volumes withdrawn for each patient were tabulated. Primary outcomes were in-hospital mortality and length of stay (LOS); secondary outcomes were development of anaemia (Hgb < 9 g/dl) and need for blood transfusion. A cost analysis was performed to determine the financial impact of the blood tests ordered.ResultsThe 360 patients in 2009 and 384 patients in 2004 demonstrated no significant differences in demographics or clinical data. When outcomes were compared, there were no significant differences in hospital LOS, ICU LOS or mortality. From 2004 to 2009, the mean number of laboratory tests per patient increased significantly (21.2 ± 32.5 to 28.5 ± 44.4, p = 0.003). The total blood volumes drawn during the hospital stay also increased significantly (144.4 ± 191.2 ml to 187.3 ± 265.1 ml, p = 0.025). For ICU patients (329.7 ± 351.0 ml to 435.9 ± 346.3 ml, p = 0.048). There was a 25% increase in costs due to laboratory blood tests over the study period. For ICU patients, a 36% increase in costs was observed.ConclusionsFrom 2004 to 2009, there was a significant increase in the utilisation of diagnostic laboratory tests in the management of the injured patient with no demonstrable improvements in mortality or LOS. Further prospective evaluation of these results is warranted.     

Vitamin D deficiency in northern Vietnam: Prevalence,risk factors and associations with bone mineral density

PurposeVitamin D deficiency has been linked to osteoporosis and also to the risk of cancer, autoimmune disorders and cardiovascular diseases. This study sought to determine the prevalence of, and risk factors for, vitamin D deficiency and its relationship with bone mineral density (BMD) in a Vietnamese population.MethodsThis cross-sectional study involved 269 women and 222 men aged 13–83 years, who were randomly selected from urban and rural areas in northern Vietnam. Serum concentrations of 25-hydroxy-vitamin D [25(OH)D] and parathyroid hormone (PTH) were measured by electrochemiluminescence immunoassay. Vitamin D deficiency was defined as serum 25(OH)D levels below 20 ng/mL. BMD was measured by dual X-ray absorptiometry.ResultsThe prevalence of vitamin D deficiency in women was 30%, almost two-fold higher than in men (16%). Significant predictors of vitamin D deficiency in women were urban residency (p < 0.01) and age less than 30 years (p < 0.01), whereas use of contraceptive pills was protective (p < 0.01). In men, winter season was the only significant predictor of vitamin D deficiency (p < 0.01). In multiple linear regression analysis, serum levels of 25(OH)D were positively associated with BMD in both women (p < 0.001) and men (p < 0.001).ConclusionsThese data suggest that the prevalence of vitamin D deficiency is high in the Vietnamese population, and that part of this prevalence could be explained by low exposure to sunlight (urban residency and winter season). The high prevalence of vitamin D deficiency should raise the awareness of potentially important health issues such as osteoporosis within the Vietnamese society.     

Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture

BackgroundIt is not well established if and to what extent mild to moderate cognitive impairment predicts mortality and risk of nursing home admission after hip fracture.ObjectiveTo investigate prospectively whether and to what extent mild to moderate cognitive impairment, contributes to mortality and admission to nursing home in the first year after acute hip fracture.MethodsWe enrolled 173 patients with acute hip fracture age 65 and older who reached a Mini-Mental State Examination (MMSE) score of at least 15 during acute care after hip fracture repair. An MMSE score of 15 to 24 (median) was classified as mild to moderate cognitive impairment. Primary outcomes were mortality in all and admission to nursing home among seniors who lived at home prior to their hip fracture. Follow-up was 12 months with clinical visits at baseline, 6, and 12 months, plus monthly phone calls. We used Cox proportional hazards models controlling for age, sex, body mass index, baseline number of comorbidities and 25-hydroxyvitamin D status, and severe incident infections to assess the risk of mortality and nursing home admission. Because the study population was enrolled in a factorial design clinical trial testing high dose vitamin D and/or an exercise home program, all analyses also controlled for these treatment strategies.ResultsOf 173 acute hip fracture patients enrolled, 79% were women, 77% were admitted from home, and 80% were vitamin D deficient (< 20 ng/ml). Mean age was 84 years. 54% had mild to moderate cognitive impairment. Over the 12-month follow-up, 20 patients died (27% of 173) and 47 (35% of 134) were newly admitted to a nursing home. Mild to moderate cognitive impairment was associated with a more than 5-fold increased risk of mortality (HR = 5.77; 95% CI: 1.55–21.55) and a more than 7-fold increased risk of nursing home admission (HR = 7.37; 95% CI: 1.75–30.95). Additional independent risk factors of mortality were male gender (HR = 3.55; 95% CI: 1.26–9.97), low BMI (HR = 7.25; 95% CI: 1.61–33.74), and baseline 25-hydroxyvitamin D level (per 1 ng/ml: HR = 0.93; 95% CI: 0.87–0.998; p = 0.04).ConclusionsMild to moderate cognitive impairment in patients with acute hip fracture is associated with a high risk of mortality and nursing home admission during the first year after hip fracture. Female gender, a greater BMI and a higher 25-hydroxyvitamin D status may protect against mortality after hip fracture independent of cognitive function.