Hypovitaminosis D in an hospitalized old population of Western Friuli

Objectives Hypovitaminosis D is very common in the elderly in Italy and generally in the world, contributing to bone fractures and muscle weakness. The aim of the study was to evaluate bone metabolism in an old population of patients hospitalized not for musculo-skeletal complaints. Methods The clinical records of 175 patients, 98 female and 77 male, aged >65 years, hospitalized in a Department of Internal Medicine (Sacile, Western Friuli) were retrospectively reviewed. Serum levels of calcium, phosphorous, alkaline phosphatase, parathyroid hormone (PTH) and 25-OH vitamin D were evaluated. Correlations between these parameters were investigate. Results Abnormalities of bone metabolism parameters were frequently founded, particularly hypocalcemia, increased PTH and reduced 25-OH vitamin D. Hypovitaminosis D were detected in 88% of patients, low levels in 30.28% and very low levels in 57.72%. Hypovitaminosis D was related to female sex, old age of patients and high levels of PTH. Conclusions Our data confirm that hypovitaminosis D is very common in elderly population. The study has been performed in an Italian Region where the supplementation of vitamin D in the elderly is not performed, suggesting that a awareness campaign of the doctors could be very useful to prevent bone metabolism abnormalities.     

Hypovitaminosis D and its relation to demographic and laboratory data among hepatitis C patients

Background. The relationship between 25-hydroxyvitamin D [25(OH)D] serum levels and response to antiviral therapy and laboratory data in HCV infection remains unclear. The aim of this study was to determine pre-treatment 25(OH)D serum level among HCV infected individuals and to evaluate the association between vitamin D status, virological response, and laboratory data.Material and methods. Baseline serum 25(OH)D levels were measured in 237 chronic HCV infected patients (139 female, age 53.7 ± 11.2 years) using chemiluminescence immunoassay. Correlations between serum 25(OH)D levels, virological and laboratory data regarding HCV infection as well as sustained virological response (SVR) to antiviral therapy were evaluated.Results. Mean serum values of 25(OH)D was 26.2 ± 12 ng/mL and prevalence of vitamin D deficiency (< 30 ng/mL) was 66.2%. Advanced age (> 55 years), high mean values of LDL, total cholesterol, HDL and low mean values of alkaline phosphatase and hemoglobin were statistically associated to vitamin D deficiency. Antiviral treatment was underwent by 133 HCV patients and 44.3% of them achieved SVR. Most of individuals that presented SVR also presented 25(OH)D level higher than 30ng/mL (55.9%). SVR was associated to low mean values of LDL, total cholesterol and platelets; high mean values of ALT, AST and low fibrosis grade. Conclusions: In conclusion, low vitamin D levels were observed among HCV infected patients and was associated to laboratory findings, however baseline 25(OH)D level is not independently associated with SVR.     

Hypovitaminosis D in female patients with chronic low back pain

Chronic low back pain (LBP) is an extremely common problem in practice, where it is often labeled idiopathic. No sufficient studies have been conducted to analyze the contribution of hypovitaminosis D to the etiology of chronic LBP in populations wherein vitamin D deficiency is endemic. The present study was, therefore, carried out to examine hypovitaminosis D and its determinants in female patients with chronic LBP during the childbearing period. Sixty female patients complaining of LBP lasting more than 3 months were clinically studied rheumatologically and neurologically. Questionnaires and indices quantifying risk factors associated with vitamin D deficiency were utilized. Biochemical assays of serum calcium, phosphorus, alkaline phosphatase (ALP), parathormone (PTH), and 25-hydroxyvitamin D (25 OHD) were performed and compared to those of 20 matched healthy controls. The determinants of vitamin D levels in patients were examined by stepwise regression. Patients with LBP had significantly lower 25 OHD levels (p < 0.05) and significantly higher PTH (p < 0.05) and ALP (p < 0.001) than controls, although there were no significant group differences in calcium and phosphorus. Hypovitaminosis D (25 OHD < 40 ng/ml) was found in 49/60 patients (81%) and 12/20 (60%) of controls, with an odds ratio of 2.97. Although many risk factors related to sun exposure, clothing, diet, and pregnancy were significantly correlated with vitamin D levels in patients, only limited duration of sun exposure, contributing 55% to the variance of 25 OHD, limited areas of skin exposed (13%), and increased number of pregnancies (2%), were significant determinants of vitamin D levels in patients. Despite the sunny climate, hypovitaminosis D is prevalent among Egyptian women in the childbearing period, especially those presenting with chronic LBP, where it is associated with hyperphosphatasia and hyperparathyroidism, without alterations in serum calcium. The major determinant of hypovitaminosis D in our patients is limited sun exposure.     

Hypovitaminosis D in older adults

Vitamin D deficiency is increasingly recognised as a common problem among older adults. In addition to the well-known role of vitamin D in calcium homeostasis and the maintenance of bone health, recent research has started to characterise the importance of vitamin D in neuromuscular function and the way this may relate to functional performance and falls risk in older adults. In this review we describe the current state of knowledge relating to the neuromuscular effects of vitamin D and discuss treatment options.     

Fever in hospitalized medical patients

The occurrence of fever and the clinical profile of febrile patients on the medical service of a teaching hospital were studied prospectively. Thirty-six per cent of 972 patients developed fever (temperature exceeding 38°C). Their 13% mortality rate and 13.2-day average hospital stay exceeded the 3% mortality and seven-day hospitalization for afebrile patients (p<0.0001 for both). Most fever episodes occurred during the first two hospital days. Approximately 30% of first and subsequent fever episodes were caused by bacterial infections; illnesses involving tissue necrosis (e.g., stroke, myocardial infarction) accounted for 20%. Five conditions comprised 53% of diagnoses: respiratory and urinary tract infections, neoplasm, myocardial infarction, and drug reaction. Only one patient had a fever of uncertain origin. Several clinical clues used frequently to identify bacterial infections were reevaluated. Patients with bacterial infections had higher temperatures on the first febrile day (mean 38.9°C) and were more likely to have had prior infections than those with other causes of fever (mean 38.3°C, p<0.001). Older patients (>75 years) had a lower febrile response to bacterial infections than younger patients. Fever in hospitalized medical patients is a common and important concomitant of increased mortality and length of hospitalization. Supported in part by grants from the National Center for Health Services Research (HS 02063 and HS 04066) and by a grant from the Henry J. Kaiser Family Foundation. The work was performed, in part, while Dr. Bor was a Henry J. Kaiser Fellow in General Medicine, Harvard Medical School.     

Undiagnosed tuberculosis in hospitalized patients

Eighty-two cases of active tuberculosis (TB) were diagnosed only at autopsy in patients hospitalized in the Chaim Sheba Medical Center during a 21-year period (1960 to 1980). Some 75 percent of the patients were over 50 years old and a large number of them suffered from accompanying diseases or drug therapy which suppresses the immune system. Diagnostic measures for the confirmation of tuberculosis (skin tests; cultures of sputum, urine, gastric juice; liver biopsy) were not taken in 75 percent of the cases. In those taken, skin tests were negative in 75 percent of cases, most probably as a sign of anergy. The rest were borderline cases in whom the diagnosis of TB was not accepted affirmatively.     

Candida-associated diarrhea in hospitalized patients

Ten hospitalized patients with severe diarrhea associated with intestinal Candida overgrowth are reported. Candida-associated diarrhea is predominantly of the secretory type, characterized by frequent watery stools, usually without blood, mucus, tenesmus, or abdominal pain. The patients were elderly, malnourished, and critically ill, or suffered from chronic debilitating illness. Their hospital stays were prolonged, and the majority were being treated with multiple antibiotics or chemotherapeutic agents. Diarrhea often led to dehydration, prerenal azotemia, hyperchloremic metabolic acidosis, and electrolyte imbalance. Stool culture most frequently isolated Cand. albicans in association with decreased normal flora. Colonoscopy showed no evidence of colitis. Diagnosis was made based on the absence of diarrhea-producing medications, the continuation of diarrhea despite fasting, the exclusion of other infections, inflammatory conditions and other causes of secretory diarrhea, and a dramatic response to a short course of nystatin.     

Severe hypophosphatemia in hospitalized patients

Severe hypophosphatemia (serum phosphorus less than or equal to 0.48 mmol/L [less than or equal to 1.5 mg/dL]) was found in 120 patients admitted to a major university hospital, during a period of 16 months. Fifty-one patients (42.5%) developed hypophosphatemia postoperatively. Medications known to precipitate hypophosphatemia were a causative factor in 82% of the patients, with glucose administered intravenously, antacids, diuretics, and steroids being the most common agents associated with profound hypophosphatemia. Gram-negative septicemia was observed in 16 patients, and it was the second most common cause of severe hypophosphatemia. The mortality rate was 20% in patients with a serum phosphorus concentration between 0.36 and 0.48 mmol/L (1.1 and 1.5 mg/dL) (group A) and 30% in patients with a serum phosphorus concentration of less than or equal to 0.32 mmol/L (less than or equal to 1.0 mg/dL) (group B). The cause of death and its temporal association with the lowest observed values of phosphorus concentration indicate that severe hypophosphatemia might be a contributory factor to mortality. Our data indicate that severe hypophosphatemia in hospitalized patients is the result of a combination of factors. Surgery, followed by a period of fasting with intravenous administration of glucose, and gram-negative septicemia are the most common causes.     

Hypovitaminosis D in Chronic Kidney Disease

Background and objectives: Recent studies show high prevalence of suboptimal 25-hydroxyvitamin D levels in chronic kidney disease patients. This study sought to test the hypothesis that the prevalence of 25-hydroxyvitamin D deficiency is significantly higher in chronic kidney disease patients and, in diabetic nephropathy, low serum 25-hydroxyvitamin D is associated with abnormal serum parathyroid hormone, bone mineral density, and coronary artery calcification.Design, setting, participants, & measurements: Study A used data from the Third National Health and Nutrition Examination Survey. Study B was a post hoc analysis of an observational study of coronary artery calcification in non–dialysis-dependent diabetic nephropathy.Results: In study A, the adjusted odds for 25-hydroxyvitamin D deficiency were 32% higher in chronic kidney disease patients. This higher prevalence of 25-hydroxyvitamin D deficiency, however, could not be explained by differences in total vitamin D intakes. The consequences of suboptimal 25-hydroxyvitamin D levels were analyzed in 146 patients with diabetic nephropathy. The significant, inverse relationship between serum 25-hydroxyvitamin D and parathyroid hormone levels was attenuated to a nonsignificant level on multivariate adjustment. There was a significant, inverse relationship between bone mineral density and coronary artery calcification scores; neither was independently associated with serum 25-hydroxyvitamin D. The serum 25-hydroxyvitamin D levels declined modestly in 72 patients studied after 12.4 ± 0.4 mo.Conclusions: 25-Hydroxyvitamin D deficiency is more common in chronic kidney disease, but this higher prevalence is unlikely to be a result of lower vitamin D intakes. The consequences of suboptimal 25-hydroxyvitamin D levels remain to be definitively elucidated.Vitamin D is important for maintaining bone health and muscle function (1). Serum 25 hydroxyvitamin D (25OHD) levels are a sensitive marker of the total body vitamin D stores. Epidemiologic and interventional studies suggest that serum 25OHD levels of at least 30 ng/ml are probably necessary to ensure optimal bone health and muscle function (1,2). Using this threshold, a large proportion of elderly, nursing home residents, dark-skinned people, and individuals who require hospitalization are either vitamin D insufficient (15 to 30 ng/ml) or deficient (<15 ng/ml) (1,3,4). In the absence of data from individuals with chronic kidney disease (CKD), the Kidney Disease Outcomes Quality Initiative (KDOQI) workgroup extrapolated these data to make opinion-based recommendations to maintain serum 25OHD levels >30 ng/ml in patients with stage 3 or 4 CKD (5). Numerous studies have demonstrated that the vast majority of non–dialysis-dependent patients with CKD have suboptimal 25OHD levels (6–9); however, none of these studies included a sufficiently large sample of control subjects to determine whether CKD is independently associated with a higher prevalence of suboptimal 25OHD levels. Moreover, secondary hyperparathyroidism and reduced bone mineral density (BMD)—the most common consequences of suboptimal 25OHD levels in the general population—are often present in patients with CKD. There is a paucity of data evaluating the role of 25OHD in the reduced BMD in CKD.We undertook this study to test the hypothesis that CKD is an independent predictor of 25OHD deficiency in a random sample of community-dwelling individuals of the United States using the Third National Health and Nutrition Survey (NHANES III; study A); this may, in part, be accounted for by lower daily vitamin D intakes. Furthermore, in a cohort of patients with diabetes and diabetic nephropathy (DN), we sought to determine the effects of suboptimal 25OHD levels on bone health (elevated serum parathyroid hormone (PTH) levels and reduced BMD) and coronary artery calcification (CAC) scores (study B).     

湘南地区住院患者丙型肝炎病毒感染方式的特征分析

目的 了解湖南地区住院患者中HCV疑似感染方式分布的规律特征,为HCV感染的防治提供参考.方法 应用电子病历查询法对住院患者中诊断有丙型肝炎者进行回顾性分析.化学发光法检测抗HCV抗体,实时荧光定量PCR法检测HCV RNA定量.结果 肾内科患者主要经血液透析感染(80.0％),妇产科患者主要经手术感染(64.7％),感染科患者主要为输血感染(39.0％)和静脉吸毒感染(28.6％),其他科室患者也主要为输血感染(40.7％)和静脉吸毒感染(37.0％),不同科室住院患者的HCV疑似感染方式构成比存在明显差异(P＜0.01).年龄≤40岁患者主要经静脉吸毒感染( 38.2％),而年龄＞40岁患者主要经输血感染(49.3％),不同年龄患者HCV疑似感染方式构成比存在明显差异(P＜0.01).男性患者主要经静脉吸毒(35.0％)和输血感染( 32.5％),而女性患者主要经手术(32.7％)和输血( 26.9％)感染,不同性别患者HCV疑似感染方式构成比存在明显差异(P＜0.01).结论 HCV的感染方式已呈现明显的多样化,静脉吸毒将成为越来越重要的感染因素.     

Protein C, an antithrombotic protein, is reduced in hospitalized patients with intravascular coagulation

Activated protein C is a potent anticoagulant and profibrinolytic enzyme that can be derived from the vitamin-K-dependent serine protease zymogen, protein C, by the action of thrombin. Protein C antigen concentration was determined in plasmas from normals (n = 40) and from 38 patients with intravascular coagulation as evidenced by positive FDP (greater than micrograms/ml). Plasma protein C was 4 micrograms/ml in normals and was significantly depressed (less than 2 SD below the mean of normals) in 19 of the 38 patients. Of 15 patients with suspected intravascular coagulation but normal FDP, protein C was decreased in 5 individuals; 3 of these 5 patients had liver disease. Based on these results, we suggest that extensive activation of the coagulation system in vivo causes a significant consumption of protein C, presumably due to its activation by thrombin and subsequent clearance.     

Resuscitation of hospitalized patients

Effects of in-hospital resuscitations performed by a trained resuscitation team were studied over a 20-month period during which 1653 deaths were registered. Resuscitative attempts were made in 61 patients with a mean age of 71 years (range 0-86 years). The underlying disease was ischaemic heart disease in 38 cases and most arrests occurred in general wards. Twenty-one patients were initially resuscitated; 12, however, died after an average of 3.2 days while still in hospital. Nine patients were discharged and seven are still alive after two and a half years.     

Hypovitaminosis D in obese and overweight schoolchildren

Aim: To determine the prevalence of vitamin D hypovitaminosis among obese and overweight schoolchildren.Design: A cross−sectional population based sample.Methods: In a cross−sectional study, 301 students (177 girls and 124 boys) aged 11−19 years were selected by multistage stratified sampling design. Subjects were classified according to their body mass index as obese, overweight and normal. Serum 25−hydroxyvitamin D (25−OHD), intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) were measured in late winter months. Vitamin D deficiency was defined as a 25−OHD 20 ng/ml.Results: The prevalence of hypovitaminosis D was found as 65% in all students. Vitamin D deficiency was found in 12% and insufficiency in 53% of all students. Vitamin D deficiency in female students was about two times more common than in males. In obese and overweight schoolchildren with hypovitaminosis D, serum 25−OHD levels decreased as BMI increased. There were no correlations between serum 25−OHD and ALP and iPTH levels.Conclusion: Vitamin D deficiency and insufficiency are common in obese and overweight schoolchildren, especially in girls. Obesity could be a risk factor in terms of hypovitaminosis D in adolescents. Vitamin D supplementation should be administered particularly to adolescent girls.Conflict of interest:None declared.     

Vitamin D deficiency in hospitalized patients

Vitamin D deficiency is one of the important risk factors for the development of osteoporosis and fractures. The high prevalence of hypovitaminosis in elderly people in old age pnesioners homes was proved in several investigations, similarly as the favourable effect of vitamin D (800 IU/day) and calcium supplementation on a decline of fracture risk. Risk factors of hypovitaminosis such as an inadequately varied diet; low exposure to sunlight, chronic liver and kidney disease and treatment affecting the metabolism and clearance of vitamin D are very frequent in elderly patients hospitalized in medical departments. In the submitted trial the authors assessed in a group of 38 patients, mean age 70 years, hospitalized at the medical department at the end of the winter period the vitamin D3 serum level. They found a significant reduction of the concentration of 1.25 hydroxyvitamin D3 (p < 0.01) in the investigated group. The results of the trial, along with data in the literature on the high prevalence of hypovitaminosis D in the European population, indicate the need to introduce this simple cheap and safe therapeutic modality into routine practice.     

Protein-calorie undernutrition in hospitalized cancer patients

A survey of the nutritional status of hospitalized cancer patients was conducted in two phases. In phase 1, protein-calorie nutrition was evaluated in 54 ward patients by anthropometries, creatinine excretion and serum albumin. In phase two, 30 cancer patients with protein-calorie undernutrition were transferred to the Clinical Research Unit for study of the underlying mechanisms. Evaluation in this group included anthropometries, serum albumin, creatinine excretion, vitamin levels, caloric intake, basal metabolic rate and stool fat content. Duration of survival from study was recorded in both phases.We found a nearly universal prevalence of protein-calorie undernutrition in advanced cancer, with loss of adipose tissue, visceral protein and skeletal muscle varying unpredictably from patient to patient. The creatinine to height ratio was the most sensitive indicator of protein-calorie undernutrition; 88 per cent of the patients in both phases had a creatinine to height ratio less than 80 per cent of standard, whereas only 42 per cent and 23 per cent of these patients had values less than 80 per cent of standard for triceps skin fold and mid-arm muscle area, respectively. In phase 2, plasma folate, ascorbic acid and vitamin A levels were low in 20 to 45 per cent. Steatorrhea was rare. Neither the basal metabolic rate nor caloric intake differed from expected values for normal sedentary subjects of comparable size.The degree of malnutrition significantly correlated with survival. Patients who died within 70 days of study generally had a creatinine to height ratio <60 per cent of standard (18 of 19 patients), albumin <3.5 g/dl (16 of 23 patients) and/or triceps skin fold thickness <60 per cent of standard (12 of 19 patients).We conclude that protein-calorie undernutrition is present in most hospitalized cancer patients but that it varies widely in degree between subjects and is often obscured at the bedside by residual obesity. The creatinine to height ratio, however, is a sensitive quantitative indicator of this condition. There appear to be nutritional thresholds below which survival is decreased. Survival might be enhanced if nutrition could be maintained above these critical levels.     

Incidence of sepsis in hospitalized patients

In recent years, several epidemiological studies have helped expand our knowledge of the incidence of sepsis at the intensive care unit (ICU) and population levels. However, more data are needed from developing countries. Overall, even with a lack of standardized definitions—particularly of sepsis-associated organ dysfunction, hypoperfusion or hypotension, and septic-induced cardiovascular failure despite adequate fluid resuscitation—the incidence of sepsis seems higher in Brazil, the United Kingdom, and Portugal. In the future, in order to better identify patients that need early ICU admission, aggressive care, and new therapies, we must develop and apply better instruments for definition and risk stratification, especially for evaluating the risk of progressing from sepsis to severe sepsis and septic shock.     

Hepatitis C as a prognostic indicator among noncirrhotic patients hospitalized with alcoholic hepatitis

OBJECTIVE:

A nationwide analysis of alcoholic hepatitis (AH) admissions was conducted to determine the impact of hepatitis C virus (HCV) infection on short-term survival and hospital resource utilization.

METHODS:

Using the Nationwide Inpatient Sample, noncirrhotic patients admitted with AH throughout the United States between 1998 and 2006 were identified with diagnostic codes from the International Classification of Diseases, Ninth Revision. The in-hospital mortality rate (primary end point) of AH patients with and without co-existent HCV infection was determined. Hospital resource utilization was assessed as a secondary end point through linear regression analysis.

RESULTS:

From 1998 to 2006, there were 112,351 admissions for AH. In-hospital mortality was higher among patients with coexistent HCV infection (41.1% versus 3.2%; P=0.07). The adjusted odds of in-hospital mortality in the presence of HCV was 1.48 (95% CI 1.10 to 1.98). Noncirrhotic patients with AH and HCV also had longer length of stay (5.8 days versus 5.3 days; P<0.007) as well as greater hospital charges (US$25,990 versus US$21,030; P=0.0002).

CONCLUSIONS:

Among noncirrhotic patients admitted with AH, HCV infection was associated with higher in-hospital mortality and resource utilization.     

Severe hypokalemia in hospitalized patients.

Profound hypokalemia was observed in 73 patients in a major university teaching hospital during a three-year period. When compared with hospitalized subjects used as controls, these patients experienced a greater mortality, were substantially more likely to be female, but were not more likely to suffer from cardiovascular disease. Use of a diuretic appeared to precipitate profound hypokalemia infrequently, and when it did, the clinical situation was extremely complex. Over 10% of the patients with hypokalemia had acute myeloid leukemia, an incidence 22 times greater than that expected. Hypokalemia should be sought in all patients with this disease, since it is an avoidable cause of death. Further studies into the mechanism of hypokalemia are required to explain its striking preponderance in women.