Changes in vitamin D metabolites at the time of critical illness and 6 months later-A prospective observational study.

BACKGROUND: Despite multiple studies suggesting that low 25(OH)D-vitamin levels are associated with worse outcomes in critically ill individuals, attempts to mitigate the outcomes by fixed dose enteral supplementation unguided by baseline or target blood levels have been unsuccessful. Since a single measurement of 25(OH)D may not optimally reflect an individual's vitamin D status, we studied the plasma concentration of different vitamin D metabolites and their recovery during and following resolution of acute critical illness. METHODS: A prospective observational study including patients 18 years and older admitted to a mixed medical-surgical ICU in Reykjavik, Iceland, located at a high-northern altitude (64° N). Vitamin D metabolites were measured at three timepoints; On admission (S1), 3-5 days following admission (S2) and after recovery from acute illness (median 178 days) (S3). Concentrations of total 25(OH)D-vitamin, cholecalciferol (D3 ), total 24,25(OH)D-vitamin, vitamin D binding protein (VDBP) were measured with LC-tandem mass spectrometry (LC-MS/MS) and free 25-(OH)D was measured with enzyme-linked immunosorbent assay. RESULTS: Most individuals were vitamin D deficient when assessed during critical illness, with 25(OH)D-vitamin levels under 30 ng/ml for 37/40 individuals at timepoint S1 and 34/38 at S2. After recovery, 18/30 patients were deficient at S3. Levels of all vitamin D metabolites measured were low during critical illness but rose substantially following resolution of acute illness. No strong correlation was found between markers of acute illness severity or duration and resolution of vitamin D metabolites in the interval between acute illness and recovery. CONCLUSIONS: In critically ill patients, levels of multiple vitamin D metabolites are low but substantial recovery occurs following resolution of acute illness. It is unclear whether a single metabolite is sufficient to assess vitamin D status of critically ill patients and guide potential supplementation.

Number of visits to the emergency department and risk of suicide: a population-based case-control study.

BACKGROUND: The aim was to study whether number of visits to emergency department (ED) is associated with suicide, taking into consideration known risk factors. METHODS: This is a population-based case-control study nested in a cohort. Computerized database on attendees to ED (during 2002-2008) was record linked to nation-wide death registry to identify 152 cases, and randomly selected 1520 controls. The study was confined to patients attending the ED, who were subsequently discharged, and not admitted to hospital ward. Odds ratio (OR) and 95% confidence intervals (CI) of suicide risk according to number of visits (logistic regression) adjusted for age, gender, mental and behavioral disorders, non-causative diagnosis, and drug poisonings. RESULTS: Suicide cases had on average attended the ED four times, while controls attended twice. The OR for attendance due to mental and behavioral disorders was 3.08 (95% CI 1.61-5.88), 1.60 (95% CI 1.06-2.43) for non-causative diagnosis, and 5.08 (95% CI 1.69-15.25) for poisoning. The ORs increased gradually with increasing number of visits. Adjusted for age, gender, and the above mentioned diagnoses, the OR for three attendances was 2.17, for five attendances 2.60, for seven attendances 5.97, and for nine attendances 12.18 compared with those who had one visit. CONCLUSIONS: Number of visits to the ED is an independent risk factor for suicide adjusted for other known and important risk factors. The prevalence of four or more visits was 40% among cases compared with 10% among controls. This new risk factor may open new venues for suicide prevention.

[Clostridium difficile infections at Landspítali - 1998-2008]. / Clostridium difficile sýkingar á Landspítala 1998-2008.

OBJECTIVE: To study the epidemiology and severity of C. difficile infections (CDI) at Landspítali over 11 year period, 1998-2008. MATERIAL AND METHODS: CDI were identified by a positive toxin assay in stools from the database of the Department of Microbiology. Chart review was conducted on patients diagnosed in January and June each year during the study period, a total of 237 infections. RESULTS: Overall, 1,861 of 11,968 submitted stool samples were positive for C. difficile toxin, representing 1,492 infections. The population-based incidence was 29% higher in the end than in the beginning of the period and was highest in the age group >80 years where it was 387 cases per 100,000 person-years. The incidence per 1,000 admissions and 10,000 hospital days increased by 71% and 102%, respectively. 47% of the infections were nosocomial. Most patients had history of antibiotic exposure prior to the infection and the most common symptom was diarrhea. Response to a single antibiotics course was good (93%). No patient required surgery due to colitis. CONCLUSION: The incidence of CDI was higher in 2008 than 11 years before. Most patients had well characterized risk factors for CDI. For most patients a single course of metronidazole treatment resolved the infection. Based on these data, the severity of CDI does not seem to be increasing in Iceland.