On 2015 Feb 05, William Grant commented:

Increasing vitamin D levels can reduce unplanned hospital readmissions

The paper by Merkow and colleagues points out that readmissions after surgery are largely due to new postdischarge complications related to the procedure [1]. The information about the characteristics of the patients and the factors associated with unplanned readmission provide important clues as to the causes of the readmissions. This comment examines the possible role of low 25-hydroxyvitamin D [25(OH)D] concentration as an important underlying cause of readmission.

One aspect is that blacks have higher unplanned readmissions than whites (Table 4). Blacks have much lower mean 25(OH)D concentrations than whites [2] due to the facts that most vitamin D is made from solar UVB exposure and blacks have darker skin.

The next clue is the types of disease with significantly higher unplanned readmission rates (Table 4). Risk of congestive heart failure death is significantly inversely correlated with 25(OH) concentrations [3]. Treating those with heart failure increases heart function [4]. Prevalence of chronic pulmonary obstructive disease is inversely correlated with 25(OH)D concentration [5]. Those with COPD and severe vitamin D deficiency are more likely to be hospitalized [6].

Incidence of diabetes is inversely correlated with 25(OH)D concentration [7]. Incidence and mortality rates for many types of cancer are inversely correlated with solar UVB doses and 25(OH)D concentrations [8]. Would infection: an observational study in Massachusetts found that surgical site infections for those undergoing Roux-en-Y gastric bypass surgery were linearly inversely correlated with 25(OH)D concentrations below about 30 ng/mL (75 nmol/L) [9]. Vitamin D has a number of antimicrobial actions such as inducing production of cathelicidin and defensins [10]. It has been proposed that increasing 25(OH)D concentrations would reduce the risk of hospital acquired infections [11]. Renal failure: A study in Boston found that preadmission 25(OH)D concentrations below 20 ng/mL is predictive of acute kidney injury [12]. Peripheral vascular disease: 25(OH)D concentrations are significantly inversely correlated with peripheral vascular disease [3]. Sepsis: 25(OH)D concentrations are significantly inversely correlated with risk of sepsis [13, 14].

The general finding in many observational studies is that 25(OH)D concentrations below 30 ng/mL have increased risk of many chronic and infectious diseases [15, 16].

Looking at Table 2, the two most frequent reasons for unplanned readmissions directly related to 25(OH)D concentrations are surgical site infection and sepsis. Together they account for about 22% of readmissions. This portion of the readmissions can be reduced significantly if those undergoing surgery in hospitals have higher 25(OH)D concentrations.

To reduce this portion of readmissions, it would be worthwhile to measure 25(OH)D concentrations of those planning surgery or admitted to the hospital. Giving loading doses of vitamin D3 should increase 25(OH)D concentrations rapidly. A loading dose of 250,000 IU vitamin D3 increased 25(OH)D concentrations by 58 nmol/L (23 ng/mL) after 5 days in a study with healthy adults in one study [17]. A study in Austria found that giving 550,000 IU of vitamin D3 shortly after admission to the intensive care unit followed by 90,000 IU/mo thereafter found a significant reduction in mortality rates between 28 days and 6 months after admission for those with 25(OH)D concentrations below 12 ng/mL [18]. There were no significant adverse effects associated with this dose of vitamin D in this patient population although some of the patients had elevated serum calcium levels. 550,000 IU is higher than would typically be given to raise 25(OH)D concentrations rapidly. Prescription grade 50,000 IU capsules of vitamin D3 are now available.

References 1. Merkow RP, Ju MH, Chung JW, et al. Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States. JAMA. 2015;313(5):483-495 2. Ginde AA, Liu MC, Camargo CA Jr. Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch Intern Med. 2009;169(6):626-32. 3. Anderson JL, May HT, Horne BD, et al. Relation of vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. Am J Cardiol. 2010;106(7):963-8. 4. Dalbeni A, Scaturro G, Degan M, et al. Effects of six months of vitamin D supplementation in patients with heart failure: a randomized double-blind controlled trial. Nutr Metab Cardiovasc Dis. 2014;24(8):861-8. 5. Skaaby T, Husemoen LL, Thuesen BH, et al. Vitamin D status and chronic obstructive pulmonary disease: a prospective general population study. PLoS One. 2014;9(3):e90654. 6. Malinovschi A, Masoero M, Bellocchia M, et al. Severe vitamin D deficiency is associated with frequent exacerbations and hospitalization in COPD patients. Respir Res. 2014;15(1):131. 7. Song Y, Wang L, Pittas AG, et al. Blood 25-hydroxy vitamin D levels and incident type 2 diabetes: a meta-analysis of prospective studies. Diabetes Care. 2013;36(5):1422-8. 8. Moukayed M, Grant WB. Molecular link between vitamin D and cancer prevention. Nutrients. 2013;5(10):3993-4023. 9. Quraishi SA, Bittner EA, Blum L, et al. Association between preoperative 25-hydroxyvitamin D level and hospital-acquired infections following Roux-en-Y gastric bypass surgery. JAMA Surg. 2014;149(2):112-8. 10. Youssef DA, Miller CWT, El-Abbassi AD, et al. Antimicrobial implications of vitamin D. Dermatoendocrinol, 2011;3(4):220 – 9. 11. Youssef DA, Ranasinghe T, Grant WB, Peiris AN. The potential of vitamin D to reduce the risk of hospital-acquired infections, Dermatoendocrinol. 2012;4(2):167-75. 12. Braun AB, Litonjua AA, Moromizato T, et al. Association of low serum 25-hydroxyvitamin D levels and acute kidney injury in the critically ill. Crit Care Med. 2012;40(12):3170-9. 13. Moromizato T, Litonjua AA, Braun AB, et al. Association of low serum 25-hydroxyvitamin D levels and sepsis in the critically ill. Crit Care Med. 2014;42(1):97-107. 14. Rech MA, Hunsaker T, Rodriguez J. Deficiency in 25-hydroxyvitamin D and 30-day mortality in patients with severe sepsis and septic shock. Am J Crit Care. 2014;23(5):e72-9. 15. Hossein-Nezhad A, Holick MF. Vitamin D for health: A global perspective. Mayo Clin Proc. 2013;88(7):720-55. 16. Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality- a review of recent evidence. Autoimmun Rev. 2013;12(10):976-89. 17. Kearns MD, Binongo JN, Watson D, et al. The effect of a single, large bolus of vitamin D in healthy adults over the winter and following year: a randomized, double-blind, placebo-controlled trial. Eur J Clin Nutr. 2015;69(2):193-7.<br> 18. Amrein K, Schnedl C, Holl A, et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: The VITdAL-ICU Randomized Clinical Trial. JAMA. 2014;312(15):1520-30.

Disclosure I receive funding from Bio-Tech Pharmacal, Inc. (Fayetteville, AR), MediSun Technology (Highland Park, IL), and the Vitamin D Council (San Luis Obispo, CA).

On 2015 Feb 05, William Grant commented:

Increasing vitamin D levels can reduce unplanned hospital readmissions

The paper by Merkow and colleagues points out that readmissions after surgery are largely due to new postdischarge complications related to the procedure [1]. The information about the characteristics of the patients and the factors associated with unplanned readmission provide important clues as to the causes of the readmissions. This comment examines the possible role of low 25-hydroxyvitamin D [25(OH)D] concentration as an important underlying cause of readmission.

One aspect is that blacks have higher unplanned readmissions than whites (Table 4). Blacks have much lower mean 25(OH)D concentrations than whites [2] due to the facts that most vitamin D is made from solar UVB exposure and blacks have darker skin.

The next clue is the types of disease with significantly higher unplanned readmission rates (Table 4). Risk of congestive heart failure death is significantly inversely correlated with 25(OH) concentrations [3]. Treating those with heart failure increases heart function [4]. Prevalence of chronic pulmonary obstructive disease is inversely correlated with 25(OH)D concentration [5]. Those with COPD and severe vitamin D deficiency are more likely to be hospitalized [6].

Incidence of diabetes is inversely correlated with 25(OH)D concentration [7]. Incidence and mortality rates for many types of cancer are inversely correlated with solar UVB doses and 25(OH)D concentrations [8]. Would infection: an observational study in Massachusetts found that surgical site infections for those undergoing Roux-en-Y gastric bypass surgery were linearly inversely correlated with 25(OH)D concentrations below about 30 ng/mL (75 nmol/L) [9]. Vitamin D has a number of antimicrobial actions such as inducing production of cathelicidin and defensins [10]. It has been proposed that increasing 25(OH)D concentrations would reduce the risk of hospital acquired infections [11]. Renal failure: A study in Boston found that preadmission 25(OH)D concentrations below 20 ng/mL is predictive of acute kidney injury [12]. Peripheral vascular disease: 25(OH)D concentrations are significantly inversely correlated with peripheral vascular disease [3]. Sepsis: 25(OH)D concentrations are significantly inversely correlated with risk of sepsis [13, 14].

The general finding in many observational studies is that 25(OH)D concentrations below 30 ng/mL have increased risk of many chronic and infectious diseases [15, 16].

Looking at Table 2, the two most frequent reasons for unplanned readmissions directly related to 25(OH)D concentrations are surgical site infection and sepsis. Together they account for about 22% of readmissions. This portion of the readmissions can be reduced significantly if those undergoing surgery in hospitals have higher 25(OH)D concentrations.

To reduce this portion of readmissions, it would be worthwhile to measure 25(OH)D concentrations of those planning surgery or admitted to the hospital. Giving loading doses of vitamin D3 should increase 25(OH)D concentrations rapidly. A loading dose of 250,000 IU vitamin D3 increased 25(OH)D concentrations by 58 nmol/L (23 ng/mL) after 5 days in a study with healthy adults in one study [17]. A study in Austria found that giving 550,000 IU of vitamin D3 shortly after admission to the intensive care unit followed by 90,000 IU/mo thereafter found a significant reduction in mortality rates between 28 days and 6 months after admission for those with 25(OH)D concentrations below 12 ng/mL [18]. There were no significant adverse effects associated with this dose of vitamin D in this patient population although some of the patients had elevated serum calcium levels. 550,000 IU is higher than would typically be given to raise 25(OH)D concentrations rapidly. Prescription grade 50,000 IU capsules of vitamin D3 are now available.

References 1. Merkow RP, Ju MH, Chung JW, et al. Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States. JAMA. 2015;313(5):483-495 2. Ginde AA, Liu MC, Camargo CA Jr. Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch Intern Med. 2009;169(6):626-32. 3. Anderson JL, May HT, Horne BD, et al. Relation of vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. Am J Cardiol. 2010;106(7):963-8. 4. Dalbeni A, Scaturro G, Degan M, et al. Effects of six months of vitamin D supplementation in patients with heart failure: a randomized double-blind controlled trial. Nutr Metab Cardiovasc Dis. 2014;24(8):861-8. 5. Skaaby T, Husemoen LL, Thuesen BH, et al. Vitamin D status and chronic obstructive pulmonary disease: a prospective general population study. PLoS One. 2014;9(3):e90654. 6. Malinovschi A, Masoero M, Bellocchia M, et al. Severe vitamin D deficiency is associated with frequent exacerbations and hospitalization in COPD patients. Respir Res. 2014;15(1):131. 7. Song Y, Wang L, Pittas AG, et al. Blood 25-hydroxy vitamin D levels and incident type 2 diabetes: a meta-analysis of prospective studies. Diabetes Care. 2013;36(5):1422-8. 8. Moukayed M, Grant WB. Molecular link between vitamin D and cancer prevention. Nutrients. 2013;5(10):3993-4023. 9. Quraishi SA, Bittner EA, Blum L, et al. Association between preoperative 25-hydroxyvitamin D level and hospital-acquired infections following Roux-en-Y gastric bypass surgery. JAMA Surg. 2014;149(2):112-8. 10. Youssef DA, Miller CWT, El-Abbassi AD, et al. Antimicrobial implications of vitamin D. Dermatoendocrinol, 2011;3(4):220 – 9. 11. Youssef DA, Ranasinghe T, Grant WB, Peiris AN. The potential of vitamin D to reduce the risk of hospital-acquired infections, Dermatoendocrinol. 2012;4(2):167-75. 12. Braun AB, Litonjua AA, Moromizato T, et al. Association of low serum 25-hydroxyvitamin D levels and acute kidney injury in the critically ill. Crit Care Med. 2012;40(12):3170-9. 13. Moromizato T, Litonjua AA, Braun AB, et al. Association of low serum 25-hydroxyvitamin D levels and sepsis in the critically ill. Crit Care Med. 2014;42(1):97-107. 14. Rech MA, Hunsaker T, Rodriguez J. Deficiency in 25-hydroxyvitamin D and 30-day mortality in patients with severe sepsis and septic shock. Am J Crit Care. 2014;23(5):e72-9. 15. Hossein-Nezhad A, Holick MF. Vitamin D for health: A global perspective. Mayo Clin Proc. 2013;88(7):720-55. 16. Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality- a review of recent evidence. Autoimmun Rev. 2013;12(10):976-89. 17. Kearns MD, Binongo JN, Watson D, et al. The effect of a single, large bolus of vitamin D in healthy adults over the winter and following year: a randomized, double-blind, placebo-controlled trial. Eur J Clin Nutr. 2015;69(2):193-7.<br> 18. Amrein K, Schnedl C, Holl A, et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: The VITdAL-ICU Randomized Clinical Trial. JAMA. 2014;312(15):1520-30.

Disclosure I receive funding from Bio-Tech Pharmacal, Inc. (Fayetteville, AR), MediSun Technology (Highland Park, IL), and the Vitamin D Council (San Luis Obispo, CA).