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Burn patients have little vitamin D and benefit when it is restored

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Burn Centers typically still do not test vitamin D levels- survey – March 2019

234 A Multi-center Survey of Vitamin D Monitoring and Supplementation in Patients with Thermal Injuries
Journal of Burn Care & Research, Vol 40, Issue Supt_1, 9 March 2019, Pages S97–S98, https://doi.org/10.1093/jbcr/irz013.161
S Zavala, PharmD, BCPS D M Hill, PharmD, BCPS

Results
A total of 21 responses were received. Eight respondents (38.1%) routinely check 25-hydroxyvitamin D concentrations. Two centers check concentrations on admission, two centers check within 48 hours of admission, three centers check within one week of admission. One center specifically monitors concentrations only for patients with a > 20% total body surface area (TBSA) burned. Five centers report rechecking concentrations within weeks to months of the initial level,. Four centers primarily use ergocalciferol, three use cholecalciferol, and one has no preference. Dosing varied greatly between sites. Two respondents reported adjusting dose based on degree of deficiency and admission concentration. One respondent reported a dosing regimen adjusted to age and percent TBSA burned. Thirteen respondents (61.9%) do not routinely check vitamin D concentrations, but may if patients are healing poorly, malnourished, or per nutritionist or nephrologist recommendations. One of the burn centers, who does not routinely monitor concentrations, supplements all burn patients who have ≥ 15% TBSA with cholecalciferol 2000 units daily. Barriers to routinely monitoring vitamin D concentrations cited were cost, inability to analyze in-house, and lack of evidential recommendations for monitoring and supplementing patients with thermal injuries.

Conclusions
The current practice of monitoring and supplementing vitamin D varies widely across burn centers. Future studies using consistent monitoring and dosing should be conducted to determine the clinical benefit of adequate vitamin D levels in burn patients.


Burns with higher vitamin D have fewer problems - Feb 2019

The association between postburn vitamin D deficiency and the biomechanical properties of hypertrophic scars.
J Burn Care Res. 2019 Feb 26. pii: irz028. doi: 10.1093/jbcr/irz028.
Cho YS1, Seo CH1, Joo SY1, Song J2, Cha E2, Ohn SH2.

Fibroblasts, keratinocytes, mast cells, and other cells participate in hypertrophic scar formation and express the vitamin D receptor. We investigated the association between vitamin D deficiency and the biomechanical properties of hypertrophic burn scars. This cross-sectional study analyzed 486 participants enrolled from May 1, 2013 to April 30, 2017. When complete wound healing was agreed with by the two opinions, blood sampling and scar evaluation were performed. The value of melanin and erythema, trans-epidermal water loss (TEWL), and scar distensibility and elasticity were measured using pigment- and TEWL-measuring devices and a suction skin elasticity meter. 25(OH) vitamin D deficiency was defined as plasma level of < 20 ng/mL.

The vitamin D-deficient patients had significantly higher mean values of scar melanin and TEWL (P = 0.032, P = 0.007), whereas scar erythema level was similar. They also showed significantly lower values of

  • Uf (final distensibility; P < 0.001),
  • Ua/Uf (gross elasticity; P < 0.001) and
  • Ur/Uf (biological elasticity; P = 0.014),

and higher value of Uv/Ue (viscoelasticity or potency against interstitial fluid shift; P = 0.016).
In multiple linear regression analysis, Uf, Ua/Uf, Uv/Ue, and Ur/Uf were significantly affected by 25(OH)-vitamin D level in deficient patients (Uf, P = 0.017; Ua/Uf, P = 0.045; Uv/Ue, P = 0.024; Ur/Uf, P = 0.021).
Our results demonstrated that vitamin D deficiency was significantly related to

  • increased pigmentation,
  • decreased skin barrier function,
  • low scar distensibility and elasticity, and
  • slow interstitial fluid movement in burn patients.

Nearly all burn patients have low Vitamin D levels - May 2018

"Fracture admission rates twice as high for burn cohort than Australian population."
Vitamin D in burn-injured patients
Burns Journal DOI: https://doi.org/10.1016/j.burns.2018.04.015
$36 paywall


50% fracture admissions occurred within 7 years of burn admission - Sept 2017

Fracture admissions after burns: A retrospective longitudinal study
Burn Journal https://doi.org/10.1016/j.burns.2017.02.014


Burns with low vitamin D associated with more days in ICU and hospital – Jan 2017

Low Vitamin D Level on Admission for Burn Injury Is Associated With Increased Length of Stay.
J Burn Care Res. 2017 Jan/Feb;38(1):e8-e13. doi: 10.1097/BCR.0000000000000445.
Blay B1, Thomas S, Coffey R, Jones L, Murphy CV.
Image

More Complications
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Currently, there have been few studies that have evaluated the incidence of vitamin D deficiency in adult burn patients or correlated vitamin D levels with burn-related outcomes. The primary objective of the study was to identify the incidence of vitamin D deficiency and insufficiency in an adult burn population. The secondary objective was to determine the impact of vitamin D deficiency and insufficiency on clinical outcomes in burn care. A single-center, retrospective, and observational cohort analysis of adult patients admitted for initial management of burn injury, who had a 25-hydroxyvitamin D (25D) level measured on admission, was performed. Patients were categorized as vitamin D deficient (25D <10 ng/ml), insufficient (10-29 ng/ml), or sufficient (30-100 ng/ml) based on admission measurements. Clinical outcomes including complications, intensive care unit (ICU) and hospital length of stay (LOS), and survival were compared between patients with vitamin D deficiency/insufficiency and patients with vitamin D sufficiency. Three-hundred and eighteen patients were eligible for evaluation. Admission 25D level correlated with deficiency in 46 patients (14.5%), insufficiency in 207 (65.1%), and normal in 65 (20.4%). Patients with vitamin D deficiency or insufficiency experienced higher rates of complications and longer ICU and hospital LOS compared with those with normal vitamin D levels. A large proportion of patients with burn injury presented with vitamin D insufficiency and deficiency which was associated with poor outcomes, including prolonged ICU and hospital LOS. Additional studies are needed to further describe the relationship between vitamin D status and clinical outcomes.

PMID: 27679960 DOI: 10.1097/BCR.0000000000000445  Download the PDF from Sci-Hub via VitaminDWiki


Bone fractures after a burn - none if vitamin D, 6 if no vitamin D – RCT May 2015

on VitaminDWiki

An Investigation of Bone Health Subsequent to Vitamin D Supplementation in Children Following Burn Injury.

Nutr Clin Pract. 2015 May 29. doi: 10.1177/0884533615587720
Mayes T1, Gottschlich MM2, Khoury J3, Kagan RJ4.
1Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio theresa.mayes at cchmc.org.
2Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio Department of Research, Shriners Hospitals for Children, Cincinnati, Ohio Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
3Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
4Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio Department of Surgery, Shriners Hospitals for Children, Cincinnati, Ohio.


BACKGROUND:
The effect of supplemental vitamin D on fracture occurrence following burn injuries is unclear. The objective of this study was to evaluate postintervention incidence of fractures in children during the rehabilitative phase postburn (PB) following participation in a randomized clinical trial of vitamin D supplementation.

MATERIALS AND METHODS:
Follow-up for fracture evaluation was obtained in 39 of 50 patients randomized to daily enteral vitamin D2, D3, or placebo throughout the acute burn course. Serum 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, D2, D3, calcitonin, and bone alkaline phosphatase (BAP) measurements were obtained PB day 7, midpoint, discharge, and 1-year PB. Urinary calcium was obtained PB day 7 and midpoint. Dual-energy x-ray absorptiometry (DXA) was performed at discharge and 1-year PB.

RESULTS:
Fractures were reported in 6 of 39 respondents. Four fractures occurred in the placebo group, 2 in the D2 group, and none in the D3 group. Serum vitamin D, calcitonin, BAP, and urinary calcium were similar between fracture groups. The group with fracture morbidity had larger burn size (83.8% ± 4.9% vs 53.0% ± 2.9%, P < .0001), greater full-thickness burn (69.7% ± 9.4% vs 39.4% ± 4.1%, P = .02), and increased incidence of inhalation injury (33% vs 6%, P = .04). Decreased bone mineral density z score was noted at discharge in the placebo fracture compared with no-fracture group (P < .05).

CONCLUSION:
This preliminary report suggests there may be benefit of vitamin D3 in reducing postdischarge fracture risk. Results reaffirm the importance of monitoring bone health in pediatric patients postburn.

© 2015 American Society for Parenteral and Enteral Nutrition.
PMID: 26024678


Vitamin D status after a high dose of cholecalciferol in healthy and burn subjects

Burns, DOI: http://dx.doi.org/10.1016/j.burns.2014.11.011
Anne-Françoise Rousseau afrousseau at chu.ulg.ac.be , Pierre Damas, Didier Ledoux, Pierre Lukas, Agnès Carlisi, Caroline Le Goff, Romy Gadisseur, Etienne Cavalier

VitaminDWiki Summary

Single dose of 100,000 IU of Vitamin D3, test again 7 days later

Vitamin D
initially
lowest
change
average
change
highest
change
Burn 11 ng-37%
-4 ng?
33%
+4 ng?
333%
+37 ng?
Control22 ng

Highlights

  • Levels of 25OH-D at hospital admission following burn were straightaway lower than our healthy subjects.
  • Efficacy of 100,000 IU cholecalciferol to raise 25OH-D levels (and free 25OH-D levels) was quite uncertain, lower or even zero, in burn patients when compared to healthy subjects.
  • Higher cholecalciferol doses than general recommendations should probably be considered during acute burn care.
  • Interest of free 25OH-D is still questionable.

Background
Burn patients are at risk of vitamin D (VD) deficiency and may benefit from its pleiotropic effects as soon as acute phase. Aim of this observational study was to assess effects of a cholecalciferol (VD3) bolus on VD status in adult burn patients (Group B, GB) after admission, compared to healthy subjects (Group H, GH).

Methods
Both groups received an oral dose of 100,000 IU VD3. Blood samples were collected before (D0) and 7 days (D7) after bolus to measure 250H-D, 1,25(OH)2-D, parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23). Albumin (ALB) and VD binding protein (DBP) were measured and used to calculate free 25OH-D level. Data were expressed as median (min–max) or proportions.

Results
A total of 49 subjects were included: 29 in GH and 20 in GB. At D0, prevalence of VD deficiency was higher in GB: 25OH-D was 21.5 (10.1–46.3) ng/ml in GH vs 11 (1.8–31.4) ng/ml in GB. DBP and ALB were lower in GB. At D7, DBP was stable in both groups while ALB decreased in GB. 25OH-D increased by 66.6 (13.5–260.3)% in GH. In GB, changes in 25OH-D extended from −36.7% to 333.3% with a median increase of 33.1%. Similar changes were observed in each group for free 25OH-D. High FGF23 levels were observed in GB.

Conclusions
This study highlighted the differences in VD status and in response to a high dose VD3 in burn patients when compared to healthy patients. Pitfalls in VD status assessment are numerous during acute burn care: 25OH-D measurement needs cautious interpretation and interest of free 25OH-D is still questionable. They should not prevent burn patients to receive VD supplements during acute care. Higher doses than general recommendations should probably be considered.


Quarterly Vitamin D injections (200,000 IU) helped muscles in burn patients - March 2015

Effects of cholecalciferol supplementation and optimized calcium intakes on vitamin D status, muscle strength and bone health: a one-year pilot randomized controlled trial in adults with severe burns.
Burns. 2015 Mar;41(2):317-25. doi: 10.1016/j.burns.2014.07.005. Epub 2014 Sep 16.
Rousseau AF1, Foidart-Desalle M2, Ledoux D3, Remy C4, Croisier JL5, Damas P3, Cavalier E6.
1Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium. Electronic address: afrousseau at chu.ulg.ac.be.
2Physical Medicine and Sport Traumatology Service, University of Liège, University Hospital, Liège, Belgium.
3Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium.
4Burn Centre and General Intensive Care Department, University of Liège, University Hospital, Liège, Belgium; Motility Science Department, University of Liège, Liège, Belgium.
5Motility Science Department, University of Liège, Liège, Belgium.
6Clinical Chemistry Department, University of Liège, University Hospital, Liège, Belgium.

OBJECTIVE:
Burn patients are at risk of hypovitaminosis D and osteopenia or sarcopenia. Vitamin D pleiotropic effects may influence bone and muscle health. The aim of this pilot study was to assess effects of a cholecalciferol (VD3) supplementation and an optimized calcium (Ca) regimen on vitamin D (VD) status, bone and muscle health during sequelar stage of burn injury.
DESIGN:
Monocentric randomized controlled trial.
METHODS:
Fifteen adults with thermal burns dating from 2 to 5 years were randomized into two groups. For 12 months, they either received a quarterly IM injection of 200,000IU VD3 and daily oral Ca (Group D) or placebo (Group P). VD status and bone remodeling markers were assessed every 3 months. Knee muscle strength and bone mineral density were, respectively, assessed using isokinetic dynamometry and dual X-ray absorptiometry at initiation (M0) and completion (M12) of the protocol.
RESULTS:
Of all the patients, 66% presented with VD deficiency and 53% (with 3 men <40y) were considered osteopenic at inclusion. After one year, calcidiol levels significantly increased in Group D to reach 40 (37-61)ng/ml. No significant change in bone health was observed in both groups while Group D significantly improved quadriceps strength when tested at high velocity.
CONCLUSIONS:
This VD3 supplementation was safe and efficient to correct hypovitaminosis D in burn adults. When combined with optimized Ca intakes, it demonstrated positive effects on muscle health but not on bone health. A high prevalence of hypovitaminosis D and osteopenia in these patients, as well as their wide range of muscle performances, seem to be worrying when considering rehabilitation and quality of life.

PMID: 25239849

Note: 200,000 IU over 90 days is an average of only 2200 IU daily - not very much


Both vitamins D3 and D2 (100 IU/kg) provided some help to Critically Ill Pediatric Burn Patient - June 2015

Clinical Trial of Vitamin D2 vs D3 Supplementation in Critically Ill Pediatric Burn Patients
Michele M. Gottschlich, PhD, RD, CSP1,2,3
Theresa Mayes, RD, CSP, CCRC2,4
Jane Khoury, PhD4
Richard J. Kagan, MD3,5
1Department of Research, Shriners Hospitals for Children, Cincinnati, Ohio
2Department of Nutrition, Shriners Hospitals for Children, Cincinnati, Ohio
3Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
4Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
5Department of Surgery, Shriners Hospitals for Children, Cincinnati, Ohio
Michele M. Gottschlich, PhD, RD, CSP, Shriners Hospitals for Children, 3229 Burnet Ave, Cincinnati, OH 45229, USA. Email: mgottschlich at shrinenet.org

Background: Hypovitaminosis D exists postburn. However, evidence-based guidelines for vitamin D repletion are unknown. This investigation examined differences between D2 and D3 supplementation on outcome in children with burn injuries.

Methods: Fifty patients with total body surface area burn of 55.7% ± 2.6% and full-thickness injury of 40.8% ± 3.8% were enrolled, ranging in age from 0.7–18.4 years. All participants received multivitamin supplementation per standardized clinical protocol. In addition, 100 IU/kg D2, D3, or placebo was administered daily during hospitalization using a randomized, double-blinded study design. Assay of total 25-hydroxyvitamin D (D25), 1,25-dihydroxyvitamin D (D1,25), 25-hydroxyvitamin D2 (25-OH-D2), 25-hydroxyvitamin D3 (25-OH-D3), and parathyroid hormone (PTH) was performed at 4 preplanned time intervals (baseline, midpoint, discharge, and 1 year postburn). Differences in vitamin D status were compared over time and at each specific study interval.

Results: There were no significant differences in serum vitamin D levels between groups, but >10% of patients had low D25 at discharge, and percent deficiency worsened by the 1-year follow up for the

  • placebo (75%),
  • D2 (56%), and
  • D3 (25%) groups. (note: D3 lasted much longer)

There were no statistical differences in PTH or clinical outcomes between treatment groups, although vitamin D supplementation demonstrated nonsignificant but clinically relevant decreases in exogenous insulin requirements, sepsis, and scar formation.

Conclusions: The high incidence of low serum D25 levels 1 year following serious thermal injury indicates prolonged compromise. Continued treatment with vitamin D3 beyond the acute phase postburn is recommended to counteract the trajectory of abnormal serum levels and associated morbidity.

New research calls for vitamin D supplementation in critically ill pediatric burn patients Medical Express Review of the study


97% of pediactric burn patients had low vitamin D - Feb 2016

Serum 25-Hydroxyvitamin D Levels in Pediatric Burn Patients.
Trauma Mon. 2016 Feb 6;21(1):e30905. doi: 10.5812/traumamon.30905. eCollection 2016.
Sobouti B1, Riahi A2, Fallah S3, Ebrahimi M1, Shafiee Sabet A4, Ghavami Y5.
1Burn Research Center, Shahid Motahari Burns Hospital, Iran University of Medical Sciences, Tehran, IR Iran.
2Department of Pediatric Infectious Diseases, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, IR Iran.
3Department of Neonatology, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran.
4Medical Student Research Committee (MSRC), School of Medicine, Iran University of Medical Sciences, Tehran, IR Iran.
5Burn Research Center, Iran University of Medical Sciences, Tehran, IR Iran.

BACKGROUND:
Previous studies have implicated the important and active role of vitamin D in the immune system.
OBJECTIVES:
The aim of this study was to evaluate serum levels of 25-hydroxyvitamin D in children with burn injuries.
MATERIALS AND METHODS:
In this cross-sectional study, 118 patients with various degrees of burn injuries were enrolled. A checklist consisting of demographic data, total body surface area (TBSA) affected by burn, degree of burn, serum level of 25(OH)D, total protein, albumin, electrolytes, and parathyroid hormone was recorded for each patient.
RESULTS:
Sixty-eight (57.6%) males and 50 (42.4%) females with a mean age of 4.04 years (SD = 3.04) were evaluated. The mean level of 25(OH)D was 14.58 ng/mL (SD = 6.94). Levels of 25(OH)D in four (3.39%) cases were higher than 30 ng/mL, while 95 (81.35%) cases had levels lower than 20 ng/mL, and 19 (16.10%) cases had levels of 21 - 30 ng/mL.
The level of 25(OH)D was below recommended levels in 96.61% of cases, while 81.34% had vitamin D deficiency and 16.1% had insufficiency. We found a significant correlation between vitamin 25(OH)D and total protein, albumin, and total and ionized calcium (P < 0.001). There was also a significant negative correlation between 25(OH)D and TBSA affected by burn (P = 0.001).
CONCLUSIONS:
The levels of 25(OH)D in children suffering from severe burns were low. Supplementation might be useful in patients with very low levels of serum vitamin D.

PMID: 27218060


Pain 6 months after thermal burn and skin autography asociated with low vitamin D and low Omega-3 - March 2018

Vitamin D and N-3 polyunsaturated fatty acid levels predict chronic pain following major thermal burn injury

  • "Major Thermal Burn Injury (MThBI) is a significant public health problem in which 50,000 individuals are hospitalized annually in the US. Chronic pain is common following MThBI affecting up to 60% of survivors. There are currently few treatment options to reduce chronic pain and improve mental and physical function following MThBI. Accumulating evidence suggests Vitamin D and n-3 polyunsaturated fatty acids (PUFAs, commonly found in fish oil) reduce symptom burden in other pain conditions. Therefore, we hypothesize low levels of n-3 PUFAs and Vitamin D predict greater chronic pain severity after MThBI."

DOI: https://doi.org/10.1016/j.jpain.2017.12.243. Abstract only


Burned in factory explosion: 8X less likely to get infected if treated with Magnesium and Vitamins such as B12 - RCT Nov 2018

Additional Vitamin and Mineral Support for Patients with Severe Burns: A Nationwide Experience from a Catastrophic Color-Dust Explosion Event in Taiwan
Nutrients 2018, 10(11), 1782; https://doi.org/10.3390/nu10111782 (registering DOI)
Li-Ru Chen 1,2,†, Bing-Shiang Yang 2,†, Chih-Ning Chang 1, Chia-Meng Yu 3 and Kuo-Hu Chen 4,5,* OrcID

Major burn injuries, which encompass ≥20% of the total body surface area (TBSA), are the most severe form of trauma because of the stress response they provoke, which includes hypermetabolism, muscle wasting, and stress-induced diabetes. In 2015, a color-dust explosion disaster occurred in the Formosa Fun Coast of Taiwan and injured 499 people, who were transferred via a nationwide emergency delivery system. Some recommendations are currently available regarding vitamin and mineral support for wound healing and recovery in severe burns, but there is a lack of evidence to confirm the benefits. Thus, the current study aimed to investigate the effects of additional vitamin and mineral support for patients with severe burn injuries. Sixty-one hospitalized individuals with major burns (full thickness and ≥20% TBSA) were classified into the supplement (n = 30) and control (n = 31) groups, according to whether they received supplementation with additional vitamins, calcium, and magnesium. There were significant differences between the supplement and control groups in the

  • incidence of wound infection (30.0% vs. 77.4%, p < 0.001),
  • sepsis (13.3% vs. 41.9%, p = 0.021), and
  • hospitalization days (51.80 vs. 76.81, p = 0.025).

After adjustment, logistic regression analysis revealed that, compared to those in the control group, patients in the supplement group had a

  • lower risk for wound infection (OR 0.11; 95% CI 0.03–0.43; p = 0.002) and
  • sepsis (OR 0.09; 95% CI 0.01–0.61; p = 0.014).

Supplementation of multiple vitamins, calcium, and magnesium reduced the risk of wound infection and sepsis, shortened the time of hospitalization, and can be considered for use in major burns.
 Download the PDF from VitaminDWiki
from PDF
During the first two weeks of hospitalization, daily vitamins were administered to those in the supplement group, including
vitamin A 6600 IU, vitamin B1 (thiamine) 100 mg, vitamin B6 (pyridoxine)
200 mg, vitamin B12 2000 mcg, vitamin C (ascorbic acid) 100 mg, vitamin D 0.01 mg (400 IU), and
vitamin E (dl-α-tocopheryl acetate) 20 mg. Mineral supplementation with calcium and magnesium was
provided by the administration of calcium chloride 2%, 20 mL/amp, and magnesium sulfate injection
10%, 20 mL/amp, adjusted according to serum calcium and magnesium levels after biochemistry examinations

Attached files

ID Name Comment Uploaded Size Downloads
10847 Burns Mg, etc.pdf PDF 2018 admin 16 Nov, 2018 11:08 725.07 Kb 36
9496 More Complications of low D.jpg admin 13 Mar, 2018 01:28 27.29 Kb 538
9495 Less D more days.jpg admin 13 Mar, 2018 01:28 22.89 Kb 516
9494 Burn lenght of stay SciHub.pdf admin 13 Mar, 2018 01:27 321.37 Kb 120
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