Parenteral Vitamin Research Articles

Evaluation of Parenteral Vitamin C's Effectiveness in Critically Ill Patients: A Systematic Review and Critical Appraisal.

Vitamin C, a key nutrient with potent antioxidant and immunomodulatory properties, has been explored for its therapeutic potential in treating severe infections, particularly sepsis. This systematic review aims to evaluate the effectiveness of parenteral vitamin C in improving clinical outcomes in patients with severe infections. A comprehensive search of several databases, including PubMed, EMBASE, and the Cochrane Library, was conducted for studies published between January 2000 and June 2024. Included were randomized controlled trials, observational studies, and case reports that examined the use of parenteral vitamin C in adult patients with severe infections. Data extracted included study design, sample size, intervention specifics, and clinical outcomes. Quality was assessed using tools appropriate to each study design, such as the Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. The review included nine studies with diverse methodologies. While individual studies reported benefits such as improved immune function and reduced oxidative stress, larger systematic reviews and meta-analyses did not demonstrate a significant reduction in mortality. The results indicate that while parenteral vitamin C may improve certain biochemical and physiological parameters, these improvements do not consistently translate into enhanced survival or substantial clinical benefits. Parenteral vitamin C shows potential in modulating immune response and reducing oxidative damage in severe infections. However, its impact on key clinical outcomes like mortality and long-term recovery remains uncertain. This review highlights the need for further high-quality, randomized controlled trials to clarify vitamin C's role in managing severe infections and define optimal therapeutic protocols.

Comparison of Vitamin D2 and Vitamin D3 Supplementation Parenterally in Raising Serum 25-Hydroxy vitamin D Status in Pediatric Patients

Abstract Background There is a controversy regarding the effect of vitamin D2 and D3 in elevating and sustaining 25(OH)D levels. Aim: This study will concentrate on the effect of parenteral administration of both vitamins on serum 25(OH)D levels. Methods Randomized controlled clinical trial, conducted in Pediatric Endocrinology Unit, Ain Shams University, Cairo, Egypt, where 50 participants who had vitamin D deficiency were recruited. Subjects were divided into two groups, 25 patients per group (group A received a single dose of 200,000 IU of intramuscular vitamin D2 and group B received 200,000 IU of intramuscular vitamin D3). History of sun exposure and dietary intake of calcium, assessment of anthropometric measures and tanner staging, laboratory investigations were documented. Follow up of serum level of 25(OH)D was done every month for three consecutive months. Results Parenteral vitamin D3 supplementation in group B patients resulted in significantly higher increments in 25(OH)D level than that achieved by parenteral vitamin D2 supplementation in group A after 1st, 2nd, and 3rd months of the supplement (p = 0.000). Vitamin D3 supplementation resulted in a significantly greater increment in serum 25(OH)D levels from 1st to 2nd month and from 1st to 3rd month than Vitamin D2 supplementation with a P value of 0.039 and 0.018 respectively. One hundred percent of group B participants who received vitamin D3 reached sufficient level (41.04 ± 10.04) after 1 month while 80% of participants in group A who received vitamin D2 reached a sufficient level after 1 month and 20% of participants after 2 months (P = 0.018). Conclusion We can conclude that parenteral vitamin D3 supplementation was more effective in raising serum 25(OH)D status in pediatric patients than parenteral vitamin D2 supplementation.

Anti – intercellular adhesion molecule-1(ICAM-1) nanoparticles for damaged endothelium to treat venous thromboembolism

Venous thromboembolism (VTE) is a potentially fatal vascular disease that can be successfully managed to reduce the risk of mortality and impairment. Anticoagulation therapy is frequently recommended for the treatment and prevention of venous thromboembolism. Despite breakthroughs in anticoagulant therapy using parenteral anticoagulant medications and vitamin K antagonists, limits in their usage persist, prompting research into alternative anticoagulants such as factor Xa inhibitors. Of the agents under development, edoxaban shows the most promise due to strong data confirming its therapeutic benefit for VTE. Nanoparticle drug delivery systems (NDDS) are designed technologies that employ nanoparticles to convey therapeutic drugs in a targeted and regulated manner. Intraendothelial transport of therapies in VTE is facilitated by the induction of cell adhesion molecule-mediated endocytosis upon interaction of intercellular adhesion molecule 1 (ICAM-1) on endothelium cells by ICAM-1-targeted carriers. The potential application of NDDS as nanoparticles as anticoagulant agents has been emphasized. There is proof of outstanding efficacy in preventing blood coagulation, dissolving blood clots, and improving in vivo detection of thrombus. These nanoplatforms’ growing evaluations, strong action, enhanced biocompatibility, and lack of problems from excessive bleeding are all positive signs of their possible integration in the clinical treatment of blood coagulation diseases in the future. Additionally, by avoiding biological barriers and enhancing a medication’s therapeutic index, NDDSs offer superior drug delivery to targeted treatment or even directly to the injured site as compared to standard anticoagulants. Emerging scientific and clinical data suggests that NDDS may be a safe, efficacious, and attractive treatment option for a variety of cardiovascular disorders, including thromboembolic syndromes. This study presents an updated knowledge of nanocarriers for thrombosis as well as an outline of recent significant breakthroughs in targeted thrombosis therapy.

Management of Deep Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most common manifestations of venous thromboembolism (VTE). Most DVTs affect the lower-extremity veins. Since the symptoms of DVT are non-specific, a prompt and standardised diagnostic work-up is essential to minimise the risk of PE in the acute phase and to prevent thrombosis progression, post-thrombotic syndrome and VTE recurrence in the long-term. Only recently, the AWMF S2k guidelines on Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism have been revised. In the present article, we summarize current evidence and guideline recommendations focusing on lower-extremity DVT (LEDVT). Depending on whether the diagnostic work-up is performed by a specialist in vascular medicine or by a primary care physician, different diagnostic algorithms are presented that combine clinical probability, D-dimer testing and diagnostic imaging. The diagnosis of ipsilateral recurrent DVT poses a particular challenge and is presented in a separate algorithm. Anticoagulant therapy is an essential part of therapy, with current guidelines clearly favouring regimens based on direct oral anticoagulants over the traditional sequential therapy of parenteral anticoagulants and vitamin K antagonists. For most DVTs, a duration of therapeutic-dose anticoagulation of at least 3 to 6 months is considered sufficient, and this raises the question of the risk of VTE recurrence after discontinuation of anticoagulation and the need for secondary prophylaxis in the long-term. Depending on the circumstances and trigger factors that have contributed to the occurrence of DVT, management strategies are presented that allow decision-making taking into account the individual bleeding risk and patient's preferences.

Indoxacarb poisoning causing methemoglobinemia treated with parenteral vitamin C: a case report

IntroductionThis case study reports on a suicide attempt involving indoxacarb and vitamin C. Indoxacarb is a neurotoxic insecticide used in agriculture and as a flea controller in pets. Cotton, vegetables, and fruits are treated with indoxacarb, an insecticide that can be applied both indoors and outdoors. It causes skin allergies, methemoglobinemia, and hemolytic anemia. It is also attributed to allergic reactions through ingestion, inhalation, physical contact, and translaminar action. This case report highlights use of vitamin C in methemoglobinemia caused by indoxacarb poisoning. Indoxacarb poisoning has the potential to be extremely serious and even lethal. In this instance, the patient initially had no symptoms after ingesting a substance containing indoxacarb in an attempt at suicide. However, further tests revealed methemoglobinemia and low oxygen levels.Case presentationA 28-year-old south-east Asian female patient ingested an insecticide containing 5.25% novaluron, 4.5% indoxacarb, and 25% thiamethoxam, and reported that she noticed muddy brown urine but presented with no active signs or symptoms of poisoning. Upon examination, the patient was fully conscious, alert, and hemodynamically stable, but had an oxygen saturation of 84%. Gastric lavage was performed, and blood investigations revealed a muddy-brown-colored blood sample and methemoglobin levels of 12%. The patient was treated with high-dose vitamin C and showed significant improvement, with a drop in methemoglobin levels to 1.2% and an increase in oxygen saturation to 97%.DiscussionIndoxacarb poisoning can cause severe methemoglobinemia. Vitamin C may be a useful treatment option for methemoglobinemia caused by indoxacarb, particularly in cases in which traditional treatment with methylene blue is contraindicated or not tolerated. Hence high doses of ascorbic acid, that is, vitamin C, were administered to the patient, which lowered their methemoglobin levels and improved oxygen levels without much safety concerns.ConclusionThis example emphasizes the significance of early indoxacarb poisoning detection and treatment as well as the possible advantages of utilizing ascorbic acid in the management of methemoglobinemia, and highlights the use of vitamin C in the treatment of methemoglobinemia caused by indoxacarb poisoning. Therefore, it is important for healthcare professionals to be aware of the potential for indoxacarb to cause methemoglobinemia and to consider vitamin C as a treatment option.

Open Label, Multi-Arm Randomized Clinical Trial Evaluating Vitamin E-Selenium Injection, Vitamin C Injection, and Hydrogen Peroxide Gavage as a Treatment for Gastric Cryptosporidiosis in Eastern Indigo Snakes (Drymarchon couperi)

Abstract Gastric cryptosporidiosis (GC) is an insidious infection in squamates caused by the protozoan Cryptosporidium serpentis and has impacted the captive breeding colony for the eastern indigo snake (Drymarchon couperi; EIS) reintroduction program. This study investigates a novel treatment of GC in EIS. Seventeen EIS with GC were randomly divided into three groups: A, B, and C. Group A (n = 6) received parenteral administration of 25 mg/kg vitamin C, 0.5 mg/kg vitamin E, and 50 μg/kg selenium and 5 ml/kg 3 % H2O2 gavage; Group B (n = 6) received the same injections but 5 ml/kg water gavage; and Group C received no treatments and served as controls. All EIS from Groups A and B tested negative for C. serpentis for three months following treatment, while only 60% (3/5) in Group C tested negative. EIS testing negative received one 4 mg/kg dexamethasone sodium-phosphate injection. For three months following dexamethasone, 66.7% (4/6) in Group A continued to test negative compared to 83.3% (5/6) in Group B and 20% (1/5) in Group C. EIS testing negative underwent gastric biopsies but only one from Group C was confirmed to be negative for C. serpentis. Although parenteral vitamin C, vitamin E, and selenium with H2O2 gavage decreased shedding of C. serpentis, it did not outperform the vitamins/selenium without H2O2. The parenteral use of 25 mg/kg vitamin C, 0.5 mg/kg vitamin E, and 50 ug/kg selenium once weekly cannot be recommended for treatment of C. serpentis in EIS if complete resolution of the parasite is desired.

Vitamin A deficiency with nyctalopia after bilateral cataract surgery with multifocal intraocular lenses

Introduction: The purpose of this case study was to report an unusual case of vitamin A deficiency (VAD) with nyctalopia that was diagnosed after bilateral cataract surgery with multifocal intraocular lenses (IOLs). Patient and Clinical Findings: After cataract surgery with multifocal IOLs, a 66-year-old man developed progressive intolerable night vision symptoms, requesting IOL exchange. Diagnosis, Intervention, and Outcomes: Only careful history and investigation revealed the cause to be VAD secondary to celiac disease, rather than lens-related. The patient was commenced on parenteral vitamin A resulting in a complete resolution of nyctalopia. Conclusions: To our knowledge, this is the only reported case of VAD diagnosed in this context. We reflect on the importance of thorough history taking, particularly in patients referred for cataract surgery by their optometrist, where the provided medical history may be incomplete.

Effect of oral versus parenteral vitamin D3 supplementation on nuclear factor-κB and platelet aggregation in type 2 diabetic patients.

Platelet hyperactivity is one of the key factors implicated in the development and progression of diabetic vascular complications. Activated platelets mediate leukocyte recruitment that further enhances inflammatory responses in vascular wall ultimately resulting in atherosclerotic complications. Since vitamin D insufficiency is highly prevalent in diabetics, we aimed to evaluate the effect of three dosage forms of vitamin D supplementation on lipid profile, NF-κB, platelet aggregation, and platelet calcium content in type 2 diabetic patients. Type 2 diabetic patients were randomized to receive daily (4000 IU/day) or weekly (50 000 IU/week) oral vitamin D3 for 3 months. Another group received a single parenteral dose (300 000 IU) of vitamin D3, whereas the control group received their antidiabetic drug(s) alone. Serum 25(OH)D, total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, NF-κB, and platelet aggregation were measured at the beginning and 3 months after vitamin D supplementation. Platelet calcium content was evaluated by measuring the fluorescence intensity of Rhod-2-stained platelets by confocal fluorescence microscopy. Results showed that serum 25(OH)D3 levels significantly increased in all vitamin D3-treated groups. However, the mean level for parenteral treated group was significantly lower than oral-treated groups. Oral and parenteral treatment were also able to decrease NF-κB level, platelet aggregation, and platelet calcium content. However, both oral doses of vitamin D3 were superior to the single parenteral dose. In conclusion, restoring normal levels of vitamin D is an important determinant to maintain normal platelet function and reduce inflammation. Nevertheless, further long-term studies are still needed.

The effect of parenteral vitamin B12 on the growth rate of dairy calves over the summer and autumn on seven farms from the Central Plateau, New Zealand

ABSTRACTAimsTo investigate the effect of parenteral vitamin B12 supplementation on the growth rate of dairy heifer calves over the summer and autumn on seven farms from the Central Plateau of New Zealand, an area historically associated with low cobalt levels in grazing pasture.MethodsThis was a controlled clinical trial conducted on a convenience sample of seven farms with young female calves randomly assigned to three vitamin B12 treatment groups and followed through a grazing season. Two treatment groups received either monthly SC injections of a short-acting (SA) B12 formulation or 3-monthly injections of a long-acting (LA) B12 formulation and the third group received no treatment (NT). No additional parenteral vitamin B12 was given; however, all calves received additional cobalt (0.04–0.4 mg Co/kg liveweight) in the mineralised anthelmintic drenches given orally every month. Liveweight was recorded in December/January and at the end of the trial in May/June/July depending on farm. Pasture cobalt concentrations (mg/kg DM) were measured every month using 500-g herbage samples from 100-m transects in the area about to be grazed by the trial groups.ResultsThere was evidence for a difference in growth rate between groups with mean final weight of 228 (95% CI = 212–243) kg for the LA groups, 224 (95% CI = 209–239) kg for the SA groups and 226 (95% CI = 211–241) kg for the NT groups respectively, (global p-value = 0.014). Calves given SA vitamin B12 were 3.77 (95% CI = 0.71–6.82) kg lighter than calves given LA vitamin B12 (p = 0.011). There was no evidence for a change in pasture cobalt concentrations (p = 0.32).Conclusions and clinical relevanceThe results of this trial raise the question as to whether the routine use of vitamin B12 supplementation in young cattle from areas traditionally thought to be cobalt deficient is necessary, and further raise the possibility that vitamin B12 supplementation by repeated injection of SA products may negatively impact growth rates.

Anti-Inflammatory Effect of Vitamin C during the Postoperative Period in Patients Subjected to Total Knee Arthroplasty: A Randomized Controlled Trial.

Vitamin C, a potent reducing and antioxidant agent, plays an important role in the body, aiding in the growth of cartilage and bones. It is also involved in mechanisms that help reduce inflammation and its effects on the body. In addition, vitamin C decreases pro-inflammatory cytokines, such as IL-6, which produce acute-phase proteins such as CRP and influence inflammatory markers such as ESR. We carried out a study with 110 patients who underwent total knee replacement surgery. We divided the patients into two groups, in which the intervention group received 15 g of parenteral vitamin C during the immediate postoperative period while the control group did not. Patients who received 15 g of vitamin C after total knee replacement surgery had decreased inflammatory markers, specifically CRP and ESR. Overall, administering vitamin C in the post-surgical period results in improved management of inflammation, as evidenced by a decrease in CRP and ESR values. This leads to faster recovery and better healing outcomes for patients undergoing total knee replacement surgery. Furthermore, the beneficial effects of vitamin C in reducing proinflammatory cytokines, reducing the need for opioid analgesics, and its mild adverse effects make it a promising adjuvant in managing postoperative recovery.

Autoimmune gastritis as an unexpected cause of diarrhea in a young adult with type I diabetes: a case report

BackgroundType 1 diabetes mellitus (T1DM) is a lifelong diagnosis that involves immune-mediated damage of pancreatic beta cells and subsequent hyperglycemia, manifesting as: polyuria, polydipsia, polyphagia, and weight loss. Treatment of type 1 diabetes centers on insulin administration to replace or supplement the body's own insulin with the goal of achieving euglycemia and preventing or minimizing complications. Patients with T1DM are at risk for developing other autoimmune conditions, most commonly thyroid or celiac disease.Case presentationA 20-year-old African American female with T1DM was referred by her endocrinologist to pediatric gastroenterology for 2 months of nocturnal, non-bloody diarrhea, left lower quadrant pain, and nausea; she was also being followed by neurology for complaints of lower extremity paresthesias and pain. The patient’s initial lab-workup was remarkable for a low total Immunoglobulin A (IgA) level of < 6.7 mg/dL. As IgA deficiency is associated with an increased risk of celiac disease, the patient underwent upper and lower endoscopy, which was grossly unremarkable; however, histology revealed a pattern consistent with autoimmune gastritis. Subsequent serum evaluation was remarkable for an elevated fasting gastrin level and an elevated parietal cell antibody level without macrocytic anemia, iron deficiency, or vitamin B12 depletion. The patient was diagnosed with autoimmune gastritis (AIG) and subsequently initiated on parenteral B12 supplementation therapy with improvement in her neurologic and gastrointestinal symptoms.ConclusionThis case illustrates the importance of recognition of red flag findings in a patient with known autoimmune disease. Following well-established health maintenance recommendations for individuals with T1DM ensures that common comorbidities will be detected. Autoimmune gastritis, while a rarer pathology in the pediatric population, deserves consideration in patients with pre-existing autoimmune conditions and new gastrointestinal or neurologic symptoms, as AIG can be associated with poor outcomes and risk of malignancy. Initial lab findings associated with an eventual diagnosis of AIG typically include anemia, iron deficiency, or Vitamin B12 deficiency. However, as demonstrated in this case, symptoms of AIG can rarely present before anemia or Vitamin B12 deficiency develops. To prevent permanent neurological damage, parenteral Vitamin B12 therapy must be considered even in the absence of Vitamin B12 deficiency, especially in those patients already experiencing neurological symptoms.

Effect of Parenteral Supplementation of Minerals and Vitamins on Oxidative Stress Biomarkers and Hepatic Fatty Acid Metabolism in Dairy Cows During the Transition Period.

In the present work we aimed to study the effects of parenteral vitamin and mineral supplementation on hepatic fatty acid metabolism as well as on the oxidative stress biomarkers in biological samples of transition cows. The supplemented group (SG, n = 11) received a subcutaneous injection of 5mL of vitamin A palmitate 35mg/mL, vitamin E acetate 50mg/mL plus other injection of 5mL of copper edetate 10mg/mL, zinc edetate 40mg/mL, manganese edetate 10mg/mL, and sodium selenite 5mg/mL on days - 60, - 30, and 7 (± 3) relative to calving. The control group (CG, n = 11) received two subcutaneous injections of 5mL of 9mg/mL sodium chloride at the same times of the SG. Blood, urine, and liver biopsies were sampled 21 (± 3) days before the expected calving date and 7 and 21 (± 3) days after calving. Results revealed that supplemented animals had higher glutation peroxidase (GSH-Px) activity, lower and higher concentration of 3-nitrotyrosine (3-NT) in the liver and plasma, respectively, higher expression of the mitochondrial beta-oxidation enzyme carnitine palmitoyltransferase 1 in the liver, and lower content of hepatic triacylglycerol, mirroring plasma liver function parameters. No differences between groups were found in the superoxide dismutase activity, MDA concentrations, the protein abundance of peroxisomal acyl-CoA oxidase 1, diacylglycerol O-acyltransferase 1, and peroxisome proliferator-activated receptor alpha. These results suggest that the vitamin and mineral supplementation provided to dairy cows had a beneficial effect on GSH-Px activity, hepatic 3-NT concentration, and on the metabolic adaptation during the peripartum period.

Anemia Due to Familial Vitamin B12 Deficiency: About 3 Cases

Vitamin B12 deficiency is a rare pathology in the paediatric population, most often due in our Moroccan context to a deficiency in intake. However, in rarer cases, it may be the result of an inborn anomaly in cobalamin transport or metabolism. A well-codified diagnostic approach can clarify the nature of the deficiency and adapt therapeutic options. We report 03 pediatric cases of three brothers treated for vitamin B12 deficiency. Diagnosed at 8, 4 and 3 years of age, they all presented with a severe anemic syndrome and delayed stature, two of them had seizures, and the elder brother was also delayed at school. Given the familial nature of the disease and the presence of proteinuria in 2 patients, Imerslund-Grasbëck disease was suspected in our patients. Treatment was based on parenteral vitamin B12 supplementation, with good clinical and biological progression in our patients. Vitamin B12 deficiency is a metabolic emergency and should be considered in the presence of hematological and neurological disorders. Although Imerslund-Gräsbeck disease is rare, it should be suspected and proteinuria investigated.

Comparison of the Effect of Oral Versus Parenteral Vitamin D on Serum Levels of Vitamin D in Premature Infants with Vitamin D Deficiency

Background: Vitamin D levels lower than 20 ng/mL are defined as vitamin D deficiency and levels between 20 and 30 ng/mL are defined as insufficient vitamin D. Due to the high prevalence of vitamin D deficiency in premature infants and the need for obtaining optimal treatment methods, we compared the serum levels of vitamin D before and fifteen days after administration of the drug orally and by injection. Methods: In this randomized clinical trial, 90 premature infants with gestational age &lt; 37 weeks were admitted to NICU of Shahid Akbarabadi Hospital, with concomitant vitamin D deficiency and insufficiency entered the study and randomly received oral (with oral drops of 1,000 units daily for 15 days) or injectable (a single dose of 15,000 units intramuscularly) vitamin D supplement and followed on the 16th day after drug administration by measuring 25 (OH) D, calcium, phosphorus, and serum alkaline phosphatase (ALP). Results: In this study, the gestational age of the patients was 29.39 ± 2.42 weeks, and their average birth weight was 1,208.45 ± 238.98 grams. There was no significant difference between the two groups that received the drug, and they were similar. The level of vitamin D in premature infants suffering from vitamin D deficiency was equal to 13.20 ± 6.37 ng/dL. There was no significant difference between the serum levels of ALP, phosphorus, and calcium in the patients of the injection and oral groups before and after the intervention (P-value &gt; 0.05). Although there was no significant difference between the serum vitamin D levels in the two groups before the intervention, its level in the oral group was significantly higher than in the injection group after the intervention (P-value = 0.006). However, none of the treatment methods independently changed the effectiveness of the treatment (P-value = 0.073). Conclusions: The results of our study showed that, in premature infants with vitamin D deficiency or insufficiency, administration of vitamin D orally or by injection significantly increases the serum concentration of 25 (OH) D3 to sufficient levels safely, and both treatment routes can be used in practice.

Micronutrient use in critical care: Survey of clinical practice

Micronutrients, principally vitamins and minerals, play an important role both in health and in disease. Parenteral micronutrient products are commonly prescribed for critically ill patients both in line with the terms of the product's license, and for other indications where there is an underpinning physiological rationale, or precedent, for their use but little evidence. This survey sought to understand United Kingdom (UK) prescribing practice in this area. A 12-question survey was circulated to healthcare professionals working in UK critical care units. The survey was designed to explore several aspects of micronutrient prescribing or recommendation practice by the critical care multidisciplinary team, including indications and underpinning clinical rationale for using these products, dosing, and considerations with respect to micronutrients delivered as part of nutrition. Results were analysed, exploring indications, considerations relating to diagnoses, therapies including renal replacement therapies, and method of nutrition. 217 responses were included in the analysis, with 58% from physicians and the remaining 42% from nurses, pharmacists, dietitians and other healthcare disciplines. Vitamins were most commonly prescribed or recommended for Wernicke's encephalopathy (prescribed or recommended by 76% of respondents), treatment of refeeding syndrome (64.5%), and for patients with unknown or uncertain alcohol intake history (63.6%). These clinically suspected or confirmed indications were cited more frequently as a reason to prescribe than laboratory identified deficiency states. 20% of respondents indicated that they would prescribe or recommend parenteral vitamins for patients requiring renal replacement therapy. The practice of vitamin C prescribing was heterogeneous, including dose and indication. Trace elements were prescribed or recommended less often than vitamins, with the most frequently reported indications being for patients requiring parenteral nutrition (42.9%), biochemically confirmed deficiency states (35.9%), and for treatment of refeeding syndrome (26.3%). Micronutrient prescribing in ICUs in the UK is heterogeneous, with clinical scenarios where there is an evidence base or an established precedent for their use often guiding decisions to use micronutrient products. Further work to examine the potential benefits and harms on patient-oriented outcomes of micronutrient product administration should be undertaken, to facilitate their judicious and cost-effective use, with a focus on areas where they have a theoretical benefit.

Stoss therapy versus weekly regimen of vitamin D in children with chronic liver disease: a randomized pilot study

BackgroundVitamin D, a hormone involved in the regulation of mineral homeostasis, protects skeletal integrity and modulates cell growth and differentiation. Recently, its potential antifibrotic effects have also been identified. Children with chronic liver disease mostly suffer from vitamin D deficiency. However, little knowledge is known regarding the optimum regimen that can be utilized effectively and safely to correct vitamin D deficiency in these patients and whether it could be effective in reversal or at least halting the progressive process of liver fibrosis. This study is conducted to answer these questions.ResultsTwenty-four children with chronic liver disease (13 boys and 11 girls) were included in the study. Their age ranged from 4.5 to 11.5 years with median age of 8 years. The aetiology of liver disease was heterogenous with autoimmune hepatitis, glycogen storage disease, or chronic hepatitis, and hepatitis C affects the majority. The patients were divided into two matched groups: group A (n:12) that received stoss parenteral intramuscular vitamin D3 (cholecalciferol) therapy (200,000 IU) once followed by 600 IU/day orally for 6 months (this is equivalent to the RDA as maintenance therapy) and group B (n:12) that received 50,000 IU/week oral vitamin D3 (cholecalciferol) therapy in divided daily doses adding on the maintenance dose 600 IU/day for the first 4 weeks followed by only 600 IU/day orally for the rest of the 6 months (5 months). Following vitamin D3 supplementation, in group A (vitamin D stoss therapy group) and group B (vitamin D oral therapy group), there were statistically significant improvement of Ca, alkaline phosphatase, and vitamin D levels, though there was no difference in between both groups. No significant correlation could be found between vitamin D changes and fibroscan changes in either group.ConclusionVitamin D therapy using stoss dose followed by oral therapy or oral vitamin D therapy from the start was equally safe and effective in improving the clinical and laboratory metabolic bone profile abnormalities. Vitamin D effect on liver fibrosis progression or reversion in children is still not understood, and further studies are needed in this field taking in consideration the various causes of liver disease in children.

Etiological and Clinical Spectrum of Acute Liver Failure of Infancy in Pakistan

&#x0D; Objective: To describe the aetiology and clinical spectrum of acute liver failure of infancy at a tertiary care hospital&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Paediatric Gastroenterology, Hepatology &amp; Nutrition, Children Hospital and Institute of Child Health, Lahore, from Nov 2020 to May 2021.&#x0D; Methodology: Infants under 12 months of age were enrolled having liver-based coagulopathy (not corrected after two doses of parenteral vitamin K, 10 mg) with INR &gt; 2, whether encephalopathy was present or not. Encephalo-pathy is difficult to identify in infants, so it was not essential for the diagnosis of ALFI in our study. Infants diagnosed with chronic liver disease at presentation or those without final etiological diagnosis were excluded.&#x0D; Results: A total of 31 infants were enrolled fulfilling the criteria of acute liver failure of infancy and were studied about aetiology and clinical presentation. The mean age of presentation was 4.64±3.16 months, and males predominated in the study group (64.5%). Common clinical features were in descending order ascites in 29 (93.5%), jaundice in 28 (90.3%), pallor in 24 (77.4%) and peripheral oedema in 21 (67.7%). Metabolic liver diseases were the common cause of ALFI, constituting around(18, 58%) followed by sepsis (9, 29%).Galactosemia (11, 35.5%) stands out among the metabolic causes.&#x0D; Conclusion: Metabolic disorders followed by sepsis are the most common cause of ALFI.

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Oxalate Nephropathy.

A Systematic Review and Meta-Analysis on Possible Role of Vitamin C in Sepsis.

Sepsis is a substantial healthcare burden, and its management continues to be a major challenge. Prior studies demonstrate conflicting evidence regarding the utility of vitamin C in sepsis. This systematic review and meta-analysis aim to collect data among critically ill patients (sepsis/septic shock), comparing the efficacy of parenteral vitamin C with standard care. A literature review was conducted using databases including PubMed, Web of Science, Google Scholar, and the Cochrane Library to identify randomized controlled trials (RCTs) and observational studies comparing intravenous vitamin C alone or in combination with thiamine or glucocorticoids to the standard of care. We identified 11 RCTs and seven retrospective cohort studies. The primary outcome was 28-day mortality. Secondary outcomes included intensive care unit (ICU) length of stay, change inSequential Organ Failure Assessment (SOFA) score, duration of vasopressor use, and duration of mechanical ventilation. A total of 18 studies with 4078 patients were included in our final analysis. Overall, we found no mortality reduction in patients treated with vitamin C compared to standard of care (odds ratio (OR) 0.92; 95% confidence interval (CI) 0.78 to 1.09; p = 0.34). Studies that reported a change in SOFA scores, ICU length of stay, duration of mechanical ventilation, or duration of vasopressor use did not show any significant difference between groups. Subgroup analysis with RCT versus observational studies and vitamin C dosage regimens did not show any difference. Among patients with sepsis or septic shock, treatment with vitamin C was not associated with a reduction in mortality, ICU length of stay, change in SOFA score, duration of vasopressor use, or duration of mechanical ventilation. Further studies are needed to demonstrate the potential role of vitamin C in the management of sepsis.

Exclusively breastmilk‐fed preterm infants are at high risk of developing subclinical vitamin K deficiency despite intramuscular prophylaxis at birth

BackgroundThere is near‐global consensus that all newborns be given parenteral vitamin K1 (VK1) at birth as prophylaxis against VK deficiency bleeding (VKDB). Breastmilk has a low VK content and cases of late VKDB are reported in exclusively breastmilk‐fed preterm infants despite VK prophylaxis at birth. ObjectivesTo assess the prevalence of functional VK insufficiency in preterm infants based on elevated under‐γ‐carboxylated (Glu) species of Gla proteins, factor II (PIVKA‐II), and osteocalcin (GluOC), synthesized by liver and bone, respectively. Patients/MethodsProspective, multicenter, observational study in preterm infants born <33 weeks' gestation. Blood samples and dietary history were collected before hospital discharge, and after discharge at 2–3 months’ corrected age. Outcome measures were serum VK1, PIVKA‐II, and %GluOC (GluOC as a percentage of the sum of GluOC plus GlaOC) compared between exclusively breastmilk‐fed and formula/mixed‐fed infants after discharge. ResultsAfter discharge, breastmilk‐fed babies had significantly lower serum VK1 (0.15 vs. 1.81 μg/L), higher PIVKA‐II (0.10 vs. 0.02 AU/ml) and higher %GluOC (63.6% vs. 8.1%) than those receiving a formula/mixed‐feed diet. Pre‐discharge (based on elevated PIVKA‐II), only one (2%) of 45 breastmilk‐fed infants was VK insufficient. After discharge, eight (67%) of 12 exclusively breastmilk‐fed babies were VK insufficient versus only one (4%) of 25 formula/mixed‐fed babies. ConclusionsPreterm infants who remain exclusively or predominantly human breastmilk‐fed after neonatal unit discharge are at high risk of developing subclinical VK deficiency in early infancy. Routine postdischarge VK1 supplementation of breastfed infants to provide intakes comparable to those from formula milks should prevent this deficiency.