Rotation 6 Psychiatry

H&P

Identifying Data:

Full Name: Mr. H. P.

Address: 44-44 164th street Jamaica Queens, NY

DOB: 06/08/1994

Date & Time: July 7, 2020

Location: Psych-ER/QHC

Religion: Muslim

Source of Information: Self

Source of Referral: Mother

Mode of Transport: FDNY EMS

Chief Complaint: “I think my heart is going to beat out of my chest.”

HPI: Patient is a 26-year-old Indian male, domiciled, unemployed with previous psychiatric history of psychosis (2018) brought in by EMS due to agitation and chest pain activated by mother. Patient states he has been having chest pain all day. He was brought to medical emergency room for initial evaluation of chest pain and was cleared and brought to CPEP. He states he became very anxious after fighting with his mother about finances and “my heart started pounding and was worried people are watching me and I was fearful and then my mom called the ambulance.” Pt states he feels his neighbors hacked his computer and his phone and are trying to harm him. Pt continues to mention that he is stressed from COVID pandemic and feels anxious. Pt provided Mother, Mrs. P (123) 555-1110 as collateral, who reports that the patient was very anxious and his heart was pounding and he is scared people are hacking his phone and he has not used his pone in 2 weeks and has taken his battery out of the phone. The mother states that his son has been non-compliant with his medications and has sleep disturbances. Mother reveals that the pt is stressed after his father died in February (secondary to myocardial infarction) and his girlfriend died shortly after (secondary to COVID). Lastly, his mother states that he recently lost his job due to COVID. Patient denies depression, drug use, alcohol use, suicidal ideation, homicidal ideation, visual/auditory hallucinations.

26 y/o Indian male evaluated at CPEP. Pt was found to be anxious and superficially cooperative. Alert and oriented x3/4 (unable to remember the day), guarded and paranoid, irrational with constricted affect and anxious mood, internally preoccupied with thought blocking and disorganized thoughts and illogical thinking. Patient appears to be responding to internally stimuli. Urinary drug tox was negative at medical emergency room. Pt presents disheveled and guarded minimizing symptoms and events. Patient exhibits poor insight, judgement, and impulse control. Patient is deemed to be a threat to himself and others and experiencing paranoid delusions and thus warrants admission to CPEP for observation and stabilization. Patient was cleared by medical emergency room. Case discussed with Dr. Rahman.

Past Medical History:

Patient denies any past medical hx.

​Past Surgical History:

Denies any past surgical history.

Medications:

Quetiapine 50mg by mouth, twice daily.

Allergies:

Denies any drug allergies.

Family History:

Patient denies any known family history of any psychiatric disorder, bipolar disorder, schizophrenia, and any suicide attempts.

Social History:

Mr. H. P. currently resides with his parents and cousin in Queens. He completed high school and continued to college at Queens College completing a degree in creative writing. Patient had trouble in college with finishing courses required for degree and stated he had took a couple of semesters off to “Reset.” Patient is currently unemployed but is actively looking for a job. Patient admits to smoking marijuana, but hasn’t smoked since “before COVID.”  He stated that he only does it occasionally when he hangs out with his friends but doesn’t get too high. Patient also admits to drinking alcohol only at parties. His hobbies include physical activity, reading and going for walks. Patient denies any recent travels and stated that he is trying to eat healthy and more protein so he could increase his muscle mass. Patient stated he’s single but sexually active with only women. He has multiple partners and uses protection. Patient denies STI/HIV history and has not been tested. He denies having/had COVID.

Review of Systems:

General: Denies recent weight loss or gain, loss of appetite, fever or chills, or night sweats.

Skin, hair, nails: denies discoloration, texture, excessive dryness/sweating, changes in pigmentation, moles/rashes, pruritus.

Head: denies lightheadedness, vertigo, and head trauma

Eyes: denies blurring, diplopia, halos, lacrimation,

photophobia, pruritus and glasses use.

Ears: denies deafness, discharge, tinnitus and hearing aid use.

Nose: denies discharge, epistaxis, rhinorrhea.

Mouth/throat: denies dental complaints, bleeding gums, sore throat, mouth ulcers, voice

changes and dentures.

Neck: denies edema, masses, stiffness.

Pulmonary: Admits to dyspnea. Denies cough, wheezing, hemoptysis, cyanosis, orthopnea and PND.

Cardiovascular: admits to chest pain. Denies, palpitations, syncope, edema/swelling of ankles/feet.

Gastrointestinal: Denies intolerance to certain foods, N/V, dysphagia, loss of appetite,

pyrosis, abdominal pain, flatulence, eructation, diarrhea, jaundice, changes in bowel

habits, hemorrhoids, constipation, rectal bleeding, blood in stool, hx of GI bleed GU:

denies nocturia, dysuria, frequency, oliguria, polyuria, change in color of urine,

incontinence and flank pain.

Musculoskeletal: Denies joint stiffness, muscle fatigue, arthritis, muscle deformity/swelling and redness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system: denies easy bruising, easy bleeding, anemia hx of DVT/PE.

Endocrine system: denies heat or cold intolerance, polyuria, polydipsia, polyphagia, goiter,

excessive sweating, hirsutism.

Nervous: See HPI. Denies seizures, LOC, numbness, paresthesia, dysesthesia, hyperesthesia,

ataxia, loss of strength, changes in cognition/mental status, weakness and trauma.

Psychiatric: Patient stated he gets anxious and feels like he cannot control his emotions. See HPI.

Physical exam:

General: 26-year-old Indian American male is alert and oriented x3, well-nourished, guarded and paranoid, irrational with constricted affect and anxious mood, internally preoccupied with thought blocking and disorganized thoughts and illogical thinking.

Vital Signs:     BP:      124/76  Pulse: 102. Resp: 16/min unlabored. Temp 98.1 oral.

O2 Sat: 97% Room air

Height: 71”    Weight 180 lbs.    BMI: 22.1

Mental Status Exam:

General

  1. Appearance: Medium built Indian-American male with short black hair, unkept. Cloths appear appropriate for season and appears stated age.
  2. Behavior and Psychomotor Activity: Mr. H.P made fair eye contact with the interviewer was noted sitting restlessly. When asked questions, patient appeared anxious and apprehensive at answering questions.
  3. Attitude Towards Examiner: Patient was cooperative, anxious, hyperactive, and did not show signs of aggression/agitation.

Sensorium and Cognition

  1. Alertness and Consciousness: Patient was alert and conscious during the interview, but it was noted that the patient was responding to internal stimuli.
  2. Orientation: Patient was oriented to person, place of the exam, and the date. Patient knew who he was, the location of the hospital and the date.
  3. Concentration and Attention: Patient appeared concentrated and superficially cooperative. He appeared paranoid and focused his attention on previous topics.
  4. Capacity to Read and Write: Patient had adequate reading/writing ability. He gave mother’s phone number as collateral.
  5. Abstract Thinking: Mr. H.P was able to express abstract thinking. When asked complex questioning about future plans or concerning his personal well-being.
  6. Memory: Mr. H.P’s recent, remote, and immediate memory were intact as he was able to recall phone number and recent current events.
  7. Fund of Information and Knowledge: Mr. H.P demonstrated average level of intelligence. He has a high school diploma and bachelor’s degree.

Mood and Affect

  1. Mood: Patient appeared anxious and paranoid.
  2. Affect: Constricted
  3. Appropriateness: Patients mood and affect reflected a state of paranoia and anxiety.

Motor

  1. Speech: Patient’s speech pattern was fast, but coherent.
  2. Eye Contact: Patient had appropriate eye contact.
  3. Body Movements: Patient was noted fidgeting in chair during interview.

Reasoning and Control

  1. Impulse Control: Poor impulse control.
  2. Judgment: Poor judgement secondary to paranoia.
  3. Insight: Patient has a fair insight of his current situation and is willing to take medications. But seems to be superficially cooperative.

Assessment and Plan:

Patient is a 26-year-old Indian-American male, single, domiciled with mother, college educated with past psychiatric history of psychosis evaluated by medical emergency room and cleared. Brought to CPEP for further evaluation and treatment. Patient was complaining of chest pain, anxiety and paranoia.

Differential Diagnosis:

1) Schizophrenia: Based on the chief complaint and the confirmation with the family about H.P stating people are watching him and hacking his electronic devices. The patient does appear to be responding to internal stimuli and appears to have impaired function.

2) Adjustment Disorder: Based on the recent loss of his father and girlfriend and the onset of anxiety. The patient is also experiencing disturbance of conduct and arguing with mother.

3) Paranoid Personality Disorder: Based on the description with the family and the fact that the patient is stating that his phone is being monitored the symptoms would correlate with paranoia. He has preoccupation with unjustified doubts regarding loyalty and trusting others.

4) Delusional Disorder:  Symptoms of delusions of being watched and electronic devices being hacked and anxiety related to being worried of people watching him.

5) Alcohol intoxication/drug- induced aggressive behavior: Pending drug toxicology results from medical emergency room.

  1. Admit patient to CPEP for evaluation, observation, and stabilization.
  2. Review labs and chart
    1. Urine toxicology
    2. Urine THC
  3. Order STAT mediation Risperdal 2mg tab PO in CPEP for stabilization.
  4. Consulted Dr. Rahman Attending Physician CPEP
  5. Schedule evaluation with social worker for possible outpatient services.

Critically Appraised Topic

 

Brief description of patient problem/setting (summarize the case very briefly)

67 y/o male presents to family medicine clinic for laboratory studies follow up. He is interested in adding vitamin D to his daily medication regimen to help with prevention of fractures and osteoporosis.

Search Question: Clearly state the question (including outcomes or criteria to be tracked)

Does vitamin D help prevent fractures in males older than 65 compared to calcium?

Question Type: What kind of question is this? (boxes now checkable in Word)

☐Prevalence               ☐Screening                 ☐Diagnosis

☒Prognosis                             ☒Treatment                ☐Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)?
Please explain your choices.

There was quite a lot of material to support my PICO topic. The articles were either meta-analysis or systematic reviews containing multiple randomized control trials. These articles were relatively current and provided a solid correlation to my PICO question. If meta-analysis or systematic reviews were not available then randomized control trials would be the next best article type.

PICO search terms: 

P I C O
Older Adults Vitamin D Calcium Treatment
Adult Males cholecalciferol   Therapy
Geriatric Patients     Management
      Prevention
       
       


Search tools and strategy used:

PubMed

  • Vitamin D Fractures                         7,231
  • Age over 65 2,879
  • Meta-analysis & systematic Reviews 81

PubMed

  • Vitamin D Bone                                     26,237
  • Meta-analysis & systematic Reviews 352
  • Age Over 65                         90

Cochrane

  • Vitamin D Fractures             22 Reviews

These articles were chosen because they directly answered my PICO question and had the best reflection of my clinical scenario. The articles that I chose only included meta-analysis, and systematic reviews. The Cochrane review encompassed a massive comparison of other vitamin D analogues and gave a thorough conclusion with the use of vitamin D. It is noteworthy to mention that the other articles have not contributed to the Cochrane review, the names of some of the author’s previous studies are mentioned (Reid, Bischoff-Ferrari).

Results found:

Citation:

1) Fracture Prevention with Vitamin D Supplementation. A Meta-analysis of Randomized Controlled Trials. Journal of the American Association. May 11, 2005. Bischoff-Ferrari H., Willett, W., Wong, J. Doi: 10.1001/jama.293.18.2257

https://jamanetwork-com.libauth.mskcc.org/journals/jama/fullarticle/200871
Article Type:

Meta-analysis
Abstract

Context The role and dose of oral vitamin D supplementation in nonvertebral fracture prevention have not been well established.

Objective To estimate the effectiveness of vitamin D supplementation in preventing hip and nonvertebral fractures in older persons.

Data Sources A systematic review of English and non-English articles using MEDLINE and the Cochrane Controlled Trials Register (1960-2005), and EMBASE (1991-2005). Additional studies were identified by contacting clinical experts and searching bibliographies and abstracts presented at the American Society for Bone and Mineral Research (1995-2004). Search terms included randomized controlled trial (RCT), controlled clinical trial, random allocation,double-blind method, cholecalciferol,ergocalciferol,25-hydroxyvitamin D, fractures, humans, elderly, falls, and bone density.

Study Selection Only double-blind RCTs of oral vitamin D supplementation (cholecalciferol, ergocalciferol) with or without calcium supplementation vs calcium supplementation or placebo in older persons (≥60 years) that examined hip or nonvertebral fractures were included.

Data Extraction Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators.

Data Synthesis All pooled analyses were based on random-effects models. Five RCTs for hip fracture (n = 9294) and 7 RCTs for nonvertebral fracture risk (n = 9820) met our inclusion criteria. All trials used cholecalciferol. Heterogeneity among studies for both hip and nonvertebral fracture prevention was observed, which disappeared after pooling RCTs with low-dose (400 IU/d) and higher-dose vitamin D (700-800 IU/d), separately. A vitamin D dose of 700 to 800 IU/d reduced the relative risk (RR) of hip fracture by 26% (3 RCTs with 5572 persons; pooled RR, 0.74; 95% confidence interval [CI], 0.61-0.88) and any nonvertebral fracture by 23% (5 RCTs with 6098 persons; pooled RR, 0.77; 95% CI, 0.68-0.87) vs calcium or placebo. No significant benefit was observed for RCTs with 400 IU/d vitamin D (2 RCTs with 3722 persons; pooled RR for hip fracture, 1.15; 95% CI, 0.88-1.50; and pooled RR for any nonvertebral fracture, 1.03; 95% CI, 0.86-1.24).

Conclusions Oral vitamin D supplementation between 700 to 800 IU/d appears to reduce the risk of hip and any nonvertebral fractures in ambulatory or institutionalized elderly persons. An oral vitamin D dose of 400 IU/d is not sufficient for fracture prevention.

Fractures contribute significantly to morbidity and mortality of older persons. Hip fractures increase exponentially with age so that by the ninth decade of life, an estimated 1 in every 3 women and 1 in every 6 men will have sustained a hip fracture.1 With the aging of the population, the number of hip fractures is projected to increase worldwide.2 The consequences of hip fractures are severe: 50% of older persons have permanent functional disabilities, 15% to 25% require long-term nursing home care, and 10% to 20% die within 1 year.3–6 Besides the personal burden, hip fractures account for substantial health care expenses3,7 with annual costs in the United States projected to increase from $7.2 billion in 1990 to $16 billion in 2020.7

Given the high prevalence, severity, and cost of osteoporotic fractures, prevention strategies that are effective, low in cost, and well-tolerated are needed. One promising prevention strategy may be oral vitamin D supplementation. Several randomized controlled trials (RCTs) have examined vitamin D supplements for fracture prevention, but the results were conflicting. The goal of our analysis was to determine the efficacy of oral vitamin D supplementation in preventing hip and any nonvertebral fractures among older persons by performing a systematic review of the literature with a meta-analysis of RCTs.
Key Points:

·      Study selection only involved double-blind randomized control trials.

·      This article focused only on the use of cholecalciferol.

·      The reduction in fractures (hip, nonvertebral) was based on the dosage

·       A dose of 700-800IU/d and higher showed a reduction in nonvertebral fractures.

·      Vitamin D also helps with muscle strength and balance.
Why I Chose This Article:

I chose this article for a multitude of different reasons. Chiefly, it answers my PICO question directly. It is important to note that the use of vitamin D at the appropriate level can significantly reduce hip fractures (by 26%) and nonvertebral fractures (by 23%). The article provided a number of randomized control trials that involved the use of vitamin D and compared it to placebo and calcium. However, I felt that the article lacked any documentation or mention of side effects or adverse effects of the vitamin D supplement.

 

Citation:

2) Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet. 383. 146-55. October 2013. Reid, I, Bolland, M., Grey, A. doi: 10.1016/S0140-6736(13)61647-5.

https://pubmed.ncbi.nlm.nih.gov/24119980/?from_term=vitamin+D&from_pos=4
Article Type:

Systematic Review & Meta-analysis
Abstract

Background

Findings from recent meta-analyses of vitamin D supplementation without co-administration of calcium have not shown fracture prevention, possibly because of insufficient power or inappropriate doses, or because the intervention was not targeted to deficient populations. Despite these data, almost half of older adults (older than 50 years) continue to use these supplements. Bone mineral density can be used to detect biologically significant effects in much smaller cohorts. We investigated whether vitamin D supplementation affects bone mineral density.

Methods

We searched Web of Science, Embase, and the Cochrane Database, from inception to July 8, 2012, for trials assessing the effects of vitamin D (D3 or D2, but not vitamin D metabolites) on bone mineral density. We included all randomised trials comparing interventions that differed only in vitamin D content, and which included adults (average age >20 years) without other metabolic bone diseases. We pooled data with a random effects meta-analysis with weighted mean differences and 95% CIs reported. To assess heterogeneity in results of individual studies, we used Cochran’s Q statistic and the I2 statistic. The primary endpoint was the percentage change in bone mineral density from baseline.

Findings

Of 3930 citations identified by the search strategy, 23 studies (mean duration 23·5 months, comprising 4082 participants, 92% women, average age 59 years) met the inclusion criteria. 19 studies had mainly white populations. Mean baseline serum 25-hydroxyvitamin D concentration was less than 50 nmol/L in eight studies (n=1791). In ten studies (n=2294), individuals were given vitamin D doses less than 800 IU per day. Bone mineral density was measured at one to five sites (lumbar spine, femoral neck, total hip, trochanter, total body, or forearm) in each study, so 70 tests of statistical significance were done across the studies. There were six findings of significant benefit, two of significant detriment, and the rest were non-significant. Only one study showed benefit at more than one site. Results of our meta-analysis showed a small benefit at the femoral neck (weighted mean difference 0·8%, 95% CI 0·2–1·4) with heterogeneity among trials (I2=67%, p<0·00027). No effect at any other site was reported, including the total hip. We recorded a bias toward positive results at the femoral neck and total hip.

Interpretation

Continuing widespread use of vitamin D for osteoporosis prevention in community-dwelling adults without specific risk factors for vitamin D deficiency seems to be inappropriate.
Key Points:

·      Lack of coadministration of calcium shows no evidence of reducing fractures with the use of vitamin D.

·      Results failed to show an association between supplementation and fracture prevention

·      4082 patients were studied in this article.

·      Use of vitamin D for osteoporosis prevention in community-dwelling adults is unnecessary.

·      The results from the systematic review match the results put forth by the meta-analysis.
Why I Chose This Article:

I chose this article because it strictly contradicts my PICO question. It provides a thorough investigation into the use of vitamin D supplements at its benefit in preventing fractures. The article continues to state that there is no benefit in taking vitamin D and had limited results in taking vitamin D with calcium.

 

Citation:

3) Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men (Review). The Cochrane Collaboration. 2014. Avenell, A., Mak, J., O’Connell, D. DOI: 10.1002/14651858.CD000227.pub4.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000227.pub4/epdf/full
Article Type:

Cochran Review
Abstract:

Background

Vitamin D and related compounds have been used to prevent osteoporotic fractures in older people. This is the third update of a Cochrane review first published in 1996.

Objectives

To determine the effects of vitamin D or related compounds, with or without calcium, for preventing fractures in post-menopausal women and older men.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2012), the Cochrane Central Register of Controlled Trials (2012, Issue 12), MEDLINE (1966 to November Week 3 2012), EMBASE (1980 to 2012 Week 50), CINAHL (1982 to December 2012), BIOSIS (1985 to 3 January 2013), Current Controlled Trials (December 2012) and reference lists of articles. Selection criteria

Randomised or quasi-randomised trials that compared vitamin D or related compounds, alone or with calcium, against placebo, no intervention or calcium alone, and that reported fracture outcomes in older people. The primary outcome was hip fracture.

Data collection and analysis

Two authors independently assessed trial risk of selection bias and aspects of methodological quality, and extracted data. Data were pooled, where possible, using the fixed-effect model, or the random-effects model when heterogeneity between studies appeared substantial.

Main results

We included 53 trials with a total of 91,791 participants. Thirty-one trials, with sample sizes ranging from 70 to 36,282 participants, examined vitamin D (including 25-hydroxy vitamin D) with or without calcium in the prevention of fractures in community, nursing home or hospital inpatient populations. Twelve of these 31 trials had participants with a mean or median age of 80 years or over. Another group of 22 smaller trials examined calcitriol or alfacalcidol (1-alphahydroxyvitamin D3), mostly with participants who had established osteoporosis. These trials were carried out in the setting of institutional referral clinics or hospitals.

In the assessment of risk of bias for random sequence generation, 21 trials (40%) were deemed to be at low risk, 28 trials (53%) at unclear risk and four trials at high risk (8%). For allocation concealment, 22 trials were at low risk (42%), 29 trials were at unclear risk (55%) and two trials were at high risk (4%). There is high quality evidence that vitamin D alone, in the formats and doses tested, is unlikely to be effective in preventing hip fracture (11 trials, 27,693 participants; risk ratio (RR) 1.12, 95% confidence intervals (CI) 0.98 to 1.29) or any new fracture (15 trials, 28,271 participants; RR 1.03, 95% CI 0.96 to 1.11). There is high quality evidence that vitamin D plus calcium results in a small reduction in hip fracture risk (nine trials, 49,853 participants; RR 0.84, 95% confidence interval (CI) 0.74 to 0.96; P value 0.01). In low-risk populations (residents in the community: with an estimated eight hip fractures per 1000 per year), this equates to one fewer hip fracture per 1000 older adults per year (95% CI 0 to 2). In high risk populations (residents in institutions: with an estimated 54 hip fractures per 1000 per year), this equates to nine fewer hip fractures per 1000 older adults per year (95% CI 2 to 14). There is high quality evidence that vitamin D plus calcium is associated with a statistically significant reduction in incidence of new nonvertebral fractures. However, there is only moderate quality evidence of an absence of a statistically significant preventive effect on clinical vertebral fractures. There is high quality evidence that vitamin D plus calcium reduces the risk of any type of fracture (10 trials, 49,976 participants; RR 0.95, 95% CI 0.90 to 0.99). In terms of the results for adverse effects: mortality was not adversely affected by either vitamin D or vitamin D plus calcium supplementation (29 trials, 71,032 participants, RR 0.97, 95% CI 0.93 to 1.01). Hypercalcaemia, which was usually mild (2.6 to 2.8 mmol/L), was more common in people receiving vitamin D or an analogue, with or without calcium (21 trials, 17,124 participants, RR 2.28, 95% CI 1.57 to 3.31), especially for calcitriol (four trials, 988 participants, RR 4.41, 95% CI 2.14 to 9.09), than in people receiving placebo or control. There was also a small increased risk of gastrointestinal symptoms (15 trials, 47,761 participants, RR 1.04, 95% CI 1.00 to 1.08), especially for calcium plus vitamin D (four trials, 40,524 participants, RR 1.05, 95% CI 1.01 to 1.09), and a significant increase in renal disease (11 trials, 46,548 participants, RR 1.16, 95% CI 1.02 to 1.33). Other systematic reviews have found an increased association of myocardial infarction with supplemental calcium; and evidence of increased myocardial infarction and stroke, but decreased cancer, with supplemental calcium plus vitamin D, without an overall effect on mortality.

Authors’ conclusions

Vitamin D alone is unlikely to prevent fractures in the doses and formulations tested so far in older people. Supplements of vitamin D and calcium may prevent hip or any type of fracture. There was a small but significant increase in gastrointestinal symptoms and renal disease associated with vitamin D and calcium. This review found that there was no increased risk of death from taking calcium and vitamin D.

 
Key Points:

·      A total of 91,791 patients participated in the study through 53 clinical trials.

·      Taking vitamin D alone likely does not prevent fractures

·      Vitamin D with calcium only slightly reduces the likelihood of hip fractures

·      There was no evidence of increased risk of death with taking vitamin D.

·      Adverse effects include gastrointestinal symptoms and renal disease.
Why I Chose This Article:

I chose this article for a couple of reasons. Chiefly, the Cochrane review encompassed a massive study on the use of vitamin D and vitamin D analogues. Secondly, the article directly contradicts my PICO question by stating that the use of vitamin D alone does not reduce the likelihood of fractures in older adults. It is important to note that there was a reduction in bone fractures among patients who took both vitamin D and calcium.

 

  Citation:

4) The effect of vitamin D and calcium supplementation on falls in older adults. A systematic review and meta-analysis. Orthopade Journal. 2017. Wu, H., & Pang, Q. Doi: 10.1007/s00132-017-3446-y

https://pubmed.ncbi.nlm.nih.gov/28718008/?from_term=vitamin+D&from_filter=pubt.meta-analysis&from_filter=pubt.randomizedcontrolledtrial&from_filter=pubt.systematicreviews&from_page=2&from_pos=2

 

  
  Article Type:

Meta-analysis and Systematic Review

  
  Abstract

Objectives: 

A number of studies have hypothesized that vitamin D is a potential factor in the prevention of falls in the elderly; however, the effect of vitamin D is still inconsistent and not quantitative. We conducted this meta-analysis to assess the effect of vitamin D on falls among elderly individuals.

Methods: 

The PubMed and Cochrane Library databases were searched from the earliest possible year up to December 2016. Two authors working independently reviewed the trials, and odds ratios (ORs) were calculated using a fixed-effect or random-effect model by Review Manager 5.3. We included only double-blind randomized, controlled trials (RCTs) of vitamin D in elderly populations that examined fall results.

Results: 

A total of 26 articles were included in which 16,540 elderly individuals received vitamin D supplementation, while 16,146 were assigned to control groups. The meta-analysis showed that combined vitamin D plus calcium supplementation has a significant effect on the reduction in the risk of falls (OR for the risk of suffering at least one fall, 0.87; 95% CI, 0.80-0.94). However, no significant association between vitamin D2 or D3 and a reduction in the risk of falls was found (OR, 0.77; 95% CI, 0.58-1.03 for vitamin D2, and OR, 1.08; 95% CI, 0.98-1.20 for vitamin D3).

Conclusions:

Combined calcium plus vitamin D supplementation is statistically significantly associated with a reduction in fall risks across various populations.

  
  Key Points:

·      The use of vitamin D with calcium significantly reduces nonvertebral fractures.

·      Vitamin D alone on fall outcomes is limited and further research is needed.

·      Vitamin D alone has no effect on helping fractures or reducing the risk of falls.

·      Use of vitamin D significantly increased 25-hydroxyvitamin D

  
  Why I Chose This Article:

This article presented the argument of comparing vitamin D and calcium to vitamin D by itself. The evidence shows that the use of vitamin D taken alone does not reduce fractures or falls. In contrast, the use of vitamin with calcium has shown to decrease the number of fractures and the likelihood of falls. The article mentions an interesting point that describes the use of vitamin D to increase muscle tone and leading to less falls and in-turn, reduces fractures and mortality, this is why I chose this article.

  
Author (Date) Level of Evidence Sample/Setting

(# of subjects/ studies, cohort definition etc)

 Outcome(s) studied Key Findings Limitations and Biases
Bischoff-Ferrari H., Willett, W., Wong, J.

(2005)

 Meta-Analysis 9294 for hip fractures

9820 for nonvertebral disc

 Vit D dose of 700-800 IU/daily

 

 Study selection only involved double-blind randomized control trials.

This article focused only on the use of cholecalciferol.

The reduction in fractures (hip, nonvertebral) was based on the dosage

A dose of 700-800IU/d and higher showed a reduction in nonvertebral fractures.

Vitamin D also helps with muscle strength and balance.

 No evidence of publication bias
Reid, I, Bolland, M., Grey, A

(2013)

 Systematic Review & Meta-analysis 23 studies

4082 patients

 <800IU/daily of vitamin D Lack of coadministration of calcium shows no evidence of reducing fractures with the use of vitamin D.

Results failed to show an association between supplementation and fracture prevention

4082 patients were studied in this article.

Use of vitamin D for osteoporosis prevention in community-dwelling adults is unnecessary.

The results from the systematic review match the results put forth by the meta-analysis.

 No evidence of publication bias or bias toward demographics
Avenell, A., Mak, J., O’Connell, D.

(2014)

 Cochrane Review 53 trials

91,791 patients

 Vitamin D

Hip fractures

 

 

 A total of 91,791 patients participated in the study through 53 clinical trials.

Taking vitamin D alone likely does not prevent fractures

Vitamin D with calcium only slightly reduces the likelihood of hip fractures

There was no evidence of increased risk of death with taking vitamin D.

Adverse effects include gastrointestinal symptoms and renal disease.

 No bias was evident with this Cochrane Review
Wu, H., & Pang, Q.

(2017)

 Systematic Review & Meta-Analysis 26 articles

16,540 elderly patients

 Combination Vitamin D plus calcium The use of vitamin D with calcium significantly reduces nonvertebral fractures.

Vitamin D alone on fall outcomes is limited and further research is needed.

Vitamin D alone has no effect on helping fractures or reducing the risk of falls.

Use of vitamin D significantly increased 25-hydroxyvitamin D

 A publication bias has likely affected the results presented in this review.

Fracture Prevention w Vit D. Meta RCTs

Avenell_et_al-2014-Cochrane_Database_of_Systematic_Reviews

Effects of Vit D on Bone Mineral Density. Systematic Review and Meta-Analysis

The effect of vitamin D and calcium supplementation on falls in older adults

Conclusions:

Bischoff-Ferrari concluded that the use of vitamin D supplements between 700-800IU per day decreases the risk of hip and nonvertebral fractures in ambulatory or institutionalized elderly patients. The use of vitamin D supplementation could be a strategy that is effective and low in cost with good patient compliance to help with osteoporotic fractures. Several randomized controlled trials (RCTs) have examined vitamin D supplements for fracture prevention, but the results were conflicting. The goal of the analysis was to determine the efficacy of oral vitamin D  in preventing hip and nonvertebral fractures among elderly.

Reid et al concluded that the use of vitamin D supplementation for osteoporosis and fracture prevention in community-dwelling adults was inappropriate. The article composed of 4082 patients through the evaluation of 23 studies. The authors found that all but 7 of the studies were insignificant and only one study showed significant benefit for the use of vitamin D in elderly patients.

Avenell et al concluded that vitamin D as monotherapy was unlikely to prevent fractures in the doses and formulations tested. This Cochrane Review encompassed 91,791 patients and covered research articles from 1985 to 2014. The article noted a small but significant increase in gastrointestinal symptoms and renal disease associated with vitamin D and calcium. Lastly, the review found that there was no increased risk of death from taking calcium and vitamin D.

Wu and Pang concluded that the use of calcium plus vitamin D supplementation is statistically significantly associated with a reduction in fall risks. However, the article did not use the comparison of vitamin D alone for the prevention of fractures and bone health. The article encompassed 26 articles and had 16540 patients over the age of 65. Lastly, the article noted that there was no association between Vitamin D and reduction in falls.

My overall conclusion with the use of vitamin D for reducing bone fractures is not favorable. The articles listed above did not adequately support the use of vitamin D for the prevention of fractures (hip, nonvertebral or otherwise). Nevertheless, the addition of calcium with vitamin D was noted to reduce fractures in elderly patients. All of the studies above described limited side effects with the use of vitamin D and no increase in mortality or morbidity.

Clinical bottom line:

I will weigh my studies in the following order: Avenell, Reid, Bischoff-Ferarri, and Wu.

Avenell et all Cochrane review was weighed the highest for several reasons. Chiefly, the patient sampling was nearly 92,000 and reviewed articles dating back to 1985. The article compared different dosages of Vitamin D and different combinations of medications. The article involved 53 trials and concluded that vitamin D is unlikely to prevent fractures.

Reid et al was weighed second because it was systematic review and meta-analysis and published in 2013. The article’s bottom line stated that the use of vitamin D for osteoporosis or bone fractures was inappropriate. It is noteworthy to mention that the majority of the patients in this sample size were female and encompassed 23 studies.

Bischoff-Ferarri was weighed next (third) because it was a meta-analysis. The bottom line of this article was that the use of vitamin D supplementation did to reduce the risk of hip and any nonvertebral fractures in elderly patients.

Wu was weighed least even though it was a systematic review and meta-analysis. The bottom line with this article was that the use of calcium with vitamin D does reduce the chances of fractures because it reduces the chances of fall risks.

Magnitude of any effects

I believe with the overwhelming data and the thorough research on the use of vitamin D it does not effectively support the reduction in bone fractures. The focus of these studies involved fractures pertaining to the hip and other nonvertebral fractures throughout the body. It is noteworthy to mention that the data does support the use of vitamin D with calcium. Vitamin D by itself does have a limited side effect profile and his minimal contraindications for elderly patients.

Clinical Significance

Based on the findings in these articles it is evident that the use of vitamin D is not indicated for the reduction of bone fractures in elderly patients. However, the articles shown above do support vitamin D supplementation for the use of bone health with the combination of calcium supplements. Further research needs to be presented comparing the use of vitamin D and calcium on bone health and fracture reduction. The use of vitamin D and calcium may be indicated for hospitalized patients or patients in long term institutions to reduce the chances of bone fractures among elderly patients. This may reduce overall hospital costs because there of the reduction in fractures with elderly patients. Secondly, it is noteworthy to investigate the reduction in mortality and morbidity among patients who undergo vitamin D supplementation combined with calcium, compared to placebo or other vitamin D analogues. Lastly, the price of vitamin D is relatively inexpensive and that provides better chances of access among patients with poor financial stability or poor financial income. Some insurances have been able to cover the cost of vitamin D supplementation especially the high dose once weekly tablet. However, this particular dose of vitamin D was not researched in the appraised topic shown above.

Any other considerations important in weighing this evidence to guide practice:

It is important to note that this medication is not FDA approved and is only regulated as a supplement. More research may be indicated to better understand the appropriate dosage for patients taking vitamin D for bone health, with the supplementation of calcium.

Article Summary:

Psychiatric Article

This article was a meta-analysis comparing clozapine to other antipsychotics and the development of neutropenia (agranulocytosis). The article was published in 2019 and was reported out of Australia and New Zealand. There were 20 articles that were used for the study and incorporated 1260 patients.

Agranulocytosis was first identified in the 1970s with several fatalities and most countries now require hematologic monitoring for patients on clozapine which is not a requirement for other antipsychotics. There are reports of agranulocytosis associated with other antipsychotic medications besides clozapine. This study compared the incidence of neutropenia in independent cohorts of subjects exposed to clozapine and other first or second generation antipsychotics to determine the risk of neutropenia associated with clozapine exposure.  The threshold for ANC was 1500 neutrophils per microliter which is the highest threshold in clozapine monitoring guidelines globally (average 1500-8000). For this study clozapine was compared to risperidone, chlorpromazine, haloperidol, olanzapine and combinations antipsychotics. Through the analysis of the 20 studies there was no statistically significant increased risk of neutropenia associated with clozapine compared to the other antipsychotics medications. This article shows that the necessity for routine hematological testing is indicated for clozapine, but also other antipsychotics because of the changes for neutropenia in patients taking antipsychotics. There are similar incidences with agranulocytosis among other antipsychotics but the data does not support abandoning monitoring white counts with patients taking clozapine. It is noteworthy to mention that the rate of fatalities with clozapine-induced agranulocytosis is rare 1 in 8000 patients. There were limits of this study mentioning the use of combination antipsychotics and the rates of agranulocytosis.

Bottom line there is still not enough research to stop the monitoring of white blood cell counts with patients using clozapine. Furthermore, studies may be indicated to see if ANC monitoring is necessary for other antipsychotics.

Site evaluation:

My site evaluation went really well with Dr. Saint Martin. Instead of him focusing on each student reading the whole H&P he would pull certain topics about the case and we would go over them. He would give his own perspective of the case and use his clinical experience to make subtle suggestions on how to perfect the H&P. I also liked doing it with other students because it gave a better perspective on the vastness of psychiatry, the drugs used and the possible disposition for the patients. I learned that the note writing is completely different than from a typical H&P or SOAP note and it is truly painting a picture of how the patient lives, acts and appears to other practitioners reading the reports.

Typhon Report

Typhon Psychiatry

Summary

Psychiatry is a very interesting field and it is full of little changes compared to standard medicine. The major change that I noted with seeing psychiatric patients is the way that the patients are interviewed. The questions are completely different and the follow up care truly steams from proper questioning of patients. Patients are often asked who do they live with, where do they live, are they with a shelter or are they homeless? These types of questions are not often seen in the outpatient setting or seen in routine medicine.

I noticed that the practitioners often stand further away from psychiatric patients than other routine patients on other services. The physicians and other practitioners really stressed the importance of safety and knowing your surroundings when dealing with psychiatric patients. While at the psychiatric emergency room I witnessed patients ripping down solid wood/metal doors and pulling placards off the walls and throwing them at hospital staff. It is paramount to not only maintain your own personal safety but also safety of the other patients on the unit.

Overall this was a great rotation, the field of psychiatry is diverse and a necessity in the healthcare field. A lot of patients who were brought in had some form of recent struggle especially since the corona virus pandemic. It is inevitable that the number of patients dealing with mental illness is likely to rise and that the practitioners treating these patients have the tools and resources to treat them.

 

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