Vitamin-D levels for all the patients (including elderly patients with fracture neck of femur) attending Kauvery Specialty Cantonment Tertiary care hospital – An audit report

M. Kalaivanan Masilamani

Consultant Orthopaedic Surgeon, Kauvery Hospital, Tennur, Trichy

Background

  1. Vitamin D deficiency is rampant in elderly population and house bound patients.
  2. It has been suggested that Vitamin D and its deficiency play a role in the pathogenesis of many illness and disorders eg. increased fracture risk, psychiatric disorders, etc.
  3. Here I am presenting the findings of an audit, Audit of Vit D Levels in Patients Attending Tertiary Care Hospital (fracture pts)

Prevalence of Vitamin D Deficiency

  1. Epidemiological studies in children have reported vitamin D deficiency (VDD) prevalence ranging from50% to 94%, suggesting a high unmet vitamin D requirement.
  2. Nearly 76%of the Indian population suffers from vitamin D deficiency.
  3. The prevalence of patients with vitamin D deficiency is highest in the elderly, obese patients, nursing home residents, and hospitalized patients.
  4. Vitamin D deficiency may be related to populations who have higher skin melanin content and who use extensive skin coverage
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Nearly 30 min of sunlight exposure of skin over the arms and face, without application of sunscreen, preferably between 10 am to 2 pm daily is reported to be adequate to avoid Vitamin D (Vit. D) deficiency for an average healthy adult.

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Vitamin D has a crucial role in

  1. Normal growth puberty,
  2. Regulation of immune response,
  3. Cancer prevention,
  4. Controlling insulin metabolism.
  5. Reducing the risk of Alzheimers disease protects against depression/ schizophrenia
  6. Reduces the cardiovascular risk – CAD, reduces the risk of developing high BP
  7. HELPS in normal muscle function
  8. Reduces inflammation but deficiency triggers asthma/wheezing
  9. Protection against diabetes,maintains bone health, deficiency causes rickets and osteomalacia
  10. Boosts immunityReducing the chance of cancer
  11. REDUCES risks of developing RA.

How to Diagnose a Vitamin D Deficiency?

In great number of cases one may find on blood tests that 25 hydroxy vitamin D (25 OH Vit D) levels are low, but 1,25 dihydroxyvitamin D 1,25 OH Vit D) is normal or elevated. This occurs because PTH is actively transforming 25 OH Vit D to 1,25 OH Vit D. It has been considered as the best indicator of overall vitamin D status.

Some patients can increase their vitamin D levels by taking supplements either by using daily or weekly doses. And some will find that taking vitamin D supplements makes them feel worse; probably because the high PTH turns the supplements into high concentrations of 1, 25 dihydroxy vitamin D which is the active form, causing symptoms of vitamin D toxicity. When taking vitamin D makes you feel worse, you should immediately stop. In either scenario,parathyroidectomywill not only correct the calcium/PTH imbalance (PHPT) but also the vitamin D deficiency.

Classification

Sr. 25-hydroxyvitamin D (25(OH)D) levels
Normal 30 to 100 ng/mL
Toxicity 100 ng/mL
Insufficiency 20-30 ng/mL
Mild deficiency 10-20 ng/mL
Moderate deficiency 5-10 ng/mL
Severe deficiency 5 ng/mL

Management of Vitamin D deficiency

Initial supplementation for 8 weeks with Vitamin D3 either 6,000 IU daily or 50,000 IU weekly can be considered.

Aim

  1. To audit the investigation of Serum 25-hydroxy vitamin D levels,
  2. To know the Prevalence of Vit D deficiency in all the patients including Femoral Neck Fractures attending Kauvery speciality tertiary care hospital, Trichy.

Materials Methods

This was a Retrospective review of computerised patient records, for all in and out patients who had done check-up and underwent treatment for the last 1 year (from 1st September 2022 – 31st August 2023).

Measurement of Serum 25-hydroxy vitamin D levels was assessed.

Vitamin D levels of 777 patients, who attended outpatient department and admitted patients who underwent treatments including Femoral Neck Fractures attending Kauvery speciality Tertiary care Hospital [Cantonment] Trichy, for a period of 12 months from 1st September 2022 – 31st August 2023 were collected and entered in an excel sheet and the data was analysed.

This Audit cum Study analysis divided in to 3 parts

  1. Firstly – All the 777 pts (done Vit D d levels) were analyzed
  2. Secondly -All the femoral neck fracture pts with available results of Vit D levels were analyzed
  3. Finally, all the consecutive case cohort of femoral neck fracture in pts (IP) who underwent treatment in the last 3 months were analyzed (without the margin of error)

The patients were categorized as follows:

Mild Deficiency 10-20 ng/mL
Moderate Deficiency 5-10 ng/mL
Severe Deficiency 5 ng/mL
Insufficiency 20-30 ng/mL
Normal 30 to 100 ng/mL
Toxicity 100 ng/mL

Among the total 777 patients 257 were males and 520 were females.

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The most common age group tested was below 45 (62%) followed by 20-45 (31%) as shown here.

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Among the total 777 patients, more (64%) were tested on IP basis.

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Results

Analysis of Vit-D levels in total of 777 pts

  1. Among 777 patients, 61% were 25(OH) D deficient; 26% were insufficient and only 13% were having normal serum levels of 25(OH) D.
  2. Majority of deficient patients were females (61%) .
  3. Most common age group with deficiency were 45 years.
  4. Females were more [ in both deficient and insufficient levels of Vitamin D group].
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Majority of deficient patients were females (61%)

RESULT

Male (%)

Female (%)

Total

%
Deficiency 166 (21%) 309(40%) 475 61%
Insufficiency 66(8%) 134 (17%) 200 26%
Normal 24 (3%) 74 (10%) 98 13%
Toxicity 1 (0%) 3 (0%) 4 1%
Over All 257 (33%) 520 (67%) 777  

Analysis of Vit-D levels in Femoral neck fracture with available results of Vit D level pts (N=64).

Age vs Sex

Age

Male

Female

Total

%
45 – 60 2 3 5 8%
Above 60 13 46 59 92%

Total

 15 49 64  
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Vit-D levels in Femoral neck fracture with available results of Vit D level pts (N=64) [last 1 yr.].

Age

Deficiency

Insufficiency

Normal

Total
45 – 60 5% 3% 0% 8%
Above 60 59% 17% 16% 92%
Over All 64% 20% 16%  
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Analysis of Vit-D levels in Consecutive Case Cohort of Femoral neck fracture pts (last 3 months).

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Literature Review

  1. Here in this analysis, the general trend is approx. 61 -65% were 25(OH) D deficient.
  2. Several Studies indicate approximately 80-90% of hip fracture patients are vitamin D deficient.
  3. Literature shows that 25(OH) D insufficiency over 5 years was associated with an increased 10-year risk of hip and major osteoporotic fractures in elderly women.

Conclusion

  1. We conclude that the prevalence of Vit-D deficiency in-hospitalised pt presenting with #NOF is approx 61-65% in a tier II city (Trichy) in central part of Tamilnadu.
  2. We recommend either tested or treated for Vit-D deficiency in # NOF pts.
  3. Wide Spread Community based Multidimensional study is needed to evaluate the detailed analysis of Vit- D Deficiency prevalence.

Here in our ortho dept, we now routinely either do blood test or directly give treatment (in elderly people with # NOF). We recommend to introduce this as a Kauvery Guidelines, based on our study in our local population. This may be a protocol in other units of Kauvery.

Kalaivanan

Dr. M. Kalaivanan

Ortho Surgeon

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