Background: Although incidental coronary artery calcium (CAC) has been established as a surrogate measure for atherosclerotic plaque burden, little is known about its progression and the associated risks. This study looks at the association of select cardiovascular risk factors with the progression of CAC over a 2-year period and the relationship between CAC progression and experiencing a composite cardiovascular disease (CVD) event.Methods: Repeated CAC measurements were obtained for 311 asymptomatic participants aged >44 years, who were recruited from a collaborative network of primary care clinics.Results: An average of 24.4 months separated scans and CAC scores increased by a mean of 24.45 Agatston units. A total of 113 participants (30%) demonstrated CAC progression, whereas the rest showed no change or a decrease in CAC over 2 years. In adjusted regression models that controlled for age and sex, the following were associated with 2-year CAC progression: dyslipidemia, systolic blood pressure, fasting glucose, and non-high-density lipoprotein. Moreover, those with progressive CAC measures were >4 times more likely to experience a composite CVD event in 2 years, after controlling for known risk factors.Conclusions: Overall, several baseline risk factors remained significant after adjusting for age and sex. CAC progression was independently associated with a composite CVD event. (J Am Board Fam Med 2017;30:592-600.)

Introduction Patients with major burn injuries receive micro-nutrient supplementation to promote wound healing and mitigate hypermetabolic complications. Vitamin A promotes epithelialization, angiogenesis and collagen synthesis and is included in ‘trauma vitamin’ bundles. As a fat-soluble vitamin, prolonged supplementation can lead to cumulative toxicity. Hypercalcemia can cause polyuria, ECG changes, and organ dysfunction. We report a case series of potential iatrogenic vitamin A toxicity among people with major burn injury. Methods Concern for vitamin A toxicity was raised by pharmacy and endocrinology after two patients were found with severe hypercalcemia and a consistent toxidrome. In response, we performed a chart review of adult patients with ≥20% TBSA who received vitamin A 25,000 units thrice weekly for at >2 weeks during March 2021 – July 2022. Hypercalcemia was defined as serum calcium concentration >10.4 mg/dL ( >2.60 mmol/L) or ionized serum calcium >5.2 mg/dL ( >1.30 mmol/L). Kruskal-Wallis test examined differences in median values. Results A total of 67 patients met screening criteria with 25 included in the series. Nine patients (36%) developed hypercalcemia. One patient developed hypercalcemia on day 5 of admission and was excluded. Median days to hypercalcemia was 52 (IQR 39-72). There were no differences in age, burn size, or weight between patients with and without hypercalcemia. Patients with hypercalcemia had significantly longer courses of vitamin A (56 vs 27 days, p=0.03) as well as length of stay (122 vs 63 days, p=0.01). One patient required treatment with a bisphosphonate. All improved with cessation of vitamin A supplementation. Conclusions A third of patients who received high-dose vitamin A as per a micronutrient supplementation protocol developed hypercalcemia. Our protocol was changed to limit vitamin A therapy to 21 days. Given that hypercalcemia among hospitalized patients is multifactorial, further evaluation with a larger case-control study is required to determine if high-dose vitamin A is a contributing factor. Applicability of Research to Practice Recommended daily allowance of vitamin A is ~3,000 units daily. Given that patients on enteral feedings receive approximately 3,600 units daily, vitamin A supplementation may result in toxicity if provided for >3-5 weeks.