Cases Of Vitamin Research Articles

Drilling down on the vitamin D debate: where are our priorities?

Vitamin D deficiency remains a global, public health concern despite intense focus in recent years. While nuanced issues such as the most appropriate cut-offs to define degrees of vitamin D sufficiency, insufficiency and deficiency are still unsettled, these debates occur on a backdrop of children continuing to be diagnosed around the world with the most devastating consequences of overt vitamin D deficiency - rickets and hypocalcemic seizures. The fact that few, if any, countries are exempt from new cases of vitamin D deficiency rickets underscores the potential barriers to effective prevention, including well-publicized national policies, education at multiple levels of the care system, access to vitamin D supplementation and compliance. As pediatricians, the global eradication of childhood rickets due to vitamin D deficiency is arguably our most important mandate at the moment, one that should not be overshadowed by the vitamin D adequacy cut-off debate. Only a small, critical amount of vitamin D daily is required post-natally to prevent rickets, with the optimal approach to rickets prevention targeting mother-infant dyads. Single dose or intermittent therapy is an appealing strategy to overcome compliance issues, although a full understanding of the risks related to higher dose therapy during the early years is still needed. Overall, this presentation will focus primarily on issues and strategies related to the global eradication of vitamin D deficiency rickets, with some discussion around the optimization of vitamin D status throughout the pediatric years.

Vitamin D assessment in primary care: changing patterns of testing.

Over recent years there has been increased interest in the disease burden associated with vitamin D deficiency. This, combined with recognition that the prevalence of vitamin D deficiency is high in the UK, has led to increased requests for vitamin D assessment from primary care clinicians. A primary care cohort in Liverpool. How has the usefulness of vitamin D testing changed over time in identifying deficiency? Vitamin D results from primary care practices in Liverpool were collected between 2007 and 2012, inclusive. Results were allocated to six cohorts based on year of request and each was grouped into three categories (adequate, insufficient and deficient). Vitamin D results of 9460 (74%) first tests and 3263 (26%) retests were analysed. Total number of requests increased 11-fold, from 503 in 2007 to 5552 in 2012. Overall 42% of first-test results were deficient (< 30 nmol). With each incremental year, more cases of vitamin D deficiency were detected - but the odds of detecting vitamin D deficiency decreased. An exponential increase in the number of vitamin D requests was observed over this six-year period. Although more patients with vitamin deficiency were identified, the increased number of tests represents a significant cost to health services. Moreover, the practice of retesting too soon after treatment can be inappropriate. There is a need to develop clear guidance for assessing vitamin D status in primary care.

Association between vitamin D deficiency and mortality in critically ill adult patients: a meta-analysis of cohort studies.

IntroductionVitamin D deficiency is common in critically ill patients, and was reported to be associated with adverse outcomes. However, the effect of vitamin D deficiency on mortality in critically ill patients remains unclear.MethodsWe searched PubMed and EMBASE from the inception to July 2014 for cohort studies to assess the effect of vitamin D deficiency on the incidence of mortality in critically ill patients. Mortality-specific odds ratio (OR) with 95% confidence interval (CI) were pooled with a random- or fixed-effect models when appropriate.ResultsSeven cohort studies with a total of 4,204 participants including 1,679 cases of vitamin D deficiency were included in this meta-analysis. Vitamin D deficiency was significantly associated with an increased hospital mortality (OR 1.76; 95% CI, 1.38 to 2.24; P <0.001), with very low heterogeneity (I2 = 2.3%; P = 0.402). The finding of increased hospital mortality in critically ill adult patients was consistently found in every stratum of our subgroup analyses.ConclusionsThis meta-analysis suggests that vitamin D deficiency is associated with increased incidence of hospital mortality in critically ill adult patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0684-9) contains supplementary material, which is available to authorized users.

Clinical trials to prevent/treat childhood asthma: methodologic issues

There is currently much excitement about clinical trials for the primary and secondary prevention of childhood asthma [1–3]. For the first time in over 40 years there are real novel therapeutic possibilities that deserve testing. In thinking about the design of these trials, it is critical to consider four issues: the traditional validity threats to clinical trials, how fetal lung development influences clinical trial design, how asthma natural history and asthma subphenotypes influence trial design and finally, drug dosing for these studies. As might be suspected, fetal lung development has its greatest impact on primary prevention trials and asthma sub phenotypes have its greatest effect on secondary prevention trials. Although people often focus on the randomized controlled nature of clinical trials, the methodological issues of blinding and randomization address internal validity, and not the source population from which trial subjects are drawn. The greatest validity threat to any clinical trial is the external validity generalizability of results, can the trial results be extrapolated to the population at large and what will be the population impact of the new treatment or preventative. Concrete examples of these generalizability issues can be seen in the source population for two of the new primary prevention trials in childhood asthma: the Vitamin D Antenatal Asthma Reduction Trial (VDAART) and the recent trial of vitamin C to prevent asthma in smoking pregnant women [1,2]. In the former case, VDAART is focused on women with a prior personal, or family, history of asthma, or allergies and giving them vitamin D to prevent asthma in their offspring. If successful, it will be a generalizability leap to all pregnant women, even those with a low genetic risk of asthma in their children, to extrapolate the trial results. In the latter case of vitamin C, the source, or target population, is the 12% of pregnant women who smoke and, as yet, there is no evidence that vitamin C will prevent asthma in nonsmoking pregnant women. This issue of generalizability is important in targeting public health interventions particularly in the area of primary prevention.

Vitamin A Deficiency and Female Fertility Problems: A Case Report and Mini Review of the Literature

We present a case of a vitamin A deficient woman who, presented to our clinic with secondary infertility to emphasize the importance of a good history and a multidisciplinary input in the management. This is a rare case of established vitamin A deficiency related to secondary infertility. Secondary infertility was quickly solved (30-45 days) after restoration of Vitamin A levels and the woman managed to get pregnant. It also illustrates that, though highly teratogenic, pregnancies on vita A replacement can be normal. Important fact here is that she was being replaced with vitamin A that her body was deficient in rather than supplementing leading to overdose of vitamin A (as in cases of treatment for Acne etc). Therefore, it may mean that for cases of vitamin A deficient women, termination should not be considered, as replacing normal vitamin A levels does not necessarily lead to hypervitaminosis and therefore increased chances of congenital malformations.

Prevalence of vitamin D insufficiency among community dwelling elderly in Dakahlia as a representative of rural areas in Egypt

Vitamin D has a basic role in bone growth and metabolism and has been noticed for its important role in many diseases. To detect the prevalence of vitamin D insufficiency among the elderly in Dakahlia. A cross-sectional study was conducted on 176 elderly patients (60 years and older) recruited from Meet Abbad-Nabaroh-Dakahlia, Egypt. The level of 25 hydroxy vitamin D (25OHD) was measured. A normal level of vitamin D is defined as a 25OHD concentration ≥30 ng/mL. Vitamin D insufficiency is defined as a 25OHD concentration of 20-29 ng/mL. Vitamin D deficiency is defined as a 25OHD level <20 ng/mL. There were no cases of vitamin D deficiency among the studied population. The prevalence of vitamin D insufficiency (25OHD level of 20-29 ng/mL) among the elderly in Dakahlia was 26 %. Prevalence of vitamin D insufficiency was (37.9 %) in males and (15.3 %) in females. There was a low prevalence of vitamin D insufficiency in an elderly rural population and a higher prevalence of vitamin D insufficiency among males than females.

Distinct profiles of systemic biomarkers of oxidative stress in chronic human pathologies: Cardiovascular, psychiatric, neurodegenerative, rheumatic, infectious, neoplasmic and endocrinological diseases

Oxidative stress is involved in chronic and acute pathologies: cardiovascular, neurodegenerative, neoplastic, inflammatory and infectious diseases. Clinical trials focused on prevention of cardiovascular and neoplastic diseases involving antioxidant supplementation have however provided predominantly negative obserations in large-scale studies. Screening of patient cohorts to assess baseline oxidative stress on the basis of a biomarker profile is decisive but lacking. For the first time, we evaluated the level of oxidative stress, testing more than 10 established biomarkers, in a comprehensive initial survey of 617 patients displaying chronic human pathologies. Multiple diseasespecific abnormalities were identified in plasma, whole blood and/or urine. This is the case for vitamins and oligo elements, vitamin C, vitamin E, β-carotene, selenium, zinc and copper; endogenous antioxidants such as reduced and oxidised glutathione, thiols, urate, and glutathione peroxidase activity, and a biomarker of oxidative DNA damage (8-hydroxy-2’-deoxy guanosine). The distinct biomarker profiles suggest the involvment of multiple forms of oxidative insults which arein some way partially specific to each pathological condition. This finding is in favor of the determination of an integrated score to combine contributions of distinct biomarkers, in order to screen patients presenting elevated levels of oxidative stress.

Schwere bilaterale Keratomalazie

In contrast to developing countries, xerophthalmia is rather rare in developed countries. Malnutrition (e.g. in mentally deficient or psychiatric patients), chronic liver diseases (e.g. due to alcoholism), or bowel surgery can be reasons for vitamin A deficiency in developed countries. The prodromal stage of hypovitaminosis A is characterized by nyctalopia, which often manifests subclinically. Longer lasting and severe cases of vitamin A deficiency may be complicated by the occurrence of keratinizing metaplasia in the cornea and conjunctiva, xerosis, keratomalacia or blindness.

EST施行3日後に大量出血を認めたビタミン K 欠乏の1例

EST施行3日後に大量出血を認めたビタミン K 欠乏の1例

Safety of vitamin D supplementation in children: a massive vitamin D overdose with no apparent hypercalcaemia

Aim To report the highest recorded vitamin D overdose in a child. This case is also unique in that there was no associated hypercalcaemia and the child did not require treatment. Methods A 12-year-old girl of Somali descent was followed up in neurodisability clinic for complex epilepsy and a progressive movement disorder manifesting as ataxia and progressive dystonia. Her diet contained a normal amount of calcium. She was on regular lamotrigine for seizure control. She was found to be vitamin D deficient with a total 25 hydroxyvitamin D level of 32 nmol/l. Her general practitioner was asked to prescribe vitamin D supplements. In error, she was prescribed and dispensed 100,000 units of colecalciferol a day. She took the prescribed dose over a period of at least 3 months – ingesting at least 150 capsules of 50,000 units each or a total of 7.5 million units. This error came to light when her serum total 25 hydroxyvitamin D level was measured six months later to check whether she had taken enough vitamin D. A literature search was conducted to look for cases of vitamin D intoxication. Results This patient9s peak measured serum 25 hydroxyvitamin D level was 671 nmol/L with corresponding serum corrected calcium of 2.44 mmol/L. Her 1,25 dihydroxyvitamin D level a month after this was 254 pmol/L (reference range 40-150) and her parathyroid hormone level was 5.5 pmol/L, which was normal. A renal ultrasound showed no evidence of nephrocalcinosis. She remained asymptomatic and well throughout. The literature search found no reports of vitamin D overdose of higher magnitude in a child and no relationship between size of overdose and serum calcium. All cases of overdose, from 900,000 to 4.5 million units of vitamin D, were associated with hypercalcaemia, which ranged from 3-4.6 mmol/L and required treatment. Conclusions Clinicians are gaining awareness of the need for vitamin D supplementation. Many medicines in children are prescribed off-licence. It is the responsibility of physicians and pharmacists to ensure they take extra care when prescribing unlicensed medications. Recommendations for vitamin D supplementation, including indications and doses should be made widely available, e.g. in the BNF (British National Formulary).

Two Teenage Males with Hypocalcemia and Elevated Parathyroid Hormone Levels

Vitamin D deficiency is not a rare disorder, particularly in minority groups. The Institute of Medicine recommends serum 25-hydroxyvitamin (OH)D levels >20 ng/mL and The Endocrine Society recommends levels >30 ng/mL for good health. In contrast, the 2003-2006 National Health and Nutrition Examination Survey reported average total 25-(OH)D concentrations of 25.6 ± 0.4 ng/mL in whites, 19.5 ± 0.5 ng/mL in Mexican Americans, and 14.8 ± 0.4 ng/mL in blacks. Pediatric patients with vitamin D deficiency may be asymptomatic or may present either with rickets, hypocalcemia, or seizures. Pseudohypoparathyroidism (PHP) is a rare disorder characterized by parathyroid hormone (PTH) resistance with (type 1a) or without (type 1b) the Albright Hereditary Os-teodystrophy (AHO) phenotype of short stature, brachydactyly, and mental retardation. Patients with PHP have elevated PTH levels and may have hyperphosphatemia and hypocalcemia. However, the same laboratory values can be seen in children with vitamin D deficiency, and diagnostic confusion is common. We report two cases of vitamin D deficiency with presentations suggestive of PHP.

Vitamin D deficiency presenting like hypophosphatemic osteomalacia

Introduction:Osteomalacia is one of the most common osteometabolic diseases. It is typically caused by lack of vitamin D and is characterized by mineralization deficiency of the osteoid matrix in the cortical and trabecular bone. Indians are at particularly high risk for developing osteomalacia, because of their traditional clothing style and skin color. This condition is frequently misdiagnosed and it can present with bone pain and muscle weakness.Objective:We report a case of osteomalacia with predominant hypophosphatemia.Case report:A 41-year-old male presented with gradually progressive quadriparesis for past 6 months. Patient had low phosphorous (1.9 mg/dl) with calcium being 8.1 mg/dl and 25(OH)Vitamin D3 levels being 8.12 ng/ml. The patient was thought to have concomitant Vitamin D deficiency with possibility of tumor-induced osteomalacia. Further evaluation for the same was planned. However, patient was given a trial of Vitamin D supplementation before further investigations and had dramatic improvement in the form that muscle power improved gradually over next 6 weeks and was able to climb stairs after 2 months. Retrospectively patient gave a history of being at home for many months and there was no exposure to sunlight at all. The biochemical parameters normalized within 4 weeks of starting Vitamin D and serum alkaline phosphatase showed drastic reduction after 6 weeks. All his family members were screened and found to have Vitamin D deficiency including recent born twins having rachitic changes. This was a case of vitamin D deficiency, in 41-year-old male, which presented more like hypophosphatemic osteomalacia but characteristic history of lack of sunlight exposure and dramatic improvement with only vitamin D3 supplementation confirmed the diagnosis.Conclusion:The presentation of vitamin D deficiency can be varied and high index of suspicion is important for treatment of this common but frequently misdiagnosed condition.

Antioxidant Therapies for Neurodegenerative Diseases: Mechanisms, Current Trends, and Perspectives

Antioxidant Therapies for Neurodegenerative Diseases: Mechanisms, Current Trends, and Perspectives

Vitamin D Intoxication with Severe Hypercalcemia due to Manufacturing and Labeling Errors of Two Dietary Supplements Made in the United States

More than 50% of Americans use dietary supplements, and 60-70% fail to report this use to their physicians. Intoxication from vitamin D supplements has been rarely reported but may now occur more frequently. This may be attributable to an increase in vitamin D supplement intake due to the findings that deficiency is common and has been associated with a number of disease states. We report two cases of vitamin D intoxication with dietary supplements made in the United States caused by manufacturing and labeling errors. Case histories were obtained, and serial laboratory data (calcium and vitamin D metabolites) were measured. Each dietary supplement was analyzed by UV spectrophotometry followed by HPLC. In both cases, repetitive inquiries were required to elicit the use of dietary supplements. Because of significant manufacturer errors and a labeling error, patients had been consuming more than 1000 times the recommended daily dose of vitamin D(3). Hypercalcemia is directly proportional to serum 25-hydroxyvitamin D [25(OH)D] but not 1,25-dihydroxyvitamin D levels. It took approximately 1 yr to normalize 25(OH)D levels. However, once 25(OH)D levels decreased below 400 ng/ml, both patients became normocalcemic and asymptomatic without long-term sequelae. Although rare, vitamin D intoxication should be considered in the differential diagnosis of hypercalcemia. Patients should be asked whether they are using dietary supplements, and serial questioning may be required because patients may not consider these supplements to be potential health risks. Errors in the manufacturing and labeling of dietary supplements made in the United States may place individuals at increased risks for side effects.

Three Criteria for Ecological Fallacy

In a large cohort study published in Environmental Health Perspectives, Brenner et al. (2011) confirmed previous results on I-131 exposure and thyroid cancer among a Ukranian population. According to the authors, one motivation to study this association was based on evidence from ecological studies (Jacob et al. 1999) with two methodological limitations: use of grouped doses and poor control of confounding. With these new findings, evidence from ecological, case–control, and cohort studies are consistent; thus, an interesting question is whether there was an ecological fallacy. Although ecological studies are important to epidemiology (especially in environmental and social epidemiology), public health practitioners seem afraid of ecological studies. It is a common practice to assume the presence of ecological fallacy (Robinson 1950) and low-level validity when analyzing an ecological study. Most epidemiologists prefer an exclusive individualistic approach, although the importance of a multilevel causal approach is widely recognized (Diez-Roux 2002). In this sense, some authors suggest that it is as important to recognize the presence of ecological fallacy as to recognize psychologistic or individualistic fallacy (Subramanian et al. 2009) (Figure 1). Figure 1 Levels of analysys in epidemiologic studies and potential fallacies during casual inference. Thus, it is necessary to have clear guidelines on when there is or not an ecological fallacy. In this sense, I propose three criteria for the identification of ecological fallacy; all three of these should be present to confirm its existence: Results must be obtained with ecological (population) data. Data must be inferred to individuals. One use of ecological studies is to explore individual-level association when individual data are not available. When the focus of the study was contextual or based on population effects and there is no inference to individuals, ecological fallacy is not possible. When only the first two criteria are present—which is insufficient to affirm ecological fallacy—it is appropriate to acknowledge that there is a possible relationship and that further study is required. Results obtained with individual data are contradictory. Only when empirical data are available is it possible to confirm that an ecological fallacy is present.

Acute vitamin A toxicity: A report of three paediatric cases

The following report describes three paediatric cases of vitamin A toxicity secondary to carnivorous fish liver ingestion. Further discussion of vitamin A toxicity and management of toxicity is included.

Asthme, alimentation et obésité

Asthma and obesity have considerably increased all over the world in the last 20years. A large number of data in the field of epidemiology, clinics, or physiopathology hypothesis, are in favor of a real link between these two diseases. Evaluation of BMI and therapeutic approaches of obese or overweight patients might, in the future, play an important role in the control of asthma particularly in difficult-to-treat asthma. In the field of primary prevention of asthma and atopy, several nutrients and foods are candidates. They have been identified by epidemiological studies. It is the case for vitamins A, D and E, zinc, regular consumption of fruits and vegetables and for Mediterranean diet. There is a need for well-designed randomized trials to precisely confirm their preventive role.

Four Cases of Vitamin D Deficiency Rickets with Lower Extremity Deformities

Four Cases of Vitamin D Deficiency Rickets with Lower Extremity Deformities

Women in Resource-Poor Settings Are at Risk of Inadequate Intakes of Multiple Micronutrients1–4

A systematic review was conducted to identify all studies that were published between 1988 and 2008 reporting micronutrient intakes of women in resource-poor settings. Inclusion criteria were study location (resource-poor), dietary assessment method (24-h recall, estimated/weighed record, or locally validated FFQ), energy and 1 or more micronutrient intakes reported (vitamin A, vitamin B-6, vitamin B-12, vitamin C, thiamin, riboflavin, niacin, folate, iron, or zinc), age range (15–50 y), sample size (≥30), and sex (female). Of the 1560 papers identified, 52 papers were included. Results showed that, except for vitamin A (29%), vitamin C (34%), and niacin (34%), the reported mean/median intakes in over 50% of studies were below the Estimated Average Requirement (EAR). Folate intake was most often below EAR (91% of studies). Regional differences were apparent for intakes of vitamins A, C, and B-6 and riboflavin; mean/median intakes in Latin America exceeded the EAR, whereas in Asia, reported mean/median intakes of vitamin C, vitamin A, and riboflavin were below the EAR in 47, 50, and 77% of the studies, respectively, as was the case for vitamin B-6 in 75% of the studies in Africa. These results suggest that inadequate intakes of multiple micronutrients are common among women living in resource-poor settings and emphasize the need for increased attention to the quality of women’s diets. There is a need for more high-quality studies of women’s micronutrient intakes.

1056 Cardiovascular Disease Secondary to Vitamin D Deficiency: Case Series of Three Children

Deficiency of vitamin D can result from a number of factors like inadequate dietary intake, coupled with inadequate sunlight exposure and disorders that limit its absorption. Although the most recognised complication of deficiency is musculoskeletal, there is growing awareness of its impact on the cardiovascular system.We present a series of three cases of Vitamin D deficiency and its associated cardiovascular complications.Case 1: This 6 month girl of African descent presented to the emergency department in cardiac failure. The echocardiogram showed grossly dilated heart with impaired function. On evaluation she was found to have vitamin D deficiency and responded well to calcium, vitamin D, diuretics and digoxin.Case 2: This two year girl who had been treated for dilated cardiomyopathy secondary to vitamin D deficiency was brought to the emergency department in cardiac arrest. Her post-mortem examination revealed grossly dilated cardiomyopathy with extensive calcification of the conduction pathways.Case 3: This 15 year old boy of African descent was being evaluated for genu valgum. His evaluation revealed hypocalcemia, vitamin D deficiency and a prolonged QT interval. Echocardiogram was unremarkable. He was started on Vitamin D and calcium. His QT interval normalised.Conclusions: Dilated cardiomyopathy secondary to vitamin D deficiency can definitely be prevented and does have a better prognosis than idiopathic dilated cardiomyopathy. Although the risk of Vitamin D deficiency is greater in individuals with increased skin pigmentation, recently there has been a resurgence of vitamin D deficiency in the developed world, and this has become a global problem.