Large, single-dose, oral vitamin D supplementation in adult populations: a systematic review

Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications After Primary Total Joint Arthroplasty

BACKGROUND

Vitamin D deficiency is a global problem, and 13 to 75% of patients undergoing total joint arthroplasty (TJA) have vitamin D deficiency. Several studies have shown that low preoperative vitamin D levels may increase the risk of postoperative complications, including periprosthetic joint infection (PJI), in patients undergoing primary TJA. Most of the studies are underpowered. This study aimed to investigate the relationship between vitamin D deficiency and surgical and medical complications after primary TJA, with a specific focus on PJI.

METHODS

Prospectively collected institutional multicenter arthroplasty databases were reviewed to identify patients who underwent primary total knee and hip arthroplasty. The study group was defined as patients whose vitamin D level is < 30 ng/dL and who received a single oral dose of 7.5 mg (300,000 IU) D3 within two weeks before index surgery (n = 488; mean age 63 years). Patients in the control group were those whose preoperative vitamin D levels were unknown and who did not receive vitamin D supplementation (n = 592, mean age 66). The groups were compared regarding 90-day medical and surgical complications, including PJI, mortality, and readmission rates.

RESULTS

The total number of complications (8.6 and 4.3%; respectively; P = .005), superficial wound infection (2.5 and 0.2%, respectively; P < .001), and postoperative cellulitis (2.2 and 0% respectively; P < .001) were statistically significantly higher in the patient group who did not receive vitamin D supplementation. However, 90-day mortality (P = .524), PJI (P = .23), and readmission rate (P = .683) were similar between the groups.

CONCLUSIONS

This study demonstrated that preoperative optimization of vitamin D levels may be beneficial in reducing postoperative complications, including superficial wound infection and postoperative cellulitis. Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA.

Vitamin D and ischemic stroke - Association, mechanisms, and therapeutics

Confronting the rising tide of ischemic stroke and its associated mortality and morbidity with ageing, prevention and acute management of ischemic stroke is of paramount importance. Mounting observational studies have established a non-linear association of vitamin D status with cardiovascular diseases, including ischemic stroke. Paradoxically, current clinical trials fail to demonstrate the cardiovascular benefits of vitamin D supplementation. We aim to update recent clinical and experimental findings on the role of vitamin D in the disease course of ischemic stroke, from its onset, progression, recovery, to recurrence, and the established and alternative possible pathophysiological mechanisms. This review justifies the necessities to address stroke etiological subtypes and focus on vitamin D-deficient subjects for investigating the potential of vitamin D supplementation as a preventive and therapeutic approach for ischemic stroke. Well-powered clinical trials are warranted to determine the efficacy, safety, timing, target individuals, optimal dosages, and target 25OHD concentrations of vitamin D supplementation in the prevention and treatment of ischemic stroke.

High-dose vitamin D supplementation in patients with COVID-19: A meta-analysis of randomized controlled trials

The efficacy of administering high doses of vitamin D to patients diagnosed with COVID-19 remains uncertain. We conducted a comprehensive search across multiple databases (PubMed, EMBASE, Cochrane Library, and ISI Web of Science) from inception until August 2022, with no limitations on language, to locate randomized controlled trials (RCTs) that investigated the impact of high-dose vitamin D supplementation (defined as a single dose of ≥100,000 IU or daily dose of ≥10,000 IU reaching a total dose of ≥100,000 IU) on COVID-19 patients. Risk ratios (RR) with 95% confidence intervals (CI) and weighted mean differences (WMD) with 95% CI were calculated. Our meta-analysis included 5 RCTs with a total of 834 patients. High-dose vitamin D supplementation did not show any significant benefits for mortality (I 2 = 0.0%, p = .670; RR 1.092, 95% CI 0.685-1.742, p = .711) or intensive care unit (ICU) admission (I 2 = 0.0%, p = .519; RR 0.707, 95% CI 0.454-1.102, p = .126) in COVID-19 patients compared to the control group. However, it was found to be safe and well-tolerated (I 2 = 0.0%, p = .887; RR 1.218, 95% CI 0.930-1.594, p = .151). Subgroup analysis also showed no benefits in overall mortality, including for patients with vitamin D deficiency (I 2 = 0.0%, p = .452; RR 2.441, 95% CI 0.448-13.312, p = .303) or compared to the placebo (I 2 = 0.0%, p = .673; RR 1.666, 95% CI 0.711-3.902, p = .240). Our research indicates that there is no evidence to support the efficacy of high-dose vitamin D supplementation in improving clinical outcomes among individuals with COVID-19, in line with previous studies focused on contexts including rickets. Considering the limitations of the study, additional research may be required.

Vitamin D Reduces GABA-Positive Astrocytes in the 5xFAD Mouse Model of Alzheimer's Disease

Background

Vitamin D has neuroprotective and immunomodulating functions that may impact glial cell function in the brain. Previously, we reported molecular and behavioral changes caused by deficiency and supplementation of vitamin D in an Alzheimer's disease (AD) mouse model. Recent studies have highlighted reactive astrocytes as a new therapeutic target for AD treatment. However, the mechanisms underlying the therapeutic effects of vitamin D on the glial cells of AD remain unclear.

Objective

To investigate the potential association between vitamin D deficiency/supplementation and the pathological progression of AD, including amyloid-β (Aβ) pathology and reactive astrogliosis.

Methods

Transgenic hemizygous 5XFAD male mice were subjected to different dietary interventions and intraperitoneal vitamin D injections to examine the effects of vitamin D deficiency and supplementation on AD. Brain tissue was then analyzed using immunohistochemistry for Aβ plaques, microglia, and astrocytes, with quantifications performed via ImageJ software.

Results

Our results demonstrated that vitamin D deficiency exacerbated Aβ plaque formation and increased GABA-positive reactive astrocytes in AD model mice, while vitamin D supplementation ameliorated these effects, leading to a reduction in Aβ plaques and GABA-positive astrocytes.

Conclusions

Our findings highlight the significant impact of vitamin D status on Aβ pathology and reactive astrogliosis, underscoring its potential role in the prevention and treatment of AD. This study provides the first in vivo evidence of the association between vitamin D and reactive astrogliosis in AD model mice, indicating the potential for targeting vitamin D levels as a novel therapeutic approach for AD.

Efficacy and safety of single or consecutive double high-dose oral cholecalciferol supplementation in adult patients with vitamin D deficiency

BACKGROUND AND AIM

Enhancing vitamin D levels as a crucial modifiable risk factor may provide a critical contribution to prevent susceptibility to various diseases, including musculoskeletal, autoimmune, and inflammatory rheumatic diseases as well as promoting overall health. However, adherence to daily vitamin D supplementation is generally poor, and there are some concerns regarding the high-dose vitamin D supplementation's safety. We aimed to investigate whether a single oral dose of 300,000 IU or consecutive two-day dosing of 300,000 IU each day of cholecalciferol could sufficiently and safely elevate vitamin D levels.

METHODS

This cross-sectional study was conducted on 160 inpatients with vitamin D deficiency and various musculoskeletal diseases.Subjects with serum 25(OH)D levels between 10 and 20 ng/mL (mild to moderate deficiency) received a single oral dose of 300,000 IU cholecalciferol, while those with severe vitamin D deficiency (<10 ng/mL) were supplemented with consecutive two-day doses of 300,000 IU cholecalciferol (a total of 600,000 IU).

RESULTS

After one week of replacement therapy, the 25(OH)D levels increased from 6.3 (4.0-9.9) ng/mL to 53.3 (8.3-84.4) ng/mL and from 15.0 (10.1-19.6) ng/mL to 38.4 (16.3-67.7) in the group with severe and those with the mild-to-moderate vitamin D deficiency, respectively. Except for three patients, nearly all patients (98%) achieved levels above 20 ng/mL. No signs of toxicity were observed in any of the patients. During the 6-month follow-up, falls were observed in 3 patients (2.8%), but no fractures were reported.

CONCLUSION

A single dose of 300,000 IU of oral cholecalciferol or two consecutive doses with a total dose of 600,000 IU cholecalciferol can effectively and reliably increase the 25(OH)D serum levels within one week in nearly all patients. The results may contribute to optimizing treatment strategies for vitamin D deficiency and re-evaluating the potential negative impact of high-dose vitamin D supplementation.

Efficacy of zoledronate, denosumab or teriparatide in postmenopausal women with type 2 diabetes mellitus at high risk of fragility fractures: protocol of an open, blinded endpoint randomized controlled pilot trial

Background

People with type 2 diabetes (T2D) are at high risk of fragility fractures; however, there are no randomized controlled trials evaluating the efficacy of anti-osteoporosis drugs as a primary pre-specified endpoint in T2D.

Objectives

To compare the efficacy of anti-osteoporotic drugs in postmenopausal women with T2D.

Design

Prospective, randomized, open, blinded endpoint clinical pilot trial.

Methods

Postmenopausal women (⩾50 years) with T2D (duration ⩾5 years), HbA1c 7-10%, eGFR ⩾45 mL/min/1.73 m2 and prior vertebral (clinical/morphometric), hip, radius, humeral fragility fracture or bone mineral density (BMD) T-score (adjusted for diabetes) at lumbar spine/femoral neck ⩽-2.5 and high FRAX score will be eligible for inclusion. Subjects with secondary causes of osteoporosis, prior exposure to bone-active therapies or history of use of glucocorticoids/pioglitazone/thiazides/canagliflozin will be excluded. Finally, eligible subjects will undergo estimation of serum calcium, phosphate, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D and bone turnover markers (BTMs) (total procollagen type I N-propeptide, β-CTX) along with trabecular bone score (TBS) and high-resolution peripheral quantitative computed tomography (HR-pQCT) of non-dominant hand and leg. After a 2-week run in phase, they will be randomized in a 1:1:1:1 ratio to receive yearly zoledronate, or biannually denosumab or daily teriparatide (in addition to standard of care, i.e., calcium 1000 mg/day and cholecalciferol 1000 IU/day) or only standard of care (control). The primary endpoints will be change in areal BMD and frequency of incident fractures at 18 months. The secondary endpoints will be change in HR-pQCT parameters, TBS and BTMs at 18 months. Adverse events will be recorded for all randomized participants.

Ethics

The study has been approved by the Institute Ethics Committee. Written informed consent will be obtained from each participant.

Discussion

The trial is expected to provide information regarding optimal anti-osteoporotic therapy in people with T2D and bone fragility.

Registration

Prospectively registered in Clinical Trial Registry of India (CTRI/2022/02/039978).

Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.

Vitamin D and Zinc Supplementation to Improve Treatment Outcomes among COVID-19 Patients in India: Results from a Double-Blind Randomized Placebo-Controlled Trial

BACKGROUND

There remains a need to identify low-cost interventions to improve coronavirus disease 2019 (COVID-19) outcomes. Vitamin D and zinc play a role in respiratory infections and could hold value as part of therapeutic regimens.

OBJECTIVES

To determine the effect of vitamin D or zinc supplementation on recovery from COVID-19.

METHODS

We conducted a double-blind, randomly assigned 2 x 2 factorial placebo-controlled trial with 1:1:1:1 allocation ratio, enrolling nonpregnant adults with COVID-19 from hospitals in Mumbai and Pune, India (NCT04641195). Participants (N = 181) were randomly assigned to vitamin D3 (180,000 IU bolus, then 2000 IU daily), zinc (40 mg daily), vitamin D3 and zinc, or placebo, for 8 wk. Participants were followed until 8 wk. The primary outcome was time to resolution of fever, cough, and shortness of breath. Secondary outcomes were duration of individual symptoms; need for assisted ventilation; duration of hospital stay; all-cause mortality; and blood biomarkers, including nutritional, inflammatory, and immunological markers.

RESULTS

We observed no effect of vitamin D or zinc supplementation on time to resolution of all 3 symptoms [vitamin D hazard ratio (HR): 0.92; 95% confidence interval (95% CI): 0.66, 1.30; P = 0.650; zinc HR: 0.94; 95% CI: 0.67, 1.33; P = 0.745)]. Neither vitamin D nor zinc supplementation was associated with secondary outcomes, except for increased endline serum vitamin D with vitamin D supplementation [median (interquartile range) difference between endline and baseline for vitamin D: 5.3 ng/mL (-2.3 to 13.7); for no vitamin D: -1.4 ng/mL (-5.6 to 3.9); P = 0.003]. We observed nonsignificant increases in serum zinc at endline following zinc supplementation. There was no evidence of interaction between vitamin D and zinc supplementation, no effect of either on hypercalcemia, and no adverse events.

CONCLUSIONS

Results suggest that neither vitamin D nor zinc supplementation improves COVID-19 treatment outcomes in this population. However, much larger-scale evidence, particularly from populations with vitamin D or zinc deficiency and severe infection, is required to corroborate our findings. This trial was registered at ClinicalTrials.gov and the Clinical Trials Registry of India as NCT04641195 and CTRI/2021/04/032593 respectively.

Serum Oxytocin Levels Decrease 12 Months Following Sleeve Gastrectomy and Are Associated with Decreases in Lean Mass

Oxytocin (OXT), an anorexigenic hormone, is also bone anabolic. Further, OXT administration results in increases in lean mass (LM) in adults with sarcopenic obesity. We examine, for the first time, associations of OXT with body composition and bone endpoints in 25 youth 13-25 years old with severe obesity who underwent sleeve gastrectomy (SG) and 27 non-surgical controls (NS). Forty participants were female. Subjects underwent fasting blood tests for serum OXT and DXA for areal bone mineral density (aBMD) and body composition. At baseline, SG vs. NS had higher median body mass index (BMI) but did not differ for age or OXT levels. Over 12 months, SG vs. NS had greater reductions in BMI, LM, and fat mass (FM). OXT decreased in SG vs. NS 12 months post-SG. While baseline OXT predicted a 12-month BMI change in SG, decreases in OXT levels 12 months post-SG were not associated with decreases in weight or BMI. In SG, decreases in OXT were positively associated with decreases in LM but not with decreases in FM or aBMD. Loss of LM, a strong predictor of BMD, after bariatric surgery may reduce functional and muscular capacity. OXT pathways may be targeted to prevent LM loss following SG.

Prevention of COVID-19 with oral vitamin D supplemental therapy in essential healthcare teams (PROTECT): protocol for a multicentre, triple-blind, randomised, placebo-controlled trial

INTRODUCTION

In the COVID-19 pandemic, healthcare workers (HCWs) were at high risk of infection due to their exposure to COVID infections. HCWs were the backbone of our healthcare response to this pandemic; every HCW withdrawn or lost due to infection had a substantial impact on our capacity to deliver care. Primary prevention was a key approach to reduce infection. Vitamin D insufficiency is highly prevalent in Canadians and worldwide. Vitamin D supplementation has been shown to significantly decrease the risk of respiratory infections. Whether this risk reduction would apply to COVID-19 infections remained to be determined. This study aimed to determine the impact of high-dose vitamin D supplementation on incidence of laboratory-confirmed COVID-19 infection rate and severity in HCWs working in high COVID incidence areas.

METHODS AND ANALYSIS

PROTECT was a triple-blind, placebo-controlled, parallel-group multicentre trial of vitamin D supplementation in HCWs. Participants were randomly allocated in a 1:1 ratio in variable block size to intervention (one oral loading dose of 100 000 IU vitamin D₃+10 000 IU weekly vitamin D₃) or control (identical placebo loading dose+weekly placebo). The primary outcome was the incidence of laboratory-confirmed COVID-19 infection, documented by RT-qPCR on salivary (or nasopharyngeal) specimens obtained for screening or diagnostic purposes, as well as self-obtained salivary specimens and COVID-19 seroconversion at endpoint. Secondary outcomes included disease severity; duration of COVID-19-related symptoms; COVID-19 seroconversion documented at endpoint; duration of work absenteeism; duration of unemployment support; and adverse health events. The trial was terminated prematurely, due to recruitment difficulty.

ETHICS AND DISSEMINATION

This study involves human participants and was approved by the Research Ethics Board (REB) of the Centre hospitalier universitaire (CHU) Sainte-Justine serving as central committee for participating institutions (#MP-21-2021-3044). Participants provided written informed consent to participate in the study before taking part. Results are being disseminated to the medical community via national/international conferences and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT04483635.

Influence of Vitamin D supplementation on reproductive outcomes of infertile patients: a systematic review and meta-analysis

BACKGROUND

Low vitamin D status has been associated with an increased risk for infertility. Recent evidence regarding the efficacy of vitamin D supplementation in improving reproductive outcomes is inconsistent. Therefore, this systematic review was conducted to investigate whether vitamin D supplementation could improve the reproductive outcomes of infertile patients and evaluate how the parameters of vitamin D supplementation affected the clinical pregnancy rate.

METHODS

We searched seven electronic databases (CNKI, Cqvip, Wanfang, PubMed, Medline, Embase, and Cochrane Library) up to March 2022. Randomized and cohort studies were collected to assess the reproductive outcomes difference between the intervention (vitamin D) vs. the control (placebo or none). Mantel-Haenszel random effects models were used. Effects were reported as odds ratio (OR) and their 95% confidence interval (CI). PROSPERO database registration number: CRD42022304018.

RESULTS

Twelve eligible studies (n = 2352) were included: 9 randomized controlled trials (RCTs, n = 1677) and 3 cohort studies (n = 675). Pooled results indicated that infertile women treated with vitamin D had a significantly increased clinical pregnancy rate compared with the control group (OR: 1.70, 95% CI: 1.24-2.34; I² = 63%, P = 0.001). However, the implantation, biochemical pregnancy, miscarriage, and multiple pregnancy rates had no significant difference (OR: 1.86, 95% CI: 1.00-3.47; I² = 85%, P = 0.05; OR: 1.49; 0.98-2.26; I² = 63%, P = 0.06; OR: 0.98, 95% CI: 0.63-1.53; I² = 0%, P = 0.94 and OR: 3.64, 95% CI: 0.58-11.98; I² = 68%, P = 0.21). The improvement of clinical pregnancy rate in the intervention group was influenced by the vitamin D level of patients, drug type, the total vitamin D dosage, the duration, administration frequency, and daily dosage of vitamin D supplementation. The infertile women (vitamin D level < 30 ng/mL) treated with the multicomponent drugs including vitamin D (10,000-50,000 IU or 50,000-500,000 IU), or got vitamin D 1000-10,000 IU daily, lasting for 30-60 days could achieve better pregnancy outcome.

CONCLUSION

To the best of our knowledge, this is the first meta-analysis systematically investigated that moderate daily dosing of vitamin D supplementation could improve the clinical pregnancy rate of infertile women and reported the effects of vitamin D supplementation parameters on pregnancy outcomes. A larger sample size and high-quality RCTs are necessary to optimize the parameters of vitamin D supplementation to help more infertile patients benefit from this therapy.

Maternal vitamin D and growth of under-five children: a systematic review and meta-analysis of observational and interventional studies

Background

Even though previous systematic reviews have reported on the role of prenatal vitamin D on birth outcomes, its effect on child growth is poorly understood.

Objective

To synthesize a systematic summary of the literature on the effect of maternal vitamin D supplementation on the linear growth of under-five children.

Method

This study includes studies (both observational and interventional with a control group) that evaluated the effects of prenatal vitamin D status on child linear growth. The mean child length/length for age with 95% confidence interval (CI) was pooled as the weighted mean difference using a random-effects model. A funnel plot was used to assess potential publication bias.

Results

A total of 45 studies and 66 reports covering a total population of 44,992 (19,683 intervention or high vitamin D group, and 25,309 control or low vitamin D group) were analyzed. Studies spanned from 1977 to 2022. The pooled weighted mean difference was 0.4 cm (95% CI: 0.15–0.65). A subgroup analysis, based on vitamin D supplementation frequency, showed that mothers who supplemented monthly or less frequently had a 0.7 cm (95% CI: 0.2–1.16 cm) longer child. Supplementation with a dose of >2000 international units increased child length at birth. The weighted mean difference was 0.35 cm (95% CI: 0.11–0.58).

Conclusion

The evidence from this review shows that maternal supplementation of vitamin D is associated with increased birth length. This is apparent at higher doses, low frequency (monthly or less frequent), and during the second/third trimester. It appears that vitamin D supplementation during pregnancy is protective of future growth in under-five children. Clinical trials are needed to establish evidence of effectiveness for the frequency and dose of supplementation.

Oral vitamin D supplemental therapy to attain a desired serum 25-hydroxyvitamin D concentration in essential healthcare teams

BACKGROUND

The study objectives were to ascertain the efficacy of vitamin D supplementation in rapidly increasing serum vitamin D and of implementation of a hybrid (virtual and in-person) trial.

METHODS

In a randomized triple-blind controlled trial, healthcare workers were allocated to receive an oral bolus of 100,000 IU with 10,000 IU/week of vitamin D₃ or placebo. The co-primary outcomes were the change from baseline in serum 25-hydroxyvitamin D [(Δ) 25(OH)D] and proportion with vitamin D sufficiency (25(OH)D ≥ 75 nmol/L), at endpoint. Adherence to supplements and procedures as well as adverse event rates were documented.

RESULTS

Thirty-four (19 intervention, 15 control) subjects were randomized, with 28 (41%) virtual visits. After 44.78 ± 11.00 days from baseline, a significant adjusted group difference of 44.2 (34.7, 53.8) nmol/L was observed in the Δ 25(OH)D (95% CI) in favor of supplementation; 77.8% of intervention, and 13.3% of control, patients were vitamin D sufficient (OR:6.11, 95% CI:1.6, 22.9). The adherence to intervention was 94.7% in the intervention and 100% in the control groups. Irrespective of visit type, high adherence was observed in sampling procedures and completion of fortnightly online questionnaire. No adverse events attributable to vitamin D were reported.

CONCLUSION

The vitamin D supplementation rapidly and safely raised 25(OH)D levels to sufficient levels for a biological effect. Similarly high adherence to study procedures was observed with virtual and in-person participation.

TRIAL REGISTRATION

This trial was registered at https://clinicaltrials.gov on July 23, 2020 (# NCT04483635 ).

Persistent or new symptoms 1 year after a single high dose of vitamin D3 in patients with moderate to severe COVID-19

Purpose

The aim of this study was to investigate the reported persistent or new symptoms 1 year after a single dose of 200,000 IU of vitamin D₃ and hospitalization in patients with moderate to severe COVID-19.

Methods

This is a post-hoc, exploratory analysis from a multicenter, double-blind, placebo-controlled, randomized clinical trial from two hospitals in São Paulo, Brazil, registered in ClinicalTrials.gov, NCT04449718. Discharged patients were followed for up to 1 year and evaluated by telephone interviews at 6 and 12 months. The primary and secondary outcomes were previously published. These post-hoc exploratory secondary outcomes are the persistent or new symptoms and quality of life (QoL) at the post-viral stage of COVID-19. Generalized estimating equations (GEE) for repeated measures with Bonferroni’s adjustment were used for testing outcomes.

Results

Between 2 June and 27 August 2020, we randomized 240 patients of which 144 were included in this study [the vitamin D₃ (n = 71) or placebo (n = 73) group]. The mean (SD) age was 54.3 (13.1) years, and body mass index (BMI) was 32.4 (6.5) kg/m². Fever demonstrated a significant main effect of time (P < 0.001) with a reduction from baseline to 6 (52–0) and 12 months (52–0). No significant differences between groups were observed for fever, cough, fatigue, fever, myalgia, joint pain, runny nose, nasal congestion, sore throat, hypertension, diabetes, cardiovascular disease, rheumatic disease, asthma, chronic obstructive pulmonary, chronic kidney disease, QoL, and new or persistent symptoms up to 1-year of follow-up.

Conclusion

The findings do not support the use of 200,000 IU of vitamin D₃ compared to placebo for the management of persistence or new symptoms, and QoL reported by moderate to severe patients after hospitalization for COVID-19.

Randomised trial to determine the effect of vitamin D and zinc supplementation for improving treatment outcomes among patients with COVID-19 in India: trial protocol

INTRODUCTION

Presently, there are few population-level strategies to address SARS-CoV-2 infection except preventive measures such as vaccination. Micronutrient deficiency, particularly vitamin D and zinc deficiency, has been associated with dysregulated host responses, and may play an important role in COVID-19.

METHODS AND ANALYSIS

We have designed a 2×2 factorial, randomised, double-blind, multi-centre placebo-controlled trial to evaluate the effect of vitamin D and zinc on COVID-19 outcomes in Maharashtra, India. COVID-19 positive individuals are recruited from hospitals in Mumbai and Pune. Participants are provided (1) vitamin D3 bolus (180 000 IU) maintained by daily dose of 2000 IU and/or (2) zinc gluconate (40 mg daily), versus placebo for 8 weeks. Participants undergo a detailed assessment at baseline and at 8 weeks, and are monitored daily in hospital or every 3 days after leaving the hospital to assess symptoms and other clinical measures. A final follow-up telephone call occurs 12 weeks post-enrolment to assess long-term outcomes. The primary outcome of the study is to time to recovery, defined as time to resolution of all of fever, cough and shortness of breath. Secondary outcomes include: duration of hospital stay, all-cause mortality, necessity of assisted ventilation, change in blood biomarker levels and individual symptoms duration. Participant recruitment commenced on April 2021.

ETHICS AND DISSEMINATION

Ethical approval was obtained from institutional ethical committees of all participating institutions. The study findings will be presented in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBERS

NCT04641195, CTRI/2021/04/032593, HMSC (GOI)-2021-0060.

Contemporary nutrition-based interventions to reduce risk of infection among elderly long-term care residents: A scoping review

Background

Elderly long-term care residents (ELTCRs) face considerable burden of infection, especially evident during the COVID-19 pandemic. The nutritional status of the host can influence susceptibility to infection by altering immune system integrity, therefore, nutrition-based interventions may be a viable complement to existing infection prevention measures.

Objective

This scoping review sought to identify nutritional interventions and factors that have the strongest evidence to benefit ELTCRs, and thus best poised for rigorous clinical trial evaluation and subsequent implementation.

Methods

A database search of OVID-Medline, OVID-Embase, and Web of Science was performed from 2011 to 2021 to identify nutritional intervention studies which attribute to changes in infection in contemporary ELTCR settings. Articles were screened in duplicate and data extraction completed by a single reviewer, while a second reviewer verified the data which was fitted to identify evidence for nutritional interventions related to reducing rates of infection among ELTCRs.

Results

The search identified 1018 studies, of which 11 (nine clinical trials and two observational cohort studies) satisfied screening criteria. Interventions that significantly reduced risk of infection included whey protein (any infection), Black Chokeberry (urinary tract infection), and vitamin D (acute respiratory tract infection, skin and soft tissue infection). Both zinc and a dedicated meal-plan significantly improved lymphocyte parameters. Vitamin D deficiency was associated with the development of respiratory tract infections. Probiotic and soy-based protein interventions did not significantly affect risk of infection or lymphocyte parameters, respectively.

Conclusion

The current scoping review was effective in identifying the use of nutrition-based interventions for infection prevention among ELTCRs. In this study, some nutrition-based interventions were observed to significantly influence the risk of infection among ELTCRs. Nutritional interventions such as vitamin D (preventing deficiency/insufficiency), Black Chokeberry juice, zinc gluconate, whey protein, and varied and nutrient dense meal plans may be suitable for future rigorous clinical trial evaluation.

The Role of Vitamin D in Alzheimer’s Disease: A Transcriptional Regulator of Amyloidopathy and Gliopathy

Alzheimer’s disease (AD) is characterized by amyloid-beta (Aβ) accumulation and cognitive mental decline. Epidemiological studies have suggested an association between low serum vitamin D levels and an increased risk of AD. Vitamin D regulates gene expression via the vitamin D receptor, a nuclear ligand-dependent transcription factor. However, the molecular mechanism underlying the pathogenic and therapeutic effects of vitamin D on AD is not fully understood yet. To better understand how vitamin D regulates the expression of genes related to AD pathology, first, we induced vitamin D deficiency in 5xFAD mice by providing a vitamin-D-deficient diet and observed the changes in the mRNA level of genes related to Aβ processing, which resulted in an increase in the Aβ load in the brain. The vitamin D-deficient diet also suppressed the expression of genes for microglial Aβ phagocytosis. Interestingly, vitamin D deficiency in the early stage of AD resulted in earlier memory impairment. In addition, we administered vitamin D intraperitoneally to 5xFAD mice with a normal diet and found lower Aβ levels with the suppressed expression of genes for Aβ generation and observed improved memory function, which may be potentially associated with reduced MAO-B expression. These findings strongly suggest the role of vitamin D as a crucial disease-modifying factor that may modulate the amyloid pathology with regard to reducing AD symptoms.

Rapidly Increasing Serum 25(OH)D Boosts the Immune System, against Infections-Sepsis and COVID-19

Vitamin D deficiency is a global public health problem, a pandemic that commonly affects the elderly and those with comorbidities such as obesity, diabetes, hypertension, respiratory disorders, recurrent infections, immune deficiency, and malignancies, as well as ethnic minorities living in temperate countries. The same groups were worst affected by COVID-19. Since vitamin D deficiency weakens the immune system, it increases the risk of infections, complications, and deaths, such as from sepsis and COVID-19. Deficiency can be remedied cost-effectively through targeted food fortification, supplementation, and/or daily safe sun exposure. Its endocrine functions are limited to mineral metabolism, musculoskeletal systems, specific cell membrane interactions, and parathyroid gland functions. Except for the rapid, endocrine, and cell membrane-based non-genomic functions, all other biological and physiological activities of vitamin D depend on the adequate intracellular synthesis of 1,25(OH)2D (calcitriol) in peripheral target cells via the genome. Calcitriol mediates autocrine (intracrine) and paracrine signalling in immune cells, which provides broader, protective immune functions crucial to overcoming infections. The synthesis of 1,25(OH)2D (calcitriol) in peripheral target cells is dependent on diffusion and endocytosis of D3 and 25(OH)D from the circulation into them, which requires maintenance of serum 25(OH)D concentration above 50 ng/mL. Therefore, in acute infections such as sepsis and respiratory infections like COVID-19, it is necessary to rapidly provide its precursors, D3 and 25(OH)D, through the circulation to generate adequate intracellular calcitriol. Immune defence is one of the crucial non-hormonal functions of vitamin D. A single oral (bolus) dose or divided upfront loading doses between 100,000 and 500,000 IU, using 50,000 IU vitamin D3 increase the serum 25(OH)D concentrations to a therapeutic level of above 50 ng/mL that lasts between two to three months. This takes three to five days to raise serum 25(OH)D. In contrast, a single oral dose of calcifediol (0.014 mg/kg body weight) can generate the needed 25(OH)D concentration within four hours. Considering both D3 and 25(OH)D enter immune cells for generating calcitriol, using the combination of D3 (medium-term) and calcifediol (immediate) is cost-effective and leads to the best clinical outcome. To maximise protection against infections, particularly to reduce COVID-19-associated complications and deaths, healthcare workers should advise patients on safe sun exposure, adequate vitamin D supplementation and balanced diets containing zinc, magnesium, and other micronutrients to support the immune system. Meanwhile, governments, the World Health Organisation, the Centers for Disease Control, and governments should consider similar recommendations to physicians and the public, change the outdated vitamin D and other micronutrient recommendations directed to their population, and organise targetted food fortification programs for the vulnerable groups. This article discusses a rational approach to maintaining a sustained serum 25(OH)D concentration above 50 ng/mL, necessary to attain a robust immune system for overcoming infections. Such would cost-effectively improve the population’s health and reduce healthcare costs. It also describes three cost-effective, straightforward protocols for achieving and sustaining therapeutic serum 25(OH)D concentrations above 50 ng/mL (>125 nmol/L) to keep the population healthy, reduce absenteeism, improve productivity, and lower healthcare costs.

Association of vitamin D status with COVID-19 and its severity : Vitamin D and COVID-19: a narrative review

Vitamin D is associated with biological activities of the innate and adaptive immune systems, as well as inflammation. In observational studies, an inverse relationship has been found between serum 25-hydroxyvitamin D (25(OH)D) concentrations and the risk or severity of coronavirus disease 2019 (COVID-19). Several mechanisms have been proposed for the role of vitamin D in COVID-19, including modulation of immune and inflammatory responses, regulation of the renin-angiotensin-aldosterone system, and involvement in glucose metabolism and cardiovascular system. Low 25(OH)D concentrations might predispose patients with COVID-19 to severe outcomes not only via the associated hyperinflammatory syndrome but also by worsening preexisting impaired glucose metabolism and cardiovascular diseases. Some randomized controlled trials have shown that vitamin D supplementation is beneficial for reducing severe acute respiratory syndrome coronavirus 2 RNA positivity but not for reducing intensive care unit admission or all-cause mortality in patients with moderate-to-severe COVID-19. Current evidence suggests that taking a vitamin D supplement to maintain a serum concentration of 25(OH)D of at least 30 ng/mL (preferred range 40-60 ng/mL), can help reduce the risk of COVID-19 and its severe outcomes, including mortality. Although further well designed studies are warranted, it is prudent to recommend vitamin D supplements to people with vitamin D deficiency/insufficiency during the COVID-19 pandemic according to international guidelines.

High-dose vitamin D versus placebo to prevent complications in COVID-19 patients: Multicentre randomized controlled clinical trial

Background

The role of oral vitamin D₃ supplementation for hospitalized patients with COVID-19 remains to be determined. The study was aimed to evaluate whether vitamin D₃ supplementation could prevent respiratory worsening among hospitalized patients with COVID-19.

Methods and findings

We designed a multicentre, randomized, double-blind, sequential, placebo-controlled clinical trial. The study was conducted in 17 second and third level hospitals, located in four provinces of Argentina, from 14 August 2020 to 22 June 2021. We enrolled 218 adult patients, hospitalized in general wards with SARS-CoV-2 confirmed infection, mild-to-moderate COVID-19 and risk factors for disease progression. Participants were randomized to a single oral dose of 500 000 IU of vitamin D₃ or matching placebo. Randomization ratio was 1:1, with permuted blocks and stratified for study site, diabetes and age (≤60 vs >60 years). The primary outcome was the change in the respiratory Sepsis related Organ Failure Assessment score between baseline and the highest value recorded up to day 7. Secondary outcomes included the length of hospital stay; intensive care unit admission; and in-hospital mortality. Overall, 115 participants were assigned to vitamin D₃ and 105 to placebo (mean [SD] age, 59.1 [10.7] years; 103 [47.2%] women). There were no significant differences in the primary outcome between groups (median [IQR] 0.0 [0.0–1.0] vs 0.0 [0.0–1.0], for vitamin D₃ and placebo, respectively; p = 0.925). Median [IQR] length of hospital stay was not significantly different between vitamin D₃ group (6.0 [4.0–9.0] days) and placebo group (6.0 [4.0–10.0] days; p = 0.632). There were no significant differences for intensive care unit admissions (7.8% vs 10.7%; RR 0.73; 95% CI 0.32 to 1.70; p = 0.622), or in-hospital mortality (4.3% vs 1.9%; RR 2.24; 95% CI 0.44 to 11.29; p = 0.451). There were no significant differences in serious adverse events (vitamin D₃ = 14.8%, placebo = 11.7%).

Conclusions

Among hospitalized patients with mild-to-moderate COVID-19 and risk factors, a single high oral dose of vitamin D₃ as compared with placebo, did not prevent the respiratory worsening.

Trial registration

ClincicalTrials.gov Identifier: NCT04411446.

Effect of a single high dose of vitamin D3 on cytokines, chemokines, and growth factor in patients with moderate to severe COVID-19

BACKGROUND

The modulating effect of vitamin D on cytokine concentrations in severe coronavirus disease 2019 (COVID-19) remains unknown.

OBJECTIVES

We aimed to investigate the effect of a single high dose of vitamin D3 on cytokines, chemokines, and growth factor in hospitalized patients with moderate to severe COVID-19.

METHODS

This is a post hoc, ancillary, and exploratory analysis from a multicenter, double-blind, placebo-controlled, randomized clinical trial. Patients with moderate to severe COVID-19 were recruited from 2 hospitals in São Paulo, Brazil. Of 240 randomly assigned patients, 200 were assessed in this study and randomly assigned to receive a single oral dose of 200,000 IU vitamin D3 (n = 101) or placebo (n = 99). The primary outcome was hospital length of stay, which has been published in our previous study. The prespecified secondary outcomes were serum concentrations of IL-1β, IL-6, IL-10, TNF-α, and 25-hydroxyvitamin D. The post hoc exploratory secondary outcomes were IL-4, IL-12p70, IL-17A, IFN-γ, granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-8, IFN-inducible protein-10 (IP-10), macrophage inflammatory protein-1β (MIP-1β), monocyte chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGF), and leukocyte count. Generalized estimating equations for repeated measures, with Bonferroni's adjustment, were used for testing all outcomes.

RESULTS

The study included 200 patients with a mean ± SD age of 55.5 ± 14.3 y and BMI of 32.2 ± 7.1 kg/m2, of which 109 (54.5%) were male. GM-CSF concentrations showed a significant group-by-time interaction effect (P = 0.04), although the between-group difference at postintervention after Bonferroni's adjustment was not significant. No significant effects were observed for the other outcomes.

CONCLUSIONS

The findings do not support the use of a single dose of 200,000 IU vitamin D3, compared with placebo, for the improvement of cytokines, chemokines, and growth factor in hospitalized patients with moderate to severe COVID-19.This trial was registered at clinicaltrials.gov as NCT04449718.

Vitamin D Deficiency in Cushing's Disease: Before and After Its Supplementation

Background: The primary objective of the study was to assess serum 25-hydroxyvitamin D [25(OH)D] values in patients with Cushing’s disease (CD), compared to controls. The secondary objective was to assess the response to a load of 150,000 U of cholecalciferol. Methods: In 50 patients with active CD and 48 controls, we evaluated the anthropometric and biochemical parameters, including insulin sensitivity estimation by the homeostatic model of insulin resistance, Matsuda Index and oral disposition index at baseline and in patients with CD also after 6 weeks of cholecalciferol supplementation. Results: At baseline, patients with CD showed a higher frequency of hypovitaminosis deficiency (p = 0.001) and lower serum 25(OH)D (p < 0.001) than the controls. Six weeks after cholecalciferol treatment, patients with CD had increased serum calcium (p = 0.017), 25(OH)D (p < 0.001), ISI-Matsuda (p = 0.035), oral disposition index (p = 0.045) and decreased serum PTH (p = 0.004) and total cholesterol (p = 0.017) values than at baseline. Multivariate analysis showed that mean urinary free cortisol (mUFC) was independently negatively correlated with serum 25(OH)D in CD. Conclusions: Serum 25(OH)D levels are lower in patients with CD compared to the controls. Vitamin D deficiency is correlated with mUFC and values of mUFC > 240 nmol/24 h are associated with hypovitaminosis D. Cholecalciferol supplementation had a positive impact on insulin sensitivity and lipids.

A single-oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve outcomes in the COVID-19 disease: the COVID-VIT-D-a randomised multicentre international clinical trial

BACKGROUND

Vitamin D status has been implicated in COVID-19 disease. The objective of the COVID-VIT-D trial was to investigate if an oral bolus of cholecalciferol (100,000 IU) administered at hospital admission influences the outcomes of moderate-severe COVID-19 disease. In the same cohort, the association between baseline serum calcidiol levels with the same outcomes was also analysed.

METHODS

The COVID-VIT-D is a multicentre, international, randomised, open label, clinical trial conducted throughout 1 year. Patients older than 18 years with moderate-severe COVID-19 disease requiring hospitalisation were included. At admission, patients were randomised 1:1 to receive a single oral bolus of cholecalciferol (n=274) or nothing (n=269). Patients were followed from admission to discharge or death. Length of hospitalisation, admission to intensive care unit (ICU) and mortality were assessed.

RESULTS

In the randomised trial, comorbidities, biomarkers, symptoms and drugs used did not differ between groups. Median serum calcidiol in the cholecalciferol and control groups were 17.0 vs. 16.1 ng/mL at admission and 29.0 vs. 16.4 ng/mL at discharge, respectively. The median length of hospitalisation (10.0 [95%CI 9.0-10.5] vs. 9.5 [95%CI 9.0-10.5] days), admission to ICU (17.2% [95%CI 13.0-22.3] vs. 16.4% [95%CI 12.3-21.4]) and death rate (8.0% [95%CI 5.2-12.1] vs. 5.6% [95%CI 3.3-9.2]) did not differ between the cholecalciferol and control group. In the cohort analyses, the highest serum calcidiol category at admission (>25ng/mL) was associated with lower percentage of pulmonary involvement and better outcomes.

CONCLUSIONS

The randomised clinical trial showed the administration of an oral bolus of 100,000 IU of cholecalciferol at hospital admission did not improve the outcomes of the COVID-19 disease. A cohort analysis showed that serum calcidiol at hospital admission was associated with outcomes.

TRIAL REGISTRATION

COVID-VIT-D trial was authorised by the Spanish Agency for Medicines and Health products (AEMPS) and registered in European Union Drug Regulating Authorities Clinical Trials (EudraCT 2020-002274-28) and in ClinicalTrials.gov ( NCT04552951 ).

Vitamin D: Bolus Is Bogus-A Narrative Review

In this review we summarize the impact of bolus versus daily dosing of vitamin D on 25(OH)D and 1,25(OH)₂D levels, as well as on key countervailing factors that block vitamin D functions at the cellular level. Further, we discuss the role of bolus versus daily dosing of vitamin D for several health outcomes, including respiratory infections and coronavirus disease 2019 (COVID-19), rickets, falls and fractures, any cancer, and cancer-related mortality. This discussion appears timely because bolus doses continue to be tested for various disease outcomes despite a growing amount of evidence suggesting lack of efficacy or even detrimental effects of bolus dosing of vitamin D for outcomes where daily dosing at modest levels was effective in the vitamin D deficient. As a result, these discordant results may bias health recommendations for vitamin D if the recommendations are based on meta-analyses combining both daily and bolus dosing trials. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Safety and effectiveness of vitamin D mega-dose: A systematic review

INTRODUCTION

Supplementation with high doses of vitamin D, known as mega-dose or "stoss therapy," refers to administering high doses of vitamin D by oral or intramuscular route in short periods of time. In this sense, conducting a review to organize this knowledge in a single article will generate a helpful instrument for researchers working in this area and for health professionals who use this therapeutic tool.

OBJECTIVE

To carry out a literature review on safety and efficacy (normalization of serum vitamin D level, and changes in the clinical picture) of vitamin D mega-dose use.

METHODOLOGY

This is a systematic review of the literature searching data through the electronic banks of PubMed, Scielo, and LILACS, using the following keywords: "vitamin D," "mega-dose," "stoss therapy," "cholecalciferol," in different combinations. CONSORT questionnaire was used to assess the quality of the included studies.

RESULTS

Of the 59 articles screened for this review, 10 were included in the review, studying patients with rickets, osteoporosis, and critically ill patients. Two studies compared the exact dosage of vitamin D by different routes of administration, and three studies compared different doses by the same route. All others studied vitamin D mega-dose versus placebo. Adverse effects were observed through the presence of hypercalcemia/hypercalciuria. Serum vitamin D levels were normalized between 70 and 100% of patients, and adverse effects ranged between 1.9 and 18.5%.

CONCLUSION

The study demonstrated that vitamin D mega-dose therapy is effective in normalizing serum vitamin levels, and the toxicity assessed through adverse effects was low, with no expressive clinical significance. Despite this, there is still a need for further studies in the area to confirm the results found.

Vitamin D Trajectory after Total Knee Arthroplasty: A Method for Quick Correction in Deficient Patients

Backgroud

It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA.

Methods

Vit D levels < 30 ng/mL are considered insufficient. We prospectively enrolled 60 patients (20 per group): group I, vit D sufficient patients; group II, vit D insufficient patients given IM supplementation (cholecalciferol 6,00,000 IU); and group III, vit D insufficient patients given oral supplementation (cholecalciferol 600,000 IU). Vit D levels, knee flexion, Timed Up and Go (TUG) test results, and visual analog scale (VAS) score were recorded preoperatively and postoperatively on day 3 and 14.

Results

In group I, mean preoperative vit D significantly dropped at postoperative day (POD) 3 and POD 14 (p = 0.001). In group II, mean preoperative vit D rose at POD 3 and rose significantly at POD 14 (p = 0.001). In group III, mean preoperative vit D increased significantly at both POD 3 and POD 14 (p < 0.001). Also, in group III, the rise in vit D was significantly higher than that in group II both at POD 3 and POD 14 (p < 0.05). In group III, 19 of 20 insufficient patients became sufficient on POD 3 and all 20 by POD 14. In group II, even by POD 14, only 11 of 20 insufficient patients became sufficient. Functional parameters (flexion, change in flexion, TUG test results, and VAS score) were comparable (p > 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p < 0.05), suggesting a slower recovery. It remained comparable (p > 0.05) between group III and group I.

Conclusions

We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

Osteoporosis in a Rural Community - Long-Term Effects of a Community Level Program of Calcium and Vitamin D Supplementation - A Prospective Observational Study

In a defined geographic area in rural India (1,60,000 population), osteoporosis detection and calcium and vitamin D supplementation program was instituted. Of the eligible 15,386 subjects, 5,992 (38%) participated in the program; 2,882 (48%) had osteopenia and osteoporosis; supervised calcium and vitamin D supplementation was instituted; 2,113 (73.3% of those identified) completed 2 years of supplementation. The mean duration of the follow-up was 5 years (range 2-8 years). On follow-up, three groups emerged; those who were regular, those who were irregular, and those who did not take supplements. In those who were regular with calcium and vitamin D supplementation, we found a significant reduction in fractures (RR 0.27, 95% CI 0.09-0.81) compared with those who did not take supplements. There was no significant difference in falls between the three groups. Mortality was significantly lower (RR 0.53, 95% CI 0.31-0.91) in those who were regular with calcium and vitamin D supplements compared to those who did not take supplements. While the reduction in fractures was probably due to calcium and vitamin D supplementation, the reduction in mortality was probably because those who took regular supplements accessed healthcare services more readily for other comorbidities as part of their follow-up program.

Vitamin D supplementation for primary dysmenorrhea: a double-blind, randomized, placebo-controlled trial

Objective

Recent studies have shown a possible association between vitamin D deficiency and the severity of primary dysmenorrhea. The present study aimed to investigate the effect of vitamin D supplementation on pain and systemic symptoms in patients with primary dysmenorrhea.

Methods

This double-blind, randomized, placebo-controlled trial was conducted on female students aged 18 to 32 years with primary dysmenorrhea and vitamin D deficiency (25 [OH]D <30 ng/mL). The participants (n=116) received either 50,000 IU of vitamin D3 (cholecalciferol) or placebo capsules on a weekly basis for eight consecutive weeks. The outcomes were pain intensity (scored 0 to 10), number of days with pain, number of consumed pain-relief medications (per day), and severity of systemic symptoms (fatigue, headache, nausea/vomiting, and diarrhea; total score of 0 to 12).

Results

Compared with baseline, our participants who received vitamin D experienced significant reductions in pain intensity (−1.0 and −1.5 score at weeks 4 and 8, P<0.001), the number of days with pain (−1.0 day at weeks 4 and 8, P<0.001), the number of consumed pain-relief medications (−1.0 at weeks 4 and 8, P<0.001), and systemic symptoms severity (−1.0 score at weeks 4 and 8, P<0.001). No significant improvements were observed in the placebo group in terms of these outcomes.

Conclusion

Vitamin D supplementation in women with primary dysmenorrhea and vitamin D deficiency could improve systemic symptoms and reduce pain intensity, the number of days with pain, and the need for consuming pain-relief medications.

The Effect of Vitamin D Supplementation on Clinical Outcomes for Critically Ill Patients: A Systemic Review and Meta-Analysis of Randomized Clinical Trials

Purpose: Vitamin D deficiency is a common scenario in critically ill patients and has been proven to be associated with poor outcomes. However, the effect of vitamin D supplementation for critically ill patients remains controversial. Thus, we conducted a meta-analysis to evaluate the effect of vitamin D supplementation among critically ill patients. Methods: Electronic databases PubMed, Embase, Scopus, and the Cochrane Library were searched for eligible randomized controlled trials between 2000 and January 2021. The primary outcome was overall mortality, and the secondary ones were the length of intensive care unit stay, the length of hospital stay, as well as the duration of mechanical ventilation. Subgroup analyses were performed to explore the treatment effect by type of admission, route of administration, dose of supplemented vitamin D, and the degree of vitamin D deficiency. Results: A total of 14 studies involving 2,324 patients were finally included. No effect on overall mortality was found between vitamin D supplementation and control group [odds ratio (OR), 0.73; 95% CI, 0.52-1.03; I ² = 28%]. The vitamin D supplementation reduced the length of intensive care unit stay [mean difference (MD), -2.25; 95% CI, -4.07 to -0.44, I ² = 71%] and duration of mechanical ventilation (MD, -3.47; 95% CI, -6.37 to -0.57, I ² = 88%). In the subgroup analyses, the vitamin D supplementation for surgical patients (OR, 0.67; 95% CI, 0.47-0.94; I ² = 0%) or through parenteral way (OR, 0.42; 95% CI, 0.22-0.82, I ² = 0%) was associated with reduced mortality. Conclusion: In critically ill patients, the supplementation of vitamin D has no effect on overall mortality compared to placebo but may decrease the length of intensive care unit stay and mechanical ventilation. Further trials are necessary to confirm our findings.

Vitamin D status and complications, readmissions, and mortality after hip fracture

Low vitamin D in patients with hip fracture is common. In the present study, 407 of 872 (47%) patients had serum calcidiol less than 50 nmol/L. Patients with low vitamin D had more delirium, more new hip fractures, and more medical readmissions, but not more orthopedic complications after 1 year.

INTRODUCTION

We wanted to study the relation between vitamin D level and postoperative orthopedic and medical complications in patients with hip fracture. In addition, we investigated the effect of giving a single-dose cholecalciferol 100.000 IU.

METHODS

Data were taken from the local hip fracture register. Logistic regression analyses including vitamin D level and potentially confounding variables were performed for complications and readmissions.

RESULTS

A total of 407 (47%) of 872 included hip fractures had low vitamin D at baseline. A total of 155 (18%) developed delirium, and the risk was higher in vitamin D-deficient patients (odds ratio (OR) 1.48, 95% confidence interval (CI) 1.04 to 2.12; p = 0.03). A total of 261 (30%) were readmitted for non-hip-related conditions. Low vitamin D was associated with a higher risk of medical readmissions within 30 days (OR 1.64 (1.03 to 2.61); p = 0.036) and 12 weeks (OR 1.47 (95% CI 1.02 to 2.12); p = 0.039). There was a higher risk of a new hip fracture (OR 2.84 (95% CI 1.15 to 7.03) p = 0.024) in vitamin D-deficient patients. A total of 105 (12%) developed at least one orthopedic complication, with no correlation to baseline vitamin D. Among vitamin D-deficient patients, those receiving a single-dose of 100.000 IU cholecalciferol had fewer orthopedic complications (OR 0.32 (95% CI 0.11 to 0.97) p = 0.044) the first 30 days after surgery.

CONCLUSION

Low vitamin D at admission for hip fracture increased the risk of delirium, a new hip fracture, and medical readmissions, but not orthopedic complications. The role of vitamin D supplementation to prevent orthopedic complications requires further study.

Efficacy of Weekly Split versus Single Doses of Ergocalciferol on Serum 25-Hydroxyvitamin D among Patients on Continuous Ambulatory Peritoneal Dialysis: A Randomized Controlled Trial

Background

Vitamin D deficiency is a common problem among patients on continuous ambulatory peritoneal dialysis (CAPD). Vitamin D supplementation leads to reduced serum parathyroid hormone levels and improved cardiovascular markers. Different doses and time intervals of oral vitamin D supplementation may differ in each patient on dialysis. The study aimed to evaluate the efficacy of weekly split and single dose of ergocalciferol at 60,000 IU on serum 25-hydroxyvitamin D (25(OH)D) among patients on CAPD.

Methods

A randomized study was conducted among patients on CAPD with vitamin D deficiency or insufficiency (25(OH)D < 30 ng/mL). Patients were randomly assigned to two groups: the split dose group was given ergocalciferol 20,000 IU three times weekly and the single dose group was given ergocalciferol 60,000 IU once weekly for 8 weeks. Main outcomes measured serum 25(OH)D concentrations, serum calcium, serum phosphate, and intact parathyroid levels at 8 weeks after being enrolled.

Results

Of 128 screened patients, 50 met the criteria for eligibility and were randomized. At 8 weeks after treatment, mean serum 25(OH)D concentrations significantly increased from baseline 22.7 ± 5.9 to 29.5 ± 9.5 ng/mL (P=0.004) in the split dose group and 22.9 ± 5.3 to 31.2 ± 12.3 ng/mL (P=0.003) in the single dose group. No significant change was found in increase of serum 25(OH)D between the two groups (P=0.561). At the end of study, a similar proportion of patients in both groups reached the desirable serum concentration of 25(OH)D ≥ 30 ng/mL (60% in the single group vs. 40% in the split group, P=0.258). No significant cases of hypercalcemia, hyperphosphatemia, or serious adverse events occurred during the study.

Conclusion

Weekly single and split doses of ergocalciferol 60,000 IU achieved similar effects on serum 25(OH)D levels among patients on CAPD with vitamin D insufficiency or deficiency, suggesting that weekly single dose would be prescribed for adequate vitamin D repletion. This trial is registered with TCTR20200821005.

Effect of a Single High Dose of Vitamin D3 on Hospital Length of Stay in Patients With Moderate to Severe COVID-19: A Randomized Clinical Trial

IMPORTANCE

The efficacy of vitamin D3 supplementation in coronavirus disease 2019 (COVID-19) remains unclear.

OBJECTIVE

To investigate the effect of a single high dose of vitamin D3 on hospital length of stay in patients with COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This was a multicenter, double-blind, randomized, placebo-controlled trial conducted in 2 sites in Sao Paulo, Brazil. The study included 240 hospitalized patients with COVID-19 who were moderately to severely ill at the time of enrollment from June 2, 2020, to August 27, 2020. The final follow-up was on October 7, 2020.

INTERVENTIONS

Patients were randomly assigned to receive a single oral dose of 200 000 IU of vitamin D3 (n = 120) or placebo (n = 120).

MAIN OUTCOMES AND MEASURES

The primary outcome was length of stay, defined as the time from the date of randomization to hospital discharge. Prespecified secondary outcomes included mortality during hospitalization; the number of patients admitted to the intensive care unit; the number of patients who required mechanical ventilation and the duration of mechanical ventilation; and serum levels of 25-hydroxyvitamin D, total calcium, creatinine, and C-reactive protein.

RESULTS

Of 240 randomized patients, 237 were included in the primary analysis (mean [SD] age, 56.2 [14.4] years; 104 [43.9%] women; mean [SD] baseline 25-hydroxyvitamin D level, 20.9 [9.2] ng/mL). Median (interquartile range) length of stay was not significantly different between the vitamin D3 (7.0 [4.0-10.0] days) and placebo groups (7.0 [5.0-13.0] days) (log-rank P = .59; unadjusted hazard ratio for hospital discharge, 1.07 [95% CI, 0.82-1.39]; P = .62). The difference between the vitamin D3 group and the placebo group was not significant for in-hospital mortality (7.6% vs 5.1%; difference, 2.5% [95% CI, -4.1% to 9.2%]; P = .43), admission to the intensive care unit (16.0% vs 21.2%; difference, -5.2% [95% CI, -15.1% to 4.7%]; P = .30), or need for mechanical ventilation (7.6% vs 14.4%; difference, -6.8% [95% CI, -15.1% to 1.2%]; P = .09). Mean serum levels of 25-hydroxyvitamin D significantly increased after a single dose of vitamin D3 vs placebo (44.4 ng/mL vs 19.8 ng/mL; difference, 24.1 ng/mL [95% CI, 19.5-28.7]; P < .001). There were no adverse events, but an episode of vomiting was associated with the intervention.

CONCLUSIONS AND RELEVANCE

Among hospitalized patients with COVID-19, a single high dose of vitamin D3, compared with placebo, did not significantly reduce hospital length of stay. The findings do not support the use of a high dose of vitamin D3 for treatment of moderate to severe COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04449718.

Benefits of vitamin D supplementation to attenuate TBI secondary injury?

Vitamin D supplementation has been shown to improve outcomes for patients suffering from a variety of illnesses such as stroke and cancer. Vitamin D deficiencies have been associated with longer hospital stays, greater severity of symptoms, and death in some complex cases. Due to vitamin D’s burgeoning role in improving patient outcomes, a new sector of research is focusing on the lesser-known implications of vitamin D on health. Traumatic brain injury (TBI) affects approximately 69 million people worldwide per year. Here, we summarize the current scientific understanding of vitamin D dynamics with TBI to elucidate a potential way to lessen the cascade of secondary damage after an initial insult, with the goal of improving overall patient outcomes. Because vitamin D supplementation has been correlated with better outcomes in other pathologies involving immune and inflammatory molecules, it is important to study the potential effect of vitamin D deficiency (VDD) and supplementation on TBI outcomes. Research on vitamin D supplementation in TBI remains in the preliminary stages. There is still much to learn about vitamin D deficiency, dosage, variants of supplementary forms, mechanisms, and its role in TBI.

Vitamin D for prevention of sternotomy healing complications: REINFORCE-D trial

Background

Most cardiac surgery patients undergo median sternotomy during open heart surgery. Sternotomy healing is an arduous, very complex, and multifactorial process dependent on many independent factors affecting the sternum and the surrounding soft tissues. Complication rates for median sternotomy range from 0.5 to 5%; however, mortality rates from complications are very variable at 7–80%. Low calcidiol concentration below 80 nmol/L results in calcium absorptive impairment and carries a risk of bone loss, which is considered as a risk factor in the sternotomy healing process. The primary objective of this clinical trial is to compare the incidence of all postoperative sternotomy healing complications in two parallel patient groups administered cholecalciferol or placebo. The secondary objectives are focused on general patient recovery process: sternal bone healing grade at the end of the trial, length of hospitalization, number of days spent in the ICU, number of days spent on mechanical lung ventilation, and number of hospital readmissions for sternotomy complications.

Methods

This clinical trial is conducted as monocentric, randomized, double-blind, placebo-controlled, with planned enrollment of 600 patients over 4 years, approximately 300 in the placebo arm and 300 in the treatment arm. Males and females from 18 to 95 years of age who fulfill the indication criteria for undergoing cardiac surgery with median sternotomy can be included in this clinical trial, if they meet the eligibility criteria.

Discussion

REINFORCE-D is the first monocentric trial dividing patients into groups based on serum calcidiol levels, and with dosing based on serum calcidiol levels. This trial may help to open up a wider range of postoperative healing issues.

Trial registration

EU Clinical Trials Register, EUDRA CT No: 2016-002606-39. Registered on September 8, 2016.

Short term, high-dose vitamin D supplementation for COVID-19 disease: a randomised, placebo-controlled, study (SHADE study)

BACKGROUND

Vitamin D has an immunomodulatory role but the effect of therapeutic vitamin D supplementation in SARS-CoV-2 infection is not known.

AIM

Effect of high dose, oral cholecalciferol supplementation on SARS-CoV-2 viral clearance.

DESIGN

Randomised, placebo-controlled.

PARTICIPANTS

Asymptomatic or mildly symptomatic SARS-CoV-2 RNA positive vitamin D deficient (25(OH)D<20 ng/ml) individuals.

INTERVENTION

Participants were randomised to receive daily 60 000 IU of cholecalciferol (oral nano-liquid droplets) for 7 days with therapeutic target 25(OH)D>50 ng/ml (intervention group) or placebo (control group). Patients requiring invasive ventilation or with significant comorbidities were excluded. 25(OH)D levels were assessed at day 7, and cholecalciferol supplementation was continued for those with 25(OH)D <50 ng/ml in the intervention arm. SARS-CoV-2 RNA and inflammatory markers fibrinogen, D-dimer, procalcitonin and (CRP), ferritin were measured periodically.

OUTCOME MEASURE

Proportion of patients with SARS-CoV-2 RNA negative before day-21 and change in inflammatory markers.

RESULTS

Forty SARS-CoV-2 RNA positive individuals were randomised to intervention (n=16) or control (n=24) group. Baseline serum 25(OH)D was 8.6 (7.1 to 13.1) and 9.54 (8.1 to 12.5) ng/ml (p=0.730), in the intervention and control group, respectively. 10 out of 16 patients could achieve 25(OH)D>50 ng/ml by day-7 and another two by day-14 [day-14 25(OH)D levels 51.7 (48.9 to 59.5) ng/ml and 15.2 (12.7 to 19.5) ng/ml (p<0.001) in intervention and control group, respectively]. 10 (62.5%) participants in the intervention group and 5 (20.8%) participants in the control arm (p<0.018) became SARS-CoV-2 RNA negative. Fibrinogen levels significantly decreased with cholecalciferol supplementation (intergroup difference 0.70 ng/ml; P=0.007) unlike other inflammatory biomarkers.

CONCLUSION

Greater proportion of vitamin D-deficient individuals with SARS-CoV-2 infection turned SARS-CoV-2 RNA negative with a significant decrease in fibrinogen on high-dose cholecalciferol supplementation.

TRIAL REGISTER NUMBER

NCT04459247.

Hypocalcemic Seizure Due to Vitamin D Deficiency

Aim

To emphasize the importance of vitamin D supplementation.

Background

The incidence of vitamin D deficiency has been increasing worldwide, probably due to decreased exposure to sunlight and unbalanced diet. Severe hypocalcemia following vitamin D deficiency is rather uncommon, and this leading to seizures in adults is a rare scenario.

Case description

This is the case of a 70-year-old female, a known case of coronary artery disease, who presented with one episode of seizure. Computed tomography of her brain revealed diffuse age-related atrophic changes, and electroencephalogram showed diffuse cerebral dysfunction. She was found to have severe hypocalcemia with secondary hyperparathyroidism due to vitamin D deficiency. Vitamin D bolus was given along with calcium correction, following which she improved.

Conclusion

There are a few reports of hypocalcemic seizures among children; however, the incidence is rare among adults. Calcium and vitamin D supplementation forms the mainstay of treatment.

Clinical significance

Hypocalcemic seizure is uncommon, especially among adults. Vitamin D deficiency resulting in hypocalcemic seizure, to the best of our knowledge, is an unreported scenario. This case highlights the importance of vitamin D supplementation in those with reduced sunlight exposure.

How to cite this article

Manappallil RG, Krishnan R, Veetil PP, Nambiar H, Karadan U, Anil R, et al. Hypocalcemic Seizure Due to Vitamin D Deficiency. Indian J Crit Care Med 2020;24(9):882-884.

Vitamin D high doses supplementation could represent a promising alternative to prevent or treat COVID-19 infection

Although we lack enough evidence to justify supplementing with vitamin D in the prevention and treatment of COVID-19 infection, it is increasingly feasible that this hypothesis is valid. Two general underlying mechanisms should be considered. One would be the anti-infectious and immunomodulatory action that it exerts by improving intercellular barriers by stimulating innate immunity, as well as by modulating adaptive immunity. Also, vitamin D reduces the production of inflammatory cytokines, such as IL-2 and interferon-gamma (INFγ). More recently, multiple pleiotropic effects have been demonstrated on the actions of vitamin D at the anti-inflammatory and immunomodulatory level with positive results in studies with influenza, coronavirus, and other respiratory infections. An inverse relationship between serum vitamin D levels and the prevalence of the respiratory infectious disease has been described. Of interest, another mechanistic approach responds to considering the inhibition of the renin-angiotensin-aldosterone system (RAAS), which is exacerbated in COVID-19 infection because the virus binds to the enzyme ACE2, making more angiotensin II available to cause damage. Vitamin D inhibits mediators of RAAS – present in all cells of the body – and by inhibiting ACE activity and increasing ACE2, it lowers angiotensin II levels. We present studies with proposals for recommended doses of vitamin D, and although a single guideline is not specified, the possible benefits are promising. Finally, the purpose of this review is to share this idea with health professionals to ignite the debate and call for critical reflection, so that it can contribute to the undertaking of more and better clinical designs to validate the benefits of using high doses of vitamin D for the benefit of public health and especially in times of crisis for COVID-19.

Vitamin D supplementation as a rational pharmacological approach in the COVID-19 pandemic

The COVID-19 pandemic has reached most of the countries worldwide causing death, which often results from an inflammatory storm associated with severe acute respiratory syndrome (SARS). This has prompted researchers to seek specific novel and definitive treatments urgently. In this context, it is interesting to evaluate the preventive and therapeutic effects of existing pharmacological agents that could be useful. In this regard, vitamin D supplementation, particularly in individuals likely to be deficient, may be a promising option. Vitamin D is a hormone that modulates many of the same inflammatory and oxidative signaling pathways triggered during COVID-19. For example, vitamin D suppresses the actions of the renin-angiotensin system, which has a determining role in the pathophysiology of the inflammatory response related to COVID-19. This paper analyzes the evidence that vitamin D supplementation might be a valuable preventive/therapeutic measure in groups at risk for or infected with COVID-19. It also discusses how clinical studies could be best designed to evaluate the possible advantages of vitamin D supplementation for the benefit of public health during the pandemic.

Vitamin D supplementation and the outcomes of critically ill adult patients: a systematic review and meta-analysis of randomized controlled trials

This meta-analysis assessed the association between vitamin D supplementation and the outcomes of critically ill adult patients. A literature search was conducted using the PubMed, Web of Science, EBSCO, Cochrane Library, Ovid MEDLINE, and Embase databases until March 21, 2020. We only included randomized controlled trials (RCTs) comparing the efficacy of vitamin D supplementation with placebo in critically ill adult patients. The primary outcome was their 28-day mortality. Overall, 9 RCTs with 1867 patients were included. In the pooled analysis of the 9 RCTs, no significant difference was observed in 28-day mortality between the vitamin D supplementation and placebo groups (20.4% vs 21.7%, OR, 0.73; 95% CI, 0.46–1.15; I² = 51%). This result did not change as per the method of vitamin D supplementation (enteral route only: 19.9% vs 18.2%, OR, 1.19; 95% CI, 0.88–1.57; I² = 10%; intramuscular or intravenous injection route: 25.6% vs 40.8%, OR, 0.48; 95% CI, 0.21–1.06; I² = 19%) or daily dose (high dose: 20.9% vs 19.8%, OR, 0.83; 95% CI, 0.51–1.36; I² = 53%; low dose: 15.6% vs 21.3%, OR, 0.74; 95% CI, 0.32–1.68; I² = 0%). No significant difference was observed between the vitamin D supplementation and placebo groups regarding the length of ICU stay (standard mean difference [SMD], − 0.30; 95% CI, − 0.61 to 0.01; I² = 60%), length of hospital stay (SMD, − 0.17; 95% CI, − 041 to 0.08; I² = 65%), and duration of mechanical ventilation (SMD, − 0.41; 95% CI, − 081 to 0.00; I² = 72%). In conclusion, this meta-analysis suggested that the administration of vitamin D did not provide additional advantages over placebo for critically ill patients. However, additional studies are needed to confirm our findings.

Effect of Vitamin D Treatment on Dynamics of Stones Formation in the Urinary Tract and Bone Density in Children with Idiopathic Hypercalciuria

Vitamin D supplementation in patients with urolithiasis and hypercalciuria is considered to be unsafe. We analyzed the impact of vitamin D supplementation on selected health status parameters in children with idiopathic hypercalciuria. The study included 36 children with urolithiasis resulting from excessive calcium excretion. The level of calcium and 25(OH)D (hydroxylated vitamin D - calcidiol) in serum, urinary calcium excretion and the presence of stones in urinary tract were assessed prospectively. Blood and urine samples were collected at the time when the patient was qualified for the study and every three months up to 24 month of vitamin D intake at a dose of 400 or 800 IU/day. At time zero and at 12, and 24 months of vitamin D supplementation, densitometry was performed. Supplementation with vitamin D caused a statistically significant increase in the concentration of 25(OH)D in serum. There were no significant changes in calcium concentration in serum, excretion of calcium in urine but also in bone density. There was no significant increase in the risk of formation or development of stones in the urinary tract. Supplementation with vitamin D (400–800 IU/day) in children with idiopathic hypercalciuria significantly increases 25(OH)D concentration, does not affect calciuria, but also does not improve bone density.

Impact of sleeve gastrectomy on hip structural analysis in adolescents and young adults with obesity

BACKGROUND

Sleeve gastrectomy (SG), the most commonly performed metabolic and bariatric surgery, is associated with reductions in areal bone mineral density at multiple sites, and changes in bone structure at the distal radius and tibia without reductions in strength estimates at these peripheral sites. Data are lacking regarding effects on hip strength estimates.

OBJECTIVE

To evaluate effects of SG on measures of hip structural analysis in adolescents and young adults over 12 months using dual-energy x-ray absorptiometry.

SETTINGS

Translational and Clinical Research Center.

METHODS

We enrolled 48 youth 14- to 22-years old with moderate-to-severe obesity; 24 underwent SG and 24 controls were followed without surgery (18 females, 6 males in each group). Hip structure was assessed using dual-energy x-ray absorptiometry at baseline and 12 months. Analyses are adjusted for age, sex, race, and the baseline bone measure.

RESULTS

The SG group lost 25.9% weight versus .3% in controls. Compared with controls, SG had reductions in narrow neck, intertrochanteric and femoral shaft bone mineral density Z-scores (P ≤ .012). Furthermore, SG had greater reductions in narrow neck and intertrochanteric region (but not femoral shaft) cross-sectional area, cortical thickness, cross-sectional moment of inertia and section modulus, and increases in buckling ratio (P ≤ .039). Differences were attenuated after adjusting for 12-month body mass index change. At 12 months, differences were minimal after adjusting for age, sex, race, and weight.

CONCLUSIONS

Over 12 months, SG had negative effects at the narrow neck and intertrochanteric regions of the hip, but not the femoral shaft. Reduced body mass index may compensate for these deleterious effects on bone.

The effects of 1,25-dihydroxyvitamin D3 on markers related to the differentiation and maturation of bone marrow-derived dendritic cells from control and obese mice

Vitamin D has been reported to regulate the maturation and function of dendritic cells (DCs). Obesity was shown to be associated with the dysregulation of vitamin D metabolism and malfunction of DCs. We investigated the effects of in vitro 1,25(OH)₂D₃ treatment (0, 1, or 10 nM) on phenotype and expression of genes related to function of bone marrow-derived DCs (BMDCs) from control and obese mice. C57BL/6 N mice were fed a control or high-fat (10% or 45% kcal fat: CON or HFD) diets for 15 weeks. Differentiation toward DCs was induced with GM-CSF (20 ng/ml) and maturation was induced by LPS (50 ng/ml); 10 nM 1,25(OH)₂D₃ treatment inhibited BMDC differentiation (CD11c⁺) and decreased the percentage of mature DCs (MHCII^highCD11c⁺ and CD86^highCD11c⁺) in both CON and HFD groups. The Il10 expression in stimulated BMDCs from the CON group increased with the 10 nM 1,25(OH)₂D₃ treatment, but not in those from the HFD group. The Il12b mRNA levels in stimulated BMDCs were lower in the HFD group than in the CON group. In conclusion, lower levels of Cd 40, Cd83 and Il12 mRNA in LPS-stimulated BMDCs from obese mice suggest malfunction of DCs as antigen presenting cells. 1,25(OH)₂D₃ treatment inhibited the differentiation and maturation of BMDCs in both control and obese mice. Differential effects of 1,25(OH)₂D₃ on the expression of Il10 between control and obese mice suggest that regulation of immune response by vitamin D could be influenced by obesity.

Vitamin D high doses supplementation could represent a promising alternative to prevent or treat COVID-19 infection

Si bien carecemos de suficiente evidencia que justifique suplementar con vitamina D en la prevención y/o tratamiento de la infección por COVID-19, a la fecha resulta cada vez más factible que esta hipótesis sea válida. Dos mecanismos básicos generales deberían ser considerados. Uno sería la acción antiinfecciosa e inmunomoduladora que ejerce mejorando las barreras intercelulares por estímulo de la inmunidad innata, así también por modulación de la inmunidad adaptativa. También, la vitamina D reduce la producción de citoquinas inflamatorias como IL-2 e interferón gamma (INF-γ). Más recientemente se han demostrado múltiples efectos pleiotrópicos sobre las acciones de la vitamina D a nivel antiinflamatorio e inmunomodulador. Esto explica resultados positivos en estudios con influenza, coronavirus y otras infecciones respiratorias. Se ha descrito relación inversa entre niveles séricos de vitamina D y prevalencia de patología infecciosa respiratoria. De interés, otro abordaje mecanístico responde a considerar la inhibición del sistema renina-angiotensina-aldosterona, que se exacerba en la infección por COVID-19 debido a que el virus se une a la enzima ECA2, quedando disponible más angiotensina II para causar daño. La vitamina D inhibe mediadores del SRAA —presente en todas las células del organismo—, y al inhibir la actividad ECA y aumentar la ECA2, disminuye los niveles de angiotensina II. Presentamos estudios con propuestas de dosis recomendadas de vitamina D, y aunque no quede concretada una única guía, los posibles beneficios son promisorios. Finalmente, el propósito de la presente revisión es compartir esta idea con profesionales de la salud para encender el debate y llamar a la reflexión crítica, de modo tal que se pueda contribuir con el emprendimiento de diseños clínicos adecuados para validar los beneficios de utilizar altas dosis de vitamina D en beneficio de la salud pública, sobre todo en tiempos de esta emergencia por COVID-19.

Bone outcomes following sleeve gastrectomy in adolescents and young adults with obesity versus non-surgical controls

BACKGROUND

Sleeve gastrectomy is the most commonly performed weight loss surgery in adolescents with moderate-to-severe obesity. While studies in adults have reported on the deleterious effects of gastric bypass surgery on bone structure and strength estimates, data are lacking for the impact of sleeve gastrectomy on these measures in adolescents.

OBJECTIVE

To evaluate the impact of sleeve gastrectomy on bone outcomes in adolescents and young adults over 12 months using dual energy X-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HRpQCT).

PARTICIPANTS AND METHODS

We enrolled 44 youth 14-22 years old with moderate to severe obesity; 22 underwent sleeve gastrectomy and 22 were followed without surgery (16 females and 6 males in each group). At baseline and 12 months, DXA was used to assess areal bone mineral density (aBMD), HRpQCT of the distal radius and tibia was performed to assess bone geometry, microarchitecture and volumetric BMD (vBMD), and finite element analysis to assess strength estimates (stiffness and failure load). These analyses were adjusted for age, sex, race and the bone measure at baseline. Fasting blood samples were assessed for calcium, phosphorus, and 25(OH) vitamin D (25OHD) levels.

RESULTS

Over 12-months, the surgical group lost 27.2% of body weight compared to 0.1% in the non-surgical (control) group. Groups did not differ for changes in 25OHD levels (p = 0.186). Compared to controls, the surgical group had reductions in femoral neck and total hip aBMD Z-scores (p ≤ 0.0006). At the distal tibia, compared to controls, the surgical group had reductions in cortical area and thickness and trabecular number, and increases in trabecular area and separation (p ≤ 0.026). At the distal radius, the surgical group had greater reductions in trabecular vBMD, than controls (p = 0.010). The surgical group had an increase in cortical vBMD at both sites (p ≤ 0.040), possibly from a decrease in cortical porosity (p ≤ 0.024). Most, but not all, differences were attenuated after adjusting for 12-month change in BMI. Groups did not differ for changes in strength estimates over time, except that increases in tibial stiffness were lower in the surgical group (p = 0.044) after adjusting for 12-month change in BMI.

CONCLUSIONS

Over 12 months, weight loss associated with sleeve gastrectomy in adolescents had negative effects on areal BMD and certain HRpQCT parameters. However, bone strength estimates remained stable, possibly because of a simultaneous decrease in cortical porosity and increase in cortical volumetric BMD. Additional research is necessary to determine the relative contribution(s) of weight loss and the metabolic effects of surgery on bone outcomes, and whether the observed effects on bone stabilize or progress over time.