Vitamin D in pregnant women from extreme areas of latitude: review from midwifery / Vitamina D en gestantes en zonas extremas: revisión desde la matronería

Insufficient vitamin D levels occur in 88.1% of the worlds population, which constitutes a global public health problem. We analyzed vitamin D deficiency and suggested vitamin D supplementation in the perinatal health of pregnant women living in geographical areas higher than 40° south-north latitude according to reviews from the last three decades and identifying midwives role. The methodology used was a qualitative systematic review of full text studies, conducted in geographical areas higher than 40°N and 40°S. Descriptors such as: "deficiency", "vitamin D", "pregnancy", "causes", "perinatal outcomes" and "supplementation", and their respective descriptors in Spanish. The matrices were tabulated according to the modified PRISMA. Eight studies were obtained in English from the Northern Hemisphere only, mostly with good quality evidence and related to the role of midwifing according to the expert round. The results showed risks such as: origin of the pregnant woman, ethnicity, low sun exposure, obesity, socioeconomic status, and perinatal risks. No studies were found in pregnant women from the Southern Hemisphere or related to the role of the midwife in this area. In conclusion, midwifery should considerer the social determinants of vitamin D deficiency in pregnant women, especially those in extreme southern areas where incorporation of supplementation are suggested as a public policy.

Los niveles insuficientes de vitamina D se dan en el 88,1% de la población mundial, lo que constituye un problema de salud pública global. Se analizó la deficiencia y la sugerencia de suplementación de vitamina D en la salud perinatal de las gestantes residentes en áreas geográficas de latitud 40° sur-norte según revisiones de las últimas tres décadas identificando el rol de la matrona. La metodología utilizada fue una revisión sistemática cualitativa de estudios a texto completo, realizados en áreas geográficas mayores al paralelo 40°N y 40°S. Descriptores como: "deficiencia", "vitamina D", "embarazo", "causas", "resultados perinatales" y "suplementación", y sus respectivos descriptores en español. Las matrices se tabularon según el PRISMA modificado. Se obtuvo ocho estudios en inglés pertenecientes sólo al hemisferio norte, la mayoría con buena calidad de evidencia. Los resultados arrojaron factores como origen de la embarazada, etnia, baja exposición al sol, obesidad, nivel socioeconómico y riesgos perinatales. No se encontraron estudios en mujeres embarazadas del hemisferio sur o relacionados con el papel de la matrona. En conclusión, desde el ejercicio de la matronería se deben considerar los determinantes sociales de las mujeres embarazadas especialmente de zonas extremas del sur donde se sugiere investigación experimental e incorporación de la suplementación como política pública.

Prevalence and risk factors associated with different comorbidities in obese children and adolescents.

INTRODUCTION: Different obesity-related comorbidities already present in childhood, such as: vitamin D deficiency, impaired carbohydrate metabolism, dyslipidaemia, arterial hypertension and non-alcoholic steatohepatitis. In this study, we aim to analyse the prevalence of comorbidities and to determine the predictive factors that affect these comorbidities. MATERIAL AND METHODS: Anthropometric, demographic and biochemical variables were collected from obese patients between six and 18 years of age. Subsequently, a statistical analysis was performed to describe the characteristics of the patients and the prevalence of comorbidities, as well as their predictive factors. RESULTS: A total of 158 obese children (76 boys and 82 girls) with a mean age at diagnosis of 12.48 years and a BMI Z-score of +3.24 SDS were included. The most prevalent comorbidities were vitamin D deficiency (64.2%), insulin resistance (45.1%), dyslipidaemia (32.2%), hyperuricaemia (18.5%) and arterial hypertension (15%). Age, BMI Z-score, percentage of fat mass and male sex have been found to be predictors of these comorbidities. CONCLUSION: Obese children and adolescents have a high prevalence of comorbidities. Once the diagnosis of obesity has been established, it would be very useful to identify early those patients with a higher risk of comorbidities, knowing their relationship with sex, age, BMI Z-score, percentage of fat mass and pubertal stage.

Patología sistémica múltiple en la consulta dental. A propósito de un caso ¿especial? / Multiple sistemic pathology in the dental clinic, a special case?

Introducción: La esperanza de vida en España es de las más altas del mundo. Este aumento en la esperanza de vida va unido a una mayor prevalencia de pacientes con pluripatología y polimedicación. Por lo tanto, la probabilidad de encontrar un paciente con múltiple afectación sistémica y gran carga farmacológica ha aumentado, de tal manera que lo especial se convierte en habitual. Caso clínico: Se presenta el caso clínico de una paciente con hipertensión, diabetes tipo II, hipotiroidismo, depresión, obesidad y déficit de vitamina D. Se hace una revisión de la actuación del odontólogo en la clínica cuando se presentan pacientes con dichos cuadros y las consideraciones a tener en cuenta con respecto a la prescripción y administración de medicación. El objetivo es presentar recomendaciones de tratamiento a partir de un caso clínico de una paciente con varias afecciones sistémicas en la que se realiza un tratamiento multidisciplinar. Para eso se ha realizado una revisión narrativa que se considera útil para la actividad clínica diaria. Conclusiones: Los pacientes con pluripatologías y con polimedicación no deben suponer un problema en la clínica dental. Sus patologías sistémicas suelen estar interrelacionadas y relacionadas con su patología oral por lo que mejoras esta contribuye a controlar mejor las otras. Deberíamos cuestionarnos a qué nos referimos cuando utilizamos el término “paciente especial”, ¿existe algún paciente que no sea especial? (AU)

Introduction: Life expectancy in Spain is one of the highest in the world. This increase in life expectancy is linked to a higher prevalence of patients with multiple pathologies and polypharmacy. Therefore, the probability of finding a patient with multiple systemic involvement and a high drug burden has increased, in such a way that the special becomes common. Clinical case: The clinical case of a patient with hypertension, type II diabetes, hypothyroidism, depression, obesity and vit D deficiency is presented. A review is made of the performance of the dentist in the clinic when patients with these conditions appear and the considerations to take into account with respect to the prescription and administration of medication. The objective is to present treatment recommendations based on a clinical case of a patient with several systemic conditions in which a multidisciplinary treatment is carried out. For this, a narrative review has been carried out that is considered useful for daily clinical activity. Conclusions: patients with multiple pathologies and polymedication should not pose a problem in the dental clinic. Their systemic pathologies are usually interrelated and related to their oral pathology, so improvements in this one contribute to better control the others. We should ask ourselves what we mean when we use the term “special patient”, is there a patient who is not special? (AU)

Interaction between age and vitamin D deficiency in severe COVID-19 infection.

INTRODUCTION: Background: coronavirus disease 2019 (COVID-19) can induce an exaggerated inflammatory response. Vitamin D is a key modulator of the immune system. We hypothesized that vitamin D deficiency (VDD) could increase the risk of developing severe COVID-19 infection. Methods: patients with confirmed COVID-19 seen at the emergency department of our hospital with recent measurements of 25(OH)D were recruited. We explored the association of vitamin D deficiency (VDD), defined as 25-hydroxyvitamin D < 20 ng/mL, with a composite of adverse clinical outcomes. Results: we included 80 patients, of which 31 (39 %) presented the endpoint. VDD tended to predict an increased risk of developing severe COVID-19 after adjusting for age, gender, obesity, cardiac disease, and kidney disease [OR 3.2 (95 % CI: 0.9-11.4), p = 0.07]. Age had a negative interaction with the effect of VDD on the composite outcome (p = 0.03), indicating that the effect was more noticeable at younger ages. Furthermore, male gender was associated with VDD and with severe COVID-19 at younger ages. Conclusions: in this retrospective study, vitamin D deficiency showed a signal of association with severe COVID-19 infection. A significant interaction with age was noted, suggesting VDD may have a greater impact in younger patients. These findings should be confirmed in larger, prospective, adequately powered studies.

INTRODUCCIÓN: Antecedentes: la enfermedad por coronavirus 2019 (COVID-19) puede inducir una respuesta inflamatoria exagerada. La vitamina D es un modulador clave del sistema inmune. Planteamos que la deficiencia de vitamina D (VDD) podría aumentar el riesgo de desarrollar infección grave por COVID-19. Métodos: se reclutaron pacientes consecutivos que acudieron al servicio de urgencias de nuestro centro con diagnóstico de COVID-19 confirmado (PCR-COVID-19 positiva) y mediciones recientes de 25(OH)D. Exploramos la asociación de la deficiencia de vitamina D (VDD), definida como una 25-hidroxivitamina D < 20 ng/ml, con un compuesto de resultados clínicos adversos. Resultados: se incluyeron 80 pacientes, de los cuales 31 (39 %) presentaron el criterio de valoración primario. El VDD tendió a predecir un mayor riesgo de desarrollar COVID-19 grave después de ajustar edad, sexo, obesidad, enfermedad cardíaca y enfermedad renal [OR: 3,2 (IC 95 %: 0,9-11,4), p = 0,07]. La edad tuvo una interacción negativa con el efecto de la VDD en el resultado compuesto (p = 0,03), lo que indica que el efecto fue más notable a edades más tempranas. Además, el género masculino se asoció con la VDD y con la COVID-19 grave en las edades más jóvenes. Conclusiones: en este estudio retrospectivo, la deficiencia de vitamina D mostró una tendencia de asociación con la infección grave por COVID-19. Se observó una interacción significativa con la edad, lo que sugiere que la VDD puede tener un mayor impacto en los pacientes más jóvenes. Estos hallazgos deben confirmarse en estudios más grandes, prospectivos y con potencia adecuada.

Niveles de vitamina D en pacientes asistidos en Centros de Salud Pública de la provincia de La Pampa (Argentina)

RESUMEN El objetivo fue evaluar el estatus de vitamina D (VD) en relación con la estación del año en pacientes asistidos en Centros de Salud Pública de la provincia de La Pampa mediante un estudio retrospectivo al período 01/01/17-31/12/17. Se determinó la concentración de VD por Quimioluminiscencia en 1333 pacientes, (1148 mujeres y 185 hombres) entre 18-94 años de edad. Se clasificó la concentración de VD en Deficiencia (<20 ng/ml); Insuficiencia (20-29 ng/ml) y Suficiencia (>30 ng/ml) de acuerdo a los criterios de Endocrine Society y guías de FASEN) y se lo relacionó con estación del año, género, edad y Zona Sanitaria. Se empleó un programa estadístico InfoStat versión 2017 considerando relación estadística significativa p<0.05. El 79% de los pedidos provinieron de Centros de Atención Primaria de la Salud y 21% de especialistas. Del 43.8 a 62.5% del género femenino y 36 a 63.6% del Masculino presentaban Deficiencia de VD en las Zonas Sanitarias. Se encontró diferencia significativa en la concentración de VD entre las estaciones climáticas (ANOVA Masculino FC: 9.80; Femenino FC: 31.81, ambos p<0.0001). Se observó menor concentración de VD en ambos géneros en invierno-primavera (43.8 a 62.5 % de las mujeres y 36 a 63.6% de los hombres). No hubo diferencia significativa en la Deficiencia de VD entre grupos de edad y género. Se encontró que un mayor número de pacientes del género femenino menores de 65 años tenían valores menores de 20 ng/ml de VD en invierno y primavera (p< 0.01). No hubo diferencia significativa en las de mayor edad. El médico de atención primaria es el principal prescriptor de VD en centros Asistenciales de Salud Pública de la provincia. Es necesario determinar los criterios de solicitud para disminuir el elevado retesteo debido al impacto socioeconómico que genera al sistema público.

ABSTRACT We set out to evalúate the state ofVitamin D (VD) in our context (La Pampa, Argentina) to determine the link between its deficit and the season of the year. A Retrospective study corresponding to the period of 01/01/17 to 12/31/17 was developed. The concentration of VD by Chemiluminescent Immunoassay was determined in the Central Laboratory of the Dr. Lucio Molas Hospital, Santa Rosa, La Pampa, Argentina in 1333 patients (1148 female and 185 male) between 18-94 years old. The vitamin D value was classified as deficiency less than 20 ng/ml, insufficiency between 20 and 29 ng/ml and Sufficiency >30 ng/ml (Endocrinology Society of the USA. Variables studied: gender, age, place of residence, medical speciality/Service or Primary Health Care Centers that requested VD's dosing; date of the year in which it was made. We used a program called InfoStat version 2017 considering a statistically significant relationship at p <0.05. The 79% of the orders came from Health Primary Attention Centers and 21% where from specialists. 43.8% to 62.5% women and 36% to 63.6% men had Vitamin D deficiency. There was no statistically difference in Vitamin D between groups of age and gender. Differences between seasons were found (ANOVA Male FC: 9.80; Female FC: 31.81, p<0.0001). There was a less concentration of Vitamin D in both genders in Winter-Spring. We found that 37% to 60% of male and female had defficiency of VD in Winter-Spring. Primary Health Care Physician is the main prescriptor of VD in Public Health Care Centers of La Pampa. It is necessary to determine the criteria to request. Vitamin D, to diminish the high socio-economic impact that carries to the Public Health System.

[Vitamin D deficiency and morbimortality in critically ill paediatric patients]. / Déficit de vitamina D y morbimortalidad en pacientes críticos pediátricos.

OBJECTIVES: To determine the prevalence and risks factors of vitamin D deficiency, as well as its relationship with morbidity and mortality in a PICU. MATERIAL AND METHODS: An observational prospective study in a tertiary children's University Hospital PICU conducted in two phases: i: cohorts study, and ii: prevalence study. The study included 340 critically ill children with ages comprising 6 months to 16 years old. EXCLUSION CRITERIA: Chronic kidney disease, known parathyroid disorders, and vitamin D supplementation. Total 25-hydroxyvitamin D [25(OH)D] was measured in the first 48hours of admission to a PICU. Parathormone, calcium, phosphate, blood gases, blood count, C-reactive protein, and procalcitonin were also analysed. A record was also made of demographic features, characteristics of the episode, and complications during the PICU stay. RESULTS: The overall prevalence rate of vitamin D deficiency was 43.8%, with a mean of 22.28 (95% CI 21.15-23.41) ng/ml. Patients with vitamin D deficiency were older (61 vs 47 months, P=.039), had parents with a higher level of academic studies (36.5% vs 20%, P=.016), were admitted more often in winter and spring, had a higher PRISM-III (6.8 vs 5.1, P=.037), a longer PICU stay (3 vs 2 days, P=.001), and higher morbidity (61.1% vs 30.4%, P<001) than the patients with sufficient levels of 25(OH)D. Patients who died had lower levels of 25(OH)D (14±8.81ng/ml versus 22.53±10.53ng/ml, P=.012). Adjusted OR for morbidity was 5.44 (95%CI; 2.5-11.6). CONCLUSIONS: Vitamin D deficiency is frequent in critically ill children, and it is related to both morbidity and mortality, although it remains unclear whether it is a causal relationship or it is simply a marker of severity in different clinical situations.

Valores de vitamina D en fracturas no consolidadas / Vitamin D levels in non-union fractures

Introducción: La falta de consolidacion de una fractura es, en general, un fenomeno multifactorial. El objetivo de este estudio fue estimar los valores de referencia de vitamina D (25OHD3) en fracturas que no consolidaron, estudiar su asociacion con la edad y su localizacion. Materiales y Métodos: Estudio prospectivo, de observacion y descriptivo en 29 pacientes con fracturas no consolidadas. Se determinaron las concentraciones sericas de vitamina D (25OHD3) junto con los estudios prequirurgicos. Se calcularon modelos generalizados para estimar los efectos de la edad y la localizacion, y detectar grupos de pacientes con niveles inferiores al valor recomendado. Resultados: El 68,9% de los pacientes tenia concentraciones sericas promedio de vitamina D inferiores al valor normal (30,0 ng/ml), que se asociaron inversamente con la edad, 40 anos fue el punto de corte a partir del cual otras caracteristicas, como la localizacion de la fractura (en huesos que afectan a los miembros inferiores), condicionan conjuntamente la falta de consolidacion. Conclusiones: La mayoria de los pacientes cuya fractura no consolido tenia deficiencia de vitamina D y este fenomeno es marcado a partir de los 40 anos de edad. Es importante identificar a los pacientes con mayor riesgo de presentar este deficit en las primeras etapas del tratamiento de las fracturas, ya que el aporte de este micronutriente es un factor reconocido para disminuir el riesgo de falta de consolidacion. Nivel de Evidencia: IV

Introduction: Absence of bone union after a fracture is generally multifactorial phenomenon. The objective of this study was to determine reference vitamin D values (25OHD3) in non-unions, and to study their association with age and localization. Methods: A prospective, observational and descriptive study was performed to evaluate 29 patients with non-union fractures. Serum vitamin D levels (25OHD3) were determined together with standard preoperative studies. Generalized models were used to estimate the effects of age and location, as well as to detect the group of patients with vitamin D levels lower than recommended. Results: The 68.9% had serum levels of vitamin-D lower than the normal value (30 ng/mL), which was inversely associated with age, being the age of 40 the cutoff point from which other characteristics, such as location, conditioned simultaneously the non-union. Conclusions: Most patients with a non-union fracture had vitamin D deficiency, and this phenomenon was more evident in patients >40 years. Prompt identification of patients with increased risk of presenting this deficiency is important, as treatment could reduce the incidence of fractures that evolve into a non-union. Level of Evidence: IV

Vitamin D deficiency among healthy Egyptian females.

BACKGROUND: Vitamin D deficiency is becoming endemic in many parts of the world. AIM: To study vitamin D status in Egyptian females of different age groups. SUBJECTS AND METHODS: A cross-sectional study was conducted on 404 females, who were categorized into group 1 (51 nursing females); group 2 (50 pregnant females); group 3 (208 females of childbearing age); group 4 (38 elderly females); and group 5 (57 geriatric females). Females completed a questionnaire regarding dietary calcium and vitamin D intake, sun exposure, and clothing habits, and performed laboratory tests including calcium, PO4, alkaline phosphatase, intact PTH, and 25-OH vitamin D levels. RESULTS: Median and IQR of vitamin D levels across groups 1, 2, 3 and 5 were in the deficient range, being lowest in groups 3, 5, and 1, respectively. Vitamin D deficiency was found in 72.6% of the nursing group, 54% of the pregnant group, 72% of the childbearing age group, 39.5% of the elderly group, and 77.2% of the geriatric group. Vitamin D was significantly higher in non-veiled females [23ng/dl] as compared to veiled females [16.7ng/dl]. Vitamin D levels with poor, fair, and good sun exposure were 14.1, 14, and 37ng/dl, respectively. CONCLUSION: These results show a high prevalence of vitamin D deficiency among healthy Egyptian females.

[Plasma vitamin D levels in native and immigrant children under the age of 6 years of different ethnic origins]. / Niveles plasmáticos de vitamina D en población autóctona y en poblaciones inmigrantes de diferentes etnias menores de 6 años de edad.

INTRODUCTION: Nutritional rickets is an emergent disease in Spain, and occurs particularly in black and dark-skinned infants and children from immigrant populations. The aim of this work was to ascertain the vitamin D reserve in a population of native and immigrant children under the age of 6 years. POPULATION AND METHODS: A prospective study was conducted at a Primary Healthcare Centre in Salt (Girona). PATIENTS: 307 children with the following origin and race distribution: Caucasian (n=85; 28%), Sub-Saharan (n=101; 32.5%); Maghrebí (n=87, 28.0%); Central-American (n=20; 6.4%) and Indo-Pakistani (n=14; 4.5%). The biochemistry blood parameters studied were: calcium, phosphorus, alkaline phosphatase, 25-hydroxivitamin D, and parathormone. A nutritional survey was used to estimate calcium and vitamin D intake and degree of sun exposure. RESULTS: Vitamin D deficiency (<20 ng/ml) was detected in Caucasians (8%), Sub-Saharans (18%), Central-Americans (20%), Maghrebís (34.5%), and Indo-Pakistanis (64%). Of the children studied (n=9), 2.9% had serious vitamin D deficiency (< 10 ng/ml); only one child of Sub-Saharan origin met the biochemical criteria for classical rickets. The prevalence of vitamin D deficiency was significantly higher in children not receiving vitamin D supplements in the first year of life. CONCLUSIONS: Plasma vitamin D concentrations were deficient in 22.5% of children under the age of six, being more prevalent in children of Indo-Pakistani and Maghrebí origin.

Nutritional support in patients with systemic sclerosis.

UNLABELLED: Systemic sclerosis (SSc) is a chronic multisystem autoimmune disease which involves the gastrointestinal tract in about 90% of cases. It may contribute to nutritional deterioration. OBJECTIVE: To assess whether the application of a nutritional support protocol to these patients could improve their nutritional status and quality of life. METHODS: Single center prospective study, performed on an outpatient basis, in a county hospital. The Malnutrition Universal Screening Tool (MUST) was used to screen risk for malnutrition. Health questionnaire SF-36 and the Hospital Anxiety and Depression Scale were used to assess quality of life and psychopathology respectively. Weight, height, energy and protein requirements, macronutrient intake and nutritional biochemical parameters were evaluated. Nutritional intervention was performed in patients at risk for malnutrition. RESULTS: Of the 72 patients, 12.5% were at risk for malnutrition. Iron deficiency anemia (18.35%) and vitamin D deficiency (54%) were the most frequently observed nutritional deficits. The questionnaires on psychopathology and quality of life showed a high prevalence of anxiety and depression, and lower level poor quality of life in the physical and mental component. No significant improvements were observed in the weight, food intake, nutritional biochemical parameters, psychopathology and quality of life follow-up. CONCLUSIONS: Dietary intervention was able to maintain body weight and food intake. Iron deficiency anemia and vitamin D deficiency improved with iron and vitamine D supplements. No deterioration was observed in psychological assessment or quality of life. Studies with larger numbers of patients are needed to assess the efficacy of this intervention.