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Hajeer S, Nasr F, Nabha S, Saab MB, Harati H, Desoutter A, Al Ahmar E, Estephan E. Association between vitamin D deficiency and multiple sclerosis- MRI significance: A scoping review. Heliyon 2023; 9:e15754. [PMID: 37180903 PMCID: PMC10172888 DOI: 10.1016/j.heliyon.2023.e15754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023] Open
Abstract
Background/Objective Multiple Sclerosis is a common demyelinating disease of the central nervous system. Several studies suggested a link between vitamin D deficiency and multiple sclerosis disease activity, which can be evaluated by magnetic resonance imaging. Thereby, the main objective of the following scoping review is to summarize the magnetic resonance imaging findings assessing the probable effects of vitamin D on MS disease activity. Methodology PRISMA checklist for systematic reviews and meta-analyses was employed to structure this review. Literature was searched for observational and clinical studies tackling the given matter using several search engines including PubMed, CORE, and Embase. Data was extracted in a systematic manner, and the articles meeting the inclusion criteria were quality-assessed by Jadad scale for randomized clinical trials (RCTs) and Newcastle-Ottawa scale for observational studies. Results A total of 35 articles were included. Twenty-one (60%) studies noted a statistically significant association between vitamin D and Multiple Sclerosis MRI-detected disease activity. MRI-detected features involved lower contrast-enhancing T1 lesions, lower hyperintense T2 lesions, and a decrease in lesions volume. On the other hand, 40% (14 articles) of the articles did not detect any significant effect of vitamin D on Multiple Sclerosis disease activity. Due to the heterogeneity of the studies involved, meta-analysis was not employed in the given review. Discussion/conclusion There was an abundance in the number of research studies investigating the relationship between vitamin D and Multiple Sclerosis while highlighting the significant role of MRI in assessing the activity of the disease. Numerous studies found that higher serum vitamin D levels are associated with decreased new active cortical and subcortical lesions and lower lesions volume. These findings highlight the importance of imaging modalities in the various aspects of neurological diseases and encourage further research to focus on the preventive effects of vitamin D on MS patients.
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Affiliation(s)
- Shorouk Hajeer
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Farah Nasr
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Sanaa Nabha
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Marie-belle Saab
- Faculty of Pedagogy, Lebanese University, Furn-El-Chebbak, Lebanon
| | - Hayat Harati
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | | | - Elie Al Ahmar
- Faculty of Arts and Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
- School of Engineering, Holy Spirit University of Kaslik, Jounieh, Lebanon
- Corresponding author. Faculty of Arts and Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
| | - Elias Estephan
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- LBN, University Montpellier, Montpellier, France
- Faculty of Arts and Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon
- Corresponding author. LBN, University Montpellier, Montpellier, France.
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Zorzella-Pezavento SFG, Mimura LAN, Denadai MB, de Souza WDF, Fraga-Silva TFDC, Sartori A. Is there a window of opportunity for the therapeutic use of vitamin D in multiple sclerosis? Neural Regen Res 2022; 17:1945-1954. [PMID: 35142671 PMCID: PMC8848597 DOI: 10.4103/1673-5374.335139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Multiple sclerosis is an autoimmune treatable but not curable disease. There are a multiplicity of medications for multiple sclerosis therapy, including a class entitled disease-modifying drugs that are mainly indicated to reduce the number and severity of disease relapses. Not all patients respond well to these therapies, and minor to severe adverse effects have been reported. Vitamin D, called sunshine vitamin, is being studied as a possible light at the end of the tunnel. In this review, we recapitulated the similar immunopathogenesis of multiple sclerosis and experimental autoimmune encephalomyelitis, the immunomodulatory and neuroprotective potential of vitamin D and the state-of-art concerning its supplementation to multiple sclerosis patients. Finally, based on our and other groups’ experimental findings, we analyzed the need to consider the relevance of the route and the different time-point administration aspects for a more rational indication of this vitamin to multiple sclerosis patients.
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Affiliation(s)
| | - Luiza Ayumi Nishiyama Mimura
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Marina Bonifácio Denadai
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - William Danilo Fernandes de Souza
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | | | - Alexandrina Sartori
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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Asmarian N, Sharafi Z, Mousavi A, Jacques R, Tamayo I, Bind MA, Abutorabi-Zarchi M, Moradian MJ, Izadi S. Multiple sclerosis incidence rate in southern Iran: a Bayesian epidemiological study. BMC Neurol 2021; 21:309. [PMID: 34376167 PMCID: PMC8353854 DOI: 10.1186/s12883-021-02342-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background Multiple Sclerosis (MS) remains to be a public health challenge, due to its unknown biological mechanisms and clinical impacts on young people. The prevalence of this disease in Iran is reported to be 5.30 to 74.28 per 100,000-person. Because of high prevalence of this disease in Fars province, the purpose of this study was to assess the spatial pattern of MS incidence rate by modeling both the associations s of spatial dependence between neighboring regions and risk factors in a Bayesian Poisson model, which can lead to the improvement of health resource allocation decisions. Method Data from 5468 patients diagnosed with MS were collected, according to the McDonald’s criteria. New cases of MS were reported by the MS Society of Fars province from 1991 until 2016. The association between the percentage of people with low vitamin D intake, smoking, abnormal BMI and alcohol consumption in addition to spatial structure in a Bayesian spatio-temporal hierarchical model were used to determine the relative risk and trend of MS incidence rate in 29 counties of Fars province. Results County-level crude incidence rates ranged from 0.22 to 11.31 cases per 100,000-person population. The highest relative risk was estimated at 1.80 in the county of Shiraz, the capital of Fars province, while the lowest relative risk was estimated at 0.11 in Zarindasht county in southern of Fars. The percentages of vitamin D supplementation intake and smoking were significantly associated with the incidence rate of MS. The results showed that 1% increase in vitamin D supplementation intake is associated with 2% decrease in the risk of MS and 1% increase in smoking is associated with 16% increase in the risk of MS. Conclusion Bayesian spatio-temporal analysis of MS incidence rate revealed that the trend in the south and south east of Fars province is less steep than the mean trend of this disease. The lower incidence rate was associated with a higher percentage of vitamin D supplementation intake and a lower percentage of smoking. Previous studies have also shown that smoking and low vitamin D, among all covariates or risk factors, might be associated with high incidence of MS.
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Affiliation(s)
- Naeimehossadat Asmarian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Sharafi
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran. .,Department of Epidemiology & Biostatistics, School of Health, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Amin Mousavi
- Department of Educational Psychology and Special Education, College of Education, University of Saskatchewan, Saskatoon, Canada
| | - Reis Jacques
- Service de Neurologie, Centre Hospitalier Universitaire, Hôpital de Hautepierre, 1, avenue Molière, 67200, Strasbourg, France
| | - Ibon Tamayo
- Department of Statistics, Faculty of Arts and Science, Harvard University, Cambridge, MA, USA
| | - Marie-Abèle Bind
- Department of Statistics, Faculty of Arts and Science, Harvard University, Cambridge, MA, USA
| | - Marzie Abutorabi-Zarchi
- Department of neurology, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, IR, Iran
| | - Mohammad Javad Moradian
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sadegh Izadi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Murdaca G, Tonacci A, Negrini S, Greco M, Borro M, Puppo F, Gangemi S. Emerging role of vitamin D in autoimmune diseases: An update on evidence and therapeutic implications. Autoimmun Rev 2019; 18:102350. [PMID: 31323357 DOI: 10.1016/j.autrev.2019.102350] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 12/24/2022]
Abstract
Vitamin D plays a key role in in calcium homeostasis and, thus, provides an important support in bone growth by aiding in the mineralization of the collagen matrix. However, vitamin D performs various immunomodulatory, anti-inflammatory, antioxidant and anti-fibrotic actions. Autoimmune diseases result from an aberrant activation of the immune system, whereby the immune response is directed against harmless self-antigens. Does vitamin D play a role in the pathophysiology of autoimmune diseases? And, if so, what is its role? In the last decade, researchers' interest in vitamin D and its correlations with autoimmune diseases has considerably increased. We conducted a literature review, covering the period January 1, 2009 through March 30, 2019, in PubMed. We analyzed more than 130 studies in order to find a correlation between vitamin D levels and its effect upon several autoimmune diseases. The analysis demonstrated an inverse association between vitamin D and the development of several autoimmune diseases, such as SLE, thyrotoxicosis, type 1 DM, MS, iridocyclitis, Crohn's disease, ulcerative colitis, psoriasis vulgaris, seropositive RA, polymyalgia rheumatica. International multicenter study could allow us to confirm the data already present in the literature in the single clinical studies and to evaluate when to effectively supplement vitamin D in patients who do not take corticosteroids.
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Affiliation(s)
- Giuseppe Murdaca
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino,Genoa, Italy.
| | - Alessandro Tonacci
- Clinical Physiology Institute, National Research Council of Italy (IFC-CNR), Pisa, Italy
| | - Simone Negrini
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino,Genoa, Italy
| | - Monica Greco
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino,Genoa, Italy
| | - Matteo Borro
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino,Genoa, Italy
| | - Francesco Puppo
- Clinical Immunology Unit, Department of Internal Medicine, University of Genoa and Ospedale Policlinico San Martino,Genoa, Italy
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
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Sadaka A, Nguyen K, Malik A, Brito R, Berry S, Lee AG. Vitamin D and Selenium in a Thyroid Eye Disease Population in Texas. Neuroophthalmology 2019; 43:291-294. [PMID: 31741672 DOI: 10.1080/01658107.2019.1566382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022] Open
Abstract
There is growing evidence of thyroid eye disease association with nutritional deficiencies including selenium and vitamin D. We conducted a retrospective chart review of all patients with clinical diagnosis of TED seen at our clinic from 2016 to 2017. Thirty-five patients met inclusion criteria and had serum 25-hydroxyvitamin D levels available, and 19 had selenium levels available. 7/35 (20%) patients had vitamin D deficiency, and 11 (31%) had vitamin D insufficiency, but none had selenium deficiency. Although both selenium and vitamin D supplementation have been recommended for TED, further investigation is necessary to justify supplementation for patients with TED.
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Affiliation(s)
- Ama Sadaka
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Kimberly Nguyen
- Houston Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Amina Malik
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Rosbel Brito
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Shauna Berry
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA.,Houston Medical School, University of Texas Health Science Center, Houston, Texas, USA.,Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, Houston, Texas, USA.,Department of Ophthalmology, The University of Texas Medical Branch and Texas A & M College of Medicine and the UT MD Anderson Cancer Center, Galveston, Texas, USA.,Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.,Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Simpson S, van der Mei I, Lucas RM, Ponsonby AL, Broadley S, Blizzard L, Taylor B. Sun Exposure across the Life Course Significantly Modulates Early Multiple Sclerosis Clinical Course. Front Neurol 2018; 9:16. [PMID: 29449827 PMCID: PMC5799286 DOI: 10.3389/fneur.2018.00016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/10/2018] [Indexed: 01/08/2023] Open
Abstract
Background Low vitamin D and/or sun exposure have been associated with increased risk of multiple sclerosis (MS) onset. However, comparatively, few studies have prospectively examined associations between these factors and clinical course. Objectives To evaluate the association of sun exposure parameters and vitamin D levels with conversion to MS and relapse risk in a prospectively monitored cohort of 145 participants followed after a first demyelinating event up to 5-year review (AusLong Study). Methods Sun exposure prior to and after onset measured by annual questionnaire; ultraviolet radiation (UVR) "load" estimated by location of residence over the life course and ambient UVR levels. Serum 25-hydroxyvitamin D [25(OH)D] concentrations measured at baseline, 2/3-year, and 5-year review. MS conversion and relapse assessed by neurologist assessment and medical record review. Results Over two-thirds (69%) of those followed to 5-year review (100/145) converted to MS, with a total of 252 relapses. Higher pre-MS onset sun exposure was associated with reduced risk of MS conversion, with internal consistency between measures and dose-response relationships. Analogous associations were also seen with risk of relapse, albeit less strong. No consistent associations were observed between postonset sun exposure and clinical course, however. Notably, those who increased their sun exposure during follow-up had significantly reduced hazards of MS conversion and relapse. Serum 25(OH)D levels and vitamin D supplementation were not associated with conversion to MS or relapse hazard. Conclusion We found that preonset sun exposure was protective against subsequent conversion to MS and relapses. While consistent associations between postonset sun exposure or serum 25(OH)D level and clinical course were not evident, possibly masked by behavior change, those participants who markedly increased their sun exposure demonstrated a reduced MS conversion and relapse hazard, suggesting beneficial effects of sun exposure on clinical course.
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Affiliation(s)
- Steve Simpson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Ingrid van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Robyn M Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, ACT, Australia.,Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
| | - Anne-Louise Ponsonby
- National Centre for Epidemiology and Population Health, Research School of Population Health, College of Health and Medicine, Australian National University, Canberra, ACT, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Royal Melbourne Hospital, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Broadley
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | | | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
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Reece AS, Hulse GK. What are the characteristics of vitamin D metabolism in opioid dependence? An exploratory longitudinal study in Australian primary care. BMJ Open 2018; 8:e016806. [PMID: 29331964 PMCID: PMC5780717 DOI: 10.1136/bmjopen-2017-016806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Compare vitamin D levels in opioid dependence and control population and adjust for relevant confounding effects. Nuclear hormone receptors (including the vitamin D receptor) have been shown to be key transducers and regulators of intracellular metabolism and comprise an important site of pathophysiological immune and metabolic dysregulation potentially contributing towards pro-ageing changes observed in opioid-dependent patients (ODPs). DESIGN Longitudinal prospective comparing ODPs with general medical controls (GMCs). SETTING Primary care. PARTICIPANTS Prospective review comparing 1168 ODP (72.5% men) and 415 GMC (51.6% men, p<0.0001). Mean ages were 33.92±0.31 (mean±SEM) and 41.22±1.32 years, respectively (p<0.0001). Opioid use in the ODP has been previously reported and shown to be typical. INTERVENTIONS Nil. Observational study only. PRIMARY AND SECONDARY OUTCOMES Serum vitamin D levels and relevant biochemical parameters. RESULTS Vitamin D levels were higher in the ODP (70.35±1.16 and 57.06±1.81 nmol/L, p<0.0001). The difference in ages between the two groups was handled in an age-matched case-control subanalysis and also by multiple regression. Sexes were analysed separately. The age:status (or age:time:status) was significant in case-control, cross-sectional and longitudinal analyses in both sexes (p<0.05). Modelled vitamin D was 62.71 vs 57.81 nmol/L in the two groups. Time-dependent mixed-effects models quadratic in age outperformed linear-only models (p=0.0377). ODP vitamin D was shown to vary with age and to correlate with alanine aminotransferase establishing it as a biomarker of age in this group. Hepatitis C seronegativity was significant in regression models (from p=0.0015). CONCLUSION Vitamin D was higher in ODP in both sexes in bivariate, cross-sectional, case-control and longitudinal analyses and was robust to the inclusion of metabolic and immune biomarkers. That Hepatitis C seronegativity was significant suggests opioid dependence has an effect beyond simply that of its associated hepatitides. This finding may relate to the accelerated ageing process previously described in opioid dependence.
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Affiliation(s)
- Albert Stuart Reece
- Department of Psychiatry and Clinical Neurosciences, University of Western Australia, Brisbane, Queensland, Australia
| | - Gary Kenneth Hulse
- Department of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Queensland, Australia
- Psychiatry, Edith Cowan University at Joondalup, Western Australia, Australia
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Wawrzyniak S, Mikołajewska E, Kuczko-Piekarska E, Niezgodzińska-Maciejek A, Goch A. Association of vitamin D status and clinical and radiological outcomes in a treated MS population in Poland. Brain Behav 2017; 7:e00609. [PMID: 28239520 PMCID: PMC5318363 DOI: 10.1002/brb3.609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vitamin D influences the immune system significantly. Previous studies have found that vitamin D deficiency in adolescence can play a significant role in increasing the risk of developing autoimmune diseases including multiple sclerosis. The aim of this study was to investigate the relationship between the vitamin D status in serum and clinical and radiological outcomes in a treated population in Poland. METHODS Inclusion criteria met 83 adult patients aged 20-61 years with diagnosis of relapsing-remitting multiple sclerosis, who underwent immunomodulatory treatment which lasted at least 12 months. Levels of serum 25-hydroxyvitamin D were determined using radio-immuno assay. Magnetic resonance imaging of the brain and cervical part of a spinal cord was performed each time after 12 months of the treatment. Patients were assessed neurologically after 12 months of treatment, the level of disability was also assessed using Extended Disability Status Scale. RESULTS The largest group (63.8%) showed significant vitamin D deficiency (<20 ng/ml), 21.7% showed the suboptimal level of vitamin D (20-30 ng/ml). The normal level of 25(OH)D (>30 ng/ml) was observed in 14.5% of the patients. Statistically significant correlation was observed between the vitamin D status and frequency of relapses. CONCLUSIONS Our findings confirm that deficiency of vitamin D in patients with MS is correlated with clinical and radiological course of the disease.
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Affiliation(s)
- Sławomir Wawrzyniak
- Neurology Clinic Military Clinical Hospital No. 10 with Policlinic in Bydgoszcz Bydgoszcz Poland
| | - Emilia Mikołajewska
- Department of Physiotherapy Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Toruń Toruń Poland; Neurocognitive Laboratory Centre for Modern Interdisciplinary Technologies Nicolaus Copernicus University in Toruń Toruń Poland
| | - Ewelina Kuczko-Piekarska
- Neurology Clinic Military Clinical Hospital No. 10 with Policlinic in Bydgoszcz Bydgoszcz Poland
| | | | - Aleksander Goch
- Department of Physiotherapy Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Toruń Toruń Poland; Cardiology and Cardiosurgery Clinic Military Clinical Hospital No. 10 with Policlinic in Bydgoszcz Bydgoszcz Poland
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