Vitamin D and Innate and Adaptive Immunity

Serum vitamin D levels in children with vernal keratoconjunctivitis - A study from a tertiary care pediatric hospital of North India

BACKGROUND

To study the levels of vitamin D serum levels in children with vernal keratoconjuctivits (VKC) and comparing vitamin D levels in after giving vitamin D supplements between intervention and control group.

METHODS

The study was conducted in population between 1 to 12 years in tertiary care hospital in North India. Amongst children with VKC, full ocular examination along with Boninis clinical grading of VKC and serum vitamin D levels were assessed. Whole study group was randomly divided into two groups. Intervention group had received vitamin D powder while control group kept under observation.

RESULTS

A total of 88 children received vitamin D supplementation and 39 kept in control group.

CONCLUSION

Our study suggests that children in intervention group showed improvement in serum vitamin D levels with the clinical improvement in VKC grading too.

The effect of vitamin D status on the occurrence of Kawasaki Disease: a meta-analysis

AIM

The relationship between vitamin D status and Kawasaki Disease (KD), as well as coronary artery lesion (CAL), has yet to be established.

METHODS

A meta-analysis was conducted to assess the correlation between vitamin D status and KD, as well as the impact of vitamin D status on the progression of KD into CAL.

RESULTS

The meta-analysis revealed a consistent and significant association between serum 25(OH)D level and the occurrence KD (studies N = 22; z = -3.51, P < 0.001). Patients with KD had markedly lower levels of vitamin D than healthy controls (SMD: -1.30 ng/mL, 95%CI: -2.05 to -0.55 ng/mL).

CONCLUSION

The study provided evidence supporting a significant association between lower serum vitamin D levels and the occurrence of KD, particularly within the Chinese population. However, the findings did not suggest a direct impact of vitamin D on the development of CAL in KD patients.

Effect of serum vitamin D levels on the severity of acute pancreatitis: A prospective study

Acute pancreatitis (AP) is a serious and complex disorder with varying disease course and severity. Early and prompt interventions are crucial in management of AP. Vitamin D, being a prominent actor in calcium metabolism, also takes part in immunity and thus in immune-system related disorders, ranging from infections to cancer. In this study, the role of vitamin D status of a patient on the severity of AP was investigated. This study was conducted between June 2021 to August 2022 with a total of 315 patients. Blood samples were obtained upon admission. A 25-(OH)D3 level less than 10 ng/ml was defined as vitamin D deficiency. 10-19 ng/ml was defined as vitamin D insufficiency whereas 20 ng/ml or above was considered to be sufficient. Scoring systems (Ranson score, CTSI, BISAP, Revised Atlanta Classification (RAC) were applied. Serum 25-(OH)D3 levels of patients with AP were found to be negatively correlated with severity of the disease according to RAC (p < 0.001). In concordance to this finding, both Ranson score and BISAP were found to be statistically significantly related to 25-(OH)D3 levels. Both scoring systems revealed higher scores in patients with insufficient or deficient levels of 25-(OH)D3. Serum 25-(OH)D3 levels were not found to be related to intensive care unit admission or mortality. This study revealed that serum 25-(OH)D3 level is related to the severity of AP. In the future, interventional studies with vitamin D therapy in otherwise serum 25-(OH)D3 deficient AP patients might reveal a new potential therapeutic agent in this mechanically complex, burdensome disorder.

Prognostic significance of 25-hydroxyvitamin D levels in patients with peripheral T-cell lymphoma

Vitamin D insufficiency has been linked to unfavourable outcomes in diverse malignancies. However, the prognostic significance of vitamin D levels in peripheral T-cell lymphoma (PTCL) remains unclear. In this study, we thus aimed to assess the prognostic relevance of 25-hydroxyvitamin D [25(OH)D] levels in patients newly diagnosed with PTCL. The analysis included 144 patients with PTCL treated from March 2015 to May 2020. The median 25(OH)D level was 12.2 (1.7-48.8) ng/mL, and 59 (41%) patients had vitamin D deficiency. Patients with vitamin D deficiency demonstrated significantly worse event-free survival (EFS) and overall survival (OS). In the multivariate analysis, vitamin D was independently associated with OS, with a hazard ratio of 1.66 (95% confidence interval, 1.05-2.63, p = 0.030). These findings suggest that vitamin D deficiency significantly correlates with poor survival outcomes in patients with PTCL.

The Role of Vitamins in the Pathogenesis of Asthma

Vitamins play a crucial role in the proper functioning of organisms. Disturbances of their levels, seen as deficiency or excess, enhance the development of various diseases, including those of the cardiovascular, immune, or respiratory systems. The present paper aims to summarize the role of vitamins in one of the most common diseases of the respiratory system, asthma. This narrative review describes the influence of vitamins on asthma and its main symptoms such as bronchial hyperreactivity, airway inflammation, oxidative stress, and airway remodeling, as well as the correlation between vitamin intake and levels and the risk of asthma in both pre- and postnatal life.

The Possible Role of Selected Vitamins and Minerals in the Therapeutic Outcomes of Leishmaniasis

Leishmaniasis is a protozoal disease declared as an endemic in areas suffering from severe malnutrition and poverty. The factors associated with poverty like low income, ecological factors, and malnutrition cause disruption in immunity and host defense increasing risk of infection. Altered resistance to infection and host susceptibility are associated with low micronutrient levels in undernourished patients. Malnutrition has been recognized as a poor predictive marker for leishmaniasis, in particular the deficiency of trace elements like zinc, iron, and vitamin A, B, C, D which has a prominent function in the regulation of innate and adaptive immunity, cell proliferation, human physiology, etc. Malnourishment can exacerbate host sensitivity and pathophysiologic intensity to infection in variety of ways, whereas infection can enhance underlying poor nutrition or enhance host vulnerability and sandfly's urge to attack specific hosts. The intensity of leishmaniasis can be influenced by body mass and micronutrient availability in the blood. Vitamin D, C, zinc, and iron are proved effective in inhibiting the growth of leishmaniasis in both amastigote or promastigote forms, either directly or by acting as precursor for a pathway which inhibits the parasite growth. This article elucidates a new perception to the crucial role of micronutrients and their probable role in the therapeutic outcomes of leishmaniasis. Since there is requirement of novel drugs to fight drug resistance and relapse of leishmaniasis, this article may pave way to understand the importance of micronutrients and their role in therapeutic outcomes of leishmaniasis.

High-Throughput CAMP Assay (HiTCA): A Novel Tool for Evaluating the Vitamin D-Dependent Antimicrobial Response

Vitamin D is known to modulate human immune responses, and vitamin D deficiency is associated with increased susceptibility to infection. However, what constitutes sufficient levels or whether vitamin D is useful as an adjuvant therapeutic is debated, much in part because of inadequate elucidation of mechanisms underlying vitamin D's immune modulatory function. Cathelicidin antimicrobial peptide (CAMP) has potent broad-spectrum activity, and the CAMP gene is regulated in human innate immune cells by active 1,25(OH)2D3, a product of hydroxylation of inactive 25(OH)D3 by CYP27B1-hydroxylase. We developed a CRISPR/Cas9-edited human monocyte-macrophage cell line containing the mCherry fluorescent reporter gene at the 3' end of the endogenous CAMP gene. The High Throughput CAMP Assay (HiTCA) developed here is a novel tool for evaluating CAMP expression in a stable cell line that is scalable for a high-throughput workflow. Application of HiTCA to serum samples from a small number of human donors (n = 10) showed individual differences in CAMP induction that were not fully accounted for by the serum vitamin D metabolite status of the host. As such, HiTCA may be a useful tool that can advance our understanding of the human vitamin D-dependent antimicrobial response, which is being increasingly appreciated for its complexity.

The effect of vitamin D and magnesium supplementation on clinical symptoms and serum inflammatory and oxidative stress markers in patients with COVID-19: a structured summary of a study protocol for a randomized controlled trial

OBJECTIVES

This study aims to evaluate the effect of vitamin D and magnesium supplementation on clinical symptoms and serum inflammatory and oxidative stress markers in patients with COVID-19.

TRIAL DESIGN

This study is a 4-arm randomized, double-blind, placebo-controlled clinical trial with a factorial design and the intervention period is 3 weeks.

PARTICIPANTS

This study is conducted on COVID-19 patients admitted to the Shahid Mohammadi hospital in Bandar Abbas, Iran, who are eligible for inclusion in the study. Patients are included only if they meet all of the following criteria: (1) aged from 18 to 65 years old; (2) confirmation of COVID-19 by RT-PCR test; (3) completing informed consent; (4) passing less than 48 h since the patient's hospitalization; (5) no skin or gastrointestinal allergies due to taking multivitamin supplements, vitamin D, and magnesium; and (6) having more than 30 breaths per minute and less than 93% oxygen saturation in room air and sea level. Patients are excluded if they have any of the following conditions: (1) pregnancy or lactation; (2) taking a daily multivitamin or take a vitamin D or magnesium supplement in the last month; (3) participating in other clinical trials; (4) renal failure or dialysis, severe liver disease or cirrhosis; (5) known diagnosis of hypercalcemia; (6) discharging from the hospital less than 24 h after the start of the intervention; (7) history of kidney stones in the last year; (8) transfer the patient to the ICU; (9) baseline vitamin D levels above 80 ng/ml; (10) baseline magnesium levels above 2.6 mg/dl; and (11) unwillingness of the patient to continue the study.

INTERVENTION AND COMPARATOR

Participants will be randomly allocated to one of the four following groups: (A) vitamin D (two 50,000 IU capsules at the beginning of the study, two 50,000 IU capsules on the 4th day, one 50,000 IU capsule on the 11th day, and one 50,000 IU capsule on the 17th day) and magnesium supplement (300 mg/day); (B) vitamin D capsule and magnesium placebo; (C) magnesium supplement and vitamin D placebo; and (D) vitamin D placebo and magnesium placebo.

MAIN OUTCOMES

The resolution of clinical symptoms (fever, dry cough, shortness of breath, headache, myalgia, oxygen saturation, and mortality rate) and interpretation of laboratory assays (CRP, MDA, TAC, WBC, neutrophils count, lymphocytes count, ratio of neutrophils to lymphocytes, levels of 25 hydroxyvitamin D and magnesium) will be assessed in the study groups.

RANDOMIZATION

A computer-generated block randomization list is used for randomization.

BLINDING (MASKING)

Investigators and patients are blinded to group allocation and treatment. A double-blind design is achieved using matched placebos.

NUMBERS TO BE RANDOMIZED (SAMPLE SIZE)

A total of 104 eligible patients are randomized into four groups of 26 subjects (1:1:1:1 allocation ratio).

DISCUSSION

With the rapid prevalence of COVID-19 in recent years, more attention has been paid to effective dietary supplementation to improve clinical symptoms and biochemical parameters in these patients. To our knowledge, this is the first study to evaluate the effects of vitamin D supplementation in combination with magnesium or alone with respect to this infectious disease. The findings of the current RCT will provide evidence regarding the effectiveness of dietary supplementation strategies to improve COVID-19 outcomes.

TRIAL STATUS

Ethical approval of the first version of the study protocol was obtained from the medical ethics committee of Hormozgan University of Medical Sciences, Bandar Abbas, Iran on May 30, 2021 (IR.HUMS.REC.1400.085). Currently, the recruitment phase is ongoing since August 23, 2021, and is anticipated to be complete by the end of August 2022.

TRIAL REGISTRATION

The study protocol was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir ; IRCT20210702051763N1) on August 14, 2021. https://www.irct.ir/trial/57413 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

Vitamin D induced microbicidal activity against Mycobacterium bovis BCG is dependent on the synergistic activity of bovine peripheral blood cell populations

A growing appreciation is emerging of the beneficial role of vitamin D for health and resistance against infectious diseases, including tuberculosis. However, research has predominantly focused on murine and human species and functional data in bovines is limited. Therefore, the objective of this study was to assess the microbicidal activity and immunoregulatory effect of the vitamin D metabolite 1,25(OH)2D3 on bovine peripheral blood leukocytes (PBL) in response to Mycobacterium bovis BCG (BCG) infection using a combination of functional assays and gene expression profiling. Blood from Holstein-Friesian bull calves with low circulating levels of 25(OH)D was stimulated with 1,25(OH)2D3 for 2 h, and then infected with M. bovis BCG. Results showed that 1,25(OH)2D3 supplementation significantly increased BCG killing by on average 16 %, although responses varied between 1 % and 38 % killing. Serial cell subset depletion was then performed on PBL prior to 1,25(OH)2D3 incubation and BCG infected as before to analyse the contribution of major cell types to mycobacterial growth control. Specific antibodies and either magnetic cell separation or density gradient centrifugation of monocytes, granulocytes, CD3+, CD4+, and CD8+ T lymphocytes were used to capture each cell subset. Results showed that depletion of granulocytes had the greatest impact on BCG growth, leading to a significant enhancement of bacterial colonies. In contrast, depletion of CD4+ or CD8+ T cells individually, or in combination (CD3+), had no impact on mycobacterial growth control. In agreement with our previous data, 1,25(OH)2D3 significantly increased bacterial killing in PBL, in monocyte depleted samples, and a similar trend was observed in the granulocyte depleted subset. In addition, specific analysis of sorted neutrophils treated with 1,25(OH)2D3 showed an enhanced microbicidal activity against both BCG and a virulent strain of M. bovis. Lastly, data showed that 1,25(OH)2D3 stimulation increased reactive oxygen species (ROS) production and the expression of genes encoding host defence peptides (HDP) and pathogen recognition receptors (PRRs), factors that play an important role in the microbicidal activity against mycobacteria. In conclusion, the vitamin D metabolite 1,25(OH)2D3 improves antimycobacterial killing in bovine PBLs via the synergistic activity of monocytes and granulocytes and enhanced activation of innate immunity.

Role of vitamin D in pathogenesis and severity of COVID-19 infection

Coronavirus disease (COVID-19) is an infectious disease caused by a new virus that causes respiratory illness. Older adults and individuals who have pre-existing chronic medical conditions are at higher risk for more serious complications from COVID-19. Hypovitaminosis D is attributed to the increased risk of lung injury and acute respiratory distress syndrome (ARDS) as well as diabetes, cardiovascular events and associated comorbidities, which are the main causes of severe clinical complications in COVID-19 patients. Considering the defensive role of vitamin D, mediated through modulation of the innate and adaptive immune system as well as inhibition of the Renin Angiotensin System (RAS), vitamin D supplementation might boost the immune system of COVID-19 patients and reduce severity of the disease in vitamin D deficient individuals.

Effect of third trimester maternal vitamin D levels on placental weight to birth weight ratio in uncomplicated pregnancies

OBJECTIVES

Vitamin D has critical role for the fetal and placental development. Today, placental weight (PW), fetal birth weight (BW), and the PW/BW ratio are used as markers of fetal development. The aim of this study is to evaluate the relationship between vitamin D levels and these markers in uncomplicated pregnancies.

METHODS

This study included 108 women with uncomplicated pregnancies, defined as full-term and healthy pregnancies without perinatal complications. Vitamin D levels <12 ng/mL were classified as deficient, 12-20 ng/mL as insufficient, and >20 ng/mL as normal. Postnatal BW and PW were compared according to maternal serum vitamin D levels.

RESULTS

Maternal age, maternal height, maternal weight, body mass index, nulliparity, gestational age at delivery, mode of delivery, and fetal gender were similar between groups. Postnatal BW, PW, fetal height at birth, and fetal head circumference parameters were similar between the groups. The PW/BW ratio was 21.77±2.20 in the vitamin D deficient group, 21.20±2.40 in the insufficient group, and 19.98±2.37 in the normal group (p=0.012). In addition, there was a significant negative correlation between vitamin D level and the PW/BW ratio (p=0.012, r=0.031).

CONCLUSIONS

Our results indicated that PW/BW ratio which is the marker for prediction adverse perinatal outcomes were significantly increased in the presence of vitamin D deficiency and insufficiency.

Relationship between vitamin D level and clinical status in COVID-19 patients

Objective: Vitamin D plays an important role in maintaining the integrity of mucosal barriers and in natural and acquired immunity. In the COVID-19 pandemic, the strength of personal immunity is very important in the severe or lightening of the disease, even if there are variants of the virus or if you are vaccinated. Methods: In this study, we investigated the relationship between the clinical course and vitamin D levels of outpatient and inpatient follow-up patients admitted to our hospital due to COVID-19. A total of 94 patients, 47 outpatients and 47 inpatients, were included in the study. Result: The mean age and gender distributions of both groups were similar. Vitamin D levels were found to be normal in only 7 of 94 patients who were followed up in our hospital due to COVID-19. Patients with vitamin D levels ≥30 were significantly lower than those with "

The dark satanic mills: Evaluating patterns of health in England during the industrial revolution

OBJECTIVE

this research seeks to investigate the impact the industrial revolution had on the population of England.

MATERIALS

Pre-existing skeletal data from 1154 pre-Industrial (1066-1700 CE) and 4157 industrial (1700-1905) skeletons from 21 cemeteries (N = 5411).

METHODS

Context number, sex, age-at-death, stature and presence/absence of selected pathological conditions were collated. The data were compared using chi square, Kolmogorov-Smirnov, t-tests and logistic regression (α = 0.01).

RESULTS

There was a statistically significant increase in cribra orbitalia, periosteal reactions, rib lesions, fractures, rickets, osteoporosis, osteoarthritis, enamel hypoplasia, dental caries and periapical lesions in the industrial period. Osteomyelitis decreased from the pre-industrial to industrial period.

CONCLUSION

Our results confirm the industrial revolution had a significant negative impact on human health, however the prevalence of TB, treponemal disease, maxillary sinusitis, osteomalacia, scurvy, gout and DISH did not change, suggesting these diseases were not impacted by the change in environmental conditions.

SIGNIFICANCE

This is the largest study of health in the industrial revolution that includes non-adults and adults and considers age-at-death alongside disease status to date. This data supports the hypothesis that the rise of industry was associated with a significant decline in general health, but not an increase in all pathological conditions.

Dietary Factors Associated with Asthma Development: A Narrative Review and Summary of Current Guidelines and Recommendations

Asthma is a complex disease, caused by a combination of genetic and environmental factors. The prevalence of asthma is increasing too rapidly to be attributable to genetic factors alone. Thus, environmental factors are becoming increasingly recognized as the cause of asthma. Modifying these environmental factors may be a simple approach for asthma prevention. To date, dietary intervention is an interesting modifiable factor because it can be implemented at the population level. The modification of systemic inflammation, oxidation, and microbial composition might be a mechanistic basis for prevention. This review summarizes the mechanistic basis and evidence from clinical studies on the association between dietary factors and asthma development. We also summarize the recommendations from many organizations and regional guidelines to assist the practicing physician to improve patient care.

Mammalian Neuraminidases in Immune-Mediated Diseases: Mucins and Beyond

Mammalian neuraminidases (NEUs), also known as sialidases, are enzymes that cleave off the terminal neuraminic, or sialic, acid resides from the carbohydrate moieties of glycolipids and glycoproteins. A rapidly growing body of literature indicates that in addition to their metabolic functions, NEUs also regulate the activity of their glycoprotein targets. The simple post-translational modification of NEU protein targets-removal of the highly electronegative sialic acid-affects protein folding, alters protein interactions with their ligands, and exposes or covers proteolytic sites. Through such effects, NEUs regulate the downstream processes in which their glycoprotein targets participate. A major target of desialylation by NEUs are mucins (MUCs), and such post-translational modification contributes to regulation of disease processes. In this review, we focus on the regulatory roles of NEU-modified MUCs as coordinators of disease pathogenesis in fibrotic, inflammatory, infectious, and autoimmune diseases. Special attention is placed on the most abundant and best studied NEU1, and its recently discovered important target, mucin-1 (MUC1). The role of the NEU1 - MUC1 axis in disease pathogenesis is discussed, along with regulatory contributions from other MUCs and other pathophysiologically important NEU targets.

Vitamin D3 supplementation during pregnancy and lactation for women living with HIV in Tanzania: A randomized controlled trial

BACKGROUND

Observational studies suggest that vitamin D deficiency among people living with HIV is associated with a greater risk of disease progression and death. Low levels of vitamin D in pregnancy are also associated with poor fetal and infant growth. Therefore, vitamin D supplementation may improve clinical outcomes for pregnant women living with HIV and improve fetal and postnatal growth for their infants.

METHODS AND FINDINGS

We conducted a randomized, triple-blind, placebo-controlled trial of vitamin D3 supplementation among pregnant and lactating women living with HIV in Dar es Salaam, Tanzania (ClinicalTrials.gov NCT02305927). Participants were randomized with 1:1 allocation stratified by study clinic to receive either daily 3,000 IU vitamin D3 supplements or matching placebo supplements from the second trimester of pregnancy (12-27 weeks) until 1 year postpartum. The primary outcomes were (i) maternal HIV progression or death, (ii) small-for-gestational-age (SGA) live births (<10th percentile), and (iii) infant stunting at 1 year of age (length-for-age z-score < -2). We also examined the effect of vitamin D3 supplementation on secondary maternal and infant health outcomes, maternal and infant serum 25-hydroxyvitamin D (25[OH]D) concentrations, and maternal hypercalcemia. An intent-to-treat analysis was used as the primary analytic approach. We enrolled 2,300 pregnant women between June 15, 2015, and April 17, 2018, and follow-up of mothers and infants was completed on October 20, 2019. There were 1,148 pregnant women randomly assigned to the vitamin D3 group, and 1,152 to the placebo group. The proportion of mothers lost to follow-up at 1 year postpartum was 6.6% in the vitamin D3 group (83 of 1,148) and 6.6% in the placebo group (76 of 1,152). The proportion of children lost to follow-up at 1 year of age was 5.5% in the vitamin D3 group (59 of 1,074 live births) and 5.2% in the placebo group (57 of 1,093 live births). There was no difference in the risk of maternal HIV progression or death, with 166 events during 1,461 person-years of follow-up in the vitamin D3 group and 141 events during 1,469 person-years of follow-up in the placebo group (hazard ratio 1.21, 95% CI 0.97 to 1.52, p = 0.09). There was no difference in the risk of SGA birth between the vitamin D3 (229 SGA births among 1,070 live births) and placebo groups (236 SGA births among 1,091 live births) (relative risk 1.03, 95% CI 0.87 to 1.22, p = 0.70). There was also no difference in the risk of infant stunting at 1 year of age between the vitamin D3 (407 events among 867 infants) and placebo groups (413 events among 873 infants) (relative risk 1.00, 95% CI 0.92 to 1.10, p = 0.95). In terms of adverse events, no cases of maternal hypercalcemia were identified. One hypersensitivity reaction to the trial supplements occurred for a pregnant woman in the placebo group. A limitation of our study is that our findings may not be generalizable to HIV-negative pregnant women or contexts where severe vitamin D deficiency is prevalent.

CONCLUSIONS

The trial findings do not support routine vitamin D supplementation for pregnant and lactating women living with HIV in Tanzania.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02305927.

Autoimmune disease and interconnections with vitamin D

Vitamin D has well-documented effects on calcium homeostasis and bone metabolism but recent studies suggest a much broader role for this secosteroid in human health. Key components of the vitamin D system, notably the vitamin D receptor (VDR) and the vitamin D-activating enzyme (1α-hydroxylase), are present in a wide array of tissues, notably macrophages, dendritic cells and T lymphocytes (T cells) from the immune system. Thus, serum 25-hydroxyvitamin D (25D) can be converted to hormonal 1,25-dihydroxyvitamin D (1,25D) within immune cells, and then interact with VDR and promote transcriptional and epigenomic responses in the same or neighbouring cells. These intracrine and paracrine effects of 1,25D have been shown to drive antibacterial or antiviral innate responses, as well as to attenuate inflammatory T cell adaptive immunity. Beyond these mechanistic observations, association studies have reported the correlation between low serum 25D levels and the risk and severity of human immune disorders including autoimmune diseases such as inflammatory bowel disease, multiple sclerosis, type 1 diabetes and rheumatoid arthritis. The proposed explanation for this is that decreased availability of 25D compromises immune cell synthesis of 1,25D leading to impaired innate immunity and over-exuberant inflammatory adaptive immunity. The aim of the current review is to explore the mechanistic basis for immunomodulatory effects of 25D and 1,25D in greater detail with specific emphasis on how vitamin D-deficiency (low serum levels of 25D) may lead to dysregulation of macrophage, dendritic cell and T cell function and increase the risk of inflammatory autoimmune disease.

Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain)

INTRODUCTION

Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population.

OBJECTIVE

We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing.

MATERIAL AND METHODS

Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307 651, of whom 96 544 (31.4%) were aged ≥ 65 years.

RESULTS

We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases.

CONCLUSION

The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.

Adequacy and Vitamin D in the Preoperative Period of Roux-en-Y Gastric Bypass, Bariatric Surgery, Can Protect Metabolic Health in Metabolically Healthy and Unhealthy Individuals

Evaluating the influence of vitamin D concentrations together with preoperative metabolic phenotypes on remission of chronic noncommunicable diseases (CNCDs) after 6 months of Roux-en-Y gastric bypass (RYGB). Cross-sectional analytical study comprising 30 adult individuals who were assessed preoperatively (T0) and 6 months (T1) after undergoing RYGB. Participants were distributed preoperatively into metabolically healthy obese (MHO) and metabolically unhealthy obese (MUHO) individuals according to HOMA-IR classification and to the adequacy and inadequacy of vitamin D concentrations in the form of 25(OH)D. All participants were assessed for anthropometric characteristics, biochemical variables, and presence of CNCDs. The statistical program used was the SPSS version 21. In face of vitamin D adequacy and regardless of the metabolic phenotype classification in the preoperative period, the means found for HOMA-IR allowed us to define them as metabolically healthy 6 months after RYGB. Only those with vitamin D inadequacy with the MUHO phenotype showed better results regarding the reduction of glucose that accompanied the shift in serum 25(OH)D concentrations from deficient to insufficient. It is possible that preoperative vitamin D adequacy, even in the presence of an unhealthy phenotype, may contribute to the reduction of dyslipidemia and improvement in cholesterol. It is suggested that preoperative vitamin D adequacy in both phenotypes may have a protective effect on metabolic health.

Progress in the Relationship between Vitamin D Deficiency and the Incidence of Type 1 Diabetes Mellitus in Children

Type 1 diabetes mellitus (T1DM) is an autoimmune disease, due to a large number of islet β cells damaged, resulting in an absolute lack of insulin, ultimately relying on insulin therapy. Vitamin D is a fat-soluble sterol derivative that not only participates in calcium and phosphorus metabolism but also acts as an immunomodulatory role by binding to nuclear vitamin D receptors to regulate the expression of transcription factors. Increasing evidence has shown that vitamin D has immunoregulation and anti-inflammatory effects, and it may play a role in T cell regulatory responses due to downregulation in the expression of cathepsin G and inhibition of CD4+ T cell activation and protection of β cells from immune attack and is beneficial in decreasing oxidative stress in T1DM patients. Epidemiologic evidence demonstrates involvement of vitamin D deficiency in T1DM pathogenesis, with the immune system improperly targeting and destroying its own islet β cells. In addition, polymorphisms in genes critical for vitamin D metabolism may increase the risk of islet autoimmunity and T1DM. In this paper, the relationship between vitamin D deficiency and the molecular mechanism of T1DM was discussed.

The Immunomodulatory Function of Vitamin D, with Particular Reference to SARS-CoV-2

Vaccines are the only way to reduce the morbidity associated to SARS-CoV-2 infection. The appearance of new mutations urges us to increase the effectiveness of vaccines as a complementary alternative. In this context, the use of adjuvant strategies has improved the effectiveness of different vaccines against virus infections such as dengue, influenza, and common cold. Recent reports on patients infected by COVID-19 reveal that low levels of circulating vitamin D correlate with a severe respiratory insufficiency. The immunomodulatory activity of this micronutrient attenuates the synthesis of pro-inflammatory cytokines and at the same time, increases antibody production. Therefore, the present review proposes the use of vitamin D as adjuvant micronutrient to increase the efficacy of vaccines against SARS-CoV-2 infection.

Rays of immunity: Role of sunshine vitamin in management of COVID-19 infection and associated comorbidities

The catastrophic pandemic engendered due to the Novel coronavirus (COVID-19) outbreak which causes severe clinical afflictions on the respiratory system has severely high morbidity and mortality rates. The requirement of novel compounds is at utmost importance due to lack of targeted drug molecule to treat the afflictions and restrict the viral infection and for the usage of prophylactic treatment to avoid the spread of the infection is of utmost importance. Vitamin D is one such naturally available multifunctional molecule, which plays an eminent role in the immune system and instigation of numerous cellular pathways further promoting health benefits and enhancing the human quality of life. This article reviews the current standpoint scenario and future prevalence of vitamin D supplementation in the management of covid-19 patients. Novel findings of Vitamin D suggest that along with regulation of cell growth, neuroprotective and mood-stabilizing effects, it regulates the immune response also modulate cytokine Interleukin-6 (IL-6) by inducing progesterone-induced blocking factor (PIBF), given the IL-6 levels are considerably high in COVID-19 patients which increases the further complications. Vitamin D also have its effect on angiotensin converting enzyme (ACEII) inhibitor through which the COVID-19 virus makes cell entry. Numerous research data elucidate the play of Vitamin D, in complications of COVID-19 including the most common comorbid conditions, neurological manifestations and immunological aspects makes it an ideal molecule for adjuvant therapy. Including Vitamin D as add-on therapy in the management of COVID-19 might aid the arrest of infection and helps fight this arduous epidemic.

[Immunosenescence, viral infections and nutrition: A narrative review of scientific available evidence]

Aging of the immune system, or immunosenescence, alters the viral immune response in the elderly, especially when frailty exists. Research findings have demonstrated an imbalance in pro- and anti-inflammatory mechanisms, reduced production and diversification of T lymphocytes, and an alteration in immunovigilance and antibody synthesis. In this context, nutrition has a role in combating sarcopenia and frailty. Some food components that contribute to immune-competence are protein, vitamin D, n-3 fatty acids, antioxidant vitamins (vitamins C and E), zinc, selenium and iron. In times of a pandemic, nutritional recommendations for immune-competence in the elderly should be based on clinical studies. In this article, immunosenescence and its relationship to nutrition are addressed, including interventions studied in the context of the COVID-19 pandemic.

Effects of Vitamin D in Post-Exercise Muscle Recovery. A Systematic Review and Meta-Analysis

Vitamin D is a key micronutrient modulating function and health in skeletal muscle. Therefore, we sought to systematically review the role of vitamin D in muscle recovery. A search in different databases (PubMed/MEDLINE, WOS, Google Scholar, and Scopus) was carried out following PRISMA^® and PICOS. The search period was from inception to April 2020. Changes in post-exercise muscle damage were quantified comparing experimental group vs. placebo in each study by using number of participants, standardized mean difference (SMD), and standard error of the SMD. Hedges’s g was used to calculate the SMDs for each study group and biased by the inverse of variance that allows calculating an overall effect and the 95% confidence interval (CI). The net vitamin D supplementation effect was calculated by subtracting the placebo SMD from SMD of the experimental group. The DerSimonian and Laird method was used as a random effect model, taking into account that the effect of vitamin D on muscular damage may vary according to the dose administered and additional moderators. Six studies were selected. In conclusion, regarding circulating levels of muscle biomarkers and additional limitations of the studies, it cannot be concluded that vitamin D supplementation exerts an effect in post-exercise muscle recovery. Likely, the anti-inflammatory action of vitamin D is quicker than the recovery of tissue structure and function. This aspect is pending verification in future research.

Allergic Rhinitis: What Do We Know About Allergen-Specific Immunotherapy?

Allergic rhinitis (AR) is an IgE-mediated disease that is characterized by Th2 joint inflammation. Allergen-specific immunotherapy (AIT) is indicated for AR when symptoms remain uncontrolled despite medication and allergen avoidance. AIT is considered to have been effective if it alleviated allergic symptoms, decreased medication use, improved the quality of life even after treatment cessation, and prevented the progression of AR to asthma and the onset of new sensitization. AIT can be administered subcutaneously or sublingually, and novel routes are still being developed, such as intra-lymphatically and epicutaneously. AIT aims at inducing allergen tolerance through modification of innate and adaptive immunologic responses. The main mechanism of AIT is control of type 2 inflammatory cells through induction of various functional regulatory cells such as regulatory T cells (Tregs), follicular T cells (Tfr), B cells (Bregs), dendritic cells (DCregs), innate lymphoid cells (IL-10⁺ ILCs), and natural killer cells (NKregs). However, AIT has a number of disadvantages: the long treatment period required to achieve greater efficacy, high cost, systemic allergic reactions, and the absence of a biomarker for predicting treatment responders. Currently, adjunctive therapies, vaccine adjuvants, and novel vaccine technologies are being studied to overcome the problems associated with AIT. This review presents an updated overview of AIT, with a special focus on AR.

Effect of Vitamin D Supplementation on Muscle Status in Old Patients Recovering from COVID-19 Infection

Background and Objectives: Vitamin D, in addition to its effect on mineral homeostasis, plays a key role in muscle metabolism. Vitamin D supplementation is involved in muscle recovery after damage as a consequence of either pathology or after high-intensity exercise. In this context, the aim of this study was to analyze the effect of vitamin D on muscle fitness in elderly patients in the recovery phase after SARS-CoV-2 (COVID-19) infection. Materials and Methods: This pilot study was conducted at the Soria Norte Health Center. The study consisted of a double-blind trial with two groups of men (placebo and vitamin D-supplemented) (n = 15/group). Treatment with vitamin D (cholecalciferol: 2000 IU/day) and placebo was carried out for 6 weeks. Circulating hematological and biochemical parameters (total protein, glucose, vitamin D, urea, uric acid, aspartate aminotransferase/glutamic-oxaloacetic transaminase, alanine aminotransferase/glutamic-pyruvic transaminase, creatine kinase, lactate dehydrogenase, aldolase, gamma-glutamyl transferase and myoglobin) and the hormones cortisol and testosterone were determined. As for respiratory function tests, FEV1 and respiratory flow were also studied. For physical fitness tests, the “six-minute walk test” (6MWT) was used. Results: After vitamin D supplementation, we observed that serum creatine kinase levels returned to optimal values. This change suggests a protective role of vitamin D against muscle catabolism compared to placebo. In terms of physical test results, we observed only slight non-significant improvements, although patients reported feeling better. Conclusions: Vitamin D supplementation produces decreases in indicators of muscle damage, which may ultimately contribute to improving the health status and quality of life of patients who have suffered from COVID-19, during the recovery process.

Inflammatory and Microbiota-Related Regulation of the Intestinal Epithelial Barrier

The intestinal epithelial barrier (IEB) is one of the largest interfaces between the environment and the internal milieu of the body. It is essential to limit the passage of harmful antigens and microorganisms and, on the other side, to assure the absorption of nutrients and water. The maintenance of this delicate equilibrium is tightly regulated as it is essential for human homeostasis. Luminal solutes and ions can pass across the IEB via two main routes: the transcellular pathway or the paracellular pathway. Tight junctions (TJs) are a multi-protein complex responsible for the regulation of paracellular permeability. TJs control the passage of antigens through the IEB and have a key role in maintaining barrier integrity. Several factors, including cytokines, gut microbiota, and dietary components are known to regulate intestinal TJs. Gut microbiota participates in several human functions including the modulation of epithelial cells and immune system through the release of several metabolites, such as short-chain fatty acids (SCFAs). Mediators released by immune cells can induce epithelial cell damage and TJs dysfunction. The subsequent disruption of the IEB allows the passage of antigens into the mucosa leading to further inflammation. Growing evidence indicates that dysbiosis, immune activation, and IEB dysfunction have a role in several diseases, including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and gluten-related conditions. Here we summarize the interplay between the IEB and gut microbiota and mucosal immune system and their involvement in IBS, IBD, and gluten-related disorders.

Vitamin D, Its Role in Recovery after Muscular Damage Following Exercise

Aside from its role in bone metabolism, vitamin D is a key immunomodulatory micronutrient. The active form of vitamin D (1,25(OH)D) seems to modulate the innate immune system through different mechanisms. The vitamin is involved in the differentiation of monocytes into macrophages, increasing the phagocytic and chemotactic functions of these cells. At the same time, vitamin D enables efferocytosis and prevents immunopathology. In addition, vitamin D is involved in other processes related to immune function, such as inflammation. Regarding muscle tissue, vitamin D plays an active role in muscle inflammatory response, protein synthesis, and regulation of skeletal muscle function. Two mechanisms have been proposed: A direct role of 1,25(OH)D binding to vitamin D receptors (VDRs) in muscle cells and the modulation of calcium transport in the sarcoplasmic reticulum. This second mechanism needs additional investigation. In conclusion, vitamin D seems to be effective in cases of deficiency and/or if there is a great muscular commitment, such as in high intensity exercises.

Immune phase transition under steroid treatment

The steroid hormone glucocorticoid (GC) is a well-known immunosuppressant that controls T-cell-mediated adaptive immune response. In this work, we have developed a minimal kinetic network model of T-cell regulation connecting relevant experimental and clinical studies to quantitatively understand the long-term effects of GC on pro-inflammatory T-cell (T_{pro}) and anti-inflammatory T-cell (T_{anti}) dynamics. Due to the antagonistic relation between these two types of T cells, their long-term steady-state population ratio helps us to characterize three classified immune regulations: (i) weak ([T_{pro}]>[T_{anti}]), (ii) strong ([T_{pro}]<[T_{anti}]), and (iii) moderate ([T_{pro}]∼[T_{anti}]), holding the characteristic bistability. In addition to the differences in their long-term steady-state outcome, each immune regulation shows distinct dynamical phases. In the presteady state, a characteristic intermediate stationary phase is observed to develop only in the moderate regulation regime. In the medicinal field, the resting time in this stationary phase is distinguished as a clinical latent period. GC dose-dependent steady-state analysis shows an optimal level of GC to drive a phase transition from the weak or autoimmune prone to the moderate regulation regime. Subsequently, the presteady state clinical latent period tends to diverge near that optimal GC level where [T_{pro}]:[T_{anti}] is highly balanced. The GC-optimized elongated stationary phase explains the rationale behind the requirement of long-term immune diagnostics, especially when long-term GC-based chemotherapeutics and other immunosuppressive drugs are administrated. Moreover, our study reveals GC sensitivity of clinical latent period, which might serve as an early warning signal in diagnosing different immune phases and determining immune phasewise steroid treatment.

Association Between Low Serum Vitamin D Levels and Sepsis: A Single-Center Study in Tehran, Iran

Background: Vitamin D insufficiency is common in critically ill patients. It is hypothesized that vitamin D deficiency would be associated with sepsis in the critically ill. Thus, the present study aimed to investigate the association between vitamin D and sepsis severity. Method: In this cross-sectional study, patients with sepsis referring to a university hospital in Tehran, Iran, from February 2018 to March 2019 were included. Plasma concentrations of vitamin D in critically ill subjects admitted were assessed. Data were analyzed using SPSS version 20.0. P-values less than 0.05 were considered statistically significant. Results: Among the investigated patients, the mean serum level of vitamin D3 was 19.03 ± 13.08 ng/mL. The prevalence of vitamin D insufficiency in critically ill subjects with sepsis was 100% (150/150). Only sex (P = 0.01) indicated a significant association with vitamin D. Patients suffering from severe sepsis had lower levels of vitamin D compared to the patients with non-severe sepsis (P = 0.07). Conclusions: The present study showed that all critically ill patients studied had vitamin D insufficiency. In line with the biological evidence, the present study suggests that vitamin D deficiency may predispose patients to sepsis. Further studies are needed to establish the causes and mechanisms underlying these interpretations.

Pathogenesis and Management of COVID-19

COVID-19, occurring due to SARS-COV-2 infection, is the most recent pandemic disease that has led to three million deaths at the time of writing. A great deal of effort has been directed towards altering the virus trajectory and/or managing the interactions of the virus with its subsequent targets in the human body; these interactions can lead to a chain reaction-like state manifested by a cytokine storm and progress to multiple organ failure. During cytokine storms the ratio of pro-inflammatory to anti-inflammatory mediators is generally increased, which contributes to the instigation of hyper-inflammation and confers advantages to the virus. Because cytokine expression patterns fluctuate from one person to another and even within the same person from one time to another, we suggest a road map of COVID-19 management using an individual approach instead of focusing on the blockbuster process (one treatment for most people, if not all). Here, we highlight the biology of the virus, study the interaction between the virus and humans, and present potential pharmacological and non-pharmacological modulators that might contribute to the global war against SARS-COV-2. We suggest an algorithmic roadmap to manage COVID-19.

Orbital inflammatory disorders: new knowledge, future challenges

PURPOSE OF REVIEW

This review aims to bring together recent advances in basic, translational and clinical research on the pathogenesis and treatment of orbital inflammatory conditions.

RECENT FINDINGS

Basic science studies provide mechanistic insights into why the orbit is targeted for inflammation by autoimmune inflammatory disorders. Using Graves' disease as a test case reveals that endocrine pathways, such as the TSH and IGF1 receptor pathways play important roles in stimulating orbital inflammation. Furthermore, orbital tissues contain high concentrations of retinoids - byproducts of the visual pathway that diffuse across the sclera and can activate de novo transcription of inflammatory cytokines. Such cytokine expression places the orbit in a hyper-inflammatory 'resting' state, prone to respond to any additional systemic or local pro-inflammatory signals. The HIF2A--LOX pathway appears important for orbital tissue fibrosis. Lastly, bench-to-bedside studies of the IGF1R pathway have led to an FDA-approved drug, teprotumumab that represents a novel treatment approach for Graves' orbitopathy. Unfortunately, high drug costs and misplaced insurance company 'step-therapy' policies may block patients from receiving therapy that can protect vision and improve quality of life.

SUMMARY

Improved understanding of orbital inflammatory conditions has led to a new drug and promises additional breakthroughs. Translational research is successful, but requires time, resources, and patience.

Oral and Topical Vitamin D, Sunshine, and UVB Phototherapy Safely Control Psoriasis in Patients with Normal Pretreatment Serum 25-Hydroxyvitamin D Concentrations: A Literature Review and Discussion of Health Implications

Vitamin D, sunshine and UVB phototherapy were first reported in the early 1900s to control psoriasis, cure rickets and cure tuberculosis (TB). Vitamin D also controlled asthma and rheumatoid arthritis with intakes ranging from 60,000 to 600,000 International Units (IU)/day. In the 1980s, interest in treating psoriasis with vitamin D rekindled. Since 1985 four different oral forms of vitamin D (D2, D3, 1-hydroxyvitaminD3 (1(OH)D3) and 1,25-dihydroxyvitaminD3 (calcitriol)) and several topical formulations have been reported safe and effective treatments for psoriasis-as has UVB phototherapy and sunshine. In this review we show that many pre-treatment serum 25(OH)D concentrations fall within the current range of normal, while many post-treatment concentrations fall outside the upper limit of this normal (100 ng/mL). Yet, psoriasis patients showed significant clinical improvement without complications using these treatments. Current estimates of vitamin D sufficiency appear to underestimate serum 25(OH)D concentrations required for optimal health in psoriasis patients, while concentrations associated with adverse events appear to be much higher than current estimates of safe serum 25(OH)D concentrations. Based on these observations, the therapeutic index for vitamin D needs to be reexamined in the treatment of psoriasis and other diseases strongly linked to vitamin D deficiency, including COVID-19 infections, which may also improve safely with sufficient vitamin D intake or UVB exposure.

Lessons Learned from Hereditary 1,25-Dihydroxyvitamin D-Resistant Rickets Patients on Vitamin D Functions

We summarize here lessons learned from studies on skeletal and extra-skeletal functions of vitamin D in hereditary 1,25-dihydroxyvitamin D-resistant rickets (HVDRR) patients with a mutant, nonfunctioning vitamin D receptor (VDR). During childhood, HVDRR patients are dependent on intestinal VDR, demonstrate low intestinal fraction calcium absorption, and have a bone calcium accretion rate that leads to hypocalcemia and rickets. After puberty, there is recovery in intestinal calcium absorption and in bone calcium accretion and structure. HVDRR monocytes and lymphocytes show impairment in the expression of antimicrobial proteins and demonstrate a proinflammatory cytokine profile. However, HVDRR patients do not exhibit increased rates of infections or inflammatory diseases. Vitamin D deficiency is associated with asthmatic exacerbations. Surprisingly, HVDRR patients do not usually develop asthma. They have normal allergic tests and lung functions and are protected against provoked bronchial hyperactivity. HVDRR patients have decreased IL-5 levels in their exhaled breath condensate. Given that IL-5 is a key cytokine in the development of airway inflammation and hyperactivity and that VDR is important for IL-5 generation, it is plausible that low lung IL-5 protects HVDRR patients from asthma. Vitamin D metabolites have suppressive effects on the renin angiotensin system. However, no HVDRR patient showed hypertension or echocardiographic pathology, and their renin angiotensin metabolites were normal. The VDR is expressed throughout the reproductive system, suggesting a role in reproduction. However, the reproductive history of HVDRR patients is normal despite the lack of a normal VDR. HVDRR patients provide a unique opportunity to study the role of the VDR and the role of vitamin D in various human systems.

Role of vitamin D in regulating COVID-19 severity-An immunological perspective

Vitamin D, a key nutrient/prohormone classically associated with skeletal health, is also an important immunomodulator, with pleotropic effects on innate and adaptive immune cells. Outcomes of several chronic, autoimmune, and infectious diseases are linked to vitamin D. Emergent correlations of vitamin D insufficiency with coronavirus‐induced disease 2019 (COVID‐19) severity, alongside empirical and clinical evidence of immunoregulation by vitamin D in other pulmonary diseases, have prompted proposals of vitamin D supplementation to curb the COVID‐19 public health toll. In this review paper, we engage an immunological lens to discuss potential mechanisms by which vitamin D signals might regulate respiratory disease severity in severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infections, vis a vis other pulmonary infections. It is proposed that vitamin D signals temper lung inflammatory cascades during SARS‐CoV2 infection, and insufficiency of vitamin D causes increased inflammatory cytokine storm, thus leading to exacerbated respiratory disease. Additionally, analogous to studies of reduced cancer incidence, the dosage of vitamin D compounds administered to patients near the upper limit of safety may serve to maximize immune health benefits and mitigate inflammation and disease severity in SARS‐CoV2 infections. We further deliberate on the importance of statistically powered clinical correlative and interventional studies, and the need for in‐depth basic research into vitamin D‐dependent host determinants of respiratory disease severity.

Can Optimum Solar Radiation Exposure or Supplemented Vitamin D Intake Reduce the Severity of COVID-19 Symptoms?

The foremost mortality-causing symptom associated with COVID-19 is acute respiratory distress syndrome (ARDS). A significant correlation has been identified between the deficiency in vitamin D and the risk of developing ARDS. It has been suggested that if we can reduce or modify ARDS in COVID-19 patients, we may significantly reduce the severity of COVID-19 symptoms and associated mortality rates. The increased mortality of dark-skinned people, who have a reduced UV absorption capacity, may be consistent with diminished vitamin D status. The factors associated with COVID-19 mortality, such as old age, ethnicity, obesity, hypertension, cardiovascular diseases, and diabetes, are all found to be linked with vitamin D deficiency. Based on this review and as a precautionary measure, it is suggested that the adoption of appropriate and safe solar exposure and vitamin D enriched foods and supplements should be considered to reduce the possible severity of COVID-19 symptoms. Safe sun exposure is deemed beneficial globally, specifically in low and middle-income countries, as there is no cost involved. It is also noted that improved solar exposure and vitamin D levels can reduce the impact of other diseases as well, thus assisting in maintaining general human well-being.

Probing the Scope and Mechanisms of Calcitriol Actions Using Genetically Modified Mouse Models

Genetically modified mice have provided novel insights into the mechanisms of activation and inactivation of vitamin D, and in the process have provided phenocopies of acquired human disease such as rickets and osteomalacia and inherited diseases such as pseudovitamin D deficiency rickets, hereditary vitamin D resistant rickets, and idiopathic infantile hypercalcemia. Both global and tissue-specific deletion studies leading to decreases of the active form of vitamin D, calcitriol [1,25(OH)2D], and/or of the vitamin D receptor (VDR), have demonstrated the primary role of calcitriol and VDR in bone, cartilage and tooth development and in the regulation of mineral metabolism and of parathyroid hormone (PTH) and FGF23, which modulate calcium and phosphate fluxes. They have also, however, extended the spectrum of actions of calcitriol and the VDR to include, among others: modulation, jointly and independently, of skin metabolism; joint regulation of adipose tissue metabolism; cardiovascular function; and immune function. Genetic studies in older mice have also shed light on the molecular mechanisms underlying the important role of the calcitriol/VDR pathway in diseases of aging such as osteoporosis and cancer. In the course of these studies in diverse tissues, important upstream and downstream, often tissue-selective, pathways have been illuminated, and intracrine, as well as endocrine actions have been described. Human studies to date have focused on acquired or genetic deficiencies of the prohormone vitamin D or the (generally inactive) precursor metabolite 25-hyrodxyvitamin D, but have yet to probe the pleiotropic aspects of deficiency of the active form of vitamin D, calcitriol, in human disease. © 2020 American Society for Bone and Mineral Research © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Vitamin D and Immune Regulation: Antibacterial, Antiviral, Anti-Inflammatory

Regulation of immune function continues to be one of the most well-recognized extraskeletal actions of vitamin D. This stemmed initially from the discovery that antigen presenting cells such as macrophages could actively metabolize precursor 25-hydroxyvitamin D (25D) to active 1,25-dihydroxyvitamin D (1,25D). Parallel observation that activated cells from the immune system expressed the intracellular vitamin D receptor (VDR) for 1,25D suggested a potential role for vitamin D as a localized endogenous modulator of immune function. Subsequent studies have expanded our understanding of how vitamin D exerts effects on both the innate and adaptive arms of the immune system. At an innate level, intracrine synthesis of 1,25D by macrophages and dendritic cells stimulates expression of antimicrobial proteins such as cathelicidin, as well as lowering intracellular iron concentrations via suppression of hepcidin. By potently enhancing autophagy, 1,25D may also play an important role in combatting intracellular pathogens such as M. tuberculosis and viral infections. Local synthesis of 1,25D by macrophages and dendritic cells also appears to play a pivotal role in mediating T-cell responses to vitamin D, leading to suppression of inflammatory T helper (Th)1 and Th17 cells, and concomitant induction of immunotolerogenic T-regulatory responses. The aim of this review is to provide an update on our current understanding of these prominent immune actions of vitamin D, as well as highlighting new, less well-recognized immune effects of vitamin D. The review also aims to place this mechanistic basis for the link between vitamin D and immunity with studies in vivo that have explored a role for vitamin D supplementation as a strategy for improved immune health. This has gained prominence in recent months with the global coronavirus disease 2019 health crisis and highlights important new objectives for future studies of vitamin D and immune function. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Human genetic susceptibility to hepatitis B virus infection

Hepatitis B virus (HBV) infection is still a serious health threat worldwide. The outcomes of HBV infection consist of spontaneous HBV clearance and chronic HBV infection. Multiple factors contribute to the disparity of HBV infection outcomes, including host factors, viral factors and environmental factors. The present review comprehends the current researches mainly focusing on the relationships between genetic determinants, including single nucleotide polymorphisms (SNPs) and haplotypes, and susceptibility of HBV infection, namely chronic (persistent) HBV infection and HBV clearance. A number of determinants in the chromosomes, including mutations in human leukocyte antigens (HLAs), cytokines genes, toll-like receptors (TLRs), and other genes are related to the human susceptibility to HBV infection. Among the above variants, some of those in HLAs have been studied and replicated in multiple-ethnic populations and came to consistent conclusions, while some others are novel and need to be evaluated further.

The role of vitamin D in head and neck cancer

OBJECTIVE

Head and neck squamous cell carcinoma (HNSCC) describes a set of malignancies of the head and neck that continue to inflict considerable morbidity and mortality. Because HNSCC often presents at an advanced stage, patients frequently undergo intensive multi-modal therapy with an intent to cure. Vitamin D is a precursor to the biologically active hormone calcitriol which governs bone and calcium physiology that is obtained from diet and UV-B exposure. Vitamin D is known to have pleiotropic effects on health and disease. In this review, we examine the role of vitamin D in cancer with emphasis on HNSCC and discuss potential avenues for further research that might better elucidate the role of vitamin D in the management of HNSCC.

REVIEW METHODS

A review of MEDLINE database indexed literature concerning the role and biology of vitamin D in HNSCC was conducted, with special consideration of recently published work and research involving immunobiology and HNSCC.

CONCLUSIONS

The available evidence suggests that vitamin D may play a role in protecting against HNSCC, particularly in persons who smoke, although conflicting and limited data exists. Promising initial work encourages the pursuit of further study.

IMPLICATIONS FOR PRACTICE

The significant morbidity and mortality that HNSCC brings warrants continued research in available and safe interventions that improve patient outcomes. With the rise of immunotherapy as an effective modality for treatment, continued research of vitamin D as an adjunct in the treatment of HNSCC is supported.

What immunological and hormonal protective factors lower the risk of COVID-19 related deaths in pregnant women?

Despite anticipated increased risk of COVID-19 and increased expression of the SARS CoV-2 receptor (ACE2), the relatively low mortality of pregnant women with COVID-19 has been an area of wonder. The immunological changes predominantly inclining to anti-inflammatory state, which is augmented by placental hormones' immune modulating action, looks against with COVID-19 inflammatory reaction leading to cytokine storm and multiple organ failure. Unlike many other viral infections, the bilateral immune activation of COVID-19 may preferentially make pregnant women at low risk. Taking the physiological advantage of pregnant women, potential clinical trials are proposed. Quite a large number of epidemiological and obstetrics related studies have addressed the cases of women with COVID-19. However, to the best of the author's knowledge, little is done to explore the physiological internal milieu of pregnant women in relation to COVID-19. This review provides an insight into how the hormonal and immunological changes in pregnancy potentially reduce SARS-CoV-2-mediated inflammatory response.

Cytokine storm in aged people with CoV-2: possible role of vitamins as therapy or preventive strategy

BACKGROUND

In December 2019, a novel human-infecting coronavirus, SARS-CoV-2, had emerged. The WHO has classified the epidemic as a "public health emergency of international concern". A dramatic situation has unfolded with thousands of deaths, occurring mainly in the aged and very ill people. Epidemiological studies suggest that immune system function is impaired in elderly individuals and these subjects often present a deficiency in fat-soluble and hydrosoluble vitamins.

METHODS

We searched for reviews describing the characteristics of autoimmune diseases and the available therapeutic protocols for their treatment. We set them as a paradigm with the purpose to uncover common pathogenetic mechanisms between these pathological conditions and SARS-CoV-2 infection. Furthermore, we searched for studies describing the possible efficacy of vitamins A, D, E, and C in improving the immune system function.

RESULTS

SARS-CoV-2 infection induces strong immune system dysfunction characterized by the development of an intense proinflammatory response in the host, and the development of a life-threatening condition defined as cytokine release syndrome (CRS). This leads to acute respiratory syndrome (ARDS), mainly in aged people. High mortality and lethality rates have been observed in elderly subjects with CoV-2-related infection.

CONCLUSIONS

Vitamins may shift the proinflammatory Th17-mediated immune response arising in autoimmune diseases towards a T-cell regulatory phenotype. This review discusses the possible activity of vitamins A, D, E, and C in restoring normal antiviral immune system function and the potential therapeutic role of these micronutrients as part of a therapeutic strategy against SARS-CoV-2 infection.

Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain)

INTRODUCTION

Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population.

OBJECTIVE

We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing.

MATERIAL AND METHODS

Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307,651, of whom 96,544 (31.4%) were aged ≥ 65 years.

RESULTS

We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases.

CONCLUSION

The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.

Efficacy of vitamin D3 supplementation for the prevention of pulmonary tuberculosis and mortality in HIV: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Observational data suggest that low vitamin D status is associated with an increased incidence of pulmonary tuberculosis and mortality among people living with HIV. The primary aims of this study were to assess the effect of vitamin D₃ supplementation on the risk of mortality and incidence of pulmonary tuberculosis among adults initiating antiretroviral therapy (ART).

METHODS

This was a randomised, double-blind, placebo-controlled trial of vitamin D₃ supplementation among adults living with HIV who initiated ART and had serum 25-hydroxyvitamin D concentrations of less than 30 ng/mL at four large HIV care and treatment centres in Dar es Salaam, Tanzania. Patients were excluded if they were younger than 18 years, pregnant at the time of randomisation, or were enrolled in any other clinical trial. Patients were randomly assigned 1:1 to receive either weekly oral 50 000 IU vitamin D₃ supplements (cholecalciferol) for the first month of ART followed by daily 2000 IU vitamin D₃ supplements or a matching weekly and daily placebo regimen. The randomisation list was computer-generated by a non-study statistician with sequence blocks of ten that were stratified by study clinic. Complete allocation concealment was ensured and patients, field team, and investigators were masked to group assignment. The trial follow-up duration was 1 year and the primary efficacy outcomes were death and incident pulmonary tuberculosis. An intention-to-treat analysis was followed for all-cause mortality; participants diagnosed with or receiving treatment for pulmonary tuberculosis at randomisation, or suspected to have tuberculosis at randomisation and who later had that diagnosis confirmed, were excluded from analyses of pulmonary tuberculosis incidence. Safety was assessed in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT01798680, and is completed.

FINDINGS

Between Feb 24, 2014, and Feb 24, 2017, 6250 adults initiating ART had serum 25-hydroxyvitamin D screening, 4000 of whom were enrolled in the trial and followed up for 1 year (follow-up of all participants was completed on March 7, 2018). 2001 patients were randomly assigned to the vitamin D₃ supplementation group, and 1999 to the placebo group. 415 deaths were recorded: 211 in the vitamin D₃ group and 204 in the placebo group. Among all randomly assigned participants, there was no overall effect of vitamin D₃ supplementation on the risk of mortality (hazard ratio [HR] 1·04, 95% CI 0·85-1·25; p=0·73). There was also no difference in the overall incidence of pulmonary tuberculosis between the vitamin D₃ (50 events in 1812 patients analysed) and placebo groups (64 events in 1827 patients; HR 0·78, 0·54-1·13; p=0·19). The vitamin D₃ regimen did not increase the risk of hypercalcaemia (three events in the vitamin D₃ group and two events in the placebo group; relative risk 1·25, 95% CI 0·43-3·66; Fisher's exact p=1·00). 101 hospital admissions were reported in the vitamin D₃ group and 94 in the placebo group (incidence rate ratio 1·06, 95% CI 0·80-1·41; p=0·66).

INTERPRETATION

Additional research is needed before vitamin D₃ supplementation should be considered for implementation in HIV care and treatment programmes for the prevention of pulmonary tuberculosis or mortality.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Association of vitamin D with the modulation of the disease severity in COVID-19

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Insufficient levels of Vitamin D could be seen in COVID-19 patients.

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Increase in the ACE could be seen in COVID-19 patients with higher quantities in the individuals who died from the COVID-19.

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The Neutrophil to Lymphocyte ratio (NLR) is higher in COVID-19 than the control group.

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Serum levels of vitamin D and ACE are associated with the progression and severity of the COVID-19.

In late 2019, SARS-CoV-2 started to spread throughout the world causing the COVID-19 that has taken a considerable number of lives. Results obtained from several investigations have explained the virus origin, pathogenicity, and transmission. Similar to SARS coronavirus, the pulmonary angiotensin converting enzyme (ACE) 2 was introduced as the virus receptor for entering the cell. An increased body of epidemiological and clinical evidences has shown modulating effects of vitamin D in lung injuries through several mechanisms. Several clinical symptoms as well as molecular factors have shown to be related to the disease transmission and severity. In this study, vitamin D, ACE concentrations, and neutrophil to lymphocyte ratio (NLR) were measured in patients with confirmed COVID-19 in comparison with control group. Results demonstrated significant alterations in vitamin D and ACE levels as well as NLR in the patients’ group. Contribution of those factors with the prognosis and severity of the disease has been shown.

Efficacy and safety of active vitamin D supplementation in chronic spontaneous urticaria patients

Background: Chronic spontaneous urticaria (CSU) is a common skin disorder affecting negatively patients' lives. Vitamin D deficiency has been reported to be associated to many allergic skin disorders.Objective: This study aimed to evaluate the association between the serum level of 25 hydroxy vitamin D and CSU and to assess the efficacy and safety of active vitamin D in management of CSU.Methods: The study was conducted on 77 patients with CSU and 67 healthy controls, then the 77 CSU patients were randomized to either the study group that received 0.25 µg alfacalcidol daily or the placebo group that received oral placebo for 12 weeks.Results: Serum 25(OH) D was significantly lower in CSU as compared to healthy controls and was negatively correlated to the urticarial severity. After alfacalcidol administration, the study group showed significant higher level of 25(OH) D compared to the placebo group. In addition, the mean serum level of IL6, hsCRP and TNFα significantly decreased in the study group in comparison to the placebo group and as compared to their baseline results.Conclusion: Vitamin D deficiency is more common in CSU patients as compared to healthy people and hence, alfacalcidol might have a beneficial role as add on therapy in CSU management with no reported side effects.