Vitamin D Insufficiency and Deficiency in Mexican Patients With Systemic Lupus Erythematosus: Prevalence and Relationship With Disease Activity

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What do We Know?" 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Exercise specialists should share their knowledge on exercise with rheumatologists, who must, in turn, share it with their patients. The role of instructors is to make exercise attractive and adapt it to the physical condition and activity of the patients, information that they should receive from the rheumatologists. The latter should do all they can to manage their patients’ disease and eliminate their fears of exercise, giving them encouragement and reminding them that it is necessary. Patients should begin immediately and make it a habit as soon as possible, with an attitude of active coping. Sports facilities should be accessible and provide atmospheres that favor participation. Patient associations could promote both, and serve as a platform for instructor training." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rafael Curbelo Rodríguez, Pedro Zarco Montejo, Raquel Almodóvar González, Mariano Flórez García, Loreto Carmona Ortells" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Rafael" "apellidos" => "Curbelo Rodríguez" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Zarco Montejo" ] 2 => array:2 [ "nombre" => "Raquel" "apellidos" => "Almodóvar González" ] 3 => array:2 [ "nombre" => "Mariano" "apellidos" => "Flórez García" ] 4 => array:2 [ "nombre" => "Loreto" "apellidos" => "Carmona Ortells" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X16000486" "doi" => "10.1016/j.reuma.2016.03.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => 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"Jiménez-Herrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Viridiana" "apellidos" => "Robles-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Alma" "apellidos" => "Rodríguez-Gallegos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Araceli" "apellidos" => "Ramos-Varela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Margarita" "apellidos" => "Muñoz-Guarneros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 9 => array:3 [ "nombre" => "Alejandro" "apellidos" => "Ruiz-Argüelles" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unidad de Investigación de Enfermedades Autoinmunes Sistémicas, Hospital General Regional N.° 36, Instituto Mexicano del Seguro Social, Puebla, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Reumatología e Inmunología, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Laboratorios Clínicos de Puebla, Puebla, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Secretaría de Estudios de Posgrado e Investigación, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Universidad de las Américas Puebla, Puebla, Mexico" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Insuficiencia y deficiencia de vitamina D en pacientes mexicanas con lupus eritematoso sistémico: prevalencia y relación con actividad de la enfermedad" ] ] "textoCompleto" => "IntroductionVitamin D (vit D) is a fat-soluble prohormone that acts by binding to vitamin D receptor (VDR).<a class="elsevierStyleCrossRef" href="#bib0150">1</a> The discovery of VDR in most of the cells of the immune system (lymphocytes and macrophages) suggests that it participates in the regulation of the immune response, beyond its traditional role in bone health and calcium homeostasis. Vitamin D has been related to several chronic diseases such as cardiovascular disease, cancer and autoimmune diseases like type 1 diabetes mellitus, multiple sclerosis, rheumatoid arthritis and systemic lupus erythematosus (SLE).<a class="elsevierStyleCrossRefs" href="#bib0155">2,3</a> The latter is a multisystem autoimmune disease characterized by a diversity of immunological changes. A number of the immunomodulatory activities of vit D deficiency counteract the immunological alterations observed in SLE. This vitamin has been related to inhibition of the production of IgG anti-double-stranded DNA (anti-dsDNA), dendritic cell maturation and interferon alpha (IFN-α) gene expression in patients with SLE.<a class="elsevierStyleCrossRefs" href="#bib0165">4,5</a> A recent study also showed that patients with SLE and vit D deficiency had greater IFN-α activity and B-cell activation compared with those who had higher vit D levels. This fact shows that vit D insufficiency can intensify the immunological changes in SLE patients<a class="elsevierStyleCrossRef" href="#bib0175">6</a>; this deficiency seems to be multifactorial (lack of sun exposure, use of sunscreens, glucocorticoid therapy and chronic kidney disease).<a class="elsevierStyleCrossRefs" href="#bib0180">7,8</a> The epidemiology of vit D insufficiency in SLE patients in tropical countries like Mexico should be analyzed, as we have access to preventive and therapeutic methods. However, the relationship between vit D levels and disease activity is a controversial subject. The objectives of this study are to determine the prevalence of vit D insufficiency and deficiency in Mexican SLE patients and compare the vit D levels in patients with and without disease activity.Patients and MethodsIn this observational, cross-sectional, prospective study we enrolled Mexican Mestizo women who met the classification criteria for SLE of the American College of Rheumatology (ACR).<a class="elsevierStyleCrossRefs" href="#bib0190">9,10</a> The patients were from the research unit for systemic autoimmune diseases of Hospital General Regional N.° 36 of the Mexican Social Security Institute, Puebla, Mexico. All of the participants signed the informed consent form. The local institutional committee approved the study. The sample size was determined in accordance with the difference in vit D in SLE patients with and without disease activity. The calculated minimum sample size was 126patients. The participating women were legally of age (≥18 years), and were excluded if they had chronic kidney disease (creatinine clearance <60mL/min), cancer or hyperparathyroidism, and if they were pregnant or breastfeeding. A structured interview was held to obtain demographic data and the medical history, including age, a history of photosensitivity, the use of sunscreens, disease duration, a diagnosis of diabetes mellitus, glucocorticoid (prednisone) therapy and dose at the time of the study, as well as administration of immunosuppressive agents, chloroquine and vit D supplementation. Physical examination provided weight, height and body mass index.Disease ActivityWe used the Systemic Lupus Erythematosus Disease Activity Index, validated for the Mexican population (MEX-SLEDAI),<a class="elsevierStyleCrossRef" href="#bib0200">11</a> to evaluate disease activity. This resulted in a group of patients with no activity—MEX-SLEDAI score of 0–2—and those with activity, indicated by a score of ≥3.<a class="elsevierStyleCrossRef" href="#bib0205">12</a>Vitamin D MeasurementsSeveral serum samples were collected to measure serum 25-hydroxyvitamin D (25[OH]D) using an ARCHITECT chemiluminescent microparticle immunoassay (Abbott, Abbott Park, IL, United States). Vitamin D insufficiency was defined as 25(OH)D levels <30ng/mL and deficiency as <10ng/mL.<a class="elsevierStyleCrossRefs" href="#bib0180">7,13</a> For the statistical analysis, we considered any level of vit D <30ng/mL to be low.Statistical AnalysisAll of the statistical estimates were performed using the statistical software package SPSS version 18.0 for Windows (SPSS Inc., Chicago, IL, United States). Normality of the data was established with the Kolmogorov–Smirnov test. Normally distributed variables were expressed using means and standard deviations, and those that were not normally distributed, by median and interquartile range. The prevalence of vit D insufficiency and deficiency was calculated as the proportion between the number of patients with 25(OH)D levels under the cut-off point (30 and 10ng/mL, respectively) and total participants. Univariate comparisons of categorical variables were done with the chi-square test. Comparisons of continuous variables in the two groups were done using Student's t test or the Mann–Whitney U test, depending on the case. In the correlation between two continuous variables, Pearson or Spearman correlation coefficient was utilized, respectively, for normal and non-normal data. We performed linear regression analysis, in the attempt to identify factors that could be associated with 25(OH)D. Statistical significance was considered to be indicated by a P value <.05.ResultsPatient CharacteristicsThe demographic, clinical and treatment characteristics of the 137 patients included are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The mean age and disease duration were 45.9±11.6 and 7.7±3.4 years, respectively. The majority of the participants had a history of photosensitivity (67%), utilization of sunscreens (52.6%) and oral vit D supplementation (77.3%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Prevalence of Vitamin D Insufficiency and Deficiency and Possible Associated FactorsThe mean 25(OH)D value was 19.7±6.3ng/mL. The prevalence of vit D insufficiency (<30ng/mL) was 89.0% (122 patients) and that of deficiency (<10ng/mL) was 2.9% (4 patients); thus, 91.9% (126 patients) had low vit D levels. Univariate analysis showed no association between insufficiency (low levels) of vit D and the demographic and clinical variables studied, including photosensitivity, the use of sunscreens, oral vit D supplementation and glucocorticoid therapy (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Vitamin D Insufficiency and Disease ActivityIn most SLE patients, the intensity of disease activity evaluated with MEX-SLEDAI was mild to moderate, with a median (interquartile range) score of 2 (0–8). In agreement with the presence and absence of activity, 31 patients (22.6%) were classified as active (20 patients [14.6%] with mild activity and 11 patients [8%] with moderate activity) and 106 patients (77.4%) as inactive. The levels of 25(OH)D were slightly lower in the group of patients with activity, compared to those with no activity; however, this difference was not statistically significant (19.3±4.5ng/mL versus 19.7±6.8ng/mL; P=.75). The 25(OH)D levels were not related to the MEX-SLEDAI values (P=.21). This variable was not a statistically significant predictor in the multiple regression model mentioned above.DiscussionThe measurement of serum 25(OH)D levels is considered to be the most accurate method of evaluating an individual's vit D status.<a class="elsevierStyleCrossRef" href="#bib0215">14</a> The results of the present study show that low vit D levels are common among patients with SLE (91.9% with levels <30ng/mL), despite the fact that the population studied lives in Mexico, a country with sunny weather most of the year. To our knowledge, this is the first Mexican study designed to identify the prevalence of vit D insufficiency and deficiency in a population with SLE. A number of studies in other populations have reported these prevalences in SLE, although the 25(OH)D levels considered for the analysis differ from one study to another (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In a recent report, Mok et al.<a class="elsevierStyleCrossRef" href="#bib0220">15</a> studied 290 SLE patients, finding a prevalence similar to the 96% observed by us, one of the highest, together with that of a Spanish study authored by Cutillas-Marco et al.<a class="elsevierStyleCrossRef" href="#bib0225">16</a> in which, in a population of 55 patients—most of whom (80%) had skin involvement—the authors found a prevalence of insufficiency of 95% and of deficiency of 11%. A Mexican report evaluated the vit D insufficiency in the general population, including 31 women, with a mean age of 34.1±9.7years. The prevalence of vit D insufficiency (<30ng/mL) in this group was 83.9%.<a class="elsevierStyleCrossRef" href="#bib0230">17</a> Clark et al.<a class="elsevierStyleCrossRef" href="#bib0235">18</a> measured serum vit D levels in 585 healthy Mexicans, 54% of whom were women; of the total population, 9.6% had adequate levels (≥30ng/mL), with prevalences of 46.8% and 43.6% for levels of 20–29ng/mL and <20ng/mL respectively. Both studies show a high prevalence of vit D insufficiency in the general population of Mexico. However, our study suggests that the frequency of vit D insufficiency is greater in SLE patients. On the other hand, in the present study, we analyzed the possible risk factors associated with vit D insufficiency in women with SLE, finding no association with age, disease duration, photosensitivity, photoprotection, vit D supplementation or glucocorticoid therapy. The absence of these associations may be due to a sample size that was insufficient for this purpose. With respect to these findings, it is important to point out that vit D plays two important physiological functions in SLE patients: first, it helps to preserve bone homeostasis, maintaining the amount of calcium-phosphate product within a normal range<a class="elsevierStyleCrossRef" href="#bib0240">19</a> and, second, it also modulates the immune system and has immunoregulatory effects. In vitro studies have shown that 1,25-hydroxyvitamin D3 modulates the immune response, both innate and adaptive.<a class="elsevierStyleCrossRef" href="#bib0245">20</a> Vitamin D increases the production of interleukin 10 and the chemokine, CCL22, derived from dendritic cells that promote the development and chemotaxis of T regulatory cells.<a class="elsevierStyleCrossRefs" href="#bib0250">21,22</a> It also decreases T lymphocyte activation mediated by dendritic cells through the downregulation of the expression of major histocompatibility complex class II molecules and costimulators.<a class="elsevierStyleCrossRef" href="#bib0170">5</a> Moreover, vit D exerts modulatory effects on the B cells, inhibiting their proliferation, their differentiation into plasma cells and the production of immunoglobulin (Ig) G and IgM.<a class="elsevierStyleCrossRef" href="#bib0260">23</a> Several of the immunoregulatory actions of vit D counteract the immunological changes observed in SLE patients. Studies have demonstrated that 1,25-hydroxyvitamin D and its analogs inhibit the production of IgG anti-dsDNA.<a class="elsevierStyleCrossRef" href="#bib0265">24</a> Likewise, vit D has been found to inhibit dendritic cell maturation and the expression of IFN-α genes in patients with SLE.<a class="elsevierStyleCrossRef" href="#bib0165">4</a> In a more recent study, it was also seen that SLE patients with vit D deficiency had a greater serum IFN-α activity and B cell activation compared with those patients who had higher levels of vit D.<a class="elsevierStyleCrossRef" href="#bib0175">6</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Considering the effects of vit D on immunological tolerance, there is growing interest in the influence of vit D deficiency on disease activity in SLE. It is evident that vit D could physiologically contribute to the regulation of the innate and adaptive immune responses. This concept is compatible with the results of research that takes into account the association between vit D insufficiency and a more marked activity in SLE; however the results are controversial. Ruiz-Irastorza et al.,<a class="elsevierStyleCrossRef" href="#bib0270">25</a> analyzing 92 SLE patients in Spain, concluded that vit D insufficiency was not associated with activity measured with the SLEDAI score, as occurred in the study of Toloza et al.,<a class="elsevierStyleCrossRef" href="#bib0275">26</a> who, in 124 SLE patients, observed no correlation between disease activity and the vit D levels. Souto et al.<a class="elsevierStyleCrossRef" href="#bib0280">27</a> recently studied 159 Brazilian patients with a diagnosis of SLE, and found no association between the score for lupus activity evaluated by SLEDAI-2K and vit D insufficiency. In our study, we failed to find an association between vit D insufficiency and lupus activity measured using the MEX-SLEDAI tool; however, it is important that we consider that most of our patients had mild-to-moderate activity, meaning that these results could not be extrapolated to populations with SLE in whom the disease activity was severe. On the other hand, Amital et al.<a class="elsevierStyleCrossRef" href="#bib0285">28</a> analyzed several cohorts of 378 SLE patients from Israel and Europe, and concluded that the serum vit D concentrations were inversely related to disease activity; however, this correlation was weak (r=−0.12). In a study in Hungary, in which 90 SLE patients were analyzed, the serum 25(OH)D levels correlated inversely with the SLEDAI score, and with the concentrations of anti-dsDNA, of anti-Smith and of immunoglobulins.<a class="elsevierStyleCrossRef" href="#bib0290">29</a> The present study has certain limitations. In the first place, the cross-sectional nature of the study design, with the possible presentation of susceptibility bias. In the second place, the absence of healthy controls with whom to compare prevalences of vit D insufficiency and deficiency. Moreover, in our study, it was not possible to determine anti-dsDNA, C3, C4 or other serum markers in all of the patients. Finally, as we mentioned above, most of the participants in our study had a lupus activity that had been classified as mild-to-moderate, a situation that limits the extrapolation of our results to other SLE populations.In conclusion, women in whom SLE has been diagnosed have an elevated prevalence of vit D insufficiency, even in a tropical country like Mexico. The prevalence of vit D insufficiency shown by our findings was higher than that of most of the studies conducted in a population with SLE. In this report, it was not possible to identify factors associated with vit D insufficiency, and the 25(OH)D levels were not related to the disease activity. The consequences of vitamin insufficiency can interfere with bone metabolism, but may have no relationship to the lupus activity.Ethical DisclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of InterestThe authors declare they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres812445" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec809882" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres812444" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec809881" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Disease Activity" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Vitamin D Measurements" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Patient Characteristics" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Prevalence of Vitamin D Insufficiency and Deficiency and Possible Associated Factors" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Vitamin D Insufficiency and Disease Activity" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0055" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of Interest" ] 10 => array:2 [ "identificador" => "xack272386" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-05" "fechaAceptado" => "2016-02-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec809882" "palabras" => array:4 [ 0 => "Systemic lupus erythematosus" 1 => "Vitamin D" 2 => "Insufficiency" 3 => "Deficiency" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec809881" "palabras" => array:4 [ 0 => "Lupus eritematoso sistémico" 1 => "Vitamina D" 2 => "Insuficiencia" 3 => "Deficiencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesTo determine and compare the prevalence of vitamin D insufficiency and deficiency in patients with systemic lupus erythematosus (SLE) with and without disease activity. Patients and methodsWe made a comparative, observational, cross-sectional, prospective study of 137 women with SLE according to American College of Rheumatology criteria. Patients with chronic kidney disease, cancer, hyperparathyroidism, pregnancy, and lactation were excluded. Disease activity was assessed using the MEX-SLEDAI score: a score of ≥3 was considered as disease activity. Data were collected on diabetes mellitus, the use of corticosteroids, chloroquine, and immunosuppressants, photoprotection and vitamin D supplementation. Vitamin D levels were measured by chemiluminescent immunoassay: insufficiency was defined as serum 25-hydroxyvitamin D <30ng/mL and deficiency as <10ng/mL. Results137 women with SLE (mean age 45.9±11.6 years, disease duration 7.7±3.4 years) were evaluated. Mean disease activity was 2 (0–8): 106 patients had no disease activity and 31 had active disease (77.4% versus 22.6%). Vitamin D insufficiency and deficiency was found in 122 (89.0%) and 4 (2.9%) patients, respectively. There was no significant difference in vitamin D levels between patients with and without active disease (19.3±4.5 versus 19.7±6.8; P=.75). No correlation between the MEX-SLEDAI score (P=.21), photosensitivity, photoprotection, prednisone or chloroquine use and vitamin D supplementation was found. ConclusionsWomen with SLE had a high prevalence of vitamin D insufficient. No association between vitamin D levels and disease activity was found." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosDeterminar la prevalencia de insuficiencia y deficiencia de vitamina D en pacientes con lupus eritematoso sistémico (LES) y compararlas con actividad de la enfermedad. Pacientes y métodosEstudio comparativo, observacional, transversal y prolectivo. Se incluyeron 137mujeres con LES según los criterios del Colegio Americano de Reumatología. Se excluyeron pacientes con enfermedad renal crónica, cáncer, hiperparatiroidismo, embarazo y lactancia. La actividad fue medida mediante el índice MEX-SLEDAI, considerando actividad ≥3. Se obtuvieron los siguientes datos: diabetes mellitus, uso de glucocorticoides, cloroquina e inmunosupresores, fotoprotección y suplementación con vitamina D. Los niveles de vitamina D se midieron con inmunoanálisis quimioluminiscente considerando insuficiencia a niveles séricos de 25-hidroxivitamina D<30ng/ml y deficiencia<10ng/ml. ResultadosSe evaluaron 137mujeres con LES (edad promedio 45,9±11,6años, duración de la enfermedad 7,7±3,4 años). La mediana de actividad mediante MEX-SLEDAI fue 2 (0-8),106pacientes en inactividad y 31 con actividad (77,4% versus 22,6%). La insuficiencia y deficiencia de vitamina D se encontró en 122 (89,0%) y 4 (2,9%) pacientes respectivamente. Al comparar los niveles de vitamina D entre pacientes con y sin actividad no existieron diferencias estadísticamente significativas (19,3±4,5 versus 19,7±6,8; p=0,75); tampoco se encontró una correlación con el puntaje MEX-SLEDAI (p=0,21) ni fotosensibilidad, fotoprotección, uso de prednisona, cloroquina ni suplementación con vitamina D. ConclusionesLas mujeres con LES presentaron elevada prevalencia de insuficiencia de vitamina D. No se encontró asociación de niveles de vitamina D con actividad de la enfermedad." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García-Carrasco M, Mendoza-Pinto C, Etchegaray-Morales I, Soto-Santillán P, Jiménez-Herrera EA, Robles-Sánchez V, et al. Insuficiencia y deficiencia de vitamina D en pacientes mexicanas con lupus eritematoso sistémico: prevalencia y relación con actividad de la enfermedad. Reumatol Clin. 2017;13:97–101." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI, body mass index; MEX-SLEDAI, Mexican Systemic Lupus Erythematosus Disease Activity Index; SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics (n=137) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Values \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, mean±SD (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.9±11.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disease duration, mean±SD (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.7±3.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, mean±SD (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.7±5.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photosensitivity, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 (67) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoprotection, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 (52.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current tobacco use, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current prednisone therapy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126 (91.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present prednisone dose, mean±SD (mg/d) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.6±10.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (87.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppressive therapy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (44.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral vitamin D supplementation (0.25μg), n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 (77.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI, median (interquartile range), score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0–8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI=0–2, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 (77.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI≥3, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (22.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal activity, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1364327.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic, Clinical and Therapeutic Characteristics of 137 Women With Systemic Lupus Erythematosus." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI, body mass index; SD, standard deviation; vit D, vitamin D." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Normal vit D \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Vit D insufficiency (low levels) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">P value \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">25(OH)D≥30ng/mL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">25(OH)D<30ng/mL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=11 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=126 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, mean±SD (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.0±11.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.5±12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disease duration, mean±SD (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.6±6.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3±6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, mean±SD (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.4±5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6±3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photosensitivity, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 (69.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (63.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoprotection, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (52.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (54.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current tobacco use, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (9.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current prednisone therapy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">117 (92.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (81.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present prednisone dose, mean±SD (mg/d) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.8±10.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.7±5.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">111 (88.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (81.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppressive therapy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral vit D supplementation (0.25μg), n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (77.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (72.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1364326.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of Patients With Systemic Lupus Erythematosus With Normal Vitamin D Versus Vitamin D Insufficiency (Low Levels)." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author, year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamin D status: 25(OH)D levels (ng/mL) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kamen et al., 2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Deficiency (<30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Thudi et al., 2008</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">37</td><td class="td" title="table-entry " align="left" valign="top">Insufficiency (<32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency (<19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Ruiz-Irastorza et al., 2008</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">92</td><td class="td" title="table-entry " align="left" valign="top">Insufficiency (<30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency (<10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toloza et al., 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Insufficiency (<32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Souto et al., 2011</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">159</td><td class="td" title="table-entry " align="left" valign="top">Insufficiency (<30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency (<20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Mok et al., 2012</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">290</td><td class="td" title="table-entry " align="left" valign="top">Insufficiency (<30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency (<15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1364328.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of Recent Studies on the Prevalence of Vitamin D Insufficiency and Deficiency in Patients With Systemic Lupus Erythematosus." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The vitamin D receptor: new paradigms for the regulation of gene expression by 1,25-dihydroxyvitamin D3" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.W. 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Original Article

Vitamin D Insufficiency and Deficiency in Mexican Patients With Systemic Lupus Erythematosus: Prevalence and Relationship With Disease Activity

Insuficiencia y deficiencia de vitamina D en pacientes mexicanas con lupus eritematoso sistémico: prevalencia y relación con actividad de la enfermedad

Mario García-Carrascoa,b,

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mgc30591@yahoo.com
mgarciacarrasco@yahoo.com

Corresponding author.

, Claudia Mendoza-Pintoa,b, Ivet Etchegaray-Moralesa, Pamela Soto-Santillána, Erick Alejandro Jiménez-Herreraa, Viridiana Robles-Sáncheza, Alma Rodríguez-Gallegosc, Araceli Ramos-Varelaa, Margarita Muñoz-Guarnerosd, Alejandro Ruiz-Argüellesc,e

a Unidad de Investigación de Enfermedades Autoinmunes Sistémicas, Hospital General Regional N.° 36, Instituto Mexicano del Seguro Social, Puebla, Mexico

b Departamento de Reumatología e Inmunología, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico

c Laboratorios Clínicos de Puebla, Puebla, Mexico

d Secretaría de Estudios de Posgrado e Investigación, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico

e Universidad de las Américas Puebla, Puebla, Mexico

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as we have access to preventive and therapeutic methods&#46; However&#44; the relationship between vit D levels and disease activity is a controversial subject&#46; The objectives of this study are to determine the prevalence of vit D insufficiency and deficiency in Mexican SLE patients and compare the vit D levels in patients with and without disease activity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">In this observational&#44; cross-sectional&#44; prospective study we enrolled Mexican Mestizo women who met the classification criteria for SLE of the American College of Rheumatology &#40;ACR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;10</span></a> The patients were from the research unit for systemic autoimmune diseases of Hospital General Regional N&#46;&#176; 36 of the Mexican Social Security Institute&#44; Puebla&#44; Mexico&#46; All of the participants signed the informed consent form&#46; The local institutional committee approved the study&#46; The sample size was determined in accordance with the difference in vit D in SLE patients with and without disease activity&#46; The calculated minimum sample size was 126<span class="elsevierStyleHsp" style=""></span>patients&#46; The participating women were legally of age &#40;&#8805;18 years&#41;&#44; and were excluded if they had chronic kidney disease &#40;creatinine clearance &#60;60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#41;&#44; cancer or hyperparathyroidism&#44; and if they were pregnant or breastfeeding&#46; A structured interview was held to obtain demographic data and the medical history&#44; including age&#44; a history of photosensitivity&#44; the use of sunscreens&#44; disease duration&#44; a diagnosis of diabetes mellitus&#44; glucocorticoid &#40;prednisone&#41; therapy and dose at the time of the study&#44; as well as administration of immunosuppressive agents&#44; chloroquine and vit D supplementation&#46; Physical examination provided weight&#44; height and body mass index&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Disease Activity</span><p id="par0015" class="elsevierStylePara elsevierViewall">We used the Systemic Lupus Erythematosus Disease Activity Index&#44; validated for the Mexican population &#40;MEX-SLEDAI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> to evaluate disease activity&#46; This resulted in a group of patients with no activity&#8212;MEX-SLEDAI score of 0&#8211;2&#8212;and those with activity&#44; indicated by a score of &#8805;3&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Vitamin D Measurements</span><p id="par0020" class="elsevierStylePara elsevierViewall">Several serum samples were collected to measure serum 25-hydroxyvitamin D &#40;25&#91;OH&#93;D&#41; using an ARCHITECT chemiluminescent microparticle immunoassay &#40;Abbott&#44; Abbott Park&#44; IL&#44; United States&#41;&#46; Vitamin D insufficiency was defined as 25&#40;OH&#41;D levels &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and deficiency as &#60;10<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;13</span></a> For the statistical analysis&#44; we considered any level of vit D &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL to be low&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical Analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">All of the statistical estimates were performed using the statistical software package SPSS version 18&#46;0 for Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; United States&#41;&#46; Normality of the data was established with the Kolmogorov&#8211;Smirnov test&#46; Normally distributed variables were expressed using means and standard deviations&#44; and those that were not normally distributed&#44; by median and interquartile range&#46; The prevalence of vit D insufficiency and deficiency was calculated as the proportion between the number of patients with 25&#40;OH&#41;D levels under the cut-off point &#40;30 and 10<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#44; respectively&#41; and total participants&#46; Univariate comparisons of categorical variables were done with the chi-square test&#46; Comparisons of continuous variables in the two groups were done using Student&#39;s <span class="elsevierStyleItalic">t</span> test or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#44; depending on the case&#46; In the correlation between two continuous variables&#44; Pearson or Spearman correlation coefficient was utilized&#44; respectively&#44; for normal and non-normal data&#46; We performed linear regression analysis&#44; in the attempt to identify factors that could be associated with 25&#40;OH&#41;D&#46; Statistical significance was considered to be indicated by a <span class="elsevierStyleItalic">P</span> value &#60;&#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Patient Characteristics</span><p id="par0030" class="elsevierStylePara elsevierViewall">The demographic&#44; clinical and treatment characteristics of the 137 patients included are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The mean age and disease duration were 45&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6 and 7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4 years&#44; respectively&#46; The majority of the participants had a history of photosensitivity &#40;67&#37;&#41;&#44; utilization of sunscreens &#40;52&#46;6&#37;&#41; and oral vit D supplementation &#40;77&#46;3&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Prevalence of Vitamin D Insufficiency and Deficiency and Possible Associated Factors</span><p id="par0035" class="elsevierStylePara elsevierViewall">The mean 25&#40;OH&#41;D value was 19&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;3<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; The prevalence of vit D insufficiency &#40;&#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; was 89&#46;0&#37; &#40;122 patients&#41; and that of deficiency &#40;&#60;10<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; was 2&#46;9&#37; &#40;4 patients&#41;&#59; thus&#44; 91&#46;9&#37; &#40;126 patients&#41; had low vit D levels&#46; Univariate analysis showed no association between insufficiency &#40;low levels&#41; of vit D and the demographic and clinical variables studied&#44; including photosensitivity&#44; the use of sunscreens&#44; oral vit D supplementation and glucocorticoid therapy &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Vitamin D Insufficiency and Disease Activity</span><p id="par0040" class="elsevierStylePara elsevierViewall">In most SLE patients&#44; the intensity of disease activity evaluated with MEX-SLEDAI was mild to moderate&#44; with a median &#40;interquartile range&#41; score of 2 &#40;0&#8211;8&#41;&#46; In agreement with the presence and absence of activity&#44; 31 patients &#40;22&#46;6&#37;&#41; were classified as active &#40;20 patients &#91;14&#46;6&#37;&#93; with mild activity and 11 patients &#91;8&#37;&#93; with moderate activity&#41; and 106 patients &#40;77&#46;4&#37;&#41; as inactive&#46; The levels of 25&#40;OH&#41;D were slightly lower in the group of patients with activity&#44; compared to those with no activity&#59; however&#44; this difference was not statistically significant &#40;19&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5<span class="elsevierStyleHsp" style=""></span>ng&#47;mL versus 19&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;75&#41;&#46; The 25&#40;OH&#41;D levels were not related to the MEX-SLEDAI values &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;21&#41;&#46; This variable was not a statistically significant predictor in the multiple regression model mentioned above&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The measurement of serum 25&#40;OH&#41;D levels is considered to be the most accurate method of evaluating an individual&#39;s vit D status&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> The results of the present study show that low vit D levels are common among patients with SLE &#40;91&#46;9&#37; with levels &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; despite the fact that the population studied lives in Mexico&#44; a country with sunny weather most of the year&#46; To our knowledge&#44; this is the first Mexican study designed to identify the prevalence of vit D insufficiency and deficiency in a population with SLE&#46; A number of studies in other populations have reported these prevalences in SLE&#44; although the 25&#40;OH&#41;D levels considered for the analysis differ from one study to another &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; In a recent report&#44; Mok et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> studied 290 SLE patients&#44; finding a prevalence similar to the 96&#37; observed by us&#44; one of the highest&#44; together with that of a Spanish study authored by Cutillas-Marco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> in which&#44; in a population of 55 patients&#8212;most of whom &#40;80&#37;&#41; had skin involvement&#8212;the authors found a prevalence of insufficiency of 95&#37; and of deficiency of 11&#37;&#46; A Mexican report evaluated the vit D insufficiency in the general population&#44; including 31 women&#44; with a mean age of 34&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7<span class="elsevierStyleHsp" style=""></span>years&#46; The prevalence of vit D insufficiency &#40;&#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; in this group was 83&#46;9&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Clark et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> measured serum vit D levels in 585 healthy Mexicans&#44; 54&#37; of whom were women&#59; of the total population&#44; 9&#46;6&#37; had adequate levels &#40;&#8805;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#44; with prevalences of 46&#46;8&#37; and 43&#46;6&#37; for levels of 20&#8211;29<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and &#60;20<span class="elsevierStyleHsp" style=""></span>ng&#47;mL respectively&#46; Both studies show a high prevalence of vit D insufficiency in the general population of Mexico&#46; However&#44; our study suggests that the frequency of vit D insufficiency is greater in SLE patients&#46; On the other hand&#44; in the present study&#44; we analyzed the possible risk factors associated with vit D insufficiency in women with SLE&#44; finding no association with age&#44; disease duration&#44; photosensitivity&#44; photoprotection&#44; vit D supplementation or glucocorticoid therapy&#46; The absence of these associations may be due to a sample size that was insufficient for this purpose&#46; With respect to these findings&#44; it is important to point out that vit D plays two important physiological functions in SLE patients&#58; first&#44; it helps to preserve bone homeostasis&#44; maintaining the amount of calcium-phosphate product within a normal range<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> and&#44; second&#44; it also modulates the immune system and has immunoregulatory effects&#46; In vitro studies have shown that 1&#44;25-hydroxyvitamin D3 modulates the immune response&#44; both innate and adaptive&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Vitamin D increases the production of interleukin 10 and the chemokine&#44; CCL22&#44; derived from dendritic cells that promote the development and chemotaxis of T regulatory cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21&#44;22</span></a> It also decreases T lymphocyte activation mediated by dendritic cells through the downregulation of the expression of major histocompatibility complex class II molecules and costimulators&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Moreover&#44; vit D exerts modulatory effects on the B cells&#44; inhibiting their proliferation&#44; their differentiation into plasma cells and the production of immunoglobulin &#40;Ig&#41; G and IgM&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Several of the immunoregulatory actions of vit D counteract the immunological changes observed in SLE patients&#46; Studies have demonstrated that 1&#44;25-hydroxyvitamin D and its analogs inhibit the production of IgG anti-dsDNA&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> Likewise&#44; vit D has been found to inhibit dendritic cell maturation and the expression of IFN-&#945; genes in patients with SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> In a more recent study&#44; it was also seen that SLE patients with vit D deficiency had a greater serum IFN-&#945; activity and B cell activation compared with those patients who had higher levels of vit D&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Considering the effects of vit D on immunological tolerance&#44; there is growing interest in the influence of vit D deficiency on disease activity in SLE&#46; It is evident that vit D could physiologically contribute to the regulation of the innate and adaptive immune responses&#46; This concept is compatible with the results of research that takes into account the association between vit D insufficiency and a more marked activity in SLE&#59; however the results are controversial&#46; Ruiz-Irastorza et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> analyzing 92 SLE patients in Spain&#44; concluded that vit D insufficiency was not associated with activity measured with the SLEDAI score&#44; as occurred in the study of Toloza et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> who&#44; in 124 SLE patients&#44; observed no correlation between disease activity and the vit D levels&#46; Souto et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> recently studied 159 Brazilian patients with a diagnosis of SLE&#44; and found no association between the score for lupus activity evaluated by SLEDAI-2K and vit D insufficiency&#46; In our study&#44; we failed to find an association between vit D insufficiency and lupus activity measured using the MEX-SLEDAI tool&#59; however&#44; it is important that we consider that most of our patients had mild-to-moderate activity&#44; meaning that these results could not be extrapolated to populations with SLE in whom the disease activity was severe&#46; On the other hand&#44; Amital et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> analyzed several cohorts of 378 SLE patients from Israel and Europe&#44; and concluded that the serum vit D concentrations were inversely related to disease activity&#59; however&#44; this correlation was weak &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;12&#41;&#46; In a study in Hungary&#44; in which 90 SLE patients were analyzed&#44; the serum 25&#40;OH&#41;D levels correlated inversely with the SLEDAI score&#44; and with the concentrations of anti-dsDNA&#44; of anti-Smith and of immunoglobulins&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> The present study has certain limitations&#46; In the first place&#44; the cross-sectional nature of the study design&#44; with the possible presentation of susceptibility bias&#46; In the second place&#44; the absence of healthy controls with whom to compare prevalences of vit D insufficiency and deficiency&#46; Moreover&#44; in our study&#44; it was not possible to determine anti-dsDNA&#44; C3&#44; C4 or other serum markers in all of the patients&#46; Finally&#44; as we mentioned above&#44; most of the participants in our study had a lupus activity that had been classified as mild-to-moderate&#44; a situation that limits the extrapolation of our results to other SLE populations&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; women in whom SLE has been diagnosed have an elevated prevalence of vit D insufficiency&#44; even in a tropical country like Mexico&#46; The prevalence of vit D insufficiency shown by our findings was higher than that of most of the studies conducted in a population with SLE&#46; In this report&#44; it was not possible to identify factors associated with vit D insufficiency&#44; and the 25&#40;OH&#41;D levels were not related to the disease activity&#46; The consequences of vitamin insufficiency can interfere with bone metabolism&#44; but may have no relationship to the lupus activity&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical Disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine and compare the prevalence of vitamin D insufficiency and deficiency in patients with systemic lupus erythematosus &#40;SLE&#41; with and without disease activity&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We made a comparative&#44; observational&#44; cross-sectional&#44; prospective study of 137 women with SLE according to American College of Rheumatology criteria&#46; Patients with chronic kidney disease&#44; cancer&#44; hyperparathyroidism&#44; pregnancy&#44; and lactation were excluded&#46; Disease activity was assessed using the MEX-SLEDAI score&#58; a score of &#8805;3 was considered as disease activity&#46; Data were collected on diabetes mellitus&#44; the use of corticosteroids&#44; chloroquine&#44; and immunosuppressants&#44; photoprotection and vitamin D supplementation&#46; Vitamin D levels were measured by chemiluminescent immunoassay&#58; insufficiency was defined as serum 25-hydroxyvitamin D &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and deficiency as &#60;10<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">137 women with SLE &#40;mean age 45&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6 years&#44; disease duration 7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4 years&#41; were evaluated&#46; Mean disease activity was 2 &#40;0&#8211;8&#41;&#58; 106 patients had no disease activity and 31 had active disease &#40;77&#46;4&#37; versus 22&#46;6&#37;&#41;&#46; Vitamin D insufficiency and deficiency was found in 122 &#40;89&#46;0&#37;&#41; and 4 &#40;2&#46;9&#37;&#41; patients&#44; respectively&#46; There was no significant difference in vitamin D levels between patients with and without active disease &#40;19&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5 versus 19&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;75&#41;&#46; No correlation between the MEX-SLEDAI score &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;21&#41;&#44; photosensitivity&#44; photoprotection&#44; prednisone or chloroquine use and vitamin D supplementation was found&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Women with SLE had a high prevalence of vitamin D insufficient&#46; No association between vitamin D levels and disease activity was found&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia de insuficiencia y deficiencia de vitamina D en pacientes con lupus eritematoso sist&#233;mico &#40;LES&#41; y compararlas con actividad de la enfermedad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio comparativo&#44; observacional&#44; transversal y prolectivo&#46; Se incluyeron 137<span class="elsevierStyleHsp" style=""></span>mujeres con LES seg&#250;n los criterios del Colegio Americano de Reumatolog&#237;a&#46; Se excluyeron pacientes con enfermedad renal cr&#243;nica&#44; c&#225;ncer&#44; hiperparatiroidismo&#44; embarazo y lactancia&#46; La actividad fue medida mediante el &#237;ndice MEX-SLEDAI&#44; considerando actividad &#8805;<span class="elsevierStyleHsp" style=""></span>3&#46; Se obtuvieron los siguientes datos&#58; diabetes mellitus&#44; uso de glucocorticoides&#44; cloroquina e inmunosupresores&#44; fotoprotecci&#243;n y suplementaci&#243;n con vitamina D&#46; Los niveles de vitamina D se midieron con inmunoan&#225;lisis quimioluminiscente considerando insuficiencia a niveles s&#233;ricos de 25-hidroxivitamina D<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml y deficiencia<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron 137<span class="elsevierStyleHsp" style=""></span>mujeres con LES &#40;edad promedio 45&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;6<span class="elsevierStyleHsp" style=""></span>a&#241;os&#44; duraci&#243;n de la enfermedad 7&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;4 a&#241;os&#41;&#46; La mediana de actividad mediante MEX-SLEDAI fue 2 &#40;0-8&#41;&#44;106<span class="elsevierStyleHsp" style=""></span>pacientes en inactividad y 31 con actividad &#40;77&#44;4&#37; versus 22&#44;6&#37;&#41;&#46; La insuficiencia y deficiencia de vitamina D se encontr&#243; en 122 &#40;89&#44;0&#37;&#41; y 4 &#40;2&#44;9&#37;&#41; pacientes respectivamente&#46; Al comparar los niveles de vitamina D entre pacientes con y sin actividad no existieron diferencias estad&#237;sticamente significativas &#40;19&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;5 versus 19&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;8&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;75&#41;&#59; tampoco se encontr&#243; una correlaci&#243;n con el puntaje MEX-SLEDAI &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;21&#41; ni fotosensibilidad&#44; fotoprotecci&#243;n&#44; uso de prednisona&#44; cloroquina ni suplementaci&#243;n con vitamina D&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las mujeres con LES presentaron elevada prevalencia de insuficiencia de vitamina D&#46; No se encontr&#243; asociaci&#243;n de niveles de vitamina D con actividad de la enfermedad&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Carrasco M&#44; Mendoza-Pinto C&#44; Etchegaray-Morales I&#44; Soto-Santill&#225;n P&#44; Jim&#233;nez-Herrera EA&#44; Robles-S&#225;nchez V&#44; et al&#46; Insuficiencia y deficiencia de vitamina D en pacientes mexicanas con lupus eritematoso sist&#233;mico&#58; prevalencia y relaci&#243;n con actividad de la enfermedad&#46; Reumatol Clin&#46; 2017&#59;13&#58;97&#8211;101&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; body mass index&#59; MEX-SLEDAI&#44; Mexican Systemic Lupus Erythematosus Disease Activity Index&#59; SD&#44; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>137&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Values&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disease duration&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photosensitivity&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94 &#40;67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoprotection&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72 &#40;52&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current tobacco use&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current prednisone therapy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126 &#40;91&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present prednisone dose&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;mg&#47;d&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120 &#40;87&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppressive therapy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;44&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral vitamin D supplementation &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106 &#40;77&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI&#44; median &#40;interquartile range&#41;&#44; score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#8211;2&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106 &#40;77&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MEX-SLEDAI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;22&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal activity&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic&#44; Clinical and Therapeutic Characteristics of 137 Women With Systemic Lupus Erythematosus&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; body mass index&#59; SD&#44; standard deviation&#59; vit D&#44; vitamin D&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Normal vit D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Vit D insufficiency &#40;low levels&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">25&#40;OH&#41;D<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">25&#40;OH&#41;D<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>126&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Disease duration&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photosensitivity&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87 &#40;69&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Photoprotection&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;52&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;54&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current tobacco use&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;11&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;9&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current prednisone therapy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">117 &#40;92&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;81&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present prednisone dose&#44; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;mg&#47;d&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chloroquine&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">111 &#40;88&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;81&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Immunosuppressive therapy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral vit D supplementation &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>&#956;g&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98 &#40;77&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;72&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of Patients With Systemic Lupus Erythematosus With Normal Vitamin D Versus Vitamin D Insufficiency &#40;Low Levels&#41;&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author&#44; year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vitamin D status&#58; 25&#40;OH&#41;D levels &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kamen et al&#46;&#44; 2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deficiency &#40;&#60;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Thudi et al&#46;&#44; 2008</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">37</td><td class="td" title="table-entry  " align="left" valign="top">Insufficiency &#40;&#60;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency &#40;&#60;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Ruiz-Irastorza et al&#46;&#44; 2008</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">92</td><td class="td" title="table-entry  " align="left" valign="top">Insufficiency &#40;&#60;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency &#40;&#60;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Toloza et al&#46;&#44; 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insufficiency &#40;&#60;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Souto et al&#46;&#44; 2011</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">159</td><td class="td" title="table-entry  " align="left" valign="top">Insufficiency &#40;&#60;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency &#40;&#60;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Mok et al&#46;&#44; 2012</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">290</td><td class="td" title="table-entry  " align="left" valign="top">Insufficiency &#40;&#60;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deficiency &#40;&#60;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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    "bibliografia" => array:2 [
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Article information

ISSN: 21735743
Original language: English

DOI:10.1016/j.reumae.2016.02.013

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Year/Month	Html	Pdf	Total

2024 November	6	14	20
2024 October	49	47	96
2024 September	64	29	93
2024 August	64	40	104
2024 July	51	40	91
2024 June	63	32	95
2024 May	72	28	100
2024 April	55	31	86
2024 March	65	28	93
2024 February	52	24	76
2024 January	44	29	73
2023 December	38	28	66
2023 November	46	34	80
2023 October	47	25	72
2023 September	107	43	150
2023 August	48	10	58
2023 July	43	24	67
2023 June	39	18	57
2023 May	47	23	70
2023 April	27	22	49
2023 March	107	31	138
2023 February	75	41	116
2023 January	56	26	82
2022 December	132	30	162
2022 November	85	38	123
2022 October	87	30	117
2022 September	63	32	95
2022 August	45	41	86
2022 July	38	34	72
2022 June	55	31	86
2022 May	74	42	116
2022 April	116	58	174
2022 March	71	51	122
2022 February	73	46	119
2022 January	88	56	144
2021 December	73	36	109
2021 November	88	48	136
2021 October	106	70	176
2021 September	56	44	100
2021 August	32	49	81
2021 July	46	40	86
2021 June	39	37	76
2021 May	78	83	161
2021 April	154	113	267
2021 March	107	38	145
2021 February	69	26	95
2021 January	80	26	106
2020 December	77	36	113
2020 November	98	26	124
2020 October	60	26	86
2020 September	83	43	126
2020 August	51	41	92
2020 July	41	17	58
2020 June	89	36	125
2020 May	81	28	109
2020 April	60	21	81
2020 March	36	12	48
2018 May	7	0	7
2018 April	32	9	41
2018 March	54	12	66
2018 February	16	8	24
2018 January	20	6	26
2017 December	19	11	30
2017 November	37	17	54
2017 October	38	16	54
2017 September	27	11	38
2017 August	34	9	43
2017 July	38	17	55
2017 June	45	12	57
2017 May	45	20	65
2017 April	66	35	101
2017 March	37	22	59
2017 February	2	6	8

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