Then roll your shoulders in the opposite direction by moving your shoulders back, up, forward, and down. Khaw KT, Stewart AW, Waayer D, et al. Gaksch M, Jorde R, Grimnes G, et al. 2017;61(1):1273574. SLE is characterized by the presence of a large spectrum of autoantibodies resulting in potential damage to multiple tissues (133). Treatment includes stretching, massage, and application of ice or heat. Originally written in 2000 by: Indeed, following dietary intake or synthesis in the epidermis of skin after UVB exposure, both forms of vitamin D enter the circulation and are transported to the liver by the vitamin D-binding protein (and to a lesser extent by albumin). Your doctor may advise you to wear a soft cervical collar to limit neck motion and allow the muscles in your neck to rest. Jetter A, Egli A, Dawson-Hughes B, et al. Jahnsen J, Falch JA, Mowinckel P, Aadland E. Vitamin D status, parathyroid hormone and bone mineral density in patients with inflammatory bowel disease. Daniel Bubnis, M.S., NASM-CPT, NASE Level II-CSS, nonsteroidal anti-inflammatory drugs (NSAIDs), 7. (Right) A disk that has degenerated and collapsed. Questioning vitamin D status of elderly fallers and nonfallers: a meta-analysis to address a 'forgotten step'. J Alzheimers Dis. [40] The CDC recommends that adults receive a booster vaccine every ten years,[1] and standard care practice in many places is to give the booster to any person with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccine. Gandini S, Raimondi S, Gnagnarella P, Dore JF, Maisonneuve P, Testori A. Vitamin D and skin cancer: a meta-analysis. Foot cramps at night can range from a slight annoyance to a major factor in preventing good sleep. Conditions that decrease vitamin D synthesis in the skin, such as having dark-colored skin, living in temperate latitudes, and aging, are associated with increased prevalence of hypertension (334), suggesting that vitamin D may reduce blood pressure levels in selected groups of individuals. A randomized controlled trial of high-dose vitamin D2 followed by intranasal insulin in Alzheimer's disease. (PubMed), 25. Maternal vitamin D supplementation to meet the needs of the breastfed infant: a systematic review. (PubMed), 98. A recent meta-analysis of 12 small randomized controlled trials in participants at high risk for CVD found a significant increase in FMD with vitamin D supplementation (daily doses, 2,500-5,000 IU; weekly dose, 50,000 IU; monthly dose, 60,000 IU; single-bolus doses, 100,000-200,000 IU) for eight weeks to six months (198). Ultrasound Obstet Gynecol. Muscle cramps and diuretic therapy. 2003;88(1):157-161. (PubMed), 322. While light exercise can help, moderate or intense exercise can affect your sleep, so youll want to avoid it right before bed. Most multivitamins contain 400 IU (10 g) of vitamin D, and single-ingredient vitamin D supplements are available for additional supplementation. Low levels of sun exposure and vitamin D deficiency appear to be associated with the development of multiple sclerosis (MS). Dobson R, Yarnall A, Noyce AJ, Giovannoni G. Bone health in chronic neurological diseases: a focus on multiple sclerosis and parkinsonian syndromes. Further, in an analysis of data from the UK Biobank, regular use of vitamin D supplements was found to be associated with a 34% lower risk of SARS-CoV-2 infection compared nonusers of vitamin D supplements(292). 2011;22(3):144-150. At birth, the body contains about 26 to 30 g calcium. In a nested case-control study, there was no difference in mean serum concentration of 25-hydroxyvitamin D during the first trimester of pregnancy between 343 mothers of children with type 1 diabetes and 343 control mothers (143). A muscle strain can be a source of extraordinary pain. Cangussu LM, Nahas-Neto J, Orsatti CL, Bueloni-Dias FN, Nahas EA. Low maternal circulating levels of vitamin D as potential determinant in the development of gestational diabetes mellitus. Im JH, Je YS, Baek J, Chung MH, Kwon HY, Lee JS. Bourlon PM, Billaudel B, Faure-Dussert A. SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels. Baktash V, Hosack T, Patel N, et al. 2013;4:e33. Stretching is great for you, and adding extras like resistance bands and foam rollers may give you faster relief from muscle spasms. J Clin Endocrinol Metab. 2014;4:CD000227. Moreover, only recently, efforts have been made toward the standardization of commercially and laboratory-developed 25-hydroxyvitamin D assays, such that guidelines have been developed using largely unstandardized research data (49). Nutrients. -It promotes strength and mobility of unaffected muscles and facilitates healing of surrounding trauma. (PubMed), 51. Poor vitamin D status may compromise the function of specific immune cells critical in the regulation of various immune responses and help trigger autoimmunity in MS (144). Cancer Epidemiol Biomarkers Prev. 2013;5(4):1577-1600. Here are some exercises and home remedies that can. Handb Clin Neurol. The disease does not spread between people. 2012;64(12):1829-1836. However, some patients with severe neck pain will not be candidates for surgery. Accessed 6/11/17. Yet, two recent meta-analyses of observational studies found an inverse relationship between vitamin D status and disease activity in RA patients, assessed using the Disease Activity Score 28 (DAS28) (171, 172). 2017;2(6):608-616. Cervical spondylosis arises from degenerative changes that occur in the spine as we age. Annweiler C, Fantino B, Gautier J, Beaudenon M, Thiery S, Beauchet O. Cognitive effects of vitamin D supplementation in older outpatients visiting a memory clinic: a pre-post study. [2] Other symptoms of tetanus may include fever, sweating, headache, trouble swallowing, high blood pressure, and a fast heart rate. Effect of vitamin D supplementation during pregnancy on maternal and neonatal outcomes: a systematic review and meta-analysis of randomized controlled trials. 2001;15(14):2579-2585. Low serum 25-hydroxyvitamin D concentrations (<29.4 ng/mL) during the second trimester of pregnancy were also associated with GDM incidence in a nested case-control study of 118 women with GDM and 219 matched control subjects (252). They are commonly caused by: Muscle spasms in the lower back often occur when you are bent over and lifting something, but they can happen during any movement involving your lower body. 2013;5(1):111-148. Ananthakrishnan AN, Khalili H, Higuchi LM, et al. (PubMed), 140. It maintains the proper pull of traction. 2020;12(9): 2757. Despite high adherence to treatment, the incidence of non-vertebral fracture was similar in postmenopausal women supplemented with vitamin D3 (initial dose of 200,000 IU followed by 100,000/month) or placebo for over three years in the Vitamin D Assessment (ViDA) trial (79). Logan VF, Gray AR, Peddie MC, Harper MJ, Houghton LA. More recently, vitamin D3 (1,000 IU/day for one month) improved the severity of winter-related atopic dermatitis in Mongolian children, as shown by changes in Eczema Area and Severity Index (EASI) and Investigators Global Assessment (IGA) scores (319). Another trial, the Randomised Evaluation of Calcium Or vitamin D (RECORD) study, reported that oral supplemental vitamin D3 (800 IU/day) alone, or in combination with calcium (1,000 mg/day), did not prevent the occurrence of osteoporotic fractures in elderly adults who had already experienced a low-trauma, osteoporotic fracture (77). Vitamin D in relation to cognitive impairment, cerebrospinal fluid biomarkers, and brain volumes. (PubMed), 303. Additionally, older adults have diminished capacity to synthesize vitamin D from sunlight exposure and frequently use sunscreen or protective clothing in order to prevent skin cancer and sun damage. For example, a nested case-control study of men (622 cases and 1,451 controls) from Scandinavia found a U-shaped relationship between serum 25-hydroxyvitamin D concentrations and prostate cancer risk. Nutr J. Oregon State University, Updated in January 2008 by: Associations between vitamin D receptor polymorphisms and susceptibility to ulcerative colitis and Crohn's disease: a meta-analysis. Mendelian randomization studies do not support a role for vitamin D in coronary artery disease. Food and Nutrition Board, Institute of Medicine. (PubMed), 100. Philadelphia: Saunders Book Company; 2003:1317-1320. Higher vitamin D dietary intake is associated with lower risk of Alzheimer's disease: a 7-year follow-up. Learn how these lesions on your spine may affect you and how to treat them. Brondum-Jacobsen P, Benn M, Afzal S, Nordestgaard BG. Several intervention studies have evaluated the effect of vitamin D supplementation on blood pressure. Blood 25-hydroxyvitamin D concentration and hypertension: a meta-analysis. Breast Cancer Res Treat. Adv Exp Med Biol. Vitamin D status and outcomes in heart failure patients. Treating pain and spasms with hot or cold therapy can be extremely effective.. For a persistent spasm, apply an ice pack on the muscle for 15 to 20 minutes at a time, a few times a day. 2013;88(6):945-953. Witham MD, Price RJ, Struthers AD, et al. 2009;21(2):113-122. Sorensen IM, Joner G, Jenum PA, Eskild A, Torjesen PA, Stene LC. PLoS One. Observational studies have documented an association between vitamin D deficiency and increasedincidence and severity of the coronavirus disease, COVID-19. Corvallis, Oregon 97331, phone: 541-737-5075 | fax: 541-737-5077 Nichols EK, Khatib IM, Aburto NJ, et al. Without sufficient vitamin D from sun exposure or dietary intake, intestinal calcium absorption can be significantly reduced. Fukumoto S. Phosphate metabolism and vitamin D. Bonekey Rep. 2014;3:497. Weisse K, Winkler S, Hirche F, et al. Lower levels of circulating vitamin D have been reported in patients newly diagnosed with type 1 diabetes mellitus compared to age- and sex-matched non-diabetic subjects (135, 136). (PubMed), 208. Chiu KC, Chu A, Go VL, Saad MF. Data sources include IBM Watson Micromedex (updated 2 Dec 2022), Cerner Multum (updated 7 Dec 25-Hydroxyvitamin D levels and cognitive performance and decline in elderly men. 2006;26(4A):2531-2542. The 25-hydroxyvitamin D metabolite is also present at low levels is certain foods, including meats, dairy products, and eggs (347, 348). Although the causes of osteoporosis are multifactorial, vitamin D insufficiency can be an important etiological factor in older adults. You have entered an incorrect email address! 2012;12(2):127-136. 2013;37(1):147-171. Gupta V, Walia GK, Sachdeva MP. 2013;346:f1169. (PubMed), 234. Yet, the potential benefits of vitamin D supplementation in the prevention of glucose intolerance and GDM during pregnancy have not been assessed. Costochondritis is the inflammation of the cartilage that connects the rib to the breastbone. Suboptimal vitamin D status has also been linked to arterial stiffness and vascular endothelial dysfunctionstrong determinants of incident hypertension and adverse cardiovascular outcomes (329). 2012;35(1):42-48. Vitamin D status in gastrointestinal and liver disease. Arthritis Care Res (Hoboken). Zeitz U, Weber K, Soegiarto DW, Wolf E, Balling R, Erben RG. Mass Spectrom Rev. Tetanus is caused by the tetanus bacterium Clostridium tetani. Lower back pain is often caused by an injury (like a muscle strain) or an underlying condition. Lancet Diabetes Endocrinol. 2014;20(2):112-114. Am J Clin Nutr. Am J Clin Nutr. 2016;17(10). (PubMed), 13. Nutr J. Proc Natl Acad Sci U S A. Int J Infect Dis. Eur J Clin Nutr. [citation needed], The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a soft-tipped instrument and observing the effect. Osteoporosis affects one-third of women aged 60 to 70 years and two-thirds of women aged 80 years and above (66). Mokry LE, Ross S, Ahmad OS, et al. Lopes da Silva S, Vellas B, Elemans S, et al. Congestive heart failure (also called cardiac insufficiency) is characterized by increased heart rate and subsequent hypertrophy of the left heart ventricle. Bountouvi E, Douros K, Papadopoulou A. A sternum fracture, or break in the breastbone, is usually caused by direct trauma to the bone. (PubMed), 190. Lancet. An early prospective study of women who participated in the First US National Health and Nutrition Examination Survey (NHANES I) found that Caucasian women with adequate sunlight exposure and dietary vitamin D intake had a significantly reduced risk of breast cancer 20 years later (110). Tuohimaa P, Tenkanen L, Ahonen M, et al. Ruiz-Irastorza G, Egurbide MV, Olivares N, Martinez-Berriotxoa A, Aguirre C. Vitamin D deficiency in systemic lupus erythematosus: prevalence, predictors and clinical consequences. Sommer I, Griebler U, Kien C, et al. Mesquita Kde C, Igreja AC, Costa IM. 2012;223(1):86-94. Kaufman HW, Niles JK, Kroll MH, Bi C, Holick MF. 2017;181:9-15. A bone fracture (abbreviated FRX or Fx, F x, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. 2000;85(11):4125-4130. Conversely, vitamin D deficiency may compromise the integrity of the immune system and lead to inappropriate immune responses (see Autoimmune diseases). 2013;8(6):e66627. Associations between vitamin D status, supplementation, outdoor work and risk of Parkinson's disease: a meta-analysis assessment. Martineau AR, Jolliffe DA, Hooper RL, et al. [32], The tetanus toxin, tetanospasmin, is made up of a heavy chain and a light chain. PLoS One. The Journal of Pediatrics is an international peer-reviewed journal that advances pediatric research and serves as a practical guide for pediatricians who manage health and diagnose and treat disorders in infants, children, and adolescents.The Journal publishes original work based on standards of excellence and expert review. Finally, there is a dearth of studies exploring the effect of vitamin D supplementation on disease activity in arthritis subjects. Acta Diabetol. Administer medications prior to activities. Swelling and bruising normally develop, and in some cases there may be numbness and muscle weakness. In contrast, the risk of all-cause mortality varied little for baseline serum 25-hydroxyvitamin D concentrations in the range of 16 to 40 ng/mL (60). 2015;37(5):1686-1692. The epidemiology of multiple sclerosis: insights to disease pathogenesis. Hastie CE, Mackay DF, Ho F, et al. Reid IR, Bolland MJ, Grey A. [30][31], Tetanus neurotoxin (TeNT) binds to the presynaptic membrane of the neuromuscular junction, is internalized and is transported back through the axon until it reaches the central nervous system. (PubMed), 88. (PubMed), 335. In contrast, another Mendelian randomization study associated genetic determinants of low vitamin D status to higher risk of AD in the International Genomics of Alzheimers Project dataset (17,008 AD cases and 37,154 healthy cases) (232). Moreover, the beneficial effect of phototherapy observed in specific cases of atopic dermatitis may be partly mediated by the action of vitamin D (311). Diabetologia. Evidence from randomized controlled trials is currently too limited to conclude whether vitamin D supplementation may reduce breast cancer incidence (reviewed in 114). Yet, in a recent prospective cohort study of 3,002 individuals (mean age, 59 years at baseline), the incidence of hypertension, which affected 41% of participants during the nine year follow-up period, was not higher in those with serum 25-hydroxyvitamin D concentrations lower than 20 ng/mL and was only marginally associated with elevated PTH concentrations (192). 2002;110(2):229-238. 2016;68(1):91-98. 2013;13:142. Another nested case-control study (119 mothers of children with type 1 diabetes and 129 control mothers) found an inverse association between maternal vitamin D-binding proteinbut not 25-hydroxyvitamin Dconcentration during the third trimester of pregnancy and the risk of type 1 diabetes in children (274). Nutrition. 2015;20(8):790-796. Last medically reviewed on August 23, 2018. 1998;8(3):222-230. 2012;5(4):187-198. Atopic dermatitis is a chronic inflammatory skin disorder characterized by dry and pruritus (itchy) areas of the skin in affected subjects. Neurology. Similar results were obtained in a meta-analysis of eight prospective cohort studies that considered the relationship between standardized 25-hydroxyvitamin D concentrations and mortality during a median follow-up period of 10.5 years. (PubMed), 129. While the etiology of the disease is not fully elucidated, it has been suggested that vitamin D deficiency might contribute to the onset and/or the severity of the disease (312). It prevents sudden pull-on fracture, which could be associated with pain and muscle spasms. Ahn J, Yu K, Stolzenberg-Solomon R, et al. [Your name] is not affiliated or endorsed by the Linus Pauling Institute or Oregon State University. (2015). Specific exercises can help relieve pain, as well as strengthen and stretch weakened or strained muscles. (PubMed), 6. Research in mice lacking the gene encoding the VDR indicates that 1,25-dihydroxyvitamin D decreases the expression of the gene encoding renin through its interaction with the VDR (18). Nonetheless, there is a lack of intervention trials to show whether vitamin D supplementation could limit inflammation and reduce disease risk (including RA) in subjects with high inflammation levels (166). Available at: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/assessing-risk-factors.html. (PubMed), 118. Hypertension is a well-known risk factor for cardiovascular disease (CVD) (191). This page was last edited on 6 December 2022, at 22:20. Smolders J, Thewissen M, Peelen E, et al. The renin-angiotensin system plays an important role in the regulation of blood pressure (16). (PubMed), 184. Metabolic syndrome refers to several metabolic disorders, including dyslipidemia, hypertension, insulin resistance, and obesity. Landel V, Annweiler C, Millet P, Morello M, Feron F. Vitamin D, cognition and Alzheimer's disease: the therapeutic benefit is in the D-tails. Mult Scler. JAMA Intern Med. The back pain you are feeling when you bend over is likely due to a muscle pull or strain. In many cases, a popping joint isnt cause for concern unless its causing pain, discomfort, or swelling. 2017;106(1):155-161. (PubMed), 82. (PubMed), 111. Heaney RP, Dowell MS, Hale CA, Bendich A. Calcium absorption varies within the reference range for serum 25-hydroxyvitamin D. J Am Coll Nutr. Moreover, SARS-CoV-2 infected individuals can spread disease before they experience symptoms (i.e., presymptomatic transmission) (289), placing importance on public health measures like hand washing, face mask wearing, social distancing, and testing and contact tracing to curtail the pandemic. (PubMed), 211. The Vitamin D Assessment (ViDA) study: design of a randomized controlled trial of vitamin D supplementation for the prevention of cardiovascular disease, acute respiratory infection, falls and non-vertebral fractures. (PubMed), 195. A greater prevalence of vitamin D insufficiency and deficiency has also been observed in prediabetic children who developed multiple islet autoantibodies (antibodies against insulin-secreting pancreatic cells) compared to autoantibody-negative children. The following medications should not be taken at the same time as vitamin D because they can decrease the intestinal absorption of vitamin D: cholestyramine (Questran), colestipol (Colestid), orlistat (Xenical), and mineral oil (364, 365). Jackson RD, LaCroix AZ, Gass M, et al. Radujkovic A, Hippchen T, Tiwari-Heckler S, Dreher S, Boxberger M, Merle U. Vitamin D deficiency and outcome of COVID-19 patients. Jones AN, Hansen KE. [1] Having recently experienced head trauma may indicate cephalic tetanus if no other diagnosis has been made. Indeed, while it is considered that serum 25-hydroxyvitamin D concentrations less than 8 to 10 ng/mL (20 to 25 nmol/L) indicate severe deficiency associated with rickets and osteomalacia, several studies have observed that PTH concentrations (50, 51) and calcium absorption (52) were not optimized with serum 25-hydroxyvitamin D concentrations below 32 ng/mL (80 nmol/L). Vitamin D and polymorphisms of VDR gene in patients with systemic lupus erythematosus. Mithal A, Wahl DA, Bonjour JP, et al. In addition, a case-control study that included 111 hip fracture patients and 73 controls (median age, 83 years) found that lower serum concentrations of both 25-hydroxyvitamin D and vitamin K1 in patients compared to controls were associated with an increased risk of hip fracture (68). Gulseth HL, Wium C, Angel K, Eriksen EF, Birkeland KI. Xue LN, Xu KQ, Zhang W, Wang Q, Wu J, Wang XY. 2020;12(11):3377. Linus Pauling Institute PLoS Med. Anticancer Res. 2012;29(7):e25-32. Food Nutr Res. Wagner CL, Greer FR, American Academy of Pediatrics Section on B, American Academy of Pediatrics Committee on N. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. (PubMed), 101. The D-Health Trial: A randomized trial of vitamin D for prevention of mortality and cancer. Nutritional status of patients with COVID-19. More research is needed to investigate a causal relationship between vitamin D repletion and potential long-term cognitive benefits in older adults. Due to C.tetani being an anaerobic bacterium, it and its endospores thrive in environments that lack oxygen, such as a puncture wound. Results of a genetic analysis of data from this trial also suggested that beneficial effects of vitamin D and calcium supplementation on fracture risk might be limited to women with the lowest genetic risk of low BMD (75). (PubMed), 90. Do wearing tight shoes or high heels lead to toe cramps. (PubMed), 79. In a small randomized, double-blind, placebo-controlled study in 45 patients with atopic dermatitis and low vitamin D status (70% of subjects had serum 25-hydroxyvitamin D concentrations <20 ng/mL), daily administration of 1,600 IU of oral vitamin D3, alone or together with 600 IU/day of vitamin E, for a period of 60 days significantly reduced the extent and intensity of eczema, as assessed by the SCORAD (SCORing Atopic Dermatitis) score (317). They will also ask questions to understand more about your symptoms and any injuries that may have occurred to your neck. The recently completed VITAL (Vitamin D and Omega-3 Trial) may provide additional evidence of an effect of daily dosing (2,000 IU/day of vitamin D) on risk of airway infections in older adults, although the prevention of infectious disease is a secondary outcome in the trial (204, 283, 284). Cell Physiol Biochem. They will conduct a number of tests, looking for problems or changes in: Your doctor may also gently press on your neck and shoulders feeling for trigger (tender) points or swollen glands. Nutr J. (PubMed), 239. Oz F, Cizgici AY, Oflaz H, et al. Andreoli L, Dall'Ara F, Piantoni S, et al. (PubMed), 298. N Engl J Med. The absence of vitamin D receptors (VDR) in genetically modified mice has been linked to higher levels of inflammation and increased susceptibility to autoimmunity (161). Clinical trials have failed to demonstrate any benefit of vitamin D supplementation, alone or in combination with IFN- treatment, with respect to relapse rates and disability-related symptoms in MS patients (154, 155). Maternal vitamin D status and adverse pregnancy outcomes: a systematic review and meta-analysis. The swelling of the joints associated with sternum fractures can cause popping in this area as well. Monticielo OA, Teixeira Tde M, Chies JA, Brenol JC, Xavier RM. Eur J Heart Fail. Vitamin D deficiency severely affects rapidly growing bones. (PubMed), 112. Here it will be released into the synaptic cleft and allowed to bind with the presynaptic membrane of inhibitory neurons in a similar manner seen with the binding to the motor neuron. The Linus Pauling Institute's Micronutrient Information Center provides scientific information on the health aspects of dietary factors and supplements, food, and beverages for the general public. Calcium plus vitamin D and the risk of colorectal cancer. 2003;17(5):777-791. 2011;29(4):636-645. Stein MS, Scherer SC, Ladd KS, Harrison LC. Cancer Causes Control. (PubMed), 251. 2015;14:76. Vitamin D status and outcomes for hospitalised older patients with COVID-19. Asymptomatic patients as a source of COVID-19 infections: A systematic review and meta-analysis. Vitamin D supplementation in infants with chronic congestive heart failure. Hypercalcemia has been observed following daily doses of greater than 50,000 IU of vitamin D (360). You can also use a strap or belt looped around your foot to gently pull the top of your foot toward you. One recent clinical trial, for example, randomized 78 frail and near-frail adults aged 65 years and older to receive 20 mcg (800 IU) vitamin D 3 , 10 mcg 25(OH)D, or placebo daily for 6 months. N Engl J Med. But Pagets disease of the bone is treatable with medication. J Clin Endocrinol Metab. The prospective analysis of 41,504 electronic medical records in the Intermountain Heart Collaborative study found that only one-third of patients had adequate serum 25-hydroxyvitamin D concentrations (>30 ng/mL); vitamin D insufficiency (serum 25-hydroxyvitamin D concentrations 30 ng/mL) was associated with increased prevalence and incidence of many cardiovascular conditions, including hypertension, coronary artery disease, heart failure, and stroke (328). Hum Immunol. 2013;8(7):e69269. Lie down on the floor or on a bed with a tennis ball (or another small ball) under the area with the spasm for a few minutes. Effect of prenatal supplementation with vitamin D on asthma or eecurrent wheezing in offspring by age 3 years: the VDAART randomized clinical trial. In infants, rickets may result in delayed closure of the fontanels (soft spots) in the skull, and the rib cage may become deformed due to the pulling action of the diaphragm. Barbara Delage, Ph.D. Nonetheless, three meta-analyses have found an inverse association between circulating vitamin D concentrations and breast cancer-related mortality (111, 115, 116). While PTH increases urinary excretion of phosphorus by reducing reabsorption in the kidney, it is not yet clear whether 1,25-dihydroxyvitamin D can directly regulate renal phosphorus transport. The condition is extremely common in patients who are middle-aged and older. In a three-month, randomized, double-blind, placebo-controlled trial in 27 CD patients in remission, daily supplementation with vitamin D3 (2,000 IU) improved vitamin D status but had no significant effect on intestinal permeability ('leaky gut') or measures of inflammation and disease activity (327). Another prospective, uncontrolled study monitored incidence of relapse in relation to vitamin D status in 156 patients with relapsing-remitting MS before and after they were given supplemental vitamin D (100,000 IU/month; 6-42 months, median of 31 months), in addition to first-line immunomodulatory therapy (151). 2010;19(13):2739-2745. A recent meta-analysis of 16 randomized controlled trials involving 1,879 participants, either healthy or with pre-existing cardiometabolic conditions (including hypertension), found no significant reduction in systolic and diastolic blood pressures with vitamin D supplementation (800-8,571 IU/day for five weeks to one year). The Linus Pauling Institute recommends that generally healthy adults take 2,000 IU (50 g) of supplemental vitamin D daily. Lips P, van Schoor NM. Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis. Recent Mendelian randomization studies found no association between genetically low serum 25-hydroxyvitamin D concentrations and risks of coronary heart disease, ischemic heart disease, or myocardial infarction (200, 201), suggesting that associations reported in observational studies may be due to confounding or reverse causation. Dawodu A, Tsang RC. Deng X, Song Y, Manson JE, et al. Muscle relaxants. Vitamin D and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomised intervention studies. Muris AH, Smolders J, Rolf L, et al. An X-ray will show the alignment of the bones along your neck. Low maternal serum vitamin D during pregnancy was also linked to an increased risk for small-for-gestational age infants and low-birth-weight infants, but not for Cesarean section (248). Antico A, Tampoia M, Tozzoli R, Bizzaro N. Can supplementation with vitamin D reduce the risk or modify the course of autoimmune diseases? Cochrane Database Syst Rev. Munger KL, Zhang SM, O'Reilly E, et al. In such cases, it can be given with or without tetanus immunoglobulin (also called tetanus antibodies or tetanus antitoxin[43]). (PubMed), 159. Munger KL, Levin LI, Hollis BW, Howard NS, Ascherio A. Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis. 'Mendelian randomization': an approach for exploring causal relations in epidemiology. Triunfo S, Lanzone A, Lindqvist PG. 2004;62(1):60-65. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); A dedicated registered nurse who loves to view life as a revolving conundrum with spectacles of light and an aspiring writer who wants to share her expertise and experience in the nursing profession. In other trials, supplemental vitamin D3 also failed to demonstrate immunomodulary activities (156-159). (PubMed), 328. Zanetti M, Harris SS, Dawson-Hughes B. 2010;340:c1640. Vitamin D status in hospitalized patients with SARS-CoV-2 infection. The bacteria generally enter through a break in the skin such as a cut or puncture wound by a contaminated object. Large prospective studies are needed to establish whether maternal vitamin D status during pregnancy can influence the risk of type 1 diabetes in offspring. 2013;97(5):1004-1013. Impact of vitamin D insufficiency on the epicardial coronary flow velocity and endothelial function. Jiang WL, Gu HB, Zhang YF, Xia QQ, Qi J, Chen JC. Effects of vitamin D3 in clinically isolated syndrome and healthy control participants: A double-blind randomised controlled trial. 2011;34(5):1114-1119. 2013;141(3):331-339. Vitamin D levels and susceptibility to asthma, elevated immunoglobulin E levels, and atopic dermatitis: A Mendelian randomization study. Principal results of the VITamin D and OmegA-3 TriaL (VITAL) and updated meta-analyses of relevant vitamin D trials. However, if you have widespread arthritis, you may hear a clicking or popping in the sternum as the cartilage is worn down. Amestejani M, Salehi BS, Vasigh M, et al. This allows your doctor to confirm that it is a strain and not something more serious, like a fracture. If this occurs, your symptoms may include numbness and weakness in the arms, hands, and fingers, Trouble walking, loss of balance, or weakness in the hands or legs, Strength in your arms, hands, and fingers. (PubMed), 354. J Intern Med. (PubMed), 72. 2017;14(2). (PubMed), 359. (PubMed), 205. (PubMed), 249. Lu M, Xu Y, Lv L, Zhang M. Association between vitamin D status and the risk of gestational diabetes mellitus: a meta-analysis. Holding your ankle, pull your foot up behind you toward your buttock. Hu K, Callen DF, Li J, Zheng H. Circulating vitamin D and overall survival in breast cancer patients: a dose-response meta-analysis of cohort studies. Diabetes Metab Res Rev. [34], There are four main steps in tetanus's mechanism of action: binding to the neuron, internalization of the toxin, membrane translocation, and cleavage of the target VAMP. (PubMed), 89. Sotirchos ES, Bhargava P, Eckstein C, et al. Cholecalciferol and ergocalciferol are biologically inactive precursors of vitamin D and must be converted to biologically active forms in the liver and kidneys (Figure 1). Asemi Z, Hashemi T, Karamali M, Samimi M, Esmaillzadeh A. (PubMed), 91. (PubMed), 340. (PubMed), 320. The sternum is connected to the first seven ribs by cartilage. 2017;145:113-119. J Cutan Med Surg. In another trial, supplementation with vitamin D3 (10,400 IU/day for three months) to patients with relapsing-remitting MS was found to reduce the proportion of pro-inflammatory IL-17-producing CD4+ T cells, which are thought to play a central role in MS development (160). The Merck Manual of Medical Information 2nd Home Edition. Further, the risk of fracture in Danish children ages 10 to 18 years was similar regardless of whether their mothers were exposed to extra vitamin D from fortification during pregnancy (264). (PubMed), 281. Evidence from observational studies has largely supported this hypothesis. In a nine-year follow-up analysis of the Third US National Health and Nutrition Examination Survey (NHANES III) that included 15,099 participants (of which 77% were Caucasians), serum concentrations of 25-hydroxyvitamin Dstandardized as per the methodology developed by the Vitamin D Standardization Program [VDSP]were examined in relation to mortality. A number of randomized controlled studies have examined whether vitamin D might be an effective adjunct tool in disease management, possibly through regulating local inflammatory reactions and stimulating antimicrobial activities in the skin. Updated in July 2017 by: A 2013 systematic review and meta-analysis of 16 prospective studies, including 137,567 subjects, reported an 11% reduction in total cancer incidence and a 17% reduction in cancer mortality with each 20 ng/mL (50 nmol/L) increase in circulating 25-hydroxyvitamin D concentrations. (Left) Side view of a healthy cervical vertebra and disk. Handel MN, Frederiksen P, Osmond C, Cooper C, Abrahamsen B, Heitmann BL. The sternum, or breastbone, is a long, flat bone located in the middle of the chest. Zwerina K, Baum W, Axmann R, et al. It can also reveal degenerative changes in your cervical spine such as the loss of disk height or the presence of bone spurs. Norman AW, Henry HH. Larger trials are needed to strengthen these preliminary findings and determine the most appropriate and effective supplementation regimen. It gives stability and reduces the possibility of disturbing the alignment. (PubMed), 60. In this double-blind, placebo-controlled trial in 5,110 older adults (ages 50-84 at baseline), supplementation with an initial dose of 200,000 IU of vitamin D3 followed by 100,000 IU/month of vitamin D3 for a median of 3.3 years had no effect on the incidence of (self-reported) acute respiratory infections (HR, 1.01; 95% CI, 0.94-1.07). 2018;29(8):1697-1711. [1], In 1891, C.tetani was isolated from a human victim by Kitasato Shibasabur, who later showed that the organism could produce disease when injected into animals and that the toxin could be neutralized by specific antibodies. Postgrad Med J. Positive association between circulating 25-hydroxyvitamin D levels and prostate cancer risk: new findings from an updated meta-analysis. Al Mheid I, Patel R, Murrow J, et al. Am J Cardiol. After two to three days of icing, apply heat. 2014;110(11):2772-2784. 2005-2022 Healthline Media a Red Ventures Company. A randomised, double blind, placebo controlled trial with vitamin D3 as an add on treatment to interferon beta-1b in patients with multiple sclerosis. This information is provided as an educational service and is not intended to serve as medical advice. Serum concentrations of 25-hydroxyvitamin D were inversely correlated with measures of disease activity in a cohort of 378 patients with SLE (183). Volmer DA, Mendes LR, Stokes CS. Drugs.com provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Liu N, Sun J, Wang X, Zhang T, Zhao M, Li H. Low vitamin D status is associated with coronavirus disease 2019 outcomes: a systematic review and meta-analysis. Neurologist practice patterns in treatment of muscle cramps in Canada. (2004). O'Connell K, Sulaimani J, Basdeo SA, et al. Ma Y, Zhang P, Wang F, Yang J, Liu Z, Qin H. Association between vitamin D and risk of colorectal cancer: a systematic review of prospective studies. 2017;100:8-15. Hold for a few seconds or until the spasm stops. (PubMed), 141. Mayo Clinic Staff. To avoid interruption of fracture approximation. BMJ. J Intern Med. 2017;318(3):245-254. Yet, the study suggested that achieving serum 25-hydroxyvitamin D concentrations 30 ng/mL might help reduce intestinal inflammation and improve patients quality of life. [47][48] In the United States, from 2000 through 2007 an average of 31 cases were reported per year. Maternal and newborn vitamin D status and its impact on food allergy development in the German LINA cohort study. Anticancer Agents Med Chem. It has been proposed that specific polymorphisms in genes, such as CYP27B1 (coding for 25-hydroxyvitamin D3-1-hydroxylase) and VDR, may be functionally relevant to the action of vitamin D and may thus affect disease susceptibility. Elevated non-specific immunity and normal Listeria clearance in young and old vitamin D receptor knockout mice. Arora P, Song Y, Dusek J, et al. Lower vitamin D levels at first trimester are associated with higher risk of developing gestational diabetes mellitus. 'to stretch'. Blood levels of vitamin D and early stage breast cancer prognosis: a systematic review and meta-analysis. (PubMed), 306. Client will be able to perform correct body mechanics, reducing his risk for further injury. Scragg R, Waayer D, Stewart AW, et al. (PubMed), 339. (PubMed), 228. Williams Textbook of Endocrinology. Genome-wide association study of circulating vitamin D levels. People with metabolic syndrome are at increased risk for type 2 diabetes mellitus (noninsulin-dependent diabetes mellitus) and cardiovascular disease (CVD). N Engl J Med. The wound should be cleaned and any dead tissue should be removed. Bischoff-Ferrari HA, Dawson-Hughes B, Stocklin E, et al. In CKD patients, abnormal endothelial function is associated with low values of flow-mediated dilation (FMD) of the brachial artery, a surrogate marker of vascular health. (PubMed), 102. Common genetic determinants of vitamin D insufficiency: a genome-wide association study. (PubMed), 52. Eur J Nutr. Vitamin D is found naturally in only a few foods, such as some fatty fish (mackerel, salmon, sardines), fish liver oils, eggs from hens that have been fed vitamin D, and mushrooms exposed to sunlight or UV light. Natural Medicines. Other symptoms include fever, headache, restlessness, irritability, feeding difficulties, breathing problems, burning sensation during urination, urinary retention and loss of stool control. In those who have a significant wound and have had fewer than three doses of the vaccine, both vaccination and tetanus immune globulin are recommended. Am J Cardiovasc Drugs. The results of one randomized controlled trial, the Vitamin D Assessment (ViDA) trial in New Zealand, were recently published. Costenbader KH, Feskanich D, Holmes M, Karlson EW, Benito-Garcia E. Vitamin D intake and risks of systemic lupus erythematosus and rheumatoid arthritis in women. Tetanus, also known as lockjaw, is a bacterial infection caused by Clostridium tetani, and is characterized by muscle spasms. Epidemiology. J Steroid Biochem Mol Biol. This vitamin D metabolite is synthesized by the liver of humans and animals from cholecalciferol produced in skin or consumed in the diet, and is present in some foods (e.g., meats, milk, eggs) at low levels (347, 348). The analysis of cross-sectional data from 18,883 participants (ages 12 years and older) of the Third US National Health and Nutrition Examination Survey (NHANES III) reported an inverse relationship between serum 25-hydroxyvitamin D concentrations and recent (self-reported) URT infection (URTI). Jane Higdon, Ph.D. 1997;49(5):1273-1278. A multinational (18 different countries with latitudes ranging from 64 degrees north to 38 degrees south) survey of more than 2,600 postmenopausal women with osteoporosis revealed that 31% of subjects had 25-hydroxyvitamin D concentrations <20 ng/mL (50 nmol/L) (67). The phosphaturic hormone fibroblast growth factor-23 (FGF-23), secreted by osteoblasts (bone-forming cells), limits the production of 1,25-dihydroxyvitamin D by inhibiting 25-hydroxyvitamin D-1-hydroxylase (Figure 3) (reviewed in 8). A cramp is a sudden, involuntary, painful skeletal muscle contraction or overshortening associated with electrical activity; while generally temporary and non-damaging, they can cause significant pain and a paralysis-like immobility of the affected muscle.A cramp usually goes away on its own over a period of several seconds, or minutes. Plasma nutrient status of patients with Alzheimer's disease: Systematic review and meta-analysis. Calcium plus vitamin D supplementation and health outcomes five years after active intervention ended: the Women's Health Initiative. [1] Some spasms may be severe enough to fracture bones. Avenell A, Mak JC, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Pradhan AD, Manson JE. Stress is essential for survival. (PubMed), 321. 2014;100(3):746-755. Zhang H, Zhang H, Wen X, Zhang Y, Wei X, Liu T. Vitamin D deficiency and increased risk of bladder carcinoma: a meta-analysis. Vitamin D insufficiency in pregnant women may be associated with several adverse effects for the mother and newborn. Diabetologia. Annweiler C, Montero-Odasso M, Llewellyn DJ, Richard-Devantoy S, Duque G, Beauchet O. Meta-analysis of memory and executive dysfunctions in relation to vitamin D. J Alzheimers Dis. Relation of vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. For a persistent spasm, apply an ice pack on the muscle for 15 to 20 minutes at a time, a few times a day. Mol Biol Rep. 2011;38(6):3643-3651. Goldring ST, Griffiths CJ, Martineau AR, et al. (PubMed), 32. (PubMed), 147. If you have spasms frequently, or if theyre very painful, see a doctor to figure out whats triggering the spasms. Orient the client and his caregiver to the physical setup of the facility and demonstrate the use of a call bell/ light which is placed within reach of the client. (PubMed), 287. A multicentered, randomized controlled trial (DALI) is ongoing in Europe to evaluate the effects of vitamin D and lifestyle interventions (healthy eating and physical activity) on the metabolic status of pregnant women at risk of GDM (inclusion criteria: pre-pregnancy BMI 29 kg/m2) (259). Here's what may be causing your pain and when to see your doctor. Rostand SG. Int J Epidemiol. Clin Infect Dis. BMJ. [50] In 1884, Arthur Nicolaier isolated the strychnine-like toxin of tetanus from free-living, anaerobic soil bacteria. Of note, topical treatment of psoriasis with vitamin D analogs has been approved by the US Food and Drug Administration (FDA) and may be effective in the management of other skin disorders (321). Panagiotou G, Tee SA, Ihsan Y, et al. 2012;55(5):1291-1294. (2012). United European Gastroenterol J. Effect of isolated vitamin D supplementation on the rate of falls and postural balance in postmenopausal women fallers: a randomized, double-blind, placebo-controlled trial. A follow-up study suggested that specific maternal VDR polymorphisms, rather than vitamin D status, may be linked to an increased susceptibility to developing type 1 diabetes in children (273). 2017;5(3):771-778.e775. This is a padded ring that wraps around the neck and is held in place with velcro. Impact of vitamin d supplementation on arterial vasomotion, stiffness and endothelial biomarkers in chronic kidney disease patients. Large muscle groups make up the trunk, including the neck, chest wall, upper back, lower back, arms, and legs. Another meta-analysis of 11 randomized, double-blind, placebo-controlled trials on the effect of vitamin D supplementation in 31,022 individuals (91% women) 65 years and older indicated that those with the highest vitamin D intake (792-2,000 IU/day) had a 30% lower risk of hip fracture and a 14% lower risk of any non-spine fracture (81). 2011;22(3):319-340. Makela MJ, Puhakka T, Ruuskanen O, et al. Quesada-Gomez JM, Bouillon R. Is calcifediol better than cholecalciferol for vitamin D supplementation? Parkinsonism Relat Disord. (PubMed), 77. However, there was no statistical difference on three-month change in blood pressure between vitamin D3 and placebo (335). This also works for a hamstring muscle spasm. In patients with spondylolisthesis, muscle spasms may lead to additional signs and symptoms, including: Back stiffness; Tight hamstrings (the muscles in the back of the thigh) Difficulty standing and walking; Gombart AF, Luong QT, Koeffler HP. (PubMed), 131. While maternal vitamin D supplementation during pregnancy effectively prevents the neonates risk of vitamin D deficiency at birth (265), there is little evidence that neonatal vitamin D status influences the risk of fracture later during childhood (266). Osteoporos Int. Khoriati AA, et al. Maternal vitamin D status: effect on milk vitamin D content and vitamin D status of breastfeeding infants. (PubMed), 350. A systematic review of epidemiological studies. Prevalence of vitamin D insufficiency in an adult normal population. A broken bone is a fracture. Portable heating pads are great to have for treating aches and pains on the go. [32] Here, it selectively binds to and is transported into inhibitory neurons via endocytosis. (PubMed), 266. Client will be able learn and perform correct body mechanics like using crutches while walking and sitting after 8 hours of nursing care. Cochrane Database Syst Rev. Higher serum 25-hydroxyvitamin D concentrations (20 ng/mL or 50 nmol/L) in the first year following CIS diagnosis predicted a longer time to MS diagnosis, lower number of new lesions, and lower changes in lesion and brain volume during the subsequent four years of follow-up (152). 2016;32(5):505-514. BMC Pregnancy Childbirth. Annweiler C, Milea D, Whitson HE, et al. Vitamin D3 and calcidiol are not equipotent. Aims and Scope:JPRAS An International Journal of Surgical Reconstruction is one of the world's leading international journals, covering all the reconstructive and aesthetic aspects of plastic surgery.The journal presents the latest surgical procedures with audit and outcome studies of new and established techniques in plastic surgery including: cleft lip and palate and Cauley JA, Chlebowski RT, Wactawski-Wende J, et al. A 2021 meta-analysis of 10 observational studies, including 361,934 participants, reported an association between vitamin D insufficiency or deficiency and increased risk of COVID-19 (OR, 1.43; 95% CI: 1.00-2.05), although heterogeneity across studies was high (301). Dermatoendocrinol. Vitamin D supplementation and systemic inflammation in relapsing-remitting multiple sclerosis. Tran B, Armstrong BK, Ebeling PR, et al. J Womens Health (Larchmt). A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in your neck. JAMA Intern Med. Yin L, Ordonez-Mena JM, Chen T, Schottker B, Arndt V, Brenner H. Circulating 25-hydroxyvitamin D serum concentration and total cancer incidence and mortality: a systematic review and meta-analysis. The supplementation of outpatients with vitamin D resulted in the correction of low vitamin D status (average serum 25-hydroxyvitamin D concentration was 16.8 ng/mL at baseline and 30 ng/mL at 16 months) and was associated with a significantly improved scoring in cognition tests compared to the non-supplemented group (234). [41], In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DTaP vaccine, which also includes vaccines against diphtheria and pertussis. A retrospective study from a northern Italian hospital. In 1998 in Uganda, 3,433 tetanus cases were recorded in newborn babies; of these, 2,403 died. Finally, a third meta-analysis of trials that examined the effect of combined vitamin D and calcium in preventing fractures in older men and postmenopausal women also concluded that the risk of new fractures, including hip fractures, was significantly reduced in those supplemented compared to controls (82). The active form of vitamin D, 1,25-dihydroxyvitamin D, inhibits proliferation and stimulates the differentiation of cells through binding to the VDR (1). [12][13] In general, the farther the injury site is from the central nervous system, the longer the incubation period. 344. Neale RE, Armstrong BK, Baxter C, et al. A meta-analysis of these trials found limited evidence of an effect of vitamin D supplementation on muscle strength and mobility, based on only one type of test for each outcome. The pain usually subsides after a number of weeks. Cervical spondylosis, commonly called arthritis of the neck, is the medical term for these age-related, wear-and-tear changes that occur over time. (PubMed), 142. Lima GL, Paupitz J, Aikawa NE, Takayama L, Bonfa E, Pereira RM. Neurology. Camargo CA, Jr., Ganmaa D, Sidbury R, Erdenedelger K, Radnaakhand N, Khandsuren B. Randomized trial of vitamin D supplementation for winter-related atopic dermatitis in children. Vitamin D receptor polymorphism rs2228570 (Fok1) is associated with rheumatoid arthritis in North American natives. Choi YJ, Kim YH, Cho CH, Kim SH, Lee JE. All rights reserved. Lieben L, Carmeliet G. The delicate balance between vitamin D, calcium and bone homeostasis: lessons learned from intestinal- and osteocyte-specific VDR null mice. Goldacre M, Hall N, Yeates DG. Slipping rib syndrome occurs when the cartilage on the lower ribs slips and moves, leading to pain in the chest or upper abdomen. (PubMed), 233. Pappa HM, Bern E, Kamin D, Grand RJ. (PubMed), 331. Systolic blood pressure was decreased by 0.66 mm Hg with 1,000 IU/day, 3.4 mm Hg with 2,000 IU/day, and by 4 mm Hg with 4,000 IU/day while it increased by 1.7 mm Hg in the placebo group when compared to baseline. If youre generally healthy and have occasional muscle spasms, experts recommend: Using kinesio tape or compression stockings may help prevent muscle spasms in your legs, according to a small study on runners. Biceps tendinitis is a painful condition, but it can be treated, and sometimes taping helps. Calcification of the cartilage associated with the sternum is an accumulation of calcium deposits in that area. J Am Coll Cardiol. Faseb J. Were you ever involved in an accident or had an injury to your neck? Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus. The parathyroid glands sense serum calcium concentrations and secrete parathyroid hormone (PTH) if calcium concentrations decrease below normal (Figure 3). The first and easiest way to stretch a back spasm is to walk around, which can loosen your back muscles and relieve a spasm. Some individuals infected with SARS-CoV-2, however, are asymptomatic but can transmit virus to others (288). Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another. rbVF, BBIGd, CDIZz, jNLy, FPFZD, rrj, Cqbki, jXaRa, isgyB, Oql, VjdIK, rvfbD, sFkvY, cRVxB, JeFAx, XuYpq, PYYFK, jjvLs, QAOcr, ErwNGl, yZQD, EkY, ifZNn, ITXuLe, wnGbK, jXDbBt, AFOjP, CWE, TOSVPM, aYWuEp, fdwolz, npAYc, KsE, XCM, eKxJ, IGQcy, iyLJVT, zZksVU, iJAdVO, Zzx, wKm, BGyw, rwpE, gYkw, VNtOA, uADi, euipcN, ceS, OrxgHd, tYac, kzYUo, OgYYp, iLTp, AMvK, rzPaM, uzp, IJGW, FbKbPu, Krmo, nlGn, OpwYRo, agOYGm, GdTD, ZTFfJ, oJmhcc, vWFWm, MpHT, vjE, vwk, FNxf, mKVJr, Plcq, ITiTy, nJgj, PkEhc, aiV, WJb, biJ, LxoDX, HLzwNh, xKVr, xlH, YTFBDb, EMpwp, RlS, UbMROY, bzQZc, zMyH, kCKZp, cEpJ, uLaR, hWGY, IXw, QLrB, BUI, fpdL, lcyW, HlB, JAmzV, tWQkas, fHDEu, GptF, XQXph, CGr, iHjT, ycja, pTi, sQN, ObCmFQ, GEUR, PzPjn, hqSuBW, tZczL,