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25-Hydroxyvitamin D serum levels in rheumatic female patients in southeast Spain: The paradigm of daily optimal sunshine levels and inadequate vitamin D status
Concentraciones séricas de 25-hidroxivitamina D en mujeres reumáticas del sureste de España: el paradigma de los niveles diarios óptimos de luz solar y la insuficiencia de vitamina D
Claudia Alejandra Peredaa,
Corresponding author
cpereda@ser.es

Corresponding author.
, María Betina Nishishinyab,c, Emilio J.A. Roldand
a Hospital Mediterráneo, Almería, Spain
b Instituto Traumatológico Quirón, Barcelona, Spain
c MD Programme in Education and Sport Sciences, Facultat de Psicologia, Ciències de l’Educació i de l’Esport Blanquerna, Barcelona, Spain
d Scientific Direction, Gador SA, Buenos Aires, Argentina
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Insufficient exposure to sunlight is a worldwide known cause of vitamin D deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> Essentially&#44; the chief determinant of circulating vitamin D levels is the total amount of sunlight exposure absorbed by the skin&#44; following solar ultraviolet radiation &#40;UVR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a> Besides&#44; numerous investigations suggest that individual differences together with geographical and seasonal variances exert a critical influence on vitamin D status&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Evidence of vitamin D beneficial effect on reducing the risk of different adverse health outcomes has been increasingly growing in the past years&#46; Predominantly&#44; there is data on bone health&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;5</span></a> cancer&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> autoimmune&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> cardiovascular diseases<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> and recently in respiratory tract infections&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> So far&#44; the best marker of vitamin D status is circulating 25OHD concentration&#59; though&#44; there is no formal consensus on the optimal 25OHD serum values<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> and besides&#44; what constitutes vitamin D deficiency is still troublesome&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Almeria is a Spanish province&#44; located in the extreme southeast of the country&#44; receiving a mean well above the 240<span class="elsevierStyleHsp" style=""></span>h of sunlight per month&#44; ranging from 176 to 336<span class="elsevierStyleHsp" style=""></span>h per year&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> The region accumulates the highest amount of hours of daylight both in Spain&#44; and in most European countries&#46; The aim of our study&#44; according to Almeria advantageous location&#44; was to make out 25OHD serum status in a population with distinct rheumatic conditions according to age and season&#44; to identify subgroups at risk of vitamin D deficiency&#44; and evaluate the impact of long sunlight exposure in vitamin D sufficiency&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design and study population</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a cross sectional study conducted between September 2008 and August 2014 in an outpatient rheumatology clinic in Almer&#237;a province &#40;located 36&#46;5&#176; latitude N&#44; 2&#176; LW&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This geographical location benefits from optimal annual sunshine levels&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> good air quality &#40;particulate matter&#58; 10 and real time quality index &#40;AQI&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5&#59; plus a very low precipitation rate &#40;around 9&#44; 4<span class="elsevierStyleHsp" style=""></span>mm&#47;year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> Patients eligible for the study were women older than 18 years&#44; able to walk&#44; unaided&#44; and not living in care institutions&#46; Menopausal status was defined as when menstruation has failed to occur over a 12 month period while women whose status was uncertain and who replied that they had an unsettled menopause were classified as premenopausal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion criteria comprised inflammatory rheumatic diseases&#44; kidney&#44; hepatic or bowel diseases&#44; corticosteroid &#40;oral or inhaled&#41;&#44; and or vitamin D therapy&#46; In order to capture information from several seasons and years&#44; two days per week&#44; patients attending this clinic were invited to take part&#46; These were informed about the study and those who consent were included&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The ethics committee of Hospital Mediterraneo approved the study protocol&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurements</span><p id="par0040" class="elsevierStylePara elsevierViewall">Blood samples were taken after an eight-hour fast&#46; Vitamin D measurements were performed with ADVIA Centaur XP Vitamin D Total assay &#40;Siemens Healthcare diagnostics&#41; in external labs&#44; obtaining hydroxylated form&#44; 25OHD values were considered deficient &#40;&#60;20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#44; insufficient &#40;&#62;20 and &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; and sufficient &#40;&#8805;30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> Calcium&#44; phosphorous&#44; creatinine&#44; albumin&#44; intact parathyroid hormone &#40;PTH&#41; serum levels were also determined&#46; The date of collection was recorded&#46; Seasons were divided according to standards in the northern hemisphere&#44; winter spanning from December 22 to March 20&#44; spring from March 21 to June 20&#44; summer from June 21 to September 22 and fall from September 23 to December 21&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Daylight for the date of the 25OHD sample was obtained from the European weather website &#40;<a id="intr0005" class="elsevierStyleInterRef" href="http://www.climatedata.eu/">http&#58;&#47;&#47;www&#46;climatedata&#46;eu</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> and real time air quality index from &#40;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.aqicn.org/">http&#58;&#47;&#47;www&#46;aqicn&#46;org</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were described according to the distribution of variables with summary statistics&#46; Student&#39;s <span class="elsevierStyleItalic">t</span> test and analysis of variance were used to test hypotheses concerning different distributions by groups&#46; Correlations between continuous variables were tested with the Pearson coefficient&#46; Data were analyzed using Medcalc statistical software version 9&#46;3&#46;8&#46;0 for Windows&#44; with a confident interval of 95&#37; and a significance level lower than 5&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study sample included 319 women&#44; whose mean age was 53&#46;2 &#40;SD 11&#46;1&#59; range 18&#8211;81&#41; all Caucasian&#46; Two hundred and sixty women &#40;81&#44; 5&#37;&#41; were postmenopausal&#46; The main diagnosis reported at the time of recruitment were fibromyalgia&#44; osteoarthritis&#44; osteoporosis&#47;osteopenia&#44; back pain&#44; tendinitis&#44; bursitis&#44; shoulder impidgement and polyarthralgia &#40;87&#37;&#41;&#46; Yet&#44; major prevalent comorbidities were hypertension&#44; followed by dyslipidaemia and dysthymia &#40;20&#37;&#44; 8&#37; and 12&#37; respectively&#41;&#46; Medications most frequently employed were antihypertensives and anxiolytics&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> includes a description of the sample&#44; total and by age groups&#46; The mean 25OHD values were 30&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;ml &#40;SD 16&#46;2&#59; range 6&#46;0&#8211;96&#46;1&#41;&#44; with 80 &#40;25&#46;1&#37;&#41; samples considered deficient in vitamin D&#44; 112 &#40;35&#46;1&#37;&#41; insufficient&#44; and 127 &#40;39&#46;8&#37;&#41; sufficient&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The evaluation of laboratory variables that could hamper with 25OHD status revealed no significant difference in hemoglobin&#44; leukocytes&#44; albumin&#44; calcium&#44; and phosphorus between age groups&#46; PTH values were significantly higher in women above 60 years old compared to the other groups and hematocrit significantly lower in the youngest group &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Season was associated to the level of serum 25OHD &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; with autumn being the only season in which highest levels of 25OHD serum levels were found &#40;mean 36&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#59; SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#46;8&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; with mean levels above 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml in all bands&#46; Conversely&#44; the lowest mean 25OHD concentrations were found in winter&#44; in all groups &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; All age groups exhibited mean 25OHD serum levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml in summer&#44; except for cohort between 54 and 60 years&#44; but the difference between groups was not statistically significant&#46; 25OHD serum levels followed normal distribution&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a> display the percentage of patients reaching inadequate levels according to mean serum values of 25OHD&#44; season and age bands&#46; More than 40&#37; of the patients younger than 48 years had vitamin D levels under the level of insufficiency in all seasons&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The presence or absence of menopause did not make difference in 25OHD serum levels&#46; Though significantly older&#44; the menopause group exhibited a clear correlation between age and PTH levels &#40;correlation coefficient <span class="elsevierStyleItalic">r</span>&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">We have shown that two thirds of a sample of women in a sunny region are below sufficient levels of vitamin D&#46; In point of fact&#44; the hypothesized proper exposure to sunlight capacity to sustain adequate serum levels of vitamin D in female population appears not to be fully acceptable in view of the present results&#46; Yet&#44; previous research have drawn attention to sunlight exposure &#40;UVR&#41; as a critical step in vitamin D synthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> In addition to the number of sunlight hours&#44; factors like latitude&#44; season and time of the day&#44; exert an important influence on UVR effectivity&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> Yet&#44; regions above 37&#176; latitude N during winter result in very little if any vitamin D3 produced in the skin&#44; while below 37&#176; N more vitamin D3 synthesis occurs throughout the year&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> Despite the fact of Almeria&#39;s adequate location and optimum level of sunshine throughout the year &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; insufficient 25OHD serum levels prevailed both in winter and spring in middle-aged and elderly women&#46; In this line&#44; studies carried out in similar latitudes<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">16&#8211;18</span></a> at both sides of the equator achieved comparable seasonal upshots&#46; For example&#44; early studies performed in Buenos Aires&#44; Argentina &#40;latitude 34&#176; S&#41;&#44; reported a prevalence of vitamin D deficiency of up to 65&#37; among ambulatory postmenopausal women during wintertime&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> While in Geelong region&#44; Australia &#40;latitude 38&#176; N&#41; vitamin D insufficiency reached 38&#37; in a female population under 60&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> Season is known to be associated with ambient ultraviolet radiation&#44; reaching its peak in summer and minimum in winter&#46; In this respect&#44; Almeria is outstanding&#44; as the annual average hours of sunshine can reach 247&#46;6<span class="elsevierStyleHsp" style=""></span>h&#44; and 196&#46;5<span class="elsevierStyleHsp" style=""></span>h throughout winter&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Conversely&#44; cities in northern latitudes like Copenhagen &#40;55&#46;6&#176; N&#41; or London &#40;51&#46;5&#176; N&#41; are not exposed to more than 72&#46;3<span class="elsevierStyleHsp" style=""></span>h of sunshine in winter&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> Even so&#44; an optimal level of sunshine throughout the year&#44; does not guarantee acceptable levels of 25OHD as shown in our study&#46; Perhaps&#44; changes in outdoor behavior and increased clothing worn&#44; together with decreased time spent outdoor mainly in both seasons&#44; could explain in part these results&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> On the other hand&#44; autumn is the season in which 25OHD reached optimal serum levels in all ages&#46; This finding is in full agreement with various other works&#44; placing 25OHD annual peak in autumn and nadir in winter-spring&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">These percentages of deficiency in our study were even higher than expected&#46; In this regard Rodriguez Sangrador et al&#46;&#44; <a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> drew attention to the fact that more than 50&#37; of women patients in his trial avoided exposing to sunlight in summer&#46; Similar results were displayed in studies located in Brazil&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> Iran<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> and also in an interesting paper by Al-Daghri et al&#46;&#44; in Saudi Arabia&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a> Regardless of the fact that these regions are well below 37&#176; latitude S and N respectively&#44; summer months present very high temperatures &#40;&#62;40<span class="elsevierStyleHsp" style=""></span>&#176;C at noon&#41; increasing risk of heat strokes&#46; In this line&#44; Almeria&#44; also achieve high temperatures in summer &#40;well &#62;30<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; possibly preventing patients &#62;60 years in particular from exposing to sunlight&#44; and therefore reducing outdoors activities&#46; This is something to take into account&#44; as summer has been traditionally defined as the season were Caucasians and some other skin types can make optimal vitamin D3&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">26&#44;27</span></a> Concerning younger population&#44; unacceptable high insufficient levels&#44; reaching &#62;50&#37;&#44; extended to female patients below 48 and above 60 years old in the present study&#46; Indeed&#44; most trials describe the expected decrease in 25OHD during winter in young population&#44; particularly in northern latitudes&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">28&#44;29</span></a> In this respect&#44; Trangpricha et al&#46; revealed that the prevalence of vitamin D deficiency increased from 3 to 30&#37; between summer and winter in young healthy adults aged 18&#8211;29 years&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> However&#44; Gagnon et al&#46;&#44; concluded that about a third of women of childbearing age have suboptimal serum 25OHD levels during summer&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a> Also&#44; Gonzalez-Padilla et al&#46;&#44; revealed that almost 2&#47;3 of young healthy medicine students at University of Las Palmas of Gran Canarias Islands &#40;28 N&#41;&#44; had mean levels of 25OHD &#60;30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#46; Apart from reasons others than avoiding sunlight exposure and time spent indoors during summer&#44; the use of sunscreen in all ages could exert additional influence in reducing 25OHD serum levels&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a> though this is still controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">32&#44;33</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">We found that menopause did not exert particular influence on 25OHD serum levels along seasons&#46; In contrast&#44; previous reports suggest the prevalence of inadequate vitamin D levels in post-menopausal women&#44; particularly in those with osteoporosis and history of fractures in northern latitudes&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> Also&#44; vitamin D deficiency was corroborated during menopause in studies performed in South America&#44; despite their location at latitudes with abundant sunlight&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">This study identified patients &#62;60 years as being at higher risk of inadequate vitamin D serum levels &#40;both insufficiency and deficiency&#41;&#46; However&#44; low 25OHD serum levels were also observed in the other age bands&#46; These inadequacies extended not only to the winter-spring seasons&#44; but also to summer period particularly in the eldest group&#46; The decreased vitamin D status of elderly persons is well known&#44; with numerous factors implicated including lack of dietary consumption&#44; malabsorption&#44; and what is most important&#44; a reduction in 7-dehydrocholesterol &#40;7-DHC&#41; in the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> 7-DHC is a chemical precursor required for vitamin D synthesis&#44; which decrease by nearly half from a 21-year-old to an 88-year-old&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> However&#44; the youngest group exhibited almost 60&#37; insufficient 25OHD serum levels in winter&#44; spring and 50&#37; in summer&#44; while deficient levels were not significant in this group&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The main strengths of our study include its large sample size and low frequency of missing data&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">However&#44; some limitations are worth noting&#46; To begin with&#44; all women included in the study were Caucasian&#44; corresponding to skin photo type III&#8211;IV according to Fitzpatrick classification&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a> Therefore caution should be applied when extrapolating these results to the general population&#46; Another limitation was the fact that body mass index was not included in clinical records&#46; As Vitamin D3 is fat-soluble and store in body fat&#44; we could have missed the magnitude of overweight subjects with vitamin D deficiency&#46; Finally&#44; we could not perform a detailed evaluation of vitamin D taken from the diet and obtain accurate data about the quantity of sun exposure&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another interesting point regards to the variety of assays used to measure 25OHD&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">38</span></a> Chemiluminescence immunoassay employed in this trial show acceptable correlation with the goal standard liquid chromatography-tandem mass spectrometry&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a> Still&#44; immunoassays intermethod variability exist&#44;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> thus standardization of vitamin D assays and consideration of assay-specific decision limits should be addressed&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In all cases&#44; patients with either deficiency or insufficiency of vitamin D&#44; were supplemented with oral calcifediol according to 25OHD serum levels and independently of the season&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Several clinical conclusions could be drawn from this study despite the aforementioned limitations&#46; In first place&#44; though the abundant sunlight throughout the year and optimal location of the study&#44; insufficient 25OHD serum levels was commonly observed in winter and spring while autumn exhibited optimal levels in all population groups&#46; Secondly&#44; female elderly patients &#62;60 yrs but also those &#62;48 yrs were at higher risk of inadequate 25OHD serum levels during those seasons and therefore should need surveillance&#46; Thirdly&#44; summer exhibited high percentage of patients with 25OHD insufficient levels in all groups&#44; which should enhance vitamin D measurements and possibly the need of supplementation during this period&#46; In the present study&#44; optimal levels of sunlight did not overcome the problem of inadequate 25OHD serum levels&#46; For all these reasons&#44; we reinforce performing 25OHD serum measurements in elderly rheumatic female population&#44; independently of the season&#46; Vitamin D supplementation may be recommended predominantly in winter but also in summer might be required&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">None of the authors declares conflict of interest&#46;</p></span></span>"
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            1 => "Sunshine"
            2 => "Women"
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            1 => "luz solar"
            2 => "Mujeres"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Almeria is a region in southeast Spain with optimal sunlight levels&#44; along with low pluvial and pollution rates&#46; If exposure to sunlight is sufficient to maintain adequate levels of vitamin D &#40;25OHD&#41;&#44; this population should display high serum levels&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe 25OHD serum status in women from Almeria and evaluate the impact of long sunlight exposure along the seasons on 25OHD&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study&#44; performed in women consecutively recruited from an outpatient rheumatology clinic&#46; Serum levels of 25OHD were assessed in all patients and evaluated according to age &#40;&#60;48 yrs&#44; 48&#8211;53 yrs&#44; 54&#8211;60 yrs and &#62;60 yrs&#41;&#44; season&#44; and presence or absence of menopause&#46; Clinical and laboratory variables that could affect status of vitamin D were also considered&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The sample included 319 Caucasian female patients&#46; Mean 25OHD were 30&#46;2<span class="elsevierStyleHsp" style=""></span>ng&#47;ml with 195 &#40;61&#46;1&#37;&#41; exhibiting 25OHD inadequate serum levels&#46; Season had a significant effect on 25OHD levels&#44; with autumn being the season in which 25OHD serum levels remained well above 30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml in all age bands&#44; and winter the season with more levels of insufficiency&#46; Menopause did not modify 25OH serum levels&#46; Women whose age was below 48 and over 60 had inadequate levels of 25OHD during summer&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Optimal levels of sunlight could not overcome the problem of inadequate 25OHD serum levels&#44; particularly in elderly and young female population&#46; Vitamin D supplementation may be recommended predominantly in winter and summer in this population&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Almer&#237;a es una regi&#243;n del sureste de Espa&#241;a con un grado &#243;ptimo de luz solar&#44; junto con bajas tasas de contaminaci&#243;n y lluvia&#46; Si la exposici&#243;n a la luz solar es suficiente para mantener niveles adecuados de vitamina D &#40;25OHD&#41;&#44; esta poblaci&#243;n deber&#237;a presentar concentraciones s&#233;ricas altas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Describir los valores s&#233;ricos de 25OHD en mujeres de Almer&#237;a y evaluar el efecto de la exposici&#243;n prolongada a la luz solar sobre la 25OHD a lo largo de las distintas estaciones&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en mujeres reclutadas consecutivamente en una consulta externa de reumatolog&#237;a&#46; Se determinaron las concentraciones s&#233;ricas de 25OHD en todas las pacientes y se valoraron en funci&#243;n de la edad &#40;&#60; 48 a&#241;os&#44; 48-53 a&#241;os&#44; 54-60 a&#241;os y &#62; 60 a&#241;os&#41;&#44; la estaci&#243;n y la presencia o ausencia de menopausia&#46; Tambi&#233;n se tuvieron en cuenta las variables cl&#237;nicas y anal&#237;ticas que pudieran afectar al estado de la vitamina D&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La muestra incluy&#243; 319 mujeres de raza blanca&#46; El valor medio de 25OHD fue de 30&#44;2 ng&#47;ml&#44; y 195 &#40;61&#44;1&#37;&#41; mostraron concentraciones s&#233;ricas inadecuadas de 25OHD&#46; La estaci&#243;n ten&#237;a un efecto importante en las concentraciones de 25OHD&#44; y el oto&#241;o era la estaci&#243;n en la que los valores s&#233;ricos de 25OHD se manten&#237;an bastante por encima de 30 ng&#47;ml en todas las franjas de edad&#44; y el invierno la estaci&#243;n con m&#225;s grado de insuficiencia&#46; La menopausia no modificaba las concentraciones s&#233;ricas de 25OH&#46; Las mujeres menores de 48 a&#241;os y mayores de 60 a&#241;os ten&#237;an niveles insuficientes de 25OHD durante el verano&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La luz solar &#243;ptima no pod&#237;a superar el problema de la insuficiencia de las concentraciones s&#233;ricas de 25OHD&#44; sobre todo en las poblaciones de mujeres mayores y j&#243;venes&#46; Pueden recomendarse suplementos de vitamina D predominantemente en invierno y en verano en esta poblaci&#243;n&#46;</p></span>"
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            "titulo" => "Objetivos"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1221
            "Ancho" => 1583
            "Tamanyo" => 82261
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patients mean 25OHD serum levels according to different seasons&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1040
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            "Tamanyo" => 74252
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients with vitamin D insufficiency according to age and season&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1193
            "Ancho" => 2083
            "Tamanyo" => 71858
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Percentage of patients with vitamin D deficiency according to age and season&#46;</p>"
        ]
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      3 => 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"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; Ca&#44; calcium&#59; P&#44; phosphorous&#59; PTH&#44; parathyroid hormone&#59; AST&#47;GOT&#44; aspartate aminotransferase&#59; ALT&#47;GPT&#44; alanine aminotransferase&#59; GGT&#44; gamma-glutamyl transpeptidase&#59; Leuc&#44; leucocytes&#44; ng&#47;ml&#44; nanogram per mililitre&#59; mg&#47;dl&#44; milligrams per decilitre&#59; pg&#47;ml&#44; picogram per mililitre&#59; g&#47;dl&#44; grams per decilitre&#59; mm<span class="elsevierStyleSup">3</span>&#44; cubic milimeter&#59; Ref&#46; values&#44; reference values&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">All values are expressed as mean &#40;SD&#41; unless otherwise noted&#46;</p>"
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                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="" 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">Ref&#46; values&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">Total&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">&#60;48 yr &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#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">48&#8211;53 yr &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>75&#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">54&#8211;60 yr &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>74&#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">&#62;60 yr &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>78&#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"><span class="elsevierStyleItalic">p</span>&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#46;3 &#40;6&#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">50&#46;9 &#40;1&#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">56&#46;7 &#40;1&#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">67&#46;2 &#40;5&#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">&#8211;&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">25OHD &#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;30&#46;0&#8211;&#60;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&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;8 &#40;14&#46;4&#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;8 &#40;16&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;8 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;9 &#40;15&#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">0&#46;64&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">Ca &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;6&#8211;10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&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;4 &#40;0&#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">9&#46;4 &#40;0&#46;4&#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&#46;5 &#40;0&#46;4&#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&#46;5 &#40;0&#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">0&#46;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">P &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;2&#8211;4&#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">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;6 &#40;0&#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">3&#46;7 &#40;0&#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">3&#46;6 &#40;0&#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">3&#46;5 &#40;0&#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">0&#46;78&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">Menopause &#40;<span class="elsevierStyleItalic">n</span>&#44; &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">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">61&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#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">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&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">PTH &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;4&#8211;88&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;4 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;4 &#40;19&#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">42&#46;1 &#40;20&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;4 &#40;26&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&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">Albumin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;5&#8211;5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;0&#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">4&#46;1 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;0&#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">0&#46;33&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">AST&#47;GOT &#40;U&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;34&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;5 &#40;5&#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">21&#46;7 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;4 &#40;8&#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">20&#46;1 &#40;6&#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">&#60;0&#46;05&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">ALT&#47;GPT &#40;U&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;0&#8211;53&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;6 &#40;7&#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">21&#46;0 &#40;8&#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">22&#46;4 &#40;12&#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">19&#46;5 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&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">GGT &#40;U&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;0&#8211;50&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;6 &#40;5&#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">23&#46;1 &#40;16&#46;1&#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;4 &#40;20&#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">20&#46;9 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&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">Haematocrit &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&#46;0&#8211;52&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;9 &#40;2&#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">40&#46;1 &#40;3&#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">40&#46;3 &#40;3&#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">40&#46;8 &#40;2&#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">&#60;0&#46;05&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">Hemoglobin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;0&#8211;17&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;0 &#40;1&#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">13&#46;5 &#40;1&#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">13&#46;3 &#40;16&#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">13&#46;5 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0130" class="elsevierStylePara elsevierViewall">The authors are grateful to Mrs&#46; Mercedes Guerra&#44; manager of documents and archives of the Spanish Rheumatology Society &#40;SER&#41; Research Unit&#44; for her assistance in the reference strategy performance and in obtaining the articles&#44; and to Dr Loreto Carmona for helping with the figures and checking the manuscript&#46; This study has no financial support&#46;</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos