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Review article
Vitamin D and remyelination in multiple sclerosis
Vitamina D y remielinización en la esclerosis múltiple
J. Matías-Guíu
Corresponding author
matiasguiu@gmail.com

Corresponding author.
, C. Oreja-Guevara, J.A. Matias-Guiu, U. Gomez-Pinedo
Servicio de Neurología, Hospital Clinico San Carlos, Facultad de Medicina, Universidad Complutense, IdiSSC, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vitamin D &#40;VD&#41; is a group of hormones including vitamin D<span class="elsevierStyleInf">2</span>&#44; or ergocalciferol&#44; and vitamin D<span class="elsevierStyleInf">3</span>&#44; or cholecalciferol&#46; VD is acquired mainly from the diet and through exposure to sunlight&#46; Several analytical epidemiological studies have suggested an association between VD deficiency and multiple sclerosis &#40;MS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">1&#8211;6</span></a> The biological basis of this association is unknown&#46; Hypotheses include causal mechanisms&#44; the interaction between genetic and environmental factors&#44; or simply the combination of multiple environmental factors&#46; Research on the topic has focused on the role of VD and its metabolites in experimental allergic encephalomyelitis &#40;EAE&#41; in in vitro and animal studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">7&#44;8</span></a> Most researchers have analysed the association between VD and the risk of inflammation&#44; while others have evaluated the role of VD in myelination and remyelination&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">9</span></a> The present review addresses the latter topic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Vitamin D deficiency</span><p id="par0010" class="elsevierStylePara elsevierViewall">VD levels are usually determined by measuring plasma 25-hydroxyvitamin D &#40;25&#91;OH&#93;D&#41; concentration&#44; due to the long half-life of this metabolite &#40;15-35 days&#41;&#46; However&#44; the suitability of using total 25&#40;OH&#41;D levels to determine VD sufficiency has been questioned in recent years&#58; detractors propose determining levels of the active forms or the free fraction&#44; given that protein-bound metabolites may be inactive and may therefore not constitute adequate markers&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">10</span></a> Circulating VD may be either free or bound to albumin or to vitamin D-binding protein &#40;DBP&#41;&#46; The free fraction of VD constitutes a very small proportion of circulating metabolites &#40;below 1&#37;&#41; and may have a different biological function from that of the protein-bound fraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0710"><span class="elsevierStyleSup">11&#44;12</span></a> The concepts of VD sufficiency or deficiency are therefore difficult to define&#46; Furthermore&#44; the plasma concentration of circulating 25&#40;OH&#41;D varies depending on the patient&#39;s health status and certain genetic factors&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">13</span></a> The issue is further complicated by the fact that the free fraction of circulating VD is usually calculated through mathematical estimation rather than by direct measurement<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">14</span></a>&#59; these 2 methods deliver considerably different results&#46; The terminology used in the literature is also potentially confusing&#46; The term &#8220;bioavailable&#8221; 25&#40;OH&#41;D is used for circulating 25&#40;OH&#41;D which is not bound to DBP&#44; that is the free and albumin-bound fractions&#59; this represents approximately 10&#37; of total circulating 25&#40;OH&#41;D&#59; this should not be mistaken for free 25&#40;OH&#41;D&#46; These methodological aspects make it difficult to determine the role of VD deficiency as a risk factor for MS in general&#44; and even more difficult in individual patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Plasma transport of vitamin D and transformation into active metabolites</span><p id="par0015" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; VD is transported to cells and tissues via transport proteins &#40;DBP and albumin&#41;&#46; DBP is produced in the liver&#46; In addition to transporting VD&#44; this protein promotes the conversion of the prohormone 25&#40;OH&#41;D&#44; an inactive circulating metabolite&#44; into the active metabolite&#44; 1&#44;25-dihydroxyvitamin D &#40;1&#44;25&#91;OH&#93;<span class="elsevierStyleInf">2</span>D&#41;&#46; This requires the action of 25-hydroxyvitamin D-1&#945;-hydroxylase&#44; also known as cytochrome p450 27B1 &#40;CYP27B1&#41; or simply 1-&#945;-hydroxylase&#44; which is encoded by the <span class="elsevierStyleItalic">CYP27B1</span> gene&#46; This enzyme is expressed in renal tubule cells and other types of cells&#44; such as immune and central nervous system &#40;CNS&#41; cells&#46; It catalyses the conversion of 25&#40;OH&#41;D to 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#46; This metabolite acts on the VD receptor &#40;VDR&#41;&#44; the nuclear receptor for 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#46; As mentioned previously&#44; 99&#37; of circulating 25&#40;OH&#41;D is bound either to DBP or to albumin&#44;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">15</span></a> and only a small fraction is free&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">16</span></a> 25&#40;OH&#41;D is a lipophilic molecule&#59; therefore&#44; it is capable of passively penetrating cell membranes&#46; The idea that the free fraction is the active form&#44; as occurs with other hormones&#44; is debated for 2 main reasons&#46; Firstly&#44; serum concentrations of the free fraction of 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D are 10<span class="elsevierStyleSup">&#8722;13</span><span class="elsevierStyleHsp" style=""></span>M&#44; nearly 1000 times lower than the concentration necessary for binding to VDR&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">17</span></a> Secondly&#44; megalin&#44; also known as low-density lipoprotein-related protein 2 &#40;LRP2&#41;&#44; has been shown to play an important role in VD metabolism&#46; This transmembrane protein acts as a multiligand receptor in various tissues and binds to DBP&#44; creating a compound that is internalised by endocytosis into the proximal tubule cells&#44; where 1-&#945;-hydroxylase is expressed&#46; Megalin acts as an endocytic receptor which binds to extracellular ligands and internalises them by endocytosis&#44; leading to the activation of certain signalling pathways involving lipoproteins&#44; hormones&#44; drugs&#44; and DBP itself&#44; which are dependent on binding with adaptor proteins that recognise specific cytoplasmic domains of megalin&#46; These pathways are involved in protein trafficking&#44;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">18</span></a> interaction with cytoskeletal or cytoplasmic proteins&#44; and SHH signalling&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">19</span></a> Megalin may be phosphorylated by GSK3&#44; PKC&#44; CK-II&#44; or PKA for endosomal recycling&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">20</span></a> As occurs with vitamin D-deficient mice&#44; megalin-deficient mice develop the bone phenotype of rickets&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">21</span></a> In addition to megalin&#44; the proteins cubilin<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">22</span></a> and Dab2 adaptor protein<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">23</span></a> also bind to DBP&#46; Megalin is expressed not only in the kidney but also in the nervous system and in such other tissues as the placenta&#44; mammary glands&#44; and parathyroid glands&#46; It has therefore been suggested that VD binds to megalin in these tissues&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In healthy brains&#44; megalin is preferentially expressed in the ependymal cells lining the ventricular wall&#44; capillaries&#44; and choroid plexus&#44;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">24</span></a> but has also been observed in the central and peripheral nervous systems&#46; Inactivation of the megalin gene results in developmental alterations of the forebrain&#44; absence of the olfactory apparatus&#44; and craniofacial malformations&#44;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">25</span></a> whereas a mutation in the gene results in abnormalities in the dorsal diencephalon&#44; with hypertrophy of the choroid plexus of the third ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">26</span></a> In the CNS&#44; megalin is expressed in neurons and astrocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">27</span></a> Astrocytes need megalin to internalise albumin&#44; which is in turn necessary for the synthesis of neurotrophic factors by nearby neurons&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">28</span></a> Megalin has also been found in retinal ganglion cells&#44; where it interacts with metallothionein-IIA&#44; enabling the activation of various intracellular signalling pathways involved in neuroprotection&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">29</span></a> Megalin has also been found in different neuronal populations of the cortex&#44; hippocampus&#44; striatum&#44; thalamus&#44; olfactory bulb&#44; and cerebellum of healthy human&#44; monkey&#44; rat&#44; and mouse brains&#46; The protein is upregulated in damaged neurons in patients with Alzheimer disease&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">30</span></a> In the brain&#44; megalin is involved in the endocytosis and internalisation of apolipoprotein E and the amyloid precursor protein &#40;APP&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Internalisation of vitamin D metabolites</span><p id="par0025" class="elsevierStylePara elsevierViewall">The internalisation of VD metabolites is mediated by the DBP-megalin complex in various tissues&#46; If the VD&#8211;DBP complex is present in high concentrations&#44; more VD metabolites will be available for megalin-mediated internalisation and&#44; consequently&#44; the free fraction available for passive diffusion will be smaller&#46; DBP concentration influences the availability of the free fraction of VD&#59; an increase in the levels of circulating VD may result in a decrease in the free fraction available&#46; On the other hand&#44; lower DBP concentrations may increase the concentration of free VD metabolites at the cell membrane&#44; promoting passive diffusion of these molecules&#46; This is not always the case&#44; however&#58; some cells may internalise DBP by mechanisms involving proteins other than megalin&#44; internalising bound rather than free VD metabolites&#46; B-lymphocytes may internalise 25&#40;OH&#41;D by binding DBP without the presence of megalin&#59; this may involve Fc &#947; receptors&#44; which also associate with immunoglobulins&#46; Some tissues do not express megalin&#44; which suggests that they internalise free 25&#40;OH&#41;D&#46; It has been hypothesised that free 25&#40;OH&#41;D especially affects immune cells &#40;e&#46;g&#46; monocytes&#44; macrophages&#44; and dendritic cells&#41;&#46; In vitro studies have shown that monocytes exposed to increasing doses of 25&#40;OH&#41;D in the presence of DBP display dose-dependent induction of antibacterial proteins&#46; In the absence of DBP&#44; however&#44; this response is much more marked&#59; the capacity of 25&#40;OH&#41;D to promote monocyte antibacterial activity is dependent on both serum concentration and DBP genotype&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">31</span></a> Similar observations have been made for regulatory T cells&#46; However&#44; this inverse relationship also involves other variables&#46; Thus&#44; VD metabolites may also bind serum albumin&#44; although the affinity of 25&#40;OH&#41;D and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D for albumin is considerably lower&#46; Furthermore&#44; due to the relative abundance of serum albumin &#40;650<span class="elsevierStyleHsp" style=""></span>&#956;M&#41; compared to DBP &#40;5<span class="elsevierStyleHsp" style=""></span>&#956;M&#41;&#44; we should consider the possibility that VD metabolites may be transported by albumin in certain situations&#46; As a result&#44; part of the DBP in the serum may not be bound to any metabolite&#46; Therefore&#44; the binding of 25&#40;OH&#41;D and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D to albumin may also have an impact on the free fraction&#46; Less than 0&#46;1&#37; of total circulating 25&#40;OH&#41;D is free&#46; Dietary changes may decrease the binding affinity of DBP for VD metabolites&#59; for example&#44; polyunsaturated fatty acids can decrease this affinity&#44; resulting in changes in the bioavailability of VD metabolites&#46; The behaviour of free 25&#40;OH&#41;D in patients receiving oral and parenteral VD supplementation is unknown&#46; However&#44; the correlation between serum 25&#40;OH&#41;D and DBP concentrations seems to suggest that these supplements do not modify either total or free 25&#40;OH&#41;D concentrations&#46; Total serum 25&#40;OH&#41;D&#44; 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#44; and DBP concentrations do not change at the onset of treatment with vitamin D<span class="elsevierStyleInf">3</span> or vitamin D<span class="elsevierStyleInf">2</span> supplementation&#46; At the end of treatment&#44; however&#44; the serum concentration of 25&#40;OH&#41;D<span class="elsevierStyleInf">3</span> increases significantly more than that of 25&#40;OH&#41;D<span class="elsevierStyleInf">2</span>&#59; serum DBP concentrations also change&#44; whereas free and bioavailable 25&#40;OH&#41;D levels are similar in patients receiving vitamin D<span class="elsevierStyleInf">2</span> or vitamin D<span class="elsevierStyleInf">3</span> supplements&#46; The lower efficiency of vitamin D<span class="elsevierStyleInf">2</span>&#44; compared to vitamin D<span class="elsevierStyleInf">3</span>&#44; in increasing total serum 25&#40;OH&#41;D levels has been attributed to the weaker affinity of 25&#40;OH&#41;D<span class="elsevierStyleInf">2</span> for DBP&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A third factor in the association between DBP and the free fraction is that DBP has phenotypic variations that may influence its affinity for VD metabolites&#46; The different forms of DBP &#40;group-specific component &#91;Gc&#93;1F&#44; Gc1S&#44; and Gc2&#41; are associated with polymorphisms in the <span class="elsevierStyleItalic">DBP</span> gene or the <span class="elsevierStyleItalic">Gc</span> gene&#46; These DBP variants result from changes in the protein&#39;s amino acid sequence&#44; altering the binding affinity of DBP for VD metabolites&#59; Gc1F displays the greatest affinity and Gc2 the lowest&#46;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">32&#44;33</span></a> This is compensated for by changes in serum DBP levels&#44; with Gc2 levels being the highest and Gc1F levels the lowest&#44;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">34</span></a> meaning that DBP concentration increases with lower affinity&#44; and vice versa&#46; Gc allele variability is associated with racial differences&#58; in black and Asian populations&#44; the Gc1F form of DBP is more prevalent&#44; whereas Gc1S is more prevalent in white populations&#46; Gc2&#44; which has lower affinity for VD metabolites&#44; is more frequent in white populations and has rarely been observed in black populations&#59; DBP affinity is therefore linked to skin pigmentation&#46; The phenotypic variations of DBP also include those caused by such single-nucleotide polymorphisms &#40;SNP&#41; as rs7041 and rs4588&#46; These 2 SNPs are associated with lower 25&#40;OH&#41;D levels&#44; and are more frequent in Hispanic and African-American populations&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">35</span></a> Combinations of these alleles may alter DBP concentration and affinity for 25&#40;OH&#41;D and 25&#40;OH&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0835"><span class="elsevierStyleSup">36&#44;37</span></a> Santos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">38</span></a> report that the rs4588 and rs7044 SNPs are associated with lower 25&#40;OH&#41;D concentrations in young healthy women&#46; Cheung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">39</span></a> identified 4 SNPs &#40;rs2282679&#44; rs10741657&#44; rs12785878&#44; and rs6013897&#41; linked to 25&#40;OH&#41;D concentration&#44; and found that rs2282679 was associated with low serum 25&#40;OH&#41;D levels whereas rs12785878 was associated with VD deficiency only&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The idea that internalisation is megalin-independent in most immune cells is relevant&#44; since it means that the internalisation of VD metabolites into these cells may be dependent on Fc &#947; receptors or the free fraction of VD&#44; which has an inverse relationship with plasma DBP concentration&#44; and consequently with plasma circulating VD concentration&#46; This is the opposite of what occurs in CNS cells&#44; where VD internalisation is megalin-mediated&#46; We may therefore hypothesise that low DBP concentrations may result in a high level of internalisation into immune cells and a low level into CNS cells&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Enzymes involved in vitamin D metabolism</span><p id="par0040" class="elsevierStylePara elsevierViewall">Multiple enzymes are involved in VD metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">40</span></a> The first of these&#44; CYP2R1&#44; converts VD into 25&#40;OH&#41;D&#46;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">41</span></a> The enzyme 1-&#945;-hydroxylase &#40;CYP27B1&#41;&#44; encoded by the <span class="elsevierStyleItalic">CYP27B1</span> gene&#44; catalyses the hydroxylation of 25&#40;OH&#41;D into 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#44; which subsequently binds to VDR&#46; The third enzyme&#44; 1&#44;25-dihydroxyvitamin D-24-hydroxylase &#40;24-hydroxylase&#44; CYP24A1&#41;&#44; is encoded by the <span class="elsevierStyleItalic">CYP24A1</span> gene&#46; It is involved in VD degradation via 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D hydroxylation&#44; acting in the opposite direction&#46; The 3 enzymes are members of the cytochrome P450 superfamily of enzymes&#46; No association has been found between MS and different variants of the gene coding for DBP&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">The vitamin D receptor</span><p id="par0045" class="elsevierStylePara elsevierViewall">The VD metabolite 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D binds to VDR&#44; a nuclear receptor&#46; Under pathological conditions&#44; VDR is located mainly in the cytoplasm&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">43</span></a> The interaction between VDR and its ligand&#44; 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#44; results in 2 independent protein interaction surfaces on the VDR&#44; promoting interaction with the retinoid X receptor &#40;RXR&#41;&#44; which is necessary for DNA binding&#44; and the recruitment of co-regulators involved in gene modulation&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">44</span></a> After dimerising with RXR&#44; the VDR-1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D complex translocates to the nucleus&#44; where it binds to vitamin D response elements &#40;VDRE&#41; in VD responsive genes&#46; Target genes may act as co-activators or co-repressors&#59; the VDR-RXR complex induces or represses gene transcription in a process involving ATPases and proteins participating in RNA polymerase II recruitment&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">45</span></a> In addition to this VDRE-regulated mechanism&#44; VDR may also inhibit genes by antagonising certain transcription factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">46&#44;47</span></a> There are several alleles of the <span class="elsevierStyleItalic">VDR</span> gene&#46; Certain variants have been associated with increased susceptibility to infections and a greater incidence of such autoimmune diseases as MS and cancer&#44; which may be due to a decrease in VDR mRNA stability&#44; and consequently to a decrease in VDR expression&#46; Some variants of the <span class="elsevierStyleItalic">VDR</span> gene result in a non-functional receptor&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">48</span></a> The literature describes several polymorphisms in the gene coding for VDR &#40;Apa-I&#44; Taq-I&#44; Fok-I&#44; and Bsm-I&#41;&#46; While some studies have found significant associations between these polymorphisms and MS&#44;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">49&#8211;51</span></a> others have not&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">52&#8211;57</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Vitamin D metabolism in the central nervous system</span><p id="par0050" class="elsevierStylePara elsevierViewall">Although VD has traditionally been considered to participate in bone metabolism&#44; its presence in the CNS suggests that it is also involved in some CNS functions&#59; it is even considered a neurosteroid&#46;<a class="elsevierStyleCrossRef" href="#bib0945"><span class="elsevierStyleSup">58</span></a> A CSF study of both patients with MS and controls revealed presence of 25&#40;OH&#41;D&#44; which was positively correlated with serum 25&#40;OH&#41;D&#46;<a class="elsevierStyleCrossRef" href="#bib0950"><span class="elsevierStyleSup">59</span></a> DBP was also observed in the CSF of controls&#44; although it was more frequently found in patients with MS&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">60</span></a> This confirms that VD and its main transport protein enter the CNS&#46; VDR mRNA and CYP27B1 mRNA expression in the CNS is greater in animals with EAE than in controls&#46;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">61</span></a> Considering that VDR and CYP27B1 are expressed in the neurons and astrocytes of healthy individuals&#44; it may be hypothesised that VD plays a role in certain functions of the CNS&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">62</span></a> In vitro studies of glial cell cultures have reported that 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> supplementation has an anti-inflammatory effect&#44;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">63</span></a> which supports the therapeutic potential of VD in MS&#46; Considering that 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D can cross the blood-brain barrier and that most CNS cells&#44; including the microglia&#44;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">64</span></a> express VDR&#44; it seems plausible to consider that VD acts directly on the CNS&#46; VD has recently been observed to act on histones&#44; causing epigenetic changes<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">65</span></a> that have been associated with MS&#46;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">66&#44;67</span></a> As mentioned previously&#44; VDR is present in neurons and glial cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0995"><span class="elsevierStyleSup">68&#44;69</span></a> An animal model found that 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> increases VDR nRNA and CYP27B1 mRNA expression in female mice with EAE&#44; compared to controls&#46;<a class="elsevierStyleCrossRef" href="#bib0960"><span class="elsevierStyleSup">61</span></a> CYP24A1 mRNA expression increases with exposure to 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D in C6 glioma and rat primary glial cell cultures&#46;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">70</span></a> IFN-&#947; alters CYP24A1 expression in macrophages&#46;<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">71</span></a> TNF and interleukin-1&#946; production have been found to decrease in a microglial cell line exposed to 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#46;<a class="elsevierStyleCrossRef" href="#bib1015"><span class="elsevierStyleSup">72</span></a> Likewise&#44; 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> has been shown to reduce TNF nRNA and expression of the macrophage colony-stimulating factor in primary rat astrocytes and glioma cells&#46;<a class="elsevierStyleCrossRef" href="#bib1020"><span class="elsevierStyleSup">73</span></a> Furthermore&#44; MHC class II immunoreactivity decreases in EAE after treatment with 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#46;<a class="elsevierStyleCrossRef" href="#bib1025"><span class="elsevierStyleSup">74</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A study by Smolders et al&#46;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">75</span></a> extrapolates VD metabolism in the CNS of healthy individuals to patients with MS&#46; The researchers confirm VDR expression in the nuclei of all neurons&#44; including in the hypothalamus&#46; CYP24A1 is expressed in the cytoplasm of virtually all neurons&#44; including those of the hypothalamus&#44; and especially in the cells of the supraoptic and periventricular nuclei&#59; in the hypothalamus&#44; CYP24A1 co-localises with cortisol-releasing hormone&#44; vasopressin&#44; and oxytocin&#46; Normal-appearing white matter of MS patients and controls shows VDR nuclear activity in oligodendrocytes&#46; Microglia also display VDR expression&#44; but no CYP24A expression&#46; Astrocytes show both nuclear VDR and cytoplasmic CYP24A expression&#46; However&#44; some patients show cytoplasmic expression of VDR&#44; especially in glial cells displaying increased GFAP expression&#46; In normal-appearing white matter&#44; glial expression of VDR mRNA and CYP27B1 mRNA is similar to that found in peripheral mononuclear cells&#44; whereas CYP24A1 mRNA and LRP2 mRNA expression is increased in controls&#46; VDR mRNA expression is significantly greater in patients with MS than in controls&#44; whereas expression of CYP24A1 mRNA&#44; CYP27B1 mRNA&#44; and megalin mRNA is similar&#46; The researchers observed cytoplasmic VDR expression in glial cells at the core of chronic&#44; inactive MS lesions as well as in some cells in the perilesional white matter&#46; VDR mRNA and CYP27B1 mRNA expression is greater in chronic&#44; active lesions than in normal-appearing white matter&#46; However&#44; the researchers found no differences between chronic&#44; inactive lesions and normal-appearing white matter&#46; Megalin mRNA expression is lower in chronic&#44; active and inactive lesions than in normal-appearing white matter&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The researchers include a series of in vitro experiments demonstrating the effects of VD in certain CNS cell lines&#46; In vitro 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> supplementation in a culture of SH-SY5Y neuroblastoma cell line&#44; which mainly includes neurons&#44; induces CYP24A mRNA expression&#46;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">75</span></a> In vitro exposure of primary human astrocytes and astroglioma cell lines &#40;U343 and U373&#41; to 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> showed dose-dependent VDR mRNA and CYP24A1 mRNA upregulation&#44; but had no effect on CYP27B1 mRNA expression&#46; Primary astrocyte and microglia cultures were exposed to IFN-&#947;&#44; TNF&#44; and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span>&#46; IFN-&#947; and TNF were found to upregulate CYP27B1 mRNA both in astrocytes and in microglia&#46; CYP27B1 mRNA expression was lower in cells exposed to IFN-&#947; or TNF and treated with 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> than in those not treated with 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span>&#46; CYP27B1 and CYP24A1 upregulation secondary to exposure to IFN-&#947;&#47;TNF and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D<span class="elsevierStyleInf">3</span> was more marked in astrocytes than in microglia&#46; Immunohistochemical studies have found megalin in the choroidal plexus and the endothelium of brain microvessels&#44;<a class="elsevierStyleCrossRef" href="#bib1035"><span class="elsevierStyleSup">76</span></a> which suggests that megalin transports DBP and VD into the CNS&#46; Furthermore&#44; megalin mRNA expression has been observed to be lower in both active and inactive MS lesions&#46; The mechanism by which 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D promotes neuronal differentiation is unclear&#46; It is hypothesised that the mechanism involves growth factors&#44; based on observations that 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D upregulates the expression of NT-3 and NGF&#44;<a class="elsevierStyleCrossRef" href="#bib1040"><span class="elsevierStyleSup">77</span></a> GDNF&#44;<a class="elsevierStyleCrossRef" href="#bib1045"><span class="elsevierStyleSup">78</span></a> CNTF&#44; or BDNF&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">79</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Vitamin D metabolism and remyelination in multiple sclerosis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Myelination is the process by which axons are wrapped in myelin&#46; Remyelination of demyelinated lesions has been observed in the early stages of MS<a class="elsevierStyleCrossRefs" href="#bib1055"><span class="elsevierStyleSup">80&#8211;82</span></a>&#59; this is supported by neuroimaging findings&#46;<a class="elsevierStyleCrossRefs" href="#bib1070"><span class="elsevierStyleSup">83&#8211;89</span></a> However&#44; remyelination is incomplete<a class="elsevierStyleCrossRef" href="#bib1105"><span class="elsevierStyleSup">90</span></a> and eventually ceases&#44;<a class="elsevierStyleCrossRef" href="#bib1110"><span class="elsevierStyleSup">91</span></a> perhaps due to the inability of oligodendrocyte precursor cells &#40;OPC&#41; to migrate and reach the site of demyelination&#44;<a class="elsevierStyleCrossRef" href="#bib1115"><span class="elsevierStyleSup">92</span></a> or to a lack of suitable conditions for differentiation&#46;<a class="elsevierStyleCrossRef" href="#bib1120"><span class="elsevierStyleSup">93</span></a> Post mortem studies of patients with MS show that depletion of the OPCs available for remyelination is not a likely explanation of remyelination failure&#46;<a class="elsevierStyleCrossRefs" href="#bib1125"><span class="elsevierStyleSup">94&#8211;97</span></a> Remyelination decreases with age&#44; regardless of health status&#46;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">98&#44;99</span></a> The most likely explanation of this phenomenon is the inability of OPCs to mature into oligodendrocytes&#44; probably because the microenvironment prevents OPC differentiation and subsequent axon remyelination&#46; This is relevant for MS treatment since current treatments are effective only in controlling immune mechanisms &#40;that is&#44; in the early stages of the disease&#41; but have no effect on remyelination&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Little is known about the role of VD in myelination&#46; According to a number of studies&#44; however&#44; VD may be involved in myelination and remyelination at different levels &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1155"><span class="elsevierStyleSup">100&#8211;108</span></a> Combined treatment with myelin peptides and VD protects against EAE<a class="elsevierStyleCrossRefs" href="#bib1170"><span class="elsevierStyleSup">103&#44;104</span></a> and an animal model of Krabbe disease&#46;<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">105</span></a> Given that VD decreases inducible nitric acid synthase expression in the microglia&#44; it may have an impact on the balance between the inflammatory and anti-inflammatory mechanisms involved in remyelination&#46; VD also increases microglial activation&#44; promoting the clearance of myelin debris and&#44; as a consequence&#44; remyelination&#46;<a class="elsevierStyleCrossRef" href="#bib1185"><span class="elsevierStyleSup">106</span></a> In OPC cell cultures&#44; VD upregulates the transcription of VDR and NGF mRNA&#44; but not of myelin basic protein or proteolipid protein mRNA&#46; As mentioned previously&#44; oligodendrocytes express VDR&#44; and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D depletion results in reduced differentiation into oligodendrocytes and demyelination<a class="elsevierStyleCrossRef" href="#bib1190"><span class="elsevierStyleSup">107</span></a>&#59; VD and VDR therefore positively regulate OPC differentiation&#46; VDR expression has been observed in OPCs in MS tissue cultures&#46;<a class="elsevierStyleCrossRefs" href="#bib1195"><span class="elsevierStyleSup">108&#44;109</span></a> In OPCs&#44; VDR heterodimerises with RXR-&#947; and participates in OPC differentiation&#59; RXR-&#947; is expressed in OPCs during remyelination&#46;<a class="elsevierStyleCrossRef" href="#bib1205"><span class="elsevierStyleSup">110</span></a> In vitro studies show that blocking VDR reduces OPC differentiation&#44; myelination&#44; and remyelination&#44; whereas activating VDR via VD increases differentiation&#46;<a class="elsevierStyleCrossRef" href="#bib1210"><span class="elsevierStyleSup">111</span></a> Likewise&#44; neural stem cells &#40;NSC&#41; express VDR and 1&#44;25&#40;OH&#41;<span class="elsevierStyleInf">2</span>D&#46; The latter increases NSC proliferation and differentiation into neurons and oligodendrocytes&#44; reducing astrogliosis&#46;<a class="elsevierStyleCrossRef" href="#bib1215"><span class="elsevierStyleSup">112</span></a> VD promotes NSC proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib1220"><span class="elsevierStyleSup">113</span></a> It has been suggested that Spp1&#44; a VD-regulated cytokine&#44; plays a role in MS&#46;<a class="elsevierStyleCrossRef" href="#bib1225"><span class="elsevierStyleSup">114</span></a> Spp1 boosts myelin formation in vitro<a class="elsevierStyleCrossRef" href="#bib1230"><span class="elsevierStyleSup">115</span></a>&#59; and its expression has been shown to increase during remyelination in an animal model of toxin-induced demyelination&#46;<a class="elsevierStyleCrossRef" href="#bib1235"><span class="elsevierStyleSup">116</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">VD-induced microglial activation promotes phagocytosis of amyloid-&#946; peptides &#40;A&#946;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib1240"><span class="elsevierStyleSup">117</span></a> thus preventing axon damage&#58; A&#946; expression is increased in demyelinating plaques&#44;<a class="elsevierStyleCrossRefs" href="#bib1245"><span class="elsevierStyleSup">118&#8211;120</span></a> which&#44; although initially beneficial&#44; may cause toxicity at later stages&#46; Megalin is involved in APP and A&#946; endocytosis and internalisation&#46;<a class="elsevierStyleCrossRef" href="#bib9000"><span class="elsevierStyleSup">121</span></a> A megalin-APP-Fe65 complex has been found in hippocampal neurons&#59; this complex would act as a regulator of A&#946; toxicity&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">122</span></a> We have recently studied the potential role of APP and its signalling pathway<a class="elsevierStyleCrossRef" href="#bib1270"><span class="elsevierStyleSup">123</span></a> based on PET imaging findings of amyloid tracer uptake in myelin&#46;<a class="elsevierStyleCrossRef" href="#bib1275"><span class="elsevierStyleSup">124</span></a> APP is upregulated in demyelinated axons&#44; which activates the amyloid cascade&#44; promoting A&#946; production&#46;<a class="elsevierStyleCrossRefs" href="#bib1280"><span class="elsevierStyleSup">125&#44;126</span></a> APP expression also increases after spinal white matter compression injury in rats&#46;<a class="elsevierStyleCrossRef" href="#bib1290"><span class="elsevierStyleSup">127</span></a> VD increases APP expression in rats<a class="elsevierStyleCrossRef" href="#bib1295"><span class="elsevierStyleSup">128</span></a> and is thought to play a role in remyelination&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0080" class="elsevierStylePara elsevierViewall">In advanced stages of MS&#44; the ability to remyelinate axons is lost&#46;<a class="elsevierStyleCrossRefs" href="#bib1060"><span class="elsevierStyleSup">81&#44;129</span></a> This is relevant to MS treatment&#58; current treatments control immune mechanisms and are therefore effective only in the early stages of the disease&#59; they have no effect on remyelination and consequently on sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib1305"><span class="elsevierStyleSup">130&#44;131</span></a> VD metabolism is present in the CNS&#44; participates in myelination&#44; and may be influenced by such external factors as diet&#44; sun exposure&#44; or VD supplementation&#46; Understanding the role of VD in myelination may eventually allow us to better manage patients with MS and VD deficiency&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Vitamin D deficiency"
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          "identificador" => "sec0015"
          "titulo" => "Plasma transport of vitamin D and transformation into active metabolites"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Internalisation of vitamin D metabolites"
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          "identificador" => "sec0025"
          "titulo" => "Enzymes involved in vitamin D metabolism"
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        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "The vitamin D receptor"
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        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Vitamin D metabolism in the central nervous system"
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        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Vitamin D metabolism and remyelination in multiple sclerosis"
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          "titulo" => "Conclusions"
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    "fechaRecibido" => "2016-05-08"
    "fechaAceptado" => "2016-05-12"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:6 [
            0 => "Myelin"
            1 => "Vitamin D"
            2 => "Vitamin D receptor"
            3 => "Oligodendrocyte"
            4 => "Oligodendrocyte progenitor cells"
            5 => "Multiple sclerosis"
          ]
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          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Mielina"
            1 => "Vitamina D"
            2 => "Receptor de Vitamina D"
            3 => "Oligodendrocito"
            4 => "C&#233;lulas precursoras de oligodendrocitos"
            5 => "Esclerosis multiple"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Several studies have found an association between multiple sclerosis and vitamin D &#40;VD&#41; deficiency&#44; which suggests that VD may play a role in the immune response&#46; However&#44; few studies have addressed its role in remyelination&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Development</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The VD receptor and the enzymes transforming VD into metabolites which activate the VD receptor are expressed in central nervous system &#40;CNS&#41; cells&#44; which suggests a potential effect of VD on the CNS&#46; Both in vitro and animal model studies have shown that VD may play a role in myelination by acting on factors that influence the microenvironment which promotes both proliferation and differentiation of neural stem cells into oligodendrocyte progenitor cells and oligodendrocytes&#46; It remains unknown whether the mechanisms of internalisation of VD in the CNS are synergistic with or antagonistic to the mechanisms that facilitate the entry of VD metabolites into immune cells&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">VD seems to play a role in the CNS and our hypothesis is that VD is involved in remyelination&#46; Understanding the basic mechanisms of VD in myelination is necessary to manage multiple sclerosis patients with VD deficiency&#46;</p></span>"
        "secciones" => array:3 [
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            "titulo" => "Introduction"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diferentes estudios han asociado la deficiencia en VD a la esclerosis m&#250;ltiple lo que ha llevado a plantear su potencial papel en la respuesta inmune&#46; Existe menos informaci&#243;n sobre su papel en la remielinizaci&#243;n&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Desarrollo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En las c&#233;lulas del SNC existe el receptor VD as&#237; como las enzimas que transforman los metabolitos de la VD para poder activar este receptor&#44; lo que plantea un potencial efecto de la VD&#46; Tanto estudios in vitro como modelos animales han mostrado que la VD puede tener un papel sobre la mielinizaci&#243;n actuando en factores que influyen en el microambiente que favorece la mielinizaci&#243;n como en la proliferaci&#243;n y diferenciaci&#243;n tanto de las c&#233;lulas madre neuronales en c&#233;lulas precursoras de oligodendrocitos como en &#233;stas en oligodendrocitos&#46; No se conoce si los mecanismos de internalizaci&#243;n de la VD en el SNC son sin&#233;rgicos o antag&#243;nicos a los que permiten la entrada de los metabolitos de la VD en las c&#233;lulas inmunes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La VD debe tener un papel en el SNC y se puede hipotetizar si act&#250;a en la remielinizaci&#243;n&#46; El conocimiento de los mecanismos b&#225;sicos de los efectos de la VD en la mielinizaci&#243;n parece necesario para poder aconsejar a los pacientes con esclerosis m&#250;ltiple ante deficiencias de VD en la cl&#237;nica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mat&#237;as-Gu&#237;u J&#44; Oreja-Guevara C&#44; Matias-Guiu JA&#44; Gomez-Pinedo U&#46; Vitamina D y remielinizaci&#243;n en la esclerosis m&#250;ltiple&#46; Neurolog&#237;a&#46; 2018&#59;33&#58;177&#8211;186&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Level&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">General action&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">Role of vitamin D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Immediate consequence&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" title="table-entry  " rowspan="4" align="left" valign="top">Microenvironment</td><td class="td" title="table-entry  " align="left" valign="top">Promoting a suitable environment for remyelination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing microglial activation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clearance of myelin debris&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">Preventing toxic effects on axons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing microglial activation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clearance of amyloid-&#946;&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">Promoting remyelination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing Spp1 expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myelin production&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">Promoting remyelination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increasing APP expression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myelin production&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">Promoting proliferation and differentiation into oligodendrocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Promoting OPC differentiation into oligodendrocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VDR upregulation in OPCs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heterodimerisation of VDR with RXR-&#947;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Promoting proliferation and differentiation into OPCs</td><td class="td" title="table-entry  " align="left" valign="top">Promoting NSC differentiation into OPCs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Activating VDR in NSCs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater numbers of OPCs&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">Promoting NSC proliferation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Activating VDR in NSCs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater numbers of NSCs and subsequently of OPCs&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">Reducing NSC differentiation into astrocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Activating VDR in NSCs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reduction in astrocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                      "titulo" => "Vitamin D intake and incidence of multiple sclerosis"
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                        0 => array:2 [ …2]
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                    0 => array:1 [
                      "Revista" => array:6 [
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                      "titulo" => "Serum 25-hydroxyvitamin D levels and risk of multiple sclerosis"
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                      "titulo" => "Vitamin D and risk of multiple sclerosis&#58; a Mendelian randomization study"
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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