scholarly journals Vitamin D assessment in perioperative medicine and critical care

2019 ◽  
Author(s):  
Paul Zajic ◽  
Stefan Heschl ◽  
Michael Schörghuber ◽  
Petra Srekl-Filzmaier ◽  
Tatjana Stojakovic ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
False Positive Rate ◽  
Fluid Loading ◽  
Vitamin D Levels ◽  
Positive Rate ◽  
25 Hydroxy Vitamin D ◽  
The Mean ◽  
Clinical Trials Registry ◽  
The Impact

Summary Background There is controversy about the impact of acute illness on vitamin D levels. This study was carried out to assess the influence of perioperative fluid loading on 25-hydroxy-vitamin D [25(OH)D] levels. The study evaluated the clinical utility of a commonly available chemiluminescence assay (ECLIA, IDS-iSYS) and liquid chromatography/mass spectrometry (LC-MS/MS) in the diagnosis of vitamin D deficiency in this setting. Methods In this prospective observational pilot study in adult patients undergoing cardiovascular surgery on cardiopulmonary bypass (CPB), blood samples drawn at preoperative baseline (t1), after weaning from CPB (t2), on intensive care unit (ICU) admission (t3) and on the first (t4) and second (t5) postoperative days were analyzed. Results A total of 26 patients (130 samples) were included in this study. Fluid loading by CPB led to a median reduction of 25(OH)D by −22.6% (range −54.5% to −19.5%) between t1 and t2. Cohen’s kappa (κ) for method agreement for vitamin D deficiency (tested cut-off values 20 ng/ml and 12 ng/ml), was κ = 0.291 (p < 0.001) and κ = 0.469 (p < 0.001), respectively. The mean difference between measurements by ECLIA and LC-MS/MS was 4.8 ng/ml (±5.7), Pearson’s r for correlation was 0.73 (p < 0.001). The biologically inactive C3-epimer did not contribute to 25(OH)D levels assessed by LC-MS/MS. Conclusion The 25(OH)D measurements by chemiluminescence assays can noticeably deviate from those measured by LC-MS/MS, which can be considered the unequivocal gold standard. These assays may still be acceptably reliable in the screening for vitamin D deficiency, especially in the setting of low vitamin D levels. Stricter definitions, e.g. serum 25(OH)D levels lower than 12 ng/ml, may be used to diagnose deficiency with low false positive rate. Trial Registration DRKS00009216, German Clinical Trials Registry (www.drks.de)

scholarly journals Effect of vitamin D on sleep quality in hemodialysis patients

2020 ◽  
Vol 10 (4) ◽  
pp. e32-e32
Author(s):  
Narges Sadat Zahed ◽  
Maryam Namakchian ◽  
Zahra Davoudi ◽  
Adineh Taherkhani
Keyword(s):  
Vitamin D ◽  
Sleep Quality ◽  
Vitamin D Deficiency ◽  
Controlled Trial ◽  
Life Quality ◽  
Hemodialysis Patients ◽  
25 Hydroxy Vitamin D ◽  
The Mean ◽  
The Impact

Introduction: Quality of sleep is among the factors that affect the improvement of life quality. The previous studies showed that 50%-80% of hemodialysis patients experience sleeping disturbances. Additionally, dialysis patients commonly experience vitamin D deficiency. Objectives: We aimed to determine the impact of vitamin D deficiency therapy on sleep quality of hemodialysis patients. Patients and Methods: Thirty hemodialysis patients with 25-hydroxy vitamin D deficiency and Pittsburgh Sleep Quality Index (PSQI) ≥5 were enrolled in this clinical trial. Patients were treated with 50000-unit vitamin D per week for 12 weeks. After treatment, the PSQI score was recalculated for each patient. Results: Nineteen out of 30 patients (63.3%) were men and 11(36.7%) were women, with a mean age of 56.7 ± 14.3 years. The mean of vitamin D level was 18.61 ± 6.32 ng/mL before treatment and 41.14 ± 9.62 ng/mL after the treatment. The mean of PSQI score at the start of study was 9.97 and after treatment with vitamin D3, it was 9.47 (P > 0.05). Conclusion: Treatment of vitamin D deficiency did not have any effect on the sleep quality according to the PSQI score in hemodialysis patients. Trial registration: This randomized controlled trial was registered in the Iranian Registry of Clinical Trials (identifier: IRCT20200223046593N1; https://en.irct.ir/trial/46126, ethical code; IR.SBMU.RETECH.REC.1397.1277).

Serum 25-hydroxy vitamin D and nutritional status: Implications for vitamin D assessment and dietary supplementation in oncology

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 9638-9638
Author(s):  
K. Trukova ◽  
D. Gupta ◽  
P. G. Vashi ◽  
A. Adams ◽  
G. M. Lambert ◽  
...  
Keyword(s):  
Vitamin D ◽  
Nutritional Status ◽  
Serum Albumin ◽  
Vitamin D Deficiency ◽  
Cancer Survival ◽  
Case Series ◽  
Vitamin D Levels ◽  
Significant Difference ◽  
25 Hydroxy Vitamin D ◽  
The Mean

9638 Background: There is emerging evidence in the literature to suggest a protective role of vitamin D in cancer survival. Vitamin D status is not routinely assessed, despite the high prevalence of malnutrition in this population. We hypothesized that malnutrition could contribute to vitamin D deficiency, and therefore expected mean serum 25-hydroxy-vitamin D [25(OH)D] levels to be significantly lower in malnourished oncology patients. Methods: A consecutive case series of 737 cancer patients seen at Cancer Treatment Centers of America between Jan-June 08. Nutritional status was assessed using Subjective Global Assessment (SGA) and serum albumin. SGA categorizes patients into 3 distinct classes of nutritional status; well nourished (SGA-A), moderately malnourished (SGA-B) and severely malnourished (SGA-C). Serum albumin was divided into 2 groups: >=3.6 g/dl and <=3.5 g/dl. Mean serum 25(OH)D was compared across 3 categories of SGA using ANOVA and across 2 categories of serum albumin using 2 sample t test. Results: Of 737 patients, 302 were males and 435 females. The mean age at presentation was 55.7 years (SD = 10.2). The most common cancer types were lung (133, 18%), breast (131, 17.8%), colorectal (97, 13.2%), pancreas (86, 11.7%), prostate (44, 6%) and ovarian (38, 5.2%). The mean serum albumin and serum 25(OH)D was 3.5g/dl (SD = 0.6) and 21.9 ng/ml (SD = 13.5) respectively. There was no significant difference in the mean vitamin D levels across serum albumin (p = 0.76). The mean vitamin D levels across the 3 classes of SGA also showed no statistically significant difference ( Table ). Conclusions: Contrary to what we expected, vitamin D deficiency was found to be prevalent in cancer regardless of nutritional status. No significant differences were found across the 3 classes of SGA. Based on these results, screening for vitamin D deficiency and aggressive vitamin D repletion should be considered for all people with cancer. [Table: see text] No significant financial relationships to disclose.

scholarly journals 25-Hydroxyl Vitamin D Deficiency in Nasal Polyposis

2019 ◽  
Vol 24 (03) ◽  
pp. e308-e312
Author(s):  
Ankur Kumar Chandrakar ◽  
Arun Alexander ◽  
Medha R. ◽  
Kalaiselvi Rajendiran ◽  
Karthikeyan Ramasamy
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Disease Severity ◽  
Nasal Polyposis ◽  
Enzyme Linked Immunosorbent Assay ◽  
Cross Sectional ◽  
Vitamin D Levels ◽  
25 Hydroxy Vitamin D ◽  
The Mean ◽  
Hs Crp

Abstract Introduction Vitamin D is known to have immunomodulatory functions and has action on chronic inflammatory processes, such as nasal polyposis. Objective The present study assessed the levels of 25-hydroxy vitamin D and high-sensitivity C-reactive protein (hs-CRP) in patients with nasal polyposis, as compared with healthy control subjects, and identified their association with disease severity in nasal polyposis. It further assessed the levels of 25-hydroxyl vitamin D and hs-CRP in patients with nasal polyposis and atopy and compared it with patients with nasal polyposis without atopy. Methods This was a cross-sectional study involving 2 groups: 80 patients with nasal polyposis and 80 healthy subjects. In patients with nasal polyposis, the disease severity is assessed by the sino-nasal outcome test (SNOT20) and by the Lund & Mackay staging system. Levels of 25-hydroxy vitamin D and hs-CRP were measured by enzyme-linked immunosorbent assay (ELISA). Result The mean 25-hydroxyl vitamin D levels (ng/ml) was 12.01 ± 7.29 for cases and 22.87 ± 14.95 for controls, with p < 0.0001. The mean hs-CRP levels (mg/L) was 5.99 ± 2.74 in cases and 2.41 ± 1.95 in controls, with p < 0.0001. The severity of polyposis correlated negatively with serum levels of 25-hydroxy vitamin D and positively with hs-CRP. Conclusion The study has thus shown significant correlation between vitamin D deficiency and inflammation in patients with nasal polyps.

scholarly journals Vitamin D and Postoperative Vasopressor Use in Cardiopulmonary Bypass

2018 ◽  
Vol 24 (8) ◽  
pp. 1322-1326 ◽  
Author(s):  
Michael J. Javorski ◽  
Mina M. Kerolos ◽  
Jawed Fareed ◽  
R. Anthony Perez-Tamayo
Keyword(s):  
Vitamin D ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Vitamin D Deficiency ◽  
Low Cost ◽  
Vitamin D Levels ◽  
25 Hydroxy Vitamin D ◽  
The Mean ◽  
D 20 ◽  
Vasopressor Use

The use of cardiopulmonary bypass (CPB) in cardiac surgery often leads to a systemic inflammatory response. Up to 25% of patients undergoing CPB for cardiac surgery are reported to develop vasoplegic syndrome in the acute postoperative period, in which the patients are refractory to vasopressors. The purpose of this study is to assess vitamin D deficiency as a risk factor for vasoplegia after using CPB. We performed a retrospective review of 1322 patients undergoing adult cardiac surgery requiring CPB. Forty-six patients with previously recorded 25-hydroxy vitamin D (25(OH)D) levels within 6 months of surgery met the conditions of this study. The mean level of 25(OH)D was 32.7 ng/mL (standard deviation [SD] = 15.1). The mean age of patients was 67 (SD = 10.1) years old, most were male (63%) and white (78%). Average CPB time was 140 ± 44 minutes. Postoperative vasopressor use was compared to individual preoperative 25(OH)D levels. As a secondary end point, postoperative vasopressor use and vasoplegia were analyzed between 3 groups: Vitamin D deficient defined as 25(OH)D ≤20 ng/mL (n = 7), vitamin D insufficient defined as 25(OH)D between 20 and 29 ng/mL (n = 15), and vitamin D sufficient defined as 25(OH)D ≥30 ng/mL (n = 24). There was no correlation between vitamin D levels and postoperative vasopressor use. The mean doses of postoperative vasopressor use were 0.088 µg/kg/min (standard error of the mean [SEM] = 0.032), 0.085 µg/kg/min (SEM = 0.037), and 0.072 µg/kg/min (SEM = 0.024) of norepinephrine equivalents for the vitamin D deficient, insufficient, and sufficient groups, respectively. Incidence of vasoplegia for each group was the following: 0.143 for vitamin D deficient, 0.067 for vitamin D insufficient, and 0.125 for vitamin D sufficient. In this pilot study, there does not appear to be a relationship between vitamin D and vasopressor use following cardiac surgery utilizing CPB; however, there appears to be a trend toward an increased vasopressor usage in patients with decreased vitamin D levels. A larger sample size and a prospective analysis are warranted to further assess the significance of the relationship between vasoplegia and vitamin D deficiency. With further investigation, vitamin D has the potential to become a low-cost, low-risk therapeutic for improving outcomes in CPB surgery.

Prevalence of Vitamin-D Deficiency in Patients with Acute Coronary Syndrome in Syria

2016 ◽  
Vol 9 (6) ◽  
pp. 3544-3548
Author(s):  
Aya Hallak ◽  
Malhis Mahmoud ◽  
Yaser Abajy Mohammad
Keyword(s):  
Vitamin D ◽  
Acute Coronary Syndrome ◽  
Vitamin D Deficiency ◽  
Hypovitaminosis D ◽  
Control Group ◽  
Coronary Syndrome ◽  
Normal Individuals ◽  
Vitamin D Levels ◽  
25 Hydroxy Vitamin D ◽  
Coronary Syndromes

The objectives of this study were to estimate the prevalence of vitamin D deficiency in patients with acute coronary syndrome in comparison with normal individuals and study the correlation between these two conditions. We measured the plasma 25-hydroxy vitamin D (25-OH-D) levels in 60 patients with acute coronary syndromes (ACS) of both gender and in 30 age matched control individuals of both gender without any known cardiovascular or systemic diseases. The levels of 25-OH-D were measured by ELISA method and the results were statically analyzed to find out any possible correlation. We classified the cases according to their plasma 25(OH)D levels. 25(OH)D levels of ≥ 30 ng/ml were considered normal, levels < 30 and > 20 ng/ml were classified as insufficient, while levels of ≤ 20 ng/ml were classified as deficient. In the current study the prevalence of hypovitaminosis D in the patients group was much higher than it was in the control group. Vitamin D deficiency was observed in 80% and insufficiency in 13% of total patients of ACS, there by bringing the total count to 93%. Whereas only 7% of the patients had adequate vitamin D levels. Thus, these results indicate the existence of a significant correlation between the vitamin D deficiency and ACS in comparison to healthy controls

scholarly journals Correlation Between 25-hydroxy-Vitamin D and Parkinson's Disease:A Case-Control study

2020 ◽  
Author(s):  
ming xia ◽  
wenjuan Xiu ◽  
Xuliang Wang ◽  
Tingting Wu ◽  
Yingying Zheng ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Vitamin D ◽  
Parkinson's Disease ◽  
Vitamin D Deficiency ◽  
Case Control Study ◽  
Case Control ◽  
Lower Serum ◽  
Vitamin D Levels ◽  
25 Hydroxy Vitamin D ◽  
Control Study

Abstract Background: Previous cross-sectional studies have shown that Parkinson’s disease (PD) patients have lower serum 25- hydroxy vitamin D (25(OH)D) concentrations than controls. whether the research in other regions findings are generalizable to China populations remains untested in other studies. In this case-control study we examined the Correlation between 25-hydroxy-vitamin D and Parkinson's disease.Methods:We establish an association between deficiency of 25-hydroxy-vitamin D and PD in a case-control study of 100 PD patients and 100 control subjects free of neurologic disease in the First Affliated Hospital of Xinjiang Medical University.Results:Total 25-hydroxy-vitamin D levels, were deficient in 21% of patients with PD compared with 4% of controls. In univariate analyses Plasma levels of 25-hydroxy-vitamin D were associated with PD(p<0.001), respectively. In multivariate analyses, Vitamin D deficiency(25(OH)D <20 ng/mL) were significant associated with PD (p=0.008,OR=17.13,95% CI, 2.082-141.075). Individuals with levels in the lowest quartile of 25(OH)D values had the highest prevalence of PD(p =0.026,OR=11.786,95%CI,1.342-103.51)compared with individuals with values in the highest quartile.Conclusions:Our study reveals an association between 25-hydroxy-vitamin D and PD.Patients with incident PD had significantly lower serum 25(OH)D concentrations than age-matched controls, High-risk PD patients with vitamin D deficiency who have not yet developed exercise impairment, these populations should undergo vitamin D measurement and vitamin D treatment as soon as possible.

scholarly journals Vitamin D levels in children with COVID-19: a report from Turkey

2021 ◽  
Vol 149 ◽  
Author(s):  
Aysegul Alpcan ◽  
Serkan Tursun ◽  
Yaşar Kandur
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Statistical Significance ◽  
Serum Vitamin ◽  
University Hospital ◽  
Control Group ◽  
Serum Vitamin D ◽  
Vitamin D Levels ◽  
Normal Vitamin ◽  
The Mean

Abstract Several studies have demonstrated that higher levels of vitamin D are associated with better prognosis and outcomes in infectious diseases. We aimed to compare the vitamin D levels of paediatric patients with mild/moderate coronavirus disease 2019 (COVID-19) disease and a healthy control group. We retrospectively reviewed the medical records of patients who were hospitalised at our university hospital with the diagnosis of COVID-19 during the period between 25 May 2020 and 24 December 2020. The mean age of the COVID-19 patients was 10.7 ± 5.5 years (range 1–18 years); 43 (57.3%) COVID-19 patients were male. The mean serum vitamin D level was significantly lower in the COVID-19 group than the control group (21.5 ± 10.0 vs. 28.0 ± 11.0 IU, P < 0.001). The proportion of patients with vitamin D deficiency was significantly higher in the COVID-19 group than the control group (44% vs. 17.5%, P < 0.001). Patients with low vitamin D levels were older than the patients with normal vitamin D levels (11.6 ± 4.9 vs. 6.2 ± 1.8 years, P = 0.016). There was a significant male preponderance in the normal vitamin D group compared with the low vitamin D group (91.7% vs. 50.8%, P = 0.03). C-reactive protein level was higher in the low vitamin D group, although the difference did not reach statistical significance (9.6 ± 2.2 vs. 4.5 ± 1.6 mg/l, P = 0.074). Our study provides an insight into the relationship between vitamin D deficiency and COVID-19 for future studies. Empiric intervention with vitamin D can be justified by low serum vitamin D levels.

Vitamin D levels in children with otitis media with effusion

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Ahmed Adly Mohamed ◽  
Marwa Mohamed EL-Begermy ◽  
Ahmed Abdelmoneim Teaima ◽  
Mohamed Ali Abdelghafar
Keyword(s):  
Vitamin D ◽  
Otitis Media ◽  
Otitis Media With Effusion ◽  
Serum Vitamin ◽  
Control Group ◽  
University Hospitals ◽  
Serum Vitamin D ◽  
Vitamin D Levels ◽  
25 Hydroxy Vitamin D ◽  
The Mean

Abstract Objective To investigate the relationship between otitis media with effusion (OME) and serum vitamin D level in children. Methods This prospective case control study was conducted at Ain Shams University Hospitals between February 2018 and May 2019. The study population included 50 children with OME confirmed by tympanometry type (B) who will undergo adenotonsillectomy and grommet tube insertion compared to 50 children without OME confirmed by tympanometry type (A) who will undergo adenotonsillectomy. Measurement of serum 25-hydroxy vitamin D using electrochemiluminescence technique from a blood sample (3cm) taken from them on the day of surgery. Results In this study, the mean age of the cases was 4.24 ± 0.80 and 5.34 ± 1.19 years for the controls besides 23 (46%) of the OME group were boys and 27 (54%) were girls, compared with 29 (58%) boys and 21 (42%) were girls in the control group. The mean levels of vitamin D in children with OME was 16.24 ± 7.14 ng/mL and in children in the control group was 15.89 ± 5.84 ng/mL (P = 0.815) and it was statistically non significant. Conclusion There was no significant relation between vitamin D serum level and the incidence of OME in children.

Relationship between calcium metabolism and benign paroxysmal positional vertigo in north Sardinia population

2020 ◽  
Vol 30 (6) ◽  
pp. 375-382
Author(s):  
Andrea Melis ◽  
Davide Rizzo ◽  
Roberto Gallus ◽  
Maria Eleonora Leo ◽  
Nicola Turra ◽  
...  
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Benign Paroxysmal Positional Vertigo ◽  
High Accuracy ◽  
T Score ◽  
Positional Vertigo ◽  
Vitamin D Levels ◽  
The Impact ◽  
Paroxysmal Positional Vertigo ◽  
Group 1

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) has a reported recurrence ranging from 26.8 to 50%. Osteoporosis and Vitamin D deficiency seems to have an impact on recurrence of BPPV. OBJECTIVE: to evaluate the impact of osteoporosis and Vitamin D deficiency on recurrence of BPPV. METHODS: 73 consecutive patients were divided in two groups according to the presence (group 1) or absence (group 0) of a recurrent episode. BMD, femoral and lumbar T-scores and Vitamin D levels were recorded. Statistical analysis was performed to investigate correlations. RESULTS: patients in group 1 had statistically significant lower values of both femoral (–1,62±1,06 vs. –0,53±1,51; p = 0,001), lumbar T-score (–2,10±1,19 vs –0, 53±1.51, p = 0.001) and Vitamin D (19.53±15.33). The values of femoral T-score and Vitamin D could be combined in a model able to properly classify 65.8% of the cases (p = 0.002) as isolated or recurrent BPPV, with high accuracy (AUC 0.710 [0.590 –0.830]). CONCLUSION: present data show a probable correlation between osteoporosis and Vitamin D with recurrent BPPV.

scholarly journals Vitamin D Deficiency and Outcomes after Ankle Fusion

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0007
Author(s):  
Deepak Ramanathan ◽  
Mark J. Berkowitz ◽  
Alan Davis ◽  
Stephen J. Pinney ◽  
Sara Lyn Miniaci-Coxhead
Keyword(s):  
Risk Factors ◽  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Reoperation Rate ◽  
Hardware Removal ◽  
Ankle Fusion ◽  
Vitamin D Levels ◽  
Normal Vitamin ◽  
Local Risk ◽  
The Impact

Category: Ankle Arthritis; Ankle; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: Ankle fusions are associated with a complication profile including nonunion with associated poor functional outcomes, chronic pain, and need for reoperation. Local risk factors (bone and soft-tissue loss, infection, ankle and hindfoot deformity, and neuropathy) and systemic risk factors (advanced age, smoking, alcohol abuse, worker’s compensation, noncompliance, obesity, and systemic comorbidities such as diabetes and immunodeficiency) have been shown to be associated with the development of a nonunion following fusion procedures. Vitamin D has an important role in bone healing, and vitamin D deficiency has been proposed as a potential risk factor for the development of non-unions. The purpose of this study is to assess the impact of low vitamin D levels on reoperation rates and the development of nonunions following ankle fusion surgery. Methods: A retrospective chart review of all ankle fusions performed at a major health system from January 2010 to July 2019 was performed. In total, 240 ankle fusions were performed by seven surgeons. All patients who underwent primary fusion procedures were eligible for inclusion in this study. Exclusion criteria included: age less than 18 years; revision surgery; ankle fusion with the use of bulk allograft; ankle fusion performed as part of an oncologic reconstruction; and an absence of recorded vitamin D levels with 12 months of surgery. In total, 47 patients met inclusion criteria and formed the study group. In this group, 29/47 (61.7%) were female and 18/47 (38.3%) were male. Average age was 57.0 +- 12.3 years (range: 18.6 to 75.7). Patients were grouped according to their vitamin D levels as being deficient (<31 ng/ml) or normal (31-80 ng/ml). Results: Prevalence of vitamin D deficiency was 36.2% (17/47) at average of 35.7 ng/ml. In vitamin D deficient subgroup (n=17), average vitamin D level was 16.9 ng/ml. In normal vitamin D subgroup (n=30), average vitamin D was 46.4 ng/ml. Overall, reoperation rate was 21.3% (10/47). Reoperation rate was 35.3% (6/17) in vitamin D deficiency subgroup compared with 13.3% (4/30) reoperation rate in normal vitamin D subgroup (p<0.05). In vitamin D deficient subgroup, 5 procedures for nonunion included: dynamization (n=1), revision fusion (n=1), staged revision (n=2) and amputation (n=1) due to infected nonunion. There was also a symptomatic hardware removal. In normal vitamin D subgroup, reoperation indications included: malunion (n=1), elective dynamization before weightbearing (n=1), and symptomatic hardware removal (n=2). Normal vitamin D subgroup had zero nonunions. Conclusion: In patients undergoing ankle fusion, vitamin D deficiency (< 31 ng/ml) was associated with a reoperation rate over double that of patients with normal vitamin D levels. In the vitamin D deficient subgroup, nearly all reoperations were for nonunion as compared to zero nonunion incidence in those with normal vitamin D levels. These results suggest routine preoperative screening of vitamin D level is indicated as a key component of ankle fusion care. Vitamin D supplementation during the perioperative period may be indicated in regions with low sunlight to improve fusion rates and lower the risk of reoperation.

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