Vitamin D, Parathyroid Hormone, and Acroosteolysis in Systemic Sclerosis

2008 ◽  
Vol 35 (11) ◽  
pp. 2201-2205 ◽  
Author(s):  
YOLANDA BRAUN-MOSCOVICI ◽  
DANIEL E. FURST ◽  
DORON MARKOVITS ◽  
ALEXANDER ROZIN ◽  
PHILIP J. CLEMENTS ◽  
...  
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Systemic Sclerosis ◽  
Secondary Hyperparathyroidism ◽  
Vitamin D Deficiency ◽  
Medical Records ◽  
Disease Duration ◽  
Laboratory Evaluation ◽  
Vitamin D Levels ◽  
Calcium Phosphorus

ObjectiveSclerodactyly with acroosteolysis (AO) and calcinosis are prominent features of systemic sclerosis (SSc), but the pathogenesis of these findings is poorly understood. Vitamin D and parathyroid hormone (PTH) have a crucial role in bone metabolism and resorption and may affect AO and calcinosis. We assessed vitamin D and PTH in patients with SSc.MethodsMedical records of 134 consecutive patients with SSc (American College of Rheumatology criteria) followed at the rheumatology department during the years 2003–2006 were reviewed for clinical assessment, laboratory evaluation [including 25(OH) vitamin D, calcium, phosphorus, alkaline phosphatase, PTH, creatinine, and albumin]; imaging data confirming AO and/or calcinosis. Patients followed routinely at least once a year were included (81 patients). Of these, 60 patients’ medical records were found to have complete, relevant clinical, laboratory, and radiographic imaging.ResultsThirteen patients had diffuse disease and 47 limited disease — 51 women and 9 men, 44 Jews and 16 Arabs; mean age 55 ± 14 years; disease duration 8 ± 6 years. AO with or without calcinosis was observed in 42 patients (70%). Vitamin D deficiency was found in 46% of patients (16 out of 44 Jewish patients, 10 out of 16 Arab patients). PTH was elevated in 21.7% of patients. Significant correlations were observed between acroosteolysis and PTH (p = 0.015), calcinosis (p = 0.009), and disease duration (p = 0.008), and between PTH and vitamin D levels (p = 0.01). All patients had normal serum concentrations of calcium, phosphorus, magnesium, and albumin, and liver and kidney functions.ConclusionIn this group of Mediterranean patients with SSc, the incidence of vitamin D deficiency and secondary hyperparathyroidism was surprisingly high. This finding correlated with the occurrence of AO and calcinosis. Low levels of vitamin D may reflect silent malabsorption and might be a risk factor for secondary hyperparathyroidism and bone resorption. Traditional dress habits and low exposure to sun may contribute to vitamin D deficiency in an Arab population but do not explain all the findings. The pathogenesis of these findings needs to be corroborated in other SSc populations.

Relationship of Vitamin D Deficiency and Intraoperative Parathyroid Hormone Elevation in Completion and Total Thyroidectomy

2019 ◽  
Vol 160 (4) ◽  
pp. 612-615 ◽  
Author(s):  
Bradley R. Lawson ◽  
Andrew M. Hinson ◽  
Jacob C. Lucas ◽  
Donald L. Bodenner ◽  
Brendan C. Stack
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Secondary Hyperparathyroidism ◽  
Total Thyroidectomy ◽  
Vitamin D Deficiency ◽  
Case Series ◽  
Hormone Levels ◽  
Parathyroid Autotransplantation ◽  
Vitamin D Levels ◽  
Intraoperative Parathyroid Hormone

Objective To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone. Study Design Case series with chart review. Setting Tertiary academic center. Subjects and Methods A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation. Results A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03). Conclusion Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.

scholarly journals An Unusual Case of Hypercalcemia Associated with Graves’ Disease and Vitamin D Deficiency

2011 ◽  
Vol 4 ◽  
pp. CMED.S7116 ◽  
Author(s):  
Evgenia Korytnaya ◽  
Nagashree Gundu Rao ◽  
Jane V. Mayrin
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Vitamin D Deficiency ◽  
Serum Calcium ◽  
Graves Disease ◽  
Hydroxyvitamin D ◽  
Vitamin D Levels ◽  
Calcium Phosphorus ◽  
25 Hydroxyvitamin D ◽  
25 Oh Vitamin D

Objective To present a case of hypercalcemia associated with thyrotoxicosis in a patient with vitamin D deficiency and review biochemical changes during the course of treatment. Methods We report a case, describe the changes in serum calcium, phosphorus, parathyroid hormone in Graves’ disease and concomitant Vitamin D deficiency. We compare our findings to those reported in literature. Results Our patient had hypercalcemia secondary to thyrotoxicosis alone, which was confirmed by low parathyroid hormone level and resolution of hypercalcemia with treatment of thyrotoxicosis. The case was complicated by a concomitant vitamin D deficiency. Serum calcium elevation in patients with thyrotoxicosis occurs secondary to hyperthyroidism alone or due to concurrent hyperparathyroidism. Hypercalcemia from thyrotoxicosis is usually asymptomatic and is related to bone resorption. Vitamin D deficiency can be seen in patients with thyrotoxicosis because of accelerated metabolism, poor intestinal absorption and increased demand during bone restoration phase. Coexistence of hypercalcemia and Vitamin D deficiency in patients with thyrotoxicosis is rare, but possible, and 25-hydroxyvitamin D levels should be checked. The definite treatment for hypercalcemia in thyrotoxicosis is correction of thyroid function. Conclusion Hypercalcemia in thyrotoxicosis should be distinguished from concomitant hyperparathyroidism and confirmed by resolution of hypercalcemia with control of thyrotoxicosis. Patients with hypercalcemia and thyrotoxicosis may also have vitamin D deficiency and 25-OH Vitamin D levels should be checked.

Abstract 121: Vitamin D Deficiency Study in Postural Orthostatic Tachycardia Syndrome

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Chandralekha Ashangari ◽  
Amer Suleman
Keyword(s):  
Vitamin D ◽  
Vitamin D Deficiency ◽  
Electronic Medical Records ◽  
Vitamin D3 ◽  
Medical Records ◽  
Postural Orthostatic Tachycardia Syndrome ◽  
Vitamin D Levels ◽  
The World ◽  
25 Oh Vitamin D ◽  
Vitamin D3 Deficiency

Objectives The aim of this study is to assess vitamin D levels, including the prevalence of vitamin D deficiency/insufficiency in Postural Orthostatic Tachycardia Syndrome (POTS) patients. Background : The Postural Orthostatic Tachycardia Syndrome (POTS) affects primarily young women. POTS is a form of dysautonomia that is estimated to impact between 1,000,000 and 3,000,000 Americans, and millions more around the world. We frequently find vitamin D deficiency in patients who present with POTS Methods: 180 patients were selected randomly from our clinic with POTS. Patients Vitamin D levels charts were reviewed from electronic medical records, 25-OH vitamin D (Vitamin D3 ) status was defined as Normal (>30 ng/mL), Insufficient (20.0-29.9 ng/mL), and deficient (<20 ng/mL). Results: Out of 180 patients, 170 patients are female (94%, n=170, age 31.88±10.36), 10 patients are male (6% ,age 25.83±6.19). 79 patients had vitamin D3 level >30 ng/ml, 10 patients had vitamin D3 level range >20.0 to 29.9 ng/mL, 91 patients had vitamin D3 level < 20ng/mL. Conclusion: Our research results demonstrated that Postural Orthostatic Tachycardia Syndrome (POTS) patients have a higher rate of vitamin D3 deficiency (51% have Vitamin D3 less than 20 ng/mL). Vitamin D3 levels are low in more than half of POTS patients (56% had less than 30 ng/mL )

scholarly journals Association of vitamin D and osteocalcin levels in post-menopausal women with osteoporosis

2017 ◽  
Vol 6 (4) ◽  
pp. 1244
Author(s):  
Yogiraj Vaijanathrao Chidre ◽  
Amir Babansab Shaikh
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Vitamin D Deficiency ◽  
Fragility Fractures ◽  
Bone Fragility ◽  
Vitamin D Supplementation ◽  
Mineral Density ◽  
Age Related ◽  
Calcium Phosphorus ◽  
Post Menopausal

Background: Osteoporosis is a common age related problem especially in women, with a consequent increase in bone fragility and susceptibility to fracture. Apart from Calcium, another nutrient that plays an important role in the mineralization of skeleton in Vitamin D. Osteocalcin, which is produced primarily by osteoblasts during bone formation, is considered to be one of the markers for osteoporosis.Methods: 314 women above the age of 40 were included into the study. A thorough physical and clinical examination, assessment of vital parameters, anthropometry evaluation was done for all patients. Bone mineral density was calculated using central DXA osteodensitometer at lumbar spine L1-L4, hip and ultradistal radius (in some cases.). Blood samples were taken for the detection of ionized calcium, phosphorus, alkaline phosphatase, 25hydroxivitamin D (25 ODH) and serum parathyroid hormone (PTH) by chemiluminiscent assay. Bone markers such as osteocalcin were measured as required.Results: Out of the 314 women attending our OPD, 96 of them were diagnosed as having osteoporosis. 24 out of them had fragility fractures, mainly of the hip, and 82 had ostepenia. Elevated levels of calcium (8.96 mg/dl), parathyroid hormone (58.76 pg/ml) and osteocalcin (24.46 ng/ml) were observed. Vitamin D deficiency of ≤ 20 was seen in 59 (63%) of the cases, insufficient in 23 (24%) and only 12 (13%) of these women had normal Vitamin D levels.Conclusions: Osteocalcin is a promising marker for the detection of osteoporosis. There is a considerable Vitamin D deficiency among the women with osteoporosis, and it is under-treated. It is essential to provide Vitamin D supplementation to these women especially those who are at high risk for fragility fractures.

scholarly journals The effectiveness of nutritional vitamin D supplementation and selective vitamin D receptor agonists treatment on secondary hyperparathyroidism in chronic kidney diseases patients

2018 ◽  
Vol 21 (2) ◽  
pp. 12-22 ◽  
Author(s):  
Lilit V. Egshatyan ◽  
Natalya G. Mokrisheva
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Secondary Hyperparathyroidism ◽  
Vitamin D Receptor ◽  
Vitamin D Supplementation ◽  
Target Range ◽  
Receptor Agonists ◽  
Stage 4 ◽  
Calcium Phosphorus ◽  
Phosphorus Levels

Background: secondary hyperparathyroidism (SHPT) is an early complication of chronic kidney disease (CKD). Maintaining the level of 25(OH)D and parathyroid hormone concentrations in the target range reduce its associated complications (fractures and cardiovascular calcification). Aims: to examine the effectiveness of vitamin D supplementation and selective vitamin D receptor agonists treatment on SHPT in CKD. Material and methods: prospective observational study to evaluate the efficacy and safety of vitamin D therapy SHPT in 54 in patients with CKD. The first phase (24 weeks) – treatment of suboptimal 25-hydroxycalciferol (25(OH)D) levels. The second (16 weeks) – treatment colecalciferol-resistant SHPT by combination of cholecalciferol with paricalcitol. Blood samples were taken to assess parathyroid hormone (PTH), 25(OH)D, creatinine, calcium, phosphorus levels and calcium excretion. Results: After 8 weeks of cholecalciferol treatment all patients achieved 25(OH)D levels above 20 ng/ml, however 78% of patients still had SHPT. After 16 weeks, the decrease of PTH was achieved in all patients, but significantly only in patients with CKD 2 (19.2%, p< 0.01) and 3 (31%, p <0.05), compared with CKD 4 (17%, p >0.05). After 24 weeks of therapy, PTH normalized in all patients with CKD 2, in 15 (79%) with CKD 3 and in 9 (50%) patients with CKD 4. Cholecalciferol treatment resulted in a substantial increase in 25(OH)D levels with minimal or no impact on calcium, phosphorus levels and kidney function. After 24 weeks we initiated combination therapy (cholecalciferol and paricalcitol) for patients with colecalciferol-resistant SHPT (n=13). PTH levels decreased from 149.1±13.4 to 118.2±14.1 pg/ml at 8 weeks, and to 93.1±9.7 pg/ml (p <0.05) at 16 weeks of treatment. No significant differences in serum calcium, phosphorus or urinary calcium levels. Normalization of PTH was achieved in all patients with CKD 3 and in 8 patients with stage 4. One patient with CKD 4 needed an increase in paricalcitol dose. Conclusion: Cholecalciferol can be used in correcting vitamin D deficiency in patients with all stages of CKD, however, its effectiveness in reducing PTH in stage 4 is limited. Selective analogs, such as paricalcitol, were well-tolerated and effectively decreased PTH levels.

Vitamin D deficiency and exercise-induced laryngospasm in young competitive rowers

2016 ◽  
Vol 41 (7) ◽  
pp. 735-740 ◽  
Author(s):  
Enrico Heffler ◽  
Matteo Bonini ◽  
Luisa Brussino ◽  
Paolo Solidoro ◽  
Giuseppe Guida ◽  
...  
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Vitamin D Deficiency ◽  
Muscle Relaxation ◽  
Forced Expiratory Volume ◽  
Northern Latitudes ◽  
Vitamin D Levels ◽  
Eucapnic Voluntary Hyperventilation ◽  
Exercise Induced ◽  
Age Range

Exercise-induced dyspnea is common among adolescents and young adults and often originates from exercise-induced bronchoconstriction (EIB). Sometimes, dyspnea corresponds to exercise-induced laryngospasm (EILO), which is a paradoxical decrease in supraglottic/glottic area. Vitamin D deficiency, which occurs frequently at northern latitudes, might favor laryngospasm by impairing calcium transport and slowing striate muscle relaxation. The aim of this study was to evaluate whether vitamin D status has an influence on bronchial and laryngeal responses to exercise in young, healthy athletes. EIB and EILO were investigated during winter in 37 healthy competitive rowers (24 males; age range 13–25 years), using the eucapnic voluntary hyperventilation test (EVH). EIB was diagnosed when forced expiratory volume in the first second decreased by 10%, EILO when maximum mid-inspiratory flow (MIF50) decreased by 20%. Most athletes (86.5%) had vitamin D deficiency (below 30 ng/mL), 29 mild-moderate (78.4%) and 3 severe (8.1%). EVH showed EIB in 10 subjects (27%), EILO in 16 (43.2%), and combined EIB and EILO in 6 (16.2%). Athletes with EILO had lower vitamin D (19.1 ng/mL vs. 27.0 ng/mL, p < 0.001) and higher parathyroid hormone (30.5 pg/mL vs. 19.2 pg/mL, p = 0.006) levels. The degree of laryngoconstriction (post-EVH MIF50 as a percentage of pre-EVH MIF50) was related directly with vitamin D levels (r = 0.51; p = 0.001) and inversely with parathyroid hormone levels (r = –0.53; p = 0.001). We conclude that vitamin D deficiency is common during winter in young athletes living above the 40th parallel north and favors laryngospasm during exercise, probably by disturbing calcium homeostasis. This effect may negatively influence athletic performance.

scholarly journals Vitamin D Metabolism Is Significantly Impaired in COVID-19 Inpatients

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A281-A282
Author(s):  
Alexandra Povaliaeva ◽  
Liudmila Ya Rozhinskaya ◽  
Ekaterina A Pigarova ◽  
Larisa K Dzeranova ◽  
Nino N Katamadze ◽  
...  
Keyword(s):  
Vitamin D ◽  
Secondary Hyperparathyroidism ◽  
Vitamin D Deficiency ◽  
Serum Calcium ◽  
Vitamin D Supplementation ◽  
Vitamin D Metabolites ◽  
Lung Involvement ◽  
Hydroxylase Activity ◽  
Vitamin D Metabolism ◽  
Vitamin D Levels

Abstract Objective: to assess the state of vitamin D metabolism in patients hospitalized with COVID-19 infection. Materials and methods: We examined 49 patients, which were hospitalized for inpatient treatment of COVID-19 infection from May to June 2020. Study group included 24 men (49%) and 25 women (51%), median age 58 years [48; 70], BMI 26.4 kg/m2 [24.3; 30.5]. All patients were diagnosed with pneumonia due to SARS-CoV-2 with median percent of lung involvement equal to 29% [14; 37], 22 patients (45%) required oxygen support upon admission. Median SpO2 was equal to 95% (92; 97), median NEWS score was equal to 3 [2; 6]. Participants were tested for vitamin D metabolites (25(OH)D3, 1,25(OH)2D3, 3-epi-25(OH)D3, 24,25(OH)2D3 and D3) by UPLC-MS/MS, free 25(OH)D and vitamin D-binding protein by ELISA, as well as PTH by electrochemiluminescence immunoassay and routine biochemical parameters of blood serum (calcium, phosphorus, albumin) at the time of admission. Results: patients had in general very low 25()D3 levels - median 10.9 ng/mL [6.9; 15.6], corresponding to a pronounced vitamin D deficiency in half of the patients. Levels of 24,25(OH)2D3 were also low – 0.5 ng/mL [0.2; 0.9], and resulting vitamin D metabolite ratios (25(OH)D3/24,25(OH)2D3) were high-normal or elevated in most patients – 24.1 [19.0; 39.2], indicating decreased activity of 24-hydroxylase. Levels of 1,25(OH)2D3, on the contrary, were high-normal or elevated - 57 pg/mL [46; 79], which, in accordance with 25(OH)D3/1,25(OH)2D3 ratio (219 [134; 266]) suggests an increase in 1α-hydroxylase activity. Median level of 3-epi-25(OH)D3 was 0.7 ng/mL [0.4; 1.0] and D3 metabolite was detectable only in 6 patients. Median DBP level was 432 mg/L [382; 498], median free 25(OH)D was 5.6 pg/mL [3.3; 6.7], median calculated free 25(OH)D was 2.0 pg/mL [1.4; 3.3]. Most patients had albumin-adjusted serum calcium level in the lower half of reference range (median 2.24 mmol/L [2.14; 2.34]). Seven patients had secondary hyperparathyroidism and one patient had primary hyperparathyroidism, the rest of the patients had PTH levels within the normal range.25(OH)D3 levels showed significant negative correlation with percent of lung involvement (r = -0.36, p&lt;0.05) and positive correlation with SpO2 (r = 0.4, p&lt;0.05). 1,25(OH)2D3 levels correlated positively with 25(OH)D3 levels (r = 0.38, p&lt;0.05) and did not correlate significantly with PTH levels (p&gt;0.05). Conclusion: Our data suggests that hospitalized patients with COVID-19 infection have significant impairment of vitamin D metabolism, in particular, an increase in 1α-hydroxylase activity, which cannot be fully explained by pre-existing conditions such as vitamin D deficiency and secondary hyperparathyroidism. The observed profound vitamin D deficiency and association of vitamin D levels with markers of disease severity indicate the importance of vitamin D supplementation in these patients.

scholarly journals Can Vitamin D Therapy Contribute to the Conservative Resolution of Osteolytic Lesions of the Jaws?

2021 ◽  
Vol 2021 ◽  
pp. 1-4
Author(s):  
Kamis Gaballah ◽  
Sami Kenz ◽  
Raeefa Anis ◽  
Omar Kujan
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Vitamin D Deficiency ◽  
Surgical Intervention ◽  
Bone Lesions ◽  
Osteolytic Lesions ◽  
Intervention Treatment ◽  
Vitamin D Levels ◽  
Jaw Cyst ◽  
Radiolucent Lesion

Osteolytic lesions of the jaw are not uncommon. Such lesions usually arise from local pathologies, but some have systemic backgrounds. We describe a 12-year-old girl who presented with an asymptomatic left mandibular swelling. The bony swelling was corresponding to a radiolucent lesion in the left premolar/molar region. This lesion could have represented an inflammatory and developmental odontogenic jaw cyst, giant cell lesion, and odontogenic tumor. However, the workup investigations revealed secondary hyperparathyroidism due to vitamin D deficiency. A vitamin D replacement was initiated with a single I.M. injection of 300,000 I.U followed by 10,000 I.U orally, weekly. Six weeks later, her Vitamin D and parathyroid hormone were normalized, and she showed significant clinical and radiological improvement of the jaw lesion. At 18 months, follow-up the panoramic image revealed complete resolution of the radiolucency and stable normal parathyroid hormone and vitamin D levels. In conclusion, Jaw bone lesions can develop secondary to hyperparathyroidism due to vitamin D deficiency, and this should be ruled out before any surgical intervention. Treatment of such lesions lies in the correction of parathyroid excess with a careful and systematic approach. This may prevent unnecessary surgical intervention in such patients.

scholarly journals Analysis of Changes in Parathyroid Hormone and 25 (OH) Vitamin D Levels with Respect to Age, Gender and Season: A Data Mining Study

2017 ◽  
Vol 36 (1) ◽  
pp. 73-83 ◽  
Author(s):  
Muhittin A. Serdar ◽  
Başar Batu Can ◽  
Meltem Kilercik ◽  
Zeynep A. Durer ◽  
Fehime Benli Aksungar ◽  
...  
Keyword(s):  
Vitamin D ◽  
Parathyroid Hormone ◽  
Vitamin D Deficiency ◽  
Large Data ◽  
Seasonal Effects ◽  
Data Set ◽  
Vitamin D Levels ◽  
25 Oh Vitamin D ◽  
And Gender ◽  
Opposite Response

SummaryBackground:25 (OH) vitamin D3 (25(OH)D) and parathyroid hormone (PTH) are important regulators of calcium homeostasis. The aim of this study was to retrospectively determine the cut–off for sufficient 25(OH)D in a four-season region and the influence of age, seasons, and gender on serum 25(OH)D and PTH levels.Methods:Laboratory results of 9890 female and 2723 male individuals aged 38.8±22.1 years who had simultaneous measurements of 25(OH)D and PTH were retrospectively analyzed by statistical softwares. Serum 25(OH)D and PTH levels were measured by a mass spectrometry method and by an electrochemiluminescence immunoassay, respectively.Results:Mean serum 25(OH)D levels showed a sinusoidal fluctuation throughout the year and were significantly (p<0.01) higher in summer and autumn. On the other hand, PTH levels were significantly higher (p<0.01) in women and showed an opposite response to seasonal effects relative to 25(OH)D. Lowest levels of 25(OH)D were detected in people aged between 20 and 40 years whereas PTH hormone levels were gradually increasing in response to aging. The significant exponential inverse relationship that was found between PTH and 25(OH)D (PTH=exp(4.12–0.064*sqrt(25(OH)D)) (r=−0.325, R–squared=0.105, p<0.001)) suggested that the cut–off for sufficient 25(OH)D should be 75 nmol/L.Conclusions:Our retrospective study based on large data set supports the suitability of the currently accepted clinical cut–off of 75 nmol/L for sufficient 25(OH)D. However, the issue of assessing Vitamin D deficiency remains difficult due to seasonal variations in serum 25(OH)D. Therefore, PTH measurements should complement 25(OH)D results for diagnosing Vitamin D deficiency. It is imperative that seasonally different criteria should be considered in future.

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