Effect of vitamin D supplementation on bone status, glucose homeostasis and immune function in children with vitamin D deficiency

Background: Between 1961-1971 vitamin D deficiency was recognized as a public health issue in the UK, because of the lack of effective sunlight and the population mix [1, 2]. In recent years, health care professionals have cited evidence suggesting a re-emergence of the vitamin D deficiency linked to a number of health consequences as a concern [3-6]. Evidence from observational studies has linked low vitamin D status with impairment in glucose homeostasis and immune dysfunction [7-9]. However, interventional studies, particularly those focused on paediatric populations, have been limited and inconsistent. There is a need for detailed studies, to clarify the therapeutic benefits of vitamin D in these important clinical areas. Objective: The aims of this PhD thesis were two-fold. Firstly, to perform preliminary work assessing the association between vitamin D deficiency and bone status, glucose homeostasis and immune function, and to explore any changes in these parameters following short term vitamin D3 replacement therapy. Secondly, to assess the effectiveness of an electronic surveillance system (ScotPSU) as a tool to determine the current incidence of hospital-based presentation of childhood vitamin D deficiency in Scotland. Methods: Active surveillance was performed for a period of two years as a part of an electronic web-based surveillance programme performed by the Scottish Paediatric Surveillance Unit (ScotPSU). The validity of the system was assessed by identifying cases with profound vitamin D deficiency (in Glasgow and Edinburgh) from the regional laboratory. All clinical details were checked against those identified using the surveillance system. Thirty-seven children aged 3 months to 10 years, who had been diagnosed with vitamin D deficiency, were recruited for the bone, glucose and immunity studies over a period of 24 months. Twenty-five samples were analysed for the glucose and bone studies; of these, 18 samples were further analysed for immune study. Treatment consisted of six weeks taking 5000 IU units cholecalciferol orally once a day. At baseline and after completion of treatment, 25 hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), alkaline phosphatase (ALP), collagen type 1 cross-linked C-telopeptide (CTX), osteocalcin (OCN), calcium, phosphate, insulin, glucose, homeostasis model assessment index, estimated insulin resistance (HOMA IR), glycated hemoglobin (HbA1c), sex hormone binding globulin (SHBG), lipids profiles, T helper 1 (Th1) cytokines (interleukin-2 ( IL-2), tumor necrosis factors-alpha (TNF-α), interferon-gamma (INF-γ)), T helper 2 (Th2) cytokines (interleukin-4 (IL-4), interleukin-5 (IL-5), interleukin-6 (IL-6)), T helper 17 (Th17) cytokine (interleukin-17 (IL-17)), Regulatory T (Treg) cytokine (interleukin-10 (IL-10)) and chemokines/cytokines, linked with Th1/Th2 subset balance and/or differentiation (interleukin-8 (IL-8), interleukin-12 (IL-12), eosinophil chemotactic protein ( EOTAXIN), macrophage inflammatory proteins-1beta (MIP-1β), interferon-gamma-induced protein-10 (IP-10), regulated on activation, normal T cell expressed and secreted (RANTES), monocyte chemoattractant protein-1(MCP-1)) were measured. Leukoocyte subset analysis was performed for T cells, B cells and T regulatory cells and a luminex assay was used to measure the cytokiens. Results: Between September 2009 and August 2011, 163 cases of vitamin D deficiency were brought to the attention of the ScotPSU, and the majority of cases (n = 82) were reported in Glasgow. The cross-validation checking in Glasgow and Edinburgh over a one-year period revealed only 3 (11%) cases of clearly symptomatic vitamin D deficiency, which had been missed by the ScotPSU survey in Glasgow. While 16 (67%) symptomatic cases had failed to be reported through the ScotPSU survey in Edinburgh. For the 23 children who are included in bone and glucose studies, 22 (96%) children had basal serum 25(OH)D in the deficiency range (< 50 nmol/l) and one (4%) child had serum 25(OH)D in the insufficiency range (51-75 nmol/l). Following vitamin D3 treatment, 2 (9%) children had final serum 25(OH)D lower than 50 nmol/l, 6 (26%) children had final serum 25(OH)D between >50-75 nmol/l, 12 (52%) children reached a final serum 25(OH)D >75-150 nmol/l and finally 3 (13%) exceeded the normal reference range with a final 25(OH)D >150 nmol/l. Markers for remodelling ALP and PTH had significantly decreased (p = 0.001 and <0.0001 for ALP and PTH respectively). In 17 patients for whom insulin and HOMA IR data were available and enrolled in glucose study, significant improvements in insulin resistance (p = 0.04) with a trend toward a reduction in serum insulin (p = 0.05) was observed. Of those 14 children who had their cytokines profile data analysed and enrolled in the immunity study, insulin and HOMA IR data were missed in one child. A significant increase in the main Th2 secreted cytokine IL-4 (p = 0.001) and a tendency for significant increases in other Th2 secreted cytokines IL-5 (p = 0.05) and IL-6 (p = 0.05) was observed following vitamin D3 supplementation. Conclusion: An electronic surveillance system can provide data for studying the epidemiology of vitamin D deficiency. However, it may underestimate the number of positive cases. Improving vitamin D status in vitamin D deficient otherwise healthy children significantly improved their vitamin D deficient status, and was associated with an improvement in bone profile, improvements in insulin resistance and an alteration in main Th2 secreting cytokines.

The subjunctive mood in Late Middle English adverbial clauses: the interaction of form and function

This thesis focuses on the history of the inflexional subjunctive and its functional substitutes in Late Middle English. To explore why and how the inflexional subjunctive declined in the history of English language, I analysed 2653 examples of three adverbial clauses introduced by if (1882 examples), though (305 examples) and lest (466 examples). Using a corpus-based approach, this thesis argues that linguistic change in subjunctive constructions did not happen suddenly but rather gradually, and the way it changed was varied , and that different constructions changed at different speeds in different environments. It is well known that the inflexional subjunctive declined in the history of English, mainly because of inflexional loss. Strangely however this topic has been comparatively neglected in the scholarly literature, especially with regard to the Middle English period, probably due to the limitations of data and also because study of this development requires very cumbersome textual research. This thesis has derived and analysed the data from three large corpora in the public domain: the Middle English Grammar Corpus (MEG-C for short), the Innsbruck Computer Archive of Machine-Readable English Texts (ICAMET for short), and some selected texts from The Corpus of Middle English Prose and Verse, part of the Middle English Compendium that also includes the Middle English Dictionary. The data were analysed from three perspectives: 1) clausal type, 2) dialect, and 3) textual genre. The basic methodology for the research was to analyse the examples one by one, with special attention being paid to the peculiarities of each text. In addition, this thesis draw on some complementary – indeed overlapping -- linguistic theories for further discussion: 1) Biber’s multi-dimensional theory, 2) Ogura and Wang’s (1994) S-curve or ‘diffusion’ theory, 3) Kretzchmar’s (2009) linguistics of speech, and 4) Halliday’s (1987) notion of language as a dynamic open system. To summarise the outcomes of this thesis: 1) On variation between clausal types, it was shown that the distributional tendencies of verb types (sub, ind, mod) are different between the three adverbial clauses under consideration. 2) On variation between dialects, it has been shown that the northern area, i.e. the so-called Great Scandinavian Belt, displays an especially high comparative ratio of the inflexional subjunctive construction compared to the other areas. This thesis suggests that this result was caused by the influence of Norse, relating the finding to the argument of Samuels (1989) that the present tense -es ending in the northern dialect was introduced by the influence of the Scandinavians. 3) On variation between genres, those labelled Science, Documents and Religion display relatively high ratio of the inflexional subjunctive, while Letter, Romance and History show relatively low ratio of the inflexional subjunctive. This results are explained by Biber’s multi-dimensional theory, which shows that the inflexional subjunctive can be related to the factors ‘informational’, ‘non-narrative’, ‘persuasive’ and ‘abstract’. 4) Lastly, on the inflexional subjunctive in Late Middle English, this thesis concludes that 1) the change did not happen suddenly but gradually, and 2) the way language changes varies. Thus the inflexional subjunctive did not disappear suddenly from England, and there was a time lag among the clausal types, dialects and genres, which can be related to Ogura and Wang’s S-curve (“diffusion”) theory and Kretzchmars’s view of “linguistic continuum”. This thesis has shown that the issues with regard to the inflexional subjunctive are quite complex, so that research in this area requires not only textual analysis but also theoretical analysis, considering both intra- and extra- linguistic factors.