La vitamina D es esencial para la salud de los huesos La investigación sobre el raquitismo, una enfermedad que apareció en miles de niños a principios de la década de 1920 como consecuencia del aumento de la niebla contaminante en las ciudades industriales, ha permitido descubrir una vitamina hasta ahora desconocida.
La vitamina D es esencial para la salud de los huesos
La investigación sobre el raquitismo, una enfermedad que apareció en miles de niños a principios de los años 20 como consecuencia del aumento de la niebla contaminante en las ciudades industriales, condujo al descubrimiento de una vitamina hasta entonces desconocida. Finalmente se reconoció que la deficiencia de esta vitamina D recién descubierta es una causa de enfermedad ósea.
Ahora sabemos que la vitamina D no sólo cura el raquitismo que se temía en el pasado, sino que también tiene multitud de efectos positivos sobre los huesos. Estos beneficios se despliegan a través de dos mecanismos principales:
- La vitamina D regula la asimilación del calcio
- El nivel de vitamina D activa en sangre regula la asimilación del calcio en el intestino y, por tanto, la mineralización ósea.
- La vitamina D regula las células y proteínas óseas esenciales
- Casi todas las células óseas principales tienen la capacidad de convertir por sí mismas la vitamina D en vitamina D activa. Además, la vitamina D regula muchas proteínas que son esenciales para la construcción de los huesos. Así pues, la vitamina D tiene una influencia considerable en la transformación constante de los huesos.
El objetivo de este artículo es indicar la relación exacta entre la vitamina D y la salud ósea, pero también cómo puede utilizarse la vitamina D en la prevención y el tratamiento de enfermedades óseas como el raquitismo, la osteomalacia y la osteoporosis.
Vitamina D y asimilación del calcio
El calcio y el fosfato son los principales materiales de construcción de nuestros huesos, por lo que son esenciales para construir y mantener un esqueleto sano.
Por el contrario, la ingesta de calcio y fosfato depende directamente del nivel de vitamina D: el calcitriol, la hormona activa de la vitamina D, regula la cantidad de calcio que puede asimilarse en el intestino, donde abre canales específicos de calcio y regula las moléculas de transporte de calcio, como la calbindina. Además, la hormona de la vitamina D aumenta el proceso de recuperación del calcio en los riñones y, por tanto, desempeña un importante papel general en la regulación de los niveles de calcio y del metabolismo óseo.
El calcio: mucho más que un material de construcción para los huesos
El calcio no sólo es un material de construcción para los huesos, sino que también es un elemento esencial para otros procesos fisiológicos. Por ejemplo, el calcio es una de las sustancias bioquímicas mensajeras celulares más importantes del organismo y es esencial para las funciones nerviosas y musculares. El músculo cardíaco también depende de un suministro constante de calcio. Por tanto, un descenso significativo de los niveles de calcio en sangre representa un riesgo vital para la salud.
Debido a la importancia fundamental del calcio, el cuerpo se esfuerza por mantener un nivel constante de calcio a perpetuidad. Esto se consigue principalmente a través de un ciclo de regulación por medio de las sustancias mensajeras vitamina D y parathormona, que regulan la absorción y eliminación del calcio para que el nivel en sangre se mantenga lo más regular posible.
Para ello, la glándula paratiroidea «mide» continuamente el nivel de calcio en la sangre. Si el nivel de calcio en sangre desciende, la hormona paratiroidea (PTH) se distribuye de forma más uniforme. Este fenómeno implica una mayor conversión de la vitamina D en su forma hormonal, el calcitriol, en los riñones. El aumento del nivel de calcitriol conduce a una mayor captación de calcio en el intestino, y también permite la normalización de los niveles de calcio en la sangre, siempre y cuando se tome suficiente calcio a través de la dieta.
La deficiencia de vitamina D o de calcio puede provocar la destrucción de los huesos.
Si el calcio no se asimila en cantidades suficientes a través de la dieta, el cuerpo recupera el calcio de los huesos, que, además de su función dentro de nuestro esqueleto, también actúan como depósito de calcio en nuestro organismo. La PTH activa los osteoclastos (devoradores de hueso) que descomponen los huesos, lo que permite disponer del calcio. Mediante la movilización del calcio contenido en los huesos, éstos son atacados y descompuestos. Sin embargo, un nivel constante de calcio es una prioridad mucho mayor para el organismo, incluso cuando este mecanismo destruye gradualmente los huesos.
La regulación de los niveles de calcio es un sistema complejo basado en una multitud de relaciones interdependientes (véase el gráfico al final del artículo). Por lo tanto, es comúnmente aceptado que la ingesta insuficiente de calcio, pero también la deficiencia de vitamina D, provoca la descomposición de los huesos.
Por lo tanto, una ingesta diaria de al menos 1000mg de calcio y un nivel de vitaminas de al menos 30ng/ml son necesarios para prevenir el desarrollo de enfermedades óseas. La cantidad de vitamina D necesaria para ello varía individualmente según la estación del año y la exposición al sol.
La vitamina D regula las células óseas
Además de su función de regulación del capital de calcio, la vitamina D también tiene una acción directa sobre prácticamente todos los tipos de células óseas, que son responsables de la descomposición, construcción y transformación de los huesos.
Entre las células reguladas por la vitamina D se encuentran :
- Osteoblastos (formadores de hueso)
- Osteoclastos (devoradores de hueso)
- Osteocitos (reguladores óseos)
- Células madre mesenquimales (células madre óseas)
- Células madre hematopoyéticas (células madre sanguíneas de la médula ósea)
La vitamina D también regula las proteínas y sustancias esenciales para el metabolismo óseo:
- Proteína matriz GLA
- Osteocalcina
- Osteopontina
- Ostasa/fosfatasa alcalina (ALP)
- Colágeno
A diferencia de la regulación del calcio, este mecanismo de acción no está vinculado al nivel sanguíneo de la hormona de la vitamina D activa, ni está regulado centralmente. Las propias células regulan sus necesidades y convierten la vitamina D en su forma activa de forma totalmente autónoma.
Este mecanismo de acción depende, por tanto, del nivel de vitamina D3 y de 25-OH-vitamina D3. Ambas formas de vitamina D son eliminadas por el organismo en un solo día, por lo que sus niveles deben reponerse diariamente. Por el contrario, las dosis semanales o mensuales no tienen ningún efecto en este caso.
Este proceso tiene lugar en condiciones naturales, gracias a la presencia de la luz solar. En el mundo moderno en el que vivimos, y en el contexto clínico actual, tiene graves consecuencias terapéuticas. De hecho, una eficacia óptima de la vitamina D en los huesos sólo es posible con una ingesta diaria de vitamina D.
Los estudios realizados sobre la base de dosis semanales han sido infructuosos. Estas circunstancias siguen siendo ignoradas con demasiada frecuencia por la investigación científica.
La importancia de la vitamina K2 para los huesos
Además del calcio y la vitamina D, hay otros nutrientes que desempeñan un papel esencial en la salud de los huesos, como la vitamina K2. Mientras que la vitamina D es responsable de la asimilación del calcio, la vitamina K2 regula la utilización del calcio. La vitamina K2 regula la eliminación del calcio de los tejidos y los vasos al activar la proteína de la matriz GLA, evitando así la calcificación. También activa la hormona calcitonina, que es la responsable de introducir el calcio en los huesos.
La vitamina K2 favorece directamente la reconstrucción ósea a través de los osteoblastos (células que construyen el hueso) e inhibe la descomposición del tejido óseo a través de los osteoclastos (células que descomponen el hueso). Así, la vitamina K2 tiene una triple acción:
- Evita la calcificación de los vasos y órganos.
- Favorece la inserción del calcio en la matriz ósea.
- Favorece la reconstrucción del hueso e inhibe su descomposición.
Por ello, la vitamina K2 debería formar parte en todos los casos del tratamiento de las enfermedades óseas.
Magnesio y vitamina D para los huesos
Otro nutriente merece especial atención. La considerable eficacia del magnesio para la salud de los huesos se evalúa con frecuencia y se demuestra ahora de forma innegable. Por un lado, los huesos se componen de aproximadamente un 1% de magnesio, por otro lado, el magnesio tiene una multitud de efectos sobre el calcio y el metabolismo óseo :
Magnesio:
- Es necesario para la transformación de la vitamina D en sus formas activas
- Regula el transporte de calcio
- Regula la transformación y la reconstrucción de los huesos.
Por eso, como verás a continuación, el magnesio es un nutriente absolutamente esencial, especialmente en el caso de la osteoporosis.
Importante
- La carencia de vitamina D destruye los huesos.
- Es necesario un nivel en sangre de al menos 30ng/ml para prevenir la enfermedad ósea
- También debe tomarse un suplemento de calcio, magnesio y vitamina K2
- El peligro de la carencia de vitamina D es especialmente grave en el periodo invernal, ya que no hay suficiente luz solar para estimular la producción de vitamina D en la piel.
Vitamina D: Dosificación en caso de enfermedad ósea
Las siguientes dosis pueden servir de orientación general para los adultos.
| Nutrientes | Forma | Dosis/día |
| Vitamina D | Vitamina D3 | 2000-5000 UI |
| Vitamina K2 | K2 MK7 all-trans | 200µg |
| Calcio | Citrato de calcio | 1000mg |
| Magnesio | Citrato de magnesio | 200-400mg |
Deficiencia de vitamina D y enfermedades óseas
La deficiencia de vitamina D está asociada a una serie de enfermedades óseas, entre ellas :
Ablandamiento de los huesos:
- Raquitismo (niños)
- Osteomalacia (adultos)
Pérdida de hueso/Fragilidad ósea
- Osteoporosis
A continuación, analizaremos el papel de la vitamina D en la presencia de dichas enfermedades.
Ablandamiento de los huesos: raquitismo y osteomalacia
El reblandecimiento de los huesos es una consecuencia directa de la carencia de vitamina D. Puede prevenirse e incluso curarse con un consumo suficientemente elevado de vitamina D y calcio.
El ser humano está compuesto por un 75% de tejido conjuntivo y un 25% de minerales. La estructura básica construida a través del tejido conectivo se caracteriza por la sustancia ósea básica o matriz ósea. Representa una estructura básica elástica que se endurece tras la inserción de calcio. Este fenómeno genera huesos estables, que sin embargo tienen cierta elasticidad, lo que los hace especialmente robustos.
Durante el reblandecimiento del hueso, el proceso de inserción del calcio en la sustancia ósea básica se ve alterado. Aunque la matriz ósea está completamente formada, no está suficientemente mineralizada y, por tanto, se vuelve blanda y maleable.
Este fenómeno puede ser especialmente fatal en los primeros años de vida. Durante la lactancia y la primera infancia, el esqueleto se desarrolla a un ritmo vertiginoso. Hasta los 25 años, aproximadamente, debe formarse toda la masa ósea, es decir, el esqueleto completamente formado con la máxima masa ósea. Para ello, son necesarias grandes cantidades de calcio, pero también un alto nivel de vitamina D.
Si el calcio y la vitamina D no están presentes en cantidades suficientes en los primeros años, se desarrolla el raquitismo, una enfermedad relacionada con la carencia. Esta enfermedad se caracteriza por deformidades y malformaciones del esqueleto. Como consecuencia de una mineralización insuficiente, los huesos se reblandecen y el ritmo de crecimiento no está bien sellado.
En la edad adulta, una carencia de vitamina D también puede provocar una mineralización ósea insuficiente, el fenómeno de reblandecimiento de los huesos se conoce entonces como osteomalacia. La diferencia radica en que el esqueleto ya está completamente formado, por lo que no pueden producirse las malformaciones propias del raquitismo, por lo que el síntoma principal se caracteriza por un dolor óseo permanente.
El raquitismo y la osteomalacia pueden prevenirse y tratarse mediante la asimilación de la vitamina D. Los estudios han demostrado que estas enfermedades también pueden tratarse sin vitamina D, administrando dosis extremadamente altas de calcio mediante inyecciones. De este modo, una cantidad suficiente de calcio llega al torrente sanguíneo y garantiza una mineralización ósea óptima. Todo esto demuestra que en el raquitismo y la osteomalacia, el papel de la vitamina D se limita principalmente a regular la absorción del calcio.
Las pruebas realizadas en ratones también demostraron que, tras dicho tratamiento, los huesos mostraban signos de osteoporosis, independientemente de los niveles óptimos de calcio. Esta conclusión confirma el hecho de que la vitamina D sigue teniendo muchos otros efectos directos en el desarrollo de los huesos, como se ha mencionado anteriormente.
Pérdida de hueso debido a la osteoporosis
En el caso de la osteoporosis, todo ocurre prácticamente al revés que en la osteomalacia: en presencia de esta enfermedad, es la matriz ósea la que se descompone con el proceso de mineralización. Por lo tanto, la osteoporosis significa la pérdida global de masa ósea, no sólo la parte mineral. La proporción entre el tejido mineral y el conectivo se mantiene incluso relativamente normal en el caso de la osteoporosis.
Así pues, la osteoporosis no es principalmente un trastorno de la mineralización, como la osteomalacia, sino más bien un problema relacionado con la regulación del metabolismo óseo que conduce a un aumento de la descomposición ósea patológica.
Incluso cuando los huesos parecen estables y estáticos, esta impresión es engañosa. Como todos los tejidos, los huesos están sometidos a una renovación constante. Por ejemplo, cada año se renueva entre el 5 y el 10% de todo el esqueleto, de modo que cada 10-15 años aproximadamente tenemos un esqueleto completamente reconstruido.
Esta transformación ósea, que puede caracterizarse como «remodelación», sólo funciona de forma natural cuando la descomposición y la construcción ósea están en equilibrio. Sin embargo, en estos dos procesos intervienen sistemas celulares diferentes:
En primer lugar, los osteoclastos (devoradores de hueso) descomponen el hueso viejo y, a continuación, los osteoblastos (formadores de hueso) sustituyen el hueso que falta por sustancia ósea nueva. Un mecanismo de equilibrio sutil y preciso se encarga normalmente de que estos procesos estén en equilibrio y de que la cantidad de hueso acumulado sea siempre la misma que la que se descompuso anteriormente. Si este equilibrio se ve alterado por un problema de regulación y, por tanto, predomina el proceso de descomposición ósea, se desarrolla la patología de la osteoporosis.
La enfermedad de la osteoporosis afecta principalmente a la estructura interna de los huesos, es decir, al hueso trabecular. Esta microarquitectura ósea en forma de panal le confiere estabilidad y resistencia, por lo que, en presencia de huesos afectados por la osteoporosis, el riesgo de fracturas óseas aumenta considerablemente.
La vitamina D y la osteoporosis
La osteomalacia es una afección directamente atribuible a una deficiencia de vitamina D, lo que no ocurre con la osteoporosis, aunque la vitamina D tiene un papel que desempeñar.
La vitamina D también interviene en el proceso de regulación de la transformación ósea, en correlación con la parathormona. La deficiencia grave de vitamina D provoca un aumento crónico de la parathormona, conocido como hiperparatiroidismo secundario. En esta situación, el proceso de descomposición ósea está altamente regulado hacia arriba de forma sostenida para movilizar el calcio, lo que puede conducir a cambios osteoporóticos.
La ingesta insuficiente de calcio en presencia de vitamina D óptima también tiene este efecto: la PTH y la descomposición ósea también aumentan en esta situación.
Incluso con niveles normales de calcio y una ingesta ligeramente insuficiente de vitamina D, también pueden producirse efectos negativos, como demuestran estudios recientes. Se ha demostrado que los osteoblastos, los osteoclastos y muchas otras células óseas esenciales pueden activar por sí mismos la vitamina D y regular así diversas actividades.
Como se ha descrito anteriormente, los niveles en sangre de la hormona de la vitamina D activa no desempeñan un papel decisivo, a diferencia de los niveles de vitamina D libre y 25-OH-D. Esta investigación ha indicado que existe una estrecha interacción entre los nutrientes, que puede resumirse como sigue:
| Aporte en calcio | Vitamina D | Efecto |
| Bajo | Extremadamente bajo | Osteomalacia |
| Normal | Bajo | Osteoporosis |
| Bajo | Normal | Osteoporosis |
| Bajo | Muy alto | Osteoporosis |
El proceso de descomposición de los huesos se ve favorecido tanto por niveles muy bajos de calcio como de vitamina D. Del mismo modo, un nivel extremadamente alto de la hormona de la vitamina D activa aumenta el proceso de descomposición de los huesos. En todos los casos, el resultado es la osteoporosis.
Vitamina D para la prevención y el tratamiento de la osteoporosis
Para diagnosticar la osteoporosis, actualmente se utiliza el método DEXA (DMO: densidad mineral ósea) para medir la densidad mineral ósea. Este método se cuestiona cada vez más, ya que el contenido mineral por sí solo no es el único responsable de la estabilidad ósea, sino que la pérdida de matriz ósea y la microarquitectura del hueso desempeñan un papel mucho más importante. No sólo la cantidad, sino también la calidad tienen una importancia decisiva. 23-27] Por lo tanto, la relevancia absoluta de los estudios realizados hasta ahora, utilizando la DMO como único parámetro de control, también es controvertida.
Existe un relativo consenso en el ámbito de la prevención de que los niveles óptimos de vitamina D son un factor decisivo en la prevención de la osteoporosis. Durante la adolescencia ya se sientan las bases esenciales, ya que el riesgo de osteoporosis disminuye con la cantidad de masa ósea. Más adelante en la vida, los niveles óptimos de vitamina D también contribuyen a la regulación saludable de la transformación ósea.
En cuanto al tratamiento de la enfermedad, los resultados de los estudios son mucho menos explícitos. La vitamina D se aplica como tratamiento básico para garantizar un metabolismo óseo normal.
Por el contrario, la eficacia de la vitamina D como tratamiento aislado sigue siendo controvertida. En la medicina académica, la osteoporosis se trata principalmente con bifosfonatos, que provocan la muerte temprana de los osteoclastos, deteniendo así la descomposición del hueso. La vitamina D se utiliza aquí sólo como complemento terapéutico.
Aunque algunos estudios indican que la administración de suplementos de vitamina D puede detener la pérdida de masa ósea y reducir el riesgo de fracturas, estos resultados no se observaron de forma similar en cada uno de estos estudios. 29] Las claras diferencias en los resultados aún no se han explicado del todo. Sin embargo, los estudios diferían considerablemente en cuanto a la duración, las dosis de vitamina D utilizadas, los niveles de referencia y el control de los cofactores.
Se observaron resultados contundentes principalmente en los sujetos con niveles bajos de vitamina D al inicio del estudio. También se obtuvieron excelentes resultados tras la aplicación de tratamientos que combinaban vitamina D y calcio. Además, como se ha mencionado anteriormente, sólo se pudieron observar buenos resultados con la suplementación diaria, mientras que las dosis semanales no proporcionaron ningún resultado significativo.
En general, la opinión convencional que comparten actualmente las escuelas es que la vitamina D tiene un potente efecto preventivo en la osteoporosis, y que los niveles normales de vitamina D y de calcio son cofactores importantes en el tratamiento de la osteoporosis, especialmente en presencia de una deficiencia de uno de estos nutrientes. Por esta razón, siempre deben administrarse como parte del régimen de tratamiento básico, en el que sólo la normalización simultánea de los niveles de vitamina D y calcio regula la descomposición ósea a la baja.
Es probable que el espectro de efectos de la vitamina D no se aproveche al máximo, debido a protocolos de estudio erróneos y a la falta de consideración de los cofactores.
Todavía no se han tenido en cuenta los cofactores K2 y magnesio.
Como se ha mencionado anteriormente, también deben controlarse los niveles de vitamina K2 y magnesio. Sin embargo, por lo que sabemos, ningún estudio hasta la fecha ha tenido en cuenta estos dos nutrientes, a pesar de los resultados especialmente convincentes obtenidos con los tratamientos individuales. En el transcurso de estos tratamientos individuales, la vitamina K2 y el magnesio han dado lugar a mejoras significativas en la enfermedad de la osteoporosis: la densidad mineral ósea ha aumentado, la progresión de la pérdida de masa ósea se ha detenido y el número de fracturas óseas se ha reducido significativamente.
Existen estudios similares muy prometedores sobre la combinación de vitamina D y vitamina K2. La razón por la que estas interrelaciones no aparecen en la práctica científica no está del todo clara a partir de los mecanismos mencionados anteriormente, de hecho sólo un tratamiento que utilice todos los cofactores es realmente prometedor.
¿Es peligroso un nivel extremadamente alto de vitamina D?
En el caso de la osteoporosis, el objetivo de la administración de vitamina D es mantener niveles sanguíneos normales entre 30 y 60 ng/ml. Si los niveles están por encima de estos valores normales, la eficacia de la vitamina D en la osteoporosis es incierta. Paradójicamente, un nivel particularmente alto de vitamina D activa puede conducir a una mayor degradación de la masa ósea: en experimentos celulares, la hormona de la vitamina D activa aumenta la degradación ósea. ¿Este fenómeno también se produce in vivo? Esta es una cuestión controvertida.
Este fenómeno corresponde en este sentido a una especie de dispositivo de seguridad del organismo. Un nivel extremadamente alto de vitamina D activa, junto con muy poco calcio, indica al organismo que el nivel de calcio en el intestino no puede normalizarse optimizando la absorción. En estas circunstancias, la vitamina D garantiza directamente la movilización del calcio presente en los huesos, con el fin de preservar la estabilidad de los niveles vitales de calcio en la sangre.
En cualquier caso, se requiere un nivel considerablemente alto de 25-OH-D para provocar un aumento relevante de la hormona de la vitamina D en la sangre. Esto sólo puede lograrse con una sobredosis a largo plazo. También es improbable que este efecto se produzca con una absorción óptima del calcio. En ensayos con animales, incluso dosis extremadamente altas de vitamina D han mostrado un efecto positivo, por lo que la forma en que este mecanismo es realmente eficiente sigue siendo objeto de incertidumbre.
Desde el punto de vista de la salud ósea, un nivel de vitamina D entre 30 y 60 ng/ml se considera fiable y óptimo.
Es poco probable que un nivel más alto tenga algún otro beneficio para la salud ósea.
Tratamiento convencional de la osteoporosis
Los tratamientos farmacológicos utilizados en la medicina convencional para tratar la osteoporosis pueden dividirse en las siguientes áreas:
| Tratamiento | Categoría del ingrediente activo |
| Tratamiento básico | -Vitamina D -Calcio |
| Retraso en la descomposición de los huesos (antierosivo) | -Bifosfonatos -SERM’s (estrógenos artificiales) -Calcitonina -Estrógeno, progesterona (hormonas femeninas), metabolitos de la vitamina D -Inhibidor del RANKL (inhibición directa de los osteoblastos) |
| Estimulación de la construcción ósea | -Fluoruro -Metabolitos de la vitamina D -Testosterona (hormona masculina) parathormona -Strontium |
La vitamina D está presente en las tres áreas de tratamiento, pero la terapia básica es la base de todas las opciones de tratamiento posteriores, ya que sin la vitamina D, el metabolismo óseo sigue alterado y los medicamentos no pueden alcanzar la eficacia deseada.
Hay otro factor que también es la piedra angular de todos los tratamientos, aunque no es en absoluto un ingrediente activo, ya que es la actividad física. Los fármacos por sí solos no pueden estimular suficientemente el metabolismo óseo. Por lo tanto, la actividad física es particularmente esencial para la construcción de los huesos, los fármacos por sí solos son insuficientes.
Todos los fármacos que se utilizan actualmente provocan diversos efectos secundarios, las hormonas sexuales desempeñan un papel especialmente importante en el metabolismo del organismo. Por lo tanto, el uso de los ingredientes activos individuales debe ser considerado individualmente. Incluso los bifosfonatos, que se prescriben ampliamente, conllevan riesgos considerables.
Por el momento, el uso de la parathormona como tratamiento para la construcción de huesos parece absurdo, en principio, la parathormona regula sin embargo la movilización del calcio presente en los huesos. Sin embargo, se ha demostrado que los picos breves en los niveles de la hormona paratiroidea estimulan la transformación ósea en general, siempre que el nivel se vuelva a normalizar inmediatamente.
Métodos de ayuda natural en caso de osteoporosis
La osteoporosis es un trastorno de la regulación del metabolismo óseo y puede considerarse un problema sistémico. En situaciones agudas, los fármacos pueden ser importantes y útiles, pero deben ir acompañados constantemente de una transición hacia una dieta y un estilo de vida más saludables. Estos son los principales puntos clave:
- Actividad física: La actividad física provoca una tensión en los huesos, desencadenando así el proceso de construcción ósea. En este contexto, es posible comparar el hueso con el músculo: si el hueso no se utiliza, sufre una degeneración, mientras que el uso del hueso estimula su reconstrucción. En el caso de la osteoporosis, se recomienda una combinación de diferentes esfuerzos óseos: gimnasia, aeróbic, entrenamiento funcional, entrenamiento con pesas y entrenamiento vibratorio.
- Asegurar el suplemento de nutrientes esenciales: Numerosos nutrientes desempeñan un papel importante en el metabolismo óseo. Como se ha mencionado, estos nutrientes incluyen principalmente la vitamina D, el calcio, la vitamina K2 y el magnesio. Una carencia de vitaminas del grupo B, especialmente de vitamina B12, ácido fólico y vitamina B6, también conlleva un riesgo de osteoporosis. El oligoelemento boro también parece desempeñar un papel esencial e influye directamente en la construcción de los huesos.
- El equilibrio fosfato-calcio: Además de la asimilación del calcio, la vitamina D también regula la asimilación del fosfato, existiendo una estrecha interacción entre estos dos nutrientes. El fosfato estimula los mismos mecanismos de regulación que el calcio: un nivel elevado de fosfato provoca la inhibición de la vitamina D activa y, por tanto, inhibe la asimilación del calcio al tiempo que aumenta su eliminación por el organismo. Así, un exceso de fosfato puede provocar una deficiencia de calcio y un aumento de la degradación ósea, ya que todo el sistema de regulación queda inoperativo. La proporción de calcio y fósforo debe ser como máximo de 1:1 para garantizar una regulación normal del calcio. Sin embargo, las dietas modernas suelen contener cantidades significativamente mayores de fosfato, lo que resulta especialmente crítico en el caso de un consumo excesivo de productos animales. En este caso, las proporciones son en parte 20:1 a favor del fosfato. Los refrescos también contribuyen en gran medida a estas proporciones tan elevadas: un vaso de cola ya contiene unos 500 mg de fosfato, lo que equivale casi a las necesidades diarias totales.
- Alimentación básica y equilibrada: Una dieta naturalmente equilibrada no sólo es importante en términos de fosfato. También aumenta la opinión de que la acidificación excesiva debida a la dieta se considera el principal factor de riesgo para el desarrollo de la osteoporosis. Esto se debe a que el exceso de ácidos tiene que ser neutralizado por medio de minerales, el cuerpo acumula minerales básicos que actúan como un amortiguador contra los ácidos, que se extraen de los huesos cuando es extremadamente necesario.
Teorías y tratamientos alternativos para la osteoporosis
Dado que la osteoporosis no es un trastorno de la mineralización como tal, sino más bien un trastorno de la regulación del proceso de transformación ósea, cada uno de los nutrientes tiene un papel que desempeñar aquí. Los nutrientes regulan directamente el proceso de transformación de los huesos: como se ha descrito anteriormente, la vitamina K2 y el magnesio son de especial importancia en este caso.
La osteoporosis provoca la pérdida de la matriz ósea blanda (tejido conectivo) junto con los minerales, por lo que algunos terapeutas abordan ahora directamente esta pérdida de tejido conectivo. La teoría se basa en el hecho de que, en el caso de la osteoporosis, se trata en principio de una pérdida de tejido conectivo, la pérdida de minerales es sólo la consecuencia indirecta de la descomposición de la matriz ósea. La famosa paradoja del calcio también puede explicarse con esta teoría, es decir, la osteoporosis puede producirse simultáneamente con la calcificación de los vasos.
Según esta teoría, la terapia consiste, por un lado, en el apoyo a la regulación del proceso de transformación ósea con vitamina K2 y magnesio, pero también en el apoyo global a los procesos anabólicos (de construcción de tejido) y de construcción de tejido conectivo.
Los métodos naturales de tratamiento incluyen, entre otros, los siguientes:
- Vitamina D (en caso de deficiencia subyacente)
- Vitamina K2
- Magnesio
- Silicio
- Una dieta equilibrada (no demasiado ácida)
- Reducción de azúcares y carbohidratos procesados (la insulina favorece la descomposición de los huesos)
- Actividad física regular (favorece la renovación de los huesos)
- Reducción del estrés (el cortisol, la hormona del estrés, favorece el proceso de descomposición)
- Promover la testosterona anabólica
Estos terapeutas consideran que el consumo de silicio y magnesio es mucho más importante que el consumo de calcio. De hecho, los estudios citados anteriormente indican una mejora considerable gracias a los suplementos de magnesio.
Resumen de la vitamina D y los huesos
Un nivel de vitamina D de al menos 30 ng/ml es una base esencial para una salud ósea duradera. Tanto en la prevención como en el tratamiento de las enfermedades óseas, un nivel óptimo de vitamina D es el requisito previo para un metabolismo óseo perfectamente sano.
Hay que tener en cuenta que los primeros 25 años de vida son extremadamente importantes, ya que el esqueleto y la masa ósea se forman durante este periodo.
En este contexto, la vitamina D no actúa sola: todos los cofactores de la vitamina D desempeñan un papel importante en la osteoporosis.
La combinación de todos estos cofactores, junto con la asimilación diaria y los cambios simultáneos en el estilo de vida, ofrece una muy buena oportunidad de tratar la osteoporosis de forma natural y, por tanto, sin necesidad de medicación.
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Top 10 Customer Support Outsourcing Companies in 2023 | Helpware
Outsourcing customer support is a great way to provide affordable but reliable
service to your clients. Whether for voice or non-voice applications,
there are plenty of excellent customer support…
Written by Dana Mahoney
Sunday, Jan 22
Table of Contents
Outsourcing customer support is a great way to provide affordable but reliable service to your clients.
Whether for voice or non-voice applications, there are
plenty of excellent customer support outsourcing companies
that fit every requirement.
But then again, why even think about outsourcing? Isn’t local talent good enough to provide
the service needed by a company’s customers?
Plus, wouldn’t it be a disservice to customers if a company farms out its frontline operations to contractors?
What Is Customer Support Outsourcing?
By now, the best customer service companies should know the value
of customer support and why it’s an essential cog in an organization. Like sales and marketing, customer service should already be in play
during a company’s first day, as they are the group that comes into direct contact
with clients.
The main goal of customer support is to keep customers happy by attending to their needs and responding to
their questions. However, it’s also a way to instill loyalty and generate additional sales.
To do so, an outsourcing company must have its support team available whenever
the customer needs it. Outsourcing customer support allows companies to maintain an around-the-clock service team managed by industry veterans and experts.
Advantages of Customer Support Outsourcing
Admittedly, not all company startups have leaders who are experts
in every facet of their operations. Given their many responsibilities, many startup founders accept that they can’t do everything themselves.
Non-core competencies such as customer service can benefit from outsourcing.
Turning the service over to competent experts lets companies benefit from a bigger source of
talent from all over the world. At the same time, companies that outsource customer support
enjoy reduced payroll without sacrificing service quality.
Other benefits of outsourcing include:
More Opportunities to Grow the Business
By assigning customer support to expert outsourcing service providers, leaders can instead turn to scaling the business.
Overseeing the day-to-day operations can already take much of management’s time, and
customer support is equally demanding. To help executives focus on the big picture, they’ll need to partner with the best service companies
that know what they’re doing.
Enhance Customer Experience
Given the opportunity to communicate and interact with customer service, many customers will express their satisfaction in getting
their voices heard. If customer service companies and their
team address customers’ issues in a satisfactory way, they’re more than likely to remain customers.
A pleasant customer experience will almost
always lead to longer retention and a significantly higher customer lifetime value (CLV).
This isn’t to say a stellar customer experience
is only possible through outsourcing. Rather, the chances
of improving customer satisfaction come with a continuous
and consistent level of service. Providing a highly specialized, dedicated team of professionals from day one is a great way to achieve
this quickly.
Top 10 Customer Support Outsourcing Companies
We’ve narrowed down the list of companies with great customer service to
the top 10 most prominent ones in 2022. We’ll also provide a
brief description and highlight the main strong points of each outsourcing company.
1. Helpware
Helpware started in 2015 with the initial goal of providing support to startup companies.
Over the years, the company has grown big and is confident enough
to provide both enterprise and small business customer service
outsourcing solutions.
Providing back office, technical, and customer support,
Helpware specializes in assisting companies in various support areas.
This includes Omnichannel Customer Support, Technical &
IT Support, Content Moderation, CX Consulting Services, Back Office Support, Data Labeling, Digital Marketing Solutions, and Cyber Security.
The company provides only dedicated agents, in-house training, and equipment to help its clients
boost their productivity from day one. Now it’s one of the top customer service companies in the US and European markets
with numerous awards and positive reviews from satisfied clients on Clutch
and other reputable platforms. Helpware’s people-focused culture seems very attractive to businesses sharing the same philosophy.
Pros:
Shows outstanding flexibility when providing for clients’ specific needs.
This means its support can scale along with your company’s growth.
Offers turn-key solutions, so you don’t have to look for either option separately.
Helpware’s focused on developing its people and their skills and it pays off
handsomely, especially in customer support outsourcing contracts.
Some global brands are happy to have their customer support outsourced to Helpware.
2. Sykes
U.S.-based Sykes is one of the pioneers of the BPO industry.
Established in 1995, the company trailblazed its way to the top and was one of the first BPOs to open multiple locations.
In 2021, the Sitel Group acquired Sykes to
widen its reach and increase its capacity.
Sykes is one of the top 10 service companies and leading service
providers of demand generation and customer engagement services,
with clients included in the top 2000 companies worldwide. At the core of
Sykes’ business are its staple services: outsourcing, customer experience, service to sales,
digital transformation, and brand extension.
Pros:
Sykes maintains a pool of service agents from its clients’ home countries.
The company is well-versed in matters concerning data
privacy. Specifically, Sykes follows various privacy guidelines, including HIPAA compliance and Payment Card Industry (PCI) data
security certification.
3. Ascensos
Founded in 2013 in the UK, Ascensos is one of those outsourced customer service companies that wanted to change the customer
experience by applying a personal touch to customer care.
The company is now Europe’s number-one customer support outsourcing company, providing bespoke customer experience solutions to
clients around the world. In addition, its contact center operation locations include the UK, Romania,
Turkey, and South Africa.
Pros:
Ascensos is more nearshore than an offshore support center, so location and time zone
differences aren’t as pronounced as operations in Asia and
South America.
Companies that outsource customer service to Ascensos value the fact that it supports diversity and inclusivity among
staff while focusing on promoting happiness as a key asset among its workforce.
Although there aren’t any published pricing rates, instead, Ascensos will individually respond to requests for
quotes, the prices of this outsourcing customer service company are more than affordable.
4. Teleperformance
With more than 40 years of experience in the BPO industry, Teleperformance is
an established leader in solution design, business optimization strategies, and
front-office customer support. It also offers back-office services such as finance and accounting,
collections, and technical support.
Pros:
Teleperformance is a truly global service provider. It operates in 80 countries and
employs more than 330,000 agents speaking over 265 languages and
deservedly belongs to a league of good customer service companies.
You won’t find it difficult to get support in the language and location you require.
Clients also appreciate the company’s expertise in providing omnichannel solutions.
5. VXI
VXI Global Solutions is one of those outsourcing agencies that offer customer
care and customer experience (CX) solutions to
some of today’s major global brands. In addition, the company offers contact center and BPO services,
omnichannel and multilingual support, software development, CX innovation, quality assurance (QA), and infrastructure outsourcing.
VXI employs more than 35,000 workers in 43 countries throughout North America, Asia, Europe, and the Caribbean.
The company also prides itself on its ability to help clients resolve major
CX and employee experience (EX) pain points and take their customer service systems to the next
level. Like any modern BPO, VXI employs omnichannel support
services to enhance communication coverage for clients.
Also, VXI provides additional analytics and insights generation services so clients can learn as they
go.
Pros:
High CX expertise leads to enhanced customer and employee experience.
VXI displays an uncanny ability to scale up or down to fit its client’s capabilities.
6. InfluX
In its quest to build the world’s first remote-only
CX team, InfluX managed to recruit employees from more than 120 cities worldwide.
This strategy also lets them provide 24-hour customer
support outsourcing solutions within the client’s time zone.
In addition, InfluX creates specialized customer experiences that reflect the client’s vision, voice,
and values.
Pros:
Less dependence on automation and more on human interaction make
for a better customer experience.
Having employees in every time zone solves the common offshore
problem of mismatched time schedules between clients and outsourcing companies.
Pay-as-go pricing may be attractive to some clients who prefer flexible packages.
7. Skycom
Skycom is also on the list of nearshore outsourcing companies that specialize in multi-continent support services.
The company employs native English contact center agents with experience
in multiple industries. Skycom also offers a
full range of services, including business process outsourcing, telemarketing and sales,
customer support, and healthcare. With more than 15 years of experience, Skycom also employs over 2,000 workers assigned to 35
clients in five countries.
Pros:
Nearshore operations mean fewer problems dealing with
time zone and distance differences.
Skycom covers a wide range of industries, including healthcare, travel, utilities,
IT, finance, retail, and telecommunications.
8. Integra
Integra’s differentiator is its focus on training its
workforce in customer psychology. This means company-provided support
agents are more sensitive in detecting changes in the customer’s voice or tone.
As a result, they can respond to these changes to defuse any tension and lead the customer into a more positive mindset.
Starting with four employees in 2004, Integra
currently employs more than 1,400 workers stationed across four countries.
It handles customer service duties over the phone, email,
live chat, or social media.
Pros:
Integra offers some of the most cost-effective solutions in the industry.
Sales psychology is also an incredible asset to have if you work in a customer
support outsourcing company.
9. Telus
Telus International is one of the world’s leading digital CX
innovators. In particular, it designs and produces next-generation digital solutions for brands all over the world.
This is one of the Canadian top IT outsourcing companies that provide IT services and multilingual customer service to
industries such as technology, media, communications, eCommerce, financial technology,
travel, hospitality, automotive, healthcare, and games.
Pros:
Telus International is a premium multilingual contact center.
It is one of those IT support outsourcing companies that offer top-tier customer support services in various countries and more
than 50 languages.
Telus is famous among IT services outsourcing companies for organizing an annual charitable initiative called “Telus Days
of Giving.” In particular, the company taps 225,000
volunteers from its offices to complete various service projects across its many host countries.
10. Arise
Arise is a 25-year-old United States-based company that specializes in providing support outsourcing services across the USA.
It employs more than 60,000 remote agents in the U.S., Canada, and the United Kingdom.
Unlike a traditional BPO, Arise utilizes a network
of service partners to provide the needed customer
service experiences. In addition, the Arise Platform helps companies lower expenses.
As a result, Arise clients report an average 25% reduction in contact center service total costs, which is
why clients want to outsource customer service small business really needs.
Pros:
Arise deploys a tiered security approach in its communications with clients.
This ensures they preserve the confidentiality of documents or files sent over.
It also means Arise conforms to widely accepted data privacy regulations
such as HIPAA, CCPA, and others.
Arise also focuses its employment on local
talent, hiring residents of the U.S., UK,
and Canada. This means stable employment for the company and an easier method of hiring or replacing staff members.
Choose the Best Outsourcing Companies That Fit Your
Needs
Deciding which outsourcing providers to contact for your customer support outsourcing needs?
Perform the necessary research before settling on your choice.
For instance, some customer service outsource companies on our list might command a pricing structure higher than what your budget holds.
In addition, consider your company’s specific requirements
and areas for improvement. Do you need a customer support team focused on CX?
Or, do you prefer having sales psychology-trained outbound callers
who can close deals? Finally, does the appeal of higher-cost nearshoring
resonate better than offshore talents a few
time zones away?
No one-size-fits-all solution exists when it comes
to customer support outsourcing. However, if you want a highly
flexible and secure customer service solution that utilizes modern technology throughout the various stages, try the best companies for customer service.
These largest outsourcing companies not only supply the best
talent, but also the best equipment and training to prepare them.
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Желающие испытать удачу теперь могут
не посещать казино или специальные клубы.
Среди них бонусные игры,
специальные раунды и другие
опции, которые повышают интерес пользователей и позволяют
операторам увеличивать аудиторию.
В этом видеослоте огромное количество уникальных характеристик, несколько видов wild-символов, различные бонусные игры,
бесплатные спины и некоторые другие интересные опции.
Благодаря опции Allplay выигрышные комбинации формируются из
идентичных изображений, которые появляются
в любой части на соседних барабанах, включая первый.
Игроки получают выплаты за минимум пять
идентичных символов, независимо от
их расположения на барабанах.
Выигрышная комбинация, как и прежде, собирается посредством сопоставления одинаковых символов, но
игровые линии могут проходить через барабаны множеством различных способов.
Чем лучше эта комбинация, тем больше денег
получит игрок. Другие – предоставляют возможность выбрать не
только количество игровых линий, но и сумму,
которую игрок желает поставить на каждую из них.
В этих играх разработчики отказались от концепции игровых
линий, и каждый символ фактически выступает как
«разбросанный», или scatter. Эта система
называется Scatter Pays и теперь реализуется в видеослоте Spinning
Fruits. Кроме того, заметно влияние образа Гамбита на
образ Тубалкаина Альгамбры из манги и ОВА Hellsing.
Кроме того, старайтесь не поддаваться
влиянию эмоций. Кроме того, в справочном разделе
есть данные о выигрышных комбинациях
и о том, сколько начисляется за каждую из них, вдобавок к
сведениям о бонусных играх
и бесплатных спинах.
Кроме того, в онлайн-слотах благодаря применению современных технологий игрок имеет больше возможностей для увеличения прибыли.
Более того, если игрок получает от семи символов
и больше, активируются бесплатные спины.
Очень важно знать, сколько игровых линий имеет автомат и сколько из них игрок собирается задействовать.
Существует много игр всего с одной линией,
в то время как самое распространенное
количество – 3, 5, 9, 15, 20 или 25. Помимо этого, есть
автоматы с большим количеством игровых линий
– 243 или даже 1024. Их называют слотами «с 243 способами выиграть» или слотами с «1024 способами выиграть».
М. Достоевского его политические взгляды в разное время интерпретировались как
ретроградство, реакционность, национализм,
шовинизм, анахронизм, антисемитизм, черносотенство.
Во время правления короля рамы V игорный бизнес был запрещен.
Ключ к успеху состоял в том, что отец Мо поддерживал конкурентоспособность своего бизнеса, заражая другие магазины термитами, что
делало бизнес отца Мо ведущим в Спрингфилде ввиду отсутствия конкурентов.
Там представлена информация о том,
сколько в слоте игровых линий и каким образом они появляются
на барабанах.
При этом в виртуальных машинах может быть до пяти барабанов и
до 243 игровых линий. При этом сама
компания не имеет ничего против регистрации бетторов из
этих стран – им нужно находить альтернативные методы доступа.
Известная компания Novomatic
также предлагает модели данного вида, например слоты Magic 81
Lines и Hoffmania. Разработчики из Novomatic также предлагают еще
один способ получить деньги за комбинации, которые
формируются без активных линий.
Примерами автоматов 777 являются Ultra Hot Deluxe или Always Hot, созданные австрийской компанией Novomatic.
Охрана в порядке Документальный сюжет.
221 1980 Там, где кончается асфальт Мультипликационный сюжет.
Кина не будет Документальный сюжет.
Сенсация, которая живёт на крыше Документальный сюжет, рассказывающий о том, как создаётся телевизионный продукт, под названием
«журналистское расследование».
Принято считать, что игровые
автоматы были изобретены в США, однако есть и другая версия событий, которая повествует о том, что родиной слотов является Великобритания.
Когда Ава Гарднер узнала о том, что её дом начинён прослушивающими устройствами,
то закатила своему любовнику скандал.
Когда вращается барабан, потенциально существует множество
выигрышных комбинаций в разных
игровых линиях. Эти автоматы до сих
пор чрезвычайно популярны в наземных и удаленных игорных заведениях, именно они являются
простейшими с точки зрения игровых линий.
Тут может быть доступно до 720 или даже 1024 способов создать выигрышную цепочку.
Цели главного героя – стать Чемпионом
региона, а также победить возродившуюся
Команду R, преступную организацию, которая распалась за три года до действия игр.
К примеру, 1 цент, поставленный
на каждую игровую линию, в результате превращается в 25 центов
за спин, но, если увеличить сумму до $10 за игровую линию, общая сумма составит $250.
К примеру, в слотах Prowling Partner и Day of the Dead на экране
барабана имеются колонки разной
высоты. TV by the Numbers (22 января 2015).
Дата обращения: 22 января 2015.
Архивировано из оригинала 23 января 2015 года.
Зеркальный двойник Айрис обманывает Джо и крадёт у него данные полиции
о «Чёрной дыре». Стоит помнить, что игра на виртуальных автоматах также является разновидностью азартных
развлечений, способных вызывать зависимость.
Стоит отметить, что многие модели в данной серии имеют
необычный дизайн. ↑ Pokémon HeartGold Version and
Pokémon SoulSilver Version Sell Through More
Than 50,000 Units (неопр.) (недоступная ссылка
– история) (7 апреля 2010). Дата обращения:
4 января 2013. Архивировано 12 января 2013 года.
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business decision if you want to avoid all trials and tribulations of running an in-house call center this solution can be a budget-friendly way to
handle customer concerns while significantly improving the level of customer
satisfaction let s have a look at those bpo companies that take the top positions in the industry discuss what makes them stand out
and go through the main tips for choosing the right call center why outsourcing a call center creating a positive customer experience is the main priority
for most companies with so many competitors offering similar products
and services in today s marketplace it can be challenging for any particular organization to stand out and attract new customers additionally modern customers are ready to pay more if they receive an outstanding
experience offering excellent customer support services can give a
business an edge over competitors by boosting
customer retention and generating positive reviews ultimately
driving profits conversely a poor customer experience can lead
to customer loss and negative reviews which can harm a business
choosing the best call centers for your business guarantees increased customer satisfaction streamlined
operations and enhanced growth making it a crucial factor in achieving
success in today s competitive market us call center
outsourcing companies top list 1 helpware helpware is a leading customer support provider with headquarters based in the usa with call centers spread across four continents the core areas of expertise include
a wide range of bpo services such as omnichannel customer support
technical support it support content moderation data annotation data entry helpdesk back-office support etc since helpware
positions itself as a reliable outsourcing partner for both startups and
big enterprises there are companies of different sizes among
the clientele ranging from small firms to renowned
brands at helpware people come first and it pays off the needs of
employees are the main priority and it shows in their work as they provide exceptional service pros applying a customized approach to recruiting and training dedicated agents offering exceptional expertise in all kinds of customer support tailoring packages to cater to the specific needs of
different businesses 2 xact xact is a highly flexible outsourced call center based
in orlando florida catering to businesses of different sizes they specialize in providing technical support and
customer support services to businesses operating across diverse industries including property management e-commerce tourism healthcare hospitality and fintech xact has partnered with nice incontact since 2005 leveraging their cloud-based contact center toolkit to ensure the utmost data security for their clients pros providing a personalized 24 7 telephone answering service ensuring
service continuity through their fail-safe automatic transfer switches ats which seamlessly switch to an alternate power
source during power outages 3 wing assistant the
wing assistant is revolutionizing the process of recruiting remote workers on a global
scale this innovative outsourced call center provides a fully-managed virtual
assistant experience that helps entrepreneurs
and small and medium-sized businesses scale by delegating
laborious and time-consuming tasks to dedicated customer service
professionals for a fixed monthly cost they offer outbound call center outsource solutions that
are affordable and enable businesses to level up and enhance their customer service and technical support and boost their sales pros a dedicated client success manager to assist you in achieving your unique business goals and overcoming challenges a
diverse range of managed outsourcing services
including back-office support and staffing solutions with great
potential in addition to call centers 4 triniter triniter is a renowned figure in the bpo industry with a global
presence spanning the united states the philippines and india this american call center has established itself as the
preferred outsourcing provider for inbound and outbound call center solutions sought after by major corporations pros a decade-long track record of
providing customer support across more than 30
domains 24 7 customer support with an impressive 98 9 positive feedback rate 5
tmp direct for over 34 years tmp has been providing bpo services advocating for clients brands and ensuring excellence through its team with a global presence
tmp direct manages connections and relationships across various
industries they offer custom end-to-end solutions including crm tools it infrastructure
fulfillment and telecom platforms adapting to the evolving cx landscape they handle
various communication channels from inbound and outbound calls and chats to social media and personalized correspondence pros providing an in-house it development team that eliminates
the need for multiple vendors 6 answerforce this is
proud of being on the list of five star call centers providing a range of
professional call and chat answering services virtual reception services
appointment scheduling and more answerforce has
experienced call center agents at its disposal that are
available round-the-clock to handle inbound and outbound calls and live chat support and
conduct customer surveys in a professional manner this american call center works mainly with small and middle businesses
covering such industries as home service restoration plumbing and electrical pros offering customized solutions to meet the specific needs of clients
within particular industries which allows answerforce to provide highly
tailored and effective services to their clients integrating with
the client s workflow software this enables businesses to manage their customer
interactions efficiently without having to switch
between multiple platforms 7 fusion bpo services fusion bpo services group is a company with huge experience more than 33
years in the industry and offers voice services and other solutions
to more than 250 businesses worldwide however what
makes this provider stand out is its unique locations in addition to popular bpo destinations like the united states india and
the philippines the company has offices in pretty exotic countries like
el salvador jamaica morocco and colombia with 22 locations in 10 countries
fusion is capable of delivering call center services in over
40 languages pros by strategically locating its offices
around the globe this company is able to offer 24 7
customer support across multiple time zones making it easy for customers to get the help they need whenever they need it a diverse workforce
and multilingual capabilities enable them to provide support in various languages making their services accessible to a wide
range of customers the outsourced customer service of this provider is reasonably priced that varies depending on the expected amount of calls and service
level you may require 8 supportyourapp supportyourapp
is an outsourced customer support company with a multinational team
that provides inbound and outbound services and back-office
customer support for innovative software and hardware companies they have received numerous awards for providing exceptional customer
experiences but their commitment to quality and security is paramount
supportyourapp is pci dss compliant and adheres to the general data protection regulation gdpr pros ensuring the highest data security standards and preventing any data leaks they take great care in protecting sensitive information and clients
can trust that their data is safe streamlining the integration process with the help of their dedicated integration department providing
their clients with a crm solution that integrates incoming calls chats and emails into one system and implementing ai solutions to the chats which many small businesses find appealing
9 vcall global vcall global is a provider of innovative service solutions to different businesses across various industries they offer
a range of services including customer service tech support back-office solutions
interactive voice response ivr services telecom billing solutions and software development solutions using advanced technology and infrastructure they offer common services through
multiple channels vcall global is the preferred choice for businesses seeking a perfect blend of flexibility and quality
in their services pros adhering to turnaround times ensuring that clients receive their services in a timely and efficient manner empowering their call centers with
a robust cisco network which enables vcall global to offer seamless uninterrupted service to clients regardless of their location or the complexity of their needs providing
enhanced security features that protect client
data and information ensuring that their privacy is always maintained 10 call
masters bpo the company provides inbound and outbound call center
services as well as remote administrative solutions such as data
entry appointment setting reservation services etc their streamlined workflow and
marketing automation ensure that important phone calls are never missed with their expertise and dedication they can help businesses resolve
customer queries acquire leads and enhance administrative business processes too pros enabling businesses to
easily scale up or down based on demand and their remote employees to work in split shifts due to their cloud-based virtual call
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↑ Porter, Rick ‘This Is Us,’ ‘Fresh Off the Boat,’ ‘Kevin’ & World Series adjust up,
‘L&O True Crime’ down: Tuesday final ratings (неопр.).
↑ Porter, Rick Tuesday final ratings: ‘Hollywood Game Night’ and ‘iZombie’ adjust down (неопр.) (недоступная ссылка –
история). ↑ Porter, Rick ‘American Housewife’ and ‘The Voice’
adjust up, ‘Chicago Fire’, ‘SHIELD’ and ‘Real O’Neals’ down: Tuesday final ratings (неопр.)
(недоступная ссылка – история).
↑ Porter, Rick ‘The Flash’, ‘Chicago Fire’, ‘The Voise’, ‘Fresh Off
the Boat’ adjust up: Tuesday final ratings (неопр.) (недоступная ссылка – история).
↑ Porter, Rick ‘NCIS’ finale and ‘Bull’ adjust up, ‘The Middle’ adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick Tuesday final ratings: ‘The Voice,’
‘The Flash’ and ‘The Real O’Neals’ finales adjust up (неопр.).
↑ Porter, Rick ‘Dancing With the Stars,’ ‘This Is Us,
‘ all others hold: Tuesday final ratings (неопр.).
↑ Porter, Rick Tuesday final ratings: ‘The Voice’ adjusts
up (неопр.) (недоступная ссылка – история).
Эскадренный миноносец проекта 956
«Сарыч» (неопр.).
↑ Porter, Rick ‘NCIS’ and ‘The Middle’ adjust up, ‘Prison Break’ adjusts down: Tuesday final ratings (неопр.) (недоступная ссылка –
история). ↑ Porter, Rick ‘The Wall’ adjusts up, ‘Bones’ adjusts down: Tuesday final ratings
(неопр.) (недоступная ссылка – история).
↑ Голос ТВ Центра (неопр.).
↑ Дмитрий Губерниев: «Приснилось, что помирился с Малафеевым» (неопр.).
↑ Porter, Rick ‘Chicago Med’ adjusts up: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘Roseanne’ and ‘Chicago Med’ adjust up, ‘The 100’ adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘The Voice’ and ‘Chicago Med’ adjust up, ‘Bull’
adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘The Voice’ and ‘The Flash’ adjust up: Tuesday final ratings (неопр.).
↑ 1 2 Now Pay Attention, 007: Introduction and Casino Royale ’54 (англ.).
Pip – Chrono Compedium (англ.). ↑ Porter, Rick ‘This Is Us,’ ‘The Voice,’ ‘NCIS,
‘ ‘Black-ish’ adjust up, ‘Rise’ adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick TV Ratings Tuesday: ‘Containment’ has decent premiere,
‘NCIS’ and ‘The Voice’ low (неопр.). ↑ Welch, Alex ‘The Rookie,
’ ‘The Voice,’ and all others hold: Tuesday final ratings (неопр.).
↑ Porter, Rick Tuesday final ratings: ‘NCIS’ and ‘Chicago Fire’ finales adjust up (неопр.) (недоступная ссылка – история).
↑ Porter, Rick Tuesday final ratings: ‘Agent
Carter’ adjusts up (неопр.) (недоступная ссылка – история).
↑ Porter, Rick ‘The Flash,’ ‘This Is Us’ and ‘Rudolph’ adjust
up: Tuesday final ratings (неопр.). ↑ Porter, Rick Tuesday final ratings:
‘The Voice’ adjusts up, ‘Chicago Fire’ and ‘Beyond the Tank’ adjust down (неопр.) (недоступная ссылка – история).
↑ Porter, Rick ‘The Middle’ adjusts up, ‘The Mayor’ adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘NCIS,’ ‘Voice’ and ‘This Is Us’
adjust up, ‘Black-ish’ and ‘L&O True Crime’ down: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘Roseanne,’ ‘The Middle,’ ‘Lethal Weapon’ adjust
up, ‘Black-ish’ down: Tuesday final ratings (неопр.).
↑ Welch, Alex ‘New Amsterdam’ adjusts
down: Tuesday final ratings (неопр.). ↑ Welch, Alex ‘This is Us,’ ‘The Rookie,’ everything else
unchanged: Tuesday final ratings (неопр.). ↑ Welch,
Alex World Series and ‘New Amsterdam’ adjust up: Tuesday final ratings
(неопр.). ↑ Welch, Alex American Music Awards, ‘This is Us,’ everything else unchanged: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘This Is Us’ adjusts up, ‘Lethal Weapon’ adjusts down: Tuesday
final ratings (неопр.). ↑ Porter, Rick ‘Fresh Off the Boat’ adjusts down, plus State
of the Union analysis numbers: Tuesday final ratings (неопр.).
↑ Welch, Alex ‘The Conners,’ ‘The Flash,’ and more adjust up, ‘Splitting Up Together’ and ‘Black-ish’ adjust down: Tuesday final ratings
(неопр.). ↑ Porter, Rick Tuesday final ratings: ‘The Voice’ adjusts up,
‘Containment’ adjusts down (неопр.). ↑ Porter, Rick ‘The Mick’ and ‘Agents of SHIELD’ adjust up, ‘iZombie’ adjusts down: Tuesday final ratings (неопр.).
↑ Porter, Rick ‘NCIS’ and ‘Bull’ adjust up: Tuesday final ratings (неопр.).
↑ Welch, Alex ‘American Housewife’ adjusts up, everything else holds: Tuesday final ratings
(неопр.). ↑ Porter, Rick ‘NCIS’ adjusts up, ‘Agents of SHIELD’ adjusts down: Tuesday final
ratings (неопр.) (недоступная ссылка – история).
7 ratings (неопр.) (недоступная ссылка – история).
↑ Salem, Mitch SHOWBUZZDAILY’s Wednesday 6.29.2022 Top 150 Cable Originals &
Network Finals UPDATED (неопр.). ↑ Planners Guide (неопр.).
↑ В территорию игорной зоны в Калининградской области включили 99,5 га земли в пос.
↑ Иван Ковальчук. Из «Что? ↑ 1 2 3 4 Олег Бойко Архивная копия от 6
февраля 2013 на Wayback Machine в версии 2010 года Forbes.
Начиная с 1979 года призы-книги представляла Тамара Владимировна Вишнякова – член Президиума Всесоюзного общества
книголюбов, директор Московского дома книги на проспекте Калинина.
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