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Suijker KIM, Plattel CHM, Seage CH, Ward N, James DH, Vis JY. Development of a Vitamin B12 Deficiency Patient-Reported Outcome Measure for Clinical Practice and Research. Food Nutr Bull 2024; 45:S73-S79. [PMID: 38987882 DOI: 10.1177/03795721241236284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND It is difficult to recognize vitamin B12 deficiency and to evaluate the effect of B12 treatment due to a broad range of variable clinical symptoms overlapping with other diseases and diagnostic biomarkers that quickly normalize during treatment. This poses a risk of delay in diagnosis and a challenge to uniformly monitor the effect of B12 treatment. There is a need for a new clinical outcome measure suitable for clinical practice and clinical evaluation studies. OBJECTIVE To develop a Patient-Reported Outcome Measure (PROM) which measures the severity of vitamin B12 deficiency symptoms. METHODS The B12 PROM was developed by (1) gathering input from experts and literature review to define a construct and develop a conceptual model, (2) processing input from health care providers, scientists, and patients to develop items and response options, and (3) improving items based on the feedback from laypersons, test interviews, semi-structured cognitive interviews with patients, and forward and backward translation (ENG-NL). RESULTS The B12 PROM includes 62 items grouped into 8 categories of symptoms related to vitamin B12 deficiency (General, Senses, Thinking, In limbs and/or face, Movement, Emotions, Mouth & Abdomen, Urinary tract & Reproductive organs). Cognitive interviews demonstrated good comprehensibility and comprehensiveness. CONCLUSIONS This study is the first step in the development of a disease-specific PROM for vitamin B12 deficiency to measure the burden of symptoms. Further validation and reliability testing are necessary before the PROM can be applied in clinical practice and research.
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Affiliation(s)
- Kim I M Suijker
- B12 Institute Research Foundation, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Clara H M Plattel
- B12 Institute Research Foundation, Rotterdam, the Netherlands
- B12 Research Institute & Treatment Center, Rotterdam, the Netherlands
| | - Catherine H Seage
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - Nicola Ward
- Leicester School of Pharmacy, De Montfort University, Leicester, United Kingdom
| | - Delyth H James
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - Jolande Y Vis
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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2
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Nexo E, Parkner T. Vitamin B12-Related Biomarkers. Food Nutr Bull 2024; 45:S28-S33. [PMID: 38987873 DOI: 10.1177/03795721241227114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND Adult vitamin B12 (B12) deficiency may present itself with nonspecific mainly neurological symptoms, and thus plasma biomarkers are often judged to be of major importance in the further diagnostic process. Four biomarkers are of special relevance: total B12, holotranscobalamin (the part of B12 bound to the active transport protein, transcobalamin, also named holoTC or active B12) and the 2 so-called metabolic markers that accumulate if B12 is lacking, methylmalonic acid (MMA) and homocysteine. OBJECTIVE This article briefly reviews the inherent limitation of biomarkers, discusses its use in establishing the diagnosis and cause of B12 deficiency, and when following or discontinuing treatment with B12. METHODS The review is based on published papers, but also on knowledge gained from working within the area. CONCLUSION It is concluded that a combination of a B12 and a metabolic marker, for example, total B12 and MMA, may prove most useful in daily practice. An unexpectedly high level of total B12 is most often of no clinical importance, though sometimes related to the presence of underlying cancer. Measurement of total B12 is of limited value in patients on treatment with pharmacological doses of B12 but may be helpful if B12 treatment is discontinued.
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Affiliation(s)
- Ebba Nexo
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
| | - Tina Parkner
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
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3
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Wolffenbuttel BHR, McCaddon A, Ahmadi KR, Green R. A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency. Food Nutr Bull 2024; 45:S40-S49. [PMID: 38987879 DOI: 10.1177/03795721241229500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND An increasing number of adult individuals are at risk of vitamin B12 deficiency, either from reduced nutritional intake or impaired gastrointestinal B12 absorption. OBJECTIVE This study aims to review the current best practices for the diagnosis and treatment of individuals with vitamin B12 deficiency. METHODS A narrative literature review of the diagnosis and treatment of vitamin B12 deficiency. RESULTS Prevention and early treatment of B12 deficiency is essential to avoid irreversible neurological consequences. Diagnosis is often difficult due to diverse symptoms, marked differences in diagnostic assays' performance and the unreliability of second-line biomarkers, including holo-transcobalamin, methylmalonic acid and total homocysteine. Reduced dietary intake of B12 requires oral supplementation. In B12 malabsorption, oral supplementation is likely insufficient, and parenteral (i.e. intramuscular) supplementation is preferred. There is no consensus on the optimal long-term management of B12 deficiency with intramuscular therapy. According to the British National Formulary guidelines, many individuals with B12 deficiency due to malabsorption can be managed with 1000 µg intramuscular hydroxocobalamin once every two months after the initial loading. Long-term B12 supplementation is effective and safe, but responses to treatment may vary considerably. Clinical and patient experience strongly suggests that up to 50% of individuals require individualized injection regimens with more frequent administration, ranging from daily or twice weekly to every 2-4 weeks, to remain symptom-free and maintain a normal quality of life. 'Titration' of injection frequency based on measuring biomarkers such as serum B12 or MMA should not be practiced. There is currently no evidence to support that oral/sublingual supplementation can safely and effectively replace injections. CONCLUSIONS This study highlights the interindividual differences in symptomatology and treatment of people with B12 deficiency. Treatment follows an individualized approach, based on the cause of the deficiency, and tailored to help someone to become and remain symptom-free.
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Affiliation(s)
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham University, Wrexham, United Kingdom
| | - Kourosh R Ahmadi
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Ralph Green
- University of California Davis, Sacramento, CA, USA
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4
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Seage CH, Bennett A, Ward N, Semedo L, Plattel CHM, Suijker KIM, Vis JY, James DH. A Systematic Review of Symptoms of Pernicious Anemia. Food Nutr Bull 2024; 45:S34-S39. [PMID: 38987871 DOI: 10.1177/03795721241227016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND Pernicious anemia (PA) is a type of macrocytic anemia caused by autoimmune gastritis. To facilitate timely diagnosis and treatment of PA there is a pressing need for improved understanding among Healthcare providers of the condition's symptoms and diagnostic criteria. OBJECTIVE This systematic review aims to extend existing clinical knowledge on the presentation of PA by determining which symptoms and clinical complications are reported in published adult case studies. METHODS Relevant studies were identified through electronic searches of PsycINFO, Embase, and MEDLINE, via OvidSP. During data extraction symptoms were categorized according to the International Classification of Diseases and were grouped based on frequency. RESULTS Symptoms were documented for 103 adults with a diagnosis of PA; the most frequent symptoms were fatigue (55%), loss of sensation in limbs (32%), excessive weight loss (27%), and a sore tongue (23%). CONCLUSIONS This review highlights the diverse symptomology of adults who are diagnosed with PA. Most symptoms documented in case studies are consistent with the core signs of B12 and folate deficiencies. Research is needed to identify if there are common clusters of PA symptoms that can be used as prompts for diagnostic testing in patients with suspected B12 deficiency.
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Affiliation(s)
- Catherine Heidi Seage
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - Alexis Bennett
- Applied Psychology, Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
| | - Nicola Ward
- Clinical Pharmacy and Pharmacy Practice, Leicester School of Pharmacy, De Montfort University, Gateway, Leicester, United Kingdom
| | - Lenira Semedo
- School of Healthcare Sciences, Cardiff University, Cardiff, Wales, United Kingdom
| | | | - Kim I M Suijker
- B12 Research Institute Foundation, Rotterdam, the Netherlands
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jolande Y Vis
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Delyth H James
- Health Psychology in Pharmacy Practice, Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, United Kingdom
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5
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Hakami AR, AlSalman SA, Aljaziri NJ, Homoud B, Almohideb M. Prevalence of Autoimmune Diseases Among Patients With Psoriasis: A Single Tertiary Center Experience. Cureus 2024; 16:e60455. [PMID: 38883030 PMCID: PMC11179728 DOI: 10.7759/cureus.60455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Background Psoriasis is a common chronic inflammatory skin disease with an autoimmune etiology. Psoriasis has been presumed to be associated with several autoimmune diseases. We sought to determine the prevalence of autoimmune diseases in patients with psoriasis in a large referral tertiary care center. Methods This is a retrospective and cross-sectional chart review of patients with confirmed psoriasis diagnoses in the dermatology clinic of King Abdulaziz Medical City, Riyadh, Saudi Arabia. The electronic charts of patients were individually reviewed for autoimmune diseases such as hypothyroidism, hyperthyroidism, alopecia areata, vitiligo, atopic dermatitis, and inflammatory bowel diseases like Crohn's disease and celiac diseases. Results A total of 839 cases were included, 56.4% of whom were females. Most patients were between 31 and 50 years old (37.1%). The most common autoimmune disease was hypothyroidism (6.8%), seen more in females. The second most common autoimmune disease was alopecia areata (3.6%), followed by atopic dermatitis (2.9%). Rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel diseases were uncommon in our cohort. Conclusion In this single-center retrospective cohort of patients with psoriasis, hypothyroidism and alopecia areata were the most commonly encountered autoimmune diseases. Larger, multi-center studies are needed to evaluate the prevalence of autoimmune diseases among patients with psoriasis.
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Affiliation(s)
- Alanoud R Hakami
- Department of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Sarah A AlSalman
- Department of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Narjis J Aljaziri
- Department of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Bareen Homoud
- Department of Anesthesia, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Mohammad Almohideb
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Dermatology, King Abdullah International Medical Research Center, Riyadh, SAU
- Department of Dermatology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
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6
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Wolffenbuttel BH, Owen PJ, Ward M, Green R. Vitamin B 12. BMJ 2023; 383:e071725. [PMID: 37984968 PMCID: PMC10658777 DOI: 10.1136/bmj-2022-071725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
| | - P Julian Owen
- Department of Trauma and Orthopaedics, Addenbrooke's, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Mary Ward
- Nutrition Innovation Centre for Food and Health, School of Biomedical Sciences, Ulster University, Coleraine, Northern Ireland
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, USA
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7
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McCaddon A, Miller JW. Homocysteine-a retrospective and prospective appraisal. Front Nutr 2023; 10:1179807. [PMID: 37384104 PMCID: PMC10294675 DOI: 10.3389/fnut.2023.1179807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023] Open
Abstract
The biologically important amino acid homocysteine links sulfur, methionine, and one-carbon metabolism. This review describes its initial discovery, the identification of the clinical condition of "homocystinuria" and the recognition of its close relationship to folate and vitamin B12 metabolism. It discusses the history behind its current association with diverse diseases including neural tube defects, cardio- and cerebrovascular disease and, more recently, dementia and Alzheimer's Disease. It also explores current controversies and considers potential future research directions. It is intended to give a general overview of homocysteine in relation to health and disease.
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Affiliation(s)
- Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham Glyndwr University, Wrexham, United Kingdom
| | - Joshua W. Miller
- Department of Nutritional Sciences, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, NJ, United States
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8
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Kim S, Park J, Lee J, An JY. A Case of Gastric Adenocarcinoma With Pernicious Anemia, Polyneuropathy, and Subacute Combined Degeneration Caused by Autoimmune Gastritis. J Clin Neurol 2023; 19:312-314. [PMID: 36775277 PMCID: PMC10169921 DOI: 10.3988/jcn.2022.0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/02/2022] [Accepted: 10/07/2022] [Indexed: 02/14/2023] Open
Affiliation(s)
- Sanghyun Kim
- Department of Neurology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeonghyun Park
- Department of Neurology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jusuck Lee
- Department of Neurology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Young An
- Department of Neurology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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9
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Cotton M, McCaddon A. Examining the Diagnosis and Treatment Experiences of People Living With Autoimmune Gastritis and Pernicious Anemia. J Patient Exp 2023; 10:23743735231151767. [PMID: 36698620 PMCID: PMC9869222 DOI: 10.1177/23743735231151767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
There is limited research evaluating the diagnosis and treatment of patients with autoimmune gastritis (AIG) and pernicious anemia (PA). We used a 2-phase data collection process to examine the literature and individual patient accounts. Phase one comprised a systematically conducted literature review focusing on diagnosis and treatment, relationships with healthcare practitioners and health-related quality of life (HRQOL). Phase two involved analysis of individual accounts via posts in online patient forums. We identified 6 main themes: the diagnosis journey, seeking treatment, patient-provider relationships, HRQOL, patient disempowerment, and the "expert patient." Our findings confirm significant knowledge gaps concerning AIG/PA across the healthcare community. These have a cascading effect starting with delays in diagnosis and poor treatment protocols and often lead to complete withdrawal from care seeking. The establishment of standard consensus guidelines and improved clinical awareness should be urgently addressed. Interventions that better help patients understand their illness are also needed to improve psychological health. Without these changes disengagement from health systems, and poor health outcomes, will continue for this population group.
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Affiliation(s)
- Martine Cotton
- School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham Glyndwr University, Wrexham, UK,Martine Cotton, School of Public Health, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia.
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10
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Associations of Genetically Predicted Vitamin B 12 Status across the Phenome. Nutrients 2022; 14:nu14235031. [PMID: 36501061 PMCID: PMC9740080 DOI: 10.3390/nu14235031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/16/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Variation in vitamin B12 levels has been associated with a range of diseases across the life-course, the causal nature of which remains elusive. We aimed to interrogate genetically predicted vitamin B12 status in relation to a plethora of clinical outcomes available in the UK Biobank. Genome-wide association study (GWAS) summary data obtained from a Danish and Icelandic cohort of 45,576 individuals were used to identify 8 genetic variants associated with vitamin B12 levels, serving as genetic instruments for vitamin B12 status in subsequent analyses. We conducted a Mendelian randomisation (MR)-phenome-wide association study (PheWAS) of vitamin B12 status with 945 distinct phenotypes in 439,738 individuals from the UK Biobank using these 8 genetic instruments to proxy alterations in vitamin B12 status. We used external GWAS summary statistics for replication of significant findings. Correction for multiple testing was taken into consideration using a 5% false discovery rate (FDR) threshold. MR analysis identified an association between higher genetically predicted vitamin B12 status and lower risk of vitamin B deficiency (including all B vitamin deficiencies), serving as a positive control outcome. We further identified associations between higher genetically predicted vitamin B12 status and a reduced risk of megaloblastic anaemia (OR = 0.35, 95% CI: 0.20-0.50) and pernicious anaemia (0.29, 0.19-0.45), which was supported in replication analyses. Our study highlights that higher genetically predicted vitamin B12 status is potentially protective of risk of vitamin B12 deficiency associated with pernicious anaemia diagnosis, and reduces risk of megaloblastic anaemia. The potential use of genetically predicted vitamin B12 status in disease diagnosis, progression and management remains to be investigated.
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11
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Staley K, Ahmadi KR, Carter K, Cowan K, Seage H, Visser P, Ward N, Hooper M. Research priorities in pernicious anaemia: James Lind Alliance Priority Setting Partnership. BMJ Open 2022; 12:e065166. [PMID: 36002205 PMCID: PMC9413171 DOI: 10.1136/bmjopen-2022-065166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To form a James Lind Alliance (JLA) Priority Setting Partnership (PSP) to determine research priorities related to the cause, diagnosis, treatment and management of pernicious anaemia (PA) from the perspectives of patients, carers and clinicians. DESIGN The PSP conducted two surveys and a workshop to identify the Top 10 questions for research. A first survey identified questions relating to the cause, diagnosis, treatment and management of PA. A literature search checked whether any of these questions had already been answered. A second survey asked respondents to identify and rank their top 10 questions from the list of questions from the first survey. An online workshop used an adapted nominal group technique to agree a final Top 10. RESULTS In the first survey, 933 people submitted 3480 responses that were categorised and summarised to generate a long list of 40 questions. None had been answered by previous research. The combined rankings from the 1068 patients, carers and clinicians who took part in the second survey identified a short list of 16 questions. These were discussed at the final workshop to agree the final Top 10. The number one question was about an accurate and reliable diagnostic test for PA. The other nine questions were about making treatment safe and effective, understanding why people with PA vary in their need for treatment, links to other conditions, and how to encourage clinicians to take PA seriously and provide long-term care. CONCLUSIONS This JLA PSP enabled patients, carers and clinicians to work together to agree the Top 10 uncertainties relating to the cause, diagnosis, management and treatment of PA. Addressing any of these questions will greatly benefit the end-users of research, the people whose daily lives and decisions will be directly affected by generating high quality research evidence.
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Affiliation(s)
| | - Kourosh R Ahmadi
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | | | | | - Heidi Seage
- School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | | | - Nicola Ward
- Leicester School of Pharmacy, De Montfort University, Leicester, UK
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12
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Sobczyńska-Malefora A, Delvin E, McCaddon A, Ahmadi KR, Harrington DJ. Vitamin B 12 status in health and disease: a critical review. Diagnosis of deficiency and insufficiency - clinical and laboratory pitfalls. Crit Rev Clin Lab Sci 2021; 58:399-429. [PMID: 33881359 DOI: 10.1080/10408363.2021.1885339] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vitamin B12 (cobalamin) is an essential cofactor for two metabolic pathways. It is obtained principally from food of animal origin. Cobalamin becomes bioavailable through a series of steps pertaining to its release from dietary protein, intrinsic factor-mediated absorption, haptocorrin or transcobalamin-mediated transport, cellular uptake, and two enzymatic conversions (via methionine synthase and methylmalonyl-CoA-mutase) into cofactor forms: methylcobalamin and adenosylcobalamin. Vitamin B12 deficiency can masquerade as a multitude of illnesses, presenting different perspectives from the point of view of the hematologist, neurologist, gastroenterologist, general physician, or dietician. Increased physician vigilance and heightened patient awareness often account for its early presentation, and testing sometimes occurs during a phase of vitamin B12 insufficiency before the main onset of the disease. The chosen test often depends on its availability rather than on the diagnostic performance and sensitivity to irrelevant factors interfering with vitamin B12 markers. Although serum B12 is still the most commonly used and widely available test, diagnostics by holotranscobalamin, serum methylmalonic acid, and plasma homocysteine measurements have grown in the last several years in routine practice. The lack of a robust absorption test, coupled with compromised sensitivity and specificity of other tests (intrinsic factor and gastric parietal cell antibodies), hinders determination of the cause for depleted B12 status. This can lead to incorrect supplementation regimes and uncertainty regarding later treatment. This review discusses currently available knowledge on vitamin B12, informs the reader about the pitfalls of tests for assessing its deficiency, reviews B12 status in various populations at different disease stages, and provides recommendations for interpretation, treatment, and associated risks. Future directions for diagnostics of B12 status and health interventions are also discussed.
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Affiliation(s)
- Agata Sobczyńska-Malefora
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Edgard Delvin
- Sainte-Justine UHC Research Centre, Montreal, Canada.,Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, Canada
| | | | - Kourosh R Ahmadi
- Department of Nutrition & Metabolism, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Dominic J Harrington
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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13
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Morrison T, Bösch F, Landolt MA, Kožich V, Huemer M, Morris AAM. Homocystinuria patient and caregiver survey: experiences of diagnosis and patient satisfaction. Orphanet J Rare Dis 2021; 16:124. [PMID: 33691747 PMCID: PMC7945666 DOI: 10.1186/s13023-021-01764-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background The main genetic causes of homocystinuria are cystathionine beta-synthase (CBS) deficiency and the remethylation defects. Many patients present in childhood but milder forms may present later in life. Some countries have newborn screening programs for the homocystinurias but these do not detect all patients.
Results HCU Network Australia is one of the very few support groups for patients with homocystinurias. Here we report the results of its survey of 143 patients and caregivers from 22 countries, evaluating current diagnostic pathways and management for the homocystinurias. Most (110) of the responses related to patients with CBS deficiency. The diagnosis was made by newborn screening in 20% of patients and in 50% of the others within 1 year of the initial symptom but in 12.5% it took over 15 years. The delay was attributed mainly to ignorance of the disease. Physicians need to learn to measure homocysteine concentrations in children with neurodevelopmental problems, and in patients with heterogeneous symptoms such as thromboembolism, dislocation of the optic lens, haemolytic uraemic syndrome, and psychiatric disease. Even when the diagnosis is made, the way it is communicated is sometimes poor. Early-onset CBS deficiency usually requires a low-protein diet with amino acid supplements. More than a third of the participants reported problems with the availability or cost of treatment. Only half of the patients always took their amino acid mixture. In contrast, good adherence to the protein restriction was reported in 98% but 80% said it was hard, time-consuming and caused unhappiness. Conclusions There is often a long delay in diagnosing the homocystinurias unless this is achieved by newborn screening; this survey also highlights problems with the availability and cost of treatment and the palatability of protein substitutes.
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Affiliation(s)
- T Morrison
- HCU Network Australia, Baulkham Hills, Australia
| | - F Bösch
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - M A Landolt
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland.,Department of Psychosomatics and Psychiatry and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - V Kožich
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine, General University Hospital, Prague, Czech Republic
| | - M Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland. .,Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria.
| | - A A M Morris
- Division of Evolution and Genomic Sciences, Institute of Human Development, University of Manchester, Manchester, UK.,Willink Metabolic Unit, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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14
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Seage CH, Semedo L. How Do Patients Receiving Prescribed B 12 Injections for the Treatment of PA Perceive Changes in Treatment During the COVID-19 Pandemic? A UK-Based Survey Study. J Patient Exp 2021; 8:2374373521998842. [PMID: 34179404 PMCID: PMC8205392 DOI: 10.1177/2374373521998842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pernicious anemia (PA) is a chronic condition that is usually treated using B12 injections. Due to the pandemic, many patients were prescribed an alternative oral B12 treatment. There is limited evidence that this is effective at managing symptoms of PA. The aim of this study was to document treatment changes across the United Kingdom and the impact on patient experience. An online survey explored how the treatment of PA has been managed during the early stages of the pandemic; responses were analyzed for a subsample of participants receiving prescribed B12 injections and where changes in treatment applied (n = 329) using content analysis. The most common reported change was the suspension of injections, with oral B12 being offered as an alternative treatment. Patients were concerned about the long-term impact that changes would have on their condition management, and many stated that they were dissatisfied with the level of care received. Those who were supported by health care providers to continue their usual treatment reported experiencing improved health and well-being. This study highlights the major impact of treatment changes on patient health outcomes and the need to further support health care professionals with PA management during and beyond the pandemic.
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Affiliation(s)
- Catherine Heidi Seage
- Department of Applied Psychology, Cardiff Metropolitan University, Cardiff School of Sport and Health Sciences, Cardiff, United Kingdom
| | - Lenira Semedo
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
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15
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McCaddon A, Regland B. COVID-19: A methyl-group assault? Med Hypotheses 2021; 149:110543. [PMID: 33657459 PMCID: PMC7890339 DOI: 10.1016/j.mehy.2021.110543] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/28/2021] [Accepted: 02/14/2021] [Indexed: 12/22/2022]
Abstract
The socio-economic implications of COVID-19 are devastating. Considerable morbidity is attributed to ‘long-COVID’ – an increasingly recognized complication of infection. Its diverse symptoms are reminiscent of vitamin B12 deficiency, a condition in which methylation status is compromised. We suggest why SARS-CoV-2 infection likely leads to increased methyl-group requirements and other disturbances of one-carbon metabolism. We propose these might explain the varied symptoms of long-COVID. Our suggested mechanism might also apply to similar conditions such as myalgic encephalomyelitis/chronic fatigue syndrome. The hypothesis is evaluable by detailed determination of vitamin B12 and folate status, including serum formate as well as homocysteine and methylmalonic acid, and correlation with viral and host RNA methylation and symptomatology. If confirmed, methyl-group support should prove beneficial in such individuals.
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Affiliation(s)
- Andrew McCaddon
- Gardden Road Surgery, Rhosllanerchrugog Wrexham, LL14 2EN, UK.
| | - Björn Regland
- Institute of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden.
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16
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Tyler N, Giles S, Daker-White G, McManus BC, Panagioti M. A patient and public involvement workshop using visual art and priority setting to provide patients with a voice to describe quality and safety concerns: Vitamin B12 deficiency and pernicious anaemia. Health Expect 2020; 24:87-94. [PMID: 33180344 PMCID: PMC7879548 DOI: 10.1111/hex.13152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022] Open
Abstract
Background Patient and public involvement and engagement (PPIE) is recognized as important for improved quality in health service provision and research. Vitamin B12 deficiency is one area where PPIE has potential to benefit patients, as patients often report sub‐optimal care due to diagnostic delay, insufficient treatment and poor relationships with health professionals. Objective In an effort to engage an understudied patient population in health‐care quality and safety discussions, and provide patients with an opportunity to have a voice, contribute to research priorities and express their current quality and safety concerns, we hosted a PPIE workshop. Methods One researcher (with lived experience) facilitated a one day workshop with 12 patients with varied demographics. The workshop had four components (a) one‐to‐one sessions with an artist, (b) quality and safety research/education priority setting, (c) comments on research proposals, and (d) development of a PPIE group for future research. Results All elements of the workshop elicited a number of quality and safety priorities for the group. Priority setting highlighted issues with interpretation of test results, symptom‐based treatment, self‐medication and relationship with primary care health‐care professionals. One of the major safety issues highlighted in the visual art element was feeling ignored, silenced or not listened too by health‐care professionals. Discussion Visual art methods to express experiences of health, and research priority setting tasks achieved the aim of providing patients with an opportunity to have a voice and express concerns about health‐care quality and safety issues. The addition of visual art allowed patients to articulate emotions and impacts on everyday life associated with quality and safety. Patient or public contribution A public contributor was involved in preparation of this manuscript. The event aimed to enable PPIE contribution in future research.
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Affiliation(s)
- Natasha Tyler
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Sally Giles
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Gavin Daker-White
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | | | - Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
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17
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Seage CH, Glover E, Mercer J. Receiving a Diagnosis of Pernicious Anemia: Exploring Experiences of Relationships With Health Professionals. J Patient Exp 2020; 7:766-770. [PMID: 33294613 PMCID: PMC7705842 DOI: 10.1177/2374373519883497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Pernicious anemia (PA) is a chronic condition caused by vitamin B12 deficiency. This is a qualitative study using interpretative phenomenological analysis (IPA), which aimed to explore the patients lived experience of diagnosis and treatment. METHODS Eleven semistructured interviews were conducted in PA patients; these covered participants' diagnostic and treatment journeys, the responses of others to their diagnosis, and the role health professionals have played in their medical care. Interviews were analyzed for recurrent themes using IPA. RESULTS Three superordinate themes were identified: "The struggle to achieve a diagnosis," "The significance of a diagnosis," and "Battling for sufficient treatment." Participants were dissatisfied with their medical care due to diagnostic delay, insufficient treatment, and poor relationships with their health professionals. Many experienced, anticipated, and internalized stigma, which led to a reduced quality of life and withdrawal from the medical profession. DISCUSSION Participants' interactions with their health professionals hindered their adaptation to their condition; this affected their psychological and physical well-being. Increased clinician awareness of stigma in the PA population symptoms and effective patient-centered communication is required.
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Affiliation(s)
- Catherine Heidi Seage
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
| | - Emily Glover
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
| | - Jenny Mercer
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Wales, United Kingdom
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18
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Kamran S, Dilling MK, Parker NA, Alderson J, Tofteland ND, Truong QV. Case Report: Simultaneously diagnosed gastric adenocarcinoma and pernicious anemia - a classic association. F1000Res 2020; 9:604. [PMID: 33214873 PMCID: PMC7656275 DOI: 10.12688/f1000research.24353.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 11/20/2022] Open
Abstract
Primary gastric cancer remains one of the most prevalent malignancies worldwide. Often patients remain asymptomatic until it is detected at an advanced stage with a poor prognosis. Thus, it’s characteristically difficult to initially diagnose until it becomes late stage, at which point prognosis becomes poor. Pernicious anemia is a classic risk factor for the development of primary gastric cancer, but is uncommonly seen in clinical practice. Over time, patients who produce the autoantibodies to intrinsic factor that cause pernicious anemia typically will present initially with clinically significant megaloblastic anemia and peripheral neuropathy. However, patients can also present with more nonspecific signs and symptoms. Thus, clinicians should remain vigilant as circulating anti-intrinsic factor antibodies only worsen the disease over time and increase the risk of developing primary gastric cancer. This report not only presents the rare concurrent diagnosis of pernicious anemia and gastric cancer, but also aims to increase clinical awareness of these two conditions’ classic association because early diagnosis and treatment significantly impacts morbidity and mortality.
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Affiliation(s)
- Syed Kamran
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita, KS, 67214, USA
| | - Mattias K Dilling
- Department of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Kansas City, MO, 64106, USA
| | - Nathaniel A Parker
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita, KS, 67214, USA
| | - Joel Alderson
- Pathology Department, Ascension Via Christi St. Francis Hospital, Wichita, KS, 67214, USA
| | - Nathan D Tofteland
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita, KS, 67214, USA
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19
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Affiliation(s)
- Muhajir Mohamed
- Department of Medicine, Launceston General Hospital, Australia
- University of Tasmania, Launceston Clinical School, Launceston, Australia
| | - Joel Thio
- Department of Medicine, Launceston General Hospital, Australia
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20
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Arendt JFH, Nexo E. Vitamin B12 Therapy in Older Adults and Misconception of Its Inappropriateness. JAMA Intern Med 2019; 179:1605. [PMID: 31682696 DOI: 10.1001/jamainternmed.2019.4899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Ebba Nexo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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21
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Seage CH. Living with Pernicious Anaemia: exploring the link between anticipated stigma and wellbeing. J Psychosom Res 2018; 113:72-73. [PMID: 30190051 DOI: 10.1016/j.jpsychores.2018.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Catherine Heidi Seage
- Cardiff Metropolitan University, Department of Applied Psychology, Cardiff School of Sport and Health Sciences, United Kingdom.
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22
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Elamami AH, Elmehdwi N, Younis EZ, Zwawi H, Elsahli R, Latiwesh OB, Hussain A. Pernicious Anemia Presented with Isolated Nominal Dysphasia in Type Ill Polyglandular Failure Female Patient. Cureus 2018; 10:e3306. [PMID: 30519517 PMCID: PMC6277171 DOI: 10.7759/cureus.3306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Pernicious anemia (also known as Biermer's disease) is an autoimmune atrophic gastritis which predominantly affects the fundus of the stomach. It results in a deficiency of vitamin B12 (cobalamin) as it affects the normal process of absorption in the ileum. The pernicious anemia is characterized by a wide range of hematological and neurological features. Neurological features can present without hematological manifestations. One of the early neurological features of this anemia is nominal dysphasia (word-finding difficulties), which was usually not reported before as an isolated finding. We present a case of pernicious anemia with isolated nominal dysphasia responding dramatically to parenteral vitamin B12 therapy.
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Affiliation(s)
| | | | - Eman Z Younis
- Laboratory Medicine, University of Benghazi, Benghazi, LBY
| | - Hamid Zwawi
- Internal Medicine, University of Benghazi, Benghazi, LBY
| | - Rabha Elsahli
- Internal Medicine, University of Benghazi, Benghazi, LBY
| | - Omar B Latiwesh
- Medical Laboratory, Higher Institute of Medical Professions, Benghazi, LBY
| | - Azhar Hussain
- Medicine, Xavier University School of Medicine, Oranjestad, ABW
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23
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Abstract
The biosynthesis of B12, involving up to 30 different enzyme-mediated steps, only occurs in bacteria. Thus, most eukaryotes require an external source of B12, and yet the vitamin appears to have only two functions in eukaryotes: as a cofactor for the enzymes methionine synthase and methylmalonylCoA mutase. These two functions are crucial for normal health in humans, and in particular, the formation of methionine is essential for providing methyl groups for over 100 methylation processes. Interference with the methionine synthase reaction not only depletes the body of methyl groups but also leads to the accumulation of homocysteine, a risk factor for many diseases. The syndrome pernicious anemia, characterized by lack of intrinsic factor, leads to a severe, sometimes fatal form of B12 deficiency. However, there is no sharp cutoff for B12 deficiency; rather, there is a continuous inverse relationship between serum B12 and a variety of undesirable outcomes, including neural tube defects, stroke, and dementia. The brain is particularly vulnerable; in children, inadequate B12 stunts brain and intellectual development. Suboptimal B12 status (serum B12<300pmol/L) is very common, occurring in 30%-60% of the population, in particular in pregnant women and in less-developed countries. Thus, many tens of millions of people in the world may suffer harm from having a poor B12 status. Public health steps are urgently needed to correct this inadequacy.
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Affiliation(s)
- A David Smith
- Department of Pharmacology, University of Oxford, Oxford, United Kingdom.
| | - Martin J Warren
- School of Biosciences, University of Kent, Canterbury, Kent, United Kingdom
| | - Helga Refsum
- Department of Nutrition, University of Oslo, Oslo, Norway
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24
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An In Vitro Model of Gastric Inflammation and Treatment with Cobalamin. Int J Inflam 2017; 2017:5968618. [PMID: 28676841 PMCID: PMC5476893 DOI: 10.1155/2017/5968618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/26/2017] [Accepted: 05/07/2017] [Indexed: 02/04/2023] Open
Abstract
Pernicious anaemia (PA) is an autoimmune condition where antibodies target intrinsic factor and parietal cells, reducing the patient's ability to absorb cobalamin promoting atrophic gastritis. Treatment guidelines are based on excretion data of hydroxocobalamin from healthy individuals obtained 50 years ago. This manuscript describes the use of phorbol 12-myristate 13-acetate (PMA) to stimulate low grade inflammation in an epithelial colorectal cell line to assess the efficacy of methylcobalamin and hydroxocobalamin. Nitric oxide increased significantly in cells exposed to higher doses of PMA (100 ng/ml, 150 ng/ml, and 200 ng/ml) accompanied by a loss of the characteristic cobblestone morphology with no negative effect on cell activity or viability. A significant reduction in nitric oxide production was associated with the addition of 200 pg/ml hydroxocobalamin, alongside a return to the characteristic cobblestone morphology. This study highlights the use of PMA to promote low grade inflammation in human cell lines to model gastric inflammation associated with autoimmunity; furthermore it raises questions regarding the concentration of cobalamin administered clinically to restore cell functionality, feasibly allowing the patient to receive reduced quantity of the vitamin more regularly, providing the patient with levels which are akin to dietary intake.
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25
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O'Malley P. The Lived Experience of Anemia Without a Cause. Crit Care Nurs Clin North Am 2017; 29:389-396. [PMID: 28778298 DOI: 10.1016/j.cnc.2017.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article explores anemia without an obvious cause from two perspectives: a patient and the evidence. Although evidence is required to drive favorable patient outcomes, the focus on evidence often hides the patient experience during diagnosis and treatment. Knowledge of experience with evidence can provide a deeper perspective for clinical decision making and meet nursing's ethical mandate to relieve suffering. Although one patient experience does not reflect every patient experience, this patient's experience demonstrates how difficult and dark anemia can be.
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Affiliation(s)
- Patricia O'Malley
- Department of Nursing Research, Premier Health, Center of Nursing Excellence, 1 Wyoming Street, Dayton, OH 45409, USA; School of Nursing, Indiana University East, 2325 Chester Boulevard, Richmond, IN 47374, USA.
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