Cobalamin deficiency, hyperhomocysteinemia, and dementia

Vitamin B12 status and hyperhomocysteinemia in patients with Rheumatoid arthritis treated with methotrexate and folic acid

BACKGROUND

Rheumatoid arthritis (RA) is an inflammatory arthritis in which the immune system targets synovial joints. Methotrexate serves as the mainstay of treatment for RA due to its efficacy. However, patients treated with methotrexate are uniquely at risk for vitamin B12 deficiency and hyperhomocysteinemia due to coincident disease risk factors and the fact that methotrexate use is associated with malabsorption. The objective of this study was to assess for vitamin B12 deficiency among patients with RA treated with methotrexate and folic acid.

METHODS

This cross-sectional study included 50 patients with RA treated with methotrexate and folic acid and 49 patients with RA treated with other therapies. Patients were matched by age, sex, race, renal function, and disease activity. We compared plasma vitamin B12, methylmalonic acid, and homocysteine levels between these two groups utilizing quantitative and categorical analyses.

RESULTS

Thirty-seven (74%) RA patients on methotrexate and folic acid had elevated plasma homocysteine levels compared with only 27 (55%) RA patients receiving other therapies (P < 0.05). The proportion of patients with low vitamin B12 and high methylmalonic acid levels did not differ between the two groups.

CONCLUSIONS

Our data show high plasma homocysteine levels among RA patients treated with methotrexate and folic acid. While plasma vitamin B12 levels were similar between the two groups, high plasma homocysteine is also a sensitive marker of vitamin B12 deficiency. Additional studies should evaluate for the presence of clinical features of vitamin B12 deficiency and hyperhomocysteinemia among RA patients treated with methotrexate and folic acid.

Proton Pump Inhibitors, Kidney Damage, and Mortality: An Updated Narrative Review

Since their approval by the Food and Drug Administration (FDA) in 1989, proton pump inhibitors (PPIs) have become one of the most highly utilized drugs in the United States, assuming a position as one of the top 10 most prescribed medications in the country. The purpose of PPIs is to limit the amount of gastric acid secreted by the parietal cells via irreversible inhibition of the H+/K+-ATPase pump, therefore maintaining an elevated gastric acid pH of greater than 4 for 15-21 h. Even though PPIs have many clinical uses, they are not without their adverse effects, mimicking achlorhydria. Besides electrolyte abnormalities and vitamin deficiencies, long-term use of PPIs has been linked to acute interstitial nephritis, bone fractures, poor COVID-19 infection outcomes, pneumonia, and possibly an increase in all-cause mortality. The causality between PPI use and increased mortality and disease risk can be questioned since most studies are observational. Confounding variables can greatly affect an observational study and explain the wide-ranging associations with the use of PPIs. Patients on PPIs are generally older, obese, sicker with a higher number of baseline morbidities, and on more medications than the compared PPI non-users. These findings suggest that PPI users are at a higher risk of mortality and complications based on pre-existing conditions. This narrative review aims to update readers on the concerning effects that proton pump inhibitor use can have on patients and give providers a resource to create informed decisions on appropriate PPI use.

Impact of Vitamin B12 Insufficiency on the Incidence of Sarcopenia in Korean Community-Dwelling Older Adults: A Two-Year Longitudinal Study

The longitudinal effect of B12 insufficiency on sarcopenia has not yet been investigated in older adults. We aimed to study the impact of B12 levels on alterations in muscle mass, function and strength over two years. Non-sarcopenic older adults (n = 926) aged 70-84 were included. Using the Korean Frailty and Aging Cohort Study, this two-year longitudinal study used data across South Korea. The tools used for assessing muscle criteria were based on the Asian Working Group for Sarcopenia guidelines. Participants were divided into the insufficiency (initial serum B12 concentration < 350 pg/mL) and sufficiency groups (≥350 pg/mL). Logistic regression analyses were performed to evaluate the effect of initial B12 concentration on sarcopenia parameters over a two-year period. In women, multivariate analysis showed that the B12 insufficiency group had a significantly higher incidence of low SPPB scores (odds ratio [OR] = 3.28, 95% confidence interval [CI] = 1.59-6.76) and sarcopenia (OR = 3.72, 95% CI = 1.10-12.62). However, the B12 insufficiency group did not have a greater incidence of sarcopenia or other parameters in men. Our findings suggest B12 insufficiency negatively impacts physical performance and increases the incidence of sarcopenia only in women.

Beneficial effects of vitamin B12 treatment in pediatric patients diagnosed with vitamin B12 deficiency regarding total-native thiol, oxidative stress, and mononuclear leukocyte DNA damage

Vitamin B₁₂ is involved in biochemical metabolic pathways. B₁₂ deficiency is common in childhood when the need for the vitamin increases and growth and development occur. Various hematological, neurological, psychiatric, and gastrointestinal disorders are observed in its deficiency. In addition, B₁₂ deficiency is associated with oxidative stress and DNA damage. Therefore, the aim of our study is to evaluate oxidative stress, thiol/disulfide homeostasis, and DNA damage pre and post-treatment in children diagnosed with B₁₂ deficiency. A total of 40 children with B₁₂ deficiency were included in the study after the consent form was approved. Blood was drawn from children pre and posttreatment. Hemoglobin (HGB), hematocrit (HCT), and red blood cells (RBC) were measured by autoanalyzer; total antioxidant status (TAS), total oxidant status (TOS), total thiol (TT), and native thiol (NT) were measured by the photometric method, and DNA damage was analyzed by the comet assay method. Oxidative stress index (OSI) and disulfide (DIS) values were calculated. As a result of the experiments, HGB, HCT, and RBC increased with treatment. While TAS, TT, and NT as antioxidant parameters increased; TOS, OSI, and DIS decreased with treatment compared to pretreatment. DNA damage was also found to decrease with treatment. Additionally, these data were statistically significant (p < 0.001). It was found that oxidative stress and DNA damage decreased with oral B₁₂ treatment in children with B₁₂ deficiency, and clinical parameters were also improved.

Neuropsychiatric Disorders Associated With Vitamin B12 Deficiency: An Autobiographical Case Report

Vitamin B12 is an essential vitamin. Among its many functions is its crucial role as a coenzyme in a step of normal synthesis of myelin. Likewise, it is a vital coenzyme in the synthesis of neurotransmitters. Therefore, it is no surprise that vitamin B12 deficiency is linked to a spectrum of neuropsychiatric disorders. Most physicians can quickly pick up typical pernicious anemia, but very few remember the association of vitamin B12 with neuropsychiatric disorders. In this case report, the author presents his own experience of neuropsychiatric disorder (presenting as carpal tunnel syndrome along with anxiety) related to vitamin B12 deficiency with a strong recommendation to include vitamin B12 in the initial set of laboratory investigations suggested for patients over 40 years of age presenting with neuropsychiatric disorders.

Impact of Vitamin B12 Insufficiency on Sarcopenia in Community-Dwelling Older Korean Adults

Vitamin B12 (B12) is involved as a cofactor in the synthesis of myelin. A lack of B12 impairs peripheral nerve production, which can contribute to sarcopenia. In this cross-sectional study, we aimed to investigate the relationship between B12 insufficiency and sarcopenia in community-dwelling older Korean adults. A total of 2325 (1112 men; 1213 women) adults aged 70-84 years were recruited. The tools used for sarcopenia were based on the Asian Working Group for Sarcopenia (AWGS) guidelines. Individuals with low appendicular skeletal muscle mass index (ASMI) (<7.0 kg/m² for men; <5.4 kg/m² for women) and low hand grip strength (HGS) (<28 kg for men; <18 kg for women) were defined as the sarcopenia group. Among this group, those who showed low physical performance (≤9 points on the Short Physical Performance Battery (SPPB)) were defined as the severe sarcopenia group. B12 concentrations were classified into insufficient (<350 pg/mL) and sufficient (≥350 pg/mL). Univariate and multivariate logistic regression analyses were used to evaluate the relationship between sarcopenia and B12 levels. Low ASMI showed a high incidence in the B12-insufficient group. However, HGS, SPPB, and the severity of sarcopenia showed no correlation with B12. Further, insufficient B12 may affect muscle quantity rather than muscle strength or physical performance.

Association between Inflammatory Conditions and Alzheimer's Disease Age of Onset in Down Syndrome

Adults with Down syndrome (DS) have an exceptionally high prevalence of Alzheimer disease (AD), with an earlier age of onset compared with the neurotypical population. In addition to beta amyloid, immunological processes involved in neuroinflammation and in peripheral inflammatory/autoimmune conditions are thought to play important roles in the pathophysiology of AD. Individuals with DS also have a high prevalence of autoimmune/inflammatory conditions which may contribute to an increased risk of early AD onset, but this has not been studied. Given the wide range in the age of AD onset in those with DS, we sought to evaluate the relationship between the presence of inflammatory conditions and the age of AD onset. We performed a retrospective study on 339 adults with DS, 125 who were cognitively stable (CS) and 214 with a diagnosis of AD. Data were available for six autoimmune conditions (alopecia, celiac disease, hypothyroidism, psoriasis, diabetes and vitamin B12 deficiency) and for one inflammatory condition, gout. Gout was associated with a significant delay in the age of AD onset by more than 2.5 years. Our data suggests that inflammatory conditions may play a role in the age of AD onset in DS. Further studies are warranted.

Pernicious anemia: Pathophysiology and diagnostic difficulties

Pernicious anemia (PA) is the most common cause of vitamin B12 (cobalamin) deficiency anemia in the world. It is an autoimmune disease, comprising of salient features of autoimmune chronic atrophic gastritis (CAG) and cobalamin deficiency (CD). Although the anemia was first described as pernicious, it may well be controlled with vitamin B12 replacement. The onset and progression of PA is often insidious. Alternatively, patients may have no anemic symptoms since they become acclimatized to the subtle nature of the disease. Oftentimes, there is a possibility that the underlying disease may be missed unless a full blood count (FBC) is investigated, leading to hindrance in the treatment journey. Diagnostic challenges remain tangible for many practicing clinicians, since there is lack of reliable cobalamin assays to diagnose CD as well as clinical mimics, which simulate many other hematological conditions, such as myelodysplastic syndrome, acute leukemia, sideroblastic anemias, bone marrow failure states, thrombotic microangiopathy, and thromboembolism. Moreover, prompt recognition of the symptoms of CD is also vital, because some neurologic sequalae may become irreversible despite replenishing cobalamin. Herein, we discuss a literature review on the pathophysiology, challenging clinical presentations and diagnostic difficulties of PA. Since the cobalamin replacement therapy for PA is straightforward, it will not be discussed in this review.

Intake of vitamin B12 and other characteristics of women of reproductive age on a vegan diet in Australia

OBJECTIVE

(i) To examine demographic and health characteristics of women of reproductive age on a vegan diet in Australia and compare these to the general population; (ii) to identify sources and intake of vitamin B12 and compare intake to current recommendations and (iii) examine associations between participant characteristics and adequacy of vitamin B12 intake.

DESIGN

In this cross-sectional study, data were collected via an online survey. Demographic and health characteristics of women on a vegan diet were compared with women in the general population (using Australian Bureau of Statistics data). Intake of vitamin B12 was estimated using a FFQ and estimation of supplemental intake.

SETTING

Australia.

PARTICIPANTS

Participants (n 1530) were women aged 18-44 years who had been on a vegan diet for at least 6 months.

RESULTS

While BMI, smoking habits and intakes of fruit and vegetables compared favourably with the general population, 26 % of respondents had estimated intakes of vitamin B12 below recommendations. Analyses of relationships between vitamin B12 intake and participant characteristics revealed that the strongest predictor of intake was supplementation (P < 0·001); however, 25 % had not supplemented with vitamin B12 in the past 3 months.

CONCLUSIONS

The vitamin B12 intakes of a substantial proportion of Australian women of reproductive age consuming a vegan diet do not meet the recommended intake, which could adversely affect their health, and, if they are pregnant or lactating, that of their infants too. There is a need for further research in this area to identify effective strategies to address this situation.

Association between frailty and vitamin B12 in the older Korean population

Frailty is a common geriatric condition due to aging and defined as a decline in strength and a decrease in the physiologic ability to maintain the homeostasis. Vitamin B12 (B12), water-soluble vitamins, are a cofactor in DNA synthesis and involved in the metabolism of every cell in the human body, including the central nervous system. Demyelination neuromuscular symptoms observed in the peripheral nervous system, along with signs of significant damage to nerve fibers, often cause weakness, numbness in distal limbs, impaired balance, gait ataxia, and even physical frailty. In this cross-sectional study, we aimed to investigate the relationship between frailty and B12 level in community-dwelling Korean older adults.Using the data from the Korean Frailty and Aging Cohort Study, 2938 participants (1400 men and 1538 women) were recruited in this study. To evaluate frailty, we compared the frail group and not-frail group based on the modified Korean version of the cardiovascular health study frailty index developed by Fried. SARC-F is used to screen for sarcopenia. The short physical performance battery (SPPB) timed up and go (TUG) test and activities-specific balance confidence scale used to evaluate the physical function and fall risk of participants. B12 concentrations were classified into clinically relevant categories: insufficient (<350 pg/mL) and sufficient (≥350 pg/mL). Linear and logistic regression analyses were used to evaluate the relationship between frailty and B12 levels.The mean age of the frail group was 77.8 (standard deviation = 3.7) years, while that of the not-frail group was 76.7 (SD = 4.0); of which the frail group's mean age was significantly high. In the unadjusted model, frailty was highly prevalent in the B12 insufficient group (odds ratio = 1.298). In the model fully adjusted for demographic data and comorbidities, these associations were attenuated. The B12 sufficiency group showed better total SPPB and TUG test scores. However, they were not statistically significant in the fully adjusted model.In this cross-sectional study, low B12 increased the incidence of frailty and affected physical performance, but it does not increase the incidence of frailty when considering the confounding factors. Frailty is caused by several factors rather than 1 factor, and B12 is one of these factors.

Association between Vitamin B12 levels and cognitive function in the elderly Korean population

Vitamin B12 (B12), also known as cobalamin, is a water-soluble vitamin. It is a cofactor in DNA synthesis and is involved in the metabolism of every cell of the human body, including the central nervous system. Those with a deficiency of B12 can present with peripheral neuropathy, pernicious anemia, or a cognitive disorder. Previous studies have revealed that a deficiency of B12 is associated with cognitive decline or Alzheimer disease.The data of 2991 people were evaluated from 2 years of the Korean Frailty and Aging Cohort Study, a nationwide multicenter survey. To assess cognitive function, a short form of the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD-K) was used. Of the CERAD-K tests, we included the Mini-Mental State Examination in the Korean version of the CERAD assessment packet (MMSE-KC), the word list: memory/recall/recognition, digit span (forward, backward), trail making test-A, and the frontal assessment battery. B12 concentrations were classified into clinically relevant categories, insufficient (<350 pg/mL) and sufficient (≥350 pg/mL). A linear regression analysis was used to evaluate the relationship between cognitive function and B12 levels.The mean age of the 2991 participants was 76.4 ± 3.9 years old. Overall, 414 (13.8%) were classified as B12 insufficient, and 2577 (86.2%) as B12 sufficient. The sufficient B12 group performed better in the MMSE-KC, Wordlist: memory, Wordlist: recognition, TMT-A test, digit span, and FAB tests. This was statistically significant (P < .05). However, in the multivariable linear regression analysis, after adjusting for age, sex, education period, marriage, smoking and drinking habits, and comorbidities, the association between the B12 group and cognitive function was not statistically significant.Although our study does not show that B12 insufficiency is a direct risk factor to cognitive decline, B12 levels could be a contributing factor to cognitive function. Our results suggest that cognition was affected by the B12 levels, along with demographic and sociological variables.

Intake of Meat, Fish, Fruits, and Vegetables and Long-Term Risk of Dementia and Alzheimer's Disease

BACKGROUND

The links between diet and the risk of dementia have never been studied considering the possibility of protopathic bias (i.e., reverse causation).

OBJECTIVE

We aimed to examine the relationship between consumption frequency of meat, fish, fruits, and vegetables and long-term risk of dementia and Alzheimer's disease (AD), by taking into account this possibility.

METHODS

We analyzed data of 5,934 volunteers aged 65 and over from the Three-city study who were followed every 2 to 4 years for 12 years. Dietary habits were assessed at inclusion using a brief food frequency questionnaire. The presence of symptoms of dementia was investigated at each follow-up visit. To limit the risk of protopathic bias, a 4-year lag window between exposure and disease assessment was implemented by excluding from the analyses all dementia cases that occurred during the first four years after inclusion. Analyses were performed using a Cox proportional hazard model and were adjusted for socio-demographic, lifestyle, and health factors.

RESULTS

The average follow-up time was 9.8 years. During this period, 662 cases of dementia, including 466 of AD, were identified. After adjustment, only low meat consumption (≤1 time/week) was associated with an increased risk of dementia and AD compared with regular consumption (≥4 times/week) (HR = 1.58 95% CI = [1.17-2.14], HR = 1.67 95% CI = [1.18-2.37], respectively). No association was found between the consumption of fish, raw fruits, or cooked fruits and vegetables and the risk of dementia or AD.

CONCLUSION

These findings suggest very low meat consumption increases the long-term risk of dementia and AD, and that a protopathic bias could have impacted finding from previous studies.

The relationship between serum cobalamin, folic acid, and homocysteine and the risk of post-cardiac surgery delirium

Purpose: It has been reported that cobalamin and folate deficiency is related to delirium in persons with dementia. We evaluated the association of admission serum levels of cobalamin, folic acid, and homocysteine with the occurrence of acute delirium after coronary artery bypass surgery. Methods: In this prospective cohort study, serum levels of cobalamin, folic acid, and homocysteine were measured for 296 patients upon admission. Delirium was defined by the confusion assessment method for the intensive care unit. Results: Postoperative delirium was detected in 23% (n=68) of patients. Cobalamin deficiency, folate deficiency, and hyperhomocysteinemia were observed in 29% (n=86), 6% (n=18), and 68% (n=200) of patients, respectively. The mean ± SD serum levels of folic acid were 10.77±5.39 ng/mL and 12.86±6.51 ng/mL in delirium and non-delirium patients, respectively (P=0.008). The median (interquartile range [IQR]) serum levels of cobalamin were 280 (216-351) and 247 (195.5-336) in delirium and non-delirium patients, respectively (P=0.09). The median (IQR) serum levels of homocysteine were 18.5 (14.5-22.1) µmol/L and 17.33 (14.2-23.2) µmol/L in delirium and non-delirium patients, respectively (P=0.94). Multivariate regression analysis adjusted by other risk factors indicated that serum homocysteine, folate, and cobalamin levels had no association with the occurrence of delirium. Conclusion: There was no relationship between the preoperative levels of cobalamin, folate, and homocysteine, and acute occurrence of delirium observed after cardiac surgery.

Effect of donepezil on Hcy level in serum of Alzheimer's disease patients and correlation analysis of Hcy and dyssomnia

Effect of donepezil on the homocysteine (Hcy) level in serum of Alzheimer's disease (AD) patients and correlation between Hcy and dyssomnia was investigated. A retrospective analysis of 124 AD patients in Zhengzhou University People's Hospital between January 2015 and October 2017 was performed, including 64 cases in the observation group and 60 cases in the control group. The control group was treated with folic acid, vitamin B12 and memantine hydrochloride tablet, and the observation group combined with donepezil on this basis, and both groups were treated for 4 months. The Hcy level before and after treatment was detected in the groups using ELISA method, dyssomnia score of patients was performed before and after treatment in the observation group according to Pittsburgh Sleep Quality Index (PSQI), and correlation analysis between the Hcy level before and after treatment and dyssomnia was performed in AD patients in the study group using Pearson's correlation analysis. The differences were statistically significant in the Hcy level before and after treatment in both groups (P<0.001). The Hcy level after treatment in the observation group was significantly lower than that in the control group (P<0.001). The dyssomnia score before treatment was higher that after treatment in the observation group (P<0.001). There was a positive correlation between the Hcy level before treatment and dyssomnia score (r=0.658, P<0.001). There was also a positive correlation between the Hcy level after treatment and dyssomnia score (r=0.670, P<0.001). Donepezil can effectively improve the sleep function of patients and reduce the Hcy level in serum in the treatment of AD patients. The application of donepezil was of great significance in the clinical treatment of AD patients.

Vitamin B12

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.

Vitamin B12 among Vegetarians: Status, Assessment and Supplementation

Cobalamin is an essential molecule for humans. It acts as a cofactor in one-carbon transfers through methylation and molecular rearrangement. These functions take place in fatty acid, amino acid and nucleic acid metabolic pathways. The deficiency of vitamin B12 is clinically manifested in the blood and nervous system where the cobalamin plays a key role in cell replication and in fatty acid metabolism. Hypovitaminosis arises from inadequate absorption, from genetic defects that alter transport through the body, or from inadequate intake as a result of diet. With the growing adoption of vegetarian eating styles in Western countries, there is growing focus on whether diets that exclude animal foods are adequate. Since food availability in these countries is not a problem, and therefore plant foods are sufficiently adequate, the most delicate issue remains the contribution of cobalamin, which is poorly represented in plants. In this review, we will discuss the status of vitamin B12 among vegetarians, the diagnostic markers for the detection of cobalamin deficiency and appropriate sources for sufficient intake, through the description of the features and functions of vitamin B12 and its absorption mechanism.

Serum Vitamin B12 and thyroid hormone levels in Saudi patients with multiple sclerosis

Objectives:

To determine the relationship between Vitamin B12 levels and thyroid hormones in patients with multiple sclerosis (MS).

Materials and Methods:

One hundred and ten patients with MS were recruited for this study after Institutional Review Board approval. All patients signed a written informed consent form and donated a single blood sample. Plasma Vitamin B12 levels, triiodothyronine (T3), and thyroxine (T4) hormone levels were measured. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software.

Results:

Analysis of Vitamin B12 levels in 110 patients with MS revealed that 65% had normal levels of Vitamin B12 (200–900 pg/ml), 30% had low levels of Vitamin B12 (<200 pg/ml), and 5% high levels of Vitamin B12 (higher than 900 pg/ml). Further analysis of patients with low levels of Vitamin B12 revealed that this cohort exhibited a significantly high number of patients with low levels of the thyroid hormones triiodothyronine (T3) and thyroxine (T4) (P < 0.005).

Conclusion:

This study suggests a relationship between Vitamin B12 levels and thyroid hormones. This opens the possibility that the use of therapies that increase triiodothyronine (T3) and thyroxine (T4) levels might be beneficial to patients with MS.

Prevalence of Relative Deficiencies in Testosterone and Vitamin B12 Among Patients Referred for Chronic Orchialgia: Implications for Management

Chronic testicular pain (CTP) is a complex pain syndrome that is widely variable in presentation and etiology. Many cases of CTP are thought to be associated with neuropathy and recent data suggest an inflammation-mediated process is more common among patients with CTP. Deficiencies in vitamin B12 and testosterone are common in chronic pain syndromes may play a role in CTP. A retrospective review of men treated for CTP by a single provider over a 2-year period was performed. Patients with serum screening of testosterone and B12 were selected. Patients with total testosterone below 300 ng/dl, free testosterone below 46 pg/ml, or B12 below 400 pg/ml were deemed deficient and offered repletion. Efficacy of treatment was measured based on patient report with a minimum follow-up of either 3 months or resolution of pain symptoms. One hundred and fifty-four (154) men with CTP were identified, with 125 assessed for testosterone and B12 levels. Of these, 95 patients (76%) were deemed deficient. Fifty-six (56) patients elected to receive B12/testosterone replacement. In patients with sufficient follow-up, 24 patients (65%) reported significant improvement of symptoms, 6 patients (16%) reported some improvement, and 7 patients (19%) reported no improvement. The prevalence of testosterone and B12 deficiencies in this study is much higher than that reported for the general population. In addition, when chemical deficiencies were corrected, greater than 80% of patients with sufficient follow-up reported some improvement in pain. This suggests that screening of B12 and testosterone should be incorporated into the assessment of patients with CTP.

Oxidative Stress Markers in Vitamin B12 Deficiency

In this study, we report the status of oxidative stress markers in vitamin B12 deficiency and their relation to clinical, laboratory, and neurophysiological findings. Fifty-one subjects with serum vitamin B12 deficiency (<211 pg/ml) were included. Plasma glutathione (GSH), malondialdehyde (MDA) and serum total antioxidant capacity (TAC) were measured in the patients and 53 controls. These markers were also compared between subacute combined degeneration (SACD) and non-SACD vitamin B12 deficiency patients groups as well as with normal controls. In the patients, GSH, MDA and TAC were correlated with demographic, clinical, hematological, biochemical, nerve conduction study (NCS), visual evoked potential (VEP) and somatosensory-evoked potential (SEP) findings. In the study group, 20 (39.2 %) patients had SACD manifesting with myeloneuropathy, cognitive or behavioral abnormalities, and 31(60.8 %) patients had non-SACD neurological manifestations. The GSH (2.46 ± 0.32 vs. 2.70 ± 0.36 mg/dl; P = 0.002) and TAC (2.13 ± 0.38 vs. 2.33 ± 0.24 nmol Trolox eq/l, P = 0.005) levels were lower, and MDA levels (4.01 ± 0.69 vs. 3.00 ± 0.45 nmol/ml, P < 0.001) were higher in B12 deficiency group compared with controls. Similar trend was found in SACD and non-SACD vitamin B12 deficiency groups. GSH levels correlated with abnormal VEP (r = 0.54; P < 0.01), TAC with female gender (r = 0.43; P = 0.002) and joint position impairment (r = -0.34; P = 0.01), and MDA with LDH (r = 0.41; P = 0.01). Vitamin B12 deficiency was associated with reduction in GSH and TAC and increase in MDA levels which were more marked in SACD compared to non-SACD group.

Assessment of brain cognitive functions in patients with vitamin B12 deficiency using resting state functional MRI: A longitudinal study

INTRODUCTION

The resting state functional MRI (rsfMRI) approach is useful to explore the brain's functional organization in health and disease conditions. In this study, using rsfMRI the alteration in brain due to vitamin B12 deficiency and reversibility of these alterations following therapy was studied.

METHODS

Thirteen patients with clinical and biochemical evidence of vitamin B12 deficiency were recruited in this study. Fifteen age and sex matched healthy controls were also included. Patients and controls were clinically evaluated using neuropsychological test (NPT). The analysis was carried out using regional homogeneity (ReHo) and low frequency oscillations (LFO) of BOLD signals in resting state. Six patients were also evaluated with rsfMRI and NPT after 6 weeks replacement therapy.

RESULTS

ReHo values in patients with vitamin B12 deficiency were significantly lower than controls in the entire cerebrum and the brain networks associated with cognition control, i.e., default mode, cingulo-opercular and fronto-parietal network. There was no significant difference using LFO and it did not show significant correlations with NPT scores. ReHo showed significant correlation with NPT scores. All the 6 patients showed increase in ReHo after replacement therapy.

CONCLUSION

We conclude that brain networks associated with cognition control are altered in patients with vitamin B12 deficiency, which partially recover following six weeks of replacement therapy. This is the first study to evaluate the rsfMRI in the light of clinical neuropsychological evaluation in patients. rsfMRI may be used as functional biomarker to assess therapeutic response in vitamin B12 deficiency patients.

Vitamin D as a marker of cognitive decline in elderly Indian population

Objectives:

Very few studies in India have addressed the role of vitamin D in cognitive function. The present study was conducted to assess the serum levels of 25-hydroxyvitamin D (25(OH)D) and its association with markers of cognitive impairment and homocysteine levels in the elderly Indian population.

Materials and Methods:

The study population consisted of patients with dementia (Group A, n = 32), mild cognitive impairment (MCI; Group B, n = 24), and elderly age-matched controls (Group C, n = 30). Measurement of serum levels of 25(OH)D and total homocysteine were done.

Results:

Significant decreased concentration of 25(OH)D and increased concentration of homocysteine was observed. Association of serum levels of vitamin D with markers of cognitive decline as well as serum homocysteine levels was observed in patients with dementia and MCI when compared to controls.

Conclusion:

Correlation of vitamin D with markers of cognitive decline and homocysteine opens a new door for early diagnosis of cognitive impairment.

Assessment of functional and structural damage in brain parenchyma in patients with vitamin B12 deficiency: A longitudinal perfusion and diffusion tensor imaging study

INTRODUCTION

Vitamin B12 deficiency may cause neural tissue damage. Even in advanced stages, conventional imaging of brain usually appears normal in vitamin B12 deficient patients. The aim of this study was to assess the structural and functional changes in brain of patients with vitamin B12 deficiency before and after six weeks of vitamin B12 supplementation using diffusion tensor imaging and pseudo-continuous arterial spin labelling (PCASL).

METHODS

MR imaging including DTI and PCASL and neuropsychological tests (NPT) were performed in 16 patients with vitamin B12 deficiency and 16 controls before and after 6weeks of therapy. Cerebral blood flow (CBF) derived from PCASL and DTI indices was calculated in brain of patients with vitamin B12 deficiency and controls.

RESULTS

Patient with vitamin B12 deficiency showed altered neuropsychological scores and altered CBF as well as fractional anisotropy (FA) values in various brain regions as compared with controls. Both CBF values and neuropsychological scores showed complete reversibility at 6weeks post therapy. Though FA values showed significant recovery, it failed to show complete recovery.

CONCLUSION

Our results suggest that micro-structural recovery lags behind functional recovery in patients with vitamin B12 deficiency following therapy and CBF change may be used as an early predictor of complete recovery in patients with B12 deficiency.

Relationship between cobalamin deficiency and delirium in elderly patients undergoing cardiac surgery

BACKGROUND

Delirium is common after cardiac surgery and is independently associated with increased morbidity, mortality, prolonged hospital stays, and higher costs. Cobalamin (vitamin B12) deficiency is a common cause of neuropsychiatric symptoms and affects up to 40% of elderly people. The relationship between cobalamin deficiency and the occurrence of delirium after cardiac surgery has not been examined in previous studies. We examined the relationship between cobalamin deficiency and delirium in elderly patients undergoing coronary artery bypass grafting (CABG) surgery.

MATERIAL AND METHODS

A total of 100 patients with cobalamin deficiency undergoing CABG were enrolled in this retrospective study. Control group comprised 100 patients without cobalamin deficiency undergoing CABG. Patients aged 65 years or over were included. Diagnosis of delirium was made using Intensive Care Delirium Screening Checklist. Delirium severity was measured using the Delirium Rating Scale-revised-98.

RESULTS

Patients with cobalamin deficiency had a significantly higher incidence of delirium (42% vs 26%; P=0.017) and higher delirium severity scores (16.5±2.9 vs 15.03±2.48; P=0.034) than patients without cobalamin deficiency. Cobalamin levels were significantly lower in patients with delirium than patients without delirium (P=0.004). Delirium severity score showed a moderate correlation with cobalamin levels (ρ=-0.27; P=0.024). Logistic regression analysis demonstrated that cobalamin deficiency was independently associated with postoperative delirium (OR 1.93, 95% CI 1.03-3.6, P=0.038).

CONCLUSION

The results of our study suggest that cobalamin deficiency may be associated with increased risk of delirium in patients undergoing CABG. In addition, we found that preoperative cobalamin levels were associated with the severity of delirium. This report highlights the importance of investigation for cobalamin deficiency in patients undergoing cardiac surgery, especially in the elderly.

A photochemical method for determining plasma homocysteine with limited sample processing

The photolytic formation of thiyl radicals allows for the selective detection of total homocysteine (tHcy) in plasma after reduction and filtering. The mechanism is based on the reduction of viologens by the α-amino carbon centred radical of Hcy generated by intramolecular hydrogen atom transfer (HAT) of its thiyl radical.

Vitamin B₁₂ status, cognitive decline and dementia: a systematic review of prospective cohort studies

Poor vitamin B₁₂ status may lead to the development of cognitive decline and dementia but there is a large variation in the quality, design of and results reported from these investigations. We have undertaken a systematic review of the evidence for the association between vitamin B₁₂ status and cognitive decline in older adults. A database search of the literature to 2011 was undertaken, using keywords related to vitamin B₁₂ and cognition. All prospective cohort studies assessing the association of serum vitamin B₁₂ or biomarkers were included. Quality assessment and extraction of the data were undertaken by two researchers. The quality assessment tool assigns a positive, neutral or negative rating. Of 3772 published articles, thirty-five cohort studies (n 14 325 subjects) were identified and evaluated. No association between serum vitamin B₁₂ concentrations and cognitive decline or dementia was found. However, four studies that used newer biomarkers of vitamin B₁₂ status (methylmalonic acid and holotranscobalamin (holoTC)) showed associations between poor vitamin B₁₂ status and the increased risk of cognitive decline or dementia diagnosis. In general, the studies were of reasonable quality (twenty-one positive, ten neutral and four negative quality) but of short duration and inadequate subject numbers to determine whether an effect exists. Future studies should be of adequate duration (at least 6 years), recruit subjects from the seventh decade, choose markers of vitamin B₁₂ status with adequate specificity such as holoTC and/or methylmalonic acid and employ standardised neurocognitive assessment tools and not screening tests in order to ascertain any relationship between vitamin B₁₂ status and cognitive decline.

Parkinson disease and Alzheimer disease: environmental risk factors

INTRODUCTION

The purpose of this review is to update and summarise available evidence on environmental risk factors that have been associated with risk of Parkinson disease (PD) or Alzheimer disease (AD) and discuss their potential mechanisms.

DEVELOPMENT

Evidence consistently suggests that a higher risk of PD is associated with pesticides and that a higher risk of AD is associated with pesticides, hypertension and high cholesterol levels in middle age, hyperhomocysteinaemia, smoking, traumatic brain injury and depression. There is weak evidence suggesting that higher risk of PD is associated with high milk consumption in men, high iron intake, chronic anaemia and traumatic brain injury. Weak evidence also suggests that a higher risk of AD is associated with high aluminium intake through drinking water, excessive exposure to electromagnetic fields from electrical grids, DM and hyperinsulinaemia, obesity in middle age, excessive alcohol consumption and chronic anaemia. Evidence consistently suggests that a lower risk of PD is associated with hyperuricaemia, tobacco and coffee use, while a lower risk of AD is associated with moderate alcohol consumption, physical exercise, perimenopausal hormone replacement therapy and good cognitive reserve. Weak evidence suggests that lower risk of PD is associated with increased vitamin E intake, alcohol, tea, NSAIDs, and vigorous physical exercise, and that lower risk of AD is associated with the Mediterranean diet, coffee and habitual NSAID consumption.

CONCLUSIONS

Several environmental factors contribute significantly to risk of PD and AD. Some may already be active in the early stages of life, and some may interact with other genetic factors. Population-based strategies to modify such factors could potentially result in fewer cases of PD or AD.

Diagnosis and management of pernicious anemia

Pernicious anemia is a macrocytic anemia due to cobalamin deficiency, which is the result of intrinsic factor deficiency. Pernicious anemia is associated with atrophic body gastritis, whose diagnostic criteria are based on the histologic evidence of gastric body atrophy associated with hypochlorhydria. Serological markers suggesting the presence of oxyntic mucosa damage are increased levels of fasting gastrin and decreased levels of Pepsinogen I. Without the now obsolete Schilling's test, intrinsic factor deficiency may not be proven, and gastric intrinsic factor output after pentagastric stimulation has been proposed. Intrinsic factor autoantibodies are useful surrogate markers of pernicious anemia. The management of patients with pernicious anemia should focus on the life-long replacement treatment with cobalamin and the monitoring to early diagnose an eventual onset of iron deficiency. Moreover, these patients should be advised about possible gastrointestinal long-term consequences, such as gastric cancer and carcinoids.

Association of long-term proton pump inhibitor therapy with bone fractures and effects on absorption of calcium, vitamin B12, iron, and magnesium

Proton pump inhibitors (PPI) are one of the most widely used classes of drugs. PPIs have a very favorable safety profile, and it is unusual for a patient to stop them because of side effects. However, with increasing numbers of patients chronically taking PPIs for gastroesophageal reflux disease and other common, persistent conditions, the long-term potential adverse effects are receiving increasing attention. An insufficiently studied area receiving much attention is the long-term effect of chronic acid suppression on the absorption of vitamins and nutrients. This increased attention results from the reported potential adverse effect of chronic PPI treatment leading to an increased occurrence of bone fractures. Interest in this area has led to examination of the effects of PPIs on calcium absorption/metabolism and numerous cohort, case-control, and prospective studies of their ability to affect bone density and cause bone fractures. In this article, these studies are systematically examined, as are studies of the effects of chronic PPI use on absorption of VB(12), iron, and magnesium. Studies in each area have led to differing conclusions, but when examined systematically, consistent results of several studies support the conclusion that long-term adverse effects on these processes can have important clinical implications.

Methyl Vitamin B12 but not methylfolate rescues a motor neuron-like cell line from homocysteine-mediated cell death

Homocysteine is an excitatory amino acid implicated in multiple diseases including amyotrophic lateral sclerosis (ALS). Information on the toxicity of homocysteine in motor neurons is limited and few studies have examined how this toxicity can be modulated. In NSC-34D cells (a hybrid cell line derived from motor neuron-neuroblastoma), homocysteine induces apoptotic cell death in the millimolar range with a TC₅₀ (toxic concentration at which 50% of maximal cell death is achieved) of 2.2 mM, confirmed by activation of caspase 3/7. Induction of apoptosis was independent of short-term reactive oxygen species (ROS) generation. Methyl Vitamin B12 (MeCbl) and methyl tetrahydrofolate (MTHF), used clinically to treat elevated homocysteine levels, were tested for their ability to reverse homocysteine-mediated motor neuron cell death. MeCbl in the micromolar range was able to provide neuroprotection (2 h pretreatment prior to homocysteine) and neurorescue (simultaneous exposure with homocysteine) against millimolar homocysteine with an IC₅₀ (concentration at which 50% of maximal cell death is inhibited) of 0.6 μM and 0.4 μM, respectively. In contrast, MTHF (up to 10 μM) had no effect on homocysteine-mediated cell death. MeCbl inhibited caspase 3/7 activation by homocysteine in a time- and dose-dependent manner, whereas MTHF had no effect. We conclude that MeCbl is effective against homocysteine-induced cell death in motor neurons in a ROS-independent manner, via a reduction in caspase activation and apoptosis. MeCbl decreases Hcy induced motor neuron death in vitro in a hybrid cell line derived from motor neuron-neuroblastoma and may play a role in the treatment of late stage ALS where HCy levels are increased in animal models of ALS.