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Vitamin B12 deficiency – time for a rethink?

2 Mar

Traditional view

NHS Choices offers a traditional view of vitamin B12 metabolism and diagnosis and management of vitamin B12 deficiency anaemia.

An up to date review was published recently link

Vitamin B12 deficiency anaemia or folate deficiency anaemia develops when a lack of vitamin B12 or folate causes the body to produce abnormally large red blood cells that cannot function properly.

The main symptoms of vitamin B12 deficiency or folate deficiency anaemia are:

  • tiredness
  • lethargy (lack of energy)

View from special interest group(s)

Conversations with members from Pernicious Anaemia Society and B12 deficiency support group indicate there is more to the cobalamin metabolism story than the traditional view describes.

Recent articles and abstracts scattered through the scientific literature point to a more sinister effect on human biology when there is functional deficiency of B12.

Adenosylcobalamine, the adenosyl form of Vitamin B12, is needed to keep the TCA cycle running smoothly, and many people with B12 deficiency suffer a “dreadful fatigue”. But it’s a complicated process getting B12 into mitochondria, and an awful lot of things can go wrong.

A key to better understanding is awareness of biochemical reactions in which vitamin B12 is a crucial. These include [link]:

  • conversion of odd chain fatty acids (specifically propionate) into succinate
  • conversion of homocysteine into methionine via methyl group donation

Medically Unexplained Symptoms – is this a B12 deficiency syndrome?

This week it was proposed that any patient with medically unexplained symptoms should be referred for CBT. It was estimated this may save the NHS £3 million per year. No mention by the authors of the report to explicitly exclude functional deficiency of vitamin B12 [Advances in Psychiatric Treatment (2009)15: 146-151doi:10.1192/apt.bp.107.004606]

Do not forget magnesium deficiency – it is important to ensure magnesium levels are normal in any patient who is taking high dose proton pump inhibitor especially if also prescribed a diuretic agent.

The neuropsychiatric changes caused by functional B12 deficiency may predate the typical changes seen in the blood by months (perhaps years). These are detailed by MacDonald Holmes [JMD Holmes – British Medical Journal, 1956].

McAlpine (1929) said, ” Mental changes occur not uncommonly in pernicious anaemia. They range from states of depression accompanied by loss of mental energy to definite psychoses…” [McAlpine, D. (1929). Lancet, 2. 643]

When there is doubt about the status of vitamin B12 rather than repeat the test in 6 weeks in “borderline cases” as is the present practice, serum methylmalonic acid levels and serum homocysteine levels should be measured.

Measurement of methylmalonic acid, total homocysteine, or both is useful in making the diagnosis of vitamin B12 deficiency in patients who have not received treatment. The levels of both methylmalonic acid and total homocysteine are markedly elevated in the vast majority (>98%) of patients with clinical B12 deficiency including those who have only neurologic manifestations of deficiency (i.e., no anemia). [Stabler, S NEJM 2013]

Implications for general practice

Clearly there is a need to review how we view vitamin B12 metabolism. Recognition in primary care of functional deficiency of vitamin B12 will require medical curricula to pay better attention to this. Haematology does not have a monopoly on clinical features of vitamin B12. There are too few haematologists and neurologists, at least in the UK to provide clinical opinions when vitamin B12 deficiency is suspected. This leaves it to general practice and family doctors to learn more about the protean manifestations of altered vitamin B12 metabolism.

With performance managed healthcare becoming the norm around the world, it may be time to press for explicit scrutiny of vitamin B12 levels in patients with long term conditions including many in the following systems: gastrointestinal, hepatic, psychiatric, neurological, endocrine, renal, and non-malignant anaemias. Only then might we be certain that a scourge of (modern) society will be beaten.

David Lewis

GP UK

Acknowledgement

I would like to thank @b12unme for educating me about this issue. Any errors and omissions are mine.

TASME #ukmeded Chat

31 Oct

An excellent opportunity to share ideas with #meded enthusiasts

Med Ed Connect

On Thursday 1st November at 9pm TASME will be hosting #UKmeded chat on twitter.

For those that don’t know, TASME (Trainees in the Association for the Study of Medical Education) is a Special Interest Group of ASME (Association for the Study of Medical Education) that aims to support trainee involvement in teaching. More information can be found on the website here.

The broad topic for discussion will be ‘the role of trainees in medical education’ but as well as trainees, we welcome input from a range of healthcare professionals at all levels. Are you a medical student who struggles to get teaching from trainees that are often too busy? Perhaps you are a trainee who is keen to get involved in med ed but doesn’t know to start? Maybe you’re a consultant that thinks trainees lack the experience required to teach effectively.

Some of the questions we’d like to answer…

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What does MobiMOOC 2012 offer me?

8 Sep

The gauntlet has been thrown.  MobiMOOC 2012 starts this weekend.

Two essays have me thinking – “what does MobiMOOC 2012 offer me?”; “why have I signed up for this activity?”

Michael and Rebecca have written well on their hopes and objectives.  So why shouldn’t I do so too?

Why am I signed up for MobiMOOC 2012?

The simple answer is the 2011-2012 annual appraisal concluded with my Appraiser advising I should be more active sharing what I do and know about eLearning technology and resources with my colleagues.

This sounded easy, but how do you go about demonstrating competence in an area which remains poorly defined, at least in medical education.  Yes, I use android tablet and phone. Yes, I use the cloud to share resources with my students and colleagues. However, this seems trivial when reading all about the activities of many of the facilitators and students in this year’s MobiMOOC 2012.

MobiMOOC 2012 notice turned up on Google Plus I thought this is what I think I need to gain sufficient skills, knowledge and understanding to encourage my colleagues and students to explore the education technologies available to improve the effectiveness and efficiency of their continuing professional development.

What does MobiMOOC 2012 offer me?

Well the simple answer for what is offered is contained in the introduction from Inge

There is a wealth of information and applications and contacts.  But this is worth nothing if I do not implement some of the learning points and engage with my colleagues and students to attempt to persuade more to invest some time and effort into using education technology.

So this gets me to the heart of the matter.  How do you overcome the reluctance of peers to embrace new technology to improve patient care?  Actually, is there evidence that eLearning does improve patient outcomes?  How much additional effort is needed to learn the new tools? What sort of investment?  What is the best device? Why are some patient settings so difficult to work with to improve point of care education and decision tools?

There are probably many more questions. And I hope that the discussions over the coming weeks and beyond will help me overcome the pain points which obstruct progress in the uptake of elearning tools in healthcare.

David

Redesigning Long-term Care Finance and Delivery

18 May

Joan Costa-Font, Martin Karlsson, and Bernard van den Berg

Joan Costa-Font is based at the London School of Economics and Political Science.
Martin Karlsson is based at Technische Universita¨t Darmstadt. Bernard van den
Berg is with the University of York.

Introduction
The aging of Western societies together with social changes places the question of how best to finance and deliver long-term care (LTC) services at the forefront of policy debates. The Congressional Budget Office noted that expenditures for nursing homes, home health care and other longterm treatment accounted for 8.5% of all U.S. health care spending (Gleckman, 2010). A projected three-fold increase in real-term LTC expenditures in upcoming decades will be driven largely by the aging of the U.S. population. Long-term care expenditures are one of the greatest risks facing the elderly in the United States (Brown and Finkelstein 2004; 2007), but the market for insuring against these risks is relatively small; only 4% of LTC expenditures are paid for by private insurance policies in the Unites States (Gleckman 2010 ). In Europe, private LTC insurance coverage is marginal, with the exception of France, where barely 1% of the population has subscribed to private insurance (Costa-Font and Courbage 2011).
One of the most striking issues of LTC economic analysis is the question of why the private insurance market for LTC is so miniscule, requiring the elderly to face most of the expenditure risks themselves. Although, consumer demand for LTC insurance is projected to grow in all OECD countries (Costa-Font and Courbage, 2011), the development of public insurance and socially-entrenched social norms of intergenerational care appear to exert a significant influence in the development of this market (Costa-Font, 2010b). Economic analysis can contribute to a better understanding of the factors that influence the demand and supply of LTC, and knowledge of these factors would benefit policy-makers in predicting proposed LTC systems redesigns. A crucial part of LTC market analysis is the influence that informal care availability or supply has on the use of formal LTC services. Progress has been made to analyze this impact in the United States (Van Houtven, Courtney Harold & Norton 2004) and Europe (Bolin et al. 2008). On the other hand, economists have analyzed the impact of policies that affect the availability of publicly-funded formal LTC in Canada (Stabile et al. 2006) and the United States (Orsini 2010), and suggest that changes in formal LTC impact informal care. Stabile et al. (2006) show that increased generosity of publicly-funded home care seems # The Author(s) 2012. Published by Oxford University Press, on behalf of Agricultural and Applied Economics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com. Applied Economic Perspectives and Policy (2012) volume 34, number 2, pp. 215–219. doi:10.1093/aepp/pps024 215 by guest on May 18, 2012 http://aepp.oxfordjournals.org/ Downloaded from to result in better health and is associated with a decrease in informal care-giving, while Orsini (2010) finds a decline in the fraction of elderly living in shared formal living arrangements, that is, living with somebody else, rather than alone or only with the spouse. In this respect it is worth noting that interdependent utility theory can be helpful to better understand the supply of informal care (see for example, Van den Berg et al. 2005).
Limited coverage for LTC expenditures, is explained by highly decentralized and privately-run management of LTC facilities (Costa-Font, 2010a), and an often high reliance on family structures, all having welfare implications for the elderly, for their adult children, and for government expenditures (Costa-Font 2010b). Economic analyses can contribute to a better understanding of these welfare implications and incentives; for instance, McKnight (2006) suggested that introducing tightly-binding average per-client Medicare reimbursement caps ultimately led to an increase in out-of-pocket expenditures for home health care, with the offset concentrated in higher income populations. In analyzing the effects of financial incentives in LTC, specifically prices paid and incentives involved, Van den Berg and Hassink (2008) introduced cash benefits and allowed clients to purchase care themselves. The authors conclude that when cash benefits are introduced in LTC in an attempt to make consumers more conscious about prices, successful results are found when consumers may keep the unspent part of the cash benefit.
Whether the various pieces of work have provided enough evidence to policy-makers to fully analyze the welfare impacts of their reforms is debatable. Although we are not able to fill all the gaps in the literature, this special issue of AEPP aims to contribute to the literature by presenting various case studies on financing, delivery and policy (re-)design.
Both the submitted papers and the featured articles are structured around the three main themes of this special issue: LTC financing, LTC delivery, and redesigning LTC – in other words, policy analysis.

Is it SMART to use Social Media?

11 Mar

Terms behind the letters

There is no clear consensus about what the five or seven keywords mean, or even what they are in any given situation. Typically accepted values are:
Letter Major Term Minor Terms
S Specific Significant, Stretching, Simple
M Measurable Meaningful, Motivational, Manageable
A Attainable Appropriate, Achievable, Agreed, Assignable, Actionable, Ambitious, Aligned, Aspirational, Acceptable, Action-focused
R Relevant Results-oriented, Realistic, Resourced, Resonant
T Timely Time-oriented, Time framed, Timed, Time-based, Timeboxed, Time-bound, Time-Specific, Timetabled, Time limited, Trackable, Tangible
E Evaluate Ethical, Excitable, Enjoyable, Engaging, Ecological
R Reevaluate Rewarded, Reassess, Revisit, Recordable, Rewarding, Reaching

Choosing certain combinations of these labels can cause duplication, such as selecting ‘Attainable’ and ‘Realistic’, or can cause significant overlapping as in combining ‘Appropriate’ and ‘Relevant’ for example. The term ‘Agreed’ is often used in management situations where buy-in from stakeholders is desirable (e.g. appraisal situations).
[edit] Developing SMART goals

Paul J. Meyer describes the characteristics of S.M.A.R.T. goals in Attitude is Everything. Meyer, Paul J (2003). What would you do if you knew you couldn’t fail? Creating S.M.A.R.T. Goals. Attitude Is Everything: If You Want to Succeed Above and Beyond. Meyer Resource Group, Incorporated, The. ISBN 9780898113044

Good question on #hcsmanz made me ponder on the question of why using Twitter and other social media is attractice way to learn and interact with people removed from my immediate local circle of contacts.

The S.M.A.R.T. framework does seem to hold the answer. And I am grateful to the team from #hcsmanz for indentifying this concept here.

I have learned much more from social media interactions in the past 6 months than from other sources of information. And here is why.

The topics which matter are SIGNIFICANT to me. The format is MANAGEABLE and MEANINGFUL. The concepts are ALIGNED (not least because social media does tend to herd like minded people together) and APPROPRIATE for the moment. The sentiments are RESONANT with my own. Twitter chat sessions are TIME-BOUND and TIMETABLED, while many of the ideas are TANGIBLE. The crux of the discussion today is “evaluation”, and it feels to me that most discussions do meet goals for learning for the aforementioned reasons. But there is more to social medial chat too: I find the discussions ENJOYABLE, ENGAGING, and ETHICAL. Finally, after the event, I have discovered that the discussions are RECORDABLE (transcripts often available soon afterwards), and REWARDING because some ideas and suggested actions can be used in my clinical work or interactions with colleagues soon after.

It will be a shame if bureaucrats impose more concrete evaluation on the social media discussions because, in my opinion, the unstructured nature of the social media discussion would lose something precious if the conversation were reduced to measurable outcomes. David Haslam, former RCGP Chief Examiner once stated, that not all that is measurable counts while not all that counts is measurable. It is worth keeping this in mind when thinking about evaluation of social media.

Stranglehold on free speech in academia

30 Aug

http://www.monbiot.com/2011/08/29/the-lairds-of-learning/

Good essay bemoaning the monopoly academic publishing has on information which is often publicly funded.

A Mosaic Activating Mutation in AKT1 Associated with the Proteus Syndrome — NEJM

20 Aug

Via Scoop.itOf human kindness

Original Article from The New England Journal of Medicine — A Mosaic Activating Mutation in AKT1 Associated with the Proteus Syndrome… proof of concept in this landmark study of rare condition of Chromosome 14
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Modelling the efficacy of population-wide preventative measures in preventing CVD (via Twitter Journal Club)

1 Aug

Good article. Pity BMJ/Highwire still broken so cannot read full article online

Anyone who enjoyed the discussion on Rose's Prevention Paradox back in June may find Barton et al's paper in the BMJ this week interesting. The study aimed to model the cost-effectiveness of population-wide risk-reduction strategies in preventing cardiovascular disease (CVD). Currently, CVD costs the NHS around £30bn each year and this study has been devised to inform the Department of Health via NICE. While previous studies have already shown th … Read More

via Twitter Journal Club

Type 2 diabetes and obesity in pregnancy is a daunting duo: New research

27 Jul

Via Scoop.itOf human kindness

Type 2 diabetes and obesity in pregnancy is a daunting duo, according to new research published this month in The Journal of Maternal-Fetal and Neonatal Medicine.
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Truly Bonkers, I’m Starting to Think You’re Truly Bonkers .. Early Warning Signs Your Supervisor is a Loon « The Thesis Whisperer

25 Jul

Truly Bonkers, I’m Starting to Think You’re Truly Bonkers .. Early Warning Signs Your Supervisor is a Loon « The Thesis Whisperer.

A great little essay.  Wish someone had shared something like this with me when I was doing my intercalated BSc.

Illusions of Autonomy

Where medical ethics and human behaviour meet, by Dr Philip Berry

Enjoying every second

Cada lugar, cada rincón, cada momento compartido arreglando el mundo entre imprescindibles

The Commonplace Book

Jim McManus blogs on public health, ethics, books, theology and more

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