Clinical practice. Vitamin B12 deficiency

Synergistic Benefits of Dietary Strategies in the Management of IBD

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) patients commonly inquire about the role of diet in the onset and management of their disease process. This review sought to assess the impact of the inflammatory bowel diseases on the nutritional state of patients and evaluate the evidence supporting nutritional interventions as therapy.

RECENT FINDINGS

The role of nutrition has evolved from one of deficient nutrient and calorie replacement alone into a proactive therapeutic for treating active inflammatory disease symptoms. The realization that initiating total parenteral nutrition (TPN) in place of oral take could improve disease symptoms provided the first indication that food intake played a causative role in the IBD. The evolution of TPN to enteral nutrition improved tolerance and reduced side effects but clouded the role of oral intake in the pathophysiology of IBD. Advanced understanding of the role of the microbiota in IBD combined with recognition of the influence of nutrients on microbial composition have ushered in a new era of food as therapy. The role of nutrition in IBD has evolved significantly over the past 30-40 years. From complete elimination of oral intake to the carefully curated menu intended to mold the intestinal microbiota to a non-inflammatory milieu has revolutionized the approach to dietary intervention. Additional studies are warranted to optimize dietary intervention strategies.

The Impact of Social Health Insurance on Student Performance: Evidence From an RDD in Peru

The literature on the effects of social health insurance focuses on its stated goals, which are health status and financial protection. In contrast, we examine the effect of the Peruvian program on student performance using a sharp RDD. We use a unique individual-level database built from the merger of household survey data and standardized test scores from a national census. We find that social health insurance has large effects on mathematics and reading comprehension scores. The clearest mechanism is a lower incidence of anemia among children and family members.

Biological properties of vitamin B12

Vitamin B12, cobalamin, is indispensable for humans owing to its participation in two biochemical reactions: the conversion of l-methylmalonyl coenzyme A to succinyl coenzyme A, and the formation of methionine by methylation of homocysteine. Eukaryotes, encompassing plants, fungi, animals and humans, do not synthesise vitamin B12, in contrast to prokaryotes. Humans must consume it in their diet. The most important sources include meat, milk and dairy products, fish, shellfish and eggs. Due to this, vegetarians are at risk to develop a vitamin B12 deficiency and it is recommended that they consume fortified food. Vitamin B12 behaves differently to most vitamins of the B complex in several aspects, e.g. it is more stable, has a very specific mechanism of absorption and is stored in large amounts in the organism. This review summarises all its biological aspects (including its structure and natural sources as well as its stability in food, pharmacokinetics and physiological function) as well as causes, symptoms, diagnosis (with a summary of analytical methods for its measurement), prevention and treatment of its deficiency, and its pharmacological use and potential toxicity.

Reframing Micronutrient Deficiencies for Modern times: A Review

Micronutrient deficiencies are often discounted in as an entity of the past when access to quality nutrition was scarce. However modern-day conditions such as hemodialysis, complex medication interactions, parenteral nutrition, gastrointestinal resections, institutional living, and substance use can place patients at risk. The metabolic demands of critical illness during prolonged hospitalization may provide added stressors. Food insecurity with reliance on inexpensive calorie-rich, nutrient poor diet may lead to deficiency without overt evidence of malnutrition. Moreover, clinical presentation may be subtle and easily attributed to other diagnoses. Increased awareness of current risk factors is essential for detection and treatment.

From Nutrient to Nanocarrier: The Multifaceted Role of Vitamin B12 in Drug Delivery

Vitamin B12 (B12), a crucial water-soluble vitamin, plays an essential role in various cellular functions, including DNA synthesis and cellular metabolism. This review explores recent advancements in B12 delivery systems and their potential applications in drug delivery. The unique absorption pathways of B12, which involve specific binding proteins and receptors, are highlighted, emphasizing the vitamin's protective mechanisms that enhance its bioavailability. The review discusses the intricate multi-protein network involved in B12 metabolism and the implications of B12 deficiency, which can lead to significant health issues, including neurological and hematological disorders. Additionally, the potential of B12 as a drug carrier to improve the pharmacokinetic properties of poorly bioavailable medications is examined. The findings suggest that optimizing B12 delivery could enhance therapeutic outcomes in nanomedicine and other clinical applications.

A Rare Case of Severe Pernicious Anemia with Neuropsychiatric Implications

BACKGROUND Pernicious anemia (PA) is caused by a deficiency in intrinsic factor (IF), which is necessary for vitamin B12 (cobalamin) absorption, resulting in vitamin B12 deficiency and subsequent megaloblastic anemia. Diagnosis of PA relies on the detection of circulating antibodies to IF. In addition to anemia, patients can develop neuropsychiatric conditions, such as subacute combined degeneration of the spinal cord or psychosis. We present the case of a patient with a history of schizophrenia who exhibited unusually severe manifestations of pernicious anemia, including life-threatening anemia, multiple hypersegmented neutrophils, and significantly elevated methylmalonic acid (MMA) levels. CASE REPORT A 51-year-old Hispanic woman with a history of schizophrenia was admitted with severe weakness, shortness of breath, and diarrhea. The hemoglobin (Hb) level was 2.5 g/dL and mean corpuscular volume (MCV) was 133 fL. A diagnosis of pernicious anemia was made by a low vitamin B12 level, high levels of methylmalonic acid (MMA) and homocysteine, and positive IF-blocking antibodies. Her anemia did not improve initially, even after 3 units of blood were transfused. She had no signs of bleeding. It was thought that hemoconcentration due to severe dehydration falsely raised her initial Hb levels, which were corrected by hydration. A peripheral blood smear showed many hypersegmented neutrophils. With parenteral cyanocobalamin therapy, her anemia and schizophrenia symptoms improved. The hypersegmented neutrophils disappeared by 2 weeks. CONCLUSIONS This is an extreme case of pernicious anemia with life-threatening anemia. The hypersegmented neutrophils disappeared in 2 weeks with vitamin B12 therapy. The symptoms of schizophrenia also improved.

Vitamin B12 status and metabolic health in women of reproductive age: Population-based biomarker survey

BACKGROUND AND AIMS

In clinical populations, vitamin B12 deficiency has been associated with adverse metabolic health (e.g., gestational diabetes). Population-level data among women of reproductive age could inform screening and interventions. The objective of this analysis was to examine the prevalence of adverse metabolic characteristics (elevated adiposity and central adiposity, hypertension, elevated glycated hemoglobin [HbA1c]) and associations of vitamin B12 status with metabolic characteristics in women as part of a population-based biomarker survey in Southern India.

METHODS

Participants (n = 980 women 15-40 y; not pregnant or lactating) were assessed for total vitamin B12, holotranscobalamin, methylmalonic acid, homocysteine, and HbA1c. Categorical anthropometry assessments and bioelectrical impedance analysis (e.g., whole body (WF%) and trunk (TF%) fat) were assessed among adults (≥18 y). Linear and binomial regressions were used to examine associations of vitamin B12 status with metabolic characteristics.

RESULTS

Overall, 25 % of participants had HbA1c ≥5.7 % (HbA1c ≥5.7-<6.5 %: 20.0 %; ≥6.5 %: 5.0 %), and 18.6 % had hypertension (Stage 1: 16.4 %; Stage 2: 2.2 %). Among adults, 23.4 % had body mass index of (BMI) 25.0-<30.0 kg/m2, 9.6 % had BMI ≥30.0 kg/m2, 13.4 % had elevated waist circumference (WC; >88.9 cm), and 20.8 % had elevated waist-hip ratio (WHR; ≥0.85 cm). Overall, higher vitamin B12 concentrations were associated with lower BMI and WC. Among adults, higher vitamin B12 concentrations were associated with lower WF% and TF%; and lower prevalence of overweight (BMI ≥25.0 kg/m2) and elevated WC, WHR, and WF%. Similarly, vitamin B12 <148 pmol/L was associated with higher BMI and WC overall and, among adults, higher WF% and TF%, and increased overweight (BMI ≥25.0 kg/m2; prevalence ratio: 1.31; 95 % confidence interval: 1.09-1.58), and elevated WC (>88.9 cm; 1.85 [1.32-2.60]), WHR (≥85.0; 1.38 [1.07-1.78]), WF% (>35 %; 1.29 [1.10-1.51]), and TF% (>35 %; 1.25 [1.06-1.49]).

CONCLUSIONS

The burden of adverse metabolic characteristics was substantial in this population of young, apparently healthy women. Among those with vitamin B12 <148 pmol/L there was increased central adiposity and overweight status. Evaluating vitamin B12 and metabolic outcomes prospectively could inform screening and interventions to improve women's health.

REGISTRATION NUMBER

NCT04048330.

Vitamins and dietary supplements in cancer treatment: is there a need for increased usage?

INTRODUCTION

Vitamins are essential for homeostasis and proper functioning of organisms. These micronutrients prevent tumor onset by functioning as antioxidants and enzymatic cofactors involved in anti-stress and immune responses, modulating epigenetic regulators, and shaping the microbiota composition. Unbalanced diets and sedentary lifestyles contribute to obesity, associated with increasing cancer risk. Cancer patients often exhibit vitamin deficiencies due to chronic inflammation, anticancer therapies, and tumor-induced metabolic changes, leading to malnutrition and cachexia.

AREAS COVERED

This review critically analyzes preclinical and clinical studies, sourced from PubMed and ClinicalTrials.gov databases, that investigate the potential benefits of vitamin supplementation and dietary interventions, such as intermittent fasting and ketogenic diets, in mouse tumor models and cancer patients. This analysis elucidates the limitations of such interventions and suggests optimal dietary strategies to prevent cancer and enhance patients' quality of life and prognosis.

EXPERT OPINION

To date, clinical studies have found no substantial benefit of over-the-counter vitamin supplements and dietary interventions on cancer patients' health and prognosis. To prevent the spread of useless and potentially harmful products by the nutraceutical industry, establishing a regulatory authority is necessary to monitor and ensure product quality and validity before commercialization.

Autoimmune Metaplastic Atrophic Gastritis (AMAG): Regional Demographics and Their Effect on Prevalence

Autoimmune metaplastic atrophic gastritis (AMAG) is a chronic immune-mediated form of gastritis characterized by damage to oxyntic cells, ultimately resulting in both iron deficiency with or without anemia and pernicious anemia. The current dogma is that AMAG is a disease of White Northern European women of advanced age. We, therefore, sought to examine the prevalence of AMAG in biopsies obtained from populations enriched for self-identified Hispanics for cross-comparison against data from previously reported populations enriched for self-identified White, non-Hispanic patients. To that end, we prospectively collected 1708 sequential gastric biopsies performed at the University of Miami Hospitals/Jackson Health Systems clinics from 1692 patients over a 1-year period as well as pertinent clinical parameters. These Florida data were then compared against data previously collected from the Baltimore population, which has far lower numbers of Hispanic patients. Self-identified race and/or ethnicity were used. From these 1692 patients, we identified 79 patients (4.6%) with AMAG. These included 60 women (76%) and 19 men (24%), with a F:M ratio of 3.1:1. Patients had a median age of 60 years (range: 15-83). Self-identified race and/or ethnicity were: 60 (76.0%) Hispanic, 9 (11.4%) Black, 9 (11.4%) White, and 1 Asian (1.2%). The median age at initial presentation was: 51 years (range: 15-83) in Hispanics, 77.2 years (range: 46-74) in Blacks, 59 years (range: 49-79) in Whites, and 58 years in the only Asian patient. The overall demographics of AMAG largely mirrored the Florida population, with an over-representation of Hispanics (Florida inhabitants self-report as 70% Hispanic). The overall 4.6% prevalence of AMAG in the Florida population differed significantly from the 1.1% in Baltimore (p < .00001), a finding that presumably reflects the large Hispanic population. In fact, the prevalence of AMAG is far higher in Hispanic patients. Awareness of these data should increase recognition of AMAG in this population.

Association of Transient Global Amnesia (TGA) With Dietary Intake of Vitamin B12

BACKGROUND

Transient global amnesia (TGA), which is described as short-term amnesia, may be influenced by some dietary components involved in brain function. The aim of the present study was to assess the connection between TGA and dietary intake of vitamin B12.

METHODS

This cross-sectional study was conducted on 258 people with TGA and 520 people without TGA in Sabzevar, Iran. All participants were screened for TGA (ICD-10 code: G45.4). A validated Food Frequency Questionnaire (FFQ) was utilized to estimate the dietary intake of vitamin B12. Different models of logistic regression were used to determine the association between TGA and dietary intake of vitamin B12 after adjusting the confounders.

RESULTS

There was an inverse association between the risk of TGA and the intake of vitamin B12 (OR = 0.94, CI 95%: 0.89-0.99, p = .02, effect size: -0.04). The result did not change after adjustment for age, gender, education, job, and marital status (OR = 0.93, CI 95%: 0.88-0.98, p = .01, effect size: -0.03). The result remained significant after additional adjustments for body mass index (BMI) and physical activity (OR = 0.94, CI 95%: 0.89-0.99, p = .03, effect size: -0.04), and after further adjustments for the underlying diseases, including diabetes, hypertension, and stroke (OR = 0.86, CI 95%: 0.81-0.92, p < .01, effect size: -0.10).

CONCLUSION

Vitamin B12 deficiency may increase the risk of TGA and should be considered as a potential concern for people at risk for TGA. Further studies are needed to validate these findings and to discover the underlying mechanisms of the effects of vitamin B12 on TGA.

Diagnostic yield of laboratory testing in hospitalized older adults with altered mental status

BACKGROUND

Altered mental status (AMS) is a common cause of hospitalization among older adults, with a wide range of potential etiologies. However, the diagnostic and therapeutic yield of routine laboratory testing in such patients is unknown.

METHODS

In a retrospective cohort of inpatient hospital admissions to a large academic medical center from 2017 to 2022 of patients 65 years and older for whom the admitting diagnosis was AMS, we assessed laboratory testing for thyroid stimulating hormone (TSH), syphilis, vitamin B12, folate, vitamin C, vitamin D, zinc, niacin, and thiamine. We calculated the frequency of testing, rate of abnormal results, and rate of follow-up treatment.

RESULTS

Of the 3169 patients, 2312 (73 %) received at least one designated lab, and overall, 12 % of labs were abnormal. Labs varied in frequency of use (0.2 % for niacin-66 % for TSH) and rate of abnormality (0 % for niacin-71 % for zinc). 16 % of abnormal index labs led to a new prescription at discharge. The most common tests - TSH, folate, and B12- were of relatively low diagnostic and therapeutic utility. Tests that were less common-zinc, vitamin D, and vitamin C-were more commonly abnormal. 3.8 % of patients tested for syphilis had abnormal results, and 72 % of patients with an abnormal result received treatment with penicillin during the index hospitalization.

CONCLUSIONS

These analyses suggest that commonly obtained labs in the workup of AMS have varied diagnostic and therapeutic utility. The contribution of observed laboratory abnormalities to a patients' AMS warrants further study to improve the delivery of high-value care.

A long-standing undiagnosed case of vitamin B12 deficiency: a case report

BACKGROUND

Pernicious anemia, an autoimmune disease, presents with gradual, nonspecific symptoms, often leading to delayed diagnosis owing to its overlap with other conditions and variability in laboratory findings, such as neurological symptoms without anemia or macrocytosis.

CASE PRESENTATION

This case describes a 40-year-old Iranian woman with a decade-long history of nonspecific symptoms, including fatigue, widespread musculoskeletal pain, paresthesia, cognitive disturbances, and optic neuritis; misattributed to conditions such as fibromyalgia, hypothyroidism, and autoimmune diseases. Despite annual monitoring for normocytic anemia, her critically low vitamin B12 levels (< 150 pg/mL) and a diagnosis of pernicious anemia were identified only after persistent symptoms prompted further evaluation, revealing atrophic gastritis as the underlying cause. Neurologic improvement with parenteral B12 therapy, alongside management of fibromyalgia, emphasizes the importance of considering vitamin B12 deficiency even in the absence of classic hematologic findings.

CONCLUSION

This case highlights the diagnostic challenges of pernicious anemia, where nonspecific symptoms and overlapping comorbidities obscure diagnosis, underscoring the need for a systematic, multidisciplinary approach and timely recognition of vitamin B12 deficiency to prevent irreversible complications.

Three new tools to diagnose B12 deficiency: eGFR-adjusted methylmalonic acid (MMA100), a bivariate reference area for MMA100 and cobalamin, and a cobalamin deficiency index

Vitamin B12 (s-cobalamin) and methylmalonic acid (s-MMA) are often interpreted together to diagnose cobalamin deficiency, in context with patient symptomatology, which is many cases is unspecific. Today, clinicians assess test results in relation to the univariate reference limits or decision limits. As s-MMA depends on renal function (glomerular filtration rate, GFR), interpretation can be complicated. To ease the interpretation of the two measurements, we propose three new tools: First, we developed a new formula for adjusting s-MMA to an eGFR of 100 mL/min/1.73 m2 (s-MMA100). The formula was s-MMA100 = [(eGFR/100)0.549] × s-MMA. It was derived from the median relationship between s-MMA and estimated GFR (eGFR) in an ambulant patient population of 4342 individuals, where eGFR was calculated according to the EKFC equations. S-MMA100 was not associated with eGFR in a US test population of 6852 individuals. Second, we constructed a combined reference range for s-MMA100 and s-cobalamin from data in a healthy reference population (n = 495 individuals). Third, we proposed a new cobalamin deficiency index, CDI = s-cobalamin/s-MMA100, and studied the effect of different decision limits on the prevalence of positive test results in a patient population. Using the 2.5 percentile of CDI in the reference population as a decision limit gave a prevalence of 5.2% positive test results in the patient population. However, as a gold standard for cobalamin deficiency does not exist, we were unable to study the diagnostic accuracy of the CDI. Therefore, the true diagnostic accuracy of these tools is yet unknown and should be investigated.

Association of low vitamin B12 levels with depressive and schizophrenia spectrum disorders in child and adolescent psychiatric inpatients

Folate and vitamin B12 are associated with neurodevelopment and neurotransmitter synthesis and insufficiencies of these nutrients could be linked to psychiatric disorders in children and adolescents. To assess serum levels of folate and B12 in child and adolescent psychiatric inpatients and examine possible links between these levels and different psychiatric disorders. Child and adolescent psychiatric inpatients admitted in a general hospital during a 3-year period were included for analysis. Folate and B12 levels were measured when the subjects were admitted. Psychiatric diagnoses were made following DSM-5 criteria and grouped into categories. Logistic regression analysis was used to study the effects of socio-demographic variables as well as folate and B12 levels, insufficiencies and deficits as possible predictors of outcome (psychiatric diagnostic category). 729 inpatients (60.6% female, mean age: 15.1 ± 2 years) were included. A total of 42.9% presented insufficient folate levels and 19.4% insufficient B12 levels. Insufficient B12 levels were associated with depressive disorders in the multivariate model (OR = 0.82, p = 0.002) as was female sex (OR = 1.65, p = 0.007). Moreover, low vitamin B12 levels were linked to schizophrenia spectrum disorders (SSD, OR = 0.9982, p = 0.024). In contrast, higher folate (OR = 1.15, p < 0.001) and vitamin B12 levels (1.0024, p = 0.002) as well as female sex (OR = 7.86, p < 0.001) were associated with eating disorders. Insufficient or low B12 levels could help predict depressive and SSD respectively in child and adolescent psychiatric inpatients. Further study could help us better understand the impact of this insufficiency during the neurodevelopmental period and the potential benefits of nutritional interventions.

Roth spots revealing pernicious anemia in a diabetic patient

PurposeTo report a case of pernicious anemia in a patient presenting with white-centered hemorrhages.MethodCase report.ResultsA 64-year-old man with uncontrolled hypertension, insulin-dependent type 2 diabetes, dyslipidemia, and diabetic retinopathy presented with significant bilateral visual acuity reduction. Ophthalmological examination revealed severe diabetic maculopathy, multiple peripapillary Roth spots and hemorrhages. Laboratory tests identified macrocytic anemia with severe vitamin B12 deficiency and an endoscopic biopsy of the gastric fundus led to the diagnosis of pernicious anemia. The patient received blood transfusion, vitamin B12 supplementation and underwent intravitreal anti-VEGF (aflibercept) injections and retinal panphotocoagulation. Over two months, the patient exhibited marked improvement in visual acuity and partial resolution of retinal abnormalities.ConclusionRoth spots are a nonspecific sign that can be found in various pathologies, sometimes severe, such as pernicious anemia. In those cases, adequate vitamin B12 supplementation can resolve the signs and symptoms. Therefore, it is vital to carry out a comprehensive systemic etiological work-up to quickly treat the underlying cause, keeping in mind that multiple pathologies may coexist.

European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Enhanced detection of immune complexed vitamin B12 in human serum by size-exclusion fractionation (SEF): An upgraded tool for reliable diagnosis

BACKGROUND

The elevated concentration of vitamin B12 in blood has important diagnostic implications since it is associated with different pathologies such as liver and kidney diseases and solid tumours. However, the presence of immune complexed forms of this vitamin (Ig-B12), which have no pathological implications, significantly alters its diagnostic utility because of the overestimation of B12 levels. Thus, developing efficient and selective clinical methodologies for separating Ig-B12 complexes in human serum is crucial to ensure accurate diagnosis of elevated B12 levels and avoid artificial "enrichment" of medically insignificant vitamin forms.

RESULTS

In this work, we present a new method based on the miniaturisation of the size-exclusion chromatography (SEC) gold-standard technique, capable of easily separating the Ig-B12 complexes from non-complexed vitamins (free-B12). A compact system of size-exclusion fractionation (SEF) columns has been designed, developed and tested to separate Ig-B12 and free-B12 resourcefully by rapid gel filtration. These columns are based on centrifugal filtration through a cross-linked dextran Sephadex G-100 resin. The SEF method was validated with sera from 30 patients, showing similar behaviour to the reference SEC technique for Ig-B12 detection (Pearson's coefficient 0.937, 90 % agreement). Furthermore, SEF was superior to polyethylene glycol (PEG) precipitation (Pearson's coefficient 0.769, 80 % agreement), the most utilised and standardised technique in clinical, both in correlation and concordance at a quantitative level.

SIGNIFICANCE

SEF columns allow the rapid and selective separation of Ig-B12 from free vitamin B12. This technique permits mimicking the gold-standard SEC technique but on a smaller scale, both in size and time, making it applicable in any clinical laboratory. The effective quantification of free-B12 allows the unadulterated diagnosis of the vitamin B12 concentration in blood serum.

Multiple Sclerosis and Other Acquired Demyelinating Diseases of the Central Nervous System

Acquired demyelinating diseases of the central nervous system (CNS) comprise inflammatory conditions, including multiple sclerosis (MS) and related diseases, as well as noninflammatory conditions caused by toxic, metabolic, infectious, traumatic, and neurodegenerative insults. Here, we review the spectrum of diseases producing acquired CNS demyelination before focusing on the prototypical example of MS, exploring the pathologic mechanisms leading to myelin injury in relapsing and progressive MS and summarizing the mechanisms and modulators of remyelination. We highlight the complex interplay between the immune system, oligodendrocytes and oligodendrocyte progenitor cells (OPCs), and other CNS glia cells such as microglia and astrocytes in the pathogenesis and clinical course of MS. Finally, we review emerging therapeutic strategies that exploit our growing understanding of disease mechanisms to limit progression and promote remyelination.

[A case of diagnosed pernicious anemia and subacute combined degeneration of the spinal cord with abnormally elevated serum vitamin B12]

An 86-year-old male patient developed paresthesia in both hands, and six months later, pancytopenia was noted. He was diagnosed with myelodysplastic syndrome following bone marrow aspiration. Despite high serum vitamin B12 level, elevated level of serum homocysteine, positive anti-intrinsic factor antibody, and T2-weighted hyperintense lesions on spinal cord MRI led to a diagnosis of subacute combined degeneration of the spinal cord. Treatment with intramuscular mecobalamin injections improved the pancytopenia and resolved the MRI lesions. The pancytopenia in this patient was considered to be caused by pernicious anemia. The presence of anti-intrinsic factor antibody can cause falsely normal or elevated serum vitamin B12 levels. When patients with pancytopenia report numbness, even without a decrease in serum vitamin B12 levels, pernicious anemia and subacute combined degeneration of the spinal cord should be suspected, and measurements of serum homocysteine and anti-intrinsic factor antibodies should be considered.

A Noncatalytic Cysteine Residue Modulates Cobalamin Reactivity in the Human B12 Processing Enzyme CblC

Human CblC catalyzes the indispensable processing of dietary vitamin B12 by the removal of its β-axial ligand and an either one- or two-electron reduction of its cobalt center to yield cob(II)alamin and cob(I)alamin, respectively. Human CblC possesses five cysteine residues of an unknown function. We hypothesized that Cys149, conserved in mammals, tunes the CblC reactivity. To test this, we recreated an evolutionary early variant of CblC, namely, Cys149Ser, as well as Cys149Ala. Surprisingly, substitution of Cys149 for serine or alanine led to faster observed rates of glutathione-driven dealkylation of MeCbl compared to wild-type CblC. The reaction yielded aquacobalamin and stoichiometric formation of S-methylglutathione as the demethylation products. Determination of end-point oxidized glutathione revealed significantly uncoupled electron transfer in both mutants compared with the wild type. Long incubation times revealed the conversion of aquacobalamin to cob(II)alamin in the presence of oxygen in mutants Cys149Ser and Cys149Ala but not in wild-type CblC, all without an effect on dealkylation rates. This finding is reminiscent of the catalytic behavior of CblC from Caenorhabditis elegans, wherein Cys149 is naturally substituted by Ser, and the reaction mechanism differs from that of human CblC precisely by the unusual stabilization of cob(II)alamin in the presence of oxygen. Thus, Cys149 tunes the catalytic activity of human CblC by minimizing uncoupled electron transfer that forms GSSG. This occurs at the expense of a slower observed rate constant for the demethylation of MeCbl. This adjustment is compatible with diminished needs for intracellular turnover of cobalamins and with life under increased oxygen concentration.

A sustainable mixed diet for children without compromising nutritional needs: The vitamin B12 issue

Global climate change requires a paradigm change in diets, especially in affluent countries, with a reduction of animal-based food, including children. This will have direct consequences for Vitamin B12 supply as animal-based foods are the only food source. We examined these potential consequences using the German food based dietary guidelines for infants, children, and adults in Germany as the basis for the model calculation. The guidelines for 4 representative age groups were examined, representing exclusive milk feeding (2 months), complementary feeding (8 months), and mixed family diet (children: 4-6 years, adolescents: 11-14 years). For each age group (except 2 months), the contribution of animal-based food groups (milk/dairy, meat, fish, eggs) to the total daily intake of vitamin B12 was calculated based on 7-day menus with recipes for all meals. This allowed us to assess the potential Vitamin B12 deficits due to food group exclusion. Even in the guidelines diets, including exclusive breastfeeding, the vitamin B12 intakes just reached the reference values in all age groups. In infants on complementary feeding and also later in children and adolescents, cow's milk was by far the most important source of vitamin B12. Among the other animal-based foods, meat (16.9%-23.0%) ranked first, followed by fish (11.0%-16.5%), and eggs (8.1%). In our analysis of the German food-based guidelines for infant, child, and adolescent diets, the increased planetary health due to reduction of milk intake turned out severely to compromise vitamin B12 intake. In children, a reduction in the consumption of animal foods to improve the health of the planet must be weighed against the risk of inadequate intake of individual nutrients.

Vitamin B12 Deficiency in Pernicious Anemia: A Hemolytic Anemia Mimic

Vitamin B12 deficiency can lead to a wide range of clinical symptoms and may resemble hemolytic anemia due to ineffective red blood cell production and hemolysis occurring within the bone marrow. Identifying this deficiency as a possible cause of hemolysis is essential to prevent misdiagnosis, especially when distinguishing it from thrombotic microangiopathy. We present a case involving a 60-year-old woman with a history of hypertension and type 2 diabetes who came in with symptoms of generalized weakness, dizziness, nausea, and abdominal pain. Laboratory tests showed pancytopenia, macrocytosis, and signs of hemolysis. Further investigation confirmed a severe vitamin B12 deficiency linked to pernicious anemia. After starting weekly intramuscular cyanocobalamin injections for the first month and then switching to monthly injections for four months post-discharge, her blood parameters showed significant improvement. This underlines the vital role of timely diagnosis and following established treatment protocols. This case emphasizes the importance of considering vitamin B12 deficiency as a reversible cause of hemolysis. It highlights the need to differentiate it from more serious hematologic disorders such as thrombotic microangiopathy to ensure proper management.

Effects of a Novel Dispersible Supplement Containing 2500 IU of Vitamin D and 1000 µg of B12 in Restoring Vitamin D and B12 Insufficiency: A Multicenter, Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Vitamins D and B12 play a crucial role in maintaining bone health, immune function, and neurological integrity. Combined deficiencies in these vitamins can lead to severe health consequences. Current treatment approaches, such as dietary changes and single-vitamin supplementation, often fail to address these deficiencies comprehensively. This study evaluates the effectiveness of concurrent vitamin D and B12 supplementation to correct these insufficiencies.

METHODS

A prospective, multicenter, randomized controlled trial was conducted in Greece from October 2024 to December 2024. Participants aged 20 to 80 years, with insufficient levels of 25-hydroxyvitamin D (serum < 20 ng/mL) and B12 (serum < 250 ng/L), were eligible for inclusion.

RESULTS

A total of 124 patients were randomized into three groups: one receiving vitamins B12 and D in a single supplement (2500 IU + 1000 mcg), one receiving separate doses of each vitamin (2000 IU + 1000 mcg), and a control group receiving no supplementation. The results demonstrated a significant increase in B12 and 25-hydroxyvitamin D levels among the supplemented groups. Particularly, participants in the combined supplementation group showed higher average serum levels of both vitamins. By the end of this study, 37.1% of those in the combined supplement group achieved adequate vitamin levels, compared to 29.4% in the separate supplementation group.

CONCLUSIONS

In conclusion, combined supplementation may improve patient adherence and compliance, leading to better health outcomes for individuals with combined vitamins D and B12 deficiencies.

Vitamin Bs as Potent Anticancer Agents through MMP-2/9 Regulation

In recent years, the role of coenzymes, particularly those from the vitamin B group in modulating the activity of metalloenzymes has garnered significant attention in cancer treatment strategies. Metalloenzymes play pivotal roles in various cellular processes, including DNA repair, cell signaling, and metabolism, making them promising targets for cancer therapy. This review explores the complex interplay between coenzymes, specifically vitamin Bs, and metalloenzymes in cancer pathogenesis and treatment. Vitamins are an indispensable part of daily life, essential for optimal health and well-being. Beyond their recognized roles as essential nutrients, vitamins have increasingly garnered attention for their multifaceted functions within the machinery of cellular processes. In particular, vitamin Bs have emerged as a pivotal regulator within this intricate network, exerting profound effects on the functionality of metalloenzymes. Their ability to modulate metalloenzymes involved in crucial cellular pathways implicated in cancer progression presents a compelling avenue for therapeutic intervention. Key findings indicate that vitamin Bs can influence the activity and expression of metalloenzymes, thereby affecting processes such as DNA repair and cell signaling, which are critical in cancer development and progression. Understanding the mechanisms by which these coenzymes regulate metalloenzymes holds great promise for developing novel anticancer strategies. This review summarizes current knowledge on the interactions between vitamin Bs and metalloenzymes, highlighting their potential as anticancer agents and paving the way for innovative, cell-targeted cancer treatments.

Effect of inulin on structural, physicochemical, and in vitro gastrointestinal tract release properties of core-shell hydrogel beads as a delivery system for vitamin B12

In this study, core-shell hydrogel beads were developed as a controlled-release delivery system for vitamin B12. Vitamin B12-loaded microgels (MG) were prepared using gellan gum (GG). Core-shell hydrogel beads were produced by incorporating MG into pea protein isolate (PPI) and sodium alginate (AL) matrix filled/coated with different concentrations (0 %, 1 %, 3 %, 5 %, and 10 %) of inulin (IN). Based on XRD analysis, MG was successfully incorporated into core-shell hydrogel beads. In FE-SEM and FT-IR analyses, the smoother surface and denser structure of the beads were observed as IN concentration increased due to hydrogen bonds between IN and the beads. The encapsulation efficiency increased from 68.64 % to 82.36 % as IN concentration increased from 0 % to 10 %, respectively. After exposure to simulated oral and gastric conditions, core-shell hydrogel beads exhibited a lower cumulative release than MG, and a more sustained release was observed as IN concentration increased in simulated intestinal conditions.

Subacute combined degeneration from nitrous oxide abuse

Nitrous oxide is an anesthetic medication which can also be recreationally abused in the form of whippet canisters. Its prolonged abuse can interfere with Vitamin B12 metabolism and lead to its functional deficiency. We report a case of a 30-year-old male who presented with generalized weakness and was found to have subacute combined degeneration (SCD) of the spinal cord. His laboratory workup showed low Vitamin B12 with elevated homocysteine and methylmalonic Co-A levels, and further questioning revealed prolonged nitrous oxide abuse. Nitrous oxide causes functional inactivation of methylcobalamin by rendering it unable to function as a coenzyme for methionine synthase enzyme. This leads to the decreased production of methionine and subsequent production of myelin. This case describes nitrous oxide abuse as an important etiology to be considered in patients presenting with weakness and myeloneuropathy and describes important imaging findings.

Current Perspectives in Pre- and Diabetic Peripheral Neuropathy Diagnosis and Management: An Expert Statement for the Gulf Region

Peripheral neuropathy (PN) significantly impacts the quality of life, causing substantial morbidity and increased mortality, as well as escalating healthcare costs. While PN can have various causes, the most common form, diabetic peripheral neuropathy, poses considerable risks for potential complications. Diabetic peripheral neuropathy (DPN) affects over 50% of people with prediabetes and diabetes. Despite its prevalence, a global gap in diagnosis and management exists, exacerbated by the COVID-19 pandemic. This expert consensus was formulated through a comprehensive evaluation by a panel of experts, informed by a focused literature review, aiming to establish a clinically robust approach to diagnosing and managing pre- and diabetic PN with the early utilization of neurotropic B vitamins. This document offers a consensus perspective on the existing challenges in diagnosing and managing PN, focusing on DPN. The expert panel proposes measures to address this underdiagnosed burden, highlighting the importance of early intervention through innovative screening methods, integrated care approaches, and therapeutic strategies. The document advocates for increased awareness, targeted campaigns, and proactive care strategies to bridge gaps in the patient care of individuals with diabetes, emphasizing the importance of early detection and timely management to improve overall health outcomes. Specific recommendations include incorporating simplified questionnaires and innovative screening methods into routine care, prioritizing neurotropic B vitamin supplementation, optimizing glucagon-like peptide 1 (GLP-1) receptor agonist treatments, and adopting a holistic approach to neuropathy management. The consensus underscores the urgent need to address the underdiagnosis and undertreatment of PN, offering practical measures to enhance early detection and improve health outcomes for individuals with DPN.

From OCD Symptoms to Sleep Disorders: The Crucial Role of Vitamin B12

Objective

Vitamin B12 is crucial for neurological functions and linked to various psychiatric disorders. Given its importance, this study explores the impact of vitamin B12 deficiency on sleep quality in Obsessive-Compulsive Disorder (OCD) patients, while also examining folate and homocysteine levels to explore their potential interactions with OCD symptoms and sleep quality.

Methods

This cross-sectional study included 52 patients with OCD and 42 healthy controls. Serum levels of vitamin B12, homocysteine, and folate were measured. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Pittsburgh Sleep Quality Index (PSQI) were used to evaluate the severity of OCD symptoms and the quality of sleep, respectively. Correlations and mediating effects between these variables were also assessed.

Results

Vitamin B12 levels were significantly lower in OCD patients compared to healthy controls, and scores for sleep disturbances were significantly higher in the OCD group. No significant differences were observed in the levels of folate and homocysteine between the groups. Correlation analysis indicated that lower levels of vitamin B12 were significantly associated with more severe OCD symptoms and poorer sleep quality. Further mediation analysis suggested that low levels of vitamin B12 partially mediated the relationship between OCD symptoms and sleep disturbances.

Conclusion

Lower levels of vitamin B12 not only affect sleep quality but also partially mediate the impact of OCD symptoms on sleep disturbances. Future clinical attention to vitamin B12 deficiency is crucial for further assessing the relationship between OCD symptoms and sleep disorders.

Association between homocysteine levels and mortality in CVD: a cohort study based on NHANES database

BACKGROUND

Cardiovascular disease (CVD) is a major global health concern with increasing incident cases and deaths. Homocysteine (Hcy) has been investigated for its potential association with CVD, researchers have debated the extent to which Hcy should be considered a risk factor for cardiovascular diseases, as only 50% of CVD can be explained by classical risk factors.

METHODS

We conducted a prospective cohort study using NHANES 1999-2006 data, analyzing 1,739 US patients aged at least 30 with CVD. Cox proportional hazards regression and restricted cubic splines were used to examine the relationship between Hcy levels and mortality, adjusting for covariates.

RESULT

A total of 1,739 participants with cardiovascular disease (CVD) were enrolled, with a median follow-up period of 126 months. Among them, 1,194 participants died, including 501 deaths due to cardiovascular causes. After adjusting for covariates, the hazard ratios (HR) and 95% confidence intervals (CI) for CVD mortality at different levels of homocysteine (Hcy) (T1 (< 9.3), T2 (9.3-12.5), T3 (> 12.5)) were 1.26 (0.92, 1.73) (T2), and 1.69 (1.14, 2.51) (T3) (P for trend = 0.0086). The HR and 95% CI for all-cause mortality at different levels of Hcy were 1.22 (1.05, 1.42) (T2) and 1.64 (1.29, 2.09) (T3) (P for trend < 0.0001). Elevated Hcy levels were associated with increased risks of all-cause mortality and CVD deaths, even at levels below the conventional threshold. The nonlinear relationship was observed, with inflection points at 14.5 µmol/L for all-cause mortality and 14.6 µmol/L for CVD mortality. Subgroup analyses revealed interactions with age, serum vitamin B12, and smoking.

CONCLUSION

Our study supports the notion that elevated Hcy levels are associated with higher all-cause and CVD mortality risks in CVD participants. The impact of Hcy on health outcomes can be observed at lower concentrations than previously thought.

Micronutrient Consumption Among Postpartum Women and Food Insecurity

This study aimed to assess the prevalence of inadequate micronutrient intake and its risk factors among women one year after giving birth. 240 women of reproductive age were assessed. Micronutrient intake was assessed from two 24-hour records at three stages (3-6-12 months after childbirth). A generalized linear mixed-effect model was used to assess the factors associated with food intake. A prevalence of inadequate micronutrient intake was observed, with the exception of iron. Intake was lower among food-insecure women (zinc: β -0.13; iron: β -0.09; vitamin C: β -0.44). The postpartum period and food insecurity remained statistically associated with lower food consumption in the explanatory models tested.

Correlation Between Nitrous Oxide and Functional Vitamin B12 Deficiency Resulting in Subacute Combined Degeneration of the Spinal Cord: A Case Report

Nitrous oxide (N2O) is generally used in the medical and food industries. However, it is sometimes illegally misused by young adults as a recreational drug. In either of these uses, functional vitamin B12 deficiency results in neurological implications, such as peripheral neuropathy and subacute combined degeneration (SACD). Here, we report a case of N2O-induced SACD, in which a diagnosis of functional B12 deficiency was made based on borderline normal serum vitamin B12 levels with elevated metabolites (methylmalonic acid and homocysteine). In this case, treatment with intramuscular (IM) vitamin B12 led to significant clinical improvement.

Practical supplements for prevention and management of migraine attacks: a narrative review

Background

Migraine is one of the most debilitating neurological disorders that causes frequent attacks of headaches and affects approximately 11% of the global population. Deficient or even insufficient levels of vital nutrients would increase the severity and frequency of migraine attacks. Therefore, we aimed to examine the practical supplements for the prevention and management of migraine attacks.

Method

This narrative review study was conducted by searching PubMed, ISI web of science, EMBASE, Google Scholar, and Scopus using the keywords of "dietary supplement" and "migraine" plus their MeSH terms. Original articles published in English language from their inception to July 27th, 2024, studies that investigated adult population (aged >18 years), and those assessing the impact of intended nutrient supplementation on clinical symptoms of migraine were included in the study.

Result

Oxidative stress and low intake of antioxidants would be risk factors for migraine attacks by inducing inflammation. The secretion of inflammatory cytokines, such as tumor necrosis factor (TNF)-a, would lead to neuroinflammation and migraine episodes by increasing the cellular permeability and interactions. Evidence also indicated a direct association between phases of migraine attacks and calcitonin gene-related peptide (CGRP), mitochondrial disorders, monoaminergic pathway, disruption in brain energy metabolism, and higher serum levels of glutamate and homocysteine. Therefore, supplementation with nutrients involved in mitochondrial function, brain energy metabolism, and even methyl donors would relieve migraine attacks.

Conclusion

Evidence indicated that supplementation with riboflavin, omega-3 fatty acids, alpha lipoic acid, magnesium, probiotics, coenzyme Q10, ginger, and caffeine would have favorable effects on migraine patients. However, more prospective studies are required to evaluate the effect of other nutrients on migraine patients.

Serine Hydroxymethyltransferase 2 Deficiency in the Hematopoietic System Disrupts Erythropoiesis and Induces Anemia in Murine Models

Serine and folate metabolism play critical roles in erythroid development in both embryonic and adult mice; however, the precise roles of these metabolic pathways in erythropoiesis and the pathophysiology of anemia remain inadequately characterized in the literature. To delineate the contributions of serine and folate metabolism to erythroid differentiation, we focused on serine hydroxymethyltransferase 2 (SHMT2), a key regulatory enzyme within these metabolic pathways. Using gene-editing techniques, we created fetal and adult mouse models with targeted deletion of Shmt2 in the hematopoietic system. Our findings demonstrated that the deletion of Shmt2 within the hematopoietic system led to the distinctive anemia phenotype in both fetal and adult mice. Detailed progression analysis of anemia revealed that Shmt2 deletion exerts stage-specific effects on the development and maturation of erythroid cells. Specifically, Shmt2 deficiency promoted erythroid differentiation in the R2 (CD71+ Ter119-) cell population residing in the bone marrow while concurrently inhibiting the proliferation and erythroid differentiation of the R3 (CD71+ Ter119+) cell population. This disruption resulted in developmental arrest at the R3 stage, significantly contributing to the anemia phenotype observed in the models. This study elucidates the critical role of Shmt2 in erythroid development within the hematopoietic system, highlighting the underlying mechanisms of erythroid developmental arrest associated with Shmt2 loss.

Assessment of vitamin B12 and homocysteine levels in pregnant women admitted for delivery and cord blood samples of their newborn babies: a multicenter study

BACKGROUND

Vitamin B12, an indispensable micronutrient, is pivotal in numerous physiological processes, with particular significance during pregnancy and fetal development. The increasing adoption of vegetarian diets and the economic challenges associated with accessing animal-based food sources contribute to the prevalence of vitamin B12 deficiency. This study aims to examine the levels of vitamin B12 and homocysteine in pregnant women upon admission for delivery and to analyze corresponding cord blood samples from their newborn infants in a substantial sample within the Istanbul metropolitan area.

MATERIALS AND METHODS

This cross-sectional multicenter study included women aged ≥16 years admitted for delivery and their newborns ≥34 weeks. The demographic data and the results of complete blood counts within the previous 24 hours before birth were recorded. Vitamin B12 and homocysteine levels were measured in maternal and cord blood samples. The study parameters were compared between the groups based on the mothers' and babies' homocysteine and vitamin B12 levels.

RESULTS

The study included 832 pregnant women and 832 neonates. Anemia affected 36% of pregnant women, with a higher frequency in mothers with vitamin B12 deficiency. Seventy-eight mothers and 48.9% of neonates showed Vitamin B12 levels below 200 pg/mL, while elevated homocysteine levels were observed in 30% of mothers and 26% of neonates. Maternal vitamin B12 deficiency was significantly correlated with cord blood B12 deficiency and elevated homocysteine. The median cord blood vitamin B12 level was inversely correlated with the number of previous pregnancies.

CONCLUSION

Vitamin B12 deficiency is extremely common in pregnant women before delivery, significantly correlating to cord blood homocysteine and vitamin B12 levels. However, homocysteine alone is not a reliable marker for maternal vitamin B12 status. Implementing strategies to detect vitamin B12 deficiency and supplying adequate vitamin B12 supplementation during pregnancy holds the potential to enhance maternal and neonatal health in Türkiye.

Vitamin B12 status in hospitalised cancer patients: Prevalence and clinical implications of depletion and hypervitaminosis

BACKGROUND & AIMS

The prevalence and clinical significance of vitamin B12 alterations in patients with cancer are poorly understood. We aimed to assess the prevalence and risk factors of vitamin B12 depletion or hypervitaminosis in patients with cancer.

METHODS

We retrospectively included hospitalised patients with cancer in 2017-2022. Plasma B12 levels were stratified as very low (VL, <200 pg/ml), low (L, 200-299 pg/ml), normal (N, 300-812 pg/ml), or high (H, ≥813 pg/ml). We collected demographic and several clinical data (e.g., comorbidities, nutritional status, ECOG-PS, cancer site and stage). Univariate and multivariate analyses for factors associated to the vitamin B12 status were fitted.

RESULTS

788 patients (F/M ratio 1.05, median age 72 years, [25th, 75th percentiles 62, 78 years]) were included. Vitamin B12 was VL in 14.1%, L in 19.4%, N in 49.4%, and H in 17.1% cases. Vitamin B12 distribution increased significantly as function of ECOG-PS levels. Patients with breast cancer were characterized by the highest median B12 value, while colorectal cancer patients by the lowest. Vitamin B12 was also significantly higher in advanced compared to early-stage patients as well as in those who had liver failure. Multivariate analysis showed that the probability of H vs. VL B12 levels was significantly increased in patients with hypoproteinemia, hypo-prealbuminemia, and ECOG-PS≥2, and decreased in those with colorectal and gastric cancer.

CONCLUSION

Vitamin B12 impairment is common in cancer patients. Increased vitamin B12 is associated with an impaired clinical status, while vitamin B12 depletion is more common in early-stage cancer and in elderly patients.

Low concentration of serum vitamin B12 may be a strong predictor of large-artery atherosclerosis stroke: A case-control study

INTRODUCTION

Identifying controllable risk factors for large-artery atherosclerosis (LAA) stroke is crucial due to its significant role as a leading cause of ischemic stroke. We aimed to validate the correlation of serum vitamin B12 with LAA stroke.

METHODS

Inpatients with LAA stroke and healthy controls were retrospectively collected for a case-control study from January 2020 to May 2022. Serum vitamin B12 concentration and other blood indicators, demographic, lifestyle factors and comorbidities were investigated. Logistic regression analysis was used to identify the correlation of serum vitamin B12 concentrations with LAA stroke, meanwhile adjusted for confounding factors.

RESULTS

Patients with LAA stroke had significantly lower serum vitamin B12 concentrations in comparison to those of controls. In the fully adjusted model, vitamin B12 (per 1 interquartile range increase, odds ratio [OR] = 0.84, 95 % confidence interval [CI]: 0.77-0.91), vitamin B12 < 200 pg/mL (OR=7.70, 95 %CI: 2.19-27.03) and vitamin B12 < 300 pg/mL (OR=4.19, 95 %CI: 1.82-9.66) were independently factors for LAA stroke. Furthermore, the optimal cut-off values for vitamin B12 to predict LAA stroke were 305.25 pg/mL (area under the curve [AUC] = 0.71) when unadjusted and 308.25 pg/mL when adjusted for age and sex (AUC=0.68). Lower vitamin B12 concentrations were significantly associated with male sex, smoking, older age, higher neutrophil count, higher creatinine, lower folate and higher total homocysteine.

CONCLUSION

Results indicate that low concentration of serum vitamin B12 may be a strong predictor for the risk of LAA stroke.

MTHFR polymorphisms and vitamin B12 deficiency: correlation between mthfr polymorphisms and clinical and laboratory findings

Vitamin B12 deficiency is a common condition that causes a variety of disorders ranging from the development of megaloblastic anemia to the building up of neurological damage. Historically one of the leading causes of B12 deficiency appears to be secondary to malabsorption in part caused by the development of atrophic gastritis in pernicious anemia. More recently B12 deficiency could also depend on dietary restrictions. Cobalamin deficiency also appears to be closely related to folate metabolism, causing a reduction in methionine synthase activity. This results in the accumulation of 5-methyltetrahydrofolate (5-MTHF) and defective DNA synthesis. It has been hypothesized that reduced activity of the enzyme methylene-tetrahydrofolate reductase (MTHFR) could reduce the production of 5-MTHF, thereby shifting folate metabolism to thymidylate synthesis and promoting proper DNA synthesis. Our aim was to investigate the role of the C677T and A1298C MTHFR gene polymorphisms, which are associated with reduced enzyme activity, in predisposing to the development of anemia, neurological symptoms, and atrophic gastritis in a population of 105 consecutive Italian patients with cobalamin deficiency. We found statistically significant correlations between the degree of anemia and thrombocytopenia and the C677T MTHFR polymorphism, while hemoglobin levels alone significantly correlated with A1298C polymorphism, contradicting the potential protective role of these polymorphisms. Furthermore, in patients with atrophic gastritis, we found an association between the absence of parietal cell antibodies and the presence of the C677T polymorphism in homozygosity. Our results suggest a role for MTHFR enzyme activity in the severity of hematologic manifestations of vitamin B12 deficiency and as an independent mechanism of predisposition to the development of atrophic gastritis.

Assessment and management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation: clinical practice points from the Pediatric Renal Nutrition Taskforce

Children with chronic kidney disease (CKD) are at risk for vitamin deficiency or excess. Vitamin status can be affected by diet, supplements, kidney function, medications, and dialysis. Little is known about vitamin requirements in CKD, leading to practice variation.The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric kidney dietitians and pediatric nephrologists, was established to develop evidence-based clinical practice points (CPPs) to address challenges and to serve as a resource for nutritional care. Questions were formulated using PICO (Patient, Intervention, Comparator, Outcomes), and literature searches undertaken to explore clinical practice from assessment to management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation (CKD2-5D&T). The CPPs were developed and finalized using a Delphi consensus approach. We present six CPPs for vitamin management for children with CKD2-5D&T. We address assessment, intervention, and monitoring. We recommend avoiding supplementation of vitamin A and suggest water-soluble vitamin supplementation for those on dialysis. In the absence of evidence, a consistent structured approach to vitamin management that considers assessment and monitoring from dietary, physical, and biochemical viewpoints is needed. Careful consideration of the impact of accumulation, losses, comorbidities, and medications needs to be explored for the individual child and vitamin before supplementation can be considered. When supplementing, care needs to be taken not to over-prescribe. Research recommendations are suggested.

Taurine/chenodeoxycholic acid ratio as a potential serum biomarker for low vitamin B12 levels in humans

Deficiency of vitamin B12 (B12 or cobalamin), an essential water-soluble vitamin, leads to neurological damage, which can be irreversible and anaemia, and is sometimes associated with chronic disorders such as osteoporosis and cardiovascular diseases. Clinical tests to detect B12 deficiency lack specificity and sensitivity. Delays in detecting B12 deficiency pose a major threat because the progressive decline in organ functions may go unnoticed until the damage is advanced or irreversible. Here, using targeted unbiased metabolomic profiling in the sera of subjects with low B12 levels v control individuals, we set out to identify biomarker(s) of B12 insufficiency. Metabolomic profiling identified seventy-seven metabolites, and partial least squares discriminant analysis and hierarchical clustering analysis showed a differential abundance of taurine, xanthine, hypoxanthine, chenodeoxycholic acid, neopterin and glycocholic acid in subjects with low B12 levels. Random forest multivariate analysis identified a taurine/chenodeoxycholic acid ratio, with an AUC score of 1, to be the best biomarker to predict low B12 levels. Mechanistic studies using a mouse model of B12 deficiency showed that B12 deficiency reshaped the transcriptomic and metabolomic landscape of the cell, identifying a downregulation of methionine, taurine, urea cycle and nucleotide metabolism and an upregulation of Krebs cycle. Thus, we propose taurine/chenodeoxycholic acid ratio in serum as a potential biomarker of low B12 levels in humans and elucidate using a mouse model of cellular metabolic pathways regulated by B12 deficiency.

Enhancing Differential Diagnosis Related to Oxidative Stress, Nitrous Oxide, and Nutrition by Rapid Plasma Homocysteine Measurement

BACKGROUND

Historically used as a marker for inherited disorders, the current interest in plasma homocysteine measurement lies in its ability to provide valuable information about the metabolic and nutritional status of patients. Specifically, nitrous oxide (N2O) abuse can lead to functional vitamin B12 deficiency by oxidation and increase oxidative stress, resulting in elevated plasma homocysteine levels, which mimic neurological conditions such as Guillain-Barré syndrome. Rapid identification of hyperhomocysteinemia is crucial for timely intervention and avoiding costly, unnecessary treatments.

OBJECTIVE

This study evaluates the performance of a rapid immunoassay technique (Snibe) compared to mass spectrometry (LC-MS/MS) for measuring plasma homocysteine levels in patients with nitrous oxide abuse and non-inherited caused of elevated homocysteine, aiming to enhance differential diagnosis related to oxidative stress.

METHODS

235 patients from Lille University Hospital were included. EDTA blood samples were collected and analyzed using both rapid immunoassay (Snibe) and LC-MS/MS. Neurological assessment was performed using the peripheral neuropathy disability (PND) score.

RESULTS

Firstly, significant elevations in plasma homocysteine levels were observed in patients abusing nitrous oxide measured by LC-MS/MS. Secondly, the immunoassay provided rapid results, essential for early clinical decision-making, but tended to underestimate high values compared to LC-MS/MS. A good correlation was found between the methods for low and moderate values.

CONCLUSION

The immunoassay tended to underestimate high-value samples compared to LC-MS/MS, which is a common problem with the competitive methodology. The rapid immunoassay technique is effective for initial screening and early intervention, aiding in the differential diagnosis of conditions related to oxidative stress. Therefore, it is recommended to use the CLIA method for initial screening and confirm with mass spectrometry if there are abnormal samples. Integrating both techniques can enhance diagnostic accuracy and improve patient outcomes.

Cobalamin Intake in North Indians by Food Frequency Questionnaire (COIN-FFQ) - A Development and Validation Study

Background

Vitamin B12 deficiency is widely prevalent in all age groups which is of major concern. However, there is no valid Food Frequency Questionnaire (FFQ) for dietary vitamin B12 estimation. Hence, we aimed to develop and validate an FFQ for the estimation of dietary intake of Vitamin B12.

Materials and Methods

Commonly consumed B12-rich food items were selected from literature and filtered using a market survey. For concordant and discriminant validation, B12 and homocysteine levels were estimated. To establish convergent validity, the Cobalamin Intake in North Indians by Food Frequency Questionnaire (COIN-FFQ) and 72-hour dietary recall (72HrDR) were both administered to the same subjects. The COIN-FFQ was readministered after initial administration for test-retest reliability. Internal consistency of the FFQ was then tested using Cronbach's alpha.

Results

We enrolled 115 adults with a mean age and weight of 31.9 ± 8.7 years and 66.0 ± 11.8 kg, respectively. In total, 19.1% were vegetarian. The dietary B12 using COIN-FFQ (n = 60; mean = 4.3 ± 1.8 µg/d) was significantly correlated (r = 0.255; P = 0.049) with serum levels (mean = 120.1 ± 62.6 pmol/L) establishing concordant validity. A significant difference was noted between the dietary, serum B12, and homocysteine levels of vegetarians versus nonvegetarians establishing discriminant validity (mean diff 1.4 (0.5-2.4), P = 0.004; Z-statistic -2.182, P value 0.029, and Z-statistic -2.438; P value 0.015), respectively. FFQ was strongly correlated with 72HrDR and test-retest FFQ (n = 27; r = 0.814, P < 0.001 and r = 0.869, P < 0.001, respectively) establishing convergent validity and test-retest reliability. The internal consistency with Cronbach's alpha was in the acceptable range, 0.631 (n = 115).

Conclusion

The newly developed COIN-FFQ is valid and reliable in estimating dietary B12 intake.

Impact of laboratory involvement in the characterization of B12 hypervitaminosis in clinical practice

Objectives

Unexplained B12 hypervitaminosis (HB12) in asymptomatic patients leads to a cascade of medical consultations and diagnostic tests aimed at determining its etiology. The objective of this study was to assess the efficacy of the laboratory getting involved in the detection and elimination of immune complexes with vitamin B12 in clinical practice and its economic impact.

Methods

A retrospective longitudinal study was undertaken to assess the laboratory strategy of detecting B12 macrovitamin (macro-B12) in patients with HB12 >1,000 pg/mL. The clinical characteristics of patients with HB12 referred to Internal Medicine (IM) in the pre- and post-implantation period of the new strategy were compared. Additionally, the healthcare costs of one-year follow-up were estimated.

Results

The prevalences of HB12 in the pre- and post-implantation period were 3.9 % and 3 %, respectively. Macro-B12 explained 25 % of the HB12 cases initially detected. A 41 % reduction was observed in the number of patients with HB12 after the implantation of the new strategy, thereby resulting in a cost reduction of 5,000 €.

Conclusions

The laboratory intervention for the detection of macro-B12 provides clear economic and clinical benefits in clinical practice.

Impacto de la intervención del laboratorio en la caracterización de la hipervitaminosis B12 en la práctica asistencial

Objectivos

El hallazgo de hipervitaminosis B12 (HB12) no justificado en pacientes asintomáticos desencadena consultas médicas y pruebas diagnósticas, a fin de determinar la etiología. Nuestro objetivo fue probar la eficacia de la intervención del laboratorio en la detección y eliminación de inmunocomplejos con vitamina B12 en la práctica clínica, así como su impacto económico.

Métodos

Es un estudio retrospectivo y longitudinal diseñado para evaluar la estrategia del laboratorio para detectar macrovitamina B12 (macro-B12) en aquellos pacientes con HB12 mayor a 1.000 pg/mL. Se compararon las características clínicas de los pacientes con HB12 derivados a las consultas de Medicina Interna (MI) en el año anterior y posterior a la implantación de la estrategia y se calcularon los costes asistenciales generados en el año de seguimiento de los pacientes.

Resultados

La prevalencia de HB12 en el periodo previo y posterior a la implantación fue del 3,9 % y 3 %, respectivamente. La macro-B12 fue responsable del 25 % de la HB12 iniciales detectadas. El número de pacientes con HB12 derivados a las consultas de MI se redujo en el 41 % tras la implantación, traduciéndose en un ahorro de más de 5.000€.

Conclusiones

La intervención del laboratorio de detección de macro-B12 tiene un claro beneficio asistencial y económico en la práctica clínica.

Diminished representation of vitamin-B12-producing bacteria in constipated elders with frailty

Constipation and frailty are associated with intestinal dysbiosis. This study aims to identify intestinal microbial signatures that can differentiate between constipated elders accompanied by frailty and those without frailty. We collected stool samples from 61 participants and conducted 16S rRNA gene sequencing. Constipated patients with frailty (Constipation_F) exhibited reduced gut microbial diversities compared to constipated patients without frailty (Constipation_NF) and healthy individuals (C). From differential genera, random forest models identified 14, 8, and 5 biomarkers for distinguishing Constipation_F from Constipation_NF, Constipation_F from C, and Constipation_NF from C, respectively. Functional analysis revealed that pathways (P381-PWY and PWY-5507) related to vitamin B12 synthesis were reduced in Constipation_F, which aligns with the decreased abundances of vitamin-B12-producing Actinomyces and Akkermansia in this group. Our study unveils substantial differences in gut microbiota between constipated elders with frailty and those without, underscoring the diagnostic and therapeutic potential of genera involved in vitamin B12 synthesis.

Diagnosis and management of anemia in pediatric inflammatory bowel diseases: Clinical practice guidelines on behalf of the SIGENP IBD Working group

Anemia is one of the most frequent extra-intestinal manifestations of inflammatory bowel disease. Insidious onset, variability of symptoms and lack of standardized screening practices may increase the risk of underestimating its burden in children with IBD. Despite its relevance and peculiarity in everyday clinical practice, this topic is only dealt with in a few documents specifically for the pediatric field. The aim of the current guidelines is therefore to provide pediatric gastroenterologists with a practical update to support the clinical and therapeutic management of children with IBD and anemia. A panel of 19 pediatric gastroenterologists and 1 pediatric hematologist with experience in the field of pediatric IBD was agreed by IBD Working group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) to produce the present article outlining practical clinical approaches to the pediatric patient with IBD and anemia. The levels of evidence and recommendations have been defined for each part of the statement according to the GRADE system.

Nitrous oxide-induced myeloneuropathy in a Thai adolescent: a case report

Nitrous oxide, an inhalational anaesthetic, is popular with adolescents worldwide as an accessible recreational drug which induces a euphoric effect. However, chronic abuse leads to serious complications such as myeloneuropathy and bone marrow suppression by inactivation of vitamin B12. A 17-year-old girl presented with nitrous oxide-induced myeloneuropathy. She reported chronic nitrous oxide inhalation for 10 months and was admitted to the emergency department on account of repeated falls for 2 weeks. She also had ascending paraesthesia in both legs and urinary incontinence. Neurological examination demonstrated bilateral lower extremity weakness [motor power: proximal muscles 4/5, plantar flexion and extensor hallucis longus (EHL) 3/5], decreased sensation, proprioception and vibration of the lower extremities. Deep tendon reflexes were absent in the ankles and knees. Laboratory results demonstrated mild anaemia [Hb 11.2 g/dL (12.0-16.0), haematocrit 35.4% (36-50), MCV 89.4 fl (78-102)] with significant hypersegmented neutrophils in a peripheral blood smear. Serum vitamin B12 was 340 pg/mL (197-771), but serum homocysteine was increased at 65.8 µmol/L (5-15). A nerve conduction study was prolonged, and F-waves were absent from the bilateral perineal and tibial nerves, indicating diffuse demyelinating motor polyneuropathy. Magnetic resonance imaging of the whole spine demonstrated faint T2 hypersignal intensity and an inverted V-shape appearance at the posterior column of the upper thoracic cord (around T2-T6), a pathognomonic sign of vitamin B12 deficiency or subacute combined degeneration of the nitrous oxide-induced myeloneuropathy. A 7-day course of 1000 µg cyanocobalamin was given intramuscularly, followed by weekly doses for 4 weeks. Supplements of daily oral vitamin B1, B6 and B12 (65 µg vitamin B12) were administered, along with rehabilitation. At the 6-months outpatient follow-up, there were a few residual neurological abnormalities: weakness of the left EHL (grade 4/5) and an absent deep tendon reflex in the left ankle. This case emphasises the significant health consequences of chronic abuse of nitrous oxide, myeloneuropathy and megaloblastic anaemia, by inactivation of vitamin B12. The myelopathy is noticeably improved by cyanocobalamin.Abbreviations: EHL: extensor hallucis longus; MRI: magnetic resonance imaging; NCS: nerve conduction study.

Vitamin B12 Metabolism: A Network of Multi-Protein Mediated Processes

The water-soluble vitamin, vitamin B12, also known as cobalamin, plays a crucial role in cellular metabolism, particularly in DNA synthesis, methylation, and mitochondrial functionality. Its deficiency can lead to hematological and neurological disorders; however, the manifestation of these clinical outcomes is relatively late. It leads to difficulties in the early diagnosis of vitamin B12 deficiency. A prolonged lack of vitamin B12 may have severe consequences including increased morbidity to neurological and cardiovascular diseases. Beyond inadequate dietary intake, vitamin B12 deficiency might be caused by insufficient bioavailability, blood transport disruptions, or impaired cellular uptake and metabolism. Despite nearly 70 years of knowledge since the isolation and characterization of this vitamin, there are still gaps in understanding its metabolic pathways. Thus, this review aims to compile current knowledge about the crucial proteins necessary to efficiently accumulate and process vitamin B12 in humans, presenting these systems as a multi-protein network. The epidemiological consequences, diagnosis, and treatment of vitamin B12 deficiency are also highlighted. We also discuss clinical warnings of vitamin B12 deficiency based on the ongoing test of specific moonlighting proteins engaged in vitamin B12 metabolic pathways.

Exploring Gut–Brain Interaction Disorders: Mechanisms and Translational Therapies Crossing Neurology to Gastroenterology

The bidirectional communication network between the gut and the brain, known as the gut–brain axis, plays a crucial role in health and disease. This review explores the mechanisms underlying gut–brain interaction disorders and highlights translational therapies bridging neurology and gastroenterology. Mechanisms encompass anatomical, endocrine, humoral, metabolic, and immune pathways, with the gut microbiota exerting profound influence. Clinical evidence links gut microbiota fluctuations to mood disorders, GI disruptions, and neurodevelopmental conditions, emphasizing the microbiome’s pivotal role in shaping brain–gut interactions. Pharmacological therapies such as amitriptyline and selective serotonin reuptake inhibitors modulate neurotransmitter activity, offering relief in functional gastrointestinal disorders like irritable bowel syndrome (IBS). Non-pharmacological interventions like cognitive–behavioral therapy and hypnotherapy address maladaptive thoughts and induce relaxation, alleviating gastrointestinal symptoms exacerbated by stress. Emerging therapies include gut microbiota modulation, dietary interventions, vagus nerve stimulation, and intestinal barrier modulation, offering novel approaches to manage neurological disorders via the gastrointestinal tract. Understanding and harnessing the gut–brain axis holds promise for personalized therapeutic strategies in neurogastroenterology.

Metformin-Induced Vitamin B12 Deficiency in Patients with Type 2 Diabetes: A Narrative Review with a Practical Approach for Screening, Diagnosing, and Managing Vitamin B12 Deficiency

Metformin is the most widely used antihyperglycemic drug in patients with type 2 diabetes (T2D). Over the past 2 decades, several studies have highlighted a substantial increase in the risk of vitamin B12 deficiency in patients with T2D on metformin therapy. This can lead to several complications and induce or exacerbate peripheral neuropathy. Despite these data, there are no definite guidelines for screening, diagnosing, and treating vitamin B12 deficiency in patients with T2D on metformin therapy. Therefore, in this narrative review, we aimed to suggest a practical diagnostic and therapeutic strategy to address vitamin B12 deficiency in patients with T2D receiving metformin treatment. Clinical evidence supporting an increased risk of vitamin B12 deficiency in patients with T2D on metformin therapy and its risk factors and potential complications are also discussed.