POS0279 WEARABLE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION DEMONSTRATED BETTER EFFICACY AND SAFETY THAN WEAK OPIOIDS IN THE TREATMENT OF MODERATE TO SEVERE, CHRONIC NOCICEPTIVE PAIN IN KNEE OSTEOARTHRITIS. A RANDOMIZED, CONTROLLED, NON-INFERIORITY TRIAL

Background:

In knee osteoarthritis (KOA) recommendations, the first pharmacological analgesic line is paracetamol. However, its low efficacy, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients.

Objectives:

The primary objective was to compare analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to those of WO in the treatment of moderate to severe, nociceptive, chronic pain in KOA patients.

Methods:

ArthroTENS study was a phase 3, non-inferiority, multicentric, prospective, randomized, single-blinded for primary efficacy outcome, controlled, in 2-parallel groups, clinical study comparing W-TENS versus WO on two periods: a 3-month controlled period and an additional, optional, non-controlled, 3-month follow-up for patients in W-TENS group.

Eligible participants were KOA patients, ≥55 years old, at Kellgren-Lawrence radiographic grade ≥2, with moderate to severe nociceptive chronic (≥3 months) mean 8-day pain ≥4 on a 11-point numerical rating scale, and in treatment failure with non-opioid analgesics, including NSAIDs. Patients with neuropathic pain were excluded.

Co-primary endpoints were, for efficacy, mean pain intensity (PI), assessed at M3 and, for safety, the number of adverse events (AE) during the 3-month follow-up period.

In W-TENS group, an advanced, mobile app enabled, wearable TENS was used. High (100 Hz) and low (2 Hz) frequency stimulations were delivered via electrodes with standardized positioning (Figure 1).

Figure 1.

Electrode’s positioning

In WO group, investigators chose, for each patient, the best suitable WO and its daily dose, and could switch to another WO, and/or adapt its daily dose if necessary.

A non-inferiority analysis was performed on the primary efficacy endpoint using a pre-defined non-inferiority margin (0.825 point) on PI, below the minimal clinically significant improvement.

Results:

Demographic and baseline characteristics were balanced across both groups.

110 patients (55/group) were randomized and 48/55 (87.3%) and 44/55 (80.0%) patients completed the 3-month follow-up in W-TENS and WO groups, respectively. WO’s prescriptions were balanced between codeine, opium-powder, tramadol and WO-paracetamol combinations.

Non-inferiority of W-TENS was demonstrated in the PP and ITT populations (Table 1). Since the 95% confidence interval (CI) of the between-treatments difference was below 0 in the ITT population, a planned superiority analysis was performed showing that W-TENS was significantly superior to WO at M3 (p=0.0124) on PI. Additionally, the number of AEs was significantly lower (p<0.001) in W-TENS (n=7) group than in WO (n=36) group. In WO group, AEs were systemic AEs usually reported with WO while AEs in W-TENS group were local, related to the technique used, such as local cutaneous reaction (erythema).

Table 1.

Non-inferiority analyses on pain intensity at M3. ITT and PP populations. Least squares means for each study group and study group difference estimate and corresponding 95% CI

Group PopulationWithin-group changeBetween-group differenceW-TENSWOW-TENS - WOITT Population (n)5555Non inferiorityMean (SD)3.83 (0.28)<0.0014.74 (0.28)<0.001-0.92 (0.40)Non inferiority‡ demonstrated95% CI[3.27, 4.40][4.18, 5.30][-1.71, -0.12]PP Population (n)5247Mean (SD)3.87 (0.30)<0.0014.66 (0.32)<0.001-0.79 (0.44)Non inferiority‡ demonstrated95% CI[3.28, 4.46][4.03, 5.28][-1.65, 0.08]

‡ Noninferiority was demonstrated when 95% CI < 0.825

Thirty-nine (70.9%) patients wished to extend W-TENS treatment for 3 additional months. Only one patient discontinued this additional period and results obtained at M3 remained stable at M6.

Conclusion:

In this study, W-TENS was more effective and better tolerated than WO in the treatment of nociceptive KOA chronic pain and should represent an interesting non-pharmacological alternative to WO.

Acknowledgements:

We gratefully thank P. Fardellone (Amiens), E. Coudeyre (Clermont-Ferrand), Y. Donazzolo (Gieres), A. Amouzougan (Saint-Etienne), L. Grange (Grenoble), T. Conrozier (Belfort), E. Senbel (Marseille), J.P. Sanchez (Billere), R. Forestier (Aix-les-Bains), H. Bard (Paris) and E. Gibert (Ivry-sur-Seine) for their active contribution throughout arthroTENS study

Disclosure of Interests:

Emmanuel Maheu Speakers bureau: TRB chemedica, Consultant of: SUBLIMED, Moirans, FRANCE; Sandrine Soriot-Thomas Speakers bureau: Grunenthal, Consultant of: SUBLIMED, Moirans, FRANCE;

Grunenthal

Kyowa Kirin pharma, Grant/research support from: Grunenthal

Sanofi

Teva

Mylan

Therable, Eric Noel Consultant of: SUBLIMED, Moirans, FRANCE; Eric Lespessailles Consultant of: SUBLIMED, Moirans, FRANCE; Bernard Cortet Consultant of: SUBLIMED, Moirans, FRANCE;

AB0862 CONSENSUS STATEMENT ON INTRA-ARTICULAR INJECTIONS OF PLATELET-RICH PLASMA FOR THE MANAGEMENT OF KNEE OSTEOARTHRITIS

Background:

There has been much debate regarding the use of intra-articular injections of platelet-rich plasma (PRP) as symptomatic treatment for knee osteoarthritis. The heterogeneity of the preparation and injection protocols limits the extrapolation of data from randomized controlled trials and meta-analyses.

Objectives:

The objective of this expert consensus was to develop the first clinical practice recommendations for PRP injections in knee osteoarthritis.

Methods:

Fifteen physicians (10 rheumatologists, 4 specialists in rehabilitation and sport medicine and 1 interventional radiologist) from different countries were selected given to their expertise in the fields of PRP and osteoarthritis. Twenty-five recommendations were finally retained after several meetings using the modified Delphi method to establish clinical consensus. All experts voted their agreement or not for each recommendation using a score between 1 (totally inappropriate) and 9 (totally appropriate). Depending on the median value and extreme scores, recommendations were judged as appropriated or unappropriated with a strong or relative agreement but could also be judged as uncertain due to indecision or absence of consensus.

Results:

The main recommendations are listed below:

Conclusion:

Twenty-five recommendations were discussed by an international multidisciplinary task force group in order to provide a basis for standardization of clinical practices and future research protocols.

Disclosure of Interests:

Florent Eymard Consultant of: Regenlab, Paul Ornetti: None declared, Jérémy Maillet Consultant of: Regenlab, Eric Noel Consultant of: Regenlab, Philippe Adam Consultant of: Regenlab, Virginie Legré Boyer Consultant of: Regenlab, Thierry Boyer Consultant of: Regenlab, Fadoua Allali: None declared, Vincent Grémeaux Bader: None declared, Jean-François Kaux: None declared, Karine Louati: None declared, Martin Lamontagne Consultant of: Pendopharm, Fabrice Michel: None declared, Pascal Richette: None declared, Hervé Bard Consultant of: Regenlab

Cochleovestibular manifestations in Fabry disease: Importance of screening and systematic ENT evaluation

OBJECTIVES

Fabry disease (FD) is an X-linked inherited lysosomal storage disease. It is a multisystem pathology that can include ENT disorders. The aim of the present study was to investigate the cochleovestibular manifestations of FD, in order to show the importance of screening and systematic ENT evaluation.

MATERIAL AND METHODS

A single-center retrospective study included 14 male and 23 female FD patients. Hearing impairment was defined as hearing loss greater than the 90^th percentile for at least one frequency. Vestibular impairment was defined by lateral semicircular canal dysfunction. Age, ongoing enzyme replacement therapy (ERT) and organic (renal, cardiac and cerebrovascular) complications were used as severity markers.

RESULTS

Hearing impairment was found in 62.6% of cases, mostly at high frequencies, and was associated with age, ERT, and cardiac and cerebrovascular disorder. It affected 46.7% of asymptomatic adult patients. Vestibular impairment was found in 56% of cases, associated with age; it affected two-thirds of ERT patients, more than 60% of patients with organic complications, and 50% of asymptomatic adult patients.

CONCLUSIONS

More than half of patients had ENT involvement. All FD patients should undergo early ENT screening for diagnostic, prognostic and therapeutic purposes. Systematic complete ENT follow-up with auditory and vestibular evaluation should be performed regularly, even for heterozygous women.

Trends in hepatitis B and hepatitis C seroprevalence among blood donors - Haiti, 2005-2014

Background and Objectives

Data on the seroprevalence of viral hepatitis are limited in Haiti; consequently, the epidemiology is poorly described. This study aims to provide a descriptive analysis of hepatitis B virus (HBV) and hepatitis C virus (HCV) seroprevalence of blood donations in Haiti.

Materials and Methods

Using Haiti's National Blood Safety Program and Haitian Red Cross reports from 2005 to 2014, we analysed the results of screening tests of donor serum samples to assess HBV and HCV seroprevalence among adults aged 17 to 65 years.

Results

A total of 198 758 donor samples were screened from 2005 to 2014, of which 0·56% were positive for antibody to hepatitis C virus (anti-HCV) and 3·80% were positive for hepatitis B surface antigen. Over the 10-year study period, anti-HCV seroprevalence among blood donors increased by 31% from 0.66% to 0.86% (95% CI: 1·01-1·70); however, this trend was not uniform over time, with a significant decrease from 0·66% in 2005 to 0·39% in 2009 (95% CI: 0·43- 0·82) and 0·43% in 2012 (95% CI: 0·50-0·90). Conversely, HBV decreased significantly by 13% from 3·95% in 2005 to 3·42% in 2014 (95% CI: 0·77-0·97), a trend that was also observed in 2012 and 2013.

Conclusion

The significant, uniform decrease in HBV seroprevalence in more recent years may represent the positive impact of public health interventions in preventing the transmission of blood-borne infections. More research is needed to understand why the trends in HCV transmission are non-uniform and to investigate the significant increase in more recent years.

Geographic distribution of blood collections in Haiti before and after the 2010 earthquake

BACKGROUND

The January 2010 Haiti earthquake destroyed the National Blood Transfusion Center and reduced monthly national blood collections by > 46%. Efforts to rapidly scale-up blood collections outside of the earthquake-affected region were investigated.

STUDY DESIGN AND METHODS

Blood collection data for 2004-2014 from Haiti's 10 administrative departments were grouped into four regions: Northern, Central, Port-au-Prince and Southern. Analyses compared regional collection totals during the study period.

RESULTS

Collections in Port-au-Prince accounted for 52% of Haiti's blood supply in 2009, but fell 96% in February 2010. Haiti subsequently increased blood collections in the North, Central and Southern regions to compensate. By May 2010, national blood collections were only 10·9% lower than in May 2009, with 70% of collections coming from outside of Port-au-Prince. By 2013 national collections (27 478 units) had surpassed 2009 levels by 30%, and Port-au-Prince collections had recovered (from 11 074 units in 2009 to 11 670 units in 2013).

CONCLUSION

Haiti's National Blood Safety Program managed a rapid expansion of collections outside of Port-au-Prince following the earthquake. Annual collections exceeded pre-earthquake levels by 2012 and continued rising annually. Increased regional collections provided a greater share of the national blood supply, reducing dependence on Port-au-Prince for collections.

Abstract P3-04-05: Amplification driven expression of KIAA0020, a PARP1 interacting gene, facilitates repair of replication associated DNA damage in triple-negative breast cancers

Approximately 25% of triple-negative breast cancers display increased copy number in the region of 9p24. Since several genes mapping to this genomic locus have been shown to be involved in the biology of triple-negative breast cancers, a copy number-dependent transcriptional influence of genes at 9p24 on the malignant phenotypes has been suggested. Given the limited options of targeted therapy for triple-negative breast cancer patients, further studies of genes located at this locus could therefore provide potential novel targets or companion biomarkers for this disease.

By integrating microarray-based DNA copy number and gene expression of genes located on 9p24 in 111 triple-negative breast cancers, we identified among a wider set of genes three hypothetical genes, KIAA0020, KIAA1432 and KIAA2026 whose expression was highly correlated with their copy number status. External validation through analysis of several comprehensive breast cancer cohorts, confirmed KIAA0020 as being highly abundant in basal-like/ triple-negative breast cancers. Involvement of KIAA0020 in PARP1 activity and the DNA damage response has previously been suggested. To elucidate KIAA0020's functional involvement in cell growth, cell cycle progression, apoptosis and DNA damage response in this subtype of breast cancer, breast cancer cell lines with and without increased 9p24 copy number levels were used as in vitro models. In cell lines with increased DNA copy number at 9p24, depletion of KIAA0020 expression selectively impaired growth causing an accumulation in S-phase and a decrease in cell proliferation. Furthermore, KIAA0020-silencing in such cell lines resulted in decreased repair of hydroxyurea induced replication associated DNA damage, accumulation of DNA double strand breaks and decreased occurrence of RAD51 and PAR foci, all pointing to a decreased repair of inactivated replication forks.

Taken together, our data supports the notion that genes of unknown function, residing in the 9p24 copy number aberrant region are involved in DNA repair and may thereby also contribute to the tumourigenesis of triple-negative breast cancers. A subset of such triple-negative tumours seemed to have developed a dependency on the expression of KIAA0020, a PARP1 interacting gene, for replication fork associated repair. Thus, greater understanding of KIAA0020's molecular function may provide additional information for patient selection with regards to DNA damaging chemotherapeutics or PARP inhibitors within triple-negative breast cancers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-04-05.

Multidimensional analysis of clinical symptoms in patients with Fabry's disease

AIM

Fabry's disease is an X-linked inherited lysosomal storage disorder caused by the deficient activity of alpha-galactosidase A. The interrelationships between clinical symptoms in Fabry patients have not yet been fully established. Using cluster and multivariate analysis, the aim of the study was to determine the relationships among clinical symptoms and organ involvement, and predictive clinical symptoms for disease severity.

METHODS

Clinical data obtained from 108 French Fabry patients were retrospectively collected and analysed using multiple correspondence analysis and hierachical ascendant classification. Multivariate analysis was also performed to determine among clinical symptoms predictors for cardiac disease (HRT), renal involvement (KDN) and brain complication (STR).

RESULTS

The cohort comprised 41 male patients (aged 28.9 ± 11.6 years) and 67 female patients (aged 40.4 ± 15.5 years). Three main clusters of clinical symptoms could be delineated, characterising disease progression: the first cluster grouped digestive disorders (found in 30% of the patients) and exercise intolerance (32%), the second, cluster dyshidrosis (47%), acroparesthesia (67%), angiokeratoma (44%) and cornea verticillata (54%), the third, cluster grouped KDN (30%), HRT (39%) and STR (25%) and hearing loss (44%). In univariate analysis, the patient age predicted HRT and KDN, dyshidrosis predicted HRT and STR, angiokeratoma predicted KDN and cornea verticilla and hearing loss predicted KDN, HRT and STR. In multivariate analysis, hearing loss and age were independent predictors of organ complication.

CONCLUSION

Among the various interrelated clinical symptoms occurring in Fabry disease, patients with dyshidrosis and particularly hearing disorders appear to be at higher risk of organ complications.

Fabry disease 'The New Great Imposter': results of the French Observatoire in Internal Medicine Departments (FIMeD)

Fabry disease (FD) is an X-linked lysosomal storage disorder due to α-galactosidase A deficiency. It is associated with a broad range of clinical symptoms, resulting in frequent misdiagnosis and diagnostic delay, which may impact on patient outcomes. This retrospective observational study of 58 FD patients referred to 10 internal medicine departments in France aimed to review differential diagnoses received prior to diagnosis and examines diagnostic delay. The average age at the time of diagnosis was 27.6 years (range: 10-60) and 42.2 years (range: 9-77) among the 23 males and 35 females analyzed, respectively. Most common symptoms that led to FD diagnosis were family history of FD (12 males and 27 females), followed by pain in extremities (10 males and 5 females), and angiokeratoma (8 males and 4 females). Eighteen patients had received alternative diagnoses prior to FD diagnosis, including a female patient with four previous diagnoses. Four case reports are presented, which illustrate the diagnostic 'odyssey' and delayed diagnosis often experienced by patients. Clinicians should consider a diagnosis of FD when presented with a wide range of symptoms, thus helping to shorten the diagnostic delay and facilitating early therapy with enzyme replacement therapy to improve patient outcomes.

Occupational outcome after surgery in patients with a rotator cuff tear due to a work-related injury or occupational disease. A series of 262 cases

The goals of this study were to establish the occupational outcome after surgery in patients with a rotator cuff tear from a work-related injury (WRI) or occupational disease (OD) and determine which factors and conditions affected return to work.

HYPOTHESIS

return to work was possible for this type of patient. This questionnaire-based study comprised 262 shoulders in 254 patients with a WRI/OD who had surgery performed on their shoulder between 2000 and 2005. The average age was 50.5 ± 6.4 years. The following variables were analysed: employment status (private sector, self-employed, government employee), type of work (non-manual, manual, heavy manual labour), nature of tendon injury and surgical technique (open, mini-open and arthroscopy). Return to work occurred in 59.5% of the cases. Factors that prevented return to work (40.4% of the cases) included retirement (14.1%), an unrelated medical condition (10.3%), and the outcome of the operated shoulder (16.0%). Age had an impact on return to work (P<5 × 10(-4)). The type of work and nature of tendon injury did not affect return to work, but did affect time away from work. Employment status and surgical technique had an effect on return to work, but not on time away from work. Age was a decisive factor for return to work. Retirement seemed to be the most common choice starting at 55 years of age. Arthroscopy seemed to have reduced the impact of the WRI on the results, particularly on the time away from work. A preoperative evaluation of the patient's probability of returning to work should be done based on occupational and injury features. There may be a longer delay in returning to work for certain profiles of work (manual labour) and tendon injury. Patient management can be improved by knowing the factors and conditions that influence return to work.

LEVEL OF EVIDENCE

Level IV - Retrospective study.

Meniscal ossicle in a professional soccer player

Meniscal ossicles are an unusual finding and a rare cause for knee pain. They are often initially diagnosed as a loose body, chondrocalcinosis or meniscal calcification within the knee joint. Few cases have been reported in the literature. We present a case of a meniscal ossicle with an associated femoral cartilage lesion in a healthy 26-year-old male professional soccer player who presented with swelling and pain. The purpose of this article is to discuss the origins, radiological features, clinical symptoms and prognosis of meniscal ossicles.

[Cobalamin deficiencies in adults: update of etiologies, clinical manifestations and treatment]

PURPOSE

Update of the adult cobalamin deficiencies.

CURRENT KNOWLEDGE AND KEY POINTS

More precise definitions establish the true cobalamin deficiencies and determine their real epidemiology. The current clinical data suggest the concept of food-cobalamin malabsorption as the leading etiology of cobalamin deficiency. The new features of cobalamin deficiency include neurological, gynecological and vascular manifestations. Current treatment modalities include nasal, sublingual and oral cobalamin administration.

PROSPECTS AND PROJECTS

Studies are in the way to establish the relevance of the new clinical manifestations and to validate the usefulness of oral cobalamin therapy.

Hematological response to short-term oral cyanocobalamin therapy for the treatment of cobalamin deficiencies in elderly patients

OBJECTIVES

The aim of this trial was to demonstrate the efficacy of one month of oral cobalamin (vitamin B12) therapy in elderly patients with cobalamin deficiency related to food-cobalamin malabsorption (FCM).

PATIENTS AND METHOD

Twenty elderly patients (mean age: 78+/-17 years) with established cobalamin deficiency related to FCM were included in an open-label, non-randomized, non-placebo trial. They were treated with a maximum of 1,000 microgram per day of oral crystalline cyanocobalamin for at least 1 month. Serum cobalamin levels (primary endpoint), blood count abnormalities and reticulocytes count (secondary endpoints) were determined at baseline and during the first month of treatment.

RESULTS

85% of the patients normalized their serum cobalamin levels with a mean increase of+167 pg/ml (p<0.001 compared with baseline). 100% of the patients corrected their initial macrocytosis and 25% their anemia; 100% of the patients had medullar regeneration with a mean increase of reticulocytes count of 32+/-11.3 x 106/l (p=0.03 compared with baseline).

CONCLUSIONS

Our findings support the view that one month of oral crystalline cyanocobalamin is effective to correct serum vitamin B12 levels and to obtain hematological responses in elderly patients with cobalamin deficiency related to FCM.

Current management of adult idiopathic thrombocytopenic purpura in practice: a cohort study of 201 patients from a single center

To define usefulness and response to therapy and outcome in adults with idiopathic thrombocytopenic purpura (ITP) in clinical practice. We retrospectively reviewed a cohort of 201 consecutive patients with ITP, diagnosed between 1985 and 1994. In particular, we analyzed the therapies used, their response rates, prognostic indicators of response and outcome. In 62 patients, with minor bleeding episodes and a mean (+/- SD) platelet count of 88 +/- 23 x 10(9)/l, no treatment was used and chronic ITP was diagnosed in 59%. A total of 139 patients, with bleeding episodes in 71.2% cases and a mean platelet count of 20 +/- 13 x 10(9)/l, received at least one treatment. Three patients died (1.5% of the series). Corticosteroids were used in 118 patients, with an initial response rate of 82.2% and a long-term complete response (CR) of only 22.9%. Intravenous immunoglobulin was used in 26 patients, with an initial transient response in more than 60%. A splenectomy was performed in 55 patients, with an initial response rate of 92.5% and a long-term CR in 60%. Young age and prior response to corticosteroids were significant predictors of a durable response to splenectomy. Danazol was given in 37 patients, with a favorable response in 73% of cases. Our results illustrate the guidelines of the American Society of Hematology. Patients with moderate thrombocytopenia do not require treatment. In severe cases, splenectomy is the only treatment giving durable cures in a significant proportion of patients. Despite frequent chronicity, ITP is life-threatening only in a minor subset of patients.

[Is there a link between the food-cobalamin malabsorption and the pernicious anemia?]

BACKGROUND

A relation between food-cobalamin malabsorption and pernicious anemia has been suggested, particularly in the event of food-cobalamin malabsorption related to hypochlorhydric atrophic gastritis.

STUDY DESIGN

This work describes three cases of well-documented cobalamin deficiency related to food-cobalamin malabsorption in three women aged 56, 82 and 68 Years who had atrophic gastritis (not associated with Helicobacter pylori infection) and later developed authentic pernicious anemia.

CONCLUSIONS

This work illustrates the potential relation between these two disorders responsible for cobalamin deficiency.

[Update of pernicious anemia. A retrospective study of 49 cases]

PURPOSE

The aim of this study was to describe the present clinical characteristics of the pernicious anemia (PA).

METHOD

It is a retrospective (1996-2002) multicenter (five departments of internal medicine) study of 49 patients presenting an established cobalamin deficiency related to PA.

RESULTS

The median age of the patients was 74 years (25-93), the female/male ratio 2:9. Several autoimmune disorders were noted in 35% of the patients. Various clinical manifestations, mainly neurological, cutaneous and thrombotic, were found in 65.4% of the patients, at least one hematological abnormalities in 100%. Average serum vitamin B12 and homocystein levels were with 73 pg/ml (20-1960) and 42.9 micromol/l (7, 8-124). Anti-intrinsic factor or anti-parietal gastric cells antibodies were found in 87.5% and 62% of the patients (at least one antibody, in 96%) abnormal Schilling's test results in 86%. All the followed patients were successful treated with intramuscular (n = 27) or oral crystalline cyanocobalamin (n = 5).

CONCLUSIONS

PA was associated with several autoimmune disorders; PA may be responsible of various clinical manifestations or biological abnormalities; and oral crystalline cyanocobalamin treatment may be successful.

Efficacy of short-term oral cobalamin therapy for the treatment of cobalamin deficiencies related to food-cobalamin malabsorption: a study of 30 patients

BACKGROUND

It has been suggested that oral cobalamin (vitamin (B12)) therapy may be an effective therapy for treating cobalamin deficiencies related to food-cobalamin malabsorption. However, the duration of this treatment was not determined.

PATIENTS AND METHOD

In an open-label, nonplacebo study, we studied 30 patients with established cobalamin deficiency related to food-cobalamin malabsorption, who received between 250 and 1000 microg of oral crystalline cyanocobalamin per day for at least 1 month.

ENDPOINTS

Blood counts, serum cobalamin and homocysteine levels were determined at baseline and during the first month of treatment.

RESULTS

During the first month of treatment, 87% of the patients normalized their serum cobalamin levels; 100% increased their serum cobalamin levels (mean increase, +167 pg/dl; P < 0.001 compared with baseline); 100% had evidence of medullary regeneration; 100% corrected their initial macrocytosis; and 54% corrected their anemia. All patients had increased hemoglobin levels (mean increase, +0.6 g/dl) and reticulocyte counts (mean increase, +35 x 10(6)/l) and decreased erythrocyte cell volume (mean decrease, 3 fl; all P < 0.05).

CONCLUSION

Our findings suggest that crystalline cyanocobalamin, 250-1000 microg/day, given orally for 1 month, may be an effective treatment for cobalamin deficiencies not related to pernicious anemia.

[Vitamin B12 deficiency with normal Schilling test or non-dissociation of vitamin B12 and its carrier proteins in elderly patients. A study of 60 patients]

PURPOSE

Approximately 15% of people over 60 years old have a cobalamin (Cbl) deficiency in relation with a food-cobalamin malabsorption (FCM). But to date, only case reports or small series have been reported. The aim of this study was to describe the clinical characteristics of the FCM in old subjects.

METHODS

Sixty patients, at least 65 years old, presenting a Cbl deficiency related to FCM, were extracted from a cohort study of the Hôpitaux universitaires de Strasbourg, France (n = 169). All these patients had an established diagnosis of Cbl deficiency and met the Carmel's criteria of FCM. Their clinical data were retrospectively analysed.

RESULTS

The median age of the 60 patients was 75 years and the female/male ratio was 2.3. The principal clinical symptoms were peripheral neuropathy (35%), confusion and dementia (30%) and anemia-related manifestations such as asthenia and edemas of the legs (20%). Average hemoglobin was 10.7 +/- 2.5 g/dl and average mean erythrocyte cell volume was 95.5 +/- 13.8 fl. There was an anemia, a leucopenia, a thrombocytopenia and a pancytopenia in respectively 27%, 18%, 15% and 8% of the cases. Average serum vitamin B(12) and homocystein levels were with 138 +/- 42 pg/ml and 22.5 +/- 15.2 micro mol/l. No patient had anti-intrinsic factor antibody and the Schilling's test was normal in all patients. Main disorders associated with FCM were atrophic gastritis (59%), long-term metformin or antiacid intake (17%), chronic alcohol intake (8%) and idiopathic FCM (n = 10). Sixteen patients have been successfully treated with oral crystalline cyanocobalamin (500 +/- 280 micro g/d).

CONCLUSIONS

This study shows that: firstly, the Cbl deficiency related to FCM may be responsible of severe neurological and hematologic manifestations in approximately 20% of the elderly patients; secondly, the disorders associated with the FCM are multiple in old age, with mainly atrophic gastritis; and thirdly, in clinical practice, oral cyanoCbl treatment may be successful.