divendres, de juliol 28, 2006

The limited value of methylmalonic acid, homocysteine and holotranscobalamin in the diagnosis of early B12 deficiency

28/07/06

Disorders of Erythropoiesis • Brief Report

Andrew Goringe, Richard Ellis, Ian McDowell, Josep Vidal-Alaball, Christopher Jenkins, Christopher Butler, Mark Worwood

Treatment of B12 deficiency is important to prevent progressive neurological and/or hematologic disease but requires a secure diagnosis. The aim of this study was to evaluate second line tests of B12 status as prognostic indicators of a hematologic response to vitamin B12 therapy. Forty-nine patients referred with low, serum vitamin B12 concentrations were treated with intramuscular B12 and re-assessed after 3 months. Methylmalonic acid, homocysteine, holotranscobalamin and neutrophil hypersegmentation index were measured before and after treatment. Before treatment 27/49 patients were anemic or macrocytic of whom 15 had a clear hematologic response. All the tests had a similar prognostic accuracy. Symptomatic improvement did not correlate with hematologic response. Supplementary tests of vitamin B12 status were not significantly better than total serum B12 concentration as predictors of a hematologic response to vitamin B12 therapy.

Key words: vitamin B12 deficiency, B12 therapy, methylmalonic acid, homocysteine, transcobalamin, neutrophil hypersegmentation index.

Haematologica 2006; 91:231-234

dijous, de juliol 27, 2006

Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency (Cochrane Review)

Wednesday, 10 August 2005

From The Cochrane Library, Issue 3, 2005. Chichester, UK: John Wiley & Sons, Ltd. All rights reserved.
Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency (Cochrane Review)
Vidal-Alaball J, Butler CC, Cannings-John R, Goringe A, Hood K, McCaddon A, McDowell I, Papaioannou A

ABSTRACT

Background: Vitamin B12 deficiency is common and rises with age. Most people with vitamin B12 deficiency are treated in primary care with intramuscular vitamin B12 which is a considerable source of work for health care professionals. Several case control and case series studies have reported equal efficacy of oral administration of vitamin B12 but it is rarely prescribed in this form, other than in Sweden and Canada. Doctors may not be prescribing oral formulations because they are unaware of this option or have concerns regarding effectiveness.
Objectives: To assess the effectiveness of oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency.
Search strategy: Searches were undertaken of The Cochrane Library, MEDLINE, EMBASE and Lilacs in early 2005. The bibliographies of all relevant papers identified using this strategy were searched. In addition we contacted authors of relevant identified studies and Vitamin B12 research and pharmaceutical companies to enquire about other published or unpublished studies and ongoing trials.
Selection criteria: Randomised controlled trials (RCTs) examining the use of oral or intramuscular vitamin B12 to treat vitamin B12 deficiency.
Data collection and analysis: All abstracts or titles identified by the electronic searches were independently scrutinised by two reviewers. When a difference between reviewers arose, we obtained and reviewed a hard copy of the papers and made decisions by consensus. We obtained a copy of all pre-selected papers and two researchers independently extracted the data from these studies using piloted data extraction forms. The whole group checked whether inclusion and exclusion criteria were met, and disagreement was decided by consensus. The methodological quality of the included studies was independently assessed by two researchers and disagreements were brought back to the whole group and resolved by consensus.
Main results: Two RCT's comparing oral with intramuscular administration of vitamin B12 met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to four months. High oral doses of B12 (1000 mcg and 2000 mcg) were as effective as intramuscular administration in achieving haematological and neurological responses.
Authors' conclusions: The evidence derived from these limited studies suggests that 2000 mcg doses of oral vitamin B12 daily and 1000 mcg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short term haematological and neurological responses in vitamin B12 deficient patients.

Citation: Vidal-Alaball J, Butler CC, Cannings-John R, Goringe A, Hood K, McCaddon A, McDowell I, Papaioannou A. Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency. The Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004655.pub2. DOI: 10.1002/14651858.CD004655.pub2.

RISK COMMUNICATION IN ENVIRONMENTAL HEALTH ISSUES

Dr Josep Vidal-Alaball

Public Health Medicine

July 2006

Risk Communication
• Is an interactive process of exchange of information
• People’s fears should be taken seriously and steps should be taken to address them even if they are not necessary from a technical perspective
• Management of Environmental Health issues requires more than technical expertise. Social issues such as house prices, house ownership or stigma of the neighbourhood are also important and should be considered from day one

Risk perception
• Clearly, emotions play a large role in public perception of risk
• When people become aware of a threat, they are naturally inclined to:
– Fear the unknown
– Want to maintain control
– Protect home and family
– Be alienated by dependence on others (government, industry officials)
– Protect their belief in a just world
• Experts and responsible authorities often think that the perception of the public is mistaken and irrational.
• They then try to correct the mistaken perception by the dissemination of information containing the "true" facts about the health risks.
• This nearly always fails. Technical measures alone are not enough to ease people’s worries !

• Risks are generally more worrying if perceived:
– To be involuntary
– As inequitably distributed, some benefit while others suffer
– As inescapable by taking personal precautions
– To arise from an unfamiliar or novel source
– To result from man-made, rather than natural sources
– To cause hidden and irreversible damage with onset many years later
– To pose particular danger to small children or pregnant women or more generally future generations
– To threaten a form of death (or illness/injury) arousing particular dread
– To damage identifiable rather than anonymous victims
– To be poorly understood by science
– As subject to contradictory statements from responsible sources (or even worse, from the same source), or from untrustworthy source.
– Invisible or undetectable, catastrophic, memorable, uncertain, uncontrollable or unethical risk.

Risk Comparisons
• Often, an involuntary risk is compared with a voluntary one (e.g. the risk from nearby incinerator is compared with smoking or dietary habits). If such a comparison is done in the spirit of minimising the importance of the involuntary risk, it will generate anger.
• The value of risk comparisons is also limited by the fact that risks tend to accumulate in people's minds. No matter how small the new risk, people are inclined to see it as simply one more unwelcome vexation to add to their already heavy burden of coping with modern-day problems.

Some problems….
• Health Authorities: Very late engagement with unrealistic expectation to respond
• Lack of consultation can result in:
– inaccurate health messages
– raised expectation
– unnecessary community concern

Some solutions ….
• Openness and transparency
– Trust should be based on mutual respect
– Communication should be open and honest
– An open communication process with the public and the media can be achieved by organising public meetings, issuing press reports, sending letters to residents, fact sheets, setting up internet sites, etc
– The language used should be understandable for the general public
• Do not let the media take control of the situation. Ensure that key people responsible for communication are always available and ensure a smooth hand-over between various people involved in the case.
• Engage early with Health Authorities!

Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency:

Cochrane Library, reproduced with permission

Butler CC, Vidal-Alaball J, Cannings-John R, McCaddon A, Hood K, Papaioannou A, McDowell I and Goringe A. Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency: a systematic review of randomized controlled trials. Family Practice 2006; Pages 1–7 of 7.

Background. Vitamin B12 deficiency is common, increasing with age. Most people are treated in primary care with intramuscular vitamin B12. Several studies have reported equal efficacy of oral administration of vitamin B12.
Objectives. We set out to identify randomized controlled trial (RCT) evidence for the effectiveness of oral versus intramuscular vitamin B12 to treat vitamin B12 deficiency.
Methods. We conducted a systematic review searching databases for relevant RCTs. Outcomes included levels of serum vitamin B12, total serum homocysteine and methylmalonic acid, haemoglobin and signs and symptoms of vitamin B12 deficiency.
Results. Two RCTs comparing oral with intramuscular administration of vitamin B12 met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to 4 months. In one of the studies, mean serum vitamin B12 levels were significantly higher in the oral (643 ± 328 pg/ml; n = 18) compared with the intramuscular group (306 ± 118 pg/ml; n = 15) at 2 months (P < 0.001) and 4 months (1005 ± 595 versus 325 ± 165 pg/ml; P < 0.0005) and both groups had neurological responses. In the other study, serum vitamin B12 levels increased significantly in those receiving oral vitamin B12 and intramuscular vitamin B12 (P < 0.001).
Conclusions. The evidence derived from these limited studies suggests that 2000 mg doses of oral vitamin B12 daily and 1000 mg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short-term haematological and neurological responses in vitamin B12-deficient patients.
Keywords. Cobalamin, cyanocobalamin, hydroxocobalamin, pernicious anaemia, vitamin B12.

Diploma of the Faculty of Family Planning (DFFP)

Dr Josep Vidal-Alaball 2005

Who is it for?
GPs and any doctor with an interest in family planning.
When did you do it?
In 2002, during my GP registrar year.
Why did you do it?
In general practice we see many patients wanting advice on family planning and I wanted to have a diploma certifying my proficiency in this specialty. I like the way the diploma is assessed—it requires practical and theoretical training.
How much effort did it entail?
The diploma has two components; a basic theoretical course and a practical training.
There are several approved courses available around the country, which take place over three consecutive days. You organise your own practical training, which needs to be supervised by a faculty approved instructing doctor.
Is there an exam? (and fee)
No, this is the great thing about the DFFP; no exam is required to obtain the diploma. There is a fee to go to the theoretical course and you may need to pay a small fee to attend practical training.
Top tip
Book your theoretical course early, as they are quite popular and GP registrars get priority. Organise your clinical placements in advance as it may take several months to attend all the required sessions.
Contact for further information
The Faculty of Family Planning and Reproductive Heath Care, 27 Sussex Place, Regent’s Park, London, NW1 4RG (020 7724 5669; http://www.ffprhc.org.uk/).
Was it worth it?
Pros
No exams required.
Good practical experience through direct patient contact.
Once you have the qualifications, you can earn extra income in family planning sessions.
Looks good on your CV.
Yearly subscriptions to the Faculty of Family Practice not as costly as with other memberships.
Cons
It is time consuming as you need to attend several training sessions in recognised training facilities and these may take place in the evenings.
It is strange to pay to see patients.
The logbook certifying your clinical experience is painful to fill in.
You need recertification every five years

Revalidation and Appraisal need to be evaluated

Friday, 02 April 2004

I am in favour of Appraisal and Continuous Professional Development for health care professionals but I also strongly believe that any intervention in Health Services needs to be evaluated. The efficacy of Revalidation and Appraisal needs to be evaluated moreover when this is going to be an expensive intervention. I was surprised to find very vague references about evaluation on the Department of Health web side mainly regarding at the number of doctors appraised and the quality of the process.

In a discussion group during one session of the Masters of Public Health at the UWCM in Cardiff I asked how we could possible evaluate Revalidation and Appraisal. We though that it is difficult to evaluate an intervention when the objectives of the intervention are not clear. According to the objectives of the intervention we can design a correct evaluation.

Looking at the numbers of doctors appraised and revalidated is a measure of activity but not a measure of outcome of the intervention. If the objective of appraisal and revalidation is to avoid another Shipman them we should be looking at mortality as outcome and we should be comparing mortality rates amongst doctors. If we want to assess doctor’s performance and improve patient’s care maybe we should be looking at markers of good quality of care. For example we could be looking at the use of Aspirin and B-Blockers after myocardial Infarction or the use of statins. We may find like Dr Manesh Patel, a cardiology fellow at Duke Clinical Research Institute, that educating health care professionals does not improve the care of their patients.

I believe that no evidence for a potential positive intervention should not preclude implementing it. However we should expect a clear evaluation of the intervention in order to justify the use of health care resources .

Dr Josep Vidal-Alaball

Competing interests: None declared