Polineuropatia diabética assintomática induzida pelo uso crônico de metformina e correlação com vitamina B12 / Asymptomatic diabetic polyneuropathy induced by chronic metformin use and correlation with vitamin B12

Introdução: Diabetes Mellitus é doença metabólica, caracterizada pela deficiência absoluta ou relativa de insulina, que acomete cerca de 382 milhões de pessoas em todo mundo, tendo uma das complicações mais comuns a polineuropatia. A Metformina, medicamento amplamente utilizado como tratamento do Diabetes, foi descrita como responsável, em algumas literaturas, por causar ou agravar deficiência de vitamina B12, que está similarmente relacionada ao desenvolvimento de polineuropatia.Métodos: Nesse sentido, foi conduzido um estudo no município de Soledade ­ RS, com objetivo de verificar se essa relação é condizente com a realidade da localidade. Foram escolhidos 58 pacientes, dos quais 30 responderam questionários adaptados baseados na literatura e na Classificação de Neuropatia de Michigan (MNSS-Brasil), então colhidos 5 ml de sangue venoso da fossa antecubital, preparado soro do qual uma alíquota foi separada para determinação bioquímica da vitamina B12.Resultados: Analisando os resultados, a maioria dos pacientes analisados apresentou sintomas de polineuropatia, e 10% deste, deficiência vitamínica.Conclusão: nenhuma variável explicou a correlação do uso crônico da Metformina, dose e gênero com a deficiência da vitamina B12, o que indica que não há evidências fortes o suficiente que sustentem esse fato, de acordo com as particularidades da localidade analisada.

Introduction: Diabetes Mellitus is a metabolic disease, characterized by absolute or relative insulin deficiency, which affects about 382 million people, with polyneuropathy being one of the most common complications. Metformin, a drug widely used as a treatment for diabetes, has been described as responsible, in some literature, for causing or aggravating vitamin B12 deficiency, which is similarly related to the development of polyneuropathy.Methods: In this sense, a study was conducted in Soledade ­ RS, in order to verify whether this relationship is consistent with the reality of the locality. Fifty-eight patients were selected, of which 30 answered adapted questionnaires based on the literature and on the Michigan Neuropathy Classification (MNSS-Brazil), then 5 ml of venous blood was collected from the antecubital fossa, serum prepared from which an aliquot was separated for biochemical determination of the vitamin B12.Results: Analyzing the results, most of these patients presented symptoms of polyneuropathy and, 10% of them, vitamin deficiency.Conclusion: no variable explained the correlation of chronic use of Metformin, dose and gender with vitamin B12 deficiency, which indicates that there is not enough evidence to support this fact, according to the particularities of the analyzed locality.

Tratamiento de la estomatitis aftosa recurrente en pacientes inmunocomprometidos. Revisión sistemática / Treatment of recurrent aphthous stomatitis in immunocompromised patients. Systematic review

RESUMEN Fundamento: Aunque la estomatitis aftosa recurrente no tiene una etiología bien definida porque es una enfermedad multicausal, se ha reconocido que las interacciones o el debilitamiento del sistema inmunitario, contribuyen principalmente a la magnitud del proceso patológico. Las propuestas de tratamiento en pacientes inmunocomprometidos son diversas y por lo general se centran en alteraciones inmunológicas específicas. Objetivo: Evaluar el efecto clínico de los tratamientos propuestos para la estomatitis aftosa recurrente en pacientes inmunocomprometidos. Metodología: La búsqueda se realizó en las bases de datos PubMed/Medline y Cochrane. Se incluyeron ensayos clínicos que tuviesen entre sus variables de respuesta principales: Cicatrización de la úlcera aftosa, tiempo de cicatrización, de recurrencia e intensidad del dolor y entre las variables secundarias: Los efectos adversos y los síntomas. La extracción de datos se realizó de manera independiente por los autores. Se aplicó la metodología por la colaboración Cochrane para evaluar el riesgo de sesgo en cada uno de los estudios. Resultados: Se incluyeron 11 ensayos clínicos (8 controlados) publicados entre 1995 y 2020 y que aportan resultados de la eficacia de varias intervenciones terapéuticas: talidomida (4), irsogladine (2), rebamipida (1), láser de diodo (1), cápsulas de Omega-3 (1), vitamina B 12 (1), Complejo B (1). Seis de estos estudios incluyeron pacientes con la forma menor de estomatitis aftosa recurrente. El periodo de seguimiento estuvo entre los 14 y 360 días. Conclusiones: La talidomida puede ser eficaz en el alivio de los síntomas, la cicatrización y remisión de las lesiones, el diodo de láser y vitamina B12 en la disminución de la intensidad del dolor.

ABSTRACT Background: Although recurrent aphthous stomatitis does not have a well-defined etiology due to it is a multicausal disease, it has been recognized that the interactions or the weakening of the immune system, contribute mainly to the magnitude of the process pathological. Treatment proposals in immune compromised patients are diverse and they usually focus on specific immunological alterations. Objective: To evaluate the clinical effect of the proposed treatments for recurrent aphthous stomatitis in immunocompromised patients. Methodology: The search was performed in the PubMed/Medline and Cochrane databases. Clinical trials were included that could have among their main response variables: Aphthous ulcer healing, healing time, recurrence and pain intensity and among the secondary variables: Adverse effects and symptoms. data extraction was done independently by the authors. The methodology was applied by Cochrane collaboration to assess the risk of bias in each of the studies. Results: 11 clinical trials (8 controlled) published between 1995 and 2020 and that provided the results of the efficacy of various therapeutic interventions: thalidomide (4), irsogladine (2), rebamipide (1), diode laser (1), Omega-3 capsules (1), vitamin B 12 (1), Complex B (1). Six of these studies included patients with the minor form of stomatitis recurrent aphthous. The follow-up period was between 14 and 360 days. Conclusions: Thalidomide may be effective in relieving symptoms, healing and remission of the lesions, the laser diode and vitamin B12 in the decrease of the intensity of the pain.

Comparison of sublingual and intramuscular administration of vitamin b12 for the treatment of vitamin b12 deficiency in children

Abstract Background: In most countries, contrary to some disadvantages, such as pain, relatively higher cost, and poor adherence to treatment, intramuscular (IM) route is still the primary treatment method for Vitamin B12 (VB12) deficiency. In recent years, because of these difficulties, new treatment methods are being sought for VB12 deficiency. Objectives: We aimed to compare sublingual (SL) and IM routes of VB12 administration in children with VB12 deficiency and to compare the efficacy of methylcobalamin and cyanocobalamin therapy in these children. Methods: This retrospective study comprised 129 patients with VB12 deficiency (serum Vitamin 12 level ≤ 200 pg/mL) aged 5-18 years. Based on the formulations of Vitamin 12, we divided the patients into three treatment groups as IM cyanocobalamin, SL cyanocobalamin, and SL methylcobalamin. Results: After Vitamin 12 therapy, serum Vitamin 12 levels increased significantly in all patients, and there was a statistically significant difference between the treatment groups (p < 0.05). Conclusions: SL cyanocobalamin and methylcobalamin were found as effective as IM cyanocobalamin for children with Vitamin 12 deficiency in correcting serum Vitamin 12 level and hematologic abnormalities.

Dietas vegetarianas en alumnos universitarios / Vegetarian diets in first year university students

INTRODUCCIÓN: Se ha observado un aumento en la popularidad de las dietas vegetarianas, en especial en la población adolescente y adulto joven. Estas dietas se presentan como saludables y balanceadas pero las recomendaciones son controversiales en cuanto a los potenciales déficit nutricionales. OBJETIVO: Identificar la frecuencia y tipos de dieta vegetariana utilizada, su motivación y fuentes de información. PACIENTES Y MÉTODO: Estudio transversal y analítico en universitarios de primer año de la Pontificia Universidad Católica de Chile (PUC). Se realizó una encuesta vía online obteniendo información demográfica y caracterización de dietas de aquellos que se consideraban vegetarianos. Las variables fueron analizadas mediante el software IDM SPSS Statistics® y en planilla Excel® de forma cuantitativa. RESULTADOS: 152 alumnos respondieron la encuesta (15,2% del total), siendo el 49,4% de estos vegetariano. El 32,4% inició este patrón alimentario entre los 12-18 años; sus motivaciones más frecuentes fueron las medio ambientalistas (91,9%) y animalistas (72,9%). El 52,9% de los vegetarianos reciben suplementación de vitamina b 12 pero solo un 15,9% reportó presentar este déficit. El 75,7% obtiene información relacionada acerca de las dietas vegetarianas a través de medios digitales. CONCLUSIÓN: Se encontró un alto porcentaje de estudiantes vegetarianos en las encuestas contestadas, lo que hace necesario que los profesionales de salud estén capacitados en esta área para asegurar una adecuada educación nutricional, suplementación si es necesario, y seguimiento.

INTRODUCTION: There has been an increase in the popularity of vegetarian diets, especially among adolescents and young adults. These diets seem to be healthy and balanced, but the recommendations are contro versial regarding potential nutritional deficits. OBJECTIVE: To identify the frequency and types of ve getarian diet used, their motivation, and sources of information. PATIENTS AND METHOD: Cross-sec tional analytical study in freshmen students from the Pontifical Catholic University of Chile (PUC). Through an online survey, we collected demographic information and diet characterization of those who considered themselves as vegetarians. Variables were analyzed using IDM SPSS Statistics® soft ware and in Excel® spreadsheet in a quantitative way. RESULTS: 152 students answered the survey (15.2% of the sample) and, out of these, 49.4% were vegetarian. 32.4% started this eating pattern bet ween the ages 12 and 18 and among their most frequent motivations were environmentalists (91.9%) and animalists (72.9%). 52.9% of vegetarians take vitamin B 12 supplementation but only 15.9% reported having this deficiency. 75.7% obtain information related to vegetarian diets through digital media. CONCLUSION: In the surveys answered, we found a high percentage of vegetarian students, the refore, health professionals need to be trained in this area to assure adequate nutritional education, supplementation if necessary, and follow-up.

Hiperpigmentación cutánea secundaria a déficit de vitamina B12 en un lactante / Cutaneous hyperpigmentation secondary to vitamin B12 deficiency in an infant

La hiperpigmentación cutánea es una manifestación clínica poco frecuente del déficit de vitamina B12 (cobalamina). Su causa no se conoce con exactitud, y existen varias teorías en su etiopatogenia.Se presenta a una niña de 8 meses de edad, con antecedentes de retraso neuromadurativo, hipotonía, anemia y neutrope-nia, derivada a nuestro Servicio por hiperpigmentación cutá-nea del dorso de las manos y los pies de 3 meses de evolución. Ante la sospecha clínica de déficit de vitamina B12, se realizó un análisis de laboratorio, en el que se constató una marcada disminución de los niveles séricos de cobalamina, por lo que se indicó tratamiento sustitutivo con esta.Se destaca la importancia de la presunción diagnóstica de déficit de vitamina B12 como causa de hiperpigmentación cutánea y su resolución luego de la instauración del tratamiento adecuado.

Cutaneous hyperpigmentation is a rare clinical feature of vi-tamin B12 (cobalamin) deficiency. The cause is unknown and there are different hypothesis about the pathogenesis of the hyperpigmentation.We report the case of an 8-month-old girl, with history of neu-romadurative delay, hypotonia, anemia and neutropenia, who was referred to our Service by brownishhyperpigmentation on her hands and feet of 3 months of evolution. Based on the clinical suspicion of vitamin B12 deficiency, we performed a laboratory dosage that showed decreased levels of cobalamin, reason for which replacement therapy was indicated.It highlights the importance of the presumption of vitamin B12 deficiency as a cause of cutaneous hyperpigmentation and its rapid resolution after the establishment of the appro-priate treatment.

Mecobalamin and early functional outcomes of ischemic stroke patients with H-type hypertension

SUMMARY OBJECTIVE To analyze the effect of mecobalamin on the early-functional outcomes of patients with ischemic stroke and H-type hypertension. METHODS From October of 2014 to October of 2016, 224 cases of ischemic stroke and H-type hypertension were selected. The patients were randomly divided into treatment control groups, with 112 patients in each group. The control group was treated with the conventional therapy. The observation group was treated with 500 µg of mecobalamin three times a day in addition to the conventional therapy. We compared serum homocysteine (Hcy), hs-CRP levels, carotid plaques, and NIHSS scores between the two groups on the 2nd day and at 4 weeks, 8 weeks, 3 months, and 6 months. RESULTS After 4 weeks, 8 weeks, 3 months and 6 months, the difference of serum Hcy level between the two groups was statistically significant (t = 4.049, 3.896, 6.052, 6.159, respectively. All P <0.05). After the treatment, at 4 weeks, 8 weeks, 3 months and 6 months, the levels of hs-CRP in the treatment group were significantly lower than those in the control group (t = 37.249, 28.376, 26.454, 20.522, respectively. All P <0.01). After 3 months and 6 months, the carotid artery plaques were significantly reduced in the treatment group compared to those in the control group (t = 2.309 and 2.434. All P <0.05). After 3 months and 6 months, the NIHSS score was significantly higher in the treatment group compared to those in the control group (t = 2.455 and 2.193. All P <0.05). CONCLUSION Mecobalamin can reduce the level of plasma homocysteine, then lead to reductions of levels of plasma inflammatory factors and volume of carotid artery plaques, resulting in more significant functional recovery.

RESUMO OBJETIVO Analisar o efeito de mecobalamin sobre os primeiros resultados funcionais de pacientes com AVC isquêmico e hipertensão H-type. MÉTODOS De outubro de 2014 a outubro de 2016, 224 casos de AVC isquêmico e hipertensão H-type foram selecionadas. Os pacientes foram divididos aleatoriamente em grupo de tratamento e grupo controle, com 112 doentes em cada grupo. O grupo controle foi tratado com a terapia de rotina. O grupo de observação foi tratado com 500 µg de mecobalamin três vezes por dia, além da rotina de tratamento. No segundo dia, 4 semanas, 8 semanas, 3 meses e 6 meses, comparamos níveis séricos da homocisteína (Hcy) e de hs-CRP, placas da carótida e pontuações NIHSS entre os dois grupos. RESULTADOS Após 4 semanas, 8 semanas, 3 meses e 6 meses, a diferença dos níveis séricos de Hcy entre os dois grupos foi estatisticamente significativa (t= 4,049, 3,896, 6,052, 6,159, respectivamente. Todos os P<0,05). Após o tratamento de 4 semanas, 8 semanas, 3 meses e 6 meses, os níveis de hs-CRP no grupo de tratamento foram significativamente inferiores aos do grupo controle (t=37,249, 28,376, 26,454, 20,522, respectivamente. Todos os P<0,01). Depois de 3 meses e 6 meses, as placas da artéria carótida foram significativamente reduzidas no tratamento, em comparação com os do grupo controle (t=2,309 e 2,434. Todos os P<0,05). Depois de 3 meses e 6 meses, as pontuações NIHSS foram significativamente mais elevadas no tratamento em comparação com as do grupo controle (t=2,455 e 2,193. Todos os P<0,05). CONCLUSÃO Mecobalamin pode reduzir o nível de homocisteína plasmática, o que conduz à redução dos níveis de plasma inflamatórios e do volume das placas na artéria carótida, resultando em maior recuperação funcional.

Trastornos neurológicos graves en lactante con anemia megaloblástica / Severe neurological disorders in an infant with megaloblastic anemia

La anemia megalobástica es un trastorno madurativo de los precursores eritroides y mieloides causado por déficit de vitamina B12, ácido fólico, o ambos. Es poco común en la infancia y su prevalencia se desconoce por ser una enfermedad poco frecuente. Se presenta el caso de una lactante, cuya madre tuvo una alimentación precaria durante el embarazo y la lactancia, que prolongó la lactancia materna exclusiva más de 6 meses. La paciente tuvo un desarrollo psicomotor normal hasta los 7 meses cuando comenzó a perder las habilidades ganadas y llegó a tener trastornos neurológicos graves, por lo que se consideró por neurología como una enfermedad progresiva del SNC. Al examen físico se encontró palidez en piel y mucosas, pérdida de los reflejos cocleopalpebrales bilaterales, ausencia de reflejo visual, hipertonía de los 4 miembros e hiperreflexia. Se realizaron exámenes de laboratorio por genética buscando errores congénitos del metabolismo, enfermedades mitocondriales u otras enfermedades como Tay Sachs, gangliosidosis tipo 1 y leucodistrofia metacromática, todas con resultado negativo. Se encontraron valores bajos de hemoglobina, con macrocitosis, por lo que se realizó dosificación de vitamina B12 que se encontró disminuida. Se concluyó como una anemia megaloblástica por déficit de vitamina B12.Se inició tratamiento sustitutivo con vitamina B12, con lo que se logróuna rápida recuperación clínica desde los primeros días de tratamiento y la remisión total de los trastornos neurológicos. El déficit de vitamina B12 debe ser sospechado en lactantes con anemia y trastornos neurológicos especialmente si la alimentación de la madre antes, durante el embarazo y la lactancia no es adecuada(AU)

Megaloblastic anemia is a madurative disorder of erythroid and myeloid precursors caused by deficiency of vitamin B12 and/or folic acid. It is rare in childhood and its prevalence is unknown because it is a rare disease.We report the case of a 14 month old infant with a normal psychomotor development (DPM) until 7 months after which began to lose the gained skills and had severe neurological disorders to such a degree of being studied by neurology by a progressive central nervous system disease. At physical examination pale skin and mucous membranes, loss of bilateral cocleopalpebral reflexes, no visual reflection of the 4 limbs hypertonia, hyperreflexia were found. Laboratory tests were performed reporting hemoglobin of 76 g/L, genetic tests to search for inborn errors of metabolism,mitochondrial diseases and other diseases as Tay Sachs, Gangliosidosis type 1, metachromatic leukodystrophy, all were negative. The dosage of vitamin B12 was 91 pg/mL, and megaloblastic anemia was diagnosed. At the beginning of the treatment with vitamin B12 there was a rapid clinical recovery, the severe neurological disorders were completely reversing. Vitamin B12 deficiency should be suspected in infants with anemia and neurological disorders especially if the mother´s feeding before and during pregnancy and lactation is not adequate(AU)

Polineuropatia periférica na doença de Parkinson: prevalência e fatores de risco em uma amostra na cidade de Campina Grande - PB / Peripheral neuropathy in Parkinson's disease: prevalence and risk factors in a sample of Campina Grande city - Paraíba

Polineuropatia periférica (PNP) tem sido descrita na doença de Parkinson idiopática (DP), porém a prevalência e os fatores de risco não estão bem definidos. Objetivo: Investigar a prevalência e os fatores de risco para PNP na DP, em comparação com a população geral. Método: Participaram 36 pacientes com DP recrutados no ambulatório de Neurologia do Hospital Universitário Alcides Carneiro (HUAC) da Universidade Federal de Campina Grande (UFCG), Paraíba, e 30 sujeitos controles. Todos os participantes foram submetidos a caracterização clínica da PNP, ao estudo de neurocondução (ENC) dos nervos peroneal e sural bilateral e as dosagens de vitamina B12, homocisteina, ácido metilmalônico e ácido fólico. A Escala Unificada de Avaliação da Doença de Parkinson - III e a de Hoehn-Yahr foram utilizadas na avaliação motora do grupo Parkinson (GP). Resultados: Sinais e sintomas neuropáticos foram mais frequentes no GP (61%). Alterações nos parâmetros do ENC foram observadas em 44,4% do GP e 26,7% do grupo controle, sendo a PNP confirmada em três pacientes e um controle. Análise de regressão revelou associação significativa entre os sintomas neuropáticos e a DP, sem associação com aspectos clínicos e bioquímicos. Conclusão: Pacientes com DP possuem maiores escores neuropáticos e maior prevalência de PNP que controles. Os dados sugerem a própria DP como fator de risco para o desenvolvimento da PNP, minimizando o papel da vitamina B12 e de seus metabólitos neste processo.(AU)

Peripheral neuropathy (PN) has been described in idiopathic Parkinson disease (PD) however the prevalence and the risk factors are not well established. Objective: To assess the prevalence of PN and the risk factors for neuropathy in PD against the general population. Method: Participated in the study 36 PD patients recruited from Neurology Outpatient Unit of Hospital Universitário Alcides Carneiro of the Federal University of Campina Grande, Paraíba, and 30 controls. All the participants were submitted to clinical characterization of PN, nerve conduction study (NCS) and biochemical dosages (B12 vitamin, homocysteine, methylmalonic acid and folic acid). Results: Neuropathic signs and symptoms were more frequent in PD (61%). Alterations in parameters of NCS were observed in 44.4% of Parkinson group and 26.7% of control group, and PN was confirmed in 3 PD patients and 1 control. Regression analyses showed a significant association between symptoms of PN and PD, without association with clinical and biochemical features. Conclusion: PD patients have higher neuropathic scores and frequency of PN than controls. Data suggests the PD by itself as a risk factor for development of PN, reducing the role of B12 vitamin and its metabolites in this process.(AU)

Randomized crossover trial of amoxapine versus vitamin B12 for retrograde ejaculation

ABSTRACT Objective To compare the efficacy and safety of amoxapine and vitamin B12 for treating retrograde ejaculation (RE). Materials and Methods Between May 2009 and November 2012, this open-label, randomized, crossover study enrolled 26 men suffering with RE at Department of Reproductive Medicine, Omori Hospital. Patients were randomly allocated into two groups (n=13 each). The amoxapine-B12 group received amoxapine (50 mg daily for 4 weeks, orally) followed (after a 1-week washout period) by vitamin B12 (500 μg three-times daily for 4 weeks). The B12-amoxapine group received the opposite regimen. All patients masturbated to ejaculation at least twice during each treatment period. The primary outcome was antegrade ejaculation of semen, as reported by the patient, on more than one occasion during either treatment period (defined as treatment success). Any adverse events were noted. Success rates were compared between treatments using Fisher’s exact test. Results One patient (B12-amoxapine group) withdrew for personal reasons (breakdown of marital relations); all other patients completed the study. Overall success rate was 88% (22/25). Success rate was higher for amoxapine than for vitamin B12 (80%, 20/25 vs 16%, 4/25; P<0.0001). 18 patients were responsive to amoxapine but not to vitamin B12, 2 patients were responsive to vitamin B12 but not amoxapine, 2 patients were responsive to both drugs, and 3 patients had no response to either drug. One patient (4%) reported sleepiness and 2 (8%) reported constipation while receiving amoxapine. No adverse events were reported during vitamin B12 treatment. Conclusions Amoxapine may be an effective, safe and well-tolerated therapy for RE.

Metabolismo da homocisteína em doenças neurológicas / Homocysteine metabolism in neurologic disorders

OBJETIVO: Realizar uma revisão sobre o metabolismo do aminoácido sulfurado homocisteína, analisando como elevações de seus níveis séricos se correlacionam com a fisiopatologia das mais diversas doenças neurológicas, assim como sobre o tratamento da hiper-homocisteinemia. MÉTODO: Revisão não sistemática de artigos que abordassem o papel da homocisteína associado a doenças neurológicas.Foi priorizada a utilização de artigos que apresentassem no título as palavras-chave "homocisteína" ou "hiper-homocisteinemia",associadas a palavras-chave contendo as enfermidades neurológicas de maior prevalência como acidente vascular cerebral, doença de Alzheimer, doença de Parkinson e outras. Foram utilizadas as bases de dados do PubMed, Lilacs e Google Scholar. RESULTADOS: Foram utilizados 35 artigos em inglês e 2 artigos em português para a confecção desta revisão. CONCLUSÃO: A homocisteína se encontra elevada em associação com as mais diversas doenças neurológicas. Contudo, em muitas delas não está estabelecido se esse aumento é um achado secundário ou se representa um papel da homocisteína na patogênese dessas enfermidades. Mais estudos são necessários para estabelecer o papel da homocisteína em situações neurológicas.O tratamento da hiper-homocisteinemia é fácil, sendo feito com reposição de vitamina B12 e, principalmente, de folatos.

OBJECTIVE: Review the metabolism of sulfur amino acid homocysteineand how elevation of its serum levels is correlated with the pathophysiologyof several neurological diseases, as well as the treatment of hyperhomocysteinemia. METHOD: A non-systematic review of articles discussing the role of homocysteine associated with neurological diseases was performed. The use of articles that presented in the title the keywords "homocysteine" or "hyperhomocysteinemia" associated with keywords containing the most prevalent neurological disorders such as stroke, Alzheimer's disease, Parkinson's disease and others were preferred. The search was underdone through PubMed, Google Scholar and Lilacs databases. RESULTS: There were selected 35 articles in English and 2 articles in Portuguese in this this review. CONCLUSION: High levels of homocysteine are associated with various neurological disorders. However, in many of these are not established whether this increase is a consequence of these disorders or if homocysteine plays a role in the pathogenesis of these diseases. More studies are needed to establish the participation ofhomocysteine in neurological disorders. The treatment of hyperhomocysteinemia is easy, being done with replacement of vitamin B12and especially folate.

Management of Anemia in Patients with Inflammatory Bowel Disease / 대한소화기학회지

Anemia is one of the commonest extraintestinal manifestations of inflammatory bowel disease (IBD). The pathogenesis of anemia in IBD is complex but iron deficiency combined with inflammation is the most common factor related to the development of anemia. However, other causes such as vitamin B12 and folate deficiency, hemolysis, myelosuppression and drug also should not be overlooked. In addition to ferritin, inflammatory markers and new biochemical parameters such as hepcidin and ferritin index are being tested as diagnostic a tool. First step for treatment is disease activity control and iron supplementation. Although oral iron is widely used, intravenous iron therapy should be considered in patients who are intolerant to oral iron therapy, have severe and refractory anemia or are in active disease state. Recently, new intravenous iron formulations have been introduced and due to their safety and easy usage, they have become the standard treatment modality for managing anemia in IBD. Erythropoietin and transfusion can be considered in specific situations. Vitamin B12 and folate supplementation is also important in patients who are deficient of these micronutrients. Since anemia in IBD patients could significantly influence the disease outcome, further studies and standard guideline for IBD are needed.

Mielopatia por deficiência de cobalamina: resolução clínica e de imagem / Cobalamin deficiency myelopathy: clinical and imaging resolution

Embora o quadro clássico de mielopatia por deficiência de vitaminaB12 seja a degeneração subaguda combinada da medula, a manifestaçãoclínica pode ser variável. Homem branco de 36 anos de idade com hipotireoidismo e vitiligo apresentou dormência nas mãos de início súbito. Exame físico: sinal de Lhermitte e hipoestesia nas palmas. Evidenciada alteração de sinal na ressonância magnética (RM) da medula cervical. Foram evidenciados nível sérico de vitamina B12 de 150 pg/mL, gastrite atrófica e hemograma normal. Paciente foi tratado com reposição intramuscular de vitamina B12. Após seis meses, houve remissão completa dos sintomas com normalização do exame de imagem em um ano. O presente caso ilustra discreta alteração clínica e lesão extensa na RM (dissociação entre a clínica e o exame de imagem) na deficiência de B12. A melhora dos sintomas precedeu a resolução da alteração no exame de imagem, no presente caso.

Although the classic manifestation of myelopathy due to vitamin B12deficiency is a subacute combined degeneration of the spinal cord, the clinical manifestation may be varied. A 36-year-old white man with hypothyroidism and vitiligo presented sudden onset of numbness in hands. Physical examination: Lhermitte's sign and hypoesthesia in palms. Signal change on magnetic resonance image (MRI) of the cervical spinal cord was evidenced. Serum vitamin B12 of 150 pg/mL, gastric atrophy and normal hemogram were shown. The patient was treated with intramuscular vitamin B12 replacement. After six months there was complete remission of the symptoms, and within one year the MRI was normal. This case illustrates mild clinical signs and extensive changes on MRI (dissociation between clinic and image) in B12 deficiency. Resolution of MRI was observed after the clinical signs, in the present case.

Hemocromatose hereditária / Hereditary hemochromatosis

A hemocromatose é um distúrbio autossômico recessivo ou dominante que ocorre devido ao aumento inapropriado da absorção de ferro pela mucosa gastrointestinal, resultando no armazenamento excessivo desse elemento no fígado, pâncreas, coração, articulações e gônadas. Afeta a populaçãocaucasiana, com prevalência de até um em 200 descendentes da população nórdica ou celta. O diagnóstico se faz por critérios clínicos, bioquímicos (ferritina, saturação da transferrina, etc.), genéticos epor imagem (ressonância magnética, tomografia e ultrassom).

Hemochromatosis is a disorder autosomal recessive or dominant that occurs inappropriate due to the increased absorption of iron by the gastrointestinal mucosa resulting in excessive storage of this element in the liver, pancreas, heart, joints and gonads. It affects the caucasian population with a prevalence reaching up to 1 in 200 people descendants of the population nordic or celtic. The diagnosis is made by clinical criteria, biochemical (ferritin, transferrin saturation of and so on), genetic and by image (magnetic resonance, tomography and ultrasound).

Cortical venous thrombosis due to acquired hyperhomocysteinaemia.

A 20-year-old student presented with generalized tonic– clonic seizures and was diagnosed to have cortical venous thrombosis. Her dietary history and the clinical signs of vitamin deficiency prompted further investigations, which detected hyperhomocysteinaemia secondary to vitamin B12 deficiency as a factor contributing to the hypercoagulable state. This case highlights the importance of a balanced diet, as well as the necessity for primordial prevention.

Medical management of male infertility.

Management of male infertility is always a difficult task. In recent years booming of artificial reproductive technologies (ART) has put infertologists and andrologists in front of a million dollar question whether to treat the person or the gametes. A basic andrology laboratory at present has become part and parcel of an infertility clinic. Hence treatment of male infertility has become institutional and collective for clinicians and basic scientists. The basic approach towards management of male infertility includes confirmation of diagnosis and to find out the cause for which pathological, endocrinological and biochemical tests are essential. In this series specific defects causing seminopathy has been found in 18% cases where treatment is straightforward and towards the cause. The main bulk of idiopathic seminal defects (82%) really poses challenge to the infertologists so far management is concerned. In this study commonest seminal defect has been found to be oligoasthenozoospermia which amounts to 63% cases. For medical management purpose drugs commonly used are clomiphene, gonadotrophins, bromocriptine, L-thyroxine, vitamin E, B12, etc. When they fail the main approach remains to be intra-uterine insemination (IUI) and ART eg, in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).

Severe folate deficiency mimicking HELLP syndrome--report of two cases.

Severe folate deficiency in pregnancy may mimick HELLP syndrome as there are similar features in both. Proper diagnosis is important as far as the prognosis and management are concerned. Two cases of severe folate deficiency occuring in multigravid women mimicking HELLP syndrome are reported below with review of literature.

The C677T thermolabile variant of methylene tetrahydrofolate reductase on homocysteine, folate and vitamin B12 in a hemodialysis center

Homocysteine is a risk factor for cardiovascular disease. Mutations in a key enzyme in homocysteine metabolism, methylenetetrahydrofolate reductase, may contribute to hyperhomocysteinemia and alter folate and cobalamin levels. After starting hemodialysis, 10 mg oral folate daily and 500 micrograms intravenous methylcobalamin once weekly were prescribed to 27 hemodialysis patients (time on hemodialysis > or = 12 months) and two groups were defined: Group A normal; Group B heterozygous. Initial, third and twelfth month measurements of homocysteine, serum folate and vitamin B12 levels were collected and analyzed. Heterozygous state of methylenetetrahydrofolate reductase prevalence was 48

. Hyperhomocysteinemia was present in both groups. Cobalamin final levels were significantly lower in Group B compared to Group A. Homocysteine, serum folate and cobalamin levels at third and twelfth month were significantly different from baseline levels but non-different between them in both groups. In Group B, vitamin B12 at third month was significantly higher than initial, but final measurements were not different from baseline determinations. In conclusion, the heterozygous prevalence of the enzyme in hemodialysis patients is similar to that reported in the general population; hyperhomocysteinemia is frequent in hemodialysis patients and final levels in heterozygous patients are significantly higher than in normal patients. Cobalamin levels are lower in the heterozygous group. After one year of treatment, homocysteine tends to increase, suggesting a secondary resistance phenomenon to vitamin supplementation in heterozygous patients.