Intramuscular Vitamin Research Articles

8129 A Case of Pituitary Stalk Interruption Syndrome Presenting With Panhypopituitarism

Abstract Disclosure: A. Salvat: None. M. Sevilla: None. Background: Pituitary stalk interruption syndrome (PSIS) is a rare congenital abnormality characterized by the classic triad of a thinned or interrupted pituitary stalk, an ectopic or absent neurohypophysis, and a hypoplastic or absent anterior pituitary gland. Clinical manifestations vary and can include neonatal hypoglycemia, short stature, cryptorchidism, and delayed puberty. Symptoms can present at birth or later in life with variable degrees of hormone deficiency. Clinical case: A 25-year-old male with hypothyroidism (on levothyroxine since age 13) presented for evaluation of hypogonadotropic hypogonadism. At birth, he was diagnosed with bilateral cryptorchidism and had frequent hypoglycemic episodes. During his childhood and early teenage years, his growth paralleled of his peers. However, at age 18, he experienced a growth spurt with unusually long arms and legs. He never developed secondary sexual characteristics. Physical examination showed blood pressure of 109/62 mmHg, height 193 cm, weight 76 kg, Tanner stage 1 pubic hair, microphallus, and nonpalpable testicles. The initial labs were consistent with panhypopituitarism: FSH 0.14 mIU/mL (0.95–11.95 mIU/mL), luteinizing hormone <0.09 mIU/mL (0.57–12.07 mIU/mL), total testosterone <4 ng/dL (240–871 ng/dL), prolactin 30.31 ng/dL (3.46–19.40 ng/dL), AM cortisol <1 ug/dL (3.7–19.4 ug/dL), ACTH 14 pg/mL (6–50 pg/mL ), cortisol levels 60 minutes after consyntropin stimulation test of 3.6 ug/dL (3.7–19.4 ug/dL), IFG-1 <16 ng/mL (63–373 ng/mL), TSH 7.24 uIU/mL (0.35–4.94 uIU/mL), free T4 0.53 ng/dL (0.70–1.48 ng/dL). Karyotype 46, XY, inv (9) (p12q13). The whole exome sequencing testing was negative. Pituitary magnetic resonance imaging showed hypoplasia of the anterior pituitary gland, ectopic location of the posterior pituitary gland at the expected base of the pituitary infundibulum anterior to the mammary bodies, and hypoplastic or absent pituitary infundibulum, findings suggestive of pituitary stalk interruption syndrome. Scrotal ultrasound showed no testicular or epididymal tissue within the scrotum. DEXA scan showed osteoporosis associated with a long history of non-treated testosterone deficiency. The levothyroxine was adjusted, and the patient was started on intramuscular testosterone, calcium, and vitamin D to manage the hypogonadism and improve the bone mineral density. Conclusion: Diagnosis of PSIS is often delayed due to its variable presentation and age of onset. Although this condition is considered rare, it should be in the differential diagnosis of patients presenting with panhypopituitarism. Early identification of deficient hormones, as well as prompt initialization of hormone replacement therapy, is essential to prevent serious complications associated with these deficiencies, such as adrenal crisis, osteoporosis, diminished quality of life, delayed puberty, and infertility. Presentation: 6/3/2024

Imerslund-Gräsbeck syndrome in a child with a novel compound heterozygous mutations in the AMN gene: a case report

BackgroundImerslund-Gräsbeck syndrome (IGS) is an autosomal recessive disorder characterized by selective vitamin B12 malabsorption, resulting in vitamin B12 deficiency and impaired reabsorption of proximal tubular proteins.This case highlights a previously unidentified compound heterozygous variant in the Amnionless (AMN) gene that causes IGS syndrome and underscores the importance of long-term oral vitamin B12 replacement therapy in managing the condition.Case presentationIn this retrospective analysis, we present the clinical data of a 3-year and 6-month-old female child diagnosed with IGS at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China, in November 2018. The child was admitted to the hospital due to a history of anemia persisting for over a month. There was no previous significant medical history. The admission examination revealed megaloblastic anemia with proteinuria. Serum vitamin B12 levels were decreased, while folic acid and renal function were normal. The patient was diagnosed with megaloblastic anemia and started long-term oral vitamin B12 replacement therapy. Throughout the follow-up period, blood tests consistently showed normal results, while proteinuria persisted. In November 2019, the child and her parents underwent whole exome sequencing analysis, which revealed a novel compound heterozygous variant in the AMN gene: c.162 + 1G > A and c.922 C > T (p.Q308X) in the child, c.162 + 1G > A in the father, and c.922 C > T (p.Q308X) in the mother. Therefore, this child was further diagnosed with IGS.ConclusionsIn this case, whole exome sequencing proves to be highly practical in daily healthcare for diagnosing and refining rare or ultra-rare diseases with ambiguous phenotypes or genetic diversity. It is also valuable for prognostic evaluation and personalized management. Additionally, the oral vitamin B12 treatment demonstrated positive clinical effects for the child, offering a new option for patients unable to undergo intramuscular vitamin B12 replacement therapy.

Comparison of Vitamin D2 and Vitamin D3 Supplementation Parenterally in Raising Serum 25-Hydroxy vitamin D Status in Pediatric Patients

Abstract Background There is a controversy regarding the effect of vitamin D2 and D3 in elevating and sustaining 25(OH)D levels. Aim: This study will concentrate on the effect of parenteral administration of both vitamins on serum 25(OH)D levels. Methods Randomized controlled clinical trial, conducted in Pediatric Endocrinology Unit, Ain Shams University, Cairo, Egypt, where 50 participants who had vitamin D deficiency were recruited. Subjects were divided into two groups, 25 patients per group (group A received a single dose of 200,000 IU of intramuscular vitamin D2 and group B received 200,000 IU of intramuscular vitamin D3). History of sun exposure and dietary intake of calcium, assessment of anthropometric measures and tanner staging, laboratory investigations were documented. Follow up of serum level of 25(OH)D was done every month for three consecutive months. Results Parenteral vitamin D3 supplementation in group B patients resulted in significantly higher increments in 25(OH)D level than that achieved by parenteral vitamin D2 supplementation in group A after 1st, 2nd, and 3rd months of the supplement (p = 0.000). Vitamin D3 supplementation resulted in a significantly greater increment in serum 25(OH)D levels from 1st to 2nd month and from 1st to 3rd month than Vitamin D2 supplementation with a P value of 0.039 and 0.018 respectively. One hundred percent of group B participants who received vitamin D3 reached sufficient level (41.04 ± 10.04) after 1 month while 80% of participants in group A who received vitamin D2 reached a sufficient level after 1 month and 20% of participants after 2 months (P = 0.018). Conclusion We can conclude that parenteral vitamin D3 supplementation was more effective in raising serum 25(OH)D status in pediatric patients than parenteral vitamin D2 supplementation.

Laughing gas abuse causing subacute combined spinal cord degeneration with psychiatric manifestations

Background. Nitrous oxide, a nonirritating gas commonly used as an anesthetic, is increasingly abused by the young population for its euphoric effects due to its seemingly harmless nature. However, its neurological impacts can vary in intensity and sometimes result in permanent damage. Accurate diagnosis and treatment hinge on identifying nitrous oxide use through anamnesis, clinical and paraclinical findings, as demonstrated in the following case report. Case report. A 27-year-old female with psychiatric history presented with progressive paresthesia and walking difficulty, admitting to recent nitrous oxide use, alongside other substances. Clinical examination revealed mild tetraparesis, coordination disturbances, generalized hyporeflexia, and sensory deficits. Electromyography showed severe sensory neuropathy, and spinal MRI indicated subacute combined degeneration (SCD) of the spinal cord. Laboratory tests revealed hyperhomocysteinemia and elevated methylmalonic acid levels, despite normal vitamin B12 levels. Treatment included intramuscular vitamin B12, folic acid, and neurotrophic agents, along with physical rehabilitation. Psychiatric symptoms, possibly exacerbated by nitrous oxide, and complicated adherence to therapy. Conclusions. This case underscores the neurotoxic potential of nitrous oxide, particularly its disruption of cobalamin metabolism, and highlights the need for thorough patient histories to uncover substance use contributing to neurological symptoms. Despite treatment, some neurological deficits may persist, emphasizing the importance of early intervention and comprehensive care strategies.

Oral vitamin B12 supplementation in pernicious anemia: a prospective cohort study

BackgroundThe absorption of vitamin B12 is hindered in pernicious anemia (PA) owing to intrinsic factor deficiency. Traditionally, intramuscular vitamin B12 injections were the standard treatment, bypassing the impaired absorption. Although there is potential for oral vitamin B12 supplementation through passive enteral absorption, it is not commonly prescribed in PA owing to limited studies assessing its efficacy. ObjectivesWe aimed to assess the efficacy of oral vitamin B12 supplementation in PA. MethodsWe enrolled participants diagnosed with incident vitamin B12 deficiency related to PA. The diagnosis of PA was based on the presence of classical immune gastritis and of anti-intrinsic factor and/or antiparietal cell antibodies. To evaluate the vitamin B12 status, we measured total plasma vitamin B12, plasma homocysteine, and plasma methylmalonic acid (pMMA) concentration and urinary methylmalonic acid–to–creatinine ratio. Participants were treated with oral cyanocobalamin at a dosage of 1000 μg/d throughout the study duration. Clinical and biological vitamin B12 deficiency related features were prospectively and systematically assessed over the 1-y study duration. ResultsWe included 26 patients with vitamin B12 deficiency revealing PA. Following 1 mo of oral vitamin B12 supplementation, 88.5% of patients were no longer deficient in vitamin B12, with significant improvement of plasma vitamin B12 [407 (297–485) compared with 148 (116–213) pmol/L; P < 0.0001], plasma homocysteine [13.5 (10.9–29.8) compared with 18.6 (13.7–46.8) μmol/L; P < 0.0001], and pMMA [0.24 (0.16–0.38) compared with 0.56 (0.28–1.09) pmol/L; P < 0.0001] concentrations than those at baseline. The enhancement of these biological parameters persisted throughout the 12-month follow-up, with no patients showing vitamin B12 deficiency by the end of the follow-up period. The median time to reverse initial vitamin B12 deficiency abnormalities ranged from 1 mo for hemolysis to 4 mo for mucosal symptoms. ConclusionsOral supplementation with 1000 μg/d of cyanocobalamin has been shown to improve vitamin B12 deficiency in PA.

Progressive multifocal leukoencephalopathy associated with systemic lupus erythematosus: longitudinal observation of lymphocytes, JC virus in cerebrospinal fluid, and brain magnetic resonance imaging

Progressive multifocal leukoencephalopathy (PML) rarely occurs in patients with systemic lupus erythematosus (SLE). This report presents the case of a patient who developed PML due to SLE-associated multiple factors. A 60-year-old woman diagnosed with SLE undergoing multiple immunosuppressive therapies, including azathioprine, presented with cerebral cortical symptoms, lymphocytopenia, and vitamin B12 deficiency and was subsequently diagnosed with SLE-associated PML. We evaluated the cause and disease activity of PML, focusing on the longitudinal assessment of lymphocytopenia, JC virus (JCV) DNA copy number in the cerebrospinal fluid, and magnetic resonance imaging (MRI) findings. Discontinuing azathioprine and initiating alternative immunosuppressive treatments with intramuscular vitamin B12 injections affected lymphocytopenia and disease management. However, despite recovery from lymphopenia and JCV DNA copy number being low, the large hyperintense and punctate lesions observed on the fluid-attenuated inversion recovery (FLAIR) images exhibited varying behaviors, indicating that the balance between contributing factors for PML may have fluctuated after the initial treatment. Clinicians should be meticulous when assessing the underlying pathology of the multifactorial causes of PML due to SLE. The difference in the transition pattern of these lesions on FLAIR images may be one of the characteristics of MRI findings in PML associated with SLE, reflecting fluctuations in disease activity and the progression stage of PML.

Uptake of intra-muscular vitamin K administration after birth: A national cohort study.

A long-acting monoclonal antibody against RSV (nirsevimab), given as an injection shortly after birth, is currently being rolled out globally. Carer acceptance of intra-muscular (IM) vitamin K, another injection given shortly after birth, could serve to indicate the acceptability of nirsevimab. We analysed a national dataset of postnatal health visitor visits in Scotland; individual-level data on gestation were not available. The primary outcome measure was the modality of administration of vitamin K; potential explanatory variables were maternal age, infant ethnicity, English as a first language, and measures of socio-economic deprivation. We examined associations between IM vitamin K administration or oral/no vitamin K and each explanatory variable. From 2019 to 2021, questionnaires were available for 142 857 infants; data was missing for 2.7%. IM Vitamin K uptake was high: 95.5% of carers consented, with 1.1% requesting oral vitamin K and 0.9% refusing vitamin K altogether. Infant ethnicity, use of English as a first language, socio-economic status and maternal age were not associated with reduced uptake of IM vitamin K. If IM Vitamin K administration is a valid proxy measure for nirsevimab acceptance, we did not identify groups that might require increased engagement prior to nirsevimab roll-out.

Treatment of spectacular dysecdysis in a Boa constrictor snake at Lombok Wildlife Park, Nusa Tenggara Barat

Lombok Wildlife Park is a conservation institution located in Lombok, Nusa Tenggara Barat, and with specialization for wild animals including snake. This paper reports the treatment of spectacular dysecdysis in a Boa constrictor snake. The snake Boly, approximately 1.5 years old with a body weight of 8 ounces, experienced stuck eye caps or spectacular dysecdysis after an incomplete moulting process. There was swelling of the tissue in both eyes, and the boa lost appetite. Treatment was carried out by administering antibiotics and anti-inflammatory drugs for the first 3 days and continued with supporting supplements in the form of iron and intramuscular vitamin B12 for the next 3 days. The swollen tissue in the left eye burst and caused damage to the eye organs, whereas the dried tissue in the right eye was peeled off manually. The snake's appetite has improved again, and it wants to eat on its own.

Effects of sources and routes of administration of vitamins A, D and copper on postnatal status of these micronutrients in piglets.

Twenty-six nulliparous sows were fed conventional gestation and lactation diets supplemented (N = 13) or not (N = 13) with extra daily supplements of 25-hydroxy-cholecalciferol (25-OH-D3; 4 ĸIU), β-carotene (24 ĸIU), and copper (Cu)-proteinate (45 mg) from day 90 of gestation to 21 d of lactation (L21). In each litter, 10 piglets were divided into 5 pairs received, at 2 (L2) and 8 d (L8) of age, one of the five combinations of micronutrient sources and routes of administration (N = 260 piglets total). These neonatal treatments (N = 26 pairs or 52 piglets each) consisted of oral vitamin D3, retinol acetate and CuSO4 (T1); oral 25-OH-D3, β-carotene, and Cu proteinate (T2); exposure to ultraviolet light (UVB), oral retinol palmitate and Cu gluconate (T3); intramuscular vitamin D3 and retinyl propionate and oral Cu acetate (T4); oral saline (CTRL). Oral or intramuscular provisions corresponded to 12 mg of Cu and 70 and 12 ĸIU of vitamins A and D, respectively. Blood samples were collected from all piglets at L2, L8, and L21 for determination of serum Cu, retinol, and 25-OH-D3. Body weight was measured at birth, L2, L8, and L21. Piglets were weaned at L21, and liver and blood samples were collected 2 d later to evaluate oxidative enzymes in blood and liver and hepatic ATP concentrations and expression of genes associated with antioxidant status. Sow treatments had marginal or no impacts on Cu, retinol, 25-OH-D3, or antioxidant status in piglet blood serum and liver. However, when supplements were given to piglets, hepatic Cu was 38% greater in for all treated piglets compared to CTRL (P < 0.01), hepatic retinol was 3 times higher in T1 than in CTRL (P < 0.01) and intermediate for other treatments whereas serum 25-OH-D3 was markedly increased with T2 and T3 at L8 and L21, respectively, compared to CTRL (Piglet treatment × Age interaction, P < 0.01). Concerning antioxidant activities, glutathione peroxidase, and superoxide dismutase were increased (P < 0.03) in plasma of T2 piglets whereas the highest values (P < 0.03) for indicators of oxidative damage to proteins were observed in T4 piglets. The study revealed that oral Cu proteinate from T2, oral retinol acetate from T1, oral 25-hydroxy-cholecalciferol from T2, and UVB light exposure from T3 were the most efficient ways of increasing the postnatal status of these micronutrients in suckling piglets and this may have some impacts on their peri-weaning antioxidant status.

Intramuscular vitamin A injection in newborn lambs enhances antioxidant capacity and improves meat quality.

Vitamin A (VA) and its metabolite, retinoic acid (RA) possess several biological functions. This report investigated whether neonatal intramuscular VA injection affected antioxidative activity and meat quality in longissimus dorsi (LD) muscle of lambs. Lambs were injected with 0 (control) or 7,500 IU VA palmitate into the biceps femoris muscle on day 2 after birth. At 3, 12, and 32 weeks of age, blood samples were collected in the jugular vein for serum levels of RA and muscle samples were collected in the biceps femoris for analysis of relative mRNA expression of enzyme contributors to retinoid metabolism. All animals were harvested at 32 weeks of age and muscle samples were collected to explore the role of VA on the meat quality and antioxidant capacity of lambs. Our results indicated that VA increased the redness, crude protein, and crude fat (p < 0.05), without affecting moisture, ash, and amino acid composition in LD muscle (p > 0.05). In addition, VA increased catalase (CAT) activity and decreased malondialdehyde (MDA) levels in LD muscle (p < 0.05). Meanwhile, greater levels of CAT and NRF2 mRNA and protein contents with VA treatment were observed in LD muscle (p < 0.05), partly explained by the increased level of RA (p < 0.05). Collectively, our findings indicated that VA injection at birth could improve lamb meat quality by elevating the redness, crude protein, crude fat, and antioxidative capacity in LD muscle of lambs.

Implementation of a short-term treatment protocol in anemic patients before cardiac surgery.

We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting. Starting onFrom January 1st, 20202020, to November 31st, 2022, we implemented a perioperative protocol for anemic patients (women Hemoglobin (Hb) <11.5 g/dL, men Hb<12.5 g/dL), which included subcutaneous erythropoietin alpha, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os Iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated on in the four years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission. In the months after protocol implementation, 114 patients who received the treatment protocol were compared to 236 anemic patients in the four years prior who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2-7] units vs. treatment 2 [1-3] units, p<.0001) and the incidence of post-operative blood products transfusions (treatment group 58 patients, 50.88% vs control group 177 patients, 75%, p<.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 [8.3-9.5] g/dL vs. control 8.6 [8.1-9.1] g/dL, p=0.0081). Despite some differences compared to previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting.

C8 (Clinical Case) A 10-Month-Old Male with Macrocytic Anemia and Hypoalbuminemia

Abstract Introduction/Background Transcobalamin-II Deficiency (TCII-Deficiency) is a rare autosomal-recessive metabolic condition, resulting in ineffective transport and uptake of Vitamin B12. Clinical features of pancytopenia, failure to thrive, diarrhea, and developmental delay typically present between 1-12 months of age1. Case Description A 10-month-old term, previously well male with a normal newborn screen, presented with a one-month history of decreased energy, failure to thrive, and diarrhea. He had a two-week history of gross motor regression with lower limb and periorbital edema. Examination was notable for perioral rash, severe diaper dermatitis, buccal ulcerations, pallor, and generalised edema including ascites. There was no organomegaly or any dysmorphic features. Investigations revealed macrocytic anemia, thrombocytopenia, worsening neutropenia, hypoalbuminemia, hypertriglyceridemia, and hypogammaglobulinemia (Table 1). Vitamin B12 and B9 levels were normal. Bone marrow biopsy was hypocellular, and ruled out aplastic anemia and leukemia. Intestinal biopsy showed generalized edema from duodenum to rectum with GVHD-like injury pattern, and evidence for protein-losing enteropathy (PLE). Required therapy included numerous RBC, platelet, and albumin transfusions and enteral feeding. A disorder of vitamin B12 metabolism, specifically TCII-Deficiency, was suspected based on clinical presentation with no other clear explanation. Serum MMA was highly elevated at 24,154 nmol/L (0-500 nmol/L) as was homocysteine at 27.3 umol/L (4.7-10.3 umol/L). Whole-exome sequencing identified two mutations in TCN2. Treatment with intramuscular vitamin B12 resulted in reduction of urinary MMA level to 5.6 umol/mmol Cr (&amp;lt; 2 umol/mmol Cr) in 10 days. Discussion Over the next months of treatment with intramuscular hydroxocobalamin, the MMA, homocysteine, albumin and CBC normalized and all clinical complications were resolved. Gross motor skills returned to normal, with only mild persistent speech delay. TCII-Deficiency often presents with a heterogeneous constellation of symptoms. In this case, the differential included several hematologic and gastrointestinal pathologies, including DGAT1 deficiency (due to hypertriglyceridemia, diarrhea, and PLE) and CHAPLE syndrome (due to low immunoglobulins and PLE). MMA and homocysteine levels are often markedly elevated in B12 metabolism defects, and can justify initiation of treatment with cyanocobalamin/hydroxocobalamin (Vitamin B12) while awaiting confirmatory genetic testing2. Conclusion TCII-Deficiency is a rare cause of macrocytic anemia; early consideration and treatment with intramuscular vitamin B12 leads to dramatic symptom improvement and is important for paediatricians to recognize. Clinical Pearls: • Clinicians should consider B12 metabolism defects on their differential in a young child who has macrocytic anemia with normal B12 levels. • Paediatricians can use MMA and homocysteine levels to assess for B12 metabolism defects while awaiting genetic testing.

Vitamin A injection at birth improves muscle growth in lambs.

Vitamin A and its metabolite, retinoic acid (RA) play important roles in regulating skeletal muscle development. This study was conducted to investigate the effects of early intramuscular vitamin A injection on the muscle growth of lambs. A total of 16 newborn lambs were given weekly intramuscular injections of corn oil (control group, n=8) or 7,500 IU vitamin A palmitate (vitamin A group, n=8) from birth to 3wk of age (4 shots in total). At 3wk of age and weaning, biceps femoris muscle samples were taken to analyze the effects of vitamin A on the myogenic capacity of skeletal muscle cells. All lambs were slaughtered at 8 months of age. The results suggest that vitamin A treatment accelerated the growth rate of lambs and increased the loin eye area (P<0.05). Consistently, vitamin A increased the diameter of myofibers in longissimus thoracis muscle (P<0.01) and increased the final body weight of lambs (P<0.05). Vitamin A injection did not change the protein kinase B/mammalian target of rapamycin and myostatin signaling (P>0.05). Moreover, vitamin A upregulated the expression of PAX7 (P<0.05) and the myogenic marker genes including MYOD and MYOG (P<0.01). The skeletal muscle-derived mononuclear cells from vitamin A-treated lambs showed higher expression of myogenic genes (P<0.05) and formed more myotubes (P<0.01) when myogenic differentiation was induced invitro. In addition, invitro analysis showed that RA promoted myogenic differentiation of the skeletal muscle-derived mononuclear cells in the first 3d(P<0.05) but not at the later stage (P>0.05) as evidenced by myogenic gene expression and fusion index. Taken together, neonatal intramuscular vitamin A injection promotes lamb muscle growth by promoting the myogenic potential of satellite cells.

491. VITAMIN B12 DEFICIENCY AFTER ONCOLOGICAL ESOPHAGECTOMY AND GASTRECTOMY

Abstract Vitamin B12 deficiency is common in patients with resections of the upper digestive tract and must be expected during follow-up examinations. While esophagectomy with gastric pull-ups preserve the duodenal passage and a large part of the stomach, (sub)total gastrectomies result in significant losses of gastric tissue and the common Y-Roux reconstruction bypasses the duodenal passage. This is a monocentric, retrospective, descriptive analysis of prospectively collected follow-up data. Between January 2015 and December 2019, 232 patients underwent an oncological (sub)total gastrectomy or esophagectomy. After applying the exclusion criteria (patient below 18, primary bone marrow disease, hereditary forms of anemia, postoperative tumor recurrence, R1/R2 situation), 157 patients remained for analysis: 103 patients (=66%) with esophagectomy (ER) and 54 (=34%) with (sub)total gastrectomy (SGE). Vitamin B12 levels were analyzed three, six, twelve, 18, and 24 months after the surgery. Prophylactic intramuscular vitamin B12 substitution (Erycytol 1 mg depot) was routinely prescribed quarterly only in patients with a total gastrectomy. After 3 postoperative months the incidence of vitamin B12 deficiency were 24% in the ER group vs. 5% (p = 0,064) in the SGE group; 17% vs. 10% (p = 0.4) after 6 months; 8% vs. 5% (p = 0.65) after 1 year; 10% vs. 10% (p = 0.83) after 18 months, and 12.5% vs. 39% (p = 0.022) after 2 years. The resulted incidence of hyperchromic macrocytic anemia is furtherly discussed in the abstract entitled ‘Types and incidence of postoperative anemia after oncological esophageal and gastric resections’. Comparing the total gastrectomy versus subtotal gastrectomy subgroups, patients with a subtotal gastrectomy have higher vitamin B12 deficiency incidences throughout the 24-month follow-up period. The human body physiologically provide a sufficient vitamin B12 storage for minimum 6–9 months. The high incidence of vitamin B12 deficiency in the ER group in the first 6 postoperative months might be due to a pre-existing vitamin B12 deficiency. After the 6th postoperative month there is an approximation between the Vitamin B12 deficiency incidences of ER and (S)GE patients. In the final 2-year follow-up, the incidence of vitamin B12 deficiency was significantly higher in the (S)GE group.

Therapeutic role of vitamin B12 in patients with chronic tinnitus: A pilot study

Background: True tinnitus has no audible acoustic origin and is a phantom auditoria experience originating from a cause or trigger in the cochlea, brainstem, or at highly centers. The Jastreboff neurophysiologic hypothesis, which emphasizes that tinnitus is a subcortical sensation and originates from the interpretation of weak neuronal activities in the peripherals, is the most widely recognized.&#x0D; Aim: This research seeks to understand the function of vitamin B12 in the management of chronic tinnitus.&#x0D; Methods: A total of 100 individuals participated in this randomized, double-blinded pilot study, of whom 50 in Group A (patients) obtained intramuscular treatment of 1 ml Vitamin B12 (2500 mcg) once a week for a duration of six weeks, while the remaining 50 subjects in Group B (controls) obtained isotonic salines as a placebo. Pre- and post-treatment audiological and a Vitamin B12 testing were performed on the subjects.&#x0D; Results: When standard dosages of vitamin B12 were set at 250 pg/ml, 43% of the overall tinnitus patients showed deficiencies. Upon receiving Vitamin B12 medication, individuals in Group A with Vitamin B12 insufficiency significantly improved their average tinnitus intensity index value and visual analogue scale (VAS), according to a paired t-test.&#x0D; Conclusion: This study shows the substantial predominance of Vitamin B12 deficiency among &gt;&gt;&gt; and the improved performance in tinnitus severity results and VAS in cobalamin-deficiency patients receiving intramuscular Vitamin B12 once a week for six weeks. It also establishes a connection between cobalamin deficiency and tinnitus, suggesting that B12 may be used therapeutically in cobalamins-deficient tinnitus subjects.

Stoss therapy versus weekly regimen of vitamin D in children with chronic liver disease: a randomized pilot study

BackgroundVitamin D, a hormone involved in the regulation of mineral homeostasis, protects skeletal integrity and modulates cell growth and differentiation. Recently, its potential antifibrotic effects have also been identified. Children with chronic liver disease mostly suffer from vitamin D deficiency. However, little knowledge is known regarding the optimum regimen that can be utilized effectively and safely to correct vitamin D deficiency in these patients and whether it could be effective in reversal or at least halting the progressive process of liver fibrosis. This study is conducted to answer these questions.ResultsTwenty-four children with chronic liver disease (13 boys and 11 girls) were included in the study. Their age ranged from 4.5 to 11.5 years with median age of 8 years. The aetiology of liver disease was heterogenous with autoimmune hepatitis, glycogen storage disease, or chronic hepatitis, and hepatitis C affects the majority. The patients were divided into two matched groups: group A (n:12) that received stoss parenteral intramuscular vitamin D3 (cholecalciferol) therapy (200,000 IU) once followed by 600 IU/day orally for 6 months (this is equivalent to the RDA as maintenance therapy) and group B (n:12) that received 50,000 IU/week oral vitamin D3 (cholecalciferol) therapy in divided daily doses adding on the maintenance dose 600 IU/day for the first 4 weeks followed by only 600 IU/day orally for the rest of the 6 months (5 months). Following vitamin D3 supplementation, in group A (vitamin D stoss therapy group) and group B (vitamin D oral therapy group), there were statistically significant improvement of Ca, alkaline phosphatase, and vitamin D levels, though there was no difference in between both groups. No significant correlation could be found between vitamin D changes and fibroscan changes in either group.ConclusionVitamin D therapy using stoss dose followed by oral therapy or oral vitamin D therapy from the start was equally safe and effective in improving the clinical and laboratory metabolic bone profile abnormalities. Vitamin D effect on liver fibrosis progression or reversion in children is still not understood, and further studies are needed in this field taking in consideration the various causes of liver disease in children.

The Legal Limits of Parental Autonomy: Do Parents Have the Right to Refuse Intramuscular Vitamin K for Their Newborn?

Description The American Academy of Pediatrics recommends that all newborns receive an intra-muscular (IM) dose of vitamin K within 6 hours of delivery for the prevention of vitamin K deficiency bleeding (VKDB). There has been an increase in the number of parents who have refused the IM vitamin K dose for their infant based on its possible link to leukemia, preservatives that may lead to adverse reactions, and wanting to avoid pain for the infant. When newborns do not receive IM vitamin K, the most serious feared potential complication is intracranial hemorrhage with potential neurologic sequela including seizures, developmental delay, and death. Recent studies support the contention that parents are making the choice to refuse IM vitamin K without sufficient knowledge of the potential consequences. Parental decisions typically align with the best interest of the child; however, when parental decisions veer from the child's best interest, the limit of parental autonomy is tested. The precedent set by previous cases in which parental autonomy was challenged suggests parents should not be able to refuse IM vitamin K because the therapy has nearly no burden and forgoing this therapy has the potential for substantial harm. It has been argued that as long as the degree of intrusion is modest (a single IM injection) and the benefit substantial (prevention of possible death), states are granted the power to mandate the use of such an intervention. Mandated IM vitamin K for all newborns, regardless of parental approval, would rescind some parental autonomy but improve overall beneficence, nonmaleficence, and justice in the care of newborns.

Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?

BackgroundVitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. Case ReportA 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. Why Should an Emergency Physician Be Aware of This?Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.

Deficiência de vitamina A como causa de cegueira em bezerros confinados

ABSTRACT: Vitamin A is an essential micronutrient to reproduction, development, normal growth, and function of the nervous system and vision, especially in growing animals. Hypovitaminosis A can affect any of these functions. The aim of this study was to describe the epidemiology, clinical signs, pathological aspects, and diagnostic approach in an outbreak of blindness in feedlot calves fed only grain. Five of 57 ten-month-old calves became blind after eight months at the feedlot. Clinical signs were mydriasis, absent pupillary and menace reflexes, bilaterally. Hypovitaminosis A was suspected and subsequently confirmed by low serum levels of vitamin A. One calf was euthanized and necropsied, and no gross findings were present. Histopathological lesions were restricted to the retina and characterized by degeneration and atrophy of the photoreceptor layer and some retinal scars. The calves were treated with intramuscular vitamin A injection at a dose of 5,000 international units (IU) per kilogram of body weight (kg BW) every 60 days until slaughter. Affected calves did not recover visual capacity, but no other cases occurred.

Agreement of Revised Premature Infant Pain Profile Scoring between Healthcare Providers and Laypersons: A Cross-sectional Study

Introduction: The experience of pain during the neonatal period has short and long-term consequences. The Revised Premature Infant Pain Profile (PIPP-R) is a globally accepted and validated tool for assessing pain in neonates. Adequate pain management measures can be implemented using the PIPP-R, even in the absence of consultants. Aim: To assess the agreement among healthcare providers and laypersons in scoring the PIPP-R. Materials and Methods: A cross-sectional study was conducted at Shree Krishna Hospital, a rural Tertiary Care Teaching Hospital in central Gujarat, India. The duration of the study was one year and six months, from January 2021 to June 2022. The study included 12 volunteers from various fields, such as consultant neonatologists, first year postgraduate students in Department of Paediatrics, neonatal nurses, social workers, Bachelor of Medicine, Bachelor of Surgery (MBBS) interns, and mothers of newborns. A neonatology consultant provided training on the PIPP-R scoring system using handouts and a presentation. The volunteers then evaluated 100 prerecorded videos of newborns undergoing painful procedures. Agreement between volunteers for the total PIPP-R score and its subcomponents was assessed using Bland-Altman analysis and Cohen’s Kappa statistics. Results: A total of 100 videos of newborns (51 girls, 49 boys) undergoing painful procedures were evaluated for the PIPP-R score. The mean age, gestational age, and birth weight of the newborns were 2.21±1.55 days, 37±2.44 weeks, and 2.56±0.72 kg, respectively. The procedures included heel prick for Random Blood Sugar (RBS) (44%), intravenous sampling/insertion (34%), and intramuscular vitamin K injection (22%). The mean difference with 95% Confidence Limits (CL) of total PIPP-R scores between the two consultants (neonatologists) was -0.640 (-5.196, 3.916). The length of the CL was -9.112, which fell outside the defined CL of 4.2 (20% of the total score), indicating unacceptable agreement between the two consultants. Similarly, agreement between each consultant and any of the other participants, including residents, nurses, interns, mothers, and social workers, regarding the total PIPP-R score, as well as its subcomponents, was also deemed unacceptable. Conclusion: The present study concluded that the inter-rater reliability of the PIPP-R score and its subcomponents was unacceptable between consultants and with any of the other participants.