Boring B12 Deficiency

Back in September 2014 a medical research team in England published a clinical review. On the surface there was nothing particularly earth-shattering about it; all they did was compile the most appropriate latest research studies about B12 deficiency and provide a concise summary on how to diagnose and manage the illness.

So. Boring. Right?

Well, maybe not, because the review pointed out a few home truths to clinicians which has sent many reeling. It turns out that B12 deficiency isn’t exactly the done deal most doctors seemed to think it was. In fact, for many clinicians, it turns out B12 deficiency isn’t what they thought it was at all. The B12 deficiency most doctors thought was a simple blood condition which might lead to a dangerous anaemia if B12 levels in the blood weren’t brought up to normal was, well, not exactly that.

Tyson Storms into the Ring!

The review starts out by packing a punch which for clinicians was the proverbial uppercut, as the abstract explains to doctors that B12 deficiency actually causes a dysfunction of DNA metabolism – this, to the uninitiated, means cells, and since we are made up of cells that one fact alone could be considered quite disturbing. Without pausing for breath the powerhouse article follows through with a jaw-breaking right as it goes on to explain that B12 blood levels, which doctors usually test to identify the condition, measures all B12 whether it is available for the body to use or not. The percentage of B12 which is unusable can be as high as 94 per cent.

The guffaws of denial started almost immediately. Telling doctors, even in the most impersonal way, that they have been getting something wrong was never going to be an easy task, and the clinicians were quick to respond moving in with some fancy footwork and a volley of jeering jabs. They had little impact. The paper was dominating the fight and moved relentlessly forward.

The dysfunction, it went on to explain, can result in serious clinical symptoms. Some heavy duty conditions were bandied around: Infertility, osteoporosis, cardiomyopathy, spastic ataxia, dementia, optic atrophy, axonal degeneration and a little bit of neuronal death thrown in for good measure.

The guffaws were subsiding, the footwork becoming laboured. Globally other clinicians and scientists stepped into the fray making it clear that there were indeed, a few, who were already aware of the serious implications of what had been, until now, considered by most to be a condition which was both easily diagnosed and treated.

The trainers quaked in the corner. Their fighters were getting flayed. Where was the blame for this massacre going to be placed? Several were spotted tiptoeing from the arena and back to the golf course.

The writing was on the cards and the blood was on the wall – B12 deficiency was no longer going to be a first round knockout – this was going to go the full twelve rounds!

End of Round One (and the review team were clearly ahead on points.)

The doctors staggered back to their corner and dropped heavily into soft leather executive chairs with contrasting piping, and lower lumber contouring providing additional support for the spine, with the benefit of gas-powered lift to avoid overstraining, as trainers wafted towels frantically – the clinicians spat out gumshields in response.

They had been taught B12 deficiency was primarily a blood condition! For years they had been trained that once patients’ serum levels were okay all was right with the world! Now they find out that B12 deficiency affects DNA which can cause untold damage and symptoms, and not only that but their beloved serum B12 test, was, quite likely, mostly measuring the wrong stuff!

Now, they find that out. Now! After all the weeks of sitting around the training room, cocking a snoop at the punchbag and thumbing through old copies of Expert Medical Practitioner thinking they were more than fit and able enough to counteract their opponent!

The message was sinking in – the neurological injuries could manifest in patients without the serum B12 test ever providing an inkling. Their defence was busted wide open.

No wonder they were reeling!

Round Two.

As the doctors trudged wearily back toward the enemy a low grumbling emanated from the crowd. At a glance you could see the glowering faces of patients who, for years, had been told by their trusted medics that their symptoms were not of the real variety. They had been sent away, dismissed, anti-depressed and referred for counselling to put an end to their ‘misconceptions’ and ‘cognitive conditions’. Now they could see they had been foiled. Duped. They were out for blood. And the team were not going to disappoint…because the worst was not over yet – not by a long way.

The team wound up their next punch like Popeye on fortified spinach and let rip!

The anaemia, they were informed, the dreaded anaemia which for so long doctors around the globe had used to initially identify the condition, never appears in 20 per cent of patients!

KERPOW!

ZONNK!

SPLATTT!

and

WHAPEROONIE!!!!

The doctors were on the ropes, arms akimbo like marionettes cut from their bindings. No anaemia? But they thought they were preventing or reversing the anaemia? They thought the neurological damage came after the anaemia! They were drifting around the ring, staggering amongst each other, gazing waxily into each other’s eyes.

The questions had to be asked:

How much more could they take?

Should the ref step in and stop the fight?

But the crowd were roaring. They whooped and clapped and whistled – at last, at long last they had a research team who were evidencing what they had been trying to tell doctors for so long! Finally, after decades of being ignored, the people had a voice!

Science was supporting them!

The team responded to the rapturous uproar and, refusing to show mercy, lifted the limp clinicians from the canvas. Doctors, in one last ditch attempt to regain control, practised an age-old mannerism – one that for years had pacified the patients – they lifted sweaty and bloodied brows and stared knowledgeably into the eyes of their foe. The head tilted patronisingly to one side, a smile touched fragile on their lips as they nodded slowly and graciously. A pose well practised. A tradition passed through the ages. They understood, you see. It was the ‘understanding’ look. It had all been a bit of a joke – hahaha.

But to their horror, this time, the patronising ploy did not work! The crowd, recognising the gesture of many years past when they pleaded for their own symptoms to be acknowledged, would not be pacified. They bayed for revenge and resolution. They wanted their champion to finish the job!

The end was now in sight and it came with a dizzying array of rabbit punches. One after the other like speeding bullets too fast for the crowd to count:

– Abnormal balance

– Memory loss

– Palpitations

– Hyperpigmentation

– Poor coordination

– Difficulty walking

– Weakness and stiffness

– Altered taste and smell

THWACK!

KERRUNCH!!!!

And all,

THUD!

Without,

DOOFF!

Any,

ZONK!

Anaemia

SERMASH!!!

(Or even low serum B12 levels)

Several clinicians tried to crawl out between the ropes but the crowd were having none of it and pushed them back in – a Glaswegian (Scotland being particularly noted for its obstinate refusal to acknowledge any problems with B12 deficiency unless accompanied by a ‘severe’ anaemia) being somewhat overly enthusiastic in his efforts. There was to be, the clinicians now knew, no escape.

The final blows came to the limp and ragged torsos, blasting the remaining air from their burning turgid lungs.

Did they know, the doctors were told, that raising the level of B12 in the blood was no indication of how effective the treatment was being?

They shook their heads wearily in response. Enough was enough. They could take no more.

And, the paper continued, that if patients went untreated for longer than 6 months the damage they had sustained was likely to be permanent?

Several started to sob uncontrollably.

And also, it added, 6 per cent of patients are left with permanent injury – injuries which you have been refusing to acknowledge as founded in the physical or anything to do with B12 deficiency. Patients you have been sending home?

The clinicians were by now, finished.

They clutched at the legs of their opponent, sick of the pummelling.

A shout went up from the crowd.

‘Now you know how we feel!’

‘Send ‘em to cognitive therapy!’

And another

‘Give ‘em anti-depressants!’

‘Ay. Make them work harder and if they can’t – call ‘em lazy!’

It was all over.

The work was done, the word was spread.

The paper stepped back, took its bows and provided essential citations.

The ref stepped in, crossed himself, and called it a Knock-Out.

———–

As the crowd drifted away and the nurses tried to leave incognito, the clinicians began to softly gather their senses and quietly lick their wounds.

‘You okay, Amanda?’ one doctor asked a blond as she rubbed a bruise and winced.

‘Not good, George’.

‘Me neither’. He limped to his feet and held his hand out to steady her before they started making their way slowly and painfully out of the ring.

‘Actually I always knew about all the problems with B12 deficiency’, he mumbled.

‘So did I. We just never got a chance to say anything before that blasted review paper jumped into the ring’.

‘Too right. It’s only a few rogue GPs getting it wrong, I was doing all the things they said anyway. Well, with most patients’.

‘Of course you were. We all were. It’s just the scientists showing off. You want to go for a drink?’

‘No. I think, maybe, I have a few patient files to review’.

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By Karen Thompson

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Link To Clinical Review Here
Grateful thanks to the BMJ September 2014 2014;349:g5226 and the Research Team – Hunt A, Harrington D, Robinson S.