Ben Hudson

Vitamin B-12 deficiency

An 85 year old man had a preoperative assessment for a knee replacement. His full blood count was normal apart from haemoglobin 95 g/l and mean corpuscular volume 105 fl. He drank no alcohol. Further testing showed that his vitamin B-12 was low: 90 pmol/l (reference range 160-800 pmol/l). Folate, ferritin, thyroid stimulating hormone, and liver function tests were normal. He had no other medical or surgical history and ate a balanced diet that includes meat. Vitamin B-12 is found only in foods of animal origin. Dietary B-12 is freed from food protein by pepsin in the acid gastric environment and binds to haptocorrin, a protein secreted in saliva. In the small intestine, haptocorrin is degraded by pancreatic enzymes; vitamin B-12 is released and binds with intrinsic factor, which is secreted by gastric parietal cells. This complex binds to receptors at the terminal ileum and is actively absorbed. A small fraction (1-2%) of the intake of B-12 is passively absorbed …

Information v promotion

Bekker expresses concern that “uncritical acceptance of informed choice initiatives may cause more harm than good.”1 She notes that in a study of decision aids for bowel cancer screening a smaller proportion of patients given a decision aid accepted screening than did …

Education Preferences of People With Gout: Exploring Differences Between Indigenous and Nonindigenous Peoples from Rural and Urban Locations

Gout typically responds well to medications, but adherence might be improved by education that meets individuals’ needs in a way that is inclusive of their ethnicity and rurality. The aim of this study was to compare education preferences of Māori and New Zealand European (NZEuropean) individuals with gout, and of those living in rural or urban areas.

Self-care of Canterbury general practitioners, nurse practitioners, practice nurses and community pharmacists

INTRODUCTION Pastoral care is recognised as an important aspect of a mature primary care network. Pegasus Health is now in its 25th year and has had a formal Pastoral Care Programme for doctors since 2009. AIM This study aimed to collect local data on the self-care of Canterbury (Christchurch, New Zealand) general practitioners (GPs), nurse practitioners (NPs), practice nurses (PNs) and community pharmacists (CPs). METHODS The survey was open to all participants in the Pegasus Small Group Education Programme in Canterbury. From a survey circulated to approximately 1100 primary care professionals, 504 responses were collected either electronically or as hard copies. RESULTS The themes that emerged were similar among all the health professional groups. A significant proportion of health professionals took minimal annual leave and even more worked while ill. CPs were the group with the highest rates in both these areas. Reasons given for this focused largely on a lack of locum cover. DISCUSSION Locum cover is a significant issue in Canterbury for all health professional groups in the study. The issue of locums is now being reviewed in Canterbury partly as a result of this study. Consideration is also being given to how the Pastoral Care Programme can be made more widely available.

Unmet health-care need

179 CSIRO Publishing Journal Compilation

Living with osteoarthritis is a balancing act: an exploration of patients’ beliefs about knee pain

BackgroundThis study aimed to explore the beliefs of people with knee osteoarthritis (OA) about the disease, and how these beliefs had formed and what impact these beliefs had on activity participation, health behaviour, and self-management.MethodsSemi-structured interviews were conducted with 13 people with knee OA recruited from general practices, community physiotherapy clinics, and public advertisements in two provinces of New Zealand. Data were analysed using Interpretive Description.ResultsTwo key themes emerged. 1) Knowledge: certainty and uncertainty described participants’ strong beliefs about anatomical changes in their knee. Participants’ beliefs in a biomechanical model of progressive joint degradation often appeared to originate within clinical encounters and from literal interpretation of the term ‘wear and tear’. These beliefs led to uncertainty regarding interpretation of daily symptoms and participants’ ability to influence the rate of decline and certainty that joint replacement surgery represented the only effective solution to fix the damaged knee. 2) Living with OA described broader perspectives of living with OA and the perceived need to balance competing values and risks when making decisions about activity participation, medication, attentional focus, accessing care, and making the most of today without sabotaging tomorrow. Misunderstandings about knee OA negatively impacted on activity participation, health behaviours, and self-management decisions.ConclusionBiomechanical models of OA reduced participant exploration of management options and underpinned a perceived need to balance competing values. Improved information provision to people with knee OA could help guide positive health behaviour and self-management decisions and ensure these decisions are grounded in current evidence.

Nortriptyline in knee osteoarthritis (NortIKA Study): study protocol for a randomised controlled trial

BackgroundOsteoarthritis (OA) is a common cause of pain and disability. Currently available analgesics are often insufficiently effective or have unacceptable adverse effects. Tricyclic antidepressants may offer a useful centrally-acting analgesic. Nortriptyline is a readily-available, cheap and comparatively well-tolerated tricyclic antidepressant.Methods/DesignWe will conduct a parallel group, two-arm, participant and investigator-blinded, randomised controlled superiority trial comparing nortriptyline with placebo. Two hundred participants with primary knee OA will be enrolled. Participants will take study medication for 14 weeks. The primary outcome is difference between treatment arms in mean pain score measured on the Western Ontario and McMaster Universities (WOMAC) pain scale at 14 weeks.DiscussionThis protocol describes the first randomised controlled trial of a tricyclic antidepressant in the treatment of OA. The results of the study may have significant implications for the management of this common and painful condition.Trial registrationThe trial was registered with the Australian New Zealand Clinical Trials Registry on 27 June 2014. The trial registration number is: ACTRN12614000683639.

A paucity of supporting evidence

Khunti and Davies faced an unenviable task in putting the case for screening for diabetes given the …

Vitamin-B12-Mangel

© 2010 by Verlag Hans Huber, Hogrefe AG, Bern DOI 10.1024/1661-8157/a000315 Ein 85 Jahre alter Mann wurde zur präoperativen Beurteilung wegen eines Kniegelenkersatzes vorstellig. Sein Blutbild war bis auf den Hämoglobinwert von 95 g/l und das mittlere korpuskuläre Volumen (MCV) von 105 fl unauffällig. Er trank keinen Alkohol. Weitere Tests ergaben eine niedrige Vitamin-B12Konzentration: 90 pmol/l (Referenzbereich 160–800). Folsäure, Ferritin, Thyreoidea-stimulierendes Hormon (TSH, Thyreotropin) und die Leberfunktionswerte waren normal. Er hatte keine medizinische oder chirurgische Vorgeschichte und ernährte sichmit einer ausgewogenen, auch Fleisch beinhaltenden Diät. Vitamin B12 ist ausschliesslich in tierischen Nahrungsmitteln enthalten. B12 aus der Nahrung wird durch Pepsin im sauren Milieu des Magens von anderen Nahrungsproteinen befreit und bindet an Haptocorrin, ein in den Speichel sezerniertes Protein. ImDünndarmwird Haptocorrin durch die pankreatischen Enzyme abgebaut; Vitamin B12 wird freigesetzt und bindet nun an den Intrinsic Factor, der von gastralen Parietalzellen sezerniert wird. Dieser Komplex bindet an Rezeptoren des terminalen Ileums und wird dort aktiv resorbiert. Ein geringer Anteil (1 bis 2%) des mit der Nahrung zugeführten Vitamin B12 wird passiv über die gesamte resorptive Oberfläche des Gastrointestinaltrakts aufgenommen. Die erforderliche tägliche Zufuhr von B12 (2 g pro Tag) ist im Vergleich zu den Körperreserven (2– 5 mg) gering.