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International Primary Care Association

Clinical Focus Volume 1 N3

Volume 1 Issue 3 - 2006


Vitamin B12 deficiency is associated with metformin treatment, and can result in raised plasma homocysteine, a well established cardiovascular risk factor. The mechanism of vitamin B12 deficiency in these patients is not well defined, but has been linked to relative hypocalcaemia. The question of oral B12 replacement has been raised, and studies have shown that oral replacement with high doses (1000- 2000mcg/day) may be necessary for normalisation of B12 and homocysteine levels. While this has not been directly assessed for diabetics with metformin-induced B12 deficiency, we would recommend a trial of replacement with high dose oral cyanocobalamin, with calcium replacement if appropriate. Patients in whom this treatment strategy fails should be treated with standard intramuscular hydroxycobalamin replacement as for pernicious anaemia.


A stuffy nose may be a subjective sensation in the absence of obvious structural nasal airway abnormality or obvious pathology in the nose. There is a wide normal variation in the atmospheric conditions that the nose will tolerate, producing symptoms in some while not in others.


An abnormal mass in the neck is an important clinical finding in all age groups. The challenge is to differentiate trivial disease with a self limiting natural history from more serious pathology. The aim of this article is to provide a structure in order to make the correct diagnosis in patients presenting with a neck lump. The relevant anatomy will be described as well as some important principles to aid in diagnosis. Common causes of neck lumps and their management will then be described.


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