Macrocytosis and low platelets! Nervous..

May 8th, 2015
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  1. Macrocytosis and low platelets! Nervous..
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  3. aliciabirr
  4. Message 1 of 21 , Dec 23, 2013
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  6. 60yo M with joint pain. Father passed away to MI in early 60s.Labs: MCV 100 H Hct 51 H Platelets 107 L Homocysteine 12 HI realize this is a B12/folate issue. And likely MTHFR thing. Platelets can go down in this situation, too, but what do I need to rule out? Pernicious anemia?Last labs were done 6 mo ago and they were slightly better but same pattern. I urged him to be compliant with thornes MethylGaurd at 3 caps BID and to come back 2 mo later to retest. He admitted that he hasn't taken anything in a month and he waited til 6mo to come back even with my persistent reminder calls.I will start B complex injections as soon as I return from vacation. I'm upset that I don't know what I can do to help him over the next week. I feel this has become more urgent.Alicia Birr, ND Port Townsend, WA
  9. tanianeu
  10. Message 2 of 21 , Dec 24, 2013
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  12. Hi Alicia,
  14. Not sure what you've got on your hands there but the hematocrit is high, so it's not anemia, pernicious or otherwise.
  15. I suppose the first thing that would occur to me is to get a manual differential to see if there are abnormal/cancerous type of cells that are altering the MCV. There are probably many other things that ought to be in the differential for this unusual CBC result.
  17. Tania Neubauer, ND, LMT
  18. Portland, Oregon
  21. jacobschor
  22. Message 3 of 21 , Dec 26, 2013
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  26. A normal hemoglobin does not rule out B-12 deficiency:
  28. "Although the classic hematologic expression of vitamin B12 deficiency is a megaloblastic macrocytic anemia characterized by an elevated mean corpuscular volume and mean corpuscular hemoglobin, and a peripheral smear containing macroovalocytes and hypersegmented neutrophils, up to 28 percent of affected patients may have a normal hemoglobin level, and up to 17 percent may have a normal mean corpuscular volume.8 Although folate deficiency may also produce a megaloblastic anemia, it is less common in the United States because of required folate fortification of enriched grain and cereal products.9 Clinical manifestations of megaloblastic anemia include pallor, tachycardia, weakness, fatigue, and palpitations. The evaluation and management of macrocytosis has been recently reviewed in American Family Physician (
  29. "
  31. Jacob Schor
  32. Denver CO
  35. Mona Morstein
  36. Message 4 of 21 , Dec 27, 2013
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  38. Jacob is correct about normal CBCs with B12 deficiency, which is very common with seniors. I never place much emphasis on that but more on patient symptomatology.
  40. Mona Morstein, ND
  41. Mesa, AZ
  44. Daniel H. Chong
  45. Message 5 of 21 , Dec 27, 2013
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  47. Hi,
  48. I'd agree about all the B-12 and mthfr stuff. You could run a neutrophil segmentation to further clarify. If elevated, jonathan wright says much more likely to he due to folate deficiency.No one with more knowledge on the topic than I (not hard to find) has been saying this yet but i think, in clearly identified cases of mthfr defect, neutrophil seg index coukd possibly be used as a functional objective marker to follow with treatment. What do the smart mthfr peeps out there think abou that idea?
  49. I'd also run an RF factor, total immunoglobulins and ANA, then follow up with cyrex multi tissue anti body screen if any abnormals. Low platelets can be due to autoimmune disease and he has joint pain.
  50. Daniel Chong
  51. Portland, OR
  54. jacobschor
  55. Message 6 of 21 , Dec 28, 2013
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  57. Your email made me actually go back to the initial case that started this chain. Your suggestions strike me as overly comprehensive and expensive to suggest based on the scant information we have. I think we have an ethical obligation to diagnose and treat in a cost effective manner. Macrocytosis warrants testing for B-12.
  58. This is still considered the most common cause. Could you in good conscious justify the other lab test fees to the patient when only the B-12 test comes up abnormal?
  60. Jacob Schor
  61. Denver CO
  64. Daniel H. Chong
  65. Message 7 of 21 , Dec 28, 2013
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  67. Hi Jacob,
  68. I assume your email was addressed to me?
  70. I am wondering what makes you say only the B-12 test comes up abnormal.
  72. This guy has joint pain and a low platelet count. I would feel fully justified here in trying to rule out autoimmune arthritis with these findings, using ANA and RF which I can run for under $60. As I stated, I'd only run a cyrex if these were abnormal.
  74. In terms of neutrophil seg and MTHFR testing, he has a high homocysteine and high MCV, which, as you know, should not be assumed to be B-12. My suggestion for neutrophil seg testing is another low cost way of trying to get a hint at something, in this case whether it's more likely B-12 or folate that is the issue.
  76. That all being said, your email misses the point of my original email, which I wrote back in response to Alicia's original email asking for help and ideas on what else to look for. In such circumstances, to be as helpful as possible, I try to think of everything I can (when I dare post a response). This was not a case presentation of mine reflective of what I would necessarily do with every such patient.
  78. I appreciate your thoughts, however, when you say things like "in good conscience" it feels a little more to me like you are just trying to stir up a little "you know what".
  80. --
  81. Aloha,
  82. Daniel Chong, ND
  86. mrague
  87. Dec 28, 2013
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  89. Here is Averell's business plan, which should set us free from the present insurance constraints and be tailored to our naturopathic practices (we can design our own medical coding system). We have about 80 days left to hit the initial funding cap of
  90. 50k. If we fail to hit it, all of your donations will be returned. If we hit it, we will use the 50k to attract venture capitalists. I will ask Averell to give preference to NDS. I have not done any security offerings lately, so I will probably leave that up to Averell. As I said, I have donated 500 dollars to the (see naturopathic health insurance Averell Luedecker)
  91. Website and will invest 25 thousand dollars in this project.
  92. And just so you know where I am coming from, I am here to serve. Most specifically, I am here to serve the poor, the disenfranchised and the voiceless.
  93. I will return phone calls next week. Thanks very much for those calls.
  94. Any amount donated will make a difference. One. Ten. Twenty forty fifty five hundred . If you cannot do that then please spread the word of the indiegogo website to the Aanp , all the ND schools, the leaders of the community (you know who you are) and any movers and shakers you know. Together, we can make this happen, and change the face of American medicine for all time.
  95. Folks, pls seize the moment-- moments like this are very rare.
  97. Lots of love
  98. Margaret Rague JD ND
  99. Aloha Natural Healing Center LLC
  102. PS I am going to try to attach Averell's business plan with this email. If it does not attach, I will resend it in another email on the heels of this one.
  105. Mona Morstein
  106. Message 9 of 21 , Dec 29, 2013
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  108. Hello, Margaret,
  110. Just a quick question:
  112. What does it mean, with Averill's idea we can "design our own medical coding system"? Shouldn't we use the system that is the same as other insurances, to ensure we merge and can communicate with them and other physicians? I'm assuming you are talking about CPT codes, (obviously not ICD-9). Is that possible that any insurance company can recreate their own unique medical coding? Would the insurance fraud investigators, whomever they are, be okay with that?
  114. This question is coming from sheer ignorance about all that.
  116. Mona Morstein, ND
  117. Mesa, AZ
  120. richardmaliknd
  121. Message 10 of 21 , Dec 29, 2013
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  123. I try to keep things as simple as possible. In the situation with these lab results, I would treat with B-12 1000 mcg, folate 800 mcg, and pyridoxal-5-phosphate 50 mg for 2-3 months and retest CBC, HCY, and run a methylmalonic acid. If he has not been compliant with your B-vitamin recommendations, I see no reason to go to "plan B." I would encourage compliance.
  125. I see many patients with elevated MCV and abnormal platelet values that are not related to their condition or symptoms. Alcohol intake can cause elevated MCV and some patients' MCV does not come down even when they receive large doses of B-12, folate, and B-6.
  127. This patient's joint pain may not be related to the abnormal lab values. I don't understand the level of concern or the urgency given the information provided in the original post. To me, the most disturbing part of the original post is the patient's poor compliance.
  129. Richard Malik, ND
  130. Salisbury, CT
  131. Manchester Center, VT
  134. mrague
  135. Message 11 of 21 , Dec 30, 2013
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  137. Hi Mona
  138. These are great questions. Averell will have to do the legwork to answer them. This is how I conceive the issue: we have our, for example, first visit with a patient. Say it takes one and a half to two hours. Then, we have our second visit with our patient. Say it takes an hour. We can bill for these visits and probably get paid without a problem. But then we have multiple subsequent visits as we unravel the complicated disorders that may have hurt or ravaged the patient. The amount of time we spend and the billing for it will probably eventually prompt an audit by the more allopathically geared insurance companies. I saw this right here in CT with the practice of one of our NDs. It practically wrecked the business and drained off an enormous amount of time from the NDs in the business because the
  139. insurance investigators, while both amazed and impressed with the quality of the health care delivered by the practice, did not understand it. They demanded the refund of a very large amount of money, and all that hard work went down the drain and into the pocket of Anthem--and we all know how much their CEO needs more money!
  140. This would not happen with a naturopathic health insurance company that had its own coding, tailored to what we do. I can cannot yet give you an explicit and precise answer to your legal question . For one factor the licensed states are likely to have different laws in this regard. For another factor, laws can be quite plastic and subject to creative interpretation. For a third factor,it is not all that difficult to change laws, if you know what you are doing. You just write a new law and give it to the right person and voila! There is the law you want. I learned all this at NYU School of Law and I have implemented it in my work on behalf of eg Amnesty International. Also, I was inhouse international counsel for American Express and part of my responsibilities included supervising outside foreign counsel , so I anticipate including our Canadian friends as well, subject to verification by Canadian counsel.
  141. This will be Averell's company because he is a financial maven and has all kinds of youthful energy. However, I will keep a hand in to guide the process, as I continue to practice medicine.
  142. Don't hesitate to ask other questions.
  143. All the best to you-
  144. Margaret
  145. PS There are only 49 days left to contribute on indiegogo .com ( I believe I may have misremembered the original time frame when I previously said there were 80 days left). If each person on natchat gives 40 dollars we will meet our goal and we will have the funding with which to draw venture capitalists, of which I volunteer to be one. If we do not meet our goal every single penny will be refunded. However, I am certain we can meet our goal if we all pull together. I would like to see one hundred percent participation of the entire naturopathic community, both on and off nat chat (although I want to point out that natchat has a lot of truly great leaders). This will show the American people that we are here to stay. And it will show the politicians that we are an ineluctable force with which to be reckoned. Thank you so much.
  147. Sent from my iPhone
  150. leigh kochan lewis
  151. Message 12 of 21 , Dec 30, 2013
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  153. I am sorry, but I don't see the business plan?
  155. --
  156. Leigh K. Lewis, ND, NCMP
  157. Synergy Women's Health Care
  162. James Prego, ND
  163. Message 13 of 21 , Dec 30, 2013
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  165. Margaret, you said : " For a third factor,it is not all that difficult to change laws, if you know what you are doing. You just write a new law and give it to the right person and voila! There is the law you want."
  167. If its that easy, can you please come to NY ASAP and get our licensing bill passed into law???? If its that easy for you to do, I am sure the NYANP would pay for your travel and time!
  169. Jim Prego ND
  170. Islip NY
  174. mrague
  175. Message 14 of 21 , Dec 30, 2013
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  177. Hi Jim
  178. Yes, I am willing to do that. Pls set it up and I will do that. I am about to form a not for profit organization in New York . I am a native New Yorker.
  179. Thanks very much for asking.
  180. Margaret
  182. Sent from my iPhone
  185. mrague
  186. Message 15 of 21 , Dec 30, 2013
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  188. Hi Jim
  189. I will rewrite that licensing bill . The last time I saw it , nds were put under the supervision of MDs. In no way is that acceptable. Also , our scope of practice needs to be expanded. I will also write that into the new bill. Pls give me a little time to scope out the players.
  191. Margaret
  193. Sent from my iPhone
  196. James Prego, ND
  197. Message 16 of 21 , Dec 30, 2013
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  199. You haven't seen the newest version then. That was something added in 2 yrs ago to try to make a last min deal, without most of us knowing about it.
  201. and we can always use more NDs in NY!
  203. Jim Prego ND
  204. Islip NY
  207. Anne Van Couvering
  208. Message 17 of 21 , Dec 30, 2013
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  210. They've already rewritten the bill, and it's quite nice, this go round. Go check it out!
  212. A
  214. Anne Van Couvering, ND, LMT
  215. Hamptons Naturopathic
  216. Sag Harbor, NY
  219. mrague
  220. Message 18 of 21 , Dec 31, 2013
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  222. Hi him -
  223. Good to know. Can you forward me the present bill? I am only one hour over the New York border and my mother lives in Peekskill. Thanks.
  224. Margaret
  226. Sent from my iPhone
  230. James Prego, ND
  231. Message 19 of 21 , Dec 31, 2013
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  233. Links are on the website. This is the senate bill. The assembly bill is exactly the same:
  235. Jim 'him' Prego ND
  236. Islip NY
  240. aliciabirr
  241. Message 20 of 21 , Apr 9 4:56 PM
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  243. Hello again everyone,
  244. Just an update on the patient I reported with high homocysteine, high MCV, and low platelets.
  246. 65yo M has joint pain and a history of purpura/petechiae that showed up on his arms when he was in Mexico (about a year ago). FHx- father and older brother early onset (unexplainable) heart disease, father passed at 61yo.
  248. The first visit in July, 2012- I immediately Rx a methylated B complex. After 1 year, no change. (I had tried to get him to come in after 3, 6, and 9 months but he did not comply). I was becoming concerned about the decreasing platelets so I had a very stern conversation with him about compliance and related to his family history. This was not enough as you can see in December, this patient became even more macrocytotitc. So I insisted that we do weekly IM injections of B complex with methylcobalamin added. He nearly slapped me he couldn't handle the sting of the B complex so we did them every other week with methylcobalamin (3000mcg) weekly. We see improvement today....
  250. 7/13/2012 6/25/2013 12/20/2013 4/8/14
  252. Homocysteine 15.7 H 13.6 H 12.3 H 9.9 :)
  254. HGB 16.2 15.6 16.7 HN 15.1
  256. HCT 48.1 46.6 51.3 H 45.9
  258. RDW 13.6 14.1 13.4 14.2
  260. MCV 98.4 HN 98.7 HN 100.1 H 97.4 HN
  262. MCH 33.1 H 33.1 H 32.6 HN 32.1 HN
  264. PLT 121 L 107 L 107 L 114 L (Large & Giant)
  266. But I'm obviously still very worried about the platelets. I realize that B12 is necessary for platelet levels, but the large and giant note has me concerned.
  267. Where do I go from here for testing? Should we continue with B12 shots weekly and just retest in 2 months to see if there's a change?
  268. Another physician has me worried about cancer as low platelets can be an early detection. I'm wondering about ITP.
  270. Please help! THanks :)
  272. Alicia Birr, ND
  273. Port Townsend, WA
  276. Rohina Azizi
  277. Message 21 of 21 , Apr 9 9:31 PM
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  279. Hi Alicia,
  281. Has he seen a hematologist yet?
  283. Here is an article on how to approach thrombocytopenia:
  286. I would send the pt to a hematologist for an eval but here it says that platelet counts between 100 and 150 × 109/L do not necessarily indicate disease if they have been stable for more than 6 months
  288. Rohina Azizi, ND
  289. Portland, OR
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