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Ralph Carmel, MD; Dean S. Karnaze, MD

Arch Intern Med. 1986;146(6):1161-1165.

Abstract
• Physician response to a low serum cobalamin result was evaluated in 250 patients. In 42% of cases, no response whatsoever to the low level was found. In 24%, response was suboptimal. In only 34% of cases was management adequate from a diagnostic and therapeutic aspect. Moreover, 13% of all patients were treated with folic acid alone. In addition to the lack of attention to the bulk of cases that had subtle abnormalities or that were not truly cobalamin-deficient, many cases with typical findings of deficiency were ignored. It should also be noted that many truly deficient patients had quite atypical clinical and hematologic features, and the classic picture emphasized in textbooks probably applies mainly to late cases with florid manifestations. These findings raise disturbing questions about the medical management of cobalamin deficiency. They also touch on the more general issue of how physicians view and respond to laboratory abnormalities.

Author Affiliations
From the Departments of Medicine (Dr Carmel) and Neurology (Dr Karnaze), University of Southern California School of Medicine, and the Los Angeles County-University of Southern California Medical Center.

Footnotes
Accepted for publication Oct 2, 1985.

Reprint requests to the Division of Hematology, University of Southern California School of Medicine, 2025 Zonal Ave, Los Angeles, CA 90033 (Dr Carmel).

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