I ree TTY 1, 1969 SERUM VITAMIN Bis IN VEGETARIANS ! D. K. BANERJEE, MSd. Research Assistam 3B CHATTERIEA, M.D, ENA Professor of Haematology From the Haematological Unit, Indian Council of Medical esearch, and the Department of Hacinatelogs: School of Tropical Medicine, Celeutt, Inte The vegetables normally consumed by man in general hhave a negligible amount of vitamin B,, (Lewis ef af 1949; Peeler et al, 1951), The vitamin’ By content of ilk is mach lower than that of liver, meat, fish, and tug. Thus an average vegetarian diet may not have enough ¥ilamin By, to ensure optimum human nutrition, The Nilamin Bl, content of serum in vegetarians hes Been reported to be Jow (Wokes et al, 1935: Dhopeshwarkar er al, 1956; Chatterjea er al. 1959). In RULTHTORETMMECTORytic anaenila (MER) a low concen tration of serum vitamin B,, has been found in approx}, mately $0% of cases (Das Gupta er al., 1955 ; Chatietien, 1958), The main cftie-OF-Witamin-B,, deficient N-M-Acis held to be inadequacy of the diet (Ds t al 1953; Chatteries, 1958); the possibility of ea intestinal, malaBsorpive’ factor ‘has dso bare, et sBaker, 1958). A significant proportion of the populs tion of India may be categorized as vegetarian ave to social custom, to religious tenets, or t0 poor economic Status. The average red-cell and haemoglobin levels of vegetarian Indians cannot, however, be regarded. as significantly different from’ those of non-yegetarians in India or in other parts of the world (Sokhey e/ al, 1937, 1938 ; Das Gupta, 1949), ames In view of the above considerations, it was thought worth while to investigate the serum vitamin B,. in two groups of subjects—non-vegetarian and veesatan as Seen in the general population and haematological disorders, pagent. ‘Seatteraram showing ditibuton of serum SERUM VITAMIN B,, IN VEGETARIANS vot Meancat Fommeat uv Mates and Metioa ROK ‘The present communication deals with observations (on 232 subjects, consisting of 61 normal persons, G7 with {topical eosinophilia, 39 with N.M.A., 35 with aplastic anaemia, and 30 with chronic myeloid leukaemia. ‘The distribution of non-vegetarians and vegetarians is shown in the Tables. Subjects belonging to the vegetarian group were taking rice, wheat, vegetables, pulses, and milk, but no fice meat, or egg. Each one of them had been taking the [vegetarian diet for a period varying from 5 to 25 years [The daily consumption of milk was in general small, * varying from 6 to 12 o7. (170 to 340 ml.) per head, ‘The serum vitamin B,, was estimated by the method of Ross (1952), using Euglena gracilis var. bacillaris a5 the test organism. The total vitamin B,. content was ‘expressed in micromicrograms per mililite, Results The concentration of total serum vitamin B, individual subject. belonging to the two groups is represented in the Chart ‘The mean value and range of variation of total vita- ‘min B,, of:serum in the different subjects belonging to fhe twO groups are recorded in Tables f and TI. From the Chart it is: seen that)six of the normal ubjects belonging to the vegetarian Group had serum vitamin B,, values lower than the lowest value in the fnon-vegétarian group—that is, 98 wyig./ml. In tropical eosinophilia a low level of serum vitamin By. was found in 8 out of 16 eases. Tn nutritional macrocyiic anacmia, 6 LNomseie pees, ee ant = vectmman |e i i ? é A SRM ta pam “33h min B,, in vegetarians and non-vegtaians,Retail mabe os te 1.180%03,100] 221943188) 0 low serum vitamin B,, value was found in all the vegetarians except one. Of the aplastic anaemia patients only two were vegetarians, and in both of them the serum vitamin B,, was low, being 40 and 80 g./ml respectively. No differential pattern was seen in chronic mysoid leukaemia, all the subjects showing elevated ‘A comparative study of Tables and Il shows that in the vegetarians the mean values were significantly lower than those in non-vegetarians in alll groups except chronic myeloid leukaemia, In the vegetarians the percentage of cases having a serum vitamin B,, level ower than 98 jyug./ml. was 92.3% in N.M.A., 60% in normals, and 50% in tropical eosinophilia, Discussion Results of the present investigation indicate that the regetarians have a serum vitamin B,, concentration which is significantly lower than that in the non- vegetarians. On the basis of clinical evaluation and Janalysis of dietary habits, vitamin B,, deficiency in the vegetarians appears to be dietary ia origin. In a parallel study with *Co-labelled vitamin By, for investigating “the pathogenesis of vitamin B,, defigiency in N.M.A. dietary inadequacy appeared to be more important than the factor of intestinal malabsorption (Banerjee ef al. 1959). = | | tn normal subjects and the cases of tropical eosino- philia there was no significant anaemia or macrocytosis. The blood picture in vegetarians and non-vegetarians was more or less similar, though their serum vitamin By, | [evels were different. Some of the vegetarians followed for one or two years did not show any decline of haemo- globin or R-B.C. level in spite of the serum vitamin By, level continuing to be low. These findings are not ia complete agreement with those of Wokes er al. (1955), who found evidence of anaemia ami? macroeytosis i 2 significant proportion of vegans investigated by them. It must, however, be remembered that, owing to the Jexelusion of milk’ and milk products from their food, the average diet of a vegan was relatively more deficient in vitamin B,, than that of a normal Indian vegetarian. + |) Maintenance’ of normal haemoglobin and R.B.C. values with a serum vitamin B,, valve as low at 40 jue./ml, poses certuin questions’ “of fundamental. importance, Mollin and Ross (1952) observed that a serum level of 100 jyg. ml. was the critical concentration below which signs of vitamin B,, deficiency could be recognized They confirmed their observation later by stating that early megaloblastic change was noticed in the bone- marrow of pernicious anaemia (P.A.) patients a few days after the serum vitamin B,, level had fallen below 100 ug/ml. ; at levels greater than this, the marrow remained normoblastic (Mollin and Ross, 1953). SERUM VITAMIN B,, IN WEGETARIANS Tn the present ser OW Was normo- bastig in tropical eosinophilia and aplastic anaemi Bonesnarrow examination was not done. in-notm: hd ati sign of vitamin B,, deficiency in the marrow. Repeated examination of peripheral blood did not, how ever, show any evidence of erythrocytic macrocytosis or sranulocytic abnormality. In N.M.A. the bone-marrow was, However, found to be megalobiasic. It must be Pointed out that, in NMA, mepaloblastis bone-marrow teas also seen in all the eases with high serum vitamin Be (Gee Chart, suggesting that in this disease there is no direct correlation between serum vitamin By, and bone- ‘marrow changes. Its well known that NALA. 25 seen inthe eastern part of Tndia represents deficiency of fo acid and/or vitamin B,, (Das Gupta ef al, 1953; Chatteris, 1958). The'lack of cortlation between serum vitamia B,, and bone-marrow changes in NMA may therefore be explained on the basis of associated folic-acid. defcieney, the degree of which cannot, be ascertained from the serum vitamin B,, level Tn none of the cases with low serum vitamin B, including those of N-MCA,, was there any neurological complications. This observation also was not ia com plete agreement with that of Wokes ef af. (1955), who recorded neurological sytopioms and signs in some of theie subjects, Ina few Indians with classical AdgRonian Pernicious anaemia subacute ‘combined degeneration has, however, been found (Das Gupta. and Chatterjea, 195i). In NMA. and in malabvorption syndcome neurological complications are conspicuous ‘by their Absence, though the serum vitamin B,, level in many ages may be as low as in pernicious andemia, The mai Gitference between P.A, and N.MLA. (or malabsorption Syndrome) is with reference to iatrasi factor and neuro: Ingical complications. Tn the present series all the vegetarians with low serum vitamin By. hd presumab! ho defleency of intrinsic factor. Thus the circumstantial evidence becomes very strong in favour of intrins factor having some role, dict or indirect, in protecting the nervous system. If vitamin B,, per se was respon sible or the protection of the nervous system, absence or rarity of neurological signs in N.M.A. in malabsorp- tion syadeome, and in the present Seies/of vegetarians cannot be satisfactorily explained, It is possible that vitamin B,, absorbed from a systems] with an adequate amount of intrinsic factor (as in Yegetarians, and in. patients with NM.A, and. mal- sbsorption’ syndrome) may be qualitatively. diferent from vitamin B,, absorbed froma system. grossly deficient in intrintle factor (as in P.A), “Concentration for conceatration, the former vitamin By, may be more protective to the nervous system than the later. "The “ficney of parenteral vitamin B,, therapy ia correcting the neurological complication of P.A. may be expla by assuming that the vitarnin Bas Used in therapeutics is simitar 19 the former but perhaps different from the fatier. An alternative explanation would be the sugges tion, that therapeutically administered. vitamin By. is activated” by extragasiric’ sources of vitamin 'B,. (Callender and” Tajtha, 1951). The above facts would fend {0 indicate that intinsle factor, in addition 1 iiss role as promoter of absorption, may have ‘activating or maturing influence on vitamin By Adequacy of intrinsic factor would ensure not onis absorption but also activation or maturation of Wh ever small amount of vitamin B,, may be avaiable the system due to dietary inadequacy and/or intestine malabsorption (Chatterjea, 1960).994 Ocr. 1, 1960 SERU An elevated level of serum vitamin chronie myeloid leukaemia, first reported by Bear|d er al. (1954) hhas been conclusively confirmed by a number of inves gators. ‘The exact cause of this elevated level is not lear. Lack of any differential pattert: in the two groups—vegetarian or non-vegetarian—as revealed in the present study, indicates that in this disease the factor responsible for ‘hypervitaminosis far outweighs the hypovitaminic effect of a vegetarian diet. Summary ‘The serum vitamin B,, level was studied in 232 sub- jects (196 non-vegetariaas and 46 vegetarians). The Subjects belonged to the following five categories: normal, tropical eosinophilia, nutritional macrocytic anaemia, aplastic anaemia, and chronic myeloid Teukaemia, Serum vitamin B,, in the vegetarian group was, in general, lower than that in the non-vegetarian group. Chronic myeloid leukaemia was an exception, all the patients in this category showing a raised level as previously reported. Low serum vitamin B,, was not, however, associated with any anaemia or nedrological’ complications. The implications of these findings are discussed We are indebted to Dr. R. N. Chaudhuri, Director, School of Tropical Medicine, Calcutta, for providing ‘necessary facilites for the study. We are grateful 10 Mr. S. K. Ghosh and Dr. Sandhya Ghose, of the department of haematology, for their help. . Rerenences i; rs S.J. (98%, Indu J, Poth, Bact 4, 1H ianet}s, B. Key ostin, Fy sad Chatetet, 1B, (1959). Bul, elite Sch, trop Med... 147. eta 5 nt ain 6c Ubi Bl Coleuta Soke trope Med 9. At — Baneriee'D. Ky Ghose, Stodhya, and Chaudhuri, R. N. Indl Res. Fund Aizu 18h. New Do . Calcutta Soh trap. ted 3, Whe 5, Civssy. aut Saxorkae, iss. CK Bf and Ross, Got. Me (1099, J ci, Pathe 8, 129. eer O. (ibs3}. Bet ed, Jy 2 6, -Pecle, Ht, Vatowits, Hi Cail, © W., Mill, RF, Nort, i Hegser’ G.'F 1931). J. Nie 48 Us aad Hew Rose, GM (982 le Fath $7330 ‘Solty. S'S. Gokhale, 8. K:, Malandkar. M. A., and Billimor TWR'S! QB)" nal Jed Ree 3, 368, = (C988. "Toia, 38, 735 sf Woke F., Badenoch J. and Sil) He M, (1955). Amer. J ‘cing Rares 3515 ‘The Italian Olympic Medical Committee is conducting. a Statistical study "of competitors who took part. in the Olympic Games “in ‘order 0 discover. the ‘correlations between medical characteristics and performance, “To obtain this comprehensive medical data-in all, 78 medical charac- teristics for each athlete—for at least 2,000 of the 7,000 competitors in this year’s games, the medical sections of various national’ Olympic Committees (including. the German, Traian, and Russian) have agreed t0 supply the ‘results of medical examinations of their athletes carrie oUt in their own countries. Once. this information has been collected’ it will be recorded on punched-eatds, which will then be processed by the IBM 305 RAMAC computer, VITAMIN B,, IN VEGETARIANS TREATMENT OF RESPIRATORY INFECTION IN SCHOOLBOYS WITH PHENETHICILLIN R. L. VOLLUM, M.A, D.Phil. Department of Bacteriology, Radclife Infirmary, Oxford BW. E, JUELJENSEN, M.A, BM, B.Ch., Cand.Med. Medical Offer, Simmer’ Fields’ School, Oxford ‘The administration of penicillin to childcen has hithert presented several practical problems. Crystalline peni- sillin by injection gives satisfactory blood levels, but is painful and very unpopular with young patients, Oral penicillins G and V are far more acceptable, but the Blood levels obtained are “much lower than those achieved by parenteral administration, and are indeed often insufficient for satisfactory therapeutic effect. When phenethiciliin (6-(e-phenoxypropionamido)peni- cillanie acid) was marketed as “byoxil,” it was claimed that this preparation would give blood levels at least equal to those after intramuscular injection of corre sponding doses of penicillin G. Knudsen and Rolinson (1959) investigated the absorption and excretion of Phenethicillin in adults, and their results confirmed this claim. Garrod (1960) compared the antibacterial activity of phenethicillin, penicillin G, and penicillin V. He found that, weight for weight, phenethicillin was more active than penicillin V or G against resistant staphylococci, and very slightly less active against streptococci and pretimococci In February, 1960, an outbreak of severe pharyngitis, with some complications, occurred among schoolboys aged 7-13 at Summer Fields Preparatory School, Oxford. The school is residential, and it was essential to deal promptly with the infection, which spread in a few days to 31 boys, Table I shows the incidence of uote [Clinical Diagnosis and Treatment toss | Rrapeahiedoe we baems | Gp ‘prmmareari | [Czar aa] oe hr LL Lobe pneumonia 1 | 250 me. ads. Brie ae ets tee 1 the various types of infection. Most of the boys had severe pharyngitis and cervical lymphadenopathy. The illness ran much the same course both in those infected with B-haemolytic streptococci group A and in those from whom other organisms (Str. pneumoniae, Str viridans, neisseria) were isolated. Fourteen boys had complications. One boy had uncomplicated lobar pneumonia and one had cellulitis of a finger. Methoas ‘The boys were all treated with,phenethicillin. The standard dose was 250 mg. (one tablet) fourchourly