Breakspear or Guildford Dr?

[nord]

Hello,

and thank you Maz and Binger for the initial help with suggestions per e-mail on where to find AP practitioners in Europe.

Having no diagnosis, Dr H is not an option, but on the other hand, I am not certain on how a non-diagnosed patient is viewed at Breakspear Hospital in Hemel Hempstead. So far I have not received a diagnosis from the GP I have approached with my symptoms: exam of joints (possible uveitis referred to optician, who have some medical training here), focusing on mobility of back, hips and knees (which were found normal to good) Nothing remarkable found, (jokingly mentions “good mobility”, referring to my questions if I might suffer from something rheumatic). Tests showing low lycocytes (2600/ul), retested at 3000/ul in Dec 2009, otherwise normal.

My own speculation is a ReA that has turned chronic. The initial phase is then some ten years back. All problems are actually very slight (especially when reading others' horror stories), and it is not the severity, but the persistence that is troublesome. 

Possibly, I have neglected many symptoms and attributed them to overload, and it is very possible that they have been present more since 1999. It is only recently that I have not been able to find sufficient excuses. E g I attributed the the initial left knee pain to a torn meniscus in my youth (and possibly initial stages of arthrosis from running etc, “need to back off a bit”).  In 1999 CRP was a bit elevated when tested, at 25 in April and 10 in Nov, Hemoglobin was a little low (120?) in April.

Now I am looking at the possibility to get a diagnosis elsewhere and have looked at a few places in Germany where they seem to be aware of chronic ReA. I realise that an integrated approach to ReA and possible prostatitis (or whatever it is) would be preferable to two different processes of diagnosis and treatment. I have an appointment with Dr D at Breakspear in March. Will it be valuable to have better diagnoses in advance, or with such, go to Dr H?

Any input would be greatly appreciated, thanks!

[spacehoppa]

Hi Nord,

I see Dr D at Breakspear – saw him just today actually – and think this is your best option for getting diagnosed. If you think you have chronic ReA they can run infection panels, mycoplasma and Lyme disease tests for you. If they can't get to the bottom of it, no-one can!

But the tests are expensive though – they quickly add up, so you may need to spend

[nord]

Hello Ruth,

and thank you for the quick reply with very valuable input! Having read some of your posts and reports from Breakspear, I hoped you'd post :). Also, thank you for your contributions (with vids, too, nice!), very encouraging to read about your improvment!

My CRP is normal, but, if I recall correctly, not unusual for chronic ReA; during what I suspect was the initial phase (with infection) it was at 25 three moths after getting ill, and 10 at eleven months.

As a working hypothesis I see a urogenital infection at the bottom of all my problems (such symptoms for the entire period), but surely Lyme could be a culprit. I didn't spend much time getting exposure to “ticks” during the years I got ill, but did get a few stings earlier.

My reason for looking towards Germany is primarily from finding some research by Germans on early diagnosis of SpA:s, mainly dealing with clinical signs and imaging techniques (MRI) as far as I understand.  From what you write it seems like it is better to put everything else on hold (including checking for prostatitis ? a problem sharing many aspects with Arthritis, it seems) until seeing Dr D.

Thank you for your encouragement and offer!

[Maz]

[user=2031]nord[/user] wrote:

Now I am looking at the possibility to get a diagnosis elsewhere and have looked at a few places in Germany where they seem to be aware of chronic ReA. I realise that an integrated approach to ReA and possible prostatitis (or whatever it is) would be preferable to two different processes of diagnosis and treatment. I have an appointment with Dr D at Breakspear in March. Will it be valuable to have better diagnoses in advance, or with such, go to Dr H?

Hi Nord,

So glad you found us here in the forum!

As far as I know, Dr D at Breakspear is a consultant specialists in rheumatology, so he should be able to give you a diagnosis once he's run various tests and taken in your full clinical picture. There is a gene test that he can run, called HLA-B27, which you could ask about and may help in diagnosis.

At http://www.kickas.org there are also some medical research papers by a a guy called, Dr Alan Ebringer you might be interested to read through. He has researched various organisms implicated in reactive arthritides, including Ankylosings Spondylitis. In fact, a good contact for you may be a forum user here, Dragonslayer (John) with AS in remission, who just posted this thread yesterday:

http://www.rbfbb.org/view_topic.php?id=3771&forum_id=1

Breakspear is a private clinic and you may have to dig deep in your pockets for a full workup, but if you are considering a trip to Germany, which could also rack up the costs, you might find Dr D to be just as helpful to your situation and closer to home.

In relation to your chronic prostratitis, you might find this link interesting, which suggests doxycycline and minocycline for treatment management and the infections commonly associated with this condition:

http://www.bsac.org.uk/pyxis/UTI/Chronic%20prostatitis/Chronic%20prostatitis.htm

Interestingly, the treatments outlined in this link are quite similar to the ones outlined at http://www.cpnhelp.org for various arthritides linked to the chlamydias (chlamydia pneumoniae and trachomatis).

I would put in a call to Breakspear just to be sure, but as Dr D is a rheumatologist, he should be fully equipped to both give you a diagnosis and to offer antibiotic treatments to you.

Hope this helps, Nord, and welcome!

Peace, Maz

 

[Maz]

[user=415]spacehoppa[/user] wrote:

My CRP has come down from 134 to 29 in those 5 months and I have halved my steroids and have recently come off my humira too (an immune suppressing treatment for RA). I am quite transformed!

Ruth, this is absolutely phenomenal progress!!!!!!! I have been watching your YouTubes with great interest and it's like a cliffhanger each time…can't wait for the next installment. :roll-laugh:

Well done getting off the Humira, too! I knew if anyone could navigate the minefield you were in, you could do it. Isn't it just the craziest thing to think that you were misdiagnosed all those 21 years and on the wrong treatment?

So sorry I didn't see your post before I just replied to Nord…it's great you saw it and connected. Far better to hear from someone who is seeing this doc than second hand info from someone else. You're in good shape having met Ruth, Nord! She is a whiz at research and is a prime example of self-advocacy and what it takes to get ourselves well again. 😀

Thanks for checking in, Ruth. I've missed you around here, but so chuffed you did and to hear your latest lab results! Waaaayyy to go, girl! :dude:

Peace, Maz

[spacehoppa]

Hi Nord,

I don't know much about ReA but you seem to have a lot of leads and info to go on and Maz has supplied you with more great info, as ever! A friend of mine has palindromic RA and also has regular severe bladder infections and I'm convinced there's a link for her too, but doubt she'll ever investigate it.

It's so hard to be your own advocate, but also so important. It's good that you are so proactive and determined. It's the only way to get the correct treatment I think.

I'm glad you like my silly youtube videos. I am kind of monumentally embarrassed by them, but also feel it's important to document not just that the treatment works, but also the ups and downs along the way.

Maz – Thanks so much for the encouragement! I can't imagine that anyone watches my ramblings all the way through, so bless your kind heart that you do!! I feel that my improvements have been very rapid and dramatic, though that's partly because of how bad I was before starting the abx. I imagine it will tail off and get slower from here on. But I am so, so much better that I want to shout it from the hilltops! Thanks so much to you, and everyone else here, who keep me going when the going gets tough!

[Trudi]

[user=415]spacehoppa[/user] wrote:

I can't imagine that anyone watches my ramblings all the way through…

Hi Ruth–

I watch your videos too.  You have a very calming way about you and it is very helpful to me knowing how you handle the ups and downs.  I'm just thrilled with your progress and keep cheering you on. 

Take care,

Trudi

Lyme/RA; AP 4/2008 off and on to 3/2010; past use of quinolones may be the cause of my current problems, (including wheelchair use); all supplements (which can aggravate the condition) were discontinued on 10/14/2012. Am now treating for the homozygous MTHFR 1298 mutation. Off of all pain meds since Spring '14 (was on them for years--doctor is amazed--me too). Back on pain med 1/2017. Reinfected? Frozen shoulder?

[spacehoppa]

Thanks Trudi! Not so calm in today's video unfortunately, I actually cried on camera – ugh! The reason was because I found out when I went to the Breakspear yesterday that my lovely LLMD is under investigation by the GMC (General Medical Council).

This is seriously bad news for him, and for all us UK lyme patients. Seriously bad. Why does this keep happening?!! I am very angry that such a caring and responsible doctor is being investigated. Something must be done – but what?!

[kate murrell]

Hi Ruth,

I am so heartened to discover how well you are doing. It is brilliant that you are off Humira- you must be incredibly pleased and growing in confidence. I too have watched your videos but worried that you had 'gone quiet' on the website!

I will be having my first appointment at Breakspear in a couple of weeks.
I am very concerned about the investigation you mentioned. Do you have any more details? I hope no-one tries to stop the good work of Dr D- and especially (selfishly, I know)- before my appointment with him.

Incidentally, can you  recommend an anti-inflammatory to tide me over another 2 weeks? My blood tests are not looking too good at moment -every month the CRP and ESR are rising and my Haemoglobin is falling nearly into anaemic but not quite. Actually, for some days I feel better in myself, but it feels like a cycle.
I get on Ok with Paracetamol but I know it's not an inflamm. I take 200mg Ibuprofen often and eventually it makes my stomach sore. The Ibuprofen gel doesn't seem to help at all.
Good luck and I am so pleased for you-really.

Kate M

[Trudi]

[user=415]spacehoppa[/user] wrote:

Thanks Trudi! Not so calm in today's video unfortunately, I actually cried on camera – ugh! The reason was because I found out when I went to the Breakspear yesterday that my lovely LLMD is under investigation by the GMC (General Medical Council).

This is seriously bad news for him, and for all us UK lyme patients. Seriously bad. Why does this keep happening?!! I am very angry that such a caring and responsible doctor is being investigated. Something must be done – but what?!

Hi Ruth–

“Why does this keep happening?!!”  When you asked if the American controversy has reached England, Dr. D said yes.  Very unfortunate.  It is such a mess not allowing doctors the freedom to treat–my own doctor is harrassed and at one of my visits the nurse said that “they” want to shut him down.

You may recall a while back that the governor of Connecticut signed a bill protecting doctors from prosecution:

http://www.lymediseaseassociation.org/NewsReleases/20090621.html

Many patient advocates rallied for this.  I know many on this board responded to an article in the newspaper by a doctor who was against this.  I think collective voices were heard.  Your question, “Something must be done–but what?” will surely reveal itself when the necessity arises.

I did watch your video this morning and recognize how difficult this is for you.  Keep your chin up–I'll continue to send up prayers for you!!

Take care,

Trudi

Lyme/RA; AP 4/2008 off and on to 3/2010; past use of quinolones may be the cause of my current problems, (including wheelchair use); all supplements (which can aggravate the condition) were discontinued on 10/14/2012. Am now treating for the homozygous MTHFR 1298 mutation. Off of all pain meds since Spring '14 (was on them for years--doctor is amazed--me too). Back on pain med 1/2017. Reinfected? Frozen shoulder?

[nord]

Hello Maz,
thank you for the welcome and help! Its good to be here, even if it is not to have to. 🙂 I'm glad you first missed Ruth's reply, so I could get two independent opinions saying much the same. 🙂

[user=27]Maz[/user] wrote:

Hi Nord,

So glad you found us here in the forum!

As far as I know, Dr D at Breakspear is a consultant specialists in rheumatology, so he should be able to give you a diagnosis once he's run various tests and taken in your full clinical picture. There is a gene test that he can run, called HLA-B27, which you could ask about and may help in diagnosis.

 
Yes, I know of HLA-B27, but am not tested. From what I've read so far, it is less of importance in diagnosis, as there are facts suggesting it being more of a factor in determining severity of symptoms, rather than the risk of getting the disease. E. g. one of the articles we mentioned in e-mail: John D. Carter, Alan P. Hudson: ?Reactive Arthritis: Clinical Aspects and Medical Management? Rheumatic diseases clinics of North America 35(1):21-44, 2009 February  http://www.ncbi.nlm.nih.gov/pubmed/19480995. ?Because more than half of affected patients are HLA-B27 negative and recent reports cited suggest it has no role in disease predilection, HLA-B27 should not be used as a diagnostic tool. Therefore, currently there is no practical diagnostic test.? 😐  However, they do point to some other tests that may be available, including  anti-HSP-60 specific IgG.

In the same paper, I found where I'd read that CRP and ESR can be normal in chronic ReA (and as per the wording this is more the norm, probably making the disease far more underdiagnosed than if these markers were elevated, and thus promting clinicians to further investigation): ?ReA can follow two disease courses. The first is an acute syndrome occurring shortly after the triggering infection followed by gradual resolution of the symptoms; the second begins in a similar fashion yet can progress to chronicity, sometimes years. During the acute stage, individuals often display elevated acute phase reactants, such as an elevated erythrocyte sedimentation rate or C-reactive protein level. Conversely, patients who have chronic ReA typically display normal levels. Patients in the acute phase also might display other indicators of inflammatory response, including leukocytosis or thrombocytosis.?

At http://www.kickas.org there are also some medical research papers by a a guy called, Dr Alan Ebringer you might be interested to read through. He has researched various organisms implicated in reactive arthritides, including Ankylosings Spondylitis. In fact, a good contact for you may be a forum user here, Dragonslayer (John) with AS in remission, who just posted this thread yesterday:

http://www.rbfbb.org/view_topic.php?id=3771&forum_id=1

Thank you for the links, I have a lot to read, both the kickas.org and cpnhelp.org articles look very interesting. Still there seems to be a lot of areas needing reserach (I am fairly sceptical regarding much of current research driven by commercial interests). It is easy to see that it is preferable to them to find medication that alleviates symptoms (getting lifelong customers) rather than curing a disease (making customers ex-ditto).
 

Breakspear is a private clinic and you may have to dig deep in your pockets for a full workup, but if you are considering a trip to Germany, which could also rack up the costs, you might find Dr D to be just as helpful to your situation and closer to home.

Being unwell is creating far worse havoc in my pockets, I suspect! 🙂 But, yes, I realise it is wiser to take on a more measured approach and see how the Breakspear visit turns out.

The diagnosis route suggested for possible prostatitis also includes Germany (but a different town, and with a rather hefty price-tag), but as I think the two issues are closely related, I may postpone this too. A finnish Professor of Urology actually suggested that I take this route: first to see a rheumatologist.  There is a place that is said to be good for diagnosis of prostatitis in Paris, http://www.institutfournier.org/, and it could perhaps be a better place for an integrated approach (easier to combine visits to London and Paris via the chunnel, and assuming that Breakspear doesn't do that kind of testing).

In relation to your chronic prostratitis, you might find this link interesting, which suggests doxycycline and minocycline for treatment management and the infections commonly associated with this condition:

http://www.bsac.org.uk/pyxis/UTI/Chronic%20prostatitis/Chronic%20prostatitis.htm

Interestingly, the treatments outlined in this link are quite similar to the ones outlined at http://www.cpnhelp.org for various arthritides linked to the chlamydias (chlamydia pneumoniae and trachomatis).

Chronic prostatitis (CP) seems to be sharing a lot in terms of clinical picture, etiology etc. with ReA. Pathogenic etiology in CP is generally underestimated/understated, it seems (the http://www.bsac.org.uk page has an interesting view on treatment of bacterial CP, but states it is only about 10% of the CP cases; others, having searched more thourogly for patogens states several times that). An Italian professor of pharmacology, who has co-authored several papers on CP, including combination therapies (different antibiotics, anti-inflammatories etc), mentioned in private conversation that antibiotics may need to be taken for several months or even more. This is just two examples of similarities, and there are more.

Regrettably, urologists, which is the speciality normally treating CP (as well as interstitial cystitis, mainly diagnosed in women, and chronic pelvic pain syndrome), are basically surgeons, and much of what is offered in terms of treatment is surgical procedures (often with dire side effects). I think this is comparable to patients with rheumatic disease getting treated by orthopedics (focusing on replacing destroyed joints).
 
About the similarity of antibiotic protocols for Cpn and Ctr for the different diseases http://www.ncbi.nlm.nih.gov/pubmed/19931374 is interesting. Perhaps it has some relevance to the issue of identifying Chlamydia infection in joints of ReA patients (not sure about how broadly they have tested for different strans in studies or what is common clinical practise, if any).

I would put in a call to Breakspear just to be sure, but as Dr D is a rheumatologist, he should be fully equipped to both give you a diagnosis and to offer antibiotic treatments to you.

Hope this helps, Nord, and welcome!

Peace, Maz

 

 
Sorry if my points here seem a bit negative, especially considering your contagious positive take on things, thank you!

[nord]

[user=415]spacehoppa[/user] wrote:

Hi Nord,

I don't know much about ReA but you seem to have a lot of leads and info to go on and Maz has supplied you with more great info, as ever! A friend of mine has palindromic RA and also has regular severe bladder infections and I'm convinced there's a link for her too, but doubt she'll ever investigate it.

From what I've read, and if she hasn't done any deeper probing of the infections, that is sad, as it is effectively to throw away a big chunk of her life.

It's so hard to be your own advocate, but also so important. It's good that you are so proactive and determined. It's the only way to get the correct treatment I think.

Perhaps it is hard getting started (but I've been on a sligthly similar journey before, or still is, just taking a break because of this “hassle” 🙂 ), but once getting going it is energizing and empowering to get a hold of a difficult situation.

I'm glad you like my silly youtube videos. I am kind of monumentally embarrassed by them, but also feel it's important to document not just that the treatment works, but also the ups and downs along the way.

Don't be embarrassed, it's a great documentation of the experience!

[nord]

[user=415]spacehoppa[/user] wrote:

Thanks Trudi! Not so calm in today's video unfortunately, I actually cried on camera – ugh! The reason was because I found out when I went to the Breakspear yesterday that my lovely LLMD is under investigation by the GMC (General Medical Council).

This is seriously bad news for him, and for all us UK lyme patients. Seriously bad. Why does this keep happening?!! I am very angry that such a caring and responsible doctor is being investigated. Something must be done – but what?

Is it really bad or just a complaint that they have to investigate?

I had a quick look at how GMC work, and it seems that if anything serious is going to happen, then there will be a public hearing. Just a thought 😉 There are of course a lot of things to consider in a situation like this, but his own attitude towards the issue is important of course.

History, and not least medical, is sadly full of pioneers that have become targets in witch-hunts. Discussing possible infectious causes, one cannot avoid to think of Semmelweis. 🙁

[nord]

Hello Kate!

[user=1615]kate murrell[/user] wrote:

I will be having my first appointment at Breakspear in a couple of weeks.
I am very concerned about the investigation you mentioned. Do you have any more details? I hope no-one tries to stop the good work of Dr D- and especially (selfishly, I know)- before my appointment with him.

Being in much the same position I looked around a bit on the GMC website and it looks like there will be a public hearing and other procedures before any action. Seeing that there is no hearing with Dr D scheduled on http://www.gmc-uk.org/calendar/ I hope it is not something that will happen soon. It seems that at least summaries of the complaints will be public before any final decisions. Caveat: I'm a foreigner that just had a look on this.

Incidentally, can you  recommend an anti-inflammatory to tide me over another 2 weeks? My blood tests are not looking too good at moment -every month the CRP and ESR are rising and my Haemoglobin is falling nearly into anaemic but not quite. Actually, for some days I feel better in myself, but it feels like a cycle.
I get on Ok with Paracetamol but I know it's not an inflamm.

But does NSAIDs do much about the systemic issues?

I take 200mg Ibuprofen often and eventually it makes my stomach sore.

Have you tries bilberry (preferrably the “European” variety, Vaccinum Myrtillis, wich is far more potent than the American bilberry, which is actually vastly different, despite being similarly named and looking).  It has saved my stomach a bit, and the fresh/previously frozen berries taste fantastic with yoghurt! There are extract pills etc which are rather expensive, and miss some of the good things in the real berries. Here, freeze-dried powder for making soft-drinks of it is available by normal food brands, which is a good source. Ready-made drink and Jam are other alternatives, but all that I've seen contain far too much sugar.

Dr Mercolas site lists seven natural anti-inflamatories: http://articles.mercola.com/sites/articles/archive/2005/01/12/anti-inflammatory-part-one.aspx . I only knew of the importance of omega-3, but a quick check of the first two, ginger and boswellia,  reveals that there is scientific support for those. Will try these myself.

I hope you find a way to some relief until your visit, and that you can report from it!

[Maz]

Hi Nord,

Sorry it took so long to reply. I was taking a bit of a break and wanted to read your links properly.

[user=2031]nord[/user] wrote:

Yes, I know of HLA-B27, but am not tested. From what I've read so far, it is less of importance in diagnosis, as there are facts suggesting it being more of a factor in determining severity of symptoms, rather than the risk of getting the disease.

Gosh, Nord, you're certainly doing your research! This should bode well for your recovery. Yes, can see why this test may be unhelpful in terms of diagnosis, though may be useful in terms of a prognostic indicator.

In the same paper, I found where I'd read that CRP and ESR can be normal in chronic ReA (and as per the wording this is more the norm, probably making the disease far more underdiagnosed than if these markers were elevated,

I can't remember if I shared this with you already, but in light of the above statement, you might find the following recently published study interesting….not only in terms of antibiotic therapy being used in ReA, but in respect of ReA being underdiagnosed with some regularity and thus leading patients with arthritides that are clearly linked to triggering infections being put on immunosuppressive therapies unnecessarily and perhaps to their longterm detriment:

http://www.rheumatologynews.com/article/PIIS1541980009703928/fulltext

Still there seems to be a lot of areas needing reserach (I am fairly sceptical regarding much of current research driven by commercial interests). It is easy to see that it is preferable to them to find medication that alleviates symptoms (getting lifelong customers) rather than curing a disease (making customers ex-ditto). 

Absolutely! One of the reasons there are so few studies on antibiotic therapy is that patents have run out on antibiotics and there is no money to be made by big pharma on them…there is, however, a highly lucrative payback on the newer drugs that that only offer palliation.

Being unwell is creating far worse havoc in my pockets, I suspect! 🙂 But, yes, I realise it is wiser to take on a more measured approach and see how the Breakspear visit turns out.

That's a pretty realistic way of looking at it. You can't work – you can't earn. :doh:

There is a place that is said to be good for diagnosis of prostatitis in Paris, http://www.institutfournier.org/, and it could perhaps be a better place for an integrated approach (easier to combine visits to London and Paris via the chunnel, and assuming that Breakspear doesn't do that kind of testing).

Putting a call in to Breakspear may help answer the question as regards specific testing for infections related to prostratitis. May save you time and money to do a one-stop testing trip there?

Regrettably, urologists, which is the speciality normally treating CP (as well as interstitial cystitis, mainly diagnosed in women, and chronic pelvic pain syndrome), are basically surgeons, and much of what is offered in terms of treatment is surgical procedures (often with dire side effects). I think this is comparable to patients with rheumatic disease getting treated by orthopedics (focusing on replacing destroyed joints).

T'was ever thus… we can go to physicians of various areas of specialty and receive as many paths to treatment. In the field of rheumatology, it's generally a question of “picking your poison.” I chose antibiotic therapy, knowing chronic infection was at the root of my RA, and just seemed to be the most sensible approach. I realized it would take longer than palliative approaches and understood I may incur joint damage along the way, but felt after weighing the risk/benefits of joint damage over organ damage, decided a joint replacement would be preferable, if that should happen. I am now at 96% improvement, after 3 years of therapy and no need for joint replacements. 🙂

About the similarity of antibiotic protocols for Cpn and Ctr for the different diseases http://www.ncbi.nlm.nih.gov/pubmed/19931374 is interesting. Perhaps it has some relevance to the issue of identifying Chlamydia infection in joints of ReA patients (not sure about how broadly they have tested for different strans in studies or what is common clinical practise, if any).

 

I think this field of study certainly warrants further investigation. The study above in rheumatology news is a big breakthrough in terms of proving the efficacy of antibiotic therapy in ReA patients. 😀

 
Sorry if my points here seem a bit negative, especially considering your contagious positive take on things, thank you!

Nord, I didn't think you were being negative-sounding, at all. Just employing a healthy amount of skepticism and doing due-diligence in your researches. We all become experts in our own diseases by the end of it. Three years ago, I was clueless and thought RA was something the elderly got, if they were unlucky. Having done quite a bit research now, collecting studies for RBF, I'm firmly in the camp that all it's more than likely that all rheumatic diseases are reactive in the sense that they are all reacting to some pathogenic offender(s). There can be so much overlap in rheumatic disease that probably the labels are of less import than identifying the underlying infections. And, from this starting point, determining an appropriate antibiotic protocol for each individual is probably of more import.

You have about a month to wait for your appt at Breakspear, but hope you will hang around and share your researches with us and let us know how your appt goes.

Peace, Maz

PS Don't want to presume anything, as you are such an avid researcher, but, if this helps, low hemaglobin can be related to pernicious anemia caused by lack of B12. If supplementing with orals, B12 sublinguals (dissolved under the tongue) are best for absorption in combination with a B-Complex oral supp, as all the B's work synergistically together. Sometimes B12 shots are needed, if absorption is a problem or pernicious anemia is severe.

[Author]

Posts