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Concurrent iron-deficiency anemia and folic acid deficiency may result in a blunted or impeded response to cyanocobalamin therapy.1

Although the mechanisms responsible for these alterations are not clear, at least three possibilities in addition to infiltration of macrophages might explain these findings

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Positive pressure inside the vial from repeated needle insertions can force contaminants back through the needle on subsequent draws, so always equalize pressure by injecting an equivalent volume of air before drawing liquid
