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Methylation issues are very common (up to 40% of patients) and many patients unknowingly supplement with cyanocobalamin which may increase serum levels but will not improve symptoms 5
Wells G, Shea B, OConnell D et al (2004) The NewcastleOttawa Scale (NOQAS) for assessing the quality of non-randomized studies in meta-analysis
The cycling protocols commonly recommended are partly based on this theoretical concern, though actual tolerance development has not been documented
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