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Because the toxicity of the cyanide antidote currently available in the United States renders it ill-suited for use in terrorist incidents and other situations requiring rapid out-of-hospital treatment, hydroxocobalamin--an effective and safe cyanide antidote being used in other countries--has been introduced in the United States

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Common causes include pernicious anaemia (autoimmune condition), plant-based diets without supplementation, gastrointestinal surgery, and long-term use of metformin or proton pump inhibitors