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Xu X, Zhang L, He Y, Qi C, Li F. Progress in Research on the Role of the Thioredoxin System in Chemical Nerve Injury. TOXICS 2024; 12:510. [PMID: 39058162 PMCID: PMC11280602 DOI: 10.3390/toxics12070510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/30/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024]
Abstract
(1) Background: Various factors, such as oxidative stress, mitochondrial dysfunction, tumors, inflammation, trauma, immune disorders, and neuronal toxicity, can cause nerve damage. Chemical nerve injury, which results from exposure to toxic chemicals, has garnered increasing research attention. The thioredoxin (Trx) system, comprising Trx, Trx reductase, nicotinamide adenine dinucleotide phosphate, and Trx-interacting protein (TXNIP; endogenous Trx inhibitor), helps maintain redox homeostasis in the central nervous system. The dysregulation of this system can cause dementia, cognitive impairment, nerve conduction disorders, movement disorders, and other neurological disorders. Thus, maintaining Trx system homeostasis is crucial for preventing or treating nerve damage. (2) Objective: In this review study, we explored factors influencing the homeostasis of the Trx system and the involvement of its homeostatic imbalance in chemical nerve injury. In addition, we investigated the therapeutic potential of the Trx system-targeting active substances against chemical nerve injury. (3) Conclusions: Chemicals such as morphine, metals, and methylglyoxal interfere with the activity of TXNIP, Trx, and Trx reductase, disrupting Trx system homeostasis by affecting the phosphatidylinositol-3-kinase/protein kinase B, extracellular signal-regulated kinase, and apoptotic signaling-regulated kinase 1/p38 mitogen-activated protein kinase pathways, thereby leading to neurological disorders. Active substances such as resveratrol and lysergic acid sulfide mitigate the symptoms of chemical nerve injury by regulating the Ras/Raf1/extracellular signal-regulated kinase pathway and the miR-146a-5p/TXNIP axis. This study may guide the development of Trx-targeting modulators for treating neurological disorders and chemical nerve injuries.
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Affiliation(s)
- Xinwei Xu
- School of Medicine, Jiangsu University, Zhenjiang 212013, China; (X.X.); (L.Z.); (Y.H.)
| | - Lan Zhang
- School of Medicine, Jiangsu University, Zhenjiang 212013, China; (X.X.); (L.Z.); (Y.H.)
| | - Yuyun He
- School of Medicine, Jiangsu University, Zhenjiang 212013, China; (X.X.); (L.Z.); (Y.H.)
| | - Cong Qi
- Department of Pharmacy, Jurong People’s Hospital, Jurong 212400, China;
| | - Fang Li
- School of Medicine, Jiangsu University, Zhenjiang 212013, China; (X.X.); (L.Z.); (Y.H.)
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Ryder H, Mosalski S, Bramah V, Page R, Faux SG, Shiner CT. Multidisciplinary rehabilitation following recreational nitrous oxide (N 2O) misuse: evaluating service provision and rehabilitation outcomes in a cohort with serious disability. Disabil Rehabil 2024:1-10. [PMID: 38950561 DOI: 10.1080/09638288.2024.2365987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/05/2024] [Indexed: 07/03/2024]
Abstract
Purpose: Recreational nitrous oxide (N2O) misuse is increasing globally. Chronic misuse can cause neurological impairments that require rehabilitation, though literature characterising rehabilitation is limited. This study aimed to evaluate rehabilitation service provision for impairments resulting from N2O misuse. Methods: A retrospective audit of hospitalised patients referred for rehabilitation for N2O toxicity was conducted between 2015 and 2022 at a single metropolitan hospital. Data were collected via medical record audit and analysed via descriptive and non-parametric statistics. Results: 16 eligible cases were identified, aged 18-43 years (50% female/male), with increasing case frequency. 12 cases received inpatient rehabilitation episodes for multifactorial sensorimotor, cognitive and psychosocial impairments. Cases articulated diverse rehabilitation goals and received intervention from a median of 6 clinical disciplines. All cases required assistance to mobilise or perform self-care activities on admission. Functional Independence Measure (FIM) scores significantly improved with rehabilitation (median FIM 84[75-93] to 117[112-123], p < .001). Despite gains in independence, all cases required referral for ongoing rehabilitation post-discharge. Conclusions: Demand for inpatient rehabilitation for disabling N2O toxicity appears to be increasing. In this series, cases were young, exhibited serious impairments, and had multidisciplinary rehabilitation needs. Inpatient rehabilitation led to significant functional improvements, though ongoing disability was evident post-discharge.
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Affiliation(s)
- Hannah Ryder
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Simon Mosalski
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Sydney Campus, University of Notre Dame, Australia
| | - Valerie Bramah
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
| | - Robert Page
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Australia
| | - Steven G Faux
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Sydney Campus, University of Notre Dame, Australia
| | - Christine T Shiner
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
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Fortanier E, Delmont E, Corazza G, Kouton L, Micallef J, Attarian S. Longitudinal follow-up and prognostic factors in nitrous oxide-induced neuropathy. J Peripher Nerv Syst 2024; 29:252-261. [PMID: 38772556 DOI: 10.1111/jns.12634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND AND AIM Recreational use of nitrous oxide (N2O) has been associated with the development of severe nitrous oxide-induced neuropathy (N2On). Follow-up of these patients poses challenges, and their clinical progression remains largely unknown. The identification of prognostic factors is made difficult by the lack of standardized longitudinal assessments in most studies. The objective was to document the course of neuropathy through systematic follow-up assessments in N2On patients to identify prognostic factors for persistent disability after 6 months. METHODS We gathered demographic, clinical, biological, and electrophysiological data from N2On patients hospitalized in the Referral center in Marseille, both at baseline and during a standardized follow-up assessment at 6 months. RESULTS We retrospectively included 26 N2On patients (mean age 22.6 ± 4.4). Significant improvements were observed in all main clinical scores including Rankin, ONLS, and MRC testing (p < .01). Electrophysiological studies (EDX) revealed a predominantly motor neuropathy with marked reduction in CMAP in the lower limbs at baseline, and no significant improvement in motor parameters (p = .543). Rankin score at 6 months correlated with the initial weekly N2O consumption (r = .43, p = .03) and the CMAP sum score in the lower limbs at the first EDX (r = -.47, p = .02). Patients with and without myelitis showed similar Rankin and ONLS score after 6 months. INTERPRETATION The clinical course generally improved favorably at 6 months with notable amelioration in the primary disability scores, sensory deficits, and ataxia. However, distal motor impairment associated with peripheral neuropathy persisted, with distal axonal loss emerging as the main prognostic factor for long-term disability in these young patients.
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Affiliation(s)
- Etienne Fortanier
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Emilien Delmont
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Giovanni Corazza
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Ludivine Kouton
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Joelle Micallef
- Clinical Pharmacology and Pharmacosurveillance, Regional Addictovigilance Center of Marseille, Marseille University, Hospital, Marseille, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
- Inserm, GMGF, Aix-Marseille University, Marseille, France
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Pichon M, Majhadi L, Menn AM. Neurological Manifestations Induced by Nitrous Oxide Abuse: A Case Series and Review of Literature. Neurologist 2024; 29:113-119. [PMID: 37839087 DOI: 10.1097/nrl.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Nitrous oxide (NO) abuse is increasing among young people. This can result in severe neurological disorders such as myelopathy and/or peripheral neuropathy. We report the clinical presentations, biological, radiologic and electrophysiological findings of 5 patients hospitalized with neurological symptoms consecutive to NO abuse. In addition, a literature review was conducted to describe the neurological characteristics and to identify factors associated with a poor recovery. CASE REPORT Among the 5 patients included, 2 had a myeloneuropathy, 2 had a sensorimotor neuropathy, and 1 had a normal spinal cord magnetic resonance imaging and electromyography despite neurological manifestations consistent with myeloneuropathy. After vitamin B 12 supplementation, recovery was reported in 4 patients, and 1 was lost to follow-up.From the literature review, 154 patients were included [94 males; median age 22 (19 to 26) y; NO exposure 9 (3 to 18) mo]. A myelopathy was identified in 116 patients (75%) and a peripheral neuropathy was documented in 89 patients (58%). Compared with patients who recovered, those with sequelae were more likely to have a motor deficit at presentation ( P <0.001), to use NO regularly ( P <0.001), to have a lower vitamin B 12 level ( P =0.04), and a higher concentration of homocysteine ( P =0.04). A less extensive myelopathy was more frequently found in the group with favorable outcomes ( P =0.002). CONCLUSION Neurological disorders caused by NO may be challenging with severe clinical patterns. We identified several factors associated with a poor recovery, to make clinicians aware of NO-induced neurotoxicity.
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Affiliation(s)
| | - Loubna Majhadi
- Neurology, Centre Hospitalier Victor Dupouy, Argenteuil, France
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Grzych G, Scuccimarra M, Plasse L, Gernez E, Cassim F, Touze B, Girot M, Bossaert C, Tard C. Understanding Neuropathy Features in the Context of Nitrous Oxide Abuse: A Combined Electrophysiological and Metabolic Approach. Biomedicines 2024; 12:429. [PMID: 38398031 PMCID: PMC10886673 DOI: 10.3390/biomedicines12020429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The incidence of neurological complications associated with nitrous oxide (N2O) abuse, including N2O-induced myelopathy and neuropathy, has risen in the past decade. N2O-induced neuropathy often presents as a subacute axonal pathology; however, demyelinating patterns mimicking Guillain-Barré syndrome have also been observed. This study explores the metabolic pathophysiology of N2O-induced neuropathy, focusing on the alteration in metabolism to provide a deeper understanding of the biochemical pathways influencing the diverse electrophysiological patterns observed. METHODS We conducted a combined metabolic and electrophysiological exploration of 35 patients who underwent electromyographic exams at our referral center over a three-year period for sensorimotor symptoms linked to recreational N2O use. We collected demographic, clinical, radiological, electrophysiological, and biological data. Patients were categorized into axonal or demyelinating groups based on their electrophysiological patterns, and metabolic parameters were compared. RESULTS Our cohort predominantly exhibited a length-dependent sensorimotor axonal symmetrical neuropathy affecting the lower limbs. Among the patients, 40% met the demyelinating criteria, with four patients exhibiting conduction blocks. The demyelinating group had a significantly higher peripheral neuropathy disability (PND) score at diagnosis. Elevated homocysteine and methylmalonic acid (MMA) levels were noted in all patients, but these were lower in the demyelinating group. CONCLUSIONS This study highlights the diverse electrophysiological manifestations of N2O-induced neuropathy and underscores the potential role of metabolic parameters as biomarkers to understand its pathophysiology. Lower hyperhomocysteinemia and MMA levels were observed in demyelinating patterns. In this study, we did not observe further improvement, but it is well-known that demyelinating features have a better prognosis related to the further remyelination. These findings contribute to a better understanding of N2O-related neuropathic damage and could guide future therapeutic interventions based on biochemical-neurophysiological stratifications.
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Affiliation(s)
- Guillaume Grzych
- Biology Center, Biochemistry Department, Lille University Hospital, 59000 Lille, France; (L.P.); (E.G.); (B.T.)
- IMPact de l’Environnement Chimique sur la Santé (IMPECS), University of Lille, 59000 Lille, France
| | - Marie Scuccimarra
- Reference Center for Neuromuscular Diseases, Neurology Department, Lille University Hospital, 59000 Lille, France; (M.S.); (C.T.)
| | - Laura Plasse
- Biology Center, Biochemistry Department, Lille University Hospital, 59000 Lille, France; (L.P.); (E.G.); (B.T.)
| | - Emeline Gernez
- Biology Center, Biochemistry Department, Lille University Hospital, 59000 Lille, France; (L.P.); (E.G.); (B.T.)
| | - Francois Cassim
- Neurophysiology Department, Lille University Hospital, 59000 Lille, France;
| | - Benjamin Touze
- Biology Center, Biochemistry Department, Lille University Hospital, 59000 Lille, France; (L.P.); (E.G.); (B.T.)
- IMPact de l’Environnement Chimique sur la Santé (IMPECS), University of Lille, 59000 Lille, France
| | - Marie Girot
- Emergency Department, Lille University Hospital, 59000 Lille, France; (M.G.); (C.B.)
| | - Cécile Bossaert
- Emergency Department, Lille University Hospital, 59000 Lille, France; (M.G.); (C.B.)
| | - Céline Tard
- Reference Center for Neuromuscular Diseases, Neurology Department, Lille University Hospital, 59000 Lille, France; (M.S.); (C.T.)
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Hassing LT, Jiang FY, Zutt R, Arends S. Nitrous-oxide-induced polyneuropathy and subacute combined degeneration of the spine: clinical and diagnostic characteristics in 70 patients, with focus on electrodiagnostic studies. Eur J Neurol 2024; 31:e16076. [PMID: 37754673 PMCID: PMC11235686 DOI: 10.1111/ene.16076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND PURPOSE Nitrous oxide (N2 O) induced neurological symptoms are increasingly encountered. Our aim is to provide clinical and diagnostic characteristics with a focus on electrodiagnostic studies. METHODS Patients with neurological sequelae due to N2 O presenting in our hospital between November 2018 and December 2021 reporting clinical and diagnostic data were retrospectively reviewed. RESULTS Seventy patients (median 22 years) were included. Median N2 O usage was 4 kg/week during 12 months. Patients' history revealed a higher rate of sensory symptoms compared to motor (97% vs. 57%) and 77% walking difficulties. Clinical diagnosis was polyneuropathy (PNP) in 44%, subacute combined degeneration (SCD) of the spine in 19%, both in 37%. Median vitamin B12 level was low (159 pmol/L), normal in 16%. The median methylmalonic acid was increased (2.66 μmol/L). Electrodiagnostic abnormalities were observed in 91%, with 72% fulfilling axonal PNP criteria, 20% showing mild to intermediate slowing. One patient fulfilled demyelinating PNP criteria not related to N2 O abuse (Charcot-Marie-Tooth type 1a). More prominent motor nerve conduction abnormalities were found; lower limbs were more affected. In 64% with normal conduction, myography showed signs of axonal loss. Magnetic resonance imaging showed cervical myelopathy in 58% involving generally five to six segments. CONCLUSIONS Nitrous oxide (N2 O) leads to neurological symptoms by causing PNP and/or SCD primarily involving the legs. Distinguishing PNP and SCD clinically was shown to be insufficient. Electrodiagnostic studies showed axonal PNP. Demyelinating PNP due to N2 O abuse was not present in our cohort. Therefore, further diagnostic work-up is warranted if demyelinating features are present.
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Affiliation(s)
- L. T. Hassing
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
| | - F. Y. Jiang
- HagaZiekenhuis, Department of RadiologyThe HagueThe Netherlands
| | - R. Zutt
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
| | - S. Arends
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
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Gernez E, Lee GR, Niguet JP, Zerimech F, Bennis A, Grzych G. Nitrous Oxide Abuse: Clinical Outcomes, Pharmacology, Pharmacokinetics, Toxicity and Impact on Metabolism. TOXICS 2023; 11:962. [PMID: 38133363 PMCID: PMC10747624 DOI: 10.3390/toxics11120962] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
The recreational use of nitrous oxide (N2O), also called laughing gas, has increased significantly in recent years. In 2022, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) recognized it as one of the most prevalent psychoactive substances used in Europe. Chronic nitrous oxide (N2O) exposure can lead to various clinical manifestations. The most frequent symptoms are neurological (sensitive or motor disorders), but there are also other manifestations like psychiatric manifestations or cardiovascular disorders (thrombosis events). N2O also affects various neurotransmitter systems, leading to its anesthetic, analgesic, anxiolytic and antidepressant properties. N2O is very challenging to measure in biological matrices. Thus, in cases of N2O intoxication, indirect biomarkers such as vitamin B12, plasma homocysteine and plasma MMA should be explored for diagnosis and assessment. Others markers, like oxidative stress markers, could be promising but need to be further investigated.
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Affiliation(s)
- Emeline Gernez
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
| | | | - Jean-Paul Niguet
- Service de Neurologie, Hôpital Saint Vincent de Paul–GHICL, 59000 Lille, France;
| | - Farid Zerimech
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
| | - Anas Bennis
- Assistance Publique—Hôpitaux de Paris, Service de Neurologie, Groupe Hospitalier Universitaire Paris Sud, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France;
| | - Guillaume Grzych
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
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Riccò M, Ferraro P, Corrado S, Bottazzoli M, Marchesi F. Nitrous Oxide Inhalant Abuse: Preliminary Results from a Cross-Sectional Study on Knowledge, Attitudes, and Practices of Italian Physicians (2023). MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1820. [PMID: 37893538 PMCID: PMC10608448 DOI: 10.3390/medicina59101820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Nitrous oxide (N2O) has recently emerged as a cheap alternative to other recreational substances. Although legally available, its chronic use is associated with severe neurological and hematological complications due to the irreversible inactivation of vitamin B12. While no reliable data on abuse of N2O in Italy have been provided to date, we assessed the knowledge, attitudes, and practices of Italian medical professionals on the management of N2O abuse cases. Materials and Methods: A cross-sectional study was performed as a web-based survey through a series of Facebook discussion groups (targeted medical professionals: 12,103), and participants were specifically asked about their previous understanding of N2O abuse and whether they had or not any previous experience in this topic. Results: A total 396 medical professionals participated in the survey. Overall, 115 participants had previous knowledge about N2O abuse (29.04%), with higher odds for professionals with a background in emergency medicine (adjusted odds ratio (aOR) 3.075; 95% confidence intervals (95%CI) 1.071 to 8.828) and lower for specialists in psychiatry (aOR 0.328; 95%CI 0.130 to 0.825). Knowledge status on N2O abuse was largely unsatisfying, as knowledge status, reported as a percent value, was estimated to 45.33% ± 24.71. Having previously managed a case of N2O abuse was associated with higher risk perception of the actual severity of this condition (aOR 5.070; 95%CI 1.520 to 16.980). Conclusions: Our study suggests that N2O poisoning cases are occurring in Italian settings but are not reasonably reported to national authorities. As substantial knowledge gaps of Italian medical workforces were identified, we cannot rule out that the actual abuse of N2O in the population may be far larger than currently suspected.
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Affiliation(s)
- Matteo Riccò
- Occupational Health and Safety Service on the Workplace/Servizio di Prevenzione e Sicurezza Ambienti di Lavoro (SPSAL), Department of Public Health, AUSL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Pietro Ferraro
- Occupational Medicine Unit, Direzione Sanità, Italian Railways’ Infrastructure Division, RFI SpA, 00161 Rome, Italy;
| | - Silvia Corrado
- ASST Rhodense, Dipartimento della donna e Area Materno-Infantile, UOC Pediatria, 20024 Garbagnate Milanese, Italy;
| | - Marco Bottazzoli
- Department of Otorhinolaryngology, APSS Trento, 31223 Trento, Italy;
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
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Fortanier E, Berling E, Zanin A, Guillou AL, Micaleff J, Nicolas G, Lozeron P, Attarian S. How to distinguish Guillain-Barré syndrome from nitrous oxide-induced neuropathy: A 2-year, multicentric, retrospective study. Eur J Neurol 2023; 30:3296-3306. [PMID: 37494104 DOI: 10.1111/ene.15998] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/10/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Recreational use of nitrous oxide (N2 O) has dramatically increased in recent years, resulting in numerous cases of acute sensorimotor tetraparesis secondary to nitrous oxide-induced neuropathy (N2 On). Challenging clinical features can mimic Guillain-Barré syndrome (GBS), the main differential diagnosis upon admission. The most sensitive biomarkers for distinguishing between these two conditions remain to be determined. METHODS Fifty-eight N2 On patients from three referral centers were retrospectively included over a 2-year period and compared to GBS patients hospitalized during the same timeframe (47 patients). Collected demographic, clinical, biological, and electrophysiological data were compared between the two groups. RESULTS The typical N2 On clinical pattern included distal sensorimotor deficit in lower limbs with absent reflexes, proprioceptive ataxia, and no cranial involvement (56.7% of our cohort). Misleading GBS-like presentations were found in 14 N2 On patients (24.1%), and 13 patients (22.4%) did not report N2 O use during initial interview. Only half the N2 On patients presented with reduced vitamin B12 serum levels upon admission. A slightly increased cut-off (<200 pmol/L) demonstrated 85.1% sensitivity and 84.5% specificity in distinguishing N2 On from GBS. Only 6.9% of N2 On patients met the criteria for primary demyelination (p < 0.01), with only one presenting conduction blocks. A diagnostic algorithm combining these two biomarkers successfully classified all GBS-like N2 On patients. CONCLUSIONS Vitamin B12 serum level < 200 pmol/L cut-off and conduction blocks in initial electrophysiological study are the two most sensitive biomarkers for rapidly distinguishing N2 On from GBS patients. These two parameters are particularly useful in clinically atypical N2 On with GBS-like presentation.
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Affiliation(s)
- Etienne Fortanier
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Edouard Berling
- APHP, Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence Nord-Est-Ile-de-France, FHU PHENIX, Garches, France
- Université de Versailles Saint-Quentin-en-Yvelines, U 1179 INSERM, Paris-Saclay, France
| | - Adrien Zanin
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, Paris, France
- Laboratory for Vascular Translational Science, U1148, Université de Paris, INSERM, Paris, France
| | | | - Joelle Micaleff
- Marseille University Hospital, Clinical Pharmacology and Pharmacosurveillance, Regional Addictovigilance Center of Marseille, Marseille, France
- Aix-Marseille University, INSERM UMR 1106, Marseille, France
| | - Guillaume Nicolas
- APHP, Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence Nord-Est-Ile-de-France, FHU PHENIX, Garches, France
- Université de Versailles Saint-Quentin-en-Yvelines, U 1179 INSERM, Paris-Saclay, France
| | - Pierre Lozeron
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, Paris, France
- Laboratory for Vascular Translational Science, U1148, Université de Paris, INSERM, Paris, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
- Aix-Marseille University, INSERM, GMGF, Marseille, France
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Rossor AM, Manji H. Toxic neuropathies. Curr Opin Neurol 2023; 36:402-409. [PMID: 37639472 DOI: 10.1097/wco.0000000000001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Immunotherapy has had a significant impact on the treatment of an increasing number of cancers as well as in inflammatory, rheumatological and gastroenterological conditions.Recreational nitrous oxide use is now a global epidemic. Linezolid is now recommended for the treatment of drug-resistant tuberculosis (TB); neuropathy is a significant cause of morbidity.Global warming will result in increasing toxin exposure, such as ciguatera, in previously unaffected areas. RECENT FINDINGS With increasing experience, the pathophysiology underlying the neuropathic complications of these drugs has become clear with guidelines now available, for the complications of immune check-point inhibitors and nitrous oxide toxicity. The optimum dose and duration of treatment for resistant TB with regimens, including linezolid, has been ascertained. SUMMARY Although neuropathic complications with immunotherapy are relatively rare, it is essential that they are recognized and treated early. Nitrous oxide toxicity should be in the differential diagnosis for all patients, particularly those of younger age, presenting with a neuropathy or myleo-neuropathy. Ciguatera toxicity is under recognized and its geographical spread will increase due to global warming. Further research is necessary on the mechanisms and treatment of both acute and chronic effects, which at present, are only symptomatic.
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Affiliation(s)
- Alexander M Rossor
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology, London, UK
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Mondesert E, Eiden C, Peyriere H, Formoso A, Corti L, Cristol JP, Badiou S. Functional vitamin B 12 deficiency is a consistent feature in hospital admissions for neurological disorders due to the use of nitrous oxide. Clin Toxicol (Phila) 2023; 61:674-679. [PMID: 37917184 DOI: 10.1080/15563650.2023.2274282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Introduction: Misuse of inhaled nitrous oxide is a growing concern in France. It is known to alter concentrations of vitamin B12, which is required as a cofactor for methionine synthase and methylmalonyl-CoA mutase activity. Hence, measurement of the concentrations of cobalamin metabolism biomarkers, including vitamin B12, homocysteine, and methylmalonic acid, could assist in the management of patients with a complex clinical presentation or in those who deny the consumption of nitrous oxide.Methods: We retrospectively collected clinical and biological data in patients hospitalized for nitrous oxide use in a university hospital in southern France between January 2020 and October 2022.Results: Thirty-one patients were identified during 34 months; 79% were men with a median age of 23.7 years. Most (97%) presented with peripheral polyneuropathy and/or myelopathy. The median vitamin B12 concentration was 134.6 pmol/L, with 17 of 31 patients having values less than 145 pmol/L (the lower limit of the normal range). The median plasma folate concentration was 20.1 nmol/L, which is within the normal range. The median plasma homocysteine concentration was 87.7 µmol/L (normal range <15 µmol/L), and the median plasma methylmalonic acid concentration was 3.8 µmol/L (normal range <0.5 µmol/L).Conclusion: Nitrous oxide use is an emerging public health problem in France, as shown by the number of patients admitted to our hospital. The presence of a functional vitamin B12 deficiency was a consistent feature that could be helpful in diagnosis in complex cases.
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Affiliation(s)
- Etienne Mondesert
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
| | - Céline Eiden
- Addictovigilance Center, Department of Pharmacology and Toxicology, University Hospital of Montpellier, Montpellier, France
| | - Hélène Peyriere
- Addictovigilance Center, Department of Pharmacology and Toxicology, University Hospital of Montpellier, Montpellier, France
| | - Aude Formoso
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Lucas Corti
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Jean-Paul Cristol
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
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12
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Parein G, Bollens B. Nitrous oxide-induced polyneuropathy, pancytopenia and pulmonary embolism: a case report. J Med Case Rep 2023; 17:350. [PMID: 37587485 PMCID: PMC10433604 DOI: 10.1186/s13256-023-04075-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Nitrous oxide is a medical and household gas that has seen its use drift to recreational purpose among the young population in recent years. Significant neurological, hematological and psychiatric side effects, generally related to an induced functional vitamin B12 deficiency, have been described separately in the literature. CASE REPORT A 22-year-old woman of North African origin experienced an exceptional combination of polyneuropathy, bilateral pulmonary embolism and severe pancytopenia related to vitamin B12 deficiency and hyperhomocysteinemia induced by recreational nitrous oxide use. After treatment with vitamin B12 supplementation and intensive rehabilitative management, the patient progressively regained the ability to walk and her biological parameters gradually returned to normal. The pathophysiological mechanisms related to a decrease in vitamin B12 activity are the reduction of products needed for synthesis of deoxyribonucleic acid, carbohydrate or fatty acids, and the increase of hyperhomocysteinemia. Other mechanisms involving a direct action of N2O are also suspected. CONCLUSION This case report brings elements to support our knowledge about pathological pathway, recovery and prognosis of recreational N2O abuse complications. The general and medical population should be aware to the serious consequences of this type of consumption.
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Affiliation(s)
- Guillaume Parein
- Physical and Rehabilitation Medicine Department, CHU Ambroise Paré, Mons, Wallonie, Belgium.
| | - Benjamin Bollens
- Physical and Rehabilitation Medicine Department, CHU Ambroise Paré, Mons, Wallonie, Belgium
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13
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Ménétrier T, Denimal D. Vitamin B12 Status in Recreational Users of Nitrous Oxide: A Systematic Review Focusing on the Prevalence of Laboratory Abnormalities. Antioxidants (Basel) 2023; 12:1191. [PMID: 37371921 DOI: 10.3390/antiox12061191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
The recreational use of nitrous oxide (N2O) as "laughing gas" is a growing problem. The chronic toxicity of N2O is mainly due to its ability to oxidize vitamin B12, making it dysfunctional as a cofactor in metabolic pathways. This mechanism plays a major role in the development of neurological disorders in N2O users. The assessment of vitamin B12 status in N2O users is important but challenging due to the lack of decrease in total vitamin B12 in most cases despite genuine vitamin B12 functional deficiency. Other biomarkers, such as holotranscobalamin (holoTC), homocysteine (tHcy) and methylmalonic acid (MMA), are interesting candidates to properly assess vitamin B12 status. Here, we conducted a systematic review of case series in order to assess the prevalence of abnormal values of total vitamin B12, holoTC, tHcy and MMA in recreational N2O users, which is an important prerequisite for determining the best screening strategy in future guidelines. We included 23 case series (574 N2O users) from the PubMed database. Total circulating vitamin B12 concentration was low in 42.2% (95% confidence interval 37.8-46.6%, n = 486) of N2O users, while 28.6% (7.5-49.6%, n = 21) of N2O users had low circulating concentrations of holoTC. tHcy levels were elevated in 79.7% (75.9-83.5%, n = 429) of N2O users, while 79.6% (71.5-87.7%, n = 98) of N2O users had increased concentrations of MMA. In summary, the increases in tHcy and MMA were the most prevalent abnormalities, and should be measured alone or in combination in symptomatic N2O users rather than total vitamin B12 or holoTC.
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Affiliation(s)
- Tanguy Ménétrier
- Department of Biochemistry, University Hospital of Dijon, F-21079 Dijon, France
| | - Damien Denimal
- Department of Biochemistry, University Hospital of Dijon, F-21079 Dijon, France
- UMR1231 LNC INSERM, University of Burgundy, F-21079 Dijon, France
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14
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Smyth D, Kramarz C, Carr AS, Rossor AM, Lunn MP. Toxic neuropathies: a practical approach. Pract Neurol 2023; 23:120-130. [PMID: 36697225 DOI: 10.1136/pn-2022-003444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/27/2023]
Abstract
Toxic neuropathies result from exogenous substances damaging the peripheral nerves. There are numerous causes, including prescribed and recreational drugs, heavy metals, industrial agents and biological toxins. Timely recognition of these neuropathies gives better outcomes, as they usually improve or stabilise once the toxin is removed. Most toxic neuropathies are axonal, length-dependent and sensory predominant, although some have significant motor involvement or can present acutely or subacutely. Here, we outline our clinical approach and discuss the major causes of toxic neuropathy, while emphasising the clinical and neurophysiological features and the neuropathy phenotype. We also include an update on newer medications that can cause neuropathy, including immune checkpoint inhibitors and BRAF/MEK inhibitors.
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Affiliation(s)
- Duncan Smyth
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Caroline Kramarz
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Aisling S Carr
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Alexander M Rossor
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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15
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Bonev V, Wyatt M, Barton MJ, Leitch MA. Severe length-dependent peripheral polyneuropathy in a patient with subacute combined spinal cord degeneration secondary to recreational nitrous oxide abuse: A case report and literature review. Clin Case Rep 2023; 11:e6881. [PMID: 36794039 PMCID: PMC9923462 DOI: 10.1002/ccr3.6881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/15/2022] [Accepted: 12/27/2022] [Indexed: 02/15/2023] Open
Abstract
Nitrous oxide abuse can have detrimental effects on the central and peripheral nervous systems. This case study report aims to demonstrate a combination of severe generalized sensorimotor polyneuropathy and cervical myelopathy related to vitamin B12 deficiency following nitrous oxide abuse. We present a clinical case study and literature review examining primary research-published between 2012 and 2022-reporting nitrous oxide abuse affecting the spinal cord (myelopathy) and peripheral nerves (polyneuropathy); 35 articles were included in the review with a total of 96 patients, where the mean "patients" age was 23.9 years and were in a 2:1 male/female ratio. Of the 96 cases, within the review, 56% of patients were diagnosed with polyneuropathy, most commonly impacting the nerves of the lower limb (62%), while 70% of patients were diagnosed with myelopathy, most commonly impacting the cervical region (78%) on the spinal cord. In our clinical case study, a 28-year-old male underwent a multitude of diagnostic investigations for bilateral "foot drop" and sense of lower limb stiffness as ongoing complications of a vitamin B12 deficiency secondary to recreational nitrous oxide abuse. Both the literature review and our case report emphasize the dangers of recreational nitrous oxide inhalation, colloquially termed "nanging" and the risks it presents to both the central and peripheral nervous systems, which is erroneously considered by many recreational drug users to be less harmful than other illicit substances.
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Affiliation(s)
- Ventzislav Bonev
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Coastal Neurophysiology ServicesGold CoastQueenslandAustralia
| | - Mark Wyatt
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Coastal Neurophysiology ServicesGold CoastQueenslandAustralia
| | - Matthew J. Barton
- School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia,Menzies Health Institute QueenslandGold CoastQueenslandAustralia
| | - Michael A. Leitch
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Neurosciences QueenslandBrisbaneQueenslandAustralia
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16
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Dong MX, Wang Q, Xu JF, Hu L, Yu Y, Li T. Case report: Recreational nitrous oxide abuse triggered peripheral neuropathy possibly through the immune-mediated pathogenesis. Front Neurol 2022; 13:1033327. [PMID: 36452172 PMCID: PMC9702802 DOI: 10.3389/fneur.2022.1033327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 10/17/2023] Open
Abstract
Nitrous oxide (N2O), commonly known as laughing gas, is widely used in clinical practice and food industry. However, an increasing number of young people have been abusing N2O for recreational purpose, resulting in many functional disorders and sometimes irreversible nerve damage. We present the case of a 20-year-old N2O abuser who gradually developed peripheral neuropathy after continuously inhaling N2O for 2 months. The neurological symptoms of the patient had kept exacerbation for the next 2 months until she came for medical care sitting in a wheelchair. We suggested the patient halting N2O intake and supplementing methylcobalamine according to the standardized protocol. Her symptoms had partly recovered during the following 2 weeks but remained unchanged in another 2 weeks. Antibodies against ganglioside complexes were detected and anti-GM1 IgM antibodies were positive in both cerebrospinal fluid and serum. Intravenous immunoglobulin was given as an additional treatment and the patient's symptoms had significantly recovered further. The patient discharged walking by herself. Then she has been continuously followed up in outpatient department for the next 4 months and taking steroid hormone as well as methylcobalamine. Her symptoms gradually disappeared and all the electrophysiological parameters significantly improved. With this case we were able to show that N2O-related peripheral neuropathy is not only a metabolic disorder but also an immune-mediated disease. N2O intake can trigger a mimic Guillain-Barré syndrome.
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Affiliation(s)
- Mei-Xue Dong
- Department of Neurology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Qing Wang
- Department of Neurology, Wuhan No. 9 Hospital, Wuhan, China
| | - Jun-Feng Xu
- Department of Neurology, Ezhou Central Hospital, Ezhou, China
| | - Ling Hu
- Department of Neurology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Ying Yu
- Department of Neurology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Tao Li
- Department of Neurology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
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17
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Wang Q, Duan X, Dong M, Sun S, Zhang P, Liu F, Wang L, Wang R. Clinical feature and sural biopsy study in nitrous oxide-induced peripheral neuropathy. PLoS One 2022; 17:e0274765. [PMID: 36112660 PMCID: PMC9481023 DOI: 10.1371/journal.pone.0274765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 09/04/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The objective was to analyze the clinical characteristics and pathological characteristics of sural biopsy in nitrous oxide (N2O) -induced peripheral neuropathy. Methods We recruited 18 patients with N2O abuse-induced neurological disorders and reported their demographic data, clinical manifestations, laboratory examinations, and nerve conduction studies. Seven patients underwent sural nerve biopsy pathologic examination. Results All 18 patients had polyneuropathy, the nerve conduction results showed significant reductions in motor and sensory amplitudes, slowing of conduction velocities, and prolongation of latencies in most tested nerves compared to the controls. Toluidine blue staining of semi-thin sections of sural nerve biopsy showed decreased myelinated nerve fiber density, increased thin myelinated nerve fiber density, and axonal regeneration. Electron microscopy showed axonal degeneration and nerve regeneration. Conclusion The main manifestations of peripheral nerve damage caused by the abuse of N2O are lower limb weakness and distal sensory disorder. The nerve conduction study results demonstrated that mixed axonal and demyelinating neuropathy was the most common type of neuropathy. Sural biopsy showed the main pathological change was chronic axonal degeneration.
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Affiliation(s)
- Qian Wang
- Department of Neurology, The First Hospital of Tsinghua University, Beijing, China
| | - Xiaohui Duan
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Mingrui Dong
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Shaojie Sun
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Pan Zhang
- Department of Neurology, The First Hospital of Tsinghua University, Beijing, China
| | - Fang Liu
- Department of Neurology, The First Hospital of Tsinghua University, Beijing, China
| | - Li Wang
- Department of Neurology, The First Hospital of Tsinghua University, Beijing, China
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
- * E-mail: (LW); (RW)
| | - Renbin Wang
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
- * E-mail: (LW); (RW)
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18
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Qin X, Kang L, Liu X, Jin J, Hu F, Lu W, Deng Y, Chen QY, Dang J. Acute nitrous oxide-induced neuropathy mimicking Guillain-Barré Syndrome. J Peripher Nerv Syst 2022; 27:189-196. [PMID: 35611446 DOI: 10.1111/jns.12503] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE The early clinical features of nitrous oxide (N2 O)-induced neuropathy were mimicking that of Guillain-Barré Syndrome (GBS). We aimed to explore clinical and laboratory characteristics of N2 O-induced neuropathy in comparison with GBS. METHODS We retrospectively reviewed data of 15 patients with N2 O-induced neuropathy and compared them with 15 GBS patients. RESULTS The age of the N2 O-induced neuropathy group was significantly younger than that in the GBS group (22 ± 5 vs 45 ± 17). Paresthesia was more common in N2 O-induced neuropathy group (100% vs 53.3%). The proportion of distal upper limbs weakness was lower than that in GBS group (20.0% vs 93.3%). There was no significant difference in distal weakness of the lower limbs (100% vs 80.0%). The incidence of motor conduction block and compound muscle action potential amplitude reduction in upper limbs was lower than that in GBS group (6.7% vs 60.0%; 26.7% vs 80.0%). The sensory nerve action potential amplitude drop in the lower limbs was more severe than that in GBS group (53.3% vs 0). The increase of Mean corpuscular volume (MCV) was more pronounced compared to GBS group (96.97 ± 6.00 vs 88.55 ± 5.41). High homocysteine levels were more common in N2 O-related group [29.80(11.60, 70.50) vs 14.35(9.22, 19.30)]. CONCLUSION Typical clinical features of the acute N2 O neuropathy appears to be a myeloneuropathy, affecting the lower limbs more than the upper limbs, mixed axonal-demyelinating electrophysiological performance, higher homocysteine level and larger MCV and common posterior spinal cord involvement in cervical segment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xing Qin
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Li Kang
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Xiao Liu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Jiaoting Jin
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Fangfang Hu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Wenhui Lu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Yongning Deng
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Qiao Yi Chen
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, PR China
| | - Jingxia Dang
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
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