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Zou X, Yi F, Zhou W, Dong Y, Alhaskawi A, Zhou H, Ezzi SHA, Kota VG, Abdulla MHAH, Alenikova O, Abdalbary SA, Lu H, Wang C. Mechanisms and recent advances in the diagnosis and treatment of nitrous oxide-induced peripheral neuropathy: a narrative review. Front Neurol 2024; 15:1381938. [PMID: 38854969 PMCID: PMC11158622 DOI: 10.3389/fneur.2024.1381938] [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: 02/04/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Under standard conditions, nitrous oxide (N2O) manifests as a colorless, odorless gas with a mildly sweet taste. The compound finds applications in various fields, including its use as an aerosol propellants, an accelerant in motor racing, and an anesthetic in surgical procedures and dentistry. Unfortunately, the recreational misuse of N2O has become prevalent among young individuals due to its euphoric and hallucinogenic effects. Compounding this issue is the fact that nitrous oxide can be easily obtained from over-the-counter household items, facilitating its non-medical use. The global community has witnessed a surge in the recreational utilization of nitrous oxide gas in recent years. Despite the widespread non-medical abuse of N2O, there remains inadequate understanding of the potential adverse effects resulting from exposure to it. This paper provides an overview of management findings, laboratory and electrodiagnostic characteristics, as well as clinical presentations associated with neurological disorders induced by nitrous oxide usage.
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Affiliation(s)
- Xiaodi Zou
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fangyu Yi
- The First School of Clinical of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Weijie Zhou
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Yanzhao Dong
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | | | | | - Olga Alenikova
- Department of Neurology, Republican Research and Clinical Center of Neurology and Neurosurgery, Minsk, Belarus
| | - Sahar Ahmed Abdalbary
- Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changxin Wang
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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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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De Halleux C, Juurlink DN. Diagnostic et prise en charge des effets toxiques du protoxyde d’azote utilisé à des fins récréatives. CMAJ 2023; 195:E1449-E1456. [PMID: 37903521 PMCID: PMC10615342 DOI: 10.1503/cmaj.230196-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Affiliation(s)
- Cyrille De Halleux
- Département de médecine, de pédiatrie et Institut des politiques, de la gestion et de l'évaluation de la santé (Juurlink), Université de Toronto; Centre antipoison de l'Ontario (De Halleux, Juurlink); Institut de recherche Sunnybrook (Juurlink), Toronto, Ont.; Institut de recherche en services de santé (Juurlink), Toronto, Ont.; Centre antipoison du Québec (De Halleux), Québec, Qc
| | - David N Juurlink
- Département de médecine, de pédiatrie et Institut des politiques, de la gestion et de l'évaluation de la santé (Juurlink), Université de Toronto; Centre antipoison de l'Ontario (De Halleux, Juurlink); Institut de recherche Sunnybrook (Juurlink), Toronto, Ont.; Institut de recherche en services de santé (Juurlink), Toronto, Ont.; Centre antipoison du Québec (De Halleux), Québec, Qc.
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Castellucci G, Figueroa M, Sivaswamy L. Hereditary Neuropathy With Liability to Pressure Palsy Detected During the Use of Recreational Drugs. Neurohospitalist 2023; 13:376-380. [PMID: 37701266 PMCID: PMC10494818 DOI: 10.1177/19418744231174396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Background: Nitrous oxide (N2O) has been an increasingly popular recreational drug over the past few years. Abuse is associated with severe neurological complications and even fatal outcomes. Purpose: Here we present a case of chronic nitric oxide abuse in a teenager presenting with rapidly progressive mixed sensory and motor polyneuropathy. Results: The initial diagnostic workup excluded electrolyte derangement, heavy metal intoxication, autoimmune neuropathy, myopathy, hematological disorders, and thyroid disease. On further questioning, patient reported 8-months of inhalation of nitrous oxide, commonly known as "whippets". Subsequent tests revealed low Vitamin B12 and elevated homocysteine level. Eventual genetic test demonstrated a heterozygous deletion in the gene that encodes the peripheral myelin protein 22 (PMP22), consistent with a diagnosis of Hereditary Neuropathy with Liability to Pressure Palsies (HNPP). Conclusion: The association of neurologic and genetic findings with the timeline of nitrous oxide inhalation suggests a multifactorial etiology of her symptoms, with the N2O acting as a trigger to the axonal degeneration and demyelination detected on electrodiagnostic studies.
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Affiliation(s)
| | - Michelle Figueroa
- Detroit Medical Center, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Lalitha Sivaswamy
- Detroit Medical Center, Children’s Hospital of Michigan, Detroit, MI, USA
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De Halleux C, Juurlink DN. Diagnosis and management of toxicity associated with the recreational use of nitrous oxide. CMAJ 2023; 195:E1075-E1081. [PMID: 37604519 PMCID: PMC10442242 DOI: 10.1503/cmaj.230196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Affiliation(s)
- Cyrille De Halleux
- Departments of Medicine, Pediatrics, and Health Policy, Management and Evaluation (Juurlink), University of Toronto; Ontario Poison Centre (De Halleux, Juurlink); Sunnybrook Research Institute (Juurlink), Toronto, Ont.; ICES (Juurlink), Toronto, Ont.; Centre Antipoison du Québec (De Halleux), Québec, Que
| | - David N Juurlink
- Departments of Medicine, Pediatrics, and Health Policy, Management and Evaluation (Juurlink), University of Toronto; Ontario Poison Centre (De Halleux, Juurlink); Sunnybrook Research Institute (Juurlink), Toronto, Ont.; ICES (Juurlink), Toronto, Ont.; Centre Antipoison du Québec (De Halleux), Québec, Que.
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Staudenmaier PJ, Kane V, Iyer A, Campion P. A Case Report of a Dual Diagnosis Patient: Naltrexone for the Treatment of Severe Nitrous Oxide Use Disorder with Associated Neurological and Psychiatric Sequelae. JOURNAL OF SCIENTIFIC INNOVATION IN MEDICINE 2023. [DOI: 10.29024/jsim.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
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Nitrous oxide-induced myeloneuropathy: an emerging public health issue. Ir J Med Sci 2023; 192:383-388. [PMID: 35150382 PMCID: PMC9892114 DOI: 10.1007/s11845-022-02945-8] [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: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 02/05/2023]
Abstract
Increasing use of nitrous oxide as a recreational drug has been reported among young adults in western countries over the past decade. We present two cases of young males presenting to the Emergency Department (ED) of a large urban university hospital in Dublin with progressive neurological dysfunction related to nitrous oxide use. We review the pathophysiology, clinical features and treatment of nitrous oxide neurotoxicity. It is important that clinicians are aware of this evolving public health issue and are able to recognize the clinical features of this rare presentation, which may become more common in Irish EDs and GP surgeries as nitrous oxide abuse becomes more prevalent.
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Luigi C, Stefania DS. Nitrous oxide intoxication: systematic literature review and proposal of new diagnostic possibilities. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2022. [DOI: 10.1186/s41935-022-00315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
Background
Nitrous oxide (N2O), also called “laughing gas,” is the most commonly used inhalation anesthetic in dentistry. The N2O is no longer used, because of the long-term neurologic and cardiovascular sequelae. Due to its sedative and euphoric properties, N2O is often used for recreational use or in some erotic activities. Accidental deaths are mainly associated with the uses of N2O: death can occur from sudden cardiac arrhythmia or, most commonly, acute asphyxiation due to hypoxia. This paper aims to study the literature concerning deaths due to N2O intoxication and highlight pathological findings useful for diagnosis when the crime scene investigation does not reveal any evidence.
Materials and methods
The authors conducted the literature search by PubMed and Scopus databases, searching for articles from 1 January 1970 to 1 March 2020 using the key terms: “Nitrous oxide,” “Laughing gas,” “Hypoxic damage,” “Nitrous oxide anesthesia,” and “Nitrous oxide death.”
Results and discussion
A total of 244 articles were collected. Only 26 articles were included in the systematic review. Most of the deaths from intoxication are due to asphyxiation; the diagnosis is often difficult and immunohistochemistry could be helpful. Nitrous oxide increases the intracellular adhesion molecule expression, E- and P-Selectin (markers of the early inflammatory response), and HIF-1 α (indicative of oxidative stress during ischemia-reperfusion).
Conclusion
The macroscopic and microscopic signs of N2O intoxication are non-specific, but N2O has been proven to cause hypoxic damage to the brain. The suspicion of the presence of the gas in the environment should guide the pathologist. Tissue analyzes provide important information; immunohistochemical stains can confirm hypoxic damage through the use of markers such as HIF-1 α, E-Selectin, and P-Selectin.
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Mechanisms Involved in the Neurotoxicity and Abuse Liability of Nitrous Oxide: A Narrative Review. Int J Mol Sci 2022; 23:ijms232314747. [PMID: 36499072 PMCID: PMC9738214 DOI: 10.3390/ijms232314747] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The recreational use of nitrous oxide (N2O) has increased over the years. At the same time, more N2O intoxications are presented to hospitals. The incidental use of N2O is relatively harmless, but heavy, frequent and chronic use comes with considerable health risks. Most importantly, N2O can inactivate the co-factor cobalamin, which, in turn, leads to paresthesia's, partial paralysis and generalized demyelinating polyneuropathy. In some patients, these disorders are irreversible. Several metabolic cascades have been identified by which N2O can cause harmful effects. Because these effects mostly occur after prolonged use, it raises the question of whether N2O has addictive properties, explaining its prolonged and frequent use at high dose. Several lines of evidence for N2O's dependence liability can be found in the literature, but the underlying mechanism of action remains controversial. N2O interacts with the opioid system, but N2O also acts as an N-methyl-D-aspartate (NMDA) receptor antagonist, by which it can cause dopamine disinhibition. In this narrative review, we provide a detailed description of animal and human evidence for N2O-induced abuse/dependence and for N2O-induced neurotoxicity.
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Zhang S, Zhou Z, Wu W, Yu Q, Hong M. Methylprednisolone combined vitamin supplementation reversed rapidly subacute combined degeneration of the spinal cord induced by the abuse of nitrous oxide. Acta Neurol Belg 2022; 122:1353-1355. [PMID: 33517543 DOI: 10.1007/s13760-020-01589-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Shaoru Zhang
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Zhihua Zhou
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Weifeng Wu
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Qingyun Yu
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Mingfan Hong
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China.
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11
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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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Oulkadi S, Peters B, Vliegen AS. Thromboembolic complications of recreational nitrous oxide (ab)use: a systematic review. J Thromb Thrombolysis 2022; 54:686-695. [PMID: 35759070 DOI: 10.1007/s11239-022-02673-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Abstract
The recreatinal use of nitrous oxide has become more common in recent years, especially in adolescents and young adults. It has been mainly associated with medical conditions like megaloblastic anemia and (myelo)neuropathy. We report on the thromboembolic complications, a less known side effect, associated with recreational inhalation of nitrous oxide. An extensive literature search was performed for publications reporting on the thromboembolic complications associated with recreational nitrous oxide abuse. Data about sex, age, location of thrombosis, laboratory findings, therapy and outcome were collected. A total of 13 case reports or case series were identified comprising a total of 14 patients. The reported thromboembolic side effects included deep venous thrombosis, pulmonary embolism, mesenterial-, portal and splenic vein thrombosis, cerebral sinus thrombosis, cortical vein thrombosis, stroke, acute myocardial infarction and peripheral artery thromboembolism. These side effects are possibly mediated by the interaction of nitrous oxide with vitamin B12, a cofactor of the methionine synthase complex, which eventually results in elevation of plasma levels of homocysteine. Despite being a known risk factor for cardiovascular disease, the exact pathophysiological mechanism remains unclear. Cessation of nitrous oxide inhalation is necessary to prevent recurrent thrombosis. Nitrous oxide abuse may thus result in a wide spectrum of thromboembolic complications. One should be aware of this etiology, especially in a young person with no obvious risk factors for cardiovascular disease. Spreading awareness is important to inform people about the potentially serious side effects associated with nitrous oxide inhalation.
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Affiliation(s)
- Sanad Oulkadi
- Department of Radiology, Resident Radiology, Jessa Hospital, Hasselt, Belgium. .,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Benjamin Peters
- Department of Radiology, Radiologist, Cardiac Imaging, Jessa Hospital, Hasselt, Belgium
| | - Anne-Sophie Vliegen
- Department of Radiology, Radiologist, Thoracic Imaging, Jessa Hospital, Hasselt, Belgium
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te Pas M, Olde Rikkert M, Bouwman A, Kessels R, Buise M. Screening for Mild Cognitive Impairment in the Preoperative Setting: A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10061112. [PMID: 35742163 PMCID: PMC9223065 DOI: 10.3390/healthcare10061112] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/26/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022] Open
Abstract
Cognitive impairment predisposes patients to the development of delirium and postoperative cognitive dysfunction. In particular, in older patients, the adverse sequelae of cognitive decline in the perioperative period may contribute to adverse outcomes after surgical procedures. Subtle signs of cognitive impairment are often not previously diagnosed. Therefore, the aim of this review is to describe the available cognitive screeners suitable for preoperative screening and their psychometric properties for identifying mild cognitive impairment, as preoperative workup may improve perioperative care for patients at risk for postoperative cognitive dysfunction. Electronic systematic and snowball searches of PubMed, PsycInfo, ClinicalKey, and ScienceDirect were conducted for the period 2015–2020. Major inclusion criteria for articles included those that discussed a screener that included the cognitive domain ‘memory’, that had a duration time of less than 15 min, and that reported sensitivity and specificity to detect mild cognitive impairment. Studies about informant-based screeners were excluded. We provided an overview of the characteristics of the cognitive screener, such as interrater and test-retest reliability correlations, sensitivity and specificity for mild cognitive impairment and cognitive impairment, and duration of the screener and cutoff points. Of the 4775 identified titles, 3222 were excluded from further analysis because they were published prior to 2015. One thousand four hundred and forty-eight titles did not fulfill the inclusion criteria. All abstracts of 52 studies on 45 screeners were examined of which 10 met the inclusion criteria. For these 10 screeners, a further snowball search was performed to obtain related studies, resulting in 20 articles. Screeners included in this review were the Mini-Cog, MoCA, O3DY, AD8, SAGE, SLUMS, TICS(-M), QMCI, MMSE2, and Mini-ACE. The sensitivity and specificity range to detect MCI in an older population is the highest for the MoCA, with a sensitivity range of 81–93% and a specificity range of 74–89%. The MoCA, with the highest combination of sensitivity and specificity, is a feasible and valid routine screening of pre-surgical cognitive function. This warrants further implementation and validation studies in surgical pathways with a large proportion of older patients.
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Affiliation(s)
- Mariska te Pas
- Department of Anesthesiology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (A.B.); (M.B.)
- Correspondence: ; Tel.: +31-627624857
| | - Marcel Olde Rikkert
- Radboud University Medical Center, Department of Geriatric Medicine, 6500 GL Nijmegen, The Netherlands;
| | - Arthur Bouwman
- Department of Anesthesiology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (A.B.); (M.B.)
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Roy Kessels
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6525 XZ Nijmegen, The Netherlands;
- Department of Medical Psychology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Vincent van Gogh Institute for Psychiatry, 5803 AC Venray, The Netherlands
| | - Marc Buise
- Department of Anesthesiology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (A.B.); (M.B.)
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Sharpe EE, Rollins MD. Beyond the epidural: Alternatives to neuraxial labor analgesia. Best Pract Res Clin Anaesthesiol 2022; 36:37-51. [PMID: 35659959 DOI: 10.1016/j.bpa.2022.04.005] [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: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.
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Affiliation(s)
- Emily E Sharpe
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Mark D Rollins
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Zuo C, Ma J, Pan Y, Zheng D, Chen C, Ruan N, Su Y, Nan H, Lian Q, Lin H. Isoflurane and Sevoflurane Induce Cognitive Impairment in Neonatal Rats by Inhibiting Neural Stem Cell Development Through Microglial Activation, Neuroinflammation, and Suppression of VEGFR2 Signaling Pathway. Neurotox Res 2022; 40:775-790. [PMID: 35471722 PMCID: PMC9098611 DOI: 10.1007/s12640-022-00511-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/26/2022] [Accepted: 04/12/2022] [Indexed: 12/30/2022]
Abstract
Inhaled anesthetics are known to induce neurotoxicity in the developing brains of rodents, although the mechanisms are not well understood. The aim of this study was to elucidate the molecular mechanisms underlying anesthetics-induced neurodevelopmental toxicity by VEGF receptor 2 (VEGFR2) through the interaction between microglia and neural stem cells (NSCs) in postnatal day 7 (P7) rats. Cognitive function of P7 rats exposed to isoflurane and sevoflurane were assessed using Morris Water Maze and T maze tests. We also evaluated the expression levels of NSC biomarkers (Nestin and Sox2), microglia biomarker (CD11b or or IBA1), pro-inflammatory cytokines (IL-6 and TNF-α), and VEGFR2 using western blotting and immunohistochemistry in the brains of control and anesthesia-treated rats. We found spatial learning and working memory was impaired 2 weeks after anesthetics exposure in rats. Isoflurane induced stronger and more prolonged neurotoxicity than sevoflurane. However, cognitive functions were recovered 6 weeks after anesthesia. Isoflurane and sevoflurane decreased the levels of Nestin, Sox2, and p-VEGFR2, activated microglia, decreased the number of NSCs and reduced neurogenesis and the proliferation of NSCs, and increased the levels of IL-6, TNF-α, and CD11b. Our results suggested that isoflurane and sevoflurane induced cognitive impairment in rats by inhibiting NSC development and neurogenesis via microglial activation, neuroinflammation, and suppression of VEGFR2 signaling pathway.
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Affiliation(s)
- Chunlong Zuo
- Department of Anesthesiology, The First Affiliated Hospital of AnHui Medical University, Hefei, 230022, PRC, China.,Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China
| | - Junmei Ma
- Department of Anesthesiology, Ningbo Medical Center Lihuili Hospital, Ningbo, 315040, PRC, China
| | - Yizhao Pan
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Shangcaicun, Wenzhou, 325000, PRC, China
| | - Dongxu Zheng
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China
| | - Chunjiang Chen
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China
| | - Naqi Ruan
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China
| | - Ying Su
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China
| | - Haihan Nan
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, 325035, PRC, China
| | - Qingquan Lian
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China.
| | - Han Lin
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, PRC, Zhejiang Province Key Lab of Anesthesiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, PRC, China.
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16
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Largeau B, Karam A, Potey C, Caous AS, Tard C, Carton L, Kuchcinski G, Gautier S, Deheul S, Bordet R. Myeloneuropathy induced by recreational nitrous oxide use with variable exposure levels. Eur J Neurol 2022; 29:2173-2180. [PMID: 35460312 DOI: 10.1111/ene.15370] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although several case series have described nitrous oxide-associated neurological disorders, a comprehensive assessment of exposure characteristics (e.g., time to onset, level of exposure) in substance abusers has not been performed. The aim of this study was to describe the onset patterns of recreational use of nitrous oxide-induced neurological disorders. METHODS All cases of neurological disorders related to nitrous oxide recreational use reported to the Hauts-de-France addictovigilance center between January 2019 and August 2020 were selected. Only cases requiring hospitalization with informative data to perform the nitrous oxide causality assessment were included. RESULTS A total of 20 cases from 5 hospitals were included. The male-to-female ratio was 6:1 and the median age was 19 years (range 16-34). The neurological presentation [myeloneuropathy 64% (7/11), sensorimotor neuropathy 36% (4/11)] included for all patients gait disorders due to proprioceptive ataxia and limb hypoesthesia. The median dose used per occasion was 100 cartridges (range 5-960; n=19). The median time from the start of nitrous oxide use to the onset of neurological symptoms was 6 months (range 0.7-54; n=16). The cumulative dose was significantly higher in patients with damage to all four limbs than in patients with lower limbs symptoms only (p=0.042). CONCLUSIONS A low intermittent exposure may be sufficient to cause neurological damage in some subjects, suggesting that, at the population level, there is no safe exposure to nitrous oxide in recreational settings. The severity of neurological impairment could increase once used at high doses and for prolonged durations of nitrous oxide.
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Affiliation(s)
- Bérenger Largeau
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Arnaud Karam
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Camille Potey
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Anne-Sylvie Caous
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Céline Tard
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Louise Carton
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Grégory Kuchcinski
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Neuroradiology Department, F-59000, Lille, France
| | - Sophie Gautier
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Sylvie Deheul
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Poison Control Center, F-59000, Lille, France
| | - Régis Bordet
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
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17
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Yu M, Qiao Y, Li W, Fang X, Gao H, Zheng D, Ma Y. Analysis of clinical characteristics and prognostic factors in 110 patients with nitrous oxide abuse. Brain Behav 2022; 12:e2533. [PMID: 35307992 PMCID: PMC9015005 DOI: 10.1002/brb3.2533] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/31/2021] [Accepted: 02/06/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To review the clinical symptoms, auxiliary examination findings, and outcomes of patients with nitrous oxide (N2 O) abuse, and analyze the factors that affect outcomes. METHODS Patients with N2 O abuse treated in the Department of Neurology between January 2018 and December 2020 were included. The clinical data of these patients were collected, and follow-up was conducted to determine the outcomes. RESULTS The average age of the 110 patients with N2 O abuse was 21.4 ± 4.2 years (range: 14-33 years). Clinical presentation primarily included neurological symptoms, such as limb numbness and/or weakness (97%), psychiatric symptoms, changes in appetite, and skin hyperpigmentation. Laboratory test results were characterized by vitamin B12 deficiency (60%, 34 out of 57 cases) and high homocysteine level (69%, 31 out of 45 cases). Electromyography indicated mixed axonal and demyelination injury (92%, 80 out of 87 cases). Motor and sensory nerves were simultaneously involved, and injury primarily involved the lower limbs. One hundred and seven (97%) patients were clinically diagnosed with peripheral neuropathy, of whom 26 (24%) exhibited spinal abnormalities on magnetic resonance imaging, supporting a diagnosis of subacute combined degeneration. Treatment included N2 O withdrawal and vitamin B12 supplementation. Reexamination of six patients indicated that treatment was effective. Follow-up was completed for 51 patients. Thirty-four patients (67%) recovered completely, 17 patients (33%) had residual limb numbness, and only one patient experienced relapse. Sex was an independent prognostic factor; the outcomes of female patients were better than that of male patients. CONCLUSION The recreational use of N2 O has largely expanded among youth in recent decades, which has become a growing public health concern in China. It highlights the importance of the recognition of various clinical symptoms, particularly limb numbness and/or weakness related to the cases of N2 O abuse. The therapeutic administration of vitamin B12 supplementation and N2 O withdrawal can make the overall prognosis good, especially for female patients.
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Affiliation(s)
- Miao Yu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yue Qiao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Weishuai Li
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiuying Fang
- Department of Neurofunction, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Han Gao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Dongming Zheng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Ma
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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18
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Brief Report: Pregnancy, Birth and Infant Feeding Practices: A Survey-Based Investigation into Risk Factors for Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:5072-5078. [PMID: 34766207 DOI: 10.1007/s10803-021-05348-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2021] [Indexed: 12/27/2022]
Abstract
A succession of interconnected environmental factors is believed to contribute substantially to the development of autism spectrum disorder (ASD). This exploratory study therefore aims to identify potential risk factors for ASD that are associated with pregnancy, birth and infant feeding. Demographic and health-related data on children aged 3-13 years (N = 4306) was collected through an online survey completed by biological mothers. A fitted logistic regression model identified advanced maternal age, prenatal bleeding, pre-eclampsia, perinatal pethidine usage, foetal distress before birth and male sex of child as associated with an increased risk of ASD, whereas longer gestational duration demonstrated a protective effect. These findings highlight potential risk factors and predictor interrelationships which may contribute to overall ASD risk.
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19
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Berling E, Fargeot G, Aure K, Tran TH, Kubis N, Lozeron P, Zanin A. Nitrous oxide-induced predominantly motor neuropathies: a follow-up study. J Neurol 2021; 269:2720-2726. [PMID: 34741241 DOI: 10.1007/s00415-021-10858-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Recreational nitrous oxide (N2O) abuse is increasingly popular among youth. We report a systematic clinical, electrophysiological and biological follow-up of patients with neuropathy caused by N2O. METHODS We retrospectively report seven patients with neuropathy attributed to N2O abuse and their comprehensive follow-up. Demographic, toxicological, clinical, biological and electrophysiological data were collected at first and second examination. Functional data were collected at the last evaluation. RESULTS Seven patients aged 18-30, consuming more than 140 gas-filled balloons (one balloon is filled with approximately 8 g of N2O) per week for over a month, developed a severe, predominantly motor, length-dependent, progressive neuropathy over 3 to 6 weeks. Two-thirds presented associated signs of myelopathy. Distal lower limbs motor deficit and ataxia led to moderate disability. Spinal cord imaging was frequently normal. Nerve conduction studies disclosed an almost exclusively motor axonal neuropathy affecting the lower limbs with active denervation. Homocysteine plasma level was systematically elevated, whereas cobalamin plasma levels were normal in almost all patients. At short-term follow-up after intoxication discontinuation, ataxia and motor deficit only partially resolved despite vitamin B12 supplementation, while active denervation and homocysteinemia decreased. At last follow-up (median 9.2 months, IQR 7.5-10.75), mean ONLS was 2.0 (IQR 2.0-2.0). DISCUSSION Young patients, with induced N2O motor neuropathy remain disabled after 5 to 14.5 months of gas withdrawal, despite vitamin B12 supplementation. A longer follow-up is needed to fully appraise the severity of these toxic neuropathies.
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Affiliation(s)
- Edouard Berling
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, 75010, Paris, France
| | - Guillaume Fargeot
- Service de Neurologie, APHP, Hôpital du Kremlin-Bicêtre, 94275, Le Kremlin Bicêtre, France
| | - Karine Aure
- Service de Neurophysiologie, Hôpital Foch, 92150, Suresnes, France
| | - Tuan Huy Tran
- Service de Neurologie, APHP, Hôpital Lariboisière, 75010, Paris, France
| | - Nathalie Kubis
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, 75010, Paris, France.,Laboratory for Vascular Translational Science, INSERM U1148, Université de Paris, 75018, Paris, France
| | - Pierre Lozeron
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, 75010, Paris, France. .,Laboratory for Vascular Translational Science, INSERM U1148, Université de Paris, 75018, Paris, France.
| | - Adrien Zanin
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, 75010, Paris, France.,Laboratory for Vascular Translational Science, INSERM U1148, Université de Paris, 75018, Paris, France
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20
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Menon JML, van Luijk JAKR, Swinkels J, Lukas E, Ritskes-Hoitinga M, Roeleveld N, Schlünssen V, Mandrioli D, Hoffmann S, Popa M, Scheepers PTJ. A health-based recommended occupational exposure limit for nitrous oxide using experimental animal data based on a systematic review and dose-response analysis. ENVIRONMENTAL RESEARCH 2021; 201:111575. [PMID: 34174259 DOI: 10.1016/j.envres.2021.111575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is a common inhalation anaesthetic used in medical, paramedical, and veterinary practice. Since the mid 1950's, concerns have been raised regarding occupational exposure to N2O, leading to many epidemiological and experimental animal studies. Previous evaluations resulted in the classification of N2O as a possible risk factor for adverse reproductive health outcomes based on animal data. Human data were deemed inadequate primarily because of simultaneous co-exposures to other risk factors for adverse reproductive and developmental outcomes, including other anaesthetic gases. Since previous evaluations, controversies regarding N2O use remained and new approaches for dose response modelling have been adopted, calling for an update and re-evaluation of the body of evidence. This review aims to assess available animal evidence on N2O reproductive and developmental outcomes to inform a health-based recommended occupational exposure limit (OEL) for N2O with a benchmark dose-response modelling (BMD) approach. METHODS Comprehensive searches in PubMed, EMBASE, and Web of Science were performed to retrieve all relevant studies addressing reproductive and developmental outcomes related to inhalation of N2O in animals. The articles retrieved were screened based on title-abstract and full text by two independent reviewers. After data extraction, an overview of all studies was created for the different endpoints, namely foetal outcomes (e.g., resorption), female outcomes (e.g. implantations), and male outcomes (e.g. sperm count). A subset of studies reporting on exposure relevant to workplace settings and with a sufficient number of tested doses were included in dose-response modelling using the BMD approach. RESULTS In total, 15.816 articles were retrieved, of which 47 articles were finally included while 4 of those were used for the quantitative data synthesis. The overall risk of bias was judged to be probably high (using OHAT risk of bias tool) and unclear (using SYRCLE's risk of bias tool). From eligible rat studies, three studies provided an acceptable result by fitting a Hill model to the dose-response data. The resulting benchmark dose lower bounds (BMDLs) from three studies converged to an average (±sd) exposure level of 925 ± 2 mg/m3 at an additional risk of one standard deviation of implantation losses above those observed in the control group (i.e. reduced number of live foetuses/mother). For extrapolation from rats to humans, an uncertainty factor of 10 was used and an additional factor of 5 was applied to account for interindividual variability within the population of workers. CONCLUSION With this systematic review, all available evidence for reproductive toxicity and adverse developmental outcomes in animals resulting from inhalation exposure to N2O was used to derive a health-based OEL recommendation of 20 mg/m3 as 8-h time-weighted average.
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Affiliation(s)
- Julia M L Menon
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Judith A K R van Luijk
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Janne Swinkels
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Eva Lukas
- Faculty of Science, Radboud University, Nijmegen, the Netherlands
| | - Merel Ritskes-Hoitinga
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nel Roeleveld
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Vivi Schlünssen
- Department of Public Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark and National Research Center for the Working Environment, Copenhagen, Denmark
| | - Daniele Mandrioli
- Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bologna, Italy
| | - Sebastian Hoffmann
- The Evidence-Based Toxicology Collaboration (EBTC), Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Paul T J Scheepers
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands.
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21
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Farmer J, Romain K, Ibrahim M, Kumar M, York Moore W. The neuropsychiatric effects of nitrous oxide and low vitamin B 12. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
This narrative review article aims to update knowledge on the neuropsychiatric complications of nitrous oxide use and low vitamin B12. We consider common forms and uses of nitrous oxide (N2O) and review its mechanism of action, and then explore the potential impacts of use. In particular, neuropsychiatric effects mediated by low vitamin B12 are considered and the correct interpretation of laboratory results explored. This is of particular importance as where vitamin B12 is inactivated by chronic nitrous oxide use, blood test levels of vitamin B12 may not reflect the quantity of functional B12 in patients.
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22
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Dang XT, Nguyen TX, Nguyen TTH, Ha HT. Nitrous Oxide-Induced Neuropathy among Recreational Users in Vietnam. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126230. [PMID: 34207586 PMCID: PMC8296096 DOI: 10.3390/ijerph18126230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/29/2022]
Abstract
Nitrous oxide (N2O) commonly referred to as laughing gas, has significant medical uses. This study aims to describe the neurological disorders associated with N2O. We conducted across-sectional study that enrolled patients with nitrous oxide toxicity admitted to Vietnam Poison Control Center, Bach Mai Hospital, Hanoi, Vietnam from June 2018 to July 2019. The questionnaire included demographic characteristics, characteristics of using N2O, signs and clinical symptoms, neuroimaging findings, injury on electromyography (EMG) and the Total Neuropathy Score clinical version (TNSc) criteria. A total of 47 participants were included with mean age: 24.38 ± 6.20 years. The number of balloons used per week was 130.59 ± 117.43. The mean duration of N2O exposure was 8.79 ± 7.1 months. Multivariate linear logistic regression revealed that the number of N2O balloons used per week was significantly associated with TNSc point (Beta: 0.315; 95% CI: 0.001–0.022). We found that myeloneuropathy and peripheral neuropathy were the main neurological disorders related to N2O abuse, which should improve the awareness of the appearance of neurological disorders associated with N2O abuse.
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Affiliation(s)
- Xuan Thi Dang
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Thanh Xuan Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi 100000, Vietnam
- Scientific Research Department, National Geriatric Hospital, Hanoi 100000, Vietnam
- Dinh Tien Hoang Institute of Medicine, Hanoi 100000, Vietnam
| | - Thu Thi Hoai Nguyen
- Geriatrics Department, Hanoi Medical University, Hanoi 100000, Vietnam
- Scientific Research Department, National Geriatric Hospital, Hanoi 100000, Vietnam
| | - Hung Tran Ha
- Vietnam Poison Control Center, Bach Mai Hospital, Hanoi 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi 100000, Vietnam
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23
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Laporta ML, Kruthiventi SC, Stang CD, Camerucci E, Martin DP, Weingarten TN, Hanson AC, Schroeder DR, Warner DO, Savica R, Sprung J. Exposure to anesthesia is not associated with development of α-synucleinopathies: A nested case-control study. Parkinsonism Relat Disord 2021; 88:76-81. [PMID: 34147949 DOI: 10.1016/j.parkreldis.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Preclinical studies suggest that inhalational anesthetics may induce neuropathology changes in the nigrostriatal system, leading to development of α-synucleinopathies. We explored the role of general anesthesia in the development of Parkinson disease (PD) and other α-synucleinopathies. METHODS All α-synucleinopathy cases in Olmsted County, Minnesota, from January 1991, to December 2010, were identified from diagnostic codes, and then reviewed for type and index date of diagnosis. Cases were matched by sex and age (±1 year) to a referent control, a resident living in Olmsted County, and free of α-synucleinopathies before the index date (year of onset of the α-synucleinopathy). Medical records of both cases and controls were reviewed for lifetime exposure to anesthesia prior to the index date. RESULTS A total of 431 cases with clinically defined α-synucleinopathies were identified. Of these, 321 (74%) underwent 1,069 procedures under anesthesia before the diagnosis date, and in the control group, 341 (79%) underwent 986 procedures. When assessed as a dichotomous variable, anesthetic exposure was not significantly associated with α-synucleinopathies (odds ratio [OR], 0.75; 95% CI, 0.54-1.05; P=.094). No association was observed when anesthetic exposure was quantified by the number of exposures (OR, 0.64, 0.89, and 0.74, for 1, 2-3, and ≥4 exposures, respectively, compared to no exposure as the reference; P=.137) or quantified by the cumulative duration of exposure assessed as a continuous variable (OR, 1.00; 95% CI, 0.97-1.02 per 1-h increase of anesthetic exposure; P=.776). CONCLUSIONS We did not observe a significant association between exposure to general anesthesia and risk for the development of α-synucleinopathies.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Cole D Stang
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andrew C Hanson
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Darrell R Schroeder
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
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24
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Abstract
Objective: In the young generations with nitrous oxide abuse (N2O), featured electrophysiological response of the peripheral neuropathy caused by nitrous oxide remains to be defined.Methods: Patients with nitrous oxide abuse (20 cases), two variants of Guillain-Barré syndrome (GBS), that is, acute inflammatory demyelinating polyradiculoneuropathy (GBS-AIDP, 19 cases) and acute motor axonal neuropathy (GBS-AMAN, 18 cases), as well as diabetic peripheral neuropathy (DPN, 20 cases) were enrolled into this study. Electrophysiological parameters including distal motor latency (DML), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), amplitudes of compound muscle action potential (CMAP), and sensory nerve action potential (SNAP) were measured and analyzed by comparing the parameters between the aforementioned patients groups as well as normal control group (20 subjects).Results: Compared to normal control subjects, patients with nitrous oxide abuse showed prolonged DML, slower MNCV and SNCV in the limbs, lower amplitudes of CMAP in the median, tibial and peroneal nerves, and lower SNAP in median and ulnar nerves. Abnormalities of MNCV and amplitudes of CMAP in the lower limbs were significantly higher than that in the upper limbs . Abnormal electrophysiological features of patients with nitrous oxide abuse were dramatically different from those in GBS-AIDP or DPN patients, but similar to those in GBS-AMAN patients.Conclusions: Nitrous oxide abuse could cause abnormal electrophysiological response in the limbs. Some of the parameters (DML, MNCV, SNCV, CMAP and SNAP) appeared significantly different between the patients with nitrous oxide abuse, GBS with AIDP or AMAN, and DPN patients.Significance: Electrophysiological examination could be considered as an important supporting factor in differential diagnosis for nitrous oxide abuse, GBS with AIDP or AMAN, and DPN.
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Affiliation(s)
- Yan Li
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Xiuchun Zhang
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Chuansheng Zhao
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
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25
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Xiang Y, Li L, Ma X, Li S, Xue Y, Yan P, Chen M, Wu J. Recreational Nitrous Oxide Abuse: Prevalence, Neurotoxicity, and Treatment. Neurotox Res 2021; 39:975-985. [PMID: 33770366 DOI: 10.1007/s12640-021-00352-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 01/16/2023]
Abstract
Nitrous oxide (N2O), also known as "laughing gas," is a colorless, nonirritating gas. Clinically, it is widely used as an inhaled anesthetic, analgesic, and anxiolytic. In recent years, recreational abuse of N2O has become increasingly common, especially among young adults and adolescents, but many of them lack awareness of the possible side effects associated with this drug. N2O abuse can damage multiple systems, especially the nervous system, but the exact mechanism of N2O toxicity remains controversial. At present, an increasing number of cases of nervous system damage caused by N2O abuse have been reported both at home and abroad. Discontinuation of N2O use and timely supplementation with vitamin B12 are essential for a good prognosis. Long-term abuse without timely treatment will eventually lead to irreversible neurological damage. In this article, we discuss the epidemiology of N2O abuse, neurotoxicity mechanisms, clinical manifestations, relevant auxiliary examinations, treatments, and prognosis to improve social awareness of N2O exposure risk, especially among users and clinicians.
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Affiliation(s)
- Yuanyuan Xiang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Lei Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, People's Republic of China
| | - Xiaotong Ma
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Shan Li
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Yuan Xue
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Peng Yan
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Meijie Chen
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Junwei Wu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China.
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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Assaf R, Michael PG, Langford N. Nitrous oxide-induced toxic leukoencephalopathy. BMJ Case Rep 2020; 13:13/12/e238315. [PMID: 33303508 DOI: 10.1136/bcr-2020-238315] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Toxic leukoencephalopathy (TL) is characterised by an insult to the myelin of the cerebral white manner which can be attributed to a number of offending agents, including drugs of abuse. We report a case of a fit and well young man presenting to hospital with an altered mental state. It was subsequently determined that the patient inhaled a significant volume of nitrous oxide recreationally. Nitrous oxide is easily accessible and the second most consumed drug among young adolescents (16-24 years old). Following extensive investigations and brain imaging, the patient was subsequently diagnosed with TL. After a prolonged hospital admission, he went on to make a complete neurological recovery.
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Affiliation(s)
- Ramey Assaf
- Anaesthesia, Leicester Royal Infirmary, Leicester, UK
| | | | - Nigel Langford
- Acute Medicine, Leicester Royal Infirmary, Leicester, UK
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Sprung J, Abcejo ASA, Knopman DS, Petersen RC, Mielke MM, Hanson AC, Schroeder DR, Schulte PJ, Martin DP, Weingarten TN, Pasternak JJ, Warner DO. Anesthesia With and Without Nitrous Oxide and Long-term Cognitive Trajectories in Older Adults. Anesth Analg 2020; 131:594-604. [PMID: 31651458 DOI: 10.1213/ane.0000000000004490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND We evaluated the hypothesis that the rate of postoperative decline in global cognition is greater in older adults exposed to general anesthesia with nitrous oxide (N2O) compared to general anesthesia without N2O. METHODS Longitudinal measures of cognitive function were analyzed in nondemented adults, 70-91 years of age, enrolled in the Mayo Clinic Study of Aging. Linear mixed-effects models with time-varying covariates assessed the relationship between exposure to surgery with general anesthesia (surgery/GA) with or without N2O and the rate of long-term cognitive changes. Global cognition and domain-specific cognitive outcomes were defined using z scores, which measure how far an observation is, in standard deviations, from the unimpaired population mean. RESULTS The analysis included 1819 participants: 280 exposed to GA without N2O following enrollment and before censoring during follow-up (median [interquartile range {IQR}] follow-up of 5.4 [3.9-7.9] years); 256 exposed to GA with N2O (follow-up 5.6 [4.0-7.9] years); and 1283 not exposed to surgery/GA (follow-up 4.1 [2.5-6.4] years). The slope of the global cognitive z score was significantly more negative following exposure to surgery/GA after enrollment (change in slope of -0.062 [95% confidence interval {CI}, -0.085 to -0.039] for GA without N2O, and -0.058 [95% CI, -0.080 to -0.035] for GA with N2O, both P < .001). The change in slope following exposure to surgery/GA did not differ between those exposed to anesthesia without versus with N2O (estimated difference -0.004 [95% CI, -0.035 to 0.026], P = .783). CONCLUSIONS Exposure to surgery/GA is associated with a small, but statistically significant decline in cognitive z scores. Cognitive decline did not differ between anesthetics with and without N2O. This finding provides evidence that the use of N2O in older adults does not need to be avoided because of concerns related to decline in cognition.
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Affiliation(s)
- Juraj Sprung
- From the Department of Anesthesiology and Perioperative Medicine
| | | | - David S Knopman
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Ronald C Petersen
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Michelle M Mielke
- Department of Neurology.,Division of Epidemiology, Department of Health Sciences Research
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - David P Martin
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - David O Warner
- From the Department of Anesthesiology and Perioperative Medicine
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Algahtani H, Shirah B, Abdelghaffar N, Abuhawi O, Alqahtani A. Nitrous oxide recreational abuse presenting with myeloneuropathy and mimicking Guillain-Barre syndrome. Intractable Rare Dis Res 2020; 9:54-57. [PMID: 32201677 PMCID: PMC7062599 DOI: 10.5582/irdr.2020.01007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The recreational use of nitrous oxide (N2O) is increasing in festivals, university parties, clubs, private residences, and parks. The abuse of N2O has serious complications of the central and peripheral nervous system. In this article, we report a case of a 28-year-old previously healthy man who presented with a three-day history of rapidly progressive leg numbness, tingling, and weakness with gait instability and frequent falls. He had a history of marijuana use and daily inhalation of N2O (approximately 20 whippets daily over 2-3 years). He was admitted with a presumptive diagnosis of Guillain-Barre syndrome and was started on intravenous immunoglobulin. Three days after admission, paresthesia ascended to the level of nipple line, and his weakness in the lower limb increased significantly. MRI of the cervical spine showed focal non-enhancing lesions extending from C4 to C6. Serum analysis showed low vitamin B12 level, elevated methylmalonic acid, and elevated homocysteine level. Supplemental 1000 μg/day of vitamin B12 intramuscular injections and 15 mg of folic acid tablets were given. The patient showed gradual improvement. This is a rare case of N2O recreational abuse presenting with myeloneuropathy and mimicking Guillain- Barre syndrome. This case highlights the importance of detailed history and physical examination in patients who arrive at the hospital with clinical features of Guillain-Barre syndrome. This is especially true if there are red flags such as drug abuse or discrepancy between clinical and para-clinical (investigations) parameters. Neuroimaging of the brain and spinal cord might be necessary to score the final diagnosis in such cases.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Address correspondence to:Hussein Algahtani, King Abdulaziz Medical City / King Saud bin Abdulaziz University for Health Sciences, P.O. Box: 12723, Jeddah 21483, Saudi Arabia. Contact No.: 00966556633130. E-mail:
| | - Bader Shirah
- King Abdullah International Medical Research Center / King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Yen DM, Murray MT, Puchalski R, Gould AR, Ansley J, Ow RA, Moss JR, England LJ, Syms CA. In-Office Tympanostomy Tube Placement Using Iontophoresis and Automated Tube Delivery Systems. OTO Open 2020; 4:2473974X20903125. [PMID: 32133434 PMCID: PMC7040928 DOI: 10.1177/2473974x20903125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/19/2019] [Accepted: 09/12/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES (1) To evaluate safety, tolerability, and technical success of lidocaine iontophoresis and a tympanostomy tube placement system for adults in an office setting and (2) to meet regulatory evidence requirements for new drugs and devices. STUDY DESIGN Prospective, multicenter, single arm. SETTING Patients were recruited in 8 community-based practices in the United States between June and September 2017. SUBJECTS AND METHODS This study evaluated tympanic membrane anesthesia and tube placement in 30 adults. Anesthesia was achieved via iontophoresis of a lidocaine/epinephrine solution. Tube placement was conducted using an integrated myringotomy and tube delivery system. Tolerability of tube placement was measured using a patient-reported visual analog scale from 0 mm (no pain) to 100 mm (worst possible pain). Mean pain score was compared to a performance goal of 45 mm, where statistical superiority represents mild pain or less. Technical success and safety through 3 weeks postprocedure were evaluated. RESULTS Twenty-nine (29/30, 96.7%) patients had tube(s) successfully placed in all indicated ears. One patient demonstrated inadequate tympanic membrane anesthesia, and no tube placement was attempted. The mean (SD) pain score of 9.4 (15.7) mm was statistically superior to the performance goal. There were no serious adverse events. Seven nonserious events were related to device, procedure, or drug: inadequate anesthesia (1), vertigo (1), and dizziness (1) at the time of procedure and ear discomfort (1), tube occlusion (2), and medial tube migration (1) postprocedure. CONCLUSION Lidocaine iontophoresis provides acceptable tympanic membrane anesthesia for safe, tolerable, and successful in-office tube placement using an integrated myringotomy and tube delivery system.
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Affiliation(s)
- David M. Yen
- Specialty Physician Associates, Bethlehem, Pennsylvania, USA
| | | | - Robert Puchalski
- South Carolina ENT Allergy & Sleep Medicine, Columbia, South Carolina, USA
| | | | - John Ansley
- Carolina Ear Nose & Throat Clinic, Orangeburg, South Carolina, USA
| | - Randall A. Ow
- Sacramento Ear, Nose and Throat, Roseville, California, USA
| | - Jonathan R. Moss
- Charlotte Eye Ear Nose & Throat Associates, Matthews, North Carolina, USA
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Zheng R, Wang Q, Li M, Liu F, Zhang Y, Zhao B, Sun Y, Zhang D, Yan C, Zhao Y, Li W. Reversible Neuropsychiatric Disturbances Caused by Nitrous Oxide Toxicity: Clinical, Imaging and Electrophysiological Profiles of 21 Patients with 6-12 Months Follow-up. Neuropsychiatr Dis Treat 2020; 16:2817-2825. [PMID: 33262596 PMCID: PMC7695601 DOI: 10.2147/ndt.s270179] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/18/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Nitrous oxide (N2O) abuse has become an increasingly severe problem in China. The aim of the study was to summarize the features of N2O-induced neurology and enhance the awareness of this disease among physicians. PATIENTS AND METHODS We retrospectively reviewed the clinical, imaging, electrophysiological characteristics and the prognosis of patients with N2O neurotoxicity in our hospital from January 2016 to August 2019. RESULTS Twenty-one patients (average age: 22.6±4.6 years) were collected. Eighty-six percent (18/21) patients presented with acute or subacute neurological disorders as their initial symptoms. The remaining fourteen percent (3/21) had psychiatric symptoms as the earliest symptoms. With progression, movement dysfunction appeared in ninety percent (19/21) of the patients with fifty-three percent (10/19) presented with weakness limited to both lower extremities. Sixty-two percent (13/21) of the patients presented with subjective sensory deficit. Seventy-one percent (15/21) had vibration sense impairment and positive Romberg's sign. Sixty-seven percent of the patients had hyporeflexia or areflexia. Fourteen percent (3/21) showed positive Babinski's sign. Seventy-eight percent (14/18) showed significantly increased homocysteine (HCY) level and only seventeen percent (3/18) showed decreased serum vitamin B12 level. T2 hyperintensity involving the posterior columns and lateral columns with inverted V sign in cervical spinal MRI had been observed in forty-seven percent (8/17) of the patients. Axonal peripheral neuropathy occurred in eighty-five percent (17/20) of the patients. The level of serum vitamin B12 and HCY, as well as imaging findings, were rapidly recovered after supplementation of Vitamin B12. CONCLUSION The N2O-induced neuropsychiatric disturbances mainly occurred in the young groups and should be recognized by clinicians. The prognosis of N2O intoxication is relatively good.
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Affiliation(s)
- Rui Zheng
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Qinzhou Wang
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Mingyuan Li
- EMG-Evoked Potential Room, Binzhou Medical University Hospital, Binzhou City, People's Republic of China
| | - Fuchen Liu
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Yongqing Zhang
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Bing Zhao
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Yuan Sun
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Dong Zhang
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Chuanzhu Yan
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China.,Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Yuying Zhao
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Wei Li
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
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General anesthetic neurotoxicity in the young: Mechanism and prevention. Neurosci Biobehav Rev 2019; 107:883-896. [PMID: 31606415 DOI: 10.1016/j.neubiorev.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/27/2019] [Accepted: 10/04/2019] [Indexed: 12/17/2022]
Abstract
General anesthesia (GA) is usually considered to safely induce a reversible unconscious state allowing surgery to be performed without pain. A growing number of studies, in particular pre-clinical studies, however, demonstrate that general anesthetics can cause neuronal death and even long-term neurological deficits. Herein, we report our literature review and meta-analysis data of the neurological outcomes after anesthesia in the young. We also review available mechanistic and epigenetic data of GA exposure related to cognitive impairment per se and the potential preventive strategies including natural herbal compounds to attenuate those side effects. In summary, anesthetic-induced neurotoxicity may be treatable and natural herbal compounds and other medications may have great potential for such use but warrants further study before clinical applications can be initiated.
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Pro-Con Debate: Nitrous Oxide for Labor Analgesia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4618798. [PMID: 31531352 PMCID: PMC6720045 DOI: 10.1155/2019/4618798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/19/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023]
Abstract
This Pro-Con debate will provide the practitioner with an evidence-based knowledge approach to assist the clinician in determining whether to employ (Pro) or not to employ (Con) this technique in the obstetrical suite for labor analgesia. Nitrous oxide has been used safely in dentistry and medicine for many centuries. However, accumulating preclinical and clinical evidence increasingly suggests previously unrecognized adverse maternal and fetal effects of nitrous oxide, which warrants reconsideration of its use in pregnant women and a more detailed informed consent. Nitrous oxide is associated with metabolic, oxidative, genotoxic, and transgenerational epigenetic effects in animals and humans that may warrant limiting its usefulness in labor. This debate will discuss and review the clinical uses, advantages, and disadvantages of nitrous oxide on occupational effects of nitrous oxide exposure, neuroapoptosis, FDA warning on inhalational anesthetics and the developing brain, research limitations, occupational exposure safety limits, effects on global warming, and potential for diversion.
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Kim S, Lee SH, Bang M. Double-sidedness of "laughing gas" on the N-methyl-d-aspartate receptor: A case report of acute psychosis associated with nitrous oxide-induced hyperhomocysteinemia. Schizophr Res 2019; 208:475-476. [PMID: 30795875 DOI: 10.1016/j.schres.2019.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 02/01/2019] [Accepted: 02/16/2019] [Indexed: 11/15/2022]
Affiliation(s)
- SungEun Kim
- Department of Psychiatry, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Sang-Hyuk Lee
- Department of Psychiatry, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Minji Bang
- Department of Psychiatry, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea.
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Recreational nitrous oxide abuse related subacute combined degeneration of the spinal cord in adolescents - A case series and literature review. Brain Dev 2019; 41:428-435. [PMID: 30611595 DOI: 10.1016/j.braindev.2018.12.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/03/2018] [Accepted: 12/17/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) is a commonly used inhaled anesthetic in outpatient dental procedures. However, the increasing recreational use of N2O may result in vitamin B12 deficiency-related neurologic and psychiatric symptoms. The aim of this study was to demonstrate the clinical features of chronic N2O abuse in pediatric patients. METHODS Patients under 20 years of age who were diagnosed with N2O-induced subacute combined degeneration of the spinal cord from 2012 to 2018 were enrolled in this study. Clinical presentations, laboratory, imaging, ancillary studies, treatments and outcomes were analyzed. RESULTS Nine patients were included, all of whom presented with symptoms of myeloneuropathy including limb numbness, limb weakness or unsteady gait. Six patients had low or low-normal vitamin B12 (cyanocobalamin) levels. Eight patients had evidence of subacute combined degeneration of the spinal cord via neuroimaging studies. All of the patients received vitamin B12 supplementation as treatment. All had full recovery of muscle power within 2 months. Five patients had persistent sensory deficits. CONCLUSION Chronic N2O abuse can cause permanent neurological damage if not treated promptly. Clinical staff should be aware of the various presentations of neurotoxicity related to N2O abuse.
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Jolobe OM. Other aspects of nitrous oxide-related neuromyelopathy. Am J Emerg Med 2019; 37:350-351. [DOI: 10.1016/j.ajem.2018.05.076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022] Open
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Concentration-related metabolic rate and behavioral thermoregulatory adaptations to serial administrations of nitrous oxide in rats. PLoS One 2018; 13:e0194794. [PMID: 29672605 PMCID: PMC5909668 DOI: 10.1371/journal.pone.0194794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/10/2018] [Indexed: 11/19/2022] Open
Abstract
Background Initial administration of ≥60% nitrous oxide (N2O) to rats evokes hypothermia, but after repeated administrations the gas instead evokes hyperthermia. This sign reversal is driven mainly by increased heat production. To determine whether rats will behaviorally oppose or assist the development of hyperthermia, we previously performed thermal gradient testing. Inhalation of N2O at ≥60% causes rats to select cooler ambient temperatures both during initial administrations and during subsequent administrations in which the hyperthermic state exists. Thus, an available behavioral response opposes (but does not completely prevent) the acquired hyperthermia that develops over repeated high-concentration N2O administrations. However, recreational and clinical uses of N2O span a wide range of concentrations. Therefore, we sought to determine the thermoregulatory adaptations to chronic N2O administration over a wide range of concentrations. Methods This study had two phases. In the first phase we adapted rats to twelve 3-h N2O administrations at either 0%, 15%, 30%, 45%, 60% or 75% N2O (n = 12 per group); outcomes were core temperature (via telemetry) and heat production (via respirometry). In the second phase, we used a thermal gradient (range 8°C—38°C) to assess each adapted group’s thermal preference, core temperature and locomotion on a single occasion during N2O inhalation at the assigned concentration. Results In phase 1, repeated N2O administrations led to dose related hyperthermic and hypermetabolic states during inhalation of ≥45% N2O compared to controls (≥ 30% N2O compared to baseline). In phase 2, rats in these groups selected cooler ambient temperatures during N2O inhalation but still developed some hyperthermia. However, a concentration-related increase of locomotion was evident in the gradient, and theoretical calculations and regression analyses both suggest that locomotion contributed to the residual hyperthermia. Conclusions Acquired N2O hyperthermia in rats is remarkably robust, and occurs even despite the availability of ambient temperatures that might fully counter the hyperthermia. Increased locomotion in the gradient may contribute to hyperthermia. Our data are consistent with an allostatic dis-coordination of autonomic and behavioral thermoregulatory mechanisms during drug administration. Our results have implications for research on N2O abuse as well as research on the role of allostasis in drug addiction.
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Abstract
Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. Consequently, knowledge of the efficacy, clinical implementation, and side effects of various non-neuraxial strategies is needed to provide appropriate options for laboring patients. In addition to nonpharmacologic alternatives, inhaled nitrous oxide and systemic opioids represent two broad classes of non-neuraxial pharmacologic labor analgesia most commonly available. This review summarizes the current published literature for these non-neuraxial labor analgesic options.
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Walters JL, Paule MG. Review of preclinical studies on pediatric general anesthesia-induced developmental neurotoxicity. Neurotoxicol Teratol 2017; 60:2-23. [DOI: 10.1016/j.ntt.2016.11.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022]
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Ehirim EM, Naughton DP, Petróczi A. No Laughing Matter: Presence, Consumption Trends, Drug Awareness, and Perceptions of "Hippy Crack" (Nitrous Oxide) among Young Adults in England. Front Psychiatry 2017; 8:312. [PMID: 29403400 PMCID: PMC5786547 DOI: 10.3389/fpsyt.2017.00312] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/27/2017] [Indexed: 11/22/2022] Open
Abstract
In clinical settings, nitrous oxide gas is a safe anesthetic used during childbirth, in dentistry, and to relieve anxiety in emergencies. Colloquially known as "hippy crack"' or "laughing gas," it is increasingly taken recreationally for its euphoric and relaxing effects and hallucinogenic properties. Using a self-reported survey, we gathered quantitative and qualitative information on users and non-users of hippy crack among a young population regarding: consumption patterns, knowledge, risk awareness and intentions toward future abuse. Quantitative responses from a total of 140 participants were analyzed for frequencies and relationships, whereas qualitative data were evaluated via identifying the reoccurring themes. Overall, 77.1% (n = 108) had heard of hippy crack and 27.9% (n = 39) admitted to past-year use. Prior users mostly indicated intended future use, had an average low number of past-year uses but some with > 20 occasions, had a varied number of inhalations per occasion (often 1-10) with an effect lasting up to 5 min, and a majority preferred social rather than lone use. For non-users, 79.2% said they would take hippy crack with the vast majority (94%) preferring a social setting. The results show a concerning gap between available evidence and awareness of side effects. Despite serious reported side effects, including psychosis and myeloneuropathy-especially on the young developing brain-only a minority (29.3%) was aware of any side effects. In contrast, in a hypothetical scenario depicting a first social encounter with hippy crack, the qualitative responses were in contrast to qualitative outcomes revealing that participants would try (n = 30)/not try (n = 25) it, would feel under pressure to try it (n = 6) with only 11 opting to exit the situation. In summary, this first report of trends and perceptions of the use of hippy crack among young adults in the England highlights a lack of concern with side effects, coupled to a willingness to partake. Because typical users are young with risks to the still developing brain, education about the nitrous oxide abuse is warranted to prevent impaired brain development. Further studies to investigate the possible effects of nitrous oxide on the developing brain in young adults would advance meaningful prevention.
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Affiliation(s)
- Esther M Ehirim
- School of Life Sciences, Pharmacy and Chemistry, Kingston University, Kingston upon Thames, United Kingdom
| | - Declan P Naughton
- School of Life Sciences, Pharmacy and Chemistry, Kingston University, Kingston upon Thames, United Kingdom
| | - Andrea Petróczi
- School of Life Sciences, Pharmacy and Chemistry, Kingston University, Kingston upon Thames, United Kingdom
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Clinical and electrodiagnostic characteristics of nitrous oxide-induced neuropathy in Taiwan. Clin Neurophysiol 2016; 127:3288-93. [PMID: 27567448 DOI: 10.1016/j.clinph.2016.08.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/09/2016] [Accepted: 08/07/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Nitrous oxide-induced neuropathy is toxic neuropathy occasionally encountered in Taiwanese neurological clinics. Only several case reports described their electrodiagnostic features. We used a case-control design to investigate the detailed electrodiagnostic characteristics and possible factors relating to severe nerve injury. METHODS We retrospectively reviewed 33 patients with nitrous oxide-induced neuropathy over a 10-year period and reported their demographic data, spinal cord MRI, laboratory examinations and nerve conduction studies. 56 healthy controls' nerve conduction studies were collected for comparison analysis. RESULTS We noted significant motor and sensory amplitudes reduction, conduction velocities slowing, and latencies prolongation in most tested nerves compared to the controls. Similar nerve conduction study characteristics with prominent lower limbs' motor and sensory amplitudes reduction was observed in patient groups with or without abnormal vitamin B12 and/or homocysteine levels. Among those with lower limbs' motor or sensory amplitudes reduction <20% of the lower limit of normal, higher homocysteine levels were detected. CONCLUSIONS Severe impairments of the lower limbs' sensory and motor amplitudes were frequently noted in patients with nitrous oxide exposure. Nitrous oxide exposure itself is an important factor for the development of neuropathy. SIGNIFICANCE Our study contributes to the understanding of electrodiagnostic features underlying the nitrous oxide-induced neuropathy.
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Homocysteine Aggravates Cortical Neural Cell Injury through Neuronal Autophagy Overactivation following Rat Cerebral Ischemia-Reperfusion. Int J Mol Sci 2016; 17:ijms17081196. [PMID: 27455253 PMCID: PMC5000594 DOI: 10.3390/ijms17081196] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 12/21/2022] Open
Abstract
Elevated homocysteine (Hcy) levels have been reported to be involved in neurotoxicity after ischemic stroke. However, the underlying mechanisms remain incompletely understood to date. In the current study, we hypothesized that neuronal autophagy activation may be involved in the toxic effect of Hcy on cortical neurons following cerebral ischemia. Brain cell injury was determined by hematoxylin-eosin (HE) staining and TdT-mediated dUTP Nick-End Labeling (TUNEL) staining. The level and localization of autophagy were detected by transmission electron microscopy, western blot and immunofluorescence double labeling. The oxidative DNA damage was revealed by immunofluorescence of 8-Hydroxy-2′-deoxyguanosine (8-OHdG). Hcy treatment aggravated neuronal cell death, significantly increased the formation of autophagosomes and the expression of LC3B and Beclin-1 in the brain cortex after middle cerebral artery occlusion-reperfusion (MCAO). Immunofluorescence analysis of LC3B and Beclin-1 distribution indicated that their expression occurred mainly in neurons (NeuN-positive) and hardly in astrocytes (GFAP-positive). 8-OHdG expression was also increased in the ischemic cortex of Hcy-treated animals. Conversely, LC3B and Beclin-1 overexpression and autophagosome accumulation caused by Hcy were partially blocked by the autophagy inhibitor 3-methyladenine (3-MA). Hcy administration enhanced neuronal autophagy, which contributes to cell death following cerebral ischemia. The oxidative damage-mediated autophagy may be a molecular mechanism underlying neuronal cell toxicity of elevated Hcy level.
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Garakani A, Jaffe RJ, Savla D, Welch AK, Protin CA, Bryson EO, McDowell DM. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict 2016; 25:358-69. [PMID: 27037733 DOI: 10.1111/ajad.12372] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/28/2016] [Accepted: 03/11/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/OBJECTIVES Nitrous oxide (N2 O) is known to have abuse potential, although debate regarding the toxic effects of such abuse continues. Our objective was to review the case literature and present the neurologic, psychiatric and medical consequences of N2 O abuse. METHODS A systematic literature review was completed for case reports using keywords "nitrous oxide" with "abuse/abusing" or "misuse/misusing" or "overuse/overusing" or "addiction." Non-English-language cases and cases not involving direct toxic effects of N2 O were excluded as were commentaries or personal essays. Clinical presentation, frequency of N2 O abuse, laboratory studies, imaging, ancillary tests, treatments and outcomes were collected from case reports. RESULTS Our review returned 335 Pubmed, 204 Web of Science, 73 PsycINFO, 6 CINAHL, 55 EMBASE and 0 Grey Literature results, and after exclusion and removal of duplicates, 91 individual cases across 77 publications were included. There were also 11 publications reporting 29 cases of death related to N2 O abuse. The majority of cases (N = 72) reported neurologic sequelae including myeloneuropathy and subacute combined degeneration, commonly (N = 39) with neuroimaging changes. Psychiatric (N = 11) effects included psychosis while other medical effects (N = 8) included pneumomediastinum and frostbite. Across all cases N2 O abuse was correlated with low or low-normal Vitamin B12 (cyanocobalamin) levels (N = 52) and occasionally elevated homocysteine and methylmalonic acid. CONCLUSIONS/SCIENTIFIC SIGNIFICANCE N2 O abuse represents a significant problem because of the difficulty involved with identification and the toxicity related to chronic abuse including possible death. Health professionals should be aware of the toxic effects of N2 O and be able to identify potential N2 O abuse. (Am J Addict 2016;25:358-369).
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Affiliation(s)
- Amir Garakani
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.,Silver Hill Hospital, New Canaan, Connecticut
| | - Robert J Jaffe
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dipal Savla
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alison K Welch
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caroline A Protin
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ethan O Bryson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29 Suppl 1:S21-35. [DOI: 10.1097/aco.0000000000000316] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
We demonstrated in the present study that betaine-homocysteine (Hcy) methyltransferase (BHMT) is a major pathway for Hcy removal in all situations of hyperhomocysteinaemia (HHcy). Hperhomocysteinaemia induces betaine depletion in plasma and tissues except in kidney, where betaine may play a crucial role as an osmolyte. Betaine is the substrate of the liver- and kidney-specific betaine-homocysteine (Hcy) methyltransferase (BHMT), an alternate pathway for Hcy remethylation. We hypothesized that BHMT is a major pathway for homocysteine removal in cases of hyperhomocysteinaemia (HHcy). Therefore, we measured betaine in plasma and tissues from patients and animal models of HHcy of genetic and acquired cause. Plasma was collected from patients presenting HHcy without any Hcy interfering treatment. Plasma and tissues were collected from rat models of HHcy induced by diet and from a mouse model of cystathionine β-synthase (CBS) deficiency. S-adenosyl-methionine (AdoMet), S-adenosyl-homocysteine (AdoHcy), methionine, betaine and dimethylglycine (DMG) were quantified by ESI—LC–MS/MS. mRNA expression was quantified using quantitative real-time (QRT)-PCR. For all patients with diverse causes of HHcy, plasma betaine concentrations were below the normal values of our laboratory. In the diet-induced HHcy rat model, betaine was decreased in all tissues analysed (liver, brain, heart). In the mouse CBS deficiency model, betaine was decreased in plasma, liver, heart and brain, but was conserved in kidney. Surprisingly, BHMT expression and activity was decreased in liver. However, in kidney, BHMT and SLC6A12 expression was increased in CBS-deficient mice. Chronic HHcy, irrespective of its cause, induces betaine depletion in plasma and tissues (liver, brain and heart), indicating a global decrease in the body betaine pool. In kidney, betaine concentrations were not affected, possibly due to overexpression of the betaine transporter SLC6A12 where betaine may be conserved because of its crucial role as an osmolyte.
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Morley KI, Lynskey MT, Moran P, Borschmann R, Winstock AR. Polysubstance use, mental health and high-risk behaviours: Results from the 2012 Global Drug Survey. Drug Alcohol Rev 2015; 34:427-37. [DOI: 10.1111/dar.12263] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 02/04/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Katherine I. Morley
- National Addictions Centre; Institute of Psychiatry, Psychology & Neuroscience; King's College London; London UK
- Clinical Epidemiology; Farr Institute for Health Informatics Research; University College London; London UK
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology; Melbourne School of Global and Population Health; The University of Melbourne; Melbourne Australia
| | - Michael T. Lynskey
- National Addictions Centre; Institute of Psychiatry, Psychology & Neuroscience; King's College London; London UK
| | - Paul Moran
- Health Services and Population Research Department; Institute of Psychiatry, Psychology, & Neuroscience; King's College London; London UK
| | - Rohan Borschmann
- Centre for Adolescent Health, Murdoch Children's Research Institute; University of Melbourne; Royal Children's Hospital; Melbourne Australia
| | - Adam R. Winstock
- South London and Maudsley NHS Trust/King's College London; London UK
- Global Drug Survey; London UK
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