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McLean L, Aradi S, Waknin R, Rea B, Camacho MA. HIV-associated dementia presenting predominantly with clinical motor deficits: A case report. Radiol Case Rep 2022; 17:3005-3008. [PMID: 35755114 PMCID: PMC9217990 DOI: 10.1016/j.radcr.2022.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022] Open
Abstract
HIV-associated dementia is commonly seen in older individuals and presents as a subcortical dementia associated with concentration, attention, and memory impairments. Motor signs, such as difficulty with gait, and mood changes are less prominent findings but are considered during diagnosis. We present a case of HIV-associated dementia in a young 29-year-old man who presented with progressive lower extremity weakness and difficulty ambulating.
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Affiliation(s)
- Laura McLean
- University of South Florida, Morsani College of Medicine, Tampa, FL 33612, USA
- Corresponding author.
| | - Stephen Aradi
- Department of Neurology, University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA
| | - Roy Waknin
- Department of Radiology, University of South Florida, Morsani College of Medicine, Tampa, FL 33612, USA
| | - Brittany Rea
- Department of Radiology, University of South Florida, Morsani College of Medicine, Tampa, FL 33612, USA
| | - Marc A. Camacho
- Department of Radiology, University of South Florida, Morsani College of Medicine, Tampa, FL 33612, USA
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2
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Sowers ML, Tang H, Singh VK, Khan A, Mishra A, Restrepo BI, Jagannath C, Zhang K. Multi-OMICs analysis reveals metabolic and epigenetic changes associated with macrophage polarization. J Biol Chem 2022; 298:102418. [PMID: 36030823 PMCID: PMC9525912 DOI: 10.1016/j.jbc.2022.102418] [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: 02/25/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 12/04/2022] Open
Abstract
Macrophages (MФ) are an essential immune cell for defense and repair that travel to different tissues and adapt based on local stimuli. A critical factor that may govern their polarization is the crosstalk between metabolism and epigenetics. However, simultaneous measurements of metabolites, epigenetics, and proteins (phenotype) have been a major technical challenge. To address this, we have developed a novel triomics approach using mass spectrometry to comprehensively analyze metabolites, proteins, and histone modifications in a single sample. To demonstrate this technique, we investigated the metabolic-epigenetic-phenotype axis following polarization of human blood–derived monocytes into either ‘proinflammatory M1-’ or ‘anti-inflammatory M2-’ MФs. We report here a complex relationship between arginine, tryptophan, glucose, and the citric acid cycle metabolism, protein and histone post-translational modifications, and human macrophage polarization that was previously not described. Surprisingly, M1-MФs had globally reduced histone acetylation levels but high levels of acetylated amino acids. This suggests acetyl-CoA was diverted, in part, toward acetylated amino acids. Consistent with this, stable isotope tracing of glucose revealed reduced usage of acetyl-CoA for histone acetylation in M1-MФs. Furthermore, isotope tracing also revealed MФs uncoupled glycolysis from the tricarboxylic acid cycle, as evidenced by poor isotope enrichment of succinate. M2-MФs had high levels of kynurenine and serotonin, which are reported to have immune-suppressive effects. Kynurenine is upstream of de novo NAD+ metabolism that is a necessary cofactor for Sirtuin-type histone deacetylases. Taken together, we demonstrate a complex interplay between metabolism and epigenetics that may ultimately influence cell phenotype.
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Affiliation(s)
- Mark L Sowers
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Hui Tang
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Vipul K Singh
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | - Arshad Khan
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | - Abhishek Mishra
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | | | - Chinnaswamy Jagannath
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX.
| | - Kangling Zhang
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX.
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3
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Camargo C, Abode-Iyamah K, Shah JS, Bechtle PS, Freeman WD. Comprehensive Perioperative Approach to Complex Spine Deformity Management. Clin Spine Surg 2022; 35:310-318. [PMID: 34334699 DOI: 10.1097/bsd.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Study perioperative strategies for optimizing neuroprotection in complex spine deformity correction surgery. METHODS We report the case of a patient with severe lumbar dextroscoliosis, thoracolumbar junction hyperkyphosis with a 40-degree Cobb angle levoconvex scoliosis who underwent spinal deformity correction with loss of neuromonitoring during surgery. We performed a literature review on perioperative management of complex spine deformity. RESULTS A 50-year-old man presented with lumbar pain and right L4 radiculopathy. Surgical intervention for deformity correction and decompression was indicated with T4-L4 posterior instrumentation L2/L3 and L3/L4 transforaminal lumbar interbody fusion. Surgery was aborted due to the loss of neuromonitoring. Postsurgery, the patient had left sensory deficit and the neurocritical care team clinically suspected and deduced the anatomic location of the spinal cord compression. Magnetic resonance imaging confirmed a T10-T11 hyperintensity suggestive of cord ischemia due to osteophyte compressing the spinal cord. The patient underwent a second corrective surgery with no intraoperative events and has no long-term neurological sequela. CONCLUSIONS This case illustrates that a comprehensive perioperative approach and individualized risk factor assessment is useful in complex spine deformity surgery. Further research is needed to determine how this individualized comprehensive approach can lead to intraoperative and postoperative countermeasures that improved spine surgery outcomes. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | | | | | - William D Freeman
- Departments of Neurologic Surgery
- Neurology
- Critical Care Medicine, Mayo Clinic, Jacksonville, FL
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4
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Mahgoub AE, Deliwala SS, Bachuwa G. Important reminder: nitrous oxide (N 2O) as a cause of functional vitamin B 12 deficiency. BMJ Case Rep 2021; 14:14/7/e241414. [PMID: 34290005 DOI: 10.1136/bcr-2020-241414] [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: 11/03/2022] Open
Abstract
A 32-year-old woman who misused multiple substances, including nitrous oxide (N2O), sought medical advice after she subacutely developed bilateral lower extremity weakness without a sensory level but with ataxia-her significant other developed similar symptoms with vitamin B12 deficiency due to N2O intake. Laboratory results revealed macrocytic anaemia despite normal B12 and folate levels, with serum markers pointing towards functional cobalamin deficiency. Spinal MRIs and cerebrospinal fluid analysis were unremarkable. Our patient was treated with vitamin B12 supplementation with an encouraging response.
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Affiliation(s)
| | | | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
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5
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B12 Deficiency and Clinical Presentation in the Setting of Nitric Oxide Use. Case Rep Neurol Med 2021; 2021:5590948. [PMID: 33927908 PMCID: PMC8049814 DOI: 10.1155/2021/5590948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/07/2021] [Accepted: 03/29/2021] [Indexed: 12/16/2022] Open
Abstract
B12 deficiency can arise symptomatically from an array of varying pathologies including frank deficiency from strict vegan diets. Other high-risk contributing pathological conditions include chronic alcoholism, autoimmune disease, and chronic gastrointestinal inflammatory disorders, and it is also seen in those with a history of gastric surgery. Additionally, the elderly are at an increased risk as are patients prescribed certain medications. Uncommonly suspected causes of B12 deficiency include the abuse of recreational nitrous oxide (NO) given its interference with cobalt oxidation. Here, we report two cases of hypovitaminosis B12 in association with NO abuse in an effort to highlight an increasingly dangerous trend with recreational use. Importantly, we aim to increase visibility of this malady given that improperly diagnosed neurologic deterioration following NO anesthesia has been shown to become irreversible and may even result in death.
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Abstract
BACKGROUND Nitrous oxide can induce neurotoxicity. The authors hypothesized that exposure to nitrous oxide impairs axonal regeneration and functional recovery after central nervous system injury. METHODS The consequences of single and serial in vivo nitrous oxide exposures on axon regeneration in four experimental male rat models of nervous system injury were measured: in vitro axon regeneration in cell culture after in vivo nitrous oxide administration, in vivo axon regeneration after sharp spinal cord injury, in vivo axon regeneration after sharp optic nerve injury, and in vivo functional recovery after blunt contusion spinal cord injury. RESULTS In vitro axon regeneration 48 h after a single in vivo 70% N2O exposure is less than half that in the absence of nitrous oxide (mean ± SD, 478 ± 275 um; n = 48) versus 210 ± 152 um (n = 48; P < 0.0001). A single exposure to 80% N2O inhibits the beneficial effects of folic acid on in vivo axonal regeneration after sharp spinal cord injury (13.4 ± 7.1% regenerating neurons [n = 12] vs. 0.6 ± 0.7% regenerating neurons [n = 4], P = 0.004). Serial 80% N2O administration reverses the benefit of folic acid on in vivo retinal ganglion cell axon regeneration after sharp optic nerve injury (1277 ± 180 regenerating retinal ganglion cells [n = 7] vs. 895 ± 164 regenerating retinal ganglion cells [n = 7], P = 0.005). Serial 80% N2O exposures reverses the benefit of folic acid on in vivo functional recovery after blunt spinal cord contusion (estimate for fixed effects ± standard error of the estimate: folic acid 5.60 ± 0.54 [n = 9] vs. folic acid + 80% N2O 5.19 ± 0.62 [n = 7], P < 0.0001). CONCLUSIONS These data indicate that nitrous oxide can impair the ability of central nervous system neurons to regenerate axons after sharp and blunt trauma.
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Enlund M, Enlund A, Berglund A, Bergkvist L. Rationale and Design of the CAN Study: an RCT of Survival after Propofol- or Sevoflurane-based Anesthesia for Cancer Surgery. Curr Pharm Des 2019; 25:3028-3033. [DOI: 10.2174/1381612825666190705184218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/23/2019] [Indexed: 12/27/2022]
Abstract
Background:
Based on animal data only, some clinicians have adopted propofol-based anesthesia for
cancer surgery with the aim of increased survival.
Objective:
Our objective is to verify or refute the hypothesis that survival increases after cancer surgery with
propofol compared with sevoflurane for anesthesia maintenance. This aim deserves a large-scale randomized
study. The primary hypothesis is an absolute increase of minimum 5%-units in 1- and 5-year survival with propofol-
based anesthesia for breast or colorectal cancer after radical surgery, compared with sevoflurane-based anesthesia.
Method:
Ethics and medical agency approvals were received and pre-study registrations at clinicaltrial.gov and
EudraCT were made for our now ongoing prospective, randomized, open-label, multicenter study. A power
analysis based on a retrospective study, including a safety margin for drop outs, resulted in a total requirement of
8,000 patients. The initial inclusion period constituted a feasibility phase with an emphasis on the functionality of
the infrastructure at the contributing centers and at the monitoring organization, as well as on protocol adherence.
Conclusion:
The infrastructure and organization work smoothly at the different contributing centers. Protocol
adherence is good, and the monitors are satisfied. We expect this trial to be able to either verify or refute that
propofol is better than sevoflurane for cancer surgery.
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Affiliation(s)
- Mats Enlund
- Center for Clinical Research, Uppsala University, Vasteras, Sweden and Department of Anesthesia & Intensive Care, Central Hospital, Vasteras, Sweden
| | - Anna Enlund
- Center for Clinical Research, Uppsala University, Vasteras, Sweden and Department of Anesthesia & Intensive Care, Central Hospital, Vasteras, Sweden
| | - Anders Berglund
- Center for Clinical Research, Uppsala University, Västerås, Sweden and EpiStat, Uppsala, Sweden
| | - Leif Bergkvist
- Center for Clinical Research, Uppsala University, Vasteras, Sweden and Department of Surgery, Central Hospital, Vasteras, Sweden
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Buhre W, Disma N, Hendrickx J, DeHert S, Hollmann MW, Huhn R, Jakobsson J, Nagele P, Peyton P, Vutskits L. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth 2019; 122:587-604. [PMID: 30916011 DOI: 10.1016/j.bja.2019.01.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 12/26/2018] [Accepted: 01/13/2019] [Indexed: 12/12/2022] Open
Abstract
Nitrous oxide (N2O) is one of the oldest drugs still in use in medicine. Despite its superior pharmacokinetic properties, controversy remains over its continued use in clinical practice, reflecting in part significant improvements in the pharmacology of other anaesthetic agents and developing awareness of its shortcomings. This narrative review describes current knowledge regarding the clinical use of N2O based on a systematic and critical analysis of the available scientific literature. The pharmacological properties of N2O are reviewed in detail along with current evidence for the indications and contraindications of this drug in specific settings, both in perioperative care and in procedural sedation. Novel potential applications for N2O for the prevention or treatment of chronic pain and depression are also discussed. In view of the available evidence, we recommend that the supply of N2O in hospitals be maintained while encouraging its economic delivery using modern low flow delivery systems. Future research into its potential novel applications in prevention or treatment of chronic conditions should be pursued to better identify its role place in the developing era of precision medicine.
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Affiliation(s)
- Wolfgang Buhre
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, University of Maastricht, Maastricht, the Netherlands
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jan Hendrickx
- Department of Anesthesiology, Onze-Lieve-Vrouwziekenhuis Hospital Aalst, Aalst, Belgium
| | - Stefan DeHert
- Department of Anesthesiology and Perioperative Medicine, University Hospital Ghent, Ghent, Belgium
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), AMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jan Jakobsson
- Department of Anesthesiology and Intensive Care, Institution for Clinical Science, Karolinska Institute, Danderyds University Hospital, Danderyd, Sweden
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, IL, USA
| | - Philip Peyton
- Department of Anaesthesia, Austin Health, and Anaesthesia Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals Geneva, Genève, Switzerland
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Patel KK, Mejia Munne JC, Gunness VRN, Hersey D, Alshafai N, Sciubba D, Nasser R, Gimbel D, Cheng J, Nouri A. Subacute combined degeneration of the spinal cord following nitrous oxide anesthesia: A systematic review of cases. Clin Neurol Neurosurg 2018; 173:163-168. [PMID: 30144777 DOI: 10.1016/j.clineuro.2018.08.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/03/2018] [Accepted: 08/08/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Vitamin B12 deficiency can lead to subacute combined degeneration (SCD). Nitrous oxide (N2O) is an anesthetic which oxidizes the cobalt ion of vitamin B12, interfering with its function as a coenzyme. In this study, we conduct a systematic review of reported cases of SCD following nitrous oxide anesthesia. PATIENTS AND METHODS A comprehensive search of multiple databases was conducted, and information about patient characteristics, symptomatology, clinical work-up, and treatment was extracted from eligible articles. Univariate analyses were performed to identify predictors of poor neurological recovery following SCD. RESULTS 32 studies, reporting 37 cases of nitrous oxide-induced SCD, were included through the screening process. These cases included 21 male patients and 16 female patients, with an average age of 50.4 years (SD 17.6). An etiology for subclinical B12 deficiency was determined in 30 reports; of these, 25 were due to vitamin malabsorption secondary to a gastrointestinal disorder. Duration of nitrous oxide exposure was described in 19 reports, and ranged from 30 min to 11 h. Univariate analysis failed to find an association between post-operative recovery and age (p = 0.60), sex (p = 0.46), positive MRI findings (p = 0.47), post-operative serum B12 (p = 1.00), post-operative hemoglobin (p = 0.18), type of surgery (p = 0.58), or post-operative high mean corpuscular volume (p = 0.13). CONCLUSION In patients with postsurgical myelopathy, surgeons should evaluate B12 status and consider the possibility that nitrous oxide could cause a subclinical B12 deficiency to become overt, particularly in patients with malabsorptive GI comorbidities. Treatment with B12 in this population can result in significant improvement of neurological function.
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Affiliation(s)
- Kishan K Patel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - Juan Carlos Mejia Munne
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Vimal Raj Nitish Gunness
- Department of Neurosurgery, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.
| | - Denise Hersey
- Cushing/Whitney Medical Library, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - Nabeel Alshafai
- Alshafai Neurosurgical Academy, Toronto, ON, M5J 2S2, Canada.
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA.
| | - Rani Nasser
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - David Gimbel
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
| | - Aria Nouri
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA; Department of Neurosurgery, University of Cincinnati College of Medicine, PO Box 670515, Cincinnati, OH, 45267, USA.
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Egan W, Steinberg E, Rose J. Vitamin B 12 deficiency-induced neuropathy secondary to prolonged recreational use of nitrous oxide. Am J Emerg Med 2018; 36:1717.e1-1717.e2. [PMID: 29859645 DOI: 10.1016/j.ajem.2018.05.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/13/2018] [Indexed: 11/15/2022] Open
Abstract
A 24-year-old female, otherwise healthy, presented to the Emergency Department (ED) with difficulty walking and bilateral leg pain. The patient was a recreational nitrous oxide (NO2) user, also known as "whippets" or simply nitrous. Neurologic examination demonstrated an unsteady gait and positive Romberg sign along with normal deep tendon reflexes and normal muscle strength in upper and lower extremities. Laboratory results demonstrated macrocytic erythropoiesis, reduced B12, elevated homocysteine, and elevated methylmalonic acid. Outpatient MRI later demonstrated degeneration of the posterior spinal column. The patient was empirically treated in the ED with intramuscular B12 and admitted to the evaluation unit for pain control and Physical Therapy (PT) evaluation. Emergency Medicine (EM) physicians should be aware of this condition because NO2 is used both recreationally and in medicine. With the popularity of recreational nitrous oxide, many emergency patients have experience with this drug. As in our case report, the toxic effects can be profound and mimic other emergent conditions like stroke. Emergency physicians should have a higher index of suspicion for the toxic effects of this common drug. Elderly, vegetarians and patients with Irritable Bowel Disease are at higher risk and may even experience toxicity from nitrous oxide used therapeutically during routine anesthesia.
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Chi SI. Complications caused by nitrous oxide in dental sedation. J Dent Anesth Pain Med 2018; 18:71-78. [PMID: 29744381 PMCID: PMC5932993 DOI: 10.17245/jdapm.2018.18.2.71] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 04/11/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022] Open
Abstract
The first clinical application of nitrous oxide (N2O) was in 1844, by an American dentist named Horace Wells who used it to control pain during tooth extraction. Since then, N2O has shared a 170-year history with modern dental anesthesia. N2O, an odorless and colorless gas, is very appealing as a sedative owing to its anxiolytic, analgesic, and amnestic properties, rapid onset and recovery, and, in particular, needle-free application. Numerous studies have reported that N2O can be used safely and effectively as a procedural sedation and analgesia (PSA) agent. However, N2O can lead to the irreversible inactivation of vitamin B12, which is essential for humans; although rare, this can be fatal in some patients.
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Affiliation(s)
- Seong In Chi
- Department of Pediatric Dentistry, Dankook University Sejong Dental Hospital, Sejong, South Korea
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12
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Cascella M, Cascella MM, Arcamone M, Arcamone MM, Morelli E, Morelli EE, Viscardi D, Viscardi DD, Russo V, Russo VV, De Franciscis S, De Franciscis SS, Belli A, Belli AA, Accardo R, Accardo RR, Caliendo D, Caliendo DD, De Luca E, De Luca EE, Di Caprio B, Di Caprio BB, Di Sauro F, Di Sauro FF, Giannoni G, Giannoni GG, Iermano C, Iermano CC, Maciariello M, Maciariello MM, Marracino M, Marracino MM, Cuomo A, Cuomo AA. Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: a case report and review of the literature. J Med Case Rep 2015; 9:175. [PMID: 26289647 PMCID: PMC4546078 DOI: 10.1186/s13256-015-0662-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 07/27/2015] [Indexed: 12/23/2022] Open
Abstract
Introduction Hyperhomocysteinemia is a known risk factor for myocardial infarction, stroke, peripheral vascular disease, and thrombosis. Elevated plasma homocysteine levels have been demonstrated in patients with recurrent episodes or a single episode of thrombosis. Here we describe the development of cardiovascular disease as a complication of a surgical intervention in a patient with colorectal cancer and hyperhomocysteinemia. Case presentation A 65-year-old Caucasian man complained of pain and constipation, attributed to previously diagnosed adenocarcinoma (stage IIB) of the hepatic flexure. An anamnestic investigation showed that he had undergone two surgical interventions. During both, he suffered thrombotic postoperative complications, a deep vein thrombosis of the upper extremity after the first operation and retinal vein occlusion after the second. He was diagnosed with hyperhomocysteinemia associated with a homozygous C677T mutation of the gene encoding the enzyme methylenetetrahydrofolate reductase. Our patient was initially treated with folic acid and high-dose B vitamins. On day 7 he underwent a right hemicolectomy. Anesthesia was performed with sevoflurane in 40% O2 and without the use of nitrous oxide. Postoperatively, our patient remained on folic acid and B vitamins and was without immediate or subsequent complications. Conclusions Neoplastic disease and related surgery followed by the administration of chemotherapeutic drugs alter the hemostatic balance in cancer patients. Those suspected of also having a thrombophilic disease require a thorough laboratory diagnostic workup, including a molecular analysis aimed at identifying the genetic mutation responsible for the hyperhomocysteinemia, as indicated. The case described in this report highlights the importance of a multidisciplinary approach that includes expertise in peri-operative anesthesia, surgery, oncology, and hematology.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Manuela Arcamone
- Division of Haematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Emanuela Morelli
- Division of Haematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Daniela Viscardi
- Department of Surgery, Anesthesia, Emergency and Intensive Care, University of Naples "Federico II", Naples, Italy.
| | | | - Viera Russo
- Department of Surgery, Anesthesia, Emergency and Intensive Care, University of Naples "Federico II", Naples, Italy.
| | | | - Silvia De Franciscis
- Department of Abdominal Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale"- IRCSS, Naples, Italy.
| | | | - Andrea Belli
- Department of Abdominal Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale"- IRCSS, Naples, Italy.
| | | | - Rosanna Accardo
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Domenico Caliendo
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Elena De Luca
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Barbara Di Caprio
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Francesco Di Sauro
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Giovanni Giannoni
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Carmine Iermano
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Maria Maciariello
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Marcella Marracino
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
| | | | - Arturo Cuomo
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy.
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Enlund M, Berglund A, Andreasson K, Cicek C, Enlund A, Bergkvist L. The choice of anaesthetic--sevoflurane or propofol--and outcome from cancer surgery: a retrospective analysis. Ups J Med Sci 2014; 119:251-61. [PMID: 24857018 PMCID: PMC4116765 DOI: 10.3109/03009734.2014.922649] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Commonly used inhalational hypnotics, such as sevoflurane, are pro-inflammatory, whereas the intravenously administered hypnotic agent propofol is anti-inflammatory and anti-oxidative. A few clinical studies have indicated similar effects in patients. We examined the possible association between patient survival after radical cancer surgery and the use of sevoflurane or propofol anaesthesia. PATIENTS AND METHODS Demographic, anaesthetic, and surgical data from 2,838 patients registered for surgery for breast, colon, or rectal cancers were included in a database. This was record-linked to regional clinical quality registers. Cumulative 1- and 5-year overall survival rates were assessed using the Kaplan-Meier method, and estimates were compared between patients given propofol (n = 903) or sevoflurane (n = 1,935). In a second step, Cox proportional hazard models were calculated to assess the risk of death adjusted for potential effect modifiers and confounders. RESULTS Differences in overall 1- and 5-year survival rates for all three sites combined were 4.7% (p = 0.004) and 5.6% (p < 0.001), respectively, in favour of propofol. The 1-year survival for patients operated for colon cancer was almost 10% higher after propofol anaesthesia. However, after adjustment for several confounders, the observed differences were not statistically significant. CONCLUSION Propofol anaesthesia might be better in surgery for some cancer types, but the retrospective design of this study, with uneven distributions of several confounders, distorted the picture. These uncertainties emphasize the need for a randomized controlled trial.
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Affiliation(s)
- Mats Enlund
- Centre for Clinical Research and Department of Anaesthesia and Intensive Care, Central Hospital, Västerås, Sweden
| | - Anders Berglund
- Regional Cancer Centre (AB), Uppsala University Hospital, Uppsala, Sweden
| | - Kalle Andreasson
- Centre for Clinical Research and Department of Surgery, Central Hospital, Västerås, Sweden
| | - Catharina Cicek
- Centre for Clinical Research and Department of Surgery, Central Hospital, Västerås, Sweden
| | - Anna Enlund
- Centre for Clinical Research and Department of Anaesthesia and Intensive Care, Central Hospital, Västerås, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research and Department of Surgery, Central Hospital, Västerås, Sweden
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14
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Affiliation(s)
- Yamin Shwe
- Department of Neurology, Mt. Sinai Beth Israel Medical Center, New York, NY
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15
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Sen A, Chandrasekhar K. Spinal MR imaging in Vitamin B12 deficiency: Case series; differential diagnosis of symmetrical posterior spinal cord lesions. Ann Indian Acad Neurol 2013; 16:255-8. [PMID: 23956577 PMCID: PMC3724087 DOI: 10.4103/0972-2327.112487] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/19/2012] [Accepted: 06/23/2012] [Indexed: 11/17/2022] Open
Abstract
We report three cases of Vitamin B12 deficiency with symmetrical posterior spinal cord lesions and discuss the differential diagnosis, some of which are not well known. Because the degree of resolution of the clinical symptoms in subacute combined degeneration depends on early detection, MRI findings should not be missed.
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Affiliation(s)
- Anitha Sen
- Radiodiagnosis, Government Medical College, Kottayam, Kerala, India
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16
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Abstract
OBJECTIVE The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation. DATA SOURCE A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed. RESULTS The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended. CONCLUSIONS In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.
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Nagele P, Tallchief D, Blood J, Sharma A, Kharasch ED. Nitrous oxide anesthesia and plasma homocysteine in adolescents. Anesth Analg 2011; 113:843-8. [PMID: 21680854 DOI: 10.1213/ane.0b013e31822402f5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Nitrous oxide inactivates vitamin B(12), inhibits methionine synthase, and consequently increases plasma total homocysteine (tHcy). Prolonged exposure to nitrous oxide can lead to neuropathy, spinal cord degeneration, and even death in children. We tested the hypothesis that nitrous oxide anesthesia causes a significant increase in plasma tHcy in children. METHODS Twenty-seven children (aged 10-18 years) undergoing elective major spine surgery were enrolled, and serial plasma samples from 0 to 96 hours after induction were obtained. The anesthetic regimen, including the use of nitrous oxide, was at the discretion of the anesthesiologist. Plasma tHcy was measured using standard enzymatic assays. RESULTS The median baseline plasma tHcy concentration was 5.1 μmol/L (3.9-8.0 μmol/L, interquartile range) and increased in all patients exposed to nitrous oxide (n = 26) by an average of +9.4 μmol/L (geometric mean; 95% confidence interval, 7.1-12.5 μmol/L) or +228% (mean; 95% confidence interval, 178%-279%). Plasma tHcy peaked between 6 and 8 hours after induction of anesthesia. One patient who did not receive nitrous oxide had no increase in plasma tHcy. Several patients experienced a severalfold increase in plasma tHcy (maximum +567%). The increase in plasma tHcy was strongly correlated with the duration and average concentration of nitrous oxide anesthesia (r = 0.80; P < 0.001). CONCLUSIONS Pediatric patients undergoing nitrous oxide anesthesia develop significantly increased plasma tHcy concentrations. The magnitude of this effect seems to be greater compared with adults; however, the clinical relevance is unknown.
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Affiliation(s)
- Peter Nagele
- Department of Anesthesiology, Washington University, St. Louis, MO, USA.
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18
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Orestes P, Bojadzic D, Lee J, Leach E, Salajegheh R, Digruccio MR, Nelson MT, Todorovic SM. Free radical signalling underlies inhibition of CaV3.2 T-type calcium channels by nitrous oxide in the pain pathway. J Physiol 2010; 589:135-48. [PMID: 21059758 DOI: 10.1113/jphysiol.2010.196220] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Nitrous oxide (N2O, laughing gas) has been used as an anaesthetic and analgesic for almost two centuries, but its cellular targets remain unclear. Here, we present a molecular mechanism of nitrous oxide's selective inhibition of CaV3.2 low-voltage-activated (T-type) calcium channels in pain pathways. Using site-directed mutagenesis and metal chelators such as diethylenetriamine pentaacetic acid and deferoxamine, we reveal that a unique histidine at position 191 of CaV3.2 participates in a critical metal binding site, which may in turn interact with N2O to produce reactive oxygen species (ROS). These free radicals are then likely to oxidize H191 of CaV3.2 in a localized metal-catalysed oxidation reaction. Evidence of hydrogen peroxide and free radical intermediates is given in that N2O inhibition of CaV3.2 channels is attenuated when H2O2 is neutralized by catalase. We also use the adrenochrome test as an indicator of ROS in vitro in the presence of N2O and iron. Ensuing in vivo studies indicate that mice lacking CaV3.2 channels display decreased analgesia to N2O in response to formalin-induced inflammatory pain. Furthermore, a superoxide dismutase and catalase mimetic, EUK-134, diminished pain responses to formalin in wild-type mice, but EUK-134 and N2O analgesia were not additive. This suggests that reduced ROS levels led to decreased inflammation, but without the presence of ROS, N2O was not able to provide additional analgesia. These findings reveal a novel mechanism of interaction between N2O and ion channels, furthering our understanding of this widely used analgesic in pain processing.
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Affiliation(s)
- Peihan Orestes
- Department of Anaesthesiology, University of Virginia Health System, Mail Box 800710, Charlottesville, VA 22908-0710, USA
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19
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Abstract
High plasma levels of homocysteine are associated with an increased risk for thromboembolic events. Neuraxial anesthesia techniques may be relatively contraindicated in anticoagulated patients, and nitrous oxide may exacerbate the condition by inhibiting the conversion of homocysteine to methionine. We describe the anesthetic implications and management of a patient with hyperhomocysteinemia undergoing an nonemergent cesarean delivery.
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Mathews DM, Gaba V, Zaku B, Neuman GG. Can Remifentanil Replace Nitrous Oxide During Anesthesia for Ambulatory Orthopedic Surgery with Desflurane and Fentanyl? Anesth Analg 2008; 106:101-8, table of contents. [DOI: 10.1213/01.ane.0000289526.20117.26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Tobias JD, Wall R. Anesthesia. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
There are many reasons for reviewing the neurology of vitamin-B12 and folic-acid deficiencies together, including the intimate relation between the metabolism of the two vitamins, their morphologically indistinguishable megaloblastic anaemias, and their overlapping neuropsychiatric syndromes and neuropathology, including their related inborn errors of metabolism. Folates and vitamin B12 have fundamental roles in CNS function at all ages, especially the methionine-synthase mediated conversion of homocysteine to methionine, which is essential for nucleotide synthesis and genomic and non-genomic methylation. Folic acid and vitamin B12 may have roles in the prevention of disorders of CNS development, mood disorders, and dementias, including Alzheimer's disease and vascular dementia in elderly people.
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Affiliation(s)
- Edward Reynolds
- Institute of Epileptology, King's College, Denmark Hill Campus, Cutcombe Road, London, SE5 6PJ, UK.
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23
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Affiliation(s)
- Michelle J Naidich
- Department of Radiology, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, 676 N St Clair St, Suite 800, Chicago, IL 60611, USA.
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24
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Preston G. Surrogate Models of Pain. Pain 2003. [DOI: 10.1201/9780203911259.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Abstract
Safe and predictable analgesia is required for the potentially painful or uncomfortable procedures often undertaken in an emergency department. The characteristics of an ideal analgesic agent are safety, predictability, non-invasive delivery, freedom from side effects, simplicity of use, and a rapid onset and offset. Newer approaches have threatened the widespread use of nitrous oxide, but despite its long history this simple gas still has much to offer. "I am sure the air in heaven must be this wonder-working gas of delight". Robert Southey, Poet (1774 to 1843)
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Affiliation(s)
- I O'Sullivan
- Bristol and Weston Emergency Departments, Bristol Royal Infirmary, Bristol UK. Iomhar.O'
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26
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Saperstein DS, Barohn RJ. Peripheral Neuropathy Due to Cobalamin Deficiency. Curr Treat Options Neurol 2002; 4:197-201. [PMID: 11931726 DOI: 10.1007/s11940-002-0036-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vitamin B12, or cobalamin (Cbl), deficiency can produce a number of neurologic complications, including myelopathy, peripheral neuropathy, optic neuropathy, and dementia. The myelopathy, combined systems disease, is probably the most well known manifestation, and is usually readily recognized. The frequency with which peripheral neuropathy is the sole presenting feature of Cbl deficiency is a point of controversy. The prevalence and the clinical and electrophysiologic features of Cbl deficiency peripheral neuropathy have not been well characterized. In addition, there is evidence that the commonly used assays of serum Cbl are not adequately sensitive. Testing the serum metabolites methylmalonic acid and homocysteine can increase the identification of Cbl deficient patients. Treatment with parenteral Cbl injections may not produce improvement of neurologic deficits, but might prevent worsening. In some patients with Cbl deficiency, oral Cbl may be an effective therapy.
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Affiliation(s)
- David S. Saperstein
- *Department of Neurology, Wilford Hall Medical Center, 2200 Bergquist Drive, Suite 1, San Antonio, TX 78236-5300, USA.
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27
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Wall RT. Anesthesia. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Abstract
The application of sensitive metabolic tests, such as the deoxyuridine suppression test and measurement of homocysteine and methylmalonic acid, to cobalamin status has identified the entity of mild, preclinical cobalamin deficiency. This state, common in the elderly, responds to cobalamin therapy. Preclinical deficiency may exist within the nervous system as well, although this requires further study. Nevertheless, it is well to remember that not all low cobalamin levels and not all abnormal metabolite results reflect cobalamin deficiency. Interpretation of metabolic results still requires caution, as do proposals to raise the cut-off point for low cobalamin levels to capture some normal levels that are associated with metabolic abnormality. The recognition of mild, preclinical deficiency has opened up many important issues. These include identifying its causes, what should be done about it, and what the clinical impact of the hyperhomocysteinemia itself is. Although malabsorptive disorders, especially food-cobalamin malabsorption, underlie about half of all cases of preclinical deficiency, no cause can be found in the remainder of these cases; poor dietary intake appears to be uncommon. In addition, unusual states of neurologically symptomatic cobalamin deficiency are being recognized, such as nitrous oxide exposure in patients with unrecognized deficiency and severe deficiency in children of mildly deficient mothers. All of these have broadened and complicated the picture of cobalamin deficiency while providing greater opportunities for prevention.
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Affiliation(s)
- R Carmel
- Department of Medicine, New York Methodist Hospital, Brooklyn 11215, USA.
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29
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Abstract
The risk-benefit ratio of using nitrous oxide has been debated for many years. In this article the adverse effects of nitrous oxide on patient well-being, including its role in postoperative nausea and vomiting, its toxic effects and adverse physiological changes are reviewed. Guidelines for the rational use of the drug are suggested.
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Affiliation(s)
- M F James
- Department of Anaesthesia, University of Cape Town Faculty of Health Science, Cape Town, South Africa
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30
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Jameson M, Roberts S, Anderson N, Thompson P. Nitrous oxide-induced vitamin B12 deficiency. J Clin Neurosci 1999; 6:164-6. [DOI: 10.1016/s0967-5868(99)90087-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/1996] [Accepted: 12/24/1996] [Indexed: 11/27/2022]
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32
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Affiliation(s)
- R A Wiklund
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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