Subacute combined degeneration of the spinal cord in a patient abusing nitrous oxide and self-medicating with cyanocobalamin.

PURPOSE: A case of subacute combined degeneration (SCD) of the spinal cord manifesting as severe ataxia and urinary retention in a patient with a history of heavy nitrous oxide abuse and self-supplementation with cyanocobalamin is reported. SUMMARY: A 27-year-old woman was treated in the emergency department for complaints of abdominal pain and inability to urinate for about 12 hours. The patient also complained of worsening lower-extremity weakness for 10 days and a "pins and needles" sensation in the lower extremities for approximately 1 year. She reported nitrous oxide abuse over 3 years (an average of 100-200 "whippit" cartridges daily on 3 or 4 days per week), as well as long-term self-medication with oral and i.m. cyanocobalamin for the purpose of preventing nitrous oxide-induced neurologic symptoms. Results of magnetic resonance imaging (MRI) were highly suggestive of SCD, which is typically seen in primary vitamin B12 deficiency but has been reported in the context of chronic nitrous oxide exposure. Treatment was initiated with cyanocobalamin 1000 µg i.m. daily, to be continued for 5 days and followed by a four-week regimen of 1000 µg i.m. weekly. The patient was discharged after 3 days, despite continued symptoms, with instructions to obtain ongoing care but was lost to follow-up. CONCLUSION: A patient who abused nitrous oxide chronically developed ataxia, paresthesia, and urinary retention while self-medicating with cyanocobalamin. A diagnosis of SCD was supported by MRI findings, symptoms, and the known relationship between nitrous oxide exposure and vitamin B12 deficiency.

Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program.

INTRODUCTION: Patients presenting to the emergency department (ED) with an acute uncomplicated deep vein thrombosis (DVT) may be eligible for outpatient treatment. This study aims to establish a transition of care program in the ED for patients with DVT presenting with an acute uncomplicated DVT. METHODS: This article specifies the transition of care program for DVT patients in the ED. Data was collected on patients admitted and discharged from the ED who had an acute DVT both prior to the initiation of facilitating anticoagulation for safer transitions (FAST) and after initiation of FAST. Follow-up phone calls were made to patients discharged from the ED after the initiation of FAST, and data were collected on follow-up appointments, anticoagulation adherence, readmission rates, and patient satisfaction. RESULTS: The FAST program has been successfully implemented. By the 30-day follow-up phone call, 100% of patients had attended a follow-up appointment. The average time to the follow-up appointment post-discharge was 4.4 days (range, 1-7 days). None of the patients at the 3- to 5-day follow-up phone call and 30-day phone call had any issues taking their anticoagulant, and none reported side effects of significant bleeding. One patient was re-admitted after discharge with a pulmonary embolism. Patient satisfaction has also been very high with the program, with all patients indicating at the 30-day phone call that they would recommend the program to a friend or family member. The educational components of this program also improved the discharge process for this population compared with patients discharged prior to the initiation of FAST. CONCLUSION: The FAST program is an example of a successful transition-of-care program for discharging DVT patients from the ED. Reassessment and improvements to the program are underway to ensure it remains current, sustainable, and provider friendly.