No laughing matter: subacute degeneration of the spinal cord due to nitrous oxide inhalation.

BACKGROUND: Whilst the dangers of 'legal highs' have been widely publicised in the media, very few cases of the neurological syndrome associated with the inhalation of nitrous oxide (N2O) have been reported. Here we set out to raise awareness of subacute degeneration of the spinal cord arising from recreational N2O use so that formal surveillance programs and public health interventions can be designed. METHODS: Case series documenting the clinical and investigational features of ten consecutive cases of subacute degeneration of the spinal cord presenting to a hospital with a tertiary neurosciences service in East London. RESULTS: Sensory disturbance in the lower (± upper) limbs was the commonest presenting feature, along with gait abnormalities and sensory ataxia. MRI imaging of the spine showed the characteristic features of dorsal column hyperintensity on T2 weighted sequences. Serum B12 levels may be normal because subacute degeneration of the spinal cord in this situation is triggered by functional rather than absolute B12 deficiency. DISCUSSION: A high index of suspicion is required to prompt appropriate investigation, make the diagnosis and commence treatment early. This is the largest reported series of patients with subacute degeneration of the spinal cord induced by recreational use of N2O. However, the number of patients admitted to hospital likely represents the 'tip of the iceberg', with many less severe presentations remaining undetected. After raising awareness, attention should focus on measuring the extent of the problem, the groups affected, and devising ways to prevent potentially long-term neurological damage.

Is preparedness for CBRN incidents important to general practitioners in East London?

General practitioners (GPs) have an important role in public health response to CBRN incidents, including disseminating information to worried patients and undertaking risk assessments of patients. The authors undertook the first known UK survey of GPs' CBRN preparedness to assess knowledge and attitudes towards CBRN preparedness among GPs in East London, in the area of the Olympic Park. A questionnaire was developed, focusing on GPs' self-preparedness for, and perceived roles in CBRN incidents, and GPs' access to resources and policies for dealing with such incidents. Of 157 GPs, 56 responded, although some responded collectively for their practice. The majority of respondents recognised roles for themselves in CBRN incidents, including recognition of illness, supporting decontamination, and appropriate reporting. However, 79 per cent of GPs also felt unprepared for such incidents. The most popular topic for training to address this was clinical presentation of CBRN exposures. Most practices had no policy for dealing with suspect packages and white powder incidents. Since this survey, guidance and training has been made available to local GPs. As the UK will host more events like the 2012 Olympics, preparedness for GPs will continue to be an important consideration in the UK.

Addressing the inverse care law in cardiac services.

BACKGROUND: Wide variation in rates of angiography and revascularization exist that are not explained by the level of need for these services. The National Service Framework for Coronary Heart Disease has set out a number of standards with the aim of increasing the number of revascularizations and reducing inequalities in access to care. In this study we aimed to investigate inequity in angiography and revascularization rates between the four Primary Care Group (PCG) areas in Camden and Islington Health Authority and to put in place measures to address the problems identified. METHODS: Routinely available data were collected on all residents within Camden and Islington Health Authority undergoing angiography, angioplasty (PTCA) or coronary artery bypass grafting (CABG) between 1997 and 2001. These were used to calculate intervention rates per million population for each of the three procedures within each PCG. Semi-structured interviews were carried out with a sample of clinicians to explore their views on the provision of revascularization services within the Health Authority. RESULTS: Angiography and revascularization rates varied widely between the four PCGs. In 2001 there was a two-fold difference for angiography and CABG and a 3.5-fold difference for PTCA. The variations were not explained by a measure of the level of need for these services. The highest rates were in the area with the lowest standardized mortality ratio for coronary heart disease. The interviews identified a number of possible explanations for the variations that related to differences in clinical behaviour atthe consultant level and barriers in access to interventional cardiology and cardiac services. Following this research, a further interventional cardiologist appointment is planned, joint protocols of care are being established and barriers to access are being addressed. CONCLUSIONS: The new strategic health authorities should make it a priority to assess inequity in the provision of services within their areas, investigate the possible causes and support the primary care trusts to implement plans to address them.