BACKGROUND: Chronic nitrous oxide (N2O) use causes inactivation of vitamin B12, resulting in neurological and psychiatric symptoms. This case series presents all N2O-related presentations to the emergency department at Royal Perth Hospital between June 2019 and June 2021, alongside the costs of these admissions.
METHODS: Twenty-two patients were identified; 68% (n = 15) were male. The median age was 22.4 years (interquartile range [IQR], 20-30). Median daily number of N2O bulbs inhaled was 150 (IQR, 64-300) with a median duration of use of 9 months (IQR, 3-12). Presentations included ataxia, paraesthesia and falls (n = 18), urinary retention (n = 3) and psychotic symptoms (n = 2). Fourteen patients had severe symptoms prompting a magnetic resonance imaging of brain and spine, confirming 12 cases of subacute combined degeneration of the spinal cord. All patients had IMI vitamin B12 therapy, while 14 had oral methionine therapy. The median length of admission was 4 days (IQR 1-23 days). The median cost of admission per day for patients where costs were accessible (n = 7) was $2061 (IQR, $1903-$2860).
CONCLUSIONS: A case series of symptomatic chronic N2O use with severe neurological sequelae and significant costs associated per admission. Triangulation of emergency department and Ecstasy and Related Drugs Reporting System data helped prompt a swift public health response, including mandatory warning labels, limits to transaction amounts and legislative changes to the Medicines and Poisons Act to make it illegal for sale if there is a suspicion that it will be abused.

Contextualizing the void of research on inhalant abuse among adolescents as epistemic neglect, in this study, we use mixed-methods action research to understand inhalant abuse in a specific context in the Global South. Focusing on a large metropolitan city in Western India, we surveyed 158 street-involved children and adolescents (110 boys and 48 girls, age range from 5 to 17 years) in a group setting along with follow-up group interviews. Despite finding a high prevalence rate of inhalant abuse, our work suggests an absence of supporting structures and emphasizes the need to revisit our understanding and interpretation of substance-using behavior of street-involved youth. Instead of explaining inhalant-abusing behavior as emerging from pathological deficiencies in individuals or households, we stress the need to critically examine the exploitative environment they are embedded in. In doing so, we join efforts to decolonize conventional ways of understanding \"deviant\" behavior.

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Volatile Solvents Abuse (VSA) poses major health risks, especially for young people and those living in precarious socio-economic conditions. Such substances can in fact bring about psychoactive effects such as euphoria, and even lead to sudden death from cardiac arrhythmias, respiratory depression, myocardial infarction, laryngospasm, encephalopathy, and rhabdomyolysis. The present case report is centered around a 23-year-old man who died in prison due to inhalation of a cooker gas mixture (n-butane, propane, and isobutane) inside a plastic bag. External examination and autopsy showed non-specific signs of asphyxia associated with edema and brain swelling. Histological signs of early myocardial damage and hypoxic-ischemic injury (HII) were highlighted in the brain and cerebellum, as well as activated macrophages and anthracotic-like material in the lungs. Toxicological investigations revealed the presence of propane, isobutane and n-butane in liquids and biological samples. Besides the cardiotoxic effect, there was an asphyctic component due to the plastic bag that may have facilitated death. The assessment of cerebral HII and cardiopulmonary damage in acute cases is very important to prove death by butane inhalation. In the forensic field, it may be useful to shed more light on intoxications, deaths, and butane encephalopathies, as the latter can be mistaken for a hypoxic-ischemic encephalopathy.

A 30-yr-old man developed right lower leg pain and a palpable solid mass. Radiographic imaging revealed a periosteal reaction with an exostotic mass arising from the right distal fibula. Generalized skeletal osteosclerosis with periosteal reaction was discovered on a radiographic skeletal survey. A biopsy of the right fibular mass revealed reactive woven bone. The patient was referred to a metabolic bone disease clinic, where laboratory values were consistent with secondary hyperparathyroidism and increased bone turnover. A DXA bone density scan revealed high bone density, with an L1-4 spine Z-score of +9.3, a left femoral neck Z-score of +8.5, and a total hip Z-score of +6.5. A dental exam revealed generalized gingival inflammation, teeth mobility, generalized horizontal alveolar bone loss and widening of the periodontal ligament space, increased bone density around the teeth, and thickening of the radicular lamina dura. An extensive evaluation was performed, with the result of a single test revealing the diagnosis. The differential diagnoses of osteosclerosis affecting the skeleton, teeth, and oral cavity are discussed.
A 30-yr-old man developed, over a short period, pain in his lower right leg accompanied by a hard mass. He also reported weight loss and night sweats for the past 6 months. After evaluation by his primary physician, an X-ray was ordered that reported a bony mass arising from the right fibula bone. A biopsy was performed of the mass, but no evidence of cancer or any other specific abnormality was found. The patient was then referred to a bone disease specialty clinic. Laboratory tests revealed a large increase in how quickly the patient’s skeleton was remodeling, affecting the balance of bone formation and removal involved in maintaining a healthy skeleton. A bone density scan reported that the patient had very dense bones. Other unusual changes were also discovered in a dental exam, suggesting bone thickening. After an extensive evaluation, a single blood test revealed the cause of the fibular bone mass and dense bones.

Worldwide, various inhalants are widely abused for recreational purposes, with butane and propane emerging as among the most commonly misused volatile substances, posing a significant risk of sudden death. The rapid elimination and oxidation of these highly volatile compounds upon inhalation necessitate the identification of butane and propane along with their metabolites in biological samples. Hence, the primary objective of this study is twofold: firstly, to establish a method for analyzing butane, propane, and metabolites, and secondly, to demonstrate the detection window and exposure indicators associated with the inhalation of butane and propane. In pursuit of this objective, we developed analytical methods for the determination of isobutane, n-butane, propane, and their nine metabolites in both blood and urine. Headspace-gas chromatography-mass spectrometry (GC-MS) and solid-phase microextraction-GC-MS were employed for the analyses, demonstrating acceptable precision and accuracy. An animal study revealed that isobutane and n-butane were only detectable below the limit of quantification (LOQ) in rat blood 5 min after exposure. Meanwhile, the three major metabolites-2-methyl-2-propanol, 2-butanol, and 2-butanone-were observed 5 min after exposure but persisted in rat urine even 5 h post-exposure. Additionally, human urine samples identified other metabolites, including acetone, acetoin, and 2,3-butanediol isomers. The presence of specific metabolites corresponding to each inhalant confirmed the abuse of butane and propane. This comprehensive approach provides valuable insights into the detection and assessment of inhalation to these volatile substances.

Background and Objectives: Nitrous oxide (N2O) has recently emerged as a cheap alternative to other recreational substances. Although legally available, its chronic use is associated with severe neurological and hematological complications due to the irreversible inactivation of vitamin B12. While no reliable data on abuse of N2O in Italy have been provided to date, we assessed the knowledge, attitudes, and practices of Italian medical professionals on the management of N2O abuse cases. Materials and Methods: A cross-sectional study was performed as a web-based survey through a series of Facebook discussion groups (targeted medical professionals: 12,103), and participants were specifically asked about their previous understanding of N2O abuse and whether they had or not any previous experience in this topic. Results: A total 396 medical professionals participated in the survey. Overall, 115 participants had previous knowledge about N2O abuse (29.04%), with higher odds for professionals with a background in emergency medicine (adjusted odds ratio (aOR) 3.075; 95% confidence intervals (95%CI) 1.071 to 8.828) and lower for specialists in psychiatry (aOR 0.328; 95%CI 0.130 to 0.825). Knowledge status on N2O abuse was largely unsatisfying, as knowledge status, reported as a percent value, was estimated to 45.33% ± 24.71. Having previously managed a case of N2O abuse was associated with higher risk perception of the actual severity of this condition (aOR 5.070; 95%CI 1.520 to 16.980). Conclusions: Our study suggests that N2O poisoning cases are occurring in Italian settings but are not reasonably reported to national authorities. As substantial knowledge gaps of Italian medical workforces were identified, we cannot rule out that the actual abuse of N2O in the population may be far larger than currently suspected.

Inhalant abuse and whitener addiction are serious problems among adolescents that have significant consequences for physical and mental health, as well as for families, communities, and society as a whole. This review article discusses the causes and health consequences of inhalant abuse and whitener addiction among adolescents, as well as the challenges in addressing the problem. The paper also outlines strategies for addressing inhalant abuse and whitener addiction, including education and awareness campaigns; early intervention and treatment; collaboration between schools, healthcare providers, and community organizations; and support for families affected by inhalant abuse and addiction. The paper concludes with a call to action for policymakers, healthcare providers, and community members to prioritize and address inhalant abuse and whitener addiction among adolescents. By working together, we can help to prevent substance abuse and promote the health and well-being of our youth.

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Ethyl chloride is a common topical anesthetic. However, when abused as an inhalant, effects can range from headaches and dizziness to debilitating neurotoxicity requiring intubation. While previous case reports describe the short-term reversible neurotoxicity of ethyl chloride, ours show chronic morbidity and mortality outcome. During the initial evaluation, it is essential to consider the rising trend of commercially available inhalants being used as recreational drugs. We present a case of a middle-aged man presenting with subacute neurotoxicity due to repeated abuse of ethyl chloride.