Volume 211 Issue 9

What should the health care community do when faced with major human rights abuses?

Ryan Essex · David Isaacs

Unconscious gender bias still contributes to unspoken barriers to career progression, which prevail despite increased qualifications and work performance among women; yet emerging evidence is paving the way for effective change

Helena J Teede

Australia needs a coordinated nationwide plan to reduce preventable deaths and disability from sepsis

Luregn J Schlapbach · Kelly Thompson · Simon R Finfer

A well designed National Integrated Health Services Information Analysis Asset will improve services and policy

Tom G Briffa · Louisa Jorm · Rodney T Jackson · Christopher Reid · Derek P Chew

A previously well 6-year-old girl presented to her doctor with a mildly injected right eye and upper eyelid swelling

Jiyeon Kim · Jonathan G Ussher

A 48-year-old man presented with a 3-day history of a rapidly progressing painful and pruritic cutaneous eruption and fever

Kirsty JL Wark · Helena Crawshaw

Transgender people may have a higher burden of both medical and mental health problems

Joshua D Safer

Understanding the low risk of blood-borne virus infections in donors could help expand the pool of available organs

Sakhee Kotecha · Trevor J Williams

This model of care emphasises not only early access to assessment across a number of clinical and functional domains but also rapid and ongoing provision of stage-appropriate interventions

Ian B Hickie

Gender details must be better captured to facilitate appropriate planning of sexual health services

Denton Callander · Teddy Cook · Phillip Read · Margaret E Hellard · Christopher K Fairley · John M Kaldor · Emanuel Vlahakis · Alisa Pollack · Christopher Bourne · Darren B Russell · Rebecca J Guy · Basil Donovan

The availability of helmets and the enforcement of helmet rules by police must be ensured

Narelle L Haworth · Amy Schramm

Organ donations from people at increased risk but with negative test results could expand the donor pool

Karen MJ Waller · Nicole L De La Mata · Patrick J Kelly · Vidiya Ramachandran · William D Rawlinson · Kate R Wyburn · Angela C Webster

Diverticular disease is a common gastrointestinal disorder with significant health burden; recent evidence is changing practice

Hayley You · Amy Sweeny · Michelle L Cooper · Michael Von Papen · James Innes

To the Editor: In their article, De Costa and colleagues1 clearly demonstrate the importance of making mifepristone freely available for prescription to all registered Australian medical practitioners, and they emphasise that the current need for special registration discourages general practitioners to become involved in medical abortion provision. We conducted a cross‐sectional study of 39 GPs and 30 primary health care nurses from regional or rural Victoria and identified additional uptake barriers.2 Most study participants showed important gaps in medical abortion knowledge, despite their overall positive stance on abortion and extensive experience with women with unplanned pregnancies, and only a few indicated to be current medical abortion providers. Although nearly all health practitioners indicated they would support a colleague in providing abortions, fewer GPs than nurses were interested in medical abortion training. The main reported uptake barriers to medical abortion provision included a lack of training opportunities as well as the absence of local support services required in Australia for the recommended pre‐abortion ultrasound and for surgical back‐up in the case of complications. Participants additionally worried about the legality of providing abortions, and some indicated that their practices would not allow the provision of this service. Abortion access for Australian women in regional and rural regions is still very restricted. By moving early medical abortion provision into the primary health care setting of underserved regions, and particularly in general practice, this situation can be considerably improved. However, the uptake among GPs remains low.3 In addition to addressing uptake barriers, alternative solutions to improve abortion access in underserved areas should be further explored as well, such as the use of telemedicine (until recently provided by the Tabbot Foundation) and the inclusion of primary health care nurses in the abortion provision process — an evidence‐based practice that is already extensively implemented in a range of high income countries.4,5 A nurse‐led model approach not only addresses the shortage of physicians but also the time‐intensive aspect of the medical abortion process, and it provides women with choice and flexibility, which is indispensable to their reproductive autonomy and, thus, to their overall welfare.

Caroline Moel‐Mandel · Melissa Graham

In reply

Caroline M Costa · Kirsten I Black · Darren B Russell

To the Editor: Recreational misuse of nitrous oxide remains a significant public health problem,1 sustained in part by the ready availability online of gas‐containing canisters intended for use in the catering industry. Known as “nangs” or “whippits” and usually purchased in bulk, each canister contains 8 g of nitrous oxide. When inhaled, this gives a seconds‐long “high”, which is typically prolonged by using several “nangs” in a single session. Some individuals can consume hundreds each day. Prolonged exposure to nitrous oxide leads to the oxidisation of vitamin B12, rendering it unusable in key enzymatic reactions necessary for normal myelin synthesis.2 Over time, this leads to a potentially devastating neuropsychiatric syndrome that commonly presents with ataxia.3 Notably, the culprit shortage of vitamin B12 is a qualitative one and can be purely so, meaning that marked clinical deficits emerge in the presence of serum B12 levels that appear normal on standard laboratory assays. Furthermore, with continued exposure to nitrous oxide, these deficits will respond poorly to vitamin B12 supplementation. In a year‐long clinical audit at Royal Prince Alfred Hospital (2017–2018), seven nitrous oxide users, all aged between 20 and 30 years, presented with ataxia that ranged from mild to severe (Box 1). Most patients also had psychiatric symptoms. Nearly every patient estimated using 100 or more canisters of nitrous oxide per day in the months before being seen. Four patients also reported engaging in B12 supplementation (both oral and parenteral), aiming to circumvent the harmful sequelae of prolonged nitrous oxide misuse. Laboratory studies showed that all seven patients had accumulated homocysteine, as is usually seen when vitamin B12 is in short supply in the body.2 Individuals who reported taking supplements had serum B12 levels that were either normal or in excess of normal, implicating a qualitative deficiency of metabolically useful B12. Evidence of demyelination was seen on spinal cord imaging in six patients, including all those who used supplements, with the “inverted V” sign4 visible on T2‐weighted magnetic resonance imaging sequences (Box 2). Despite treatment according to best practice guidelines, all patients left hospital with persistent symptoms, and most were unable to walk or to attend to their bodily needs without the assistance of family members (modified Rankin score, 4). Sadly, one of the least affected individuals re‐presented to hospital with worsened symptoms because of continued nitrous oxide misuse. At every opportunity nitrous oxide users should be reminded of the futility of B12 supplementation, as one of many reasons why they should choose to avoid this profoundly destructive drug. Box 1 – Patients presenting with symptoms due to nitrous oxide misuse Age (years) Sex Canister use Duration of use B12 supplementation Ataxia severity* Psychiatric symptoms† Homocysteine level Serum B12 (active) MRI: “inverted V” sign‡ mRS: Day 1 mRS: discharge 20 Female 250/day 1 year No Severe Yes High Low (low) Yes 4 4 30 Male 60/day 1 year No Moderate Yes High Low (low) Yes 1 1 30 Male 100/day 6 months No Mild No High Low (normal) No 1 1 21 Male 200/day 1 year Yes Severe Yes High Normal (normal) Yes 4 4 23 Female 300/day 2 months Yes Severe Yes High Normal (high) Yes 4 4 23 Female 200/day 2 months Yes Severe Yes High High (high) Yes 4 4 28 Male 300/day 1 year Yes Mild No High Normal (normal) Yes 1 1 MRI = magnetic resonance imaging; mRS = modified Rankin score of neurological disability. * Ataxia: mild = visible gait disturbance; moderate = frequent falls; severe = inability to walk without assistance. † Psychiatric symptoms included mood disturbance, memory impairment and psychosis. ‡ MRI findings: “inverted V” sign on T2‐weighted MRI spinal cord imaging (Box 2). mRS: 0 = no symptoms; 1 = no significant disability despite symptoms; 2 = slight disability; 3 = moderate disability; 4 = moderately severe disability, unable to walk or attend to bodily needs without assistance; 5 = severe disability, bedridden; 6 = dead. Box 2 – T2‐weighted magnetic resonance imaging sequence showing “inverted V” sign, indicating the presence of dorsal column demyelination

Christopher Blair · Chris Tremonti · Leon Edwards · Paul S Haber · G Michael Halmagyi

To the Editor: Recreational use of nitrous oxide is increasing among regular drug users in Australia1 and internationally.2 In a New South Wales survey of participants who had used ecstasy or other stimulants in the past 6 months, 75% of respondents reported recent use of nitrous oxide in 2018, up from 20% in 2013.3 Nitrous oxide use while bingeing on stimulants rose from 4% of respondents in 2013 to 16% in 2017.4,5 Access to nitrous oxide has been facilitated by businesses offering 24/7 delivery of large quantities of canisters, ostensibly for whipping cream.6 We examined presentations to 60 emergency departments (EDs) across NSW from January 2012 to December 2018 (covering about 82% of all NSW ED presentations) in which the patient reported inhaling nitrous oxide outside a therapeutic setting. We extracted records from the Rapid Emergency Department Data for Surveillance (REDDS) dataset in which the person was aged 16 years or over and “nitrous oxide” or related terms were mentioned in the presenting problem, nursing assessment or diagnosis fields. We manually reviewed records for inclusion; this method may underestimate true presentation counts. ED presentations fitting the criteria were infrequent (n = 118) but increased over time, particularly from 2016 to 2018 (Box). Most presentations were in persons aged 16–30 years (n = 98, 83%) and just over half were men (n = 66, 56%). Almost half indicated polydrug use (n = 54, 46%), and one quarter indicated chronic or heavy use of nitrous oxide (n = 28, 24%). Consistent with the case literature,7 presenting problems and diagnoses included injury (n = 15, 13%), neurological symptoms (n = 14, 12%), loss of consciousness or syncope (n = 13, 11%), respiratory arrest (n = 2, 2%), self‐harm or suicidal ideation (n = 16, 14%), or other mental health conditions (n = 28, 24%). This increase in presentations may reflect changes in the underlying population or in data collection, rather than changes in drug use. However, the trend is consistent with drug use survey findings,1,3 suggesting that recreational nitrous oxide use may be an emerging health problem in Australia. Clinicians should include nitrous oxide use as part of a drug history, consider potential use among young patients presenting with neurological symptoms resembling B12 deficiency, and educate users on the health impacts, harm minimisation strategies and available support services. NSW Health is educating at‐risk groups through multilingual fact sheets8 and targeted social media and other messaging. This report is the result of an investigation carried out by the NSW Ministry of Health under the provisions of the NSW Health Administration Act 1982; therefore, specific ethics approval was not required. Data were sourced from the REDDS, which is maintained by the Ministry of Health, and were analysed by Ministry of Health staff for the purpose of the investigation. Box – Emergency department presentations in New South Wales in which the patient reported inhaling nitrous oxide in a non‐therapeutic setting (from January 2012 to December 2018) Data source: Rapid Emergency Department Data for Surveillance (REDDS), held by NSW Ministry of Health.

Anna Bethmont · Claire E Harper · Betty SH Chan · Andrew H Dawson · Jeremy McAnulty

Med J Aust 2019; 211 (9 Suppl).