Subacute combined degeneration (SCD) is myelopathy caused by vitamin B12 deficiency, leading to demyelination of the dorsal column located in the posterior spinal cord. Despite the high prevalence of recreational nitrous oxide use, its detrimental effects, including significant nerve dysfunction, are insufficiently recognized. We present the case of a 32-year-old male who was brought to the emergency department with complaints of paresthesia of his four extremities and lower extremity weakness. He was found to have B12 deficiency from chronic nitrous oxide abuse and responded positively to intramuscular B12 supplementation. It is important to consider possible nitrous oxide abuse while investigating suspected B12 deficiency, especially in patients presenting with nonspecific myeloneuropathy. Elevated methylmalonic acid (MMA) level is specific for diagnosing B12 deficiency. Prompt diagnosis and treatment can lead to the resolution of the symptoms and prevent further nerve damage.

Introduction: Atrial Flutter is an abnormal heart rhythm affecting the heart's upper chamber. It has comparative stroke risk to atrial fibrillation but differs in the arrhythmia's origin. There is Paucity of data comparing the relationship between obesity and atrial flutter. This study aims to bridge that gap. Methods: We analyzed the National Inpatient Sample (NIS) database from 2016 to 2019. The NIS was searched for hospitalized adult patients with atrial flutter as a principal diagnosis with and without obesity as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality. The secondary outcomes were the rate of catheter ablation, cardiogenic shock (CS), cardiac arrest (CA), total hospital charge (THC), and length of stay (LOS). Multivariate logistic and linear regression analyses were used accordingly to adjust for confounders. Results: About 1,891,479 patients were admitted for Atrial Flutter, 21% (398,040) had underlying Obesity. Cohorts with Obesity vs No Obesity had a mean age of 64.4 years [CI 64.3 - 64.5] vs 72.2 years [CI 72.1 - 72.3]; male (52.4% vs 50.4%), female (47.6% vs 49.6%); white (79.8% vs 82.2%), black (11.0% vs 7.8%), and Hispanic (6.2% vs 5.9%). Compared to patients without Obesity, patients admitted with coexisting Obesity had a statistically significant decrease in mortality (0.47% vs 0.95% aOR 0.72, 95% CI 0.64 - 0.81, P 0.001), CA (0.33% vs 0.42%, P=0.003), and CS (0.58% vs 0.61%, P<0.001) compared to those without obesity. The obesity cohorts also had a statistically significant increase in rates of catheter ablation (aOR 1.18, P<0.001), LOS (aIRR 1.05, P<0.001) and THC (aIRR 1.08, P<0.001). Conclusion: Patients admitted primarily for Atrial Flutter with co-existing Obesity had lower inpatient mortality, CA, and CS. There was a statistically significant increase in the rates of catheter ablation, LOS and THC among the obese group. Additional studies are required to elaborate on the management of this patient group.

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