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OBJECTIVES To characterize the epidemiology of children and adolescents admitted for deliberate self-harm to PICUs in the United States by examining patient demographics, diagnoses, modes of self-harm, and outcomes. DESIGN Descriptive analysis of a large, multicenter, quality-controlled database. SETTING The 137 PICUs participating in the Virtual Pediatric Systems database during the study period. PATIENTS Children between 6 and 18 years old admitted to a participating PICU from January 1, 2009, to December 31, 2017, with a diagnosis involving deliberate self-harm or a suicide attempt. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 9,197 admissions for self-harm, females accounted for 6,740 (73.3%), whereas males incurred 174 of the 284 deaths (61.3%). Admissions for self-harm doubled over the study period (0.56% in 2009 vs 1.13% in 2017), with an increase observed across every age group. After PICU care, most patients were transferred to a general care floor (51.1%) or to a psychiatric rehabilitation facility (31.8%). Intentional drug ingestion (84%) was the most common mode of self-harm but was associated with less than 1% of the fatalities. Asphyxia/hanging or firearms were a factor in 411 (4.5%) and 106 (1.2%) of the admissions but were associated with 117 (28.5%) and 55 (51.9%) of the deaths, respectively. CONCLUSIONS PICU admissions due to self-harm increased for all age groups during the study period. Females accounted for most of these admissions, whereas males accrued most of the in-hospital deaths. Intentional drug ingestion was the most common mode of self-harm and was rarely fatal, whereas asphyxia and firearms were the mechanisms associated with the highest mortality.

The Food and Drug Administration (FDA) recently approved the first ever ‘digital’ drug, an antipsychotic (aripiprazole) embedded with a sensor (Abilify MyCite) that tracks data about drug ingestion...

To prove drug-related crimes, it is important to estimate the date on which a specific drug was ingested. Previously, we developed a method, "micro-segmental hair analysis," to estimate the day of ingestion of a single-dose drug by segmenting a hair strand into 0.4-mm segments, which correspond to daily hair growth. In this study, the method was improved to estimate the days of continuous drug ingestion. The subjects ingested four hay-fever medicines (fexofenadine, epinastine, cetirizine, and loratadine) continuously (1-18 days) and chlorpheniramine as a single dose at intervals of several weeks as an internal temporal marker (ITM). The hair strands of the subjects were collected and subjected to a micro-segmental analysis. The distribution curves of each hay-fever medicine in a hair strand had broad peaks reflecting the number of days of drug ingestion. The positions on the curves corresponding to the first and final ingestion days of hay-fever medicines were identified using the ITM. The positions were near the hair segments on both ends of full width at half maximum (W2 ) of the broad peak. When the first and final days of continuous ingestion were estimated using W2 , independent of peak shape, the absolute average error from the actual ingestion days was approximately 2 days. Overall, we established a method to estimate the days of both single-dose and continuous drug ingestions. Furthermore, the method would be useful to investigate drug ingestion history in various scenes such as drug-related crimes and therapeutic drug monitoring.

Cerumen was found to be a promising alternative specimen for the detection of drugs. In a pilot study, drugs of abuse were identified at a higher detection rate and a longer detection window in cerumen than in urine. In this study, cerumen from subjects was analyzed after they ingested the designer stimulant 4-fluoroamphetamine (4-FA) in a controlled manner.METHODS: Twelve subjects ingested placebo and 100 mg of 4-FA. Five of them were also given 150 mg of 4-FA in 150 mL Royal Club bitter lemon drink at least after 7 days. Cerumen was sampled using cotton swabs at baseline, 1 h after the ingestion of the drug and at the end of the study day (12 h). After extraction with ethyl acetate followed by solid-phase extraction, the extracts were analyzed using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS).RESULTS AND DISCUSSION: In the cerumen of all 12 subjects, 4-FA was detected 12 h after its ingestion; in most subjects, cerumen was detected after 1 h of ingestion, ranging from 0.06 to 13.90 (median 1.52) ng per swab. The detection of 4-FA in cerumen sampled 7 days or more after the first dose suggested a long detection window of cerumen.CONCLUSIONS: Cerumen can be successfully used to detect a single drug ingestion even immediately after the ingestion when a sufficient amount of cerumen is used.

Self-medication is determined by the use of medications chosen by the patient or by indications received from friends and family. The indiscriminate use of over-the-counter medications is a public health problem that has become routine for many people of various ages, since they have no idea about the risks. The objective was to determine the use of over-the-counter medications and their adversities in students of the Medicine Career of the Maria Serrana Private University in Asuncion. The study was quantitative descriptive transectional. The study included 79 students of both sexes, of whom 69 self-medicated and 10 did not use erroneous drugs. 70% of the respondents are male and 30% female. Both, with an average age of 19 and 40 years. Showing that 19% with 19 years old, 51% between 21 and 25 years old, 21% between 25 and 30 years old, 12% between 30 and 35 years old and 0% of those between 35- and 40-years old use medication without a prescription. 22% amoxicillin, 18% acetaminophen and 15% azithromycin were used in the analysis of the most used drugs, although knowledge of the risks of use without unregulated criteria governed 81% of the participants. In addition, 60 of the participants reported external interference for initiation of drug ingestion, 12 did not ingest drugs without external interference, and 7 did not confirm external interference. The most widely used drugs indicated 22% amoxicillin, 18% acetaminophen and 15% azithromycin, with 81% of the participants knowing about the risks of use without.

Vitamin B12 deficiency and folate deficiency are common causes of macrocytic anaemia and both are important for many cellular processes. These deficiencies could be due to inadequate dietary intake, impaired absorption or drug ingestion. We present a case of a 47-year-old male with a history of diffuse large B-cell lymphoma (DLBCL) who was admitted for fatigue, persistent frontal headache and left upper-quadrant abdominal pain. Further investigation showed that he had pancytopenia with microangiopathic haemolytic anaemia (MAHA) and intracranial bleeding (ICB). Serum vitamin B12 and folate were later found to be low and a diagnosis of combined vitamin B12 and folate deficiency mimicking thrombotic thrombocytopenic purpura (TTP) was made. The patient responded well to vitamin B12 and folate replacement.

Introduction:The aim of this study was to investigate demographic, epidemiologic, and clinical characteristics of cases admitted to pediatric intensive care unit (PICU) for poisoning.Methods:Cases with poisoning admitted to PICU between January 1, 2015 and June 30, 2016 were evaluated retrospectively.Results:Ninety two cases were enrolled in this study. The mean age was 63.65±59.1 months and 73.9% of the cases were under 5 years of age. Fifty five point four percent of the cases were male. Of the poisoning cases, 82.6% were accidental and 14.1% were suicidal. Seventy seven point two percent of the cases were drug related and 18.3% of them were multi-drug poisonings. Central nervous system drugs were the most frequently (24.2%) ingested drugs. The most common cause of non-drug poisonings were pesticide and insecticides (42.8%). The median duration of time from ingestion to admission to the pediatric emergency department was 60 (10-2880) minutes. Of the cases, 31.5% were symptomatic. Gastric lavage and activated charcoal were performed in 65.2% and 72.8% of the cases, respectively. Continuous venovenous hemodiafiltration was performed in 3 cases. The mean time of PICU and hospital stay were 19.53±14.37 and 35.91±29.46 hours, respectively. During the study period, one case died due to acute poisoning of alpha-lipoic acid.Conclusion:Pediatric poisonings are among the most common reasons for referrals to emergency department, admission to hospital and represent a preventable cause of morbidity and mortality. Parental education about prevention of poisoning and keeping drugs and household products out of children’s reach is important because most of the poisonings occur at home with drugs and household products. Recognition of epidemiologic and clinical characteristics of pediatric poisoning by healthcare providers is also important for rapid diagnosis and treatment.

Sleeping aids are often abused in the commission of drug-facilitated crimes. Generally, there is little evidence that a victim ingested a spiked drink unknowingly because the unconscious victim cannot report the situation to the police immediately after the crime occurred. Although conventional segmental hair analysis can estimate the number of months since a targeted drug was ingested, this analysis cannot determine the specific day of ingestion. We recently developed a method of micro-segmental hair analysis using internal temporal markers (ITMs) to estimate the day of drug ingestion. This method was based on volunteer ingestion of ITMs to determine a timescale within individual hair strands, by segmenting a single hair strand at 0.4-mm intervals, corresponding to daily hair growth. This study assessed the ability of this method to estimate the day of ingestion of an over-the-counter sleeping aid, diphenhydramine, which can be easily abused. To model ingestion of a diphenhydramine-spiked drink unknowingly, each subject ingested a dose of diphenhydramine, followed by ingestion of two doses of the ITM, chlorpheniramine, 14days apart. Several hair strands were collected from each subject's scalp several weeks after the second ITM ingestion. Diphenhydramine and ITM were detected at specific regions within individual hair strands. The day of diphenhydramine ingestion was estimated from the distances between the regions and the days of ITM ingestion. The error between estimated and actual ingestion day ranged from -0.1 to 1.9days regardless of subjects and hair collection times. The total time required for micro-segmental analysis of 96 hair segments (hair length: 3.84cm) was approximately 2days and the cost was almost the same as in general drug analysis. This procedure may be applicable to the investigation of crimes facilitated by various drugs.

Heat stroke is a medical emergency which may lead to mortality unless diagnosed early and treated effectively. Heat stroke may manifest rapidly, hence making it difficult to differentiate it from other clinical causes in a collapsed victim.1 We are presenting a case report of twelve patients who were admitted to our emergency department from a music festival held on 13-15th of March 2014. They developed complications arising from a combination of severe adverse weather condition, prolonged outdoor physical exertion due to long hours of dancing and drug-use, resulting in heat stroke. Three of them died while the remaining patients survived. Their condition was initially misdiagnosed as a classical illicit drug overdose. This was based on the history of drug ingestion by some of the patients who attended the music festival on that day. The information in this case report aims, to create awareness amongst members of the medical team on duty in outdoor events, pre hospital responders and ED physicians when treating and managing similar cases in the future. In addition it is intended to warn the organizers of such events to take adequate precautions to avoid such tragedies in the future.

A 54-year old, male dermatologist of African origin developed a pigmented band on his right index finger about 2 months earlier. There had been no history of trauma or drug ingestion. He had had occasional lighter bands on this fingernail and on others, which tended to wax and wane with time. This band was much darker. The patient also had pigmented bands involving several toenails.

Severe hyperthermia from classical or exertional heatstroke, or from drug ingestion or other noninfective pyrogens, is associated with a high mortality and morbidity. A systemic pro‐inflammatory response occurs during heatstroke, characterized by elevated cytokines with endotoxemia from elevated lipopolysaccharide (LPS) levels. Corticosteroids reduce LPS and cytokine levels, suggesting that they may improve outcome. A systematic review searching Embase, MEDLINE, and PubMed from the earliest date available until September 2019 was conducted, according to the PRISMA guidelines, with five papers identified. In four studies, systemic steroids administered before or at the onset of heat stress improved mortality or reduced organ dysfunction. Survival time was greatest when steroid administration preceded heat stress. In one study, a nonsignificant increase in mortality was seen. A dose response was observed, with higher doses extending survival time. Animal studies suggest that steroids improve mortality and/or organ dysfunction after an episode of heat stress or extreme hyperthermia.

Hair testing for drugs has been used extensively in the field of forensics since the 1990s as a means of obtaining firm evidence of drug ingestion. In addition to its longer detection windows, hair is the only specimen that can provide chronological information on individual drug use. Illicit drugs and hypnotics account for the majority of substances involved in crimes; they are usually analyzed to prove an addictive use or an exposure to drugs in drug-facilitated crimes. The mechanism of drug incorporation into hair has been intensively investigated to properly interpret the results of hair analysis. However, the exact mechanism remains under much discussion, despite the growing application of hair tests. Recently, the authors have applied matrix-assisted laser desorption/ionization-mass spectrometry (MALDI-MS) imaging and sectional hair analysis of 1-mm segments using liquid chromatography-tandem mass spectrometry (LC-MS/MS) for single-strand hair, to investigate the incorporation pathways of drugs into hair. Time-course changes in drug distribution along single-strand hair suggest that the incorporation of drugs occurs in two regions of the hair root, the hair bulb and the upper part of hair root, and suggest that incorporation from the hair bulb continues for about 2 weeks. Distribution profiles of different drugs in hair additionally revealed that the main incorporation pathway varies (i.e., via the hair bulb or the upper part of hair root) depending on the properties of the drug/metabolite. These findings should be taken into account upon discussing individual drug-use history based on the results of hair analysis.

The authors investigated the role of poor drug adherence in treatment‐resistant hypertension following observed drug ingestion in 102 patients. Median blood pressures (BPs) were 170/91 mm Hg at referral, 153/84 mm Hg prior to, and 142/79 mm Hg during a 4‐ to 6‐hour period after drug ingestion. Median daytime ambulatory BP monitoring (ABPM) over the following 24 hours was 142/80 mm Hg. Median BP at a final follow‐up clinic visit was 147/79 mm Hg. The cumulative number of patients achieving a goal of

Drug intoxications are common. Drug ingestion mostly occurs orally. In adults, suicidal intoxications dominate, in children accidents. After recording the specific circumstances of the intoxication, primary poison elimination should be performed using absorbents. If the poison has already been absorbed into the organism, secondary poison elimination is conducted. Repeated application of absorbents, forced diuresis, dialysis, and plasmapheresis can be applied, but the effectiveness of these measures is very different for individual drugs. For certain drugs, specific antidotes are available. However, in most cases, therapy of drug intoxications is symptomatic. Because drug intoxications are so common, preventive measures such as avoidance of polypharmacy, adherence to dosing schemes, and recognition of suicidality in depressive patients are of eminent importance.

Pavlovian learning is central to many theories of addiction. In these theories, stimuli paired with drug ingestion become conditioned stimuli (CS) and subsequently elicit drug-seeking and drug-taking. However, in most relevant studies, Pavlovian and instrumental learning are confounded. This confound may be avoided in Pavlovian-Instrumental-Transfer (PIT) procedures. In PIT, Pavlovian and instrumental learning are established separately and then combined. In order to better understand the role of CSs in addiction, we review the relevant studies using PIT.We identified seven articles examining PIT effects of ethanol- or cocaine-paired CSs. Under at least one condition, six of these articles reported CS-elicited increases in responding previously maintained by drug. However, the only study using the optimal control condition failed to find a CS-elicited increase. Two studies examining CS specificity found the CS also increased responding maintained by a different reinforcer. Two studies examined if CSs elicit increases in actual drug-taking. Both failed to find CS-elicited increases, i.e., no study shows CS-elicited increases in actual drug-taking. Further, CS-elicited increases in extinguished responding are short-lived.These findings are not entirely consistent with Pavlovian learning playing a central role in addiction. However, design issues can explain most of these inconsistencies. Studies without these design issues are needed. Additionally, existing theories hypothesize drug-paired CSs increase drug-taking by increasing motivation, by eliciting conditioned responses that make drug-seeking more probable, or by a combination of these. Work distinguishing between these mechanisms would also be useful.

We have performed a descriptive, retrospective and longitudinal study to determine both the characteristics of the individualsinvolved in a violent death as well as the circumstances surrounding the event that took place in the province of Lugo(Spain) during the time period between 2007 and 2009. Data was achieved from archives that belong to the Institute ofLegal Medicine of Galicia’s territorial branch in Lugo. Alcohol is a psychoactive substance that is very commonly used worldwide. It is the most frequently used psychoactivesubstance in our country. It has been integrated in the Western World’s cultural model of drug ingestion, coming to be considered a “partner in crime”. The association between crime and alcohol had been established many years ago. Alcoholis known to increase the possibility or to be the direct cause of criminal conduct. In this study, we found that it is also involved in situations in which people die in an unnatural manner. A total of eighty-four cases of death associated withalcohol, representing 17.75% of all violent deaths, were reported in our study. The most commonly found profile consistsin middle-aged males that suffer an accidental death during the weekend.

Objective. Intentional or unintentional substance intoxications are common in patients presenting to the Emergency Department (ED). When we treat intoxi-cated patients, it is important to know the amount of drug ingestion. We invested the actual amount of semi-quantitative term expressed by patients, and investigated the accuracy of amount estimates by the public and healthcare professionals. Participants and interventions. 200 vol-unteers (86 health care providers and 114 non-practitioners) participated. Partici-pants grabbed the 3 types of tablets (5mm, 10mm, and 15mm) in handfuls and fistfuls and estimated the tablet amounts. Actual amounts were measured. 100 volunteers (58 health care providers and 41 non-prac-titioners) participated in the investigation of accuracy of liquid amount estimation. Participant ingested water in 2.6 cm diam-eter bottle in response to request to take 1 sip, 1 mouthful, and 3 sips.Results. The estimated tablet counts be-came more accurate in terms of both fist-fuls and handfuls as the size increased within the same shape classification. Par-ticipants tended to underestimate the counts of oval-shaped tablets to a greater extent than round tablets of the same size. The estimated liquids both groups of participants tended to underestimate the amounts but both groups overestimated the volumes when drinking 3 continuous sips. In tablets and liquids, there were no statistically significant differences in accu-racy between the groups.Conclusions. When approaching intoxi-cated patients who have visited emergency department (ED), treatment should be im-plemented based on the assumption that the actual ingested amounts are higher than the amounts estimated by patients.

Background: Mass drug administration (MDA) means once-in-a-year administration of diethyl carbamazine (DEC) tablet to all people (excluding children under 2 years, pregnant women and severely ill persons) in identified endemic areas. It aims at cessation of transmission of lymphatic filariasis. Objective: To study the coverage and compliance of MDA in Tikamgarh district during the campaign in April 2010. Materials and Methods: The activities under MDA involved administration of DEC tablets to eligible population from endemic area by health staff and Integrated Child Development Scheme (ICDS) functionaries referred as drug distributors (DD) make house-to-house visits on select dates in 2010. DEC was administered to all people (excluding children under 2 years, pregnant women and severely ill persons) with the instruction to ingest the tablet preferably on the spot. Study Design: Cross-sectional population based house-to-house visit. Setting: Urban and rural areas in Tikamgarh district identified as endemic for filariasis where MDA 2010 was undertaken. Study Variables: Exploratory - Rural and urban clusters of Tikamgarh district; Outcome - coverage, compliance, actual coverage, side effects. Analysis: Percentage and proportions. Results: Four clusters, each comprising 30 households from Tikamgarh endemic district, yielded an eligible population of 641. The coverage rate was 607 (94.6% of eligible) with variation across different areas. The compliance with drug ingestion was 89.9% with a gap of 10.1% to be targeted by intensive IEC. The effective coverage (85.2%) was just above the target (85%). Side effects of DEC were minimum, transient and drug-specific. Overall coverage was marginally better in rural areas. The causes of poor coverage and compliance have been discussed and relevant suggestions have been made.

The adherence to medication in drug-resistant focal epilepsy (RFE) remains largely unknown. The present work aimed to assess the frequency of recent adherence to antiepileptic drugs (AEDs) in patients with RFE. This prospective observational study screened all patients with RFE, admitted to the Nancy University Hospital between April 2006 and September 2008, for a 5-day hospitalization without AED tapering. The adherence to AEDs was assessed by measuring serum drug levels on day 1 (reflecting the recent "at home" adherence) and day 5 (reflecting the individual reference concentration when drug ingestion was supervised). A patient was considered nonadherent if at least one of their serum drug levels was different between days 1 and 5. The day-1 value was considered different from day 5 when it was at least 30% lower (underdosed) or 30% higher (overdosed). Nonadherent patients were classified as under-consumers in the case of one or more underdosed day-1 values, over-consumers in the case of one or more overdosed day-1 values, or undefined if they exhibited both underdosed and overdosed day-1 values. Forty-four of the 48 screened patients were included. Eighteen (40.9%) of 44 patients were nonadherent. Among them, 12 (66.7%) were over-consumers, 4 (22.2%) were under-consumers, and 2 (11.1%) were undefined nonadherents. The study indicates that recent adherence to antiepileptic medication in this group of patients with RFE is poor. Overconsumption is the most frequent form of nonadherence in this population and should be specifically assessed to prevent its possible consequences in terms of AEDs dose-dependent adverse events.

This retrospective study assesses the value of routine screening for paracetamol in all adults with known or suspected drug overdose. The cases of 421 patients who presented with known or suspected drug overdose between 1 January 1994 and 31 October 1995 were reviewed. There were 119 patients with suspected paracetamol ingestion of whom 85 had elevated paracetamol levels and 17 required treatment with N-acetylcysteine. There were 293 patients in whom paracetamol ingestion was not initially suspected and of these six had elevated paracetamol levels but none were potentially hepatotoxic. No history was available in nine patients, one of whom had an elevated level which was in the potentially hepatotoxic range. The incidence of potentially hepatotoxic paracetamol ingestions which are missed by clinical assessment is very low. Therefore all adults suspected from their history of a toxic paracetamol ingestion and those in whom a history cannot be obtained, but drug ingestion is suspected should have rapid screening for paracetamol performed. Other patients may safely have the necessity for a serum paracetamol level determined by a thorough and directed history.

As transplantation has progressively become a more viable option for children with life-threatening illness, ensuring that adolescents do not lose their new organ secondary to medication non-adherence is paramount. The first step to addressing non-adherence is adequate assessment of this construct. In this investigation, we introduce the MACS. The MACS includes self-report and drug assay levels. Self-report is a subjective measure with a low false-positive rate, but is vulnerable to social desirability. Drug assays are an objective measure of drug ingestion, but values suggestive of non-adherence may be influenced by medical complications and timing. The MACS builds on the strengths of both methods and attempts to contain their weaknesses. The sample in this study consisted of 82 adolescent solid organ transplant recipients. The non-adherence rate using the MACS in this sample was 61%. Initial data to support this system are promising. The occurrence of rejection episodes and mortality were significantly related to membership in the Genuinely Non-adherent category. Beyond providing initial support for the MACS, we discuss the clinical implications of this adherence classification system.

Background: Chlorpheniramine is effective against motion sickness, but produces sedation. To reduce chlorpheniramine's sedating effect and increase its effectiveness, ephedrine was combined with chlorpheniramine to prevent motion sickness. Methods: Chlorpheniramine (C) and chlorpheniramine plus ephedrine (Chlorphedra) were studied in a randomized, double blind, crossover trial. Eighteen normal subjects were randomized to six different orderings of placebo, C (12 mg) or Chlorphedra (12 mg C + 50 mg ephedrine). They ingested the medication 3.25 hours before off vertical axis rotation in a rotating chair. Cognitive testing with both objective and subjective tests was performed before drug ingestion, at peak drug effect and following rotation. Results: Both C and Chlorphedra significantly increased chair time compared to placebo [6.6 to 10.3 minutes (C), 10.2 minutes (Chlorphedra), p < 0.01]. Subjects reported significantly more sleepiness on the Karolinska sleepiness scale after taking C (3.3 placebo, 4.9 C (p < 0.005)) but not with Chlorphedra (3.3 placebo, 3.1 Chlorphedra). Chlorphedra resulted in significantly higher reported alertness, clearheadedness and attentiveness compared to C. Deficits seen on objective tests with C were corrected with Chlorphedra. Subjects noted more side effects with Chlorphedra. Conclusion: Ephedrine does not increase the effectiveness of chlorpheniramine against motion sickness, but counteracts sedative and performance effects successfully.

A study of the characteristics before conception of 145 mothers and 135 fathers of Down's children compared to control parents has shown that the Down's mothers, even when controlled for age, had significantly more illnesses before conception, particularly psychological illness, and significantly more drug ingestion in the year before conception. There were no other differences in the mothers and the fathers did not demonstrate a similar tendency. Since morbidity and drug ingestion are both associated with increasing age, it is suggested that further investigation of the role of environmental factors such as illness or drug ingestion may elucidate further the aetiology of Down's syndrome.

Background: Mass drug administration (MDA) means once-in-a-year administration of diethyl carbamazine (DEC) tablet to all people (excluding children under 2 years, pregnant women and severely ill persons) in identified endemic areas. It aims at cessation of transmission of lymphatic filariasis. Objective: What has been the coverage and compliance of MDA in Gujarat during the campaign in December 2006? Study Design: Cross-sectional population based house-to-house visit. Setting: Urban and rural areas in Gujarat identified as endemic for filariasis where MDA 2006 was undertaken. Study Variables: Exploratory - Rural and urban districts; Outcome - coverage, compliance, actual coverage, side effects. Analysis: Percentage and proportions. Results: Twenty-six clusters, each comprising 32 households from six endemic districts, yielded an eligible population of 4164. The coverage rate was 85.2% with variation across different areas. The compliance with drug ingestion was 89% with a gap of 11% to be targeted by intensive IEC. The effective coverage (75.8%) was much below the target (85%). Side effects of DEC were minimum, transient and drug-specific. Overall coverage was marginally better in rural areas. The causes of poor coverage and compliance have been discussed and relevant suggestions have been made.

This section provides data for several human biological fluids including blood, plasma or serum, cerebrospinal (CS) fluid, lymph, synovial fluid, and tear fluid. The material presented here was gleaned from a variety of sources, with emphasis placed on the most recently published work, and includes physicochemical properties (Table C1.1), cellular compositions (Table C1.2), concentrations of inorganics (Table C1.3), organics (Table C1.4), and major proteins (Table C1.5). In addition, various properties of the major proteins are presented in Table C1.7, while Tables C1.8 and C1.9 contain information regarding the components of the coagulation and complement cascades, respectively. Because of the variability in values for many properties of biological fluids, in many cases a normal singular range of such values is listed. In all cases, the data are those compiled for normal human adults and, where possible, differences with respect to gender are included. It must be stressed that fluid properties can readily change as a result of disease, aging, or drug ingestion.

This case study documents the nearly complete consumption of adult human remains by two domestic dogs (Canis familiaris) inside a residence. While scavenging behavior has been observed for coyotes, wolves, hyenas and other canines in natural outdoor environments, little information is available concerning canine scavenging of human remains in an indoor setting. In this case, the dogs were confined with the body inside a residence for approximately 1 month. The impact of intrinsic and extrinsic factors on canine scavenging behavior and the postmortem interval are examined, such as clothing on the body, perimortem trauma, drug ingestion and the availability of alternative food sources. While cases of canine scavenging of their owners are scant in the literature, this phenomenon is probably not uncommon, particularly among the elderly and indigent who live alone with pets and are socially isolated.

In this paper, we describe an ingestible sensor system to evaluate medication adherence in elderly people. After drug ingestion, an ingestible sensor, attached on the pill, is activated upon contact with gastric fluid and communicates with a wearable monitor that records ingestion data. The monitor records biometric data (e.g. heart rate, blood pressure) and communicates with a secured server, via cellular phone, for storage and further process. Summary reports can be generated back to the phone or potentially to anyone involved with the aged person caring. Clinical research trials proved the effectiveness of the Ingestible Sensor System in evaluating medication adherence.

Drug eruption is a major problem of adverse drug reactions and may present as variform clinical manifestations. Toxic epidermal necrolysis (TEN) and acute generalized exanthematous pustulosis (AGEP) are relatively rare severe drug eruptions. It has rarely been reported that AGEP overlaps or mimics TEN, while no purulent bullous epidermal necrolysis has been reported. The present study reports a rare case of an adult female patient with the clinical manifestations of purulent bulla and epidermal necrolysis caused by drug ingestion. The case is discussed to reveal whether a new clinical pattern of drug eruption has been identified.

Syncope is a common condition that may lead to serious injuries including burns and head injury. To date, here has been no specific discussion of syncope and burns in the literature. A retrospective case-note review of consecutive patients admitted to a Tertiary Burns Centre over a 3.5-year-period was conducted. Five hundred and fifty nine patients were admitted during the study period. Six of these had burns related to alterations of consciousness that excluded alcohol/drug ingestion and epilepsy. The mean percentage body surface area burnt was 9.7%, the mean length of hospital stay was 28.5 days and the mean length of stay per percentage surface area burnt was 4.0 days per percent body surface burnt. The mean size of the injury in syncopal patients is slightly larger than the general burns patients (8.4%) but the length of stay is doubled. This is partly related to surgery being delayed due to investigation of the syncope episode. Focused investigations should reduce both the overall length of hospital stay and the number of investigations.

Background: Motion sickness remains a significant problem for travelers and for those involved in naval, aviation and space operations. Many motion sickness remedies are also sedating, making them undesirable in many settings. Methods: We studied chlorpheniramine as a potential motion sickness treatment. A placebo-controlled, double-blind, dose-ranging trial was performed to establish the most effective dose and the drug's effects on cognition. Eighteen normal, motion sickness susceptible subjects received placebo, low dose (4 mg) or high dose (12 mg) chlorpheniramine 3.5 hours before off-axis vertical rotation. Cognitive testing included a battery of objective and subjective tests performed before drug ingestion, at peak drug effect and following rotation. Results: Chlorpheniramine significantly increased the time in the chair compared to placebo at high dose (7.2 minutes to 11.7 minutes) and low dose (7.2 minutes to 10.2 minutes). Chlorpheniramine did not affect performance on objective cognitive tests. Subjects reported significantly more sleepiness and less alertness with high-dose chlorpheniramine, although they could not reliably determine when they had received active drug. Conclusion: Chlorpheniramine is effective and could be considered for use against motion sickness. Chlorpheniramine also has the potential to be administered transdermally.

Oral rapid disintegrating tablets are taken in an epochal dosage form which makes drug ingestion less trou-blesome for patients. It has indeed contributed a great deal to an improvement in the quality of health care. On the other hand, however, rapid disintegrating tablets are more vulnerable to physical impact than uncoated tablets so that one-dose packages of oral rapid disintegrating tablets may present problems when being dispensed by a fully automatic tablet packing machine. The present study was conducted to evaluate the suitability to automatic mechanical dispensing of Enalapril M Tablet 5mg EMEC® and Brotizolam M Tablet 0.25mg EMEC® (rapid disintegrating tablets produced from Elmed Eisai Co., Ltd., that have been developed in dosageforms amenable to automatic mechanical dispensing) by 18 pharmacists.The rejection rate was a meager 0.3% for both Enalapril and Brotizolam tablets. Errors occurred with a higher frequency when the rotor cassette was loaded in a mid-position than at another position. The results of experimental dispensing suggested that the greater the degree of the hardness or the heavier the weight of the tablets, the less damage that was done to them and thus the higher the rate of acceptance. When Enalapril® was administered with different tablets together, the relative rate of acceptance was Zyloric® > Amlodin® > Mevalotin®. When Brotizolam was administered with Depas®, a high rate of acceptance was shown, but when it was dispensed with Etizolam, it showed a low rate of acceptance, and its packages also contained many damaged tablets.

This study aimed to explore what distinguished injecting from other methods of drug ingestion. A qualitative method using semi-structured interviews and interpretive phenomenological analysis identified the primary themes and hence the cognitions behind the behaviour of long-term injecting drug users. Seven in-depth interviews were conducted and analysed with the intention of approaching this subject from the participant's viewpoint rather than that of either the academic researcher or the drugs worker. The master themes identified were pleasure, economy, a perceived absence of alternatives, pain, self-harm, ritual and self-image. Little evidence was found to support the notion of 'needle fixation'. No evidence was discovered to support the idea that injecting has a sexual component; other than sexual language may be used to describe the effect of injecting drugs to outsiders who have no other common experience. Suggestions are made as to how emergent themes may be incorporated into current interventions ...

Background and Objective: Verrucous carcinoma is a rare clinicopathologic entity caused by multifactorial influences. We report here a 64-year-old male patient presenting with a large exophytic mass in the right leg. Results and Conclusion: The patient had a 19-year duration of psoriasis and received various treatments. In his last year of life, he had been taking an illegally produced folk drug with the hope of controlling his psoriasis. However, 6 months after the drug ingestion, many papules appeared on his right leg, which eventually developed into a large tumor in the next few months. The patient died of acute pulmonary embolism only a week after hospitalization, when his tumor was pathologically confirmed as verrucous carcinoma. Later, the folk drug was analyzed and found to contain arsenic. The causative relevance of the tumor with his daily arsenic intake is discussed. Contexte et objectif: Le carcinome verruqueux est une entité clinicopathologique rare, causée par divers facteurs. Nous exposons ici le cas d'un homme de 64 ans, qui a consulté pour une grosse masse exophytique sur la jambe droite. Résultats et conclusions: Le patient souffrait de psoriasis depuis 19 ans et a été soumis à divers traitements. Au cours de sa dernière année de vie, il a pris un remède empirique traditionnel, illégal, dans l'espoir de soulager le psoriasis. Cependant, 6 mois après la consommation du remède, de nombreuses papules sont apparues sur la jambe droite, et ont fini par former une grosse tumeur au cours des mois suivants. Le patient est mort d'une embolie pulmonaire aiguë, une semaine seulement après son hospitalisation, lorsque l'examen histopathologique de la tumeur a révélé qu'il s'agissait d'un carcinome verruqueux. Le remède a été analysé plus tard, et il s'est avéré que celui-ci contenait de l'arsenic. Le lien de cause à effet entre la tumeur et la consommation quotidienne d'arsenic fera l'objet de discussion.

The most important cause of hypoglycaemia in the presence of high insulin and C-peptide concentrations is insulinoma. However, a similar picture arises from use of sulphonylureas, which is sometimes covert. All specimens received in two years by a supraregional assay service laboratory from adults with low glucose and inappropriately high insulin and C-peptide concentrations were tested for sulphonylureas by a radioimmunoassay that employed antibodies to glibenclamide. In sulphonylurea-positive cases a questionnaire was sent to the consultant responsible for the patient, to elicit further information. Samples from 93 adult patients met the criteria, and 34 (37%) of these gave a positive result on screening for sulphonylureas. The consultants provided further information on 31 of the 34, and in 20 the presence of a sulphonylurea was unexpected. In 10 the features were such as to raise the possibility of factitious drug ingestion. A simple screening technique applied to specimens from patients with hyperinsulinaemic hypoglycaemia indicated that, in a substantial proportion of cases, the patient was taking a sulphonylurea.

Introduction Whilst pre-eclampsia (PE) is highly prevalent amongst women with chronic hypertension, early identification of women at the highest risk is currently not possible. In this study we sought to explore the added value of ambulatory blood pressure monitoring (ABPM) for the prediction of pre-eclampsia. Methods We performed a prospective exploratory study. Women were recruited (⩽20 weeks) from the Manchester Antenatal Vascular Services (MAViS) research clinic and fitted with a Spacelabs monitor. Blood pressure (BP) readings were not revealed to the woman during the monitoring period. The BP was recorded every 30 min during the day (08:00–22:00 h) and hourly at night (22:00–08:00 h). Drug ingestion time, sleep and wake periods were self-reported [JM1]. Parameters calculated from the exported readings included: average daytime and night-time BP, maximum daytime and nighttime BP. Multivariable logistic regression was performed using AUC and likelihood ratio testing to compare model fit. Results 79 women underwent 24-h ABPM of whom 19 (25%) women developed PE. Age ( p = 0.11), BMI and clinic visit BP (136.3 ± 12.8 vs 133.0 ± 16.7 and 86.8 ± 8.7 vs 88.3 ± 12.0) were not different between the groups; PE was more common in women of non-white ethnicity ( p Conclusion Despite equivalent clinic BPs, ABPM parameters demonstrated modest prediction for PE, particularly measurements obtained overnight. On going work is continuing to explore the association between BP variability and PE to fully assess the added value of ABPM in high-risk pregnancies.

A young male adult was presented with persistent penile erection since last 3-4 days.There was no history of predisposing conditions like sickle cell disease, malignancy, drug ingestion, trauma etc. On Examination penis was erect, rigid and tender on palpation

One-dose package dispensations of tablets and capsules were performed in all outpatients in order to improve the medication compliance and prevent any incorrect drug ingestion and the effect of this method was evaluated based on a questionnaire survey for outpatients. As a result, it became clear that the age of the patient, the interval of taking medicine, the kind of drugs in the one-dose packages, the number of prescriptions and the dosage days were judgment factors in the evaluation process. In other words, the outpatients who gave “good” answers were aged, had been taking the medicine for a long time, and had received many kinds of drugs in a one-dose package. On the other hand, the outpatients who gave “not good” answers had more types of medicine prescribed, and had been taking the medicine for longer periods of time. After being the one-dose package method the number of dispensing errors decreased from 6.0 cases to 3.5 cases per day on the average.

The recent American Academy of Clinical Toxicology/European Association of Poisons Centres and Clinical Toxicologists position statement on activated charcoal stated "there are insufficient data to support or exclude its use after 1 hour of ingestion.'' The purpose of this study was to determine the effectiveness of activated charcoal administered 1, 2, and 3 hours after drug ingestion.This was a human volunteer, randomized crossover study. Ten volunteers ingested 4 g of acetaminophen on four occasions at least 1 week apart. One ingestion served as a control and the other three as experimental ingestions with charcoal being administered at 1, 2, and 3 hours after acetaminophen dosing. Eight blood specimens were obtained over the initial 8 hours for serum acetaminophen concentrations that were used for calculation of routine pharmacokinetic parameters. Repeated measures of ANOVA and Tukey's HSD test were used for statistical analysis.Pharmacokinetic parameters for acetaminophen in our volunteers were consistent with literature values. The mean area under the curve (AUC+/-SD) for the control and the 1-, 2-, and 3-hour groups were 221 +/- 54, 154 +/- 71, 206 +/- 67 and 204 +/- 58 mg/L/h, respectively. The 1-hour group was the only one differing from control (p0.01). The decrease of bioavailability at 1 hour was 30.3%, which is similar to previous studies.Our data do not support the administration of activated charcoal as a gastrointestinal decontamination strategy beyond 1 hour after drug overdose.

We report two cases of systemic photosensitivity induced by simvastatin and pravastatin that presented as photodistributed erythema multiforme. One of them occurred in a 75-year-old woman who had been suffering recurrent eruptions following sun exposures over a period of 12 years. The other patient was a 54-year-old man who had a 1-week history of pruritic lesions on the face and the hands. They had no history of herpes simplex virus infection. In both cases, the close temporal relationship between drug ingestion and onset of the conditions suggested statin-induced photosensitivity. The diagnosis was confirmed by the marked reduction of UVB-MED or both UVA and UVB-MED while taking the drug and its normalization after discontinuing the statin intake.

We report on a 35-year-old woman with cutaneous lesions characterized by an erythema multiforme-like appearance localized in the photo-distributed pattern. She had no history of systemic drug ingestion, herpes simplex virus or any other infection, possible causes of erythema multiforme, before the sun exposure. She had normal tolerance to a phototest, but photoprovocation tests could not be performed because she did not agree to them. This case was diagnosed to be an erythema multiforme-like variant of a polymorphous light eruption; the differential diagnosis of target-like lesions in a photo-distributed pattern is discussed.

Anileridine is a synthetic narcotic available in Canada by prescription as Leritine® (Frosst). An earlier review of 20 cases found that although blood concentrations greater than 1.5 mg/L and liver concentrations greater than 5 mg/kg were consistent with fatality, virtually all the cases surveyed involved multiple drug ingestion. Since that review, however, we have received four fatalities involving anileridine as the sole drug, one of which also contained ethanol. Three case histories are presented with blood concentrations ranging from 1.4 to 2.1 mg/L and liver 4.7 to 27 mg/kg, where anileridine is the cause of death. A fourth case, involving a natural death, is included as a comparison.

Background The diagnosis of fixed ‘drug’ eruption is not difficult for dermatologists, but it is difficult to identify the causative agent when the patient denies ingestion of any drugs. There have been some reported cases of fixed ‘food’ eruption. Case Summary A 71-year-old woman experienced repeated erythema and tense bulla with a burning sensation and pruritus on the right ankle. The eruption remitted leaving pigmentation. The patient denied previous ingestion of any drug. We suspected cashew nut as the causative agent. Oral challenge and patch tests with cashew nut were positive. Discussion A fixed eruption without any antecedent drug ingestion should alert us to think of food as a causative agent.

A case of accidental ingestion of cannabis by a toddler is reported. Details of her presentation, investigations performed management and her recovery are outlined. Included is a discussion of alternative differential diagnoses and a summary of similar cases reported previously in journals. The management of the toddler and her family is also addressed. The case illustrates the need to consider drug ingestion in a toddler or child with reduced conscious levels and with or without abnormal neurological findings.

Analysis of drugs in hair is often used as a routine method to obtain detailed information about drug ingestion. However, few studies have been conducted on deposition of synthetic cannabinoids and metabolites in hair. The first purpose of this study was to establish and validate an analytical method for detection of JWH-018, JWH-073, and their metabolites in hair, by use of UHPLC–MS–MS, for forensic application. The second purpose was to investigate the distribution of synthetic cannabinoids metabolites in hair and the effect of hair pigmentation, by use of an animal model. For this, JWH-073 was chosen as a representative synthetic cannabinoid. Finally, the developed method was applied to hair samples from 18 individuals suspected of synthetic cannabinoids use. JWH-018, JWH-073, and their metabolites were extracted from hair with methanol. The extract was then filtered and analyzed by UHPLC–MS–MS with an electrospray ion source in positive-ionization mode. Validation proved the method was selective, sensitive, accurate, and precise, with acceptable linearity within the calibration ranges. No significant variations were observed when different sources of both human and rat hair were used. The animal study demonstrated that JWH-073 N-COOH M was the major metabolite of JWH-073 in rat hair, and hair pigmentation did not have a significant effect on incorporation of JWH-073 and its metabolites into hair. In the analysis of 18 authentic hair samples, only JWH-018, JWH-018 N-5-OH M, and JWH-073 were detected, with wide variation in concentrations.

For many people the concept of addiction involves taking drugs. Therefore it is perhaps unsurprising that most official definitions concentrate on drug ingestion. Despite such definitions, there is now a growing movement which views a number of behaviours as potentially addictive, including many behaviours which do not involve the ingestion of a drug. But do behavioural addictions really exist? Answers this question by examining the various commonalities (psychological, sociological and cultural) between excessive behaviours (behavioural and chemical) and by drawing on the author’s own work into fruit‐machine addiction. Concludes that addictions are not just restricted to drug‐ingestion behaviours and that evidence is growing that excessive behaviours of all types do seem to have many commonalities.

Summary points Before a primary headache such as migraine is diagnosed, secondary headaches should be considered and eliminated on clinical grounds or by appropriate investigations Migraine is primarily diagnosed by eliciting a history of episodic headache with characteristic associated features. The use of diagnostic headache diaries and simple calendars is strongly encouraged Optimum treatment of migraine requires explaining the problem to the patient and identifying and avoiding precipitating factors Treatment may be non-pharmacological or pharmacological. Drugs may be for treating acute attacks, which is required by nearly all patients, or prophylaxis, which is used by patients with frequent severe attacks Treatment for an acute attack should result in mild or no headache by two hours after drug ingestion, while prophylactic treatment should result in a 50% reduction in the frequency of attacks Characterisation of the 5-hydroxytryptamine receptor of the 5-HT1 class has provided better treatments for acute attack and impetus for studying mechanism of migraine