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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.

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.

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.

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.

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.

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

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.

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.

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.

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

A 17 year old, adolescent male was treated at Jawahar Lal Nehru Medical College, Aligarh, for reason of drug ingestion. It was discovered that he took 35 tablets of alprazolam 0.25mg. Past history revealed that he had demonstrated such behaviour on several other occasions (4–5 times). This case merited attention simply for the reason that there is a variance between motive-induced self-harm and pure desire to commit suicide. This case qualifies to be called "Munchausen Syndrome" as the events unfolded in the paper.