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Integrative health is an emerging specialty inside multiple disciplines within the medical community, yet the practice of integrative physical therapy remains undefined. This perspective paper suggests a set of guiding principles to support the role of physical therapy in integrative health. These guiding principles, including therapeutic partnership, whole person health, living systems, movement as an integrative experience, and salutogenesis, are described and explored in-depth as they relate to all aspects of patient care and clinician experience. These guiding principles are articulated within the context of social determinants of health and the interrelated roles that environment, trauma, stress, and lifestyle all play within an integrative physical therapy plan of care. Examples of current integrative physical therapy practices that embody these principles are described. The 5 guiding principles are designed to elicit interprofessional inquiry into how integrative health models can be applied to the art and science of physical therapy practice. The expansion of integrative health into the field of physical therapy has the potential to improve individual and population health, as integrative physical therapy can be used to address prevention, health promotion, primary care, and wellness while acknowledging the complex, dynamic, and interconnected nature of the human condition., Impact: This perspective article presents 5 guiding principles to establish a framework to define and shape the growing application of an integrative health model to physical therapy practice. These integrative physical therapy guiding principles aim to improve the quality of whole-person, patient-centered care., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

This paper describes two fatal cases of planned complex suicide by two male individuals, 86 and 51 years old, involving ingestion of petroleum distillates and hanging. Remarkable internal findings during autopsy of both cases included the intense odor of petroleum distillates that alerted authorities to the suspicion of ingestion. The initial toxicological screening and quantitation of these compounds were performed by gas chromatography with flame-ionization detection, and confirmation was performed using gas chromatography-mass spectrometry in total ion chromatogram mode after liquid-liquid extraction of biological samples following a previously published analytical method. In Case 1, diesel fuel No. 2 concentrations were < 5 mg/L heart blood and 18,160 mg/L gastric content (total amount 6356 mg); therapeutic concentrations of citalopram were also found in blood. In Case 2, xylene (mixture of isomers) concentrations were 0.3 mg/L in heart blood and 0.1 mg/L in gastric content (total amount 0.006 mg); ethanol (1.12 g/L) and therapeutic concentrations of nordiazepam, oxcarbazepine, ibuprofen, and metamizol were also found in blood. The medical examiners in both cases reported the cause of death as hanging, and based upon examination of the scenes and the anatomopathological and toxicological data, the manners of death were determined to be planned complex suicide. We would like to alert toxicologists of the importance of testing for petroleum distillates when there is a suspicion of ingestion of these products due to the odor observed at the scene of death and/or during autopsy. The results of these toxicological investigations can help to determine the manner of death and the medicolegal interpretation.

The purpose of this paper is to report a case of fluoride poisoning along with a discussion of poisoning characteristics, analytical procedures, and a review of previous reports of fatal intoxications with analytical data. A case of suicidal ingestion of 40 mL of a rust removal agent containing hydrofluoric acid and ammonium fluoride by a 33-year-old white male is presented. He had an organic personality disorder with residual schizophrenia and previous suicide attempts with therapeutic drugs and cleaning products. At admission, he presented with a Glasgow coma score of 3, third degree atrioventricular block, and asystole. Resuscitation efforts were performed during which the patient suffered two episodes of ventricular fibrillation followed by asystole. In spite of advanced resuscitation efforts and the administration of calcium chloride, he died 2.5 h after the ingestion. Analytical data in the hospital showed calcium levels of 3.1 mg/dL and metabolic acidosis. Internal findings were erosive gastritis, brain edema, and pulmonary and hepatic congestion. Quantitation of fluoride was performed using an ion-selective electrode for the anion. Disposition of fluoride in the different tissues was as follows: peripheral blood, 19.4 mg/L; urine, 670 mg/L; vitreous humor, 2.5 mg/L; liver, 40.0 mg/kg; kidney, 60.0 mg/kg; lung, 17.5 mg/kg; brain, 2.5 mg/kg; spleen, 30.0 mg/kg; bone, 0.5 mg/ kg; and gastric content, 1120 mg/L (67 mg total). Validation of the analytical method was performed using different spiked tissues, in a range of concentrations from 2.4 to 475 mg/L or mg/kg, and submitting them to dilution (1:25) to avoid the matrix effect and to bring these concentrations to the range of the aqueous calibration curve (0.19-19 mg/L). Limits of detection and quantitation were 0.02 and 0.1 mg/L, respectively. The linearity of the method, for all studies tissues, was excellent, with r(2) values of 0.999. Accuracy and precision were within 10.5% and 5.7%, respectively. Fluoride analyses using the ion selective electrode are simple, sensitive, and rapid. This report provides an extensive tissue distribution study of fluoride after a well documented case of acute poisoning. Based on the autopsy findings, patient history, toxicology results, and previously reported data the forensic pathologists ruled that the cause of death was due to a fluoride poisoning, and the manner of death was listed as suicide.

We would like to alert toxicologists to the importance of testing for gasoline, and for volatile hydrocarbons in general, in deaths involving inhalation of exhaust fumes occurring in closed spaces with running motors or machinery. We present here a case of suicidal inhalation of motorbike exhaust, a mixture of carbon monoxide (CO) and gasoline vapor, by a 38-year-old female. She was found in her closed home garage with a hose extending from the exhaust pipe of a motorbike through a cellophane plastic device into a closed tent in which the victim lay. She left two suicide notes nearby. The carboxyhemoglobin (COHb) was measured using visible spectrophotometry. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography with flame-ionization detector and confirmation was performed using gas chromatography-mass spectrometry. The %COHb determined in blood was 73%. Gasoline concentrations in heart blood and vitreous humor were 22.3 and 1.0 mg/L, respectively. Although fatalities with CO at this rate are common, we would like to highlight the role of gasoline and add new quantitative data of this toxic substance to the scarce literature. Based upon the toxicological data, along with the information provided by the medical examiner, the cause of death was determined to be CO and gasoline poisoning and the manner of death suicide.

This paper presents a simple, rapid, reliable, and validated analytical method suited for forensic examination of diesel fuel No. 2 in biological specimens. The proposed methodology has been applied to the investigation of a forensic case with diesel fuel No. 2 ingestion. Case history and pathological and toxicological findings are described here to illustrate the toxicity of this complex hydrocarbon mixture. The toxicological significance and the possible mechanisms leading to death are also discussed. The toxicological initial screening and quantitation were performed by means of gas chromatography with flame-ionization detection and confirmation was performed using gas chromatography-mass spectrometry in total ion chromatogram mode. n-Tetradecane peak was selected to estimate diesel fuel No. 2 in all biological samples. Diesel fuel No. 2 analytical methodology was validated at five concentration levels from 5 to 400 mg/L. The method provided extraction recoveries between 89.0% and 97.9%. The limit of detection was 1 mg/L and the limit of quantitation was 5 mg/L. The linearity of the blood calibration curves was excellent with r2 values of >0.999. Intraday and interday precisions had a coefficient of variation

This report documents a case of drug-facilitated sexual assault (DFSA) under the influence of solvents. The victim was a 13-year-old female. Upon contact with law enforcement, she was still confused and could hardly explain the facts. She told authorities that she had been kidnapped 4 h previously when two individuals with covered faces put a cloth soaked in a solvent over her mouth. She spent a few hours in a room, during which she lost consciousness. The girl awakened semi-nude in the street with memory loss. No alcohol was present in the subject's body; no odor of alcohol was detected on the subject's breath. No lesions were observed during a gynecological exam. A blood sample was taken with the intent to investigate the use of chloroform or similar anesthetics. Toxicological analysis of the victim's blood revealed the presence of 7.6 mg/L of benzene, 24.8 mg/L of toluene, and 0.6 mg/L of xylene (mixture of isomers). As for other analytical findings, diazepam (0.02 mg/L) was also found. The aromatic solvents involved in this case were detected using gas chromatography with flame-ionization detection (GC-FID) and confirmed using GC-mass spectrometry (MS) in full scan mode after liquid-liquid extraction of the whole blood sample. Quantitation of the aromatic solvents was carried out using GC-FID. Diazepam was detected using GC with nitrogen-phosphorus detection (NPD) and confirmed using GC-MS with full scan mode after solid-phase extraction of the whole blood sample using Bond-Elut Certify columns. Quantitation of diazepam was carried out using GC-NPD. No other drugs, including ethanol, were detected. Recoveries for benzene, toluene, and xylene (mixture of isomers) in whole blood at 5 mg/L were 89.2%, 90.8%, and 93.4%, respectively. Intraday precisions were 5.3%, 5.0%, and 4.9%, respectively, and interday precisions were 12.1%, 11.6%, and 11.5%, respectively. The limits of detection (LOD) and quantitation (LOQ) were 30 and 100 microg/L, respectively. The linearity of the blood calibration curves was excellent with r(2) values of > 0.999 (range 0.1-10 mg/L). Recovery for diazepam in whole blood at 0.5 mg/L was 88.2% with intraday and interday precisions of 2.0% and 10.8%, respectively. The LOD and LOQ were 6 and 20 microg/L, respectively. The linearity of the blood calibration curve was excellent with r(2) values of > 0.999 (range 0.1-2 mg/L). We want to alert other toxicologists about new or unexpected products that should be taken into account when the surreptitious use of substances in DFSA is suspected.

Atracurium is a nondepolarizing skeletal muscle relaxant used to facilitate endotracheal intubation and to induce skeletal muscle relaxation during surgery or mechanical ventilation. The drug undergoes a spontaneous non-enzymatic biotransformation, yielding laudanosine and an acrylate moiety. This report documents the case of a 45-year-old anesthesiologist who was found dead at the hospital where he worked. The victim was known to be depressed and undergoing treatment with venlafaxine. An empty syringe was found near the body. Toxicological analysis revealed the presence of laudanosine in the syringe, 0.6 mg/L of laudanosine in heart blood, 0.3 mg/L in urine, and 0.02 mg/L in vitreous humor. Meanwhile, concentrations of venlafaxine and O-desmethyl-venlafaxine, its active metabolite, were 0.7 and 1.1 mg/L in heart blood, 1.7 and 5.2 mg/L in urine, 0.5 and 0.7 mg/L in vitreous humor, and 400 and 20 mg in gastric content, respectively. All drugs and metabolites involved in the case were detected using gas chromatography with nitrogen-phosphorus detection (GC-NPD) and confirmed using GC-mass spectrometry in full scan mode after solid-phase extraction using Bond-Elut Certify columns. Additional high-performance liquid chromatography coupled to diode-array detection screening also obtained the same results. Quantitation of laudanosine and venlafaxine together with its metabolite was carried out using GC-NPD. No other drugs, including ethanol, were detected. Recoveries for laudanosine and venlafaxine were 89% and 86%, respectively, at 0.5 mg/L; intraday and interday precisions were 2% and 6%, and 3% and 7%, respectively; and limits of detection and quantitation were 6 and 20 ng/mL and 18 and 59 ng/mL, respectively. The linearity of the blood calibration curves was excellent for both drugs with r(2) values of > 0.999 (range 0.1-2.0 mg/L). Based on the autopsy findings, case history, and toxicology results, the forensic pathologists ruled that the cause of death was an overdose of atracurium, and the manner of death was suicide.

This paper presents a simple, rapid, reliable, and validated method suited for forensic examination of gasoline in biological samples. The proposed methodology has been applied to the investigation of four fatal cases due to gasoline poisoning that occurred in Spain in 2003 and 2004. Case histories and pathological and toxicological findings are described in order to illustrate the danger of gasoline exposure under several circumstances. Gasoline's tissular distribution, its quantitative toxicological significance, and the possible mechanisms leading to death are also discussed. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography (GC) with flame-ionization detection, and confirmation was performed using GC-mass spectrometry in total ion chromatogram mode. m,p-Xylene peak was selected to estimate gasoline in all biological samples. Gasoline analytical methodology was validated at five concentration levels from 1 to 100 mg/L. The method provided extraction recoveries between 77.6% and 98.3%. The limit of detection was 0.3 mg/L, and the limit of quantitation was 1.0 mg/L. The linearity of the blood calibration curves was excellent with r2 values of > 0.997. Intraday and interday precisions had a coefficient of variation < or = 5.4% in all cases. Cases 1 and 2 consist of the accidental inhalation of gasoline vapor inside a small enclosed space. Case 3 is a death by recreational gasoline inhalation in a male adolescent. Heart blood concentrations were 28.4, 18.0, and 38.3 mg/L, respectively; liver concentrations were 41.4, 52.9, and 124.2 mg/kg, respectively; and lung concentrations were 5.6, 8.4, and 39.3 mg/kg, respectively. Case 4 was an accidental death due to gasoline ingestion of a woman with senile dementia. Peripheral blood concentration was 122.4 mg/L, the highest in our experience. Because pathological findings were consistent with other reports of gasoline intoxication and constituents of gasoline were found in the body, cause of death was attributed to acute gasoline intoxication. As a rule, this kind of poisoning offers little difficulty in diagnosis because there is a history of exposure, and the odor usually clings to the clothes, skin, or gastric contents. However, anatomic autopsy findings will be nonspecific and therefore toxicological analysis is necessary. There is a paucity of recent references regarding analytical and toxicological data, and this article provides evidence about toxic concentrations and is a useful adjunct to the postmortem toxicological interpretation of fatalities if the decedent has been involved in gasoline use.

Trazodone is an antidepressant agent used in Spain since 1975. There are few documented reports of fatalities solely attributed to trazodone and none in which the main metabolite is analyzed. A fatal case of self-poisoning following oral ingestion is reported along with a description of the validated analytical methods involved, a discussion of poisoning characteristics, and a review of reports describing trazodone overdose cases with analytical results. The deceased was an 86-year-old man with cancer, who suffered depression. He went to see his doctor in a primary health care unit and told him he had just taken an unknown amount of tablets of Deprax to commit suicide. The doctor induced emesis as a first emergency measure. His death occurred before arriving to the hospital, and he left a suicide note nearby. Systematic toxicological analysis of postmortem blood used routinely in our laboratory revealed the presence of trazodone 4.9 mg/L and m-chlorophenyl-piperazine (m-CPP) 0.6 mg/L, its active and major metabolite. In addition, metamizol 19.6 mg/L and 4-methyl-amino-antipyrine (4-MAA) 40.7 mg/L, its active metabolite, were also found in blood. All drugs and metabolites involved in the case were detected using gas chromatography-nitrogen-phosphorus detection (GC-NPD) and confirmed using gas chromatography-mass spectrometry (GC-MS) mode total ion chromatogram. An additional high-performance liquid chromatography-diode array detection (HPLC-DAD) screening also obtained the same results. Quantitation of trazodone together with its metabolite in blood was carried out using GC-NPD, while quantitation of metamizol was performed using HPLC-DAD. Limits of detection for trazodone and m-CPP were 33 and 11 microg/L, respectively, absolute recoveries were more than 86% and 75%, respectively, intra-assay precisions less than 4%, interassay precisions less than 5%, and linearity up to 2.0 mg/L. Limit of detection for metamizol was 1117 microg/L, absolute recovery more than 84%, intra-assay precision less than 8%, interassay precision less than 12%, and linearity up to 48 mg/L. Based on the autopsy findings, patient history, toxicology results, and previously reported trazodone intoxications, the forensic pathologists ruled that the cause of death was due to an overdose of trazodone, and the manner of death was listed as suicide.

A mild case of self-poisoning with a chlorpyrifos formulation following oral ingestion is reported. A 15-year-old female went to the emergency room after the ingestion of a product from a bottle marked with a label "Poison". On admission, she was obtunded, with normal vital signs and a strong smell of solvent. Therapeutic measures included the application of decontamination procedures, oxygen, and gastric protectors. She had a good outcome with mild CNS depression and bradycardia. Two hours after ingestion, biological samples were collected in the emergency room and sent for analysis to our laboratory with instructions to investigate the presence of solvents. The serum and gastric content contained 5.3 and 9.4 microg/mL of unmetabolized chlorpyrifos, 4.6 and 6.9 microg/mL of toluene, and 2.5 and 7.9 microg/mL of butyl acetate, respectively. Small traces of other solvents and tetradifon were also detected. Toxicological analyses were negative for ethanol, other volatile solvents, and common drugs of abuse. The simultaneous determination of chlorpyrifos, toluene, and butyl acetate was performed using the combination of gas chromatography (GC)-flame ionization detection for screening analysis and GC-mass spectrometry for confirmation of the obtained results. The method provides an excellent and rapid tool for use in cases of pesticide poisonings, allowing the simultaneous detection of the pesticide and distillates in the performance of systematic toxicological analysis in forensic and clinical laboratories.

This paper reports a simple and reliable gas chromatographic method with nitrogen-phosphorus detection without derivatization for the simultaneous detection of fluvoxamine, mianserin, doxepin, citalopram, paroxetine, and etoperidone in whole blood as part of a systematic toxicological analysis (STA). All drugs were studied at concentration levels of 100-2000 ng/mL, except paroxetine for which it was necessary to study at concentration levels of 400-8000 ng/mL. A comparative and validation study using two solid-phase extraction (SPE) columns, Chem Elut and Bond Elut Certify, was developed regarding their recovery, precision, sensitivity, and matrix purification efficiency. The Chem Elut columns, diatomaceous earth, are closely related to conventional liquid-liquid extraction. The Bond Elut Certify columns, more recently developed in the market, are mixed SPE (reversed-phase and cation exchange sorbent). Recoveries for the antidepressants using Chem Elut columns at 500 ng/mL (2000 ng/mL for paroxetine) were in the range 43-72% with intra- and interassay precisions of less than 10% and 16%, respectively. Limits of detection (LODs) and quantitation (LOQs) for fluvoxamine, mianserin, doxepin, citalopram, and etoperidone ranged from 18 to 236 ng/mL and 60 to 786 ng/mL, respectively. LOD and LOQ for paroxetine were 303 and 1009 ng/mL, respectively. Recoveries of these compounds using Bond Elut Certify columns at 500 ng/mL (2000 ng/mL for paroxetine) were in the range 52-83% with intra- and interassay precisions of less than 6% and 8%, respectively. LODs and LOQs for fluvoxamine, mianserin, doxepin, citalopram, and etoperidone ranged from 7 to 28 ng/mL and 23 to 93 ng/mL, respectively. LOD and LOQ for paroxetine were 113 and 376 ng/mL, respectively. An excellent linearity was observed with both procedures from the LOQs up to the upper studied concentration level. In general, higher recoveries, cleaner extracts, better sensitivity, better precision, and reduced solvent consumption and disposal were achieved for the screening of these antidepressants with the use of the mixed SPE Bond Elut Certify compared with Chem Elut columns. The application of these methods on a forensic case study is also presented.

This paper reports the simultaneous detection of the seven antidepressants fluoxetine, amitriptyline, nortriptyline, trimipramine, maprotiline, clomipramine, and trazodone in whole blood at concentration levels of 100-2000 ng/mL by gas chromatography with a nitrogen-phosphorus detector (GC-NPD). A comparative and validation study using two solid-phase extraction (SPE) columns, Chem Elut and Bond Elut Certify, were developed regarding their recovery, precision, sensitivity, and matrix purification efficiency. The Chem Elut columns, a diatomaceous earth, are closely related to conventional liquid-liquid extraction. The Bond Elut Certify columns, more recently developed in the market, are a mixed SPE: reversed-phase and cation exchange sorbent. Recoveries of the compounds using Chem Elut columns at 500 ng/mL were in the range 30-50%, with intra- and interassay precisions of less than 9% and 17%, respectively. Limits of detection (LODs) and quantitation (LOQs) ranged from 13 to 146 ng/mL and from 44 to 485 ng/mL, respectively. Recoveries of the compounds using Bond Elut Certify columns at 500 ng/mL were in the range 59-84% with intra- and interassay precisions of less than 8% and 11%, respectively. LODs and LOQs ranged from 8 to 67 ng/mL and from 25 to 223 ng/mL, respectively. An excellent linearity was observed with both extraction procedures from the LOQs up to 2000 ng/mL. Higher recoveries, cleaner extracts, better sensitivity, better precision, and less solvent consumption and disposal were achieved for the screening of these antidepressants with the use of the mixed SPE Bond Elut Certify compared with Chem Elut columns.

A rare fatal case of self-poisoning with nitrobenzene following oral ingestion is reported. On presentation to the hospital, severe methemoglobinemia (70%) was observed in an 82-year-old male who had ingested 250 mL of an unknown substance in the previous 24 h. Methylene blue and exchange transfusion were the therapeutic methods applied in the treatment of the methemoglobinemia. Forty-eight hours after ingestion, a blood sample was collected in ICU and sent to our laboratory. We detected that the blood contained 3.2 microg/mL of nitrobenzene. The determination of nitrobenzene was performed using the combination of GC-FID for screening analysis and quantitation and GC-MS for confirmation of the obtained results.