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The aim of this study was to evaluate the objective and subjective image quality of a novel computed tomography (CT) protocol with reduced radiation dose for body packing with 80 kVp and automated tube current modulation (ATCM) compared to a standard body packing CT protocol. 80 individuals who were examined between March 2012 and July 2015 in suspicion of ingested drug packets were retrospectively included in this study. Thirty-one CT examinations were performed using ATCM and a fixed tube voltage of 80 kVp (group A). Forty-nine CT examinations were performed using a standard protocol with a tube voltage of 120 kVp and a fixed tube current time product of 40 mAs (group B). Subjective and objective image quality and visibility of drug packets were assessed. Radiation exposure of both protocols was compared. Contrast-to-noise ratio (group A: 0.56 ± 0.36; group B: 1.13 ± 0.91) and Signal-to-noise ratio (group A: 3.69 ± 0.98; group B: 7.08 ± 2.67) were significantly lower for group A compared to group B ( p < 0.001). Subjectively, image quality was decreased for group A compared to group B (2.5 ± 0.8 vs. 1.2 ± 0.4; p < 0.001). Attenuation of body packets was higher with the new protocol (group A: 362.2 ± 70.3 Hounsfield Units (HU); group B: 210.6 ± 60.2 HU; p = 0.005). Volumetric Computed Tomography Dose Index (CTDIvol) and Dose Length Product (DLP) were significantly lower in group A (CTDIvol 2.2 ± 0.9 mGy, DLP 105.7 ± 52.3 mGycm) as compared to group B (CTDIvol 2.7 ± 0.1 mGy, DLP 126.0 ± 9.7 mGycm, p = 0.002 and p = 0.01). The novel 80 kVp CT protocol with ATCM leads to a significant dose reduction compared to a standard CT body packing protocol. The novel protocol led to a diagnostic image quality and cocaine body packets were reliably detected due to the high attenuation. [ABSTRACT FROM AUTHOR]

Body packing is the term used for the intracorporeal concealment of illicit drugs, mainly cocaine, heroin, methamphetamine, and cannabinoids. These drugs are produced in the form of packages and are swallowed or placed in various anatomical cavities and body orifices. Basing on these two ways of transportation a distinction between body stuffers and body pushers can be made, with the former described as drug users or street dealers who usually carry small amounts of drugs and the latter as professional drug couriers who carry greater amounts of drugs. A review of the literature regarding body packing is presented, with the aim to highlight the toxicological and radiological features related to this illegal practice. Raising awareness about the encountered mean body levels of the drugs and the typical imaging signs of the incorporated packages could be useful for clinicians and forensic pathologists to (a) identify possible unrecognized cases of body packing and (b) prevent the serious health consequences and deaths frequently occurring after the packages' leakage or rupture or the packages' mass obstructing the gastrointestinal lumen. [ABSTRACT FROM AUTHOR]

Purpose: This study investigated the sonographic properties of drug packets containing narcotic drugs and the diagnostic role of ultrasonography in detecting body packing in comparison with CT.Methods: Forty-five suspects admitted to our hospital for diagnosis and management were routinely evaluated by non-contrast CT for the presence of drug packets. A single radiologist blind to CT data independently performed the abdominal ultrasonographic scans.Results: Thirty-five of 45 suspects were carrying packets. In positive cases, two types of packets with different properties were noted. Twenty-eight cases had type 1 packets (solid form drug) and 7 had type 2 packets (liquid form cocaine). The sensitivity, specificity, positive, and negative predictive values of ultrasonography for detecting drug packets were 91%, 70%, 91%, and 70%, respectively. Ultrasonography accurately determined the presence or absence of packs in 39 of 45 suspects.Conclusion: Ultrasonography was found to have a high sensitivity but a low specificity in suspected cases. A negative ultrasonography cannot rule out the diagnosis of body packing. However, it may be preferred as the initial imaging method or for follow-up of suspected cases as a radiation-free, easy-to-use, and inexpensive technique. [ABSTRACT FROM AUTHOR]

Body packing is the ingestion or insertion in the human body of packed illicit substances. Over the last 20 years, drug smuggling has increased global and new means of transport of narcotics have emerged. Among these, the most frequent one is the gastrointestinal tract: from mouth to anus, vagina, and ears. Cocaine is one of the most traded drugs, followed by heroin. Condoms, latex gloves, and balloons are typically used as drug packets for retention in the body. There are different radiologic modalities to detect illicit drugs in body packing: Plain radiography, computed tomography (CT), ultrasound, and magnetic resonance. Current protocols recommend the use of radiography to confirm packet retention and, in case of doubt, the use of abdominal CT scan with reduced mAs. In case of packet rupture, catastrophic effects can occur. Management of patients carrying packets of drugs is a recurrent medico-legal problem. To improve diagnostic accuracy and prevent hazardous complications, radiologists and emergency physicians should be familiar with radiologic features of body packing. The radiologist plays both a social and a medico-legal role in their assessment, and it should not be limited only to the identification of the packages but must also provide accurate information about their number and their exact location. In this review, we focus on diagnostic errors and medico-legal issues related to the radiological assessment of body packers. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate the impact of a reduced tube potential (100 kVp) for non-enhanced abdominal low-dose CT on radiation dose and image quality (IQ) in the detection of body packing.Methods: This retrospective study was approved by the local research ethics committee of our clinic. From March 2012 to July 2014, 99 subjects were referred to our institute with suspected body packing. 50 CT scans were performed using a 120 kVp protocol (group A), and 49 CTs were performed using a low-dose protocol with a tube voltage of 100 kVp (group B). Subjective and objective IQ were assessed. DLP and CTDIvol were analyzed.Results: All examinations were of diagnostic IQ. Objective IQ was not significantly different between the 120 kVp and 100 kVp protocol. Mean density of solid and liquid body packets was 210 ± 60.2 HU at 120 kVp and 250.6 ± 29.7 HU at 100 kVp. Radiation dose was significantly lower in group B as compared to group A (p < 0.05). In group A, body packs were detected in 16 (32%) of the 50 patients. In group B, packets were observed in 15 (31%) of 49 patients. Laboratory analysis detected cocaine in all smuggled body packs.Conclusions: Low-tube voltage 100 kVp MDCT with automated tube current modulation in screening of illegal drugs leads to a diagnostic IQ and significant dose reduction compared to 120 kVp low-tube voltage protocols. Despite lower radiation dose, liquid and solid cocaine containers retain high attenuation and are easily detected. [ABSTRACT FROM AUTHOR]

To avoid detection at border crossings or airport customs, drug trafficking is increasingly performed by intra-corporeal concealment. Body packers may ingest packets of varying size and containing varying drugs (mostly cocaine, heroin and cannabis) mixed with other compounds, while body pushers will insert packets in the rectum or vaginal cavity. Body packing may lead to potential life-threatening complications with acute overdose syndromes after packet rupture and intestinal obstruction with possible ensuing bowel rupture being the most significant complications. Physicians including radiologists should be aware of the capabilities of imaging techniques to screen for presence of drug packets as well as the potential complications. Although conventional radiography has long been and still is the most important imaging modality for screening for presence of intestinal packets, the better test characteristics in conjunction with the decreasing radiation exposure, will likely render computed tomography (CT) more important in the future. For imaging of symptomatic patients, CT already is the modality of choice. Besides these modalities, ultrasound and magnetic resonance imaging will be discussed in this paper, together with more general background and clinical information. [ABSTRACT FROM AUTHOR]

A 39-year-old man died of multi-organ failure complicating mixed drug toxicity that included methadone, oxazepam, oxycodone and nitrazepam. His past medical history involved alcohol and poly-substance abuse with chronic self-harm and suicidal ideation. There had been multiple hospital admissions for drug overdoses. At autopsy the most unusual finding was of two packages of 10 tablets each, wrapped in thin plastic film within the rectum. The insertion of drugs into body orifices and cavities has been termed body pushing to distinguish it from body packing where illicit drugs are wrapped and swallowed for transport and smuggling, and body stuffing where small amounts of loosely wrapped or unwrapped drugs are swallowed to conceal evidence from police. This case demonstrates that body pushing may not always involve illicit drugs or attempted concealment from police or customs officials. It appears that the drugs had been hidden to ensure an additional supply during the time of residence in hospital. The extent to which body pushing is currently being used by patients to smuggle drugs into secure medical facilities is yet to be determined. [ABSTRACT FROM AUTHOR]

In this paper a drug fatality that involved an unintended drug delivery route is described. The decedent, a 23-year-old female in custody in a county jail on suspicion of a felony drug offense, was discovered in a holding cell unconscious and unresponsive. Following unsuccessful cardiopulmonary resuscitation attempts she was pronounced dead at the scene. At autopsy a wad of multiple small loosely wrapped plastic packages held together with another layer of clear plastic was found in the decedent's vagina. The smaller plastic packages contained an off-white pasty substance that was later identified as methamphetamine. Toxicological testing of specimens collected during autopsy revealed methamphetamine in the decedent's subclavian blood, vitreous fluid, and urine at extremely high concentrations (42.6, 20.1, and 771 mg/L, respectively). Amphetamine, the active metabolite of methamphetamine, was also present in the subclavian blood, vitreous fluid, and urine at significant concentrations (1.3, 0.5, and 20.4 mg/L, respectively). The cause of death was attributed to toxic effects of methamphetamine and the manner of death was ruled accidental. This report suggests that lethal concentrations of methamphetamine may be distributed to the systemic circulation via intravaginal absorption. [ABSTRACT FROM AUTHOR]

Purpose: To compare low-dose computed tomography (CT) with standard CT and conventional radiography (CR) regarding delineation of body packs and radiation dose. Methods: Nine samples of illicit drugs including cocaine, heroin, and hashish were positioned in the rectum of a 121.5 kg pig cadaver. Each sample was scanned on a 64-row MDCT with 120 kV: one standard modulated pelvic protocol (STD), and without modulation at 80 mA (LD80), 30 mA (LD30), and 10 mA (LD10). Additionally, conventional abdominal anterior-posterior radiographs (77 kV and 106 ± 13 mA) were taken. Body pack characteristics (wrapping, content, shape) were rated independently by two radiologists and summarized to a delineation score from 0 to 9 with scores ≥6 representing sufficient delineation. Mean delineation scores were calculated for CR and CT protocols. These were additionally differentiated for readings in soft tissue ( S), lung ( L), user defined, variable window settings ( V), and in cumulative window evaluation including all the other window settings (SLV). Effective doses were calculated (mSv). Results: The CR delineation score was insufficient (3.1 ± 2.5; 2.4 ± 0.3 mSv). For CT, the SLV window setting performed best ( p < 0.01). Its score significantly ( p < 0.01) declined with decreasing effective radiation doses: STD (8.8 ± 0.5; 10.6 mSv), LD80 (8.2 ± 0.7; 2.6 mSv), LD30 (6.8 ± 1.3; 1.0 mSv), and LD10 (4.6 ± 1.9; 0.3 mSv). Thus, LD30 was the protocol using the lowest but sufficient dose. Moreover, for LD30 further differentiation between the particular window settings resulted in scores of 6.4 ± 1.3 ( L), 6.3 ± 1.2 ( V), and 3.1 ± 1.0 ( S). Conclusions: With appropriate window settings, low-dose CT at 30 mA allowed for sufficient body-pack delineation below the dose of CR, which itself performed insufficient. [ABSTRACT FROM AUTHOR]

The article discusses several study related to medical toxicology published in different journals in 2013. It mentions about intravenous acetylcysteine treatment for paracetamol poisoning by D. N. Bateman and coworkers in "Lancet," and mortality after prison release by I. A. Biswanger and coworkers in "Annals of Internal Medicine." It also presents another study related to detection of residual packets in cocaine body packers by P. Rousset and coworkers in "European Radiology."

Objective: To evaluate if heroin and cocaine can be distinguished using dual-energy CT. Materials and methods: Twenty samples of heroin and cocaine at different concentrations and standardized compression (SC) were scanned in dual-energy mode on a newest generation Dual Energy 64-row MDCT scanner. CT number, spectral graphs, and dual-energy index (DEI) were evaluated. Results were prospectively tested on six original samples from a body packer. Wilcoxon's test was used for statistical evaluation. Results: Values are given as median and range. Under SC, the CT number of cocaine samples (−29.87 Hounsfield unit (HU) [−125.85; 16.16 HU]) was higher than the CT number of heroin samples (−184.37 HU [−199.81; −159.25 HU]; p < 0.01). Slope of spectral curves for cocaine was −2.36 HU/keV [−7.15; −0.67 HU/keV], and for heroin, 1.75 HU/keV [1.28; 2.5 HU/keV] ( p < 0.01). DEI was 0.0352 [0.0081; 0.0528] for cocaine and significantly higher than for heroin samples (−0.0127 [−0.0097; −0.0159]; p < 0.001). While CT number was inconclusive, all six original packs were correctly classified after evaluation of the spectral curve and DEI. In contrast to the CT number, slope of the spectral curve and DEI were independent of concentration and compression. Conclusion: The slope of the spectral curve and the DEI from dual-energy CT data can be used to distinguish heroin and cocaine in vitro; these results are independent of compression and concentration in the measured range. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the accuracy of abdominal radiography (AXR) for the detection of residual cocaine packets by comparison with computed tomography (CT). Methods: Over a 1-year period unenhanced CT was systematically performed in addition to AXR for pre-discharge evaluation of cocaine body packers. AXR and CT were interpreted independently by two radiologists blinded to clinical outcome. Patient and packet characteristics were compared between the groups with residual portage and complete decontamination. Results: Among 138 body packers studied, 14 (10 %) had one residual packet identified on pre-discharge CT. On AXR, at least one reader failed to detect the residual packet in 10 (70 %) of these 14 body packers. The sensitivity and specificity of AXR were 28.6 % (95 % CI: 8.4-58.1) and 100.0 % (95 % CI: 97.0-100.0) for reader 1 and 35.7 % (95 % CI: 12.8-64.9) and 97.6 % (95 % CI: 93.1-99.5) for reader 2. There were no significant patient or packet characteristics predictive of residual portage or AXR false negativity. All positive CT results were confirmed by delayed expulsion or surgical findings, while negative results were confirmed by further surveillance. Conclusion: Given the poor performance of AXR, CT should be systematically performed to ensure safe hospital discharge of cocaine body packers. Key Points: • Both abdominal radiography and computed tomography can identify gastrointestinal cocaine packets. • Ten per cent of body packers had residual packets despite two packet-free stools. • Seventy per cent of these residual packets were missed on AXR. • No patient or packet characteristics predicted residual packets or AXR false negativity. • CT is necessary to ensure safe medical discharge of body packers. [ABSTRACT FROM AUTHOR]

Body packing is a distinct method for smuggling drugs. What radiologists need to know is discussed in this pictorial review. Radiologists are confronted with diagnostic imaging of body packers because of two main reasons: complications of body packing and identifying drug packets within the gastrointestinal tract. The standard examination used is plain X-ray of the abdomen in an upright and a supine position. Computed tomography is occasionally used but nevertheless described as a very accurate diagnostic tool. Ultrasound and MR imaging do not play an important role in that field. Depending on the purity of the drug, three different forms of attenuation have been described: hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. The packets are of a round to oval form, usually of a particular uniformity and rarely confused with scybala if arranged like a pearl chain; therefore, plain X-ray is the method of choice to detect drug-filled packets within the gastrointestinal tract of body packers. [ABSTRACT FROM AUTHOR]