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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.

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.

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

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 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.

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.

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.

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

Anaesthetists require a good knowledge of the excretion of drugs in breast milk and the potential hazards to suckling infants of drug ingestion via breast milk. A brief account of the physiology of lactation is given. The mechanisms of drug passage into breast milk are discussed followed by a review of the excretion in breast milk of drugs used in anaesthetic practice. Suggestions for the management of anaesthesia in breast feeding mothers are offered.

Background: Linear IgA bullous disease (LABD) is a rare mucocutaneous autoimmune subepidermal blistering disease that can affect children mostly of pre-school age. As many as two-thirds of LABD are related to drug ingestion, particularly certain antibiotics, non-steroidal anti-inflammatory drugs and diuretics. Main observation: We describe a 3-year-old boy who presented a CMV infection followed by LABD induced by trimtheporim-sulfametoxazole. To our knowledge, this is the first reported case of trimethoprim-sulfamethoxazole that was confirmed by a rechallenge. Conclusions: Most cases of drug-induced LABD are patients being treated with multiple systemic drugs that could induce the LABD. In the lack of suitable alternative treatment, the identification of the causative drug can be achieved by a rechallenge under close medical surveillance. ____________________________________________________ Nantel-Battista M, Al Dhaybi R, Hatami A, Marcoux D, DesRoches A, Kokta V. Childhood linear IgA bullous disease induced by trimethoprim-sulfamethoxazole. J Dermatol Case Rep. 2010; 4(3): 33-35.

Aims : To investigate the relationship between the duration of comatose state, severity of rhabdomyolysis and frequency of peripheral nerve injury (PNI) in patients following psychotropic drug overdose. Materials and Methods : Medical charts were retrospectively reviewed for 41 patients admitted for disturbance of consciousness induced by an overdose of psychotropic drugs with rhabdomyolysis between October 2004 and February 2010. Subjects were divided into PNI group (n=9) and non-PNI control group (n=32). Results : Mean interval between drug ingestion and arrival, frequency of pressure ulcers, CK level at the time of patient's arrival and maximum CK level during hospitalization, duration of hospitalization and morbidity rate were all significantly higher in the PNI group than in the control group. Conclusion : In patients with a psychotropic drug overdose leading to a comatose state, the longer the comatose state, the more likely that pressure ulcers and PNI will occur.

Some investigators have reported that dexamethasone suppression test (DST) accuracy might be improved by incorporating dexamethasone concentrations ([dex]) into test results. Using receiver operating characteristic methods, we evaluated data from four studies in which cortisol and dexamethasone levels were measured simultaneously at one or more times after drug ingestion. We compared DST accuracy using cortisol alone with various diagnostic indices incorporating [dex]. In none of the 21 comparisons did the [dex] factor enhance diagnostic performance.

Radiolabelled leukocyte scanning is a valuable tool in the diagnosis and management of inflammatory bowel disease (IBO). As well as determining the presence or absence of disease and its complications, the degree of inflammation may be quantified either visually or numerically following four day fecal collection. The authors discuss the labelling techniques currently in use and the appearance of IBO using both111Indium and99mTechnetium as the labelling isotope. The advantages and disadvantages of each technique are compared. Certain diagnostic pitfalls and causes of false-positive results including radiation enteritis, nonsteroidal anti-inflammatory drug ingestion and intra- and extra-abdominal sepsis are discussed in full, and it is shown that in most cases good labelling technique, careful imaging and awareness of alternative mechanisms for leukocyte appearance in the gastrointestinal tract will ensure correct interpretation of these scans.

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.

Summary Background Post-sclerotherapy pigmentation, usually overlying the treated veins and independent of any drug ingestion, is common. This pigmentation is brown and represents haemosiderin and sometimes melanin as well. It usually slowly fades over a period of months, only uncommonly persisting for years. Cutaneous pigmentation due to minocycline ingestion is a known but rare adverse effect. It usually appears as a round or irregular shaped patch that is dark blue to black, representing minocycline moieties and iron complexes. Its persistence for years is common. Clinically and histopathologically, these two causes of pigmentation are quite distinct. In the absence of ulceration, minocycline pigmentation koebnerised by sclerotherapy has not previously been reported. Aims To determine the nature of the pigmentation appearing in three patients who had been taking minocycline at the time, or shortly after, they had received sclerotherapy. Clinically, although this pigmentation had the usual distribution observed after sclerotherapy, it was persistent and appeared dark blue to black. Results The persistent post-sclerotherapy linear pigmentation observed in all three patients had the characteistics of minocycline pigmentation. Conclusions This is the first report of such minocycline-aggravated post-sclerotherapy pigmentation. Persistent post-sclerotherapy pigmentation caused by minocycline is a risk associated with ingestion of this drug. Patients need to be warned of this risk because, unlike post-sclerotherapy pigmentation that develops in the absence of drug ingestion, minocycline-aggravated post-sclerotherapy pigmentation may persist for years.

Epidemiologic and experimental reports suggest that female hormones protect against the development of colorectal cancer, but studies are limited. We describe a patient in the placebo arm of a 4-year primary chemoprevention trial who developed adenomatous polyps and then had eradication of polyps after the administration of oral contraceptives. No change in the prostaglandin levels in the colonic mucosa was noted after polyp elimination, making nonsteroidal anti-inflammatory drug ingestion unlikely as a cause. This report represents the regression of colorectal adenomas with the use of estrogen/progesterone compounds.

Background: In the fight against the global tuberculosis epidemic, it is essential to ensure that patients adhere to the treatment prescribed. As the treatment is given for a minimum of 6 months it is common for patients not to take their drugs regularly. Strategies are therefore needed to assess adherence to treatment. One established method is to examine the patient's urine for the presence of drug metabolites. A rapid point-of-care test would overcome some of the drawbacks associated with currently available methods. Method: A rapid, safe point-of-care test for isoniazid metabolites (IsoScreen, Surescreen Diagnostics Limited, Derby, UK) has been developed and used to help assess adherence to treatment in a busy clinic for tuberculosis patients in South London. Results: Urine samples were examined from 191 patients receiving isoniazid, usually in combination with rifampicin and other anti-tuberculous drugs. Isoscreen was positive in 93.2% of patients, suggesting that 6.8% might be poorly adhering to treatment. By contrast, examining the same urine samples for evidence of rifampicin ingestion gave positive results in only 43.5%, due to the fact that this test is only positive for a few hours after drug ingestion. Conclusion: IsoScreen has been shown to provide a rapid and safe point-of-care test, which contributes to the detection of non-adherence in patients with tuberculosis.

Patients visit their doctors with the reasonable expectation that the recommended treatment is appropriate and, even if they do not know the exact terminology, that the doctor’s choice of treatment is ‘‘evidenced-based.’’ Those charged with serious crimes, such as murder, might share similar expectations about the evidence presented against them, but they would frequently be mistaken, particularly when questions about the timing of drug ingestion, or the amount of drug ingested, are at issue. Defendants have found themselves charged, and convicted, only because the jury has believed that accusations were based on a ‘‘scientific’’ method that is neither evidence-based, nor peer-reviewed, that has an unknown rate of error, and has no published standards of operation. The methodology in question is the volume of distribution (Vd) equation, a standard pharmacokinetic calculation, derived and validated from measurements made in the living, but which is now routinely applied in the dead. The murder trial of euthanasia advocate Dr. David Moor is one of the better-publicized examples. Dr. Moor was charged with the murder of Mr. George Liddell, an 85-year-old man with terminal metastatic colon cancer. Mr. Liddell was being treated at home with a heroin syringe driver, and he died shortly after a visit from Dr. Moor. At trial, the main evidence presented against Dr. Moor was given by a clinical pharmacologist who felt that the high levels of free morphine measured in cadaver blood, together with the relatively low levels of morphine metabolite detected, proved that Dr. Moor had administered a fatal overdose of diamorphine. The prosecution argued that the very high ratio of free to conjugated morphine proved that the injection had been given