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

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

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

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

Drug-dependent individuals commonly report craving, which is an urge to consume a substance to experience pleasure or provide relief. However, the motivation to use drugs is also influenced by the expectancies we hold about drug ingestion. Drug expectancies are among a range of internal and external cues that can elicit craving. Scientific advances in the neurobiology of reward have illuminated individual differences in the neurotransmitter systems involved in associative learning that underpin drug use motivation and expectancies. We have begun to elaborate the interrelationships of these constructs and mechanisms to inform new treatments that incorporate recent models of reward learning.

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

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

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.

An analysis is made of adolescent hallucinogenic plant ingestion during initiation rituals among Australian Aboriginal males, Tshogana Tsonga females and among Chumash youth of Southern California. This use pattern contrasts with abusive patterns of drug abuse found among American adolescents. Findings indicate the existence of managed altered states of consciousness in the tribal societies studied, where plant hallucinogens are given by elders to youth as part of an intensive, short-term socialization for religious and pedagogical purposes. The use of hypersuggestibility as a cultural technique to “normalize” youth in the tribal societies under study is analyzed in contrast to the role of pathology of drug ingestion patterns among American adolescents.

Fetal and neonatal injury caused by maternal drug ingestion during pregnancy is rapidly becoming both a public health and criminal justice problem. There is widespread unanimity in the medical profession that using and abusing illicit drugs during pregnancy will likely result in a host of fetal and neonate complications, some of which are irreversible. The criminal justice system has yet to develop a workable strategy to deal with this issue and, as a result, two main trends of thought have emerged. The interventionist camp argues that “harm” caused by drug use during gestation should be criminally proscribed as the only viable avenue to alert the public to this issue and to both punish and treat drug-related behavior. The non-interventionist would prefer to see less use of the criminal sanction and use in its place a treatment and education oriented policy aimed at prevention instead of prosecution. Since neither side yet commands a national consensus, courts are oftentimes left to grapple with ...

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

An increasing number of new drugs have been incriminated in the recent past. 2–9 Its clinical pattern is fascinating and has been the subject of detailed studies. 4,8,10–16 Its changing scenario in various age groups, 17–19 its presentation postoperatively, 20–22 and its occurrence in human immunodeficiency virus (HIV)-positive individuals 23–25 are vivid indicators. Several factors may be responsible for the causation of this extensive skin disorder. Subtle/sudden generalization of preexisting dermatoses may be an intriguing dilemma, and may reflect an individual variation. A detailed outline of a patient’s history to elicit possible triggering events, namely infections, drug ingestion, topical application of medicaments, sun/ultraviolet light exposure, and other factors, 16

Zaleplon ("Sonata") is a pyrazolopyrimidine derivative approved for use in the United States for the treatment of insomnia. To date, there has been little data in the toxicological literature where zaleplon has been implicated as causing a fatal intoxication, either alone or in combination with other drugs. This report documents a case where zaleplon was identified in a suicide by multiple drug ingestion. The following zaleplon concentrations were found: heart blood 2.2mg/l; bile 8.6mg/l and urine 1.4mg/l. Zaleplon was also detected but not quantitated in the kidney and liver.

This patient presented with clinical features consistent with acute cervical myelopathy or Guillain–Barré syndrome but ventricular arrhythmias on the electrocardiogram alerted the authors to a possible toxic cause. The history of drug ingestion was then elucidated, indicating aconitine poisoning from herbal medicine. Aconitine-containing plants are the most frequently encountered herbal agents that cause serious toxicity in Hong Kong (Chan et al, 1993).

The topic of drug ingestion related to pregnancy, and the peri-pregnant period including lactation has always been important but under-studied. It is therefore gratifying to see that in this issue there are 4 papers devoted to this topic, covering the period from 3 months prior to conception to early post-partum, including lactation.

Drug exposure during pregnancy is a common occurence (Doering and Stewart 1978; Hogan and Todd 2001). During pregnancy, drug ingestion may not only affect the mother, it may cross the plancenta als...

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

In general, arsenic poisoning has been reported as a consequence of using traditional medicine in Thailand (Kullavanich et al., 1987). In the past decades, the Institute of Skin Diseases, Ramathibodi and Siriraj Hospital had treated more than 100 cases of chronic arsenic poisoning from traditional drug ingestion. Very few cases were caused from work-related problems.

To determine the decrease of drug absorption when syrup of ipecac is administered at various times within one hour of drug ingestion.Ten healthy human volunteers were recruited for a four-limbed randomized crossover study. The three experimental limbs consisted of administration of 30 mL syrup of ipecac, at 5, 30, or 60 minutes after ingestion of 3900 mg acetaminophen as 12 x 325 mg tablets with 250 mL room temperature water. The fourth limb served as control. Blood samples were drawn at 0, 0.5, 1.0, 2.0, 3.0, 4.0, 6.0, and 8.0 hours after analgesic ingestion for serum acetaminophen concentration determination by high-performance liquid chromatography. Repeated measures ANOVA and Tukey's HSD tests were used for group comparisons.The area under the serum concentration vs time curve was (mean +/- SD) 206 +/- 48, 67 +/- 37, 183 +/- 78, and 162 +/- 47 mg/L for control, 5, 30, and 60 minutes, respectively. This corresponds to decreases in bioavailability of 67, 11, and 21%. Only the 5-minute group differed significantly from control (p0.05). Sedation was observed as a significant adverse effect of ipecac administration.Our data do not support benefit from ipecac administration at 30 minutes and beyond. Our data suggest that benefit is lost at some point between 5 and 30 minutes. The sedative effect of ipecac may confound the observation of patients who have ingested sedative hypnotic agents.

Formed visual hallucinations are commonly associated with seizures, drug ingestion, and psychiatric disorders, or they can occur as release phenomena in the setting of visual loss. [1] Although a picture within a picture is a desirable feature in many new televisions, we report a patient who developed this unusual release hallucination within a visual field defect. ### Case report. A 51-year-old woman complained of seeing "a picture within a picture - like the new kind of television sets" in her lower left visual field. She described a rectangular scene with a red …

Skin capillary blood flow measured with laser Doppler in the legs of subjects with chronic venous insufficiency (CVI) is known to be different from normal subjects [1]. Many factors affect skin capillary blood flow including temperature, exercise, recent food or drug ingestion, as well as postural changes.

spirin and other NSAIDs areresponsible for 21–25 per centof reported adverse drug events.Following the first description in1902 of a hypersensitivity reactionto aspirin, several types of suchreactions to NSAIDs have beendescribed. These can be immuno -logical or nonimmunological andcan present clinically as asthma,polypoid rhinosinusitis, anaphy -laxis or urticaria and a variety oflate skin and organ-specific reac -tions occurring within minutes orhours after drug ingestion, or evenappearing after days and weeks (seeTable 1).

Background: There are few diverse studies that have reported the case fatality rates of different methods of suicide, none of them are originated from developing countries. The aim of the present article is to report the case fatality rates of different methods of suicide in Ilam province of Iran. Materials and Methods: Data on 611 cases of suicide and 1807 cases of deliberate self harm (DSH) that were recorded in a comprehensive registry during 1995 through 2002 were analyzed for both genders together and for males and females, separately. Findings: For both genders together, the two most fatal methods were hanging (75.4%) and self-immolation (68.3%); for males, hanging (76.3%) and self-immolation (64.7%); and for females, firearms (75%) and hanging (73.7%), respectively. The least fatal methods for both genders together and for females and males separately were drug ingestion and cutting. Conclusion: The results of present study, which for the first time has reported the case fatality rates of suicide methods in a developing world, would not only help to better plan the local suicide prevention strategies and clinical assessment of suicidal cases but to shed light on overall understanding of this mysterious human phenomenon.

The Gram-negative bacterium, currently referred to as Helicobacter pylori 1, is now firmly established as a human pathogen causing chronic-active gastritis2. H. pylori infection fulfils each of Koch’s postulates as a cause of chronic—active gastritis3 since orogastric challenge of humans4,5 and experimental animals6 results in the development of gastritis. Therapy which clears the bacterial infection results in healing of the associated gastritis7. There is specificity to H. pylori infection because other causes of gastritis, including drug ingestion (i.e. non-steroidal anti-inflammatory agents and corticosteroids), gastroduodenal Crohn’s disease, and eosinophilic gastroenteritis are not correlated with H. pylori colonization of the gastric mucosa8–10.

To pregnant or breast feeding women drugs should be given with caution. We report the case of a 5-week-old breast-fed infant whose mother was taking 300 mg allopurinol/day for 4 weeks. Allopurinol and oxypurinol were detected by HPLC in maternal plasma and breast milk with a method first described here. In infant's plasma taken 2 h after breast feeding oxypurinol was found; allopurinol was below the limit of detection. The milk/plasma ratio in the mother 2 h (4 h) after drug ingestion was 0.9 (1.4) for allopurinol and 3.9 (2.4) for oxypurinol. The average daily dose for the baby of allopurinol was 0.14–0.20 mg/kg and that of oxypurinol 7.2–8.0 mg/kg by ingestion of breast milk after oral intake of allopurinol by the mother.

Introduction: Poisonings in childhood are a usual cause of children's admission to a pediatric ward. The most usual toxic exposures and ingestions occur at home and involve drugs, cigarettes and nondrug products such as chemical substances, plants and hydrocarbons. Aim: of the study is to make an epidemiological recording of the poisoning incidents in a distict hospital's pediatric clinic during the period 2008- 2009. Material-Methids: 96 children were admitted in a two years' period and were studied according to age, sex, nationality and the ingested substance. Results: 96/1228 (7,8%) children with a mean age 3,3y admitted because of a drug-substance poisoning. 80/96(83,3%) were greek, 13/96(13,5%) were roma and only 3/96(3,2%) were foreigners. The male children were significantly more (58/96(60,4%)) than the females (38/96(39,6%)). The majority of the incidents happened during fall (37/96(38,5%)) and spring (34/96(35,4%)). Fewer happened during summer (14,6%) and winter (11,4%). 67/96 (69,8%) were infants (1,0-3,0) y, 22/96(22,9%) were 3,1-6,0 y and 7(7,3%)were > 6 y. 19/96(19,8%) with a mean age 1,5 years old, ingested cigarettes and 48/96(50%) ingested drugs (3 of them attempted to suicide). The rest 29 cases involved non drug products (alcohol:5, hydrocarbons:8, cleaning substances: 9, plants:4, cosmetics:3) None of these cases had adverse reactions. Conclusion: Unintetional poisonings are common in children younger than 6 years of age, happen mostly at home and involve mostly cigarette and drug ingestion. Pediatricians must be aware and have to educate the parents in order the chidren to live in a safer environment.

Maternal drug intake before delivery may influence the clinical behavior of the newborn. The effects of anesthetic agents and narcotics may cause symptoms of depression in the infant. Infants of substance-abusing mothers may also have altered clinical states. This is a case report of a newborn, very depressed at birth, who apparently was sedated by diphenhydramine (Benadryl) ingested by the mother before delivery. The importance of complete history of drug ingestion by mother before delivery is important in evaluating the behavior of a neonate.

The calibrated oral syringe is considered the standard system for administering liquid formulations of medications to infants. Medication acceptance using the syringe may not always be favorable, particularly with unpleasant-tasting liquids. The Rx Medibottle (The Medicine Bottle Co, Hinsdale, Illinois), an alternate drug-delivery device, is an infant-feeding bottle that contains a central sleeve within its body into which a syringe is inserted. Depressing the syringe's plunger in quick, short squirts synchronized with an infant's sucking allows drug ingestion, preventing dilution of the drug in the formula within the bottle's nipple. The Rx Medibottle costs $14.95 retail. Kraus et al demonstrated that it was more efficacious, with a higher level of infant acceptance compared with the syringe, when used to administer a 1-time dose of a pleasant-tasting liquid (acetaminophen, Tempra Syrup; Mead Johnson Nutritionals, Evansville, Indiana). Our study tests the efficacy of this bottle in administering a single dose of generic prednisolone liquid, a bitter-tasting drug, with an oral syringe serving as the control method of delivery.

A 40-year-old man developed multiple longitudinal pigmented streaks in his nails. His sister was also found to have a single streak on a fingernail. Neither had any history of drug ingestion or recent illness and examination failed to reveal any other signs in the skin or mucosal surfaces. A biopsy of the nail matrix at the base of one streak showed no evidence of a naevus or lentigo, the principal finding being pigmentary incontinence and excess macrophages.

Each year in the United States physicians write more than 1.5 billion prescriptions for their patients. Considering this scope of drug ingestion it seems safe to assume that medication is taken by some people while they are at work. The therapeutic effects or adverse reactions of drugs may compromise safety in the workplace. Furthermore, the conditions of the job or work environment may adversely alter the expected pharmacokinetics of some agents.

Forensic toxicologists typically work with body fluids such as blood or urine, as well as visceral tissues such as liver. Very little work has been done to properly understand the utility of drug concentrations in bone tissue in a toxicologic examination. Literature reports suggest that detection of selected drugs in bone tissues is possible, but challenging work remains to determine the implications of bone tissue drug concentration measurements with respect to time lines of drug ingestion and deposition into bone, tissue sampling and sensitivity requirements, and environmental effects on measurements and their interpretation.

To the Editor. —I read with great interest the Contempo 1991 (June 19,1991) issue of JAMA . This issue allows the reader to view both the current state of the art and the future of medicine as seen through the eyes of specialists in each field. I am concerned, however, with the inclusion of a large discussion of toxicology under the Emergency Medicine section. 1 While the American Board of Medical Specialties currently does not recognize medical toxicology, it is unacceptable to ignore the fact that the American Board of Medical Toxicology and the American Academy of Clinical Toxicology have been training physicians in the practice of medical toxicology for many years. As part of my training in medical toxicology, I learned how to interpret research from other fields that attempt to answer questions of toxicological importance. After reading Dr Barsan's discussion 1 of gastrointestinal decontamination for acute drug ingestion, the

This second edition is another entry in the burgeoning area of textbooks addressing topics of the intensive care unit. It bears little similarity to the first edition, being markedly better (and larger) in all respects. The text is generally well written and covers most subjects in adequate detail for pediatric house officers and practitioners. Its 50 chapters have many excellent features. Most of the pulmonary section is superb. Roentgenographic evaluation of respiratory problems is dealt with nicely in numerous chapters. Several short chapters detail specific entities such as pneumothorax and pleural effusion. These are useful and well-written chapters that provide much valuable information to the bedside clinician. However, some areas are covered only superficially. The chapter on Reye's syndrome is six pages long; it has numerous typographical errors and covers the topic inadequately. Poisoning and drug ingestion also are covered weakly—tricyclic antidepressants and aspirin intoxication are not mentioned, for instance.

Nine cases of ‘basilar artery migraine’ (BAM) have been recorded. In 8 cases, excess of beta activity was observed during the attacks and disappeared in less than 3 days. The inter-ictal EEGs were normal. Drug ingestion was excluded each time. These EEG patterns are different from those which have been reported in the literature, i.e., transitory posterior abnormal slow waves. However, case no. 1 is in agreement with the literature. The expression ‘BAM’ probably covers different syndromes which are further discussed.

To examine the benefit of determination of the bleeding time as a preoperative screening test, the medical records of all patients who had a prolonged bleeding time during a six-month period were reviewed. At Northwestern Memorial Hospital, where the bleeding time test is part of the presurgical panel, 1,941 bleeding time determinations were performed during six months. Prolonged bleeding times were recorded in 110 preoperative patients, of whom 83 (75 percent) had bleeding risk factors, including drug ingestion, thrombocytopenia, and azotemia. In these patients, the bleeding time ranged unpredictably from 10 to more than 20 minutes. However, of the 27 patients without apparent risk factors, only two had bleeding times of more than 20 minutes. This small number probably does not justify the routine use of the test In all preoperative patients. Rather, the test should be used selectively for those subjects who, on the basis of history or laboratory evidence, are suspected of being at risk of hemorrhage. Moreover, even In these patients, prolongation of the bleeding time may not always be associated with excessive surgical blood loss.

Occurence of gastroenteric fistulae in non-surgically treated peptic ulcer disease is rare as suggested by only 26 cases published in the literature so far. We had the opportunity to care for 3 patients with this problem in a period of one year. At our institution, a search of the medical records dating back to 1955 yielded one additional case. Most of our patients had a history of salicylate or corticosteroid intake. We present here the details of these cases and discuss the possible role of the location of the ulcer and ulcerogenic anti-inflammatory drug ingestion in the causation of gastroenteric fistula. We believe the incidence of this uncommon entity may rise significantly with the more common use of salicylates and corticosteroids.

After several months of treatment, Cebus apella, Cebus albifrons, and Saimiri sciurea monkeys maintained on haloperidol, in doses of 0.5 or 1.0 mg/kg orally 5 days per week, began to display severe movement disorders, typically 1-6 h post-drug. Cebus monkeys exhibited violent, uncontrolled movements that flung the animals about the cage. Such episodes usually lasted only a few minutes, recurring several times during the period following drug ingestion. Writhing and bizarre postures dominated the response in S. sciurea. Cessation of drug treatment produced no distinctive after-effects. When tested as long as 508 days after the last administration, however, Cebus monkeys responded to haloperidol with several episodes of hyperkinesis, even at challenge doses considerably lower than those in the original treatment.

Alarcon, Dickinson, and Dohn (J. Nerv. Ment. Dis., 170: 217-223, 1982) recently reviewed the phenomenon of memory flashback following use of hallucinogenic drugs. They point out that while there are a considerable number of explanations concerning the flashback mechanism, little is known about the real causes. This paper examines flashback following drug ingestion in the light of other memory phenomena concerned with "cued retrieval" effects. Such phenomena may include dream recall, delayed post-traumatic stress, mood influence on memory, and drug effects on memory. Rather than view flashbacks as "pathological" in some sense, it may be better to view them as instances of normal memory processes, which may, nevertheless, be accompanied by emotional distress. Such a view relates flashbacks to a wider memory literature, and also makes them amenable to investigation using research designs derived from that literature.