Benzodiazepine overdose is a common cause of hospitalization in the United States, associated with about 30% of overdose cases. Such incidences fixedly increase in quantity and are important to consider when dealing with patients who have a history of drug abuse or predisposing factors for a possible overdose. These comprise e.g. psychological disorders, post-traumatic stress syndrome in patients with a military background, depressive or suicidal states.

Benzodiazepines are a class of medication with anxiolytic, analgesic, sedative and hypnotic features marking them a target of drug abuse and subsequent overdose [1]. Illegitimate practices and 'doctor shopping', involving patients visiting multiple doctors, lead to the unreasonable prescription of benzodiazepines and consecutive abuse [2]. Psychiatric patients, on the other hand, are known to use benzodiazepines in an attempt of suicide or intentional self-harm [3].

Often, polydrug users execute the administration of benzodiazepines in combination with alcohol, antidepressants or opioids giving rise to the failure of cardiovascular and respiratory systems [4]. Other complications include neurological, renal impairment, muscular complications like hypotonia, and possible hearing loss.

Acute manifestations in overdosed patients usually involve collapse with seizures, cyanosis due to respiratory failure, loss of consciousness, coma and possible cardiac arrest [5]. On examination of the eyes, the patient might have fixed miosis or pinpoint pupil.

• Pain

  […] and appropriate pain management. [fda.gov]

  Overprescribing of opioid pain relievers (OPR) and benzodiazepines is causing an epidemic of adverse health outcomes, including fatal overdoses. [mdalert.com]

  Trends in opioid prescribing and co-prescribing of sedative hypnotics for acute and chronic musculoskeletal pain: 2001-2010. Pharmacoepidemiol Drug Saf. 2015 ;24: 885 – 892. Crossref, Medline, Google Scholar 9. [doi.org]

  Pain Med Malden Mass. 2016;17(1):85-98. doi:10.1111/pme.12907. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. [drugabuse.gov]

  Experts are careful to note the benefits of both opioid pain pills and benzodiazepines for some patients. [inquirer.com]

• Weakness

  Other effects may include slurred speech, loss of motor coordination, weakness, headache, lightheadedness, blurred vision, dizziness, nausea, vomiting, low blood pressure, and slowed breathing. [www1.nyc.gov]

  Signs: shallow respiration, clammy skin, dilated pupils, weak and rapid pulse, coma Read More about Benzodiazepines Featured Articles A marijuana concentrate is a powerful substance that may look like honey or butter. [getsmartaboutdrugs.gov]

  Signs of an Overdose on Xanax, Valium, or Klonopin Symptoms of overdose on Xanax, Valium, or Klonopin include: Drowsiness or extreme fatigue Confusion, agitation, anxiety, and mood changes Dizziness Slurred speech or acting drunk Amnesia Physical weakness [americanaddictioncenters.org]

  Symptoms of BZD overdose may include the following: Dizziness Confusion Drowsiness Blurred vision Unresponsiveness Anxiety Agitation Findings on physical examination may include the following: Nystagmus Hallucinations Slurred speech Ataxia Coma Hypotonia Weakness [emedicine.medscape.com]

  and increased weakness During the 2nd and 3rd days: Seizures (in 75% of patients who were taking ≥ 800 mg/day), sometimes progressing to status epilepticus and death From the 2nd to the 5th day: Delirium, insomnia, confusion, frightening visual and [merckmanuals.com]

• Hypothermia

  Hypothermia may occur. Serious complications are more likely when newer short-acting agents are involved or when other depressant drugs have been ingested. Diagnosis usually is based on the history of ingestion ... [accessmedicine.mhmedical.com]

  3.7 Overdose Overdose with a benzodiazepine can cause drowsiness, dysarthria and nystagmus ; very large overdose may cause hypothermia and rhabdomyolysis. [mhra.gov.uk]

  Apnoea indicated airway obstruction Large ingestions can rarely cause hypothermia, bradycardia and hypotension. [lifeinthefastlane.com]

  […] been abusing these substances begins showing any of the signs listed below, seek immediate medical attention: Loss of balance Delirium Hallucinations Loss of consciousness Coma Double vision Labored or otherwise impaired breathing Irregular heart rate Hypothermia [longleafhospital.com]

• Gastric Lavage

  The use of flumazenil results in complete awakening with restoration of upper airway protective reflexes, thus enabling gastric lavage to be performed and transfer of the patient from the emergency room to another hospital department. [ncbi.nlm.nih.gov]

  Initiate gastric lavage for clinically significant recent ingestions (ie, within 30 minutes). Ensure/monitor airway patency/protective reflexes during the above treatments. [anesth.unboundmedicine.com]

  Lyons, Juan Ochoa and Christopher King, Hypothermia: An Unusual Indication for Gastric Lavage, The Journal of Emergency Medicine, 40, 2, (176), (2011). T. [doi.org]

  Occasionally, gastric lavage and administration of activated charcoal is indicated, but only if the patient is awake and potentially sensitive to benzodiazepines and if a large dose has been ingested within the last 1 to 2 hours. [link.springer.com]

  Gastric lavage is not routinely indicated. Emesis is contraindicated. The use of flumazenil is reserved for cases with severe respiratory or cardiovascular complications and should not replace the basic management of the airway and respiration. [inchem.org]

• Collapse

  Acute manifestations in overdosed patients usually involve collapse with seizures, cyanosis due to respiratory failure, loss of consciousness, coma and possible cardiac arrest. [symptoma.com]

  Its black-box warning states, “Since collapse, respiratory arrest, and cardiac arrest during initial treatment has occurred in patients who were being administered benzodiazepines or other psychotropic drugs, caution is advised when clozapine is initiated [mdedge.com]

  Table 1 : Characteristics of dependence on benzodiazepines Benzodiazepine withdrawal Presents similarly to alcohol withdrawal, with: Muscle pain Anxiety Restlessness Confusion Irritability Hallucinations Delirium Seizures Cardiovascular collapse Onset [accesspharmacy.mhmedical.com]

  Overdoses can cause confusion, slurring, sleepiness, loss of coordination and collapse. [drugscience.org.uk]

  Injecting drugs can lead to a host of potential hazards, including collapsed veins, skin infections, and a heightened risk for contracting an infectious disease like hepatitis or HIV/AIDS. [riveroakstreatment.com]

• Dyspnea

  Note: preexisting conditions that compromise respiratory function such as chronic obstructive pulmonary disease, sleep apnea, asthma, or pneumonia clinical indicators of changes in respiratory function, such as respiratory rate, dyspnea, hypoxemia, and [mdedge.com]

• Increased Appetite

  References: [1] [2] Side effects Adverse effects Blunted affect “Hangover” effect on the next day Motor incoordination and muscle weakness Amnesia Drug tolerance Paradoxical excitability Increased appetite CNS depression Concurrent use of alcohol, opioids [amboss.com]

• Jaundice

  […] common side effects : Drowsiness or dizziness Depression Blurred vision Trembling Confusion Weakness Headache Memory loss Serious side effects of taking benzodiazepines include but are not limited to a change in heart rate, vision impairment, and/or jaundice [axisresidentialtreatment.com]

  Sedation Memory impairment Improper body balance Increase or decrease in appetite Nausea Vomiting Constipation Weight gain Dry mouth Reduced libido Fatigue Serious side effects include: Respiratory depression Dependence and abuse Withdrawal symptoms Jaundice [medicinenet.com]

  […] and smooth muscle 9.4.4 Gastrointestinal Oral benzodiazepine poisoning will produce minimal effects on the gastrointestinal tract (GI) tract but can occasionally cause nausea or vomiting (Shader & Dimascio, 1970). 9.4.5 Hepatic A case of cholestatic jaundice [inchem.org]

• Hypotension

  Although rare, this may result in hypotension, cardiac dysrhythmias, lactic acidosis, seizures, or coma. [emedicine.medscape.com]

  Coma, life-threatening hypotension, bradycardia and clinically significant respiratory depression are rare if only a benzodiazepine has been taken. [mhra.gov.uk]

  Aggressive/expectant airway management for frank/anticipated inadequacy of protective airway reflexes Supine/Trendelenburg positioning and aggressive IV fluid therapy for hypotension GI decontamination Activated charcoal 1 g/kg PO or per NG tube is effective [anesth.unboundmedicine.com]

  Clinical features : CNS depressio n : lethargy, somnolence, hyporeflexia Respiratory depression Mild hypotension Ataxia Slurred speech Carbamazepine and oxcarbazepine: possibly SIADH Diagnostics Routine urine screening for benzodiazepine metabolites [amboss.com]

• Hypertension

  Cardiovascular – cutaneous vasodialation, sweating, and flushing, dysrhythmias, bradycardia, tachycardia, hypertension. CNS – dizziness, headache, abnormal or blurred vision, confusion, and convulsions. [sedationcertification.com]

  Benzodiazepines, commonly referred to as benzos, are a class of medications used to treat conditions like anxiety, insomnia, hypertension and seizures. [addictionhope.com]

  Messerli, Management of hypertension in the elderly, Current Medical Research and Opinion, 8, sup1, (30), (1982). J. Kanto and U. [doi.org]

  […] biogenic amine (DA, NE, 5HT) reuptake Intoxication presentation mental status changes euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations sympathetic activation ↓ appetite, tachycardia, pupillary dilation, hypertension [step2.medbullets.com]

• Cyanosis

  Acute manifestations in overdosed patients usually involve collapse with seizures, cyanosis due to respiratory failure, loss of consciousness, coma and possible cardiac arrest. [symptoma.com]

• Muscle Weakness

  Short-term effects of benzodiazepines The most common side effects of benzodiazepines can include: dizziness confusion drowsiness constipation memory loss slurred speech muscle weakness loss of coordination and balance Some people can also experience: [canada.ca]

  References: [1] [2] Side effects Adverse effects Blunted affect “Hangover” effect on the next day Motor incoordination and muscle weakness Amnesia Drug tolerance Paradoxical excitability Increased appetite CNS depression Concurrent use of alcohol, opioids [amboss.com]

  Benzodiazepines are commonly used in the treatment of anxiety disorders, to address seizures, as sleep aids, as muscle relaxants, and as withdrawal management medications. [sunrisehouse.com]

  When used, benzos lower anxiety levels, increase relaxation of the muscles, and produce sedation. [centerpointehospital.com]

• Flushing

  Cardiovascular – cutaneous vasodialation, sweating, and flushing, dysrhythmias, bradycardia, tachycardia, hypertension. CNS – dizziness, headache, abnormal or blurred vision, confusion, and convulsions. [sedationcertification.com]

  This phase utilizes a low-heat sauna, a regimen of nutritional supplements and moderate daily exercise to flush out the drug residues left behind after drug or alcohol abuse. [narconon.org]

  Adverse Effects The adverse effects of flumazenil include dizziness, nausea, agitation, headache, fatigue, hot flushes and sweating. Adverse reactions to this drug are usually related to reversal of the therapeutic effects of benzodiazepines. [the-medical-dictionary.com]

• Ulcer

  It is characterized by redness, ulceration in oral cavity with burning sensation, salvation and pain. Stomatitis occurs anywhere in the mouth, including the inside of cheeks, gums,... [hamrodoctor.com]

  Hernandez, Neuroendocrine mechanisms of stress ulceration: Focus on thyrotropin-releasing hormone (TRH), Life Sciences, 39, 4, (279), (1986). Roland R. Griffiths, Richard J. Lamb, Nancy A. Ator, John D. Roache and Joseph V. [doi.org]

• Withdrawn

  Name Triazolam Accession Number DB00897 (APRD00313) Type Small Molecule Groups Approved, Investigational Description Withdrawn in the United Kingdom due to risk of psychiatric adverse drug reactions. This drug continues to be available in the U.S. [redpoll.pharmacy.ualberta.ca]

  His mother arrives and is very concerned about this behavior, noting that he has been withdrawn lately and doing very poorly in school the past several months. [step2.medbullets.com]

• Behavior Disorder

  T42 ICD-10-CM Diagnosis Code T42 Poisoning by, adverse effect of and underdosing of antiepileptic, sedative- hypnotic and antiparkinsonism drugs 2016 2017 2018 2019 Non-Billable/Non-Specific Code Type 2 Excludes drug dependence and related mental and behavioral [icd10data.com]

  Template:Mental and behavioral disorders v · d · e Poisonings, toxicities, and overdoses ( T36–T65, 960–989 ) ( history ) Inorganic Metals Toxic metals Lead · Mercury · Cadmium · Silver · Thallium · Tin · Beryllium Dietary minerals Manganese · Copper [psychology.wikia.com]

• Distractibility

  Supporter of FOAMed, tox, sim, ultrasound and any other project that can distract me for 5 seconds ..... oh look squirrel. | @doctorneillong | + Neil Long | LinkedIn Reader Interactions [lifeinthefastlane.com]

• Hot Flushes

  Adverse Effects The adverse effects of flumazenil include dizziness, nausea, agitation, headache, fatigue, hot flushes and sweating. Adverse reactions to this drug are usually related to reversal of the therapeutic effects of benzodiazepines. [the-medical-dictionary.com]

• Seizure

  Seizure frequency in patients not treated with flumazenil was 0.3%. The frequency of prior seizure in flumazenil-treated patients was 30 times higher (8.8%). [ncbi.nlm.nih.gov]

  […] receptors and competitively displaces benzodiazepine molecules, preventing further benzodiazepine binding. 3 Flumazenil should not be used routinely Flumazenil is contraindicated in patients with unknown or mixed overdose, benzodiazepine tolerance, seizure [cmaj.ca]

  Seizures may be precipitated and resedation may occur in patients who awakened following flumazenil administration. Seizures may increase morbidity and mortality of the overdose. [doi.org]

  Seizures also occurred in 0.25% of BDZ OD patients in the absence of flumazenil therapy (due to coingestion of proconvulsant drugs). [orca.cf.ac.uk]

• Confusion

  Other effects can include: confusion dizziness jitteriness/excitability slurred speech loss of coordination impaired judgement difficulty in thinking clearly memory loss mood swings and aggressive behaviour. [mydr.com.au]

  In long-term users who have developed dependence, cessation of BZDs can result in a withdrawal syndrome, with manifestations including anxiety, irritability, confusion, seizures, and sleep disorders. [1] Alprazolam withdrawal syndrome may be especially [emedicine.medscape.com]

  Extreme drowsiness or trouble staying awake Slurred speech or confusion Agitation Lack of muscle coordination Coma How is a benzodiazepine overdose diagnosed? Your healthcare provider will ask about the medicines you take. [drugs.com]

  The signs and symptoms of benzodiazepine overdose are: Somnolence Confusion Diminished reflexes Respiratory depression Apnea Respiratory arrest Cardiac arrest The treatment for benzodiazepine overdose is: Discontinue dental treatment Call for assistance [dentalcare.com]

  A higher dose of benzodiazepines can make you feel drowsy, confused, aggressive, and uncoordinated. Benzodiazepine withdrawal symptoms include headaches, heart palpitations, nausea, sweating and shakiness. [drugfoundation.org.nz]

• Slurred Speech

  Other effects can include: confusion dizziness jitteriness/excitability slurred speech loss of coordination impaired judgement difficulty in thinking clearly memory loss mood swings and aggressive behaviour. [mydr.com.au]

  Other effects may include slurred speech, loss of motor coordination, weakness, headache, lightheadedness, blurred vision, dizziness, nausea, vomiting, low blood pressure, and slowed breathing. [www1.nyc.gov]

  Clinical features : CNS depressio n : lethargy, somnolence, hyporeflexia Respiratory depression Mild hypotension Ataxia Slurred speech Carbamazepine and oxcarbazepine: possibly SIADH Diagnostics Routine urine screening for benzodiazepine metabolites [amboss.com]

  Lethargy, slurred speech, ataxia, coma, and respiratory arrest may occur. Generally, patients with benzodiazepine-induced coma have hyporeflexia and midposition or small pupils. Hypothermia may occur. [accessmedicine.mhmedical.com]

  Signs of an Overdose on Xanax, Valium, or Klonopin Symptoms of overdose on Xanax, Valium, or Klonopin include: Drowsiness or extreme fatigue Confusion, agitation, anxiety, and mood changes Dizziness Slurred speech or acting drunk Amnesia Physical weakness [americanaddictioncenters.org]

• Dizziness

  Other effects may include slurred speech, loss of motor coordination, weakness, headache, lightheadedness, blurred vision, dizziness, nausea, vomiting, low blood pressure, and slowed breathing. [www1.nyc.gov]

  Other effects can include: confusion dizziness jitteriness/excitability slurred speech loss of coordination impaired judgement difficulty in thinking clearly memory loss mood swings and aggressive behaviour. [mydr.com.au]

  The most common adverse effects in patients who received flumazenil were injection site pain (10.3%), agitation (8%), vomiting (3.4%), dizziness (3.4%), headache (3.4%), tachycardia (3.4%), and crying (3.4%). Three patients developed seizures. [ncbi.nlm.nih.gov]

  Avoid consuming alcohol as it may increase dizziness and drowsiness. Inform your doctor if you are pregnant, planning to conceive or breastfeeding. [1mg.com]

  Signs of an Overdose on Xanax, Valium, or Klonopin Symptoms of overdose on Xanax, Valium, or Klonopin include: Drowsiness or extreme fatigue Confusion, agitation, anxiety, and mood changes Dizziness Slurred speech or acting drunk Amnesia Physical weakness [americanaddictioncenters.org]

• Amnesia

  BACKGROUND: A prospective study was conducted to investigate the presence of anterograde amnesia in those who attempted suicide by benzodiazepine overdose and to study the correlation with sedation. [ncbi.nlm.nih.gov]

  It provides anxiolysis, sedation, hypnosis, skeletal muscle relaxation, anterograde amnesia, respiratory depression and an anticonvulsant effect but has no analgesic properties. [dentalcare.com]

  One hundred and thirty patients responded positively to flumazenil, characterized by improved response to painful stimuli, and decreased amnesia. [mjiri.iums.ac.ir]

  Important adverse effects include confusion, impaired motor coordination, amnesia, drowsiness, and respiratory depression. [amboss.com]

  Calming, euphoria Vivid or disturbing dreams Amnesia, hostility, irritability Overdose may be fatal. [getsmartaboutdrugs.gov]

Benzodiazepine overdose is managed according to possible complications.

A magnetic resonance imaging (MRI) of the brain is a necessity if the patient appears unconscious, comatose and with a possible risk of acidosis. The MRI will expose herniations, edema and diffuse white matter injury (leukoencephalopathy) relatively excluding the lesions of the gray matter. The white matter injury may also be of connection with the use of chemotherapy agents and exposure to toxins e.g. carbon monoxide. Signs of edema and herniation may evolve and be the cause of death if not handled or monitored appropriately [6] [7].

A computed tomography (CT) examination findings include hypodensity in the affected area of the white brain matter, correlating to the clinical picture found in MRI. Reports suggest that early in the disease, the imaging of the patient's brain can appear normal which leads to discharge from the hospital. After about two weeks, a rapid deterioration of the white matter precedes and involves serious changes in consciousness, behavior, gait, parasympathetic system, etc., advancing to dramatic complications like coma or quadriparesis. Thus the importance of monitoring the affected patient is suggested [8].

Urine sample analysis may expose high levels of benzodiazepines [6].

Lumbar puncture with a collection of the cerebrospinal fluid is useful to exclude other diagnoses e.g. herpes simplex virus infection, Epstein-Barr virus disease or other infections associated with brain tissues that cause similar radiologic findings. The analysis includes cell count, protein, and glucose level determination [9].

Electroencephalography (EEG) is optional and used to discover electrical potential abnormalities if the patient experienced neurologic signs e.g. seizures. The EEG might reveal slowing of background in low frequencies [6].

It is a viable alternative to inpatient treatment for those who have home, work, or school obligations to fulfill. Cognitive behavioral therapy (CBT). This is a treatment approach that may be used in both inpatient and outpatient treatment programs. [drugabuse.com]

Amy has completed the American Psychiatric Nurses Association’s course on Effective Treatments for Opioid Use Disorder and continuing education on Screening, Brief Intervention and Referral to Treatment (SBIRT). [drugrehab.com]

[…] to speak to a treatment support advisor, who can help you find the right treatment program for your needs. [recovery.org]

Three Part Question [In adults with acute opiate overdose] is [concomitant use of benzodiazepines] associated with a [poorer prognosis in terms of death aspiration, admission to ITU] Clinical Scenario A 27 year old man comes into the emergency department [bestbets.org]

Please find relevant information on First Aid for Benzodiazepine Overdose regarding cause, signs & symptoms, administration of first aid treatment, prognosis, preventive measures, and additional resources HERE. [dovemed.com]

With good supportive care prognosis is excellent. Toxic Mechanism: Simple mechanism, they enhance the inhibitory neurotransmitter GABA by increasing the opening frequency of chlorine. [lifeinthefastlane.com]

The prognosis depends on how quickly the diagnosis is made and the treatment administered. [ncbi.nlm.nih.gov]

9.1.1 Ingestion 9.1.2 Inhalation 9.1.3 Skin exposure 9.1.4 Eye contact 9.1.5 Parenteral exposure 9.1.6 Other 9.2 Chronic poisoning 9.2.1 Ingestion 9.2.2 Inhalation 9.2.3 Skin exposure 9.2.4 Eye contact 9.2.5 Parenteral exposure 9.2.6 Other 9.3 Course, prognosis [inchem.org]

Acute poisoning with benzodiazepines and other hypnotics: etiologic cause, sex/age distribution and clinical outcome. J of IMAB. 2016 Oct-Dec;22(4):1371-1374. DOI: 10.5272/jimab.2016224.1371. [journal-imab-bg.org]

Etiology 4. Clinical Course IV. Benzodiazepine Withdrawal 1. Signs and Symptoms 2. Treatment V. Benzodiazepine Overdose 1. Clinical Presentation 2. Treatment VI. Case Study: Benzodiazepine Drug-Drug Interaction VII. [ce4less.com]

This activity reviews the pathophysiology, presentation, and etiology of benzodiazepine toxicity and highlights the role of the interprofessional team in the management of these patients. [ncbi.nlm.nih.gov]

Gökel, Etiological and demographical characteristics of acute adult poisoning in Adana, Turkey, Human & Experimental Toxicology, 26, 5, (401), (2007). M. Schmidt, Benzodiazepine, Suchtmittel in der AINS, 10.1007/978-3-540-33734-8_5, (79-89), (2007). [doi.org]

Use of flumazenil in the diagnosis and treatment of patients with coma of unknown etiology. Crit Care Med 1993; 21: 538–42 PubMed CrossRef Google Scholar 63. Skeie B, Emhjellen S, Wickstrom E, et al. [link.springer.com]

International Journal of Epidemiology, 22, 838 – 847. Shader, I. R. & Greenblat, D. J. ( 1993 ) Use of benzodiazepines in anxiety disorders. New England Journal of Medicine, 328, 1398 – 1405. [doi.org]

Epidemiology of acute drug poisoning in a tertiary center from Iasi Country, Romania. Hum Exp Toxicol. 2011 Dec;30(12):1896-903. [ PubMed ] 13. Hutton J, Dent A, Buykx P, Burgess S, Flander L, Dietze P. [journal-imab-bg.org]

Thus the prevalence of an isolated benzodiazepine use disorder is difficult to determine from epidemiologic studies. [ncbi.nlm.nih.gov]

Unfortunately, this syndrome remains of an unclear pathophysiology and with no successful treatment. [ncbi.nlm.nih.gov]

Pharmacotherapy: A Pathophysiologic Approach, 9th edition. Chapter 53: Anxiety Disorders I; Generalized Anxiety, Panic, and Social Anxiety Disorders. Access Pharmacy [online]. DiPiro et al. Pharmacotherapy: A Pathophysiologic Approach, 9th edition. [rxlist.com]

Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7987346. Accessed June 9, 2012. [accesspharmacy.mhmedical.com]

"Though broad efforts are underway to prevent overdose from opioid painkillers, there is another class of prescription drugs that require attention—benzodiazepines," she said. [forbes.com]

Vancouver’s Overdose Prevention Society says there were 16 overdoses in the city over two days last week. [globalnews.ca]

Centers for Disease Control and Prevention. National Vital Statistics System. Multiple Cause of Death 1999-2013. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2014. [doi.org]

We examined data from the Medical Expenditure Panel Survey and multiple-cause-of-death data from the Centers for Disease Control and Prevention. [ncbi.nlm.nih.gov]

“Moving forward, policy interventions should focus on preventing concurrent exposure instead of simply reducing the length of time patients use both drugs.” [upmc.com]

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