Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Methamphetamine Toxicity Clinical Presentation

  • Author: John R Richards, MD, FAAEM; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Sep 11, 2015
 

History

Cardiovascular signs and symptoms of methamphetamine use are as follows[22, 23, 24, 25, 26, 27] :

  • Chest pain, aortic dissection, myocardial ischemia/infarction
  • Palpitations, tachyarrhythmia
  • Dyspnea and edema
  • Hypertension

Central nervous system manifestations of methamphetamine use are as follows[28, 29, 30, 31] :

  • Agitation, violent behavior, self-harm
  • Coma
  • New-onset seizure, movement disorders
  • Emotional lability, confusion, psychosis, paranoia, hypersexuality, and hallucinations
  • Headache

Respiratory manifestations of methamphetamine use are as follows[32, 33, 34] :

  • Dyspnea
  • Wheezing
  • Pneumothorax

Skin manifestations of methamphetamine use are as follows[35] :

  • Delusional parasitosis
  • Abscess, cellulitis

Gastrointestinal manifestations of methamphetamine use are as follows[14, 36] :

  • Abdominal pain
  • Obstruction

Dental manifestations of methamphetamine use are as follows[37, 38] :

  • Caries
  • Peridental abscesses
Next

Physical

Acute and long-term methamphetamine use may lead to abnormal findings on examination of the following organ systems:

  • Cardiovascular
  • Central nervous system
  • Gastrointestinal
  • Renal
  • Skin
  • Dental

Cardiovascular findings are as follows:

  • Tachycardia and hypertension is frequently observed [39]
  • Atrial and ventricular arrhythmias may occur [39]
  • Chest pain from cardiac ischemia and infarction following methamphetamine use has been reported; patients are at risk because of accelerated atherosclerosis from chronic use; acute aortic dissection or aneurysm has been associated with methamphetamine abuse [26, 23]
  • Hypotension may be observed with methamphetamine overdose with profound depletion of catecholamines [40]
  • Acute and chronic cardiomyopathy results directly from methamphetamine cardiac toxicity and indirectly from chronic hypertension and ischemia; intravenous use may result in endocarditis; patients may present with dyspnea, edema, and other signs of acute congestive heart failure (CHF) exacerbation [41, 24]

Central nervous system findings are as follows:

  • New-onset seizures may occur from direct CNS methamphetamine toxicity [30]
  • Acute and chronic methamphetamine exposure has been associated with a jerking, choreoathetoid movement disorder; these repetitive movements, hyperactivity, and inability to focus thought have been referred to as "tweaking" [29, 31]
  • Headache and cerebrovascular accidents with focal neurologic deficits may be caused by hemorrhage or vasospasm, cerebral edema, and cerebral vasculitis [27]
  • Acute psychosis, agitation, violence, and paranoia frequently results from alteration in CNS dopamine, serotonin, and glutamate pathways [42, 13]
  • Coma may result from depletion of catecholamine stores and/or concomitant ingestion of sedatives such as ethanol or narcotics [40]

Respiratory findings are as follows:

  • Barotrauma, including pneumomediastinum, pneumothorax, and pneumopericardium may result from forceful inhalation [32]
  • Acute noncardiogenic pulmonary edema and pulmonary hypertension may result from acute and chronic use, as well as from adulterants introduced during intravenous use such as talc or cornstarch [32, 33, 34]
  • Wheezing from reactive airway disease may be induced by methamphetamine [32]

Gastrointestinal findings are as follows:

  • Hepatocellular damage has been reported with methamphetamine after acute and chronic abuse; direct effects such as hypotension, hepatotoxic contaminants, hepatic vasoconstriction, lipid peroxidation, occult viral causes, and necrotizing angiitis have been postulated [43]
  • Severe abdominal pain may result from acute mesenteric vasoconstriction; methamphetamine has also been associated with the formation of ulcers and ischemic colitis. [36]
  • Necrotizing angiitis with arterial aneurysms and sacculations have been observed in the liver, pancreas, and small bowel of methamphetamine drug abusers [27]

Renal failure associated with amphetamines has been related to the following[44] :

  • Hypoxemia
  • Rhabdomyolysis
  • Necrotizing angiitis
  • Acute interstitial nephritis
  • Cardiovascular shock with subsequent acute tubular necrosis

Skin findings include the following:

  • Delusions of parasitosis and chronic skin-picking may result in neurotic excoriations and prurigo nodularis ("speed bumps") [4]
  • Methamphetamine injectors frequently present with abscess and cellulitis, which they often blame on a "spider bite" [35]
  • Production workers in illicit methamphetamine laboratories may present with extensive thermal and/or chemical burns. [45]

On dental examination, severe caries, especially of the maxillary teeth, is commonly seen in chronic methamphetamine users ("meth mouth"). This results from maxillary artery vasoconstriction, xerostomia, and poor hygiene.[37, 38]

Pregnancy and lactation

Methamphetamine use during pregnancy can be fatal to the mother and fetus.[46, 47] Methamphetamine has been shown to cause placental vasoconstriction and interfere with placental monoamine transporters resulting in spontaneous abortion.[48]

Methamphetamine is secreted in breast milk. A case of infant death from ingestion of methamphetamine-toxic breast milk has been reported.[49]

Previous
Next

Causes

Methamphetamine is a derivative of phenylethylamine. The substances differ structurally in that a methyl group attaches to the terminal nitrogen to form methamphetamine.

Most of the methamphetamine abused in the United States is produced in so-called superlabs, many of which are located in Mexico.[18] However, methamphetamine is relatively easy and inexpensive to synthesize, and small-scale illicit production occurs in home kitchens, workshops, recreational vehicles, and rural cabins.[4, 45, 50] Instructions for synthesis can be found on the Internet and the precursors are not difficult to obtain.

A common method of synthesis begins with ephedrine, which is reduced to methamphetamine using hydriodic acid and red phosphorus. Alternative approaches include using a different acid, a different catalyst, or a substituted ephedrine (eg, chloroephedrine, methylephedrine). The federal government and some states have enacted laws decreasing the availability of necessary precursor chemicals such as ephedrine, but many of these agents can still be obtained in other countries.

The methamphetamine produced by ephedrine reduction is a lipid-soluble pure base form, which is fairly volatile and can evaporate if left exposed to room air temperature. This product is converted to the water-soluble form, methamphetamine hydrochloride (HCl) salt. The manufacture of "ice", the smokable form of methamphetamine, from standard quality methamphetamine HCl is essentially a purification process.

Illicitly synthesized methamphetamine is frequently contaminated by nonstimulant organic or inorganic impurities. Poisoning from heavy metals, such as lead and mercury, or from carcinogenic solvents used in the synthesis process, has been reported.[51, 52] Street methamphetamine may be mixed with other drugs, including cocaine and phencyclidine.

Previous
 
 
Contributor Information and Disclosures
Author

John R Richards, MD, FAAEM Professor, Department of Emergency Medicine, University of California, Davis, Medical Center

John R Richards, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Derlet, MD Professor of Emergency Medicine, University of California at Davis School of Medicine; Chief Emeritus, Emergency Department, University of California at Davis Health System

Robert W Derlet, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Association for the Advancement of Science, Infectious Diseases Society of America, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Timothy E Albertson, MD, MPH, PhD Professor of Pharmacology and Toxicology, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Chair, Department of Internal Medicine, University of California, Davis, School of Medicine; Professor of Anesthesiology, Professor of Emergency Medicine and Clinical Toxicology, Davis Medical Center; Chief of Pulmonary and Critical Care, Veterans Affairs, Northern California Health Care System; Medical Director of Poison Control System, University of California, San Francisco, School of Pharmacy

Timothy E Albertson, MD, MPH, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. United Nations Office on Drugs and Crime (UNODC). World Drug Report 2015. Available at http://www.unodc.org/documents/wdr2015/World_Drug_Report_2015.pdf. Accessed: September 11, 2015.

  2. Drug Abuse Warning Network (DAWN). 2011: National Estimates of Drug-Related Emergency Department Visits. Available at http://www.samhsa.gov/data/2k13/DAWN2k11ED/DAWN2k11ED.pdf. Accessed: September 11, 2015.

  3. Vearrier D, Greenberg MI, Miller SN, Okaneku JT, Haggerty DA. Methamphetamine: history, pathophysiology, adverse health effects, current trends, and hazards associated with the clandestine manufacture of methamphetamine. Dis Mon. 2012 Feb. 58(2):38-89. [Medline].

  4. Richards JR. Amphetamine derivatives. Cole SM. New research on street drugs. New York: Nova; 2006. chap 5.

  5. Hendrickson RG, Horowitz BZ, Norton RL, Notenboom H. "Parachuting" meth: a novel delivery method for methamphetamine and delayed-onset toxicity from "body stuffing". Clin Toxicol (Phila). 2006. 44(4):379-82. [Medline].

  6. Richards JR, Bretz SW, Johnson EB, Turnipseed SD, Brofeldt BT, Derlet RW. Methamphetamine abuse and emergency department utilization. West J Med. 1999 Apr. 170(4):198-202. [Medline].

  7. Hendrickson RG, Cloutier R, McConnell KJ. Methamphetamine-related emergency department utilization and cost. Acad Emerg Med. 2008 Jan. 15(1):23-31. [Medline].

  8. Uhlmann S, Debeck K, Simo A, Kerr T, Montaner JS, Wood E. Crystal methamphetamine initiation among street-involved youth. Am J Drug Alcohol Abuse. 2013 Nov 5. [Medline].

  9. Kenagy DN, Bird CT, Webber CM, Fischer JR. Dextroamphetamine use during B-2 combat missions. Aviat Space Environ Med. 2004 May. 75(5):381-6. [Medline].

  10. Panenka WJ, Procyshyn RM, Lecomte T, MacEwan GW, Flynn SW, Honer WG, et al. Methamphetamine use: a comprehensive review of molecular, preclinical and clinical findings. Drug Alcohol Depend. 2013 May 1. 129(3):167-79. [Medline].

  11. Volkow ND, Fowler JS, Wang GJ, Shumay E, Telang F, Thanos PK, et al. Distribution and pharmacokinetics of methamphetamine in the human body: clinical implications. PLoS One. 2010 Dec 7. 5(12):e15269. [Medline]. [Full Text].

  12. Cruickshank CC, Dyer KR. A review of the clinical pharmacology of methamphetamine. Addiction. 2009 Jul. 104(7):1085-99. [Medline].

  13. Krasnova IN, Cadet JL. Methamphetamine toxicity and messengers of death. Brain Res Rev. 2009 May. 60(2):379-407. [Medline]. [Full Text].

  14. Katsumata S, Sato K, Kashiwade H, et al. Sudden death due presumably to internal use of methamphetamine. Forensic Sci Int. 1993 Dec. 62(3):209-15. [Medline].

  15. Kashani J, Ruha AM. Methamphetamine toxicity secondary to intravaginal body stuffing. J Toxicol Clin Toxicol. 2004. 42(7):987-9. [Medline].

  16. Kirkpatrick MG, Gunderson EW, Levin FR, Foltin RW, Hart CL. Acute and residual interactive effects of repeated administrations of oral methamphetamine and alcohol in humans. Psychopharmacology (Berl). 2011 Jul 12. [Medline].

  17. Zhang JX, Zhang da M, Han XG. Identification of impurities and statistical classification of methamphetamine hydrochloride drugs seized in China. Forensic Sci Int. 2008 Nov 20. 182(1-3):13-9. [Medline]. [Full Text].

  18. DrugFacts: Methamphetamine. National Institute on Drug Abuse. Available at http://www.drugabuse.gov/publications/drugfacts/methamphetamine. Accessed: October 8, 2014.

  19. National Survey of Drug Use and Health. National Institute on Drug Abuse. Available at http://www.drugabuse.gov/national-survey-drug-use-health. Accessed: October 7, 2014.

  20. Swanson SM, Sise CB, Sise MJ, Sack DI, Holbrook TL, Paci GM. The scourge of methamphetamine: impact on a level I trauma center. J Trauma. 2007 Sep. 63(3):531-7. [Medline].

  21. Carvalho M, Carmo H, Costa VM, Capela JP, Pontes H, Remião F, et al. Toxicity of amphetamines: an update. Arch Toxicol. 2012 Aug. 86(8):1167-231. [Medline].

  22. Diercks DB, Kirk JD, Turnipseed SD, Amsterdam EA. Evaluation of patients with methamphetamine- and cocaine-related chest pain in a chest pain observation unit. Crit Pathw Cardiol. 2007 Dec. 6(4):161-4. [Medline].

  23. Hawley LA, Auten JD, Matteucci MJ, Decker L, Hurst N, Beer W, et al. Cardiac complications of adult methamphetamine exposures. J Emerg Med. 2013 Dec. 45(6):821-7. [Medline].

  24. Won S, Hong RA, Shohet RV, Seto TB, Parikh NI. Methamphetamine-Associated Cardiomyopathy. Clin Cardiol. 2013 Aug 27. [Medline].

  25. Turnipseed SD, Richards JR, Kirk JD. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med. 2003 May. 24(4):369-73. [Medline].

  26. Watts DJ, McCollester L. Methamphetamine-induced myocardial infarction with elevated troponin I. Am J Emerg Med. 2006 Jan. 24(1):132-4. [Medline].

  27. Davis GG, Swalwell CI. Acute aortic dissections and ruptured berry aneurysms associated with methamphetamine abuse. J Forensic Sci. 1994 Nov. 39(6):1481-5. [Medline].

  28. Gold MS, Kobeissy FH, Wang KK, Merlo LJ, Bruijnzeel AW, Krasnova IN, et al. Methamphetamine- and trauma-induced brain injuries: comparative cellular and molecular neurobiological substrates. Biol Psychiatry. July 2009. 66:118-27. [Medline]. [Full Text].

  29. Rhee KJ, Albertson TE, Douglas JC. Choreoathetoid disorder associated with amphetamine-like drugs. Am J Emerg Med. 1988 Mar. 6(2):131-3. [Medline].

  30. Bowyer JF, Thomas M, Schmued LC, Ali SF. Brain region-specific neurodegenerative profiles showing the relative importance of amphetamine dose, hyperthermia, seizures, and the blood-brain barrier. Ann N Y Acad Sci. 2008 Oct. 1139:127-39. [Medline].

  31. Granado N, Ares-Santos S, Moratalla R. Methamphetamine and Parkinson's disease. Parkinsons Dis. 2013. 2013:308052. [Medline]. [Full Text].

  32. Albertson TE, Walby WF, Derlet RW. Stimulant-induced pulmonary toxicity. Chest. 1995 Oct. 108(4):1140-9. [Medline].

  33. Nestor TA, Tamamoto WI, Kam TH, Schultz T. Crystal methamphetamine-induced acute pulmonary edema: a case report. Hawaii Med J. 1989 Nov. 48(11):457-8, 460. [Medline].

  34. Thompson CA. Pulmonary arterial hypertension seen in methamphetamine abusers. Am J Health Syst Pharm. 2008 Jun 15. 65(12):1109-10. [Medline].

  35. Cohen AL, Shuler C, McAllister S, Fosheim GE, Brown MG, Abercrombie D, et al. Methamphetamine use and methicillin-resistant Staphylococcus aureus skin infections. Emerg Infect Dis. 2007 Nov. 13(11):1707-13. [Medline].

  36. Johnson TD, Berenson MM. Methamphetamine-induced ischemic colitis. J Clin Gastroenterol. 1991 Dec. 13(6):687-9. [Medline].

  37. Richards JR, Brofeldt BT. Patterns of tooth wear associated with methamphetamine use. J Periodontol. 2000 Aug. 71(8):1371-4. [Medline].

  38. Hamamoto DT, Rhodus NL. Methamphetamine abuse and dentistry. Oral Dis. 2009 Jan. 15(1):27-37. [Medline].

  39. Haning W, Goebert D. Electrocardiographic abnormalities in methamphetamine abusers. Addiction. 2007 Apr. 102 Suppl 1:70-5. [Medline].

  40. Smit AA, Wieling W, Voogel AJ, Koster RW, van Zwieten PA. Orthostatic hypotension due to suppression of vasomotor outflow after amphetamine intoxication. Mayo Clin Proc. 1996 Nov. 71(11):1067-70. [Medline].

  41. Yeo KK, Wijetunga M, Ito H, Efird JT, Tay K, Seto TB, et al. The association of methamphetamine use and cardiomyopathy in young patients. Am J Med. 2007 Feb. 120(2):165-71. [Medline].

  42. Richards JR, Derlet RW, Duncan DR. Methamphetamine toxicity: treatment with a benzodiazepine versus a butyrophenone. Eur J Emerg Med. 1997 Sep. 4(3):130-5. [Medline].

  43. Cherner M, Letendre S, Heaton RK. Hepatitis C augments cognitive deficits associated with HIV infection and methamphetamine. Neurology. 2005. 64:1343-47. [Medline].

  44. Richards JR, Johnson EB, Stark RW, Derlet RW. Methamphetamine abuse and rhabdomyolysis in the ED: a 5-year study. Am J Emerg Med. 1999 Nov. 17(7):681-5. [Medline].

  45. Santos AP, Wilson AK, Hornung CA, Polk HC Jr, Rodriguez JL, Franklin GA. Methamphetamine laboratory explosions: a new and emerging burn injury. J Burn Care Rehabil. 2005 May-Jun. 26(3):228-32. [Medline].

  46. Stewart JL, Meeker JE. Fetal and infant deaths associated with maternal methamphetamine abuse. J Anal Toxicol. 1997 Oct. 21(6):515-7. [Medline].

  47. Catanzarite VA, Stein DA. Crystal' and pregnancy--methamphetamine-associated maternal deaths. West J Med. 1995 May. 162(5):454-7. [Medline].

  48. Ramamoorthy JD, Ramamoorthy S, Leibach FH, Ganapathy V. Human placental monoamine transporters as targets for amphetamines. Am J Obstet Gynecol. 1995 Dec. 173(6):1782-7. [Medline].

  49. Mother of baby killed by meth-contaminated breast milk gets 90 days. Available at http://www.sacbee.com/ourregion/story/1955191.html. Accessed: November 22, 2009.

  50. New meth formula avoids anti-drug laws. Available at http://www.msnbc.msn.com/id/32542373/ns/us_news-crime_and_courts/. Accessed: November 22, 2009.

  51. Burton BT. Heavy metal and organic contaminants associated with illicit methamphetamine production. NIDA Res Monogr. 1991. 115:47-59. [Medline].

  52. Conn C, Dawson M, Baker AT, et al. Identification of n-acetylmethamphetamine in a sample of illicitly synthesized methamphetamine. J Forensic Sci. 1996 Jul. 41(4):645-7. [Medline].

  53. McKinney PE, Tomaszewski C, Phillips S, Brent J, Kulig K. Methamphetamine toxicity prevented by activated charcoal in a mouse model. Ann Emerg Med. 1994 Aug. 24(2):220-3. [Medline].

  54. Richards JR, Albertson TE, Derlet RW, Lange RA, Olson KR, Horowitz BZ. Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review. Drug Alcohol Depend. 2015 May 1. 150:1-13. [Medline].

  55. Derlet RW, Albertson TE, Rice P. Protection against d-amphetamine toxicity. Am J Emerg Med. 1990 Mar. 8(2):105-8. [Medline].

  56. Derlet RW, Rice P, Horowitz BZ, Lord RV. Amphetamine toxicity: experience with 127 cases. J Emerg Med. 1989 Mar-Apr. 7(2):157-61. [Medline].

  57. Safety of Droperidol Use in the Emergency Department (9/7/2013). American Academy of Emergency Medicine (AAEM). Available at http://www.aaem.org/UserFiles/file/Safety-of-Droperidol-Use-in-the-ED.pdf. Accessed: 12/07/2013.

  58. Matteucci MJ, Auten JD, Crowley B, Combs D, Clark RF. Methamphetamine exposures in young children. Pediatr Emerg Care. 2007 Sep. 23(9):638-40. [Medline].

  59. Leelahanaj T, Kongsakon R, Netrakom P. A 4-week, double-blind comparison of olanzapine with haloperidol in the treatment of amphetamine psychosis. J Med Assoc Thai. 2005 Nov. 88 Suppl 3:S43-52. [Medline].

  60. Misra LK, Kofoed L, Oesterheld JR, Richards GA. Olanzapine treatment of methamphetamine psychosis. J Clin Psychopharmacol. 2000 Jun. 20(3):393-4. [Medline].

  61. Misra L, Kofoed L. Risperidone treatment of methamphetamine psychosis. Am J Psychiatry. 1997 Aug. 154(8):1170. [Medline].

  62. Shoptaw SJ, Kao U, Ling W. Treatment for amphetamine psychosis. Cochrane Database Syst Rev. 2009 Jan 21. CD003026. [Medline].

  63. Akingbola OA, Singh D. Dexmedetomidine to treat lisdexamfetamine overdose and serotonin toxidrome in a 6-year-old girl. Am J Crit Care. 2012 Nov. 21(6):456-9. [Medline].

  64. Tobias JD. Dexmedetomidine to control agitation and delirium from toxic ingestions in adolescents. J Pediatr Pharmacol Ther. 2010 Jan. 15(1):43-8. [Medline]. [Full Text].

  65. Ibrahim F, Viswanathan R. Management of agitation following aneurysmal subarachnoid hemorrhage: is there a role for Beta-blockers?. Case Rep Psychiatry. 2012. 2012:753934. [Medline]. [Full Text].

  66. Boehrer JD, Moliterno DJ, Willard JE, Hillis LD, Lange RA. Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med. 1993 Jun. 94(6):608-10. [Medline].

  67. Hysek CM, Vollenweider FX, Liechti ME. Effects of a beta-blocker on the cardiovascular response to MDMA (Ecstasy). Emerg Med J. 2010 Aug. 27(8):586-9. [Medline].

  68. Hysek C, Schmid Y, Rickli A, Simmler LD, Donzelli M, Grouzmann E, et al. Carvedilol inhibits the cardiostimulant and thermogenic effects of MDMA in humans. Br J Pharmacol. 2012 Aug. 166(8):2277-88. [Medline]. [Full Text].

  69. Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE Jr, Ettinger SM, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2011 May 10. 57(19):e215-367. [Medline].

  70. McKetin R, Najman JM, Baker A, Lubman DI, Dawe S, Ali R, et al. Evaluating the impact of community-based treatment options on methamphetamine use: findings from the Methamphetamine Treatment Evaluation Study (MATES). Addiction. 2012 May 7. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.