People use drugs or alcohol to escape, relax, or reward themselves. Over time they can make you believe that you need them to enjoy life, or that you can’t cope without them, which can gradually lead to dependence and addiction.
The drug addiction in youth today is a world-wide problem and more common than one can imagine. Teens are trying alcohol, marijuana, cigarettes, and heroin etc. even before they have turned 15. Just like any adult addict, the brain-working and neuron patterns of young drug addicts also show the same changes. Once the drugs and substance abuse take over their mind, their personality gradually begins to deform in a very strange way. Teens constitute an important part of our society. Imagining them to fall into the trap of substance abuse at such young age only points towards the seriousness of this issue.
The most common causes of drug addiction in youth are mainly an urge to experiment and experience something new. Then, there is peer pressure, lack of communication between parents and teens, low self-esteem, and a tendency towards seeking pleasure. Genetics and family history of substance abuse also contributed to drug addiction in teenagers. After trying the drugs once, the cycle goes on. It becomes an involuntary process and giving in to the harmful urges becomes a natural habit. The biggest reason behind the inability of our young ones to get out the drug addiction is denial and secrecy amongst both teens and their parents.
A long exposure to habit-forming substance abuse gives birth to poor memory, low self-confidence, serious health troubles, and even violent behaviors. The addicted teenagers are also more prone to having accidents, mood swings, poor sleep, and developing psychological disorders like schizophrenia and bipolar syndrome. The drug abuse may happen at a crucial time of their career-making and ruin the future despite having brilliant talents. The regret, however, may not always be reversible, leading to mental breakdown and suicidal tendencies in the teenagers.
ICD-10 Criteria for addiction:
An addiction must meet at least 3 of the following criteria.
1. Tolerance. Do you use more alcohol or drugs over time?
2. Withdrawal. Have you experienced physical or emotional withdrawal when you have stopped using? Have you experienced anxiety, irritability, shakes, sweats, nausea, or vomiting? Emotional withdrawal is just as significant as physical withdrawal.
3. Limited control. Do you sometimes drink or use drugs more than you would like? Do you sometimes drink to get drunk? Does one drink lead to more drinks sometimes? Do you ever regret how much you used the day before?
4. Negative consequences. Have you continued to use even though there have been negative consequences to your mood, self-esteem, health, job, or family?
5. Neglected or postponed activities. Have you ever put off or reduced social, recreational, work, or household activities because of your use?
6. Significant time or energy spent. Have you spent a significant amount of time obtaining, using, concealing, planning, or recovering from your use? Have you spent a lot of time thinking about using? Have you ever concealed or minimized your use? Have you ever thought of schemes to avoid getting caught?
7. Desire to cut down. Have you sometimes thought about cutting down or controlling your use? Have you ever made unsuccessful attempts to cut down or control your use?
Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behavior occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well.5 In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.
Signs and symptoms of substance abuse:
Depending on the actual compound, drug abuse including alcohol may lead to psychosis, health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.
Cannabis may trigger panic attacks during intoxication and with continued use, it may cause a state similar to dysthymia.22 Researchers have found that daily cannabis use and the use of high-potency cannabis are independently associated with a higher chance of developing schizophrenia and other psychotic disorders. In most cases drug induced psychiatric disorders fade away with prolonged abstinence.
Drug induced psychosis is a psychotic state caused by an excessive dose of both illegal and therapeutic drugs. This is supported by the West Australian Department of Health WADOH who defines stimulant-induced psychosis, as an episode where the use of a legal or illicit drug has caused a psychiatric illness where the reality of the patient is impaired. The impairment of the patient can also include hallucinations or delusions, which can cause additional communication problems or social interaction difficulties. The drug induced psychosis according to WADOH (2009) may also be as a result of the overuse or abuse of prescription medication, or the outcome of a history of illicit drug abuse.
Cannabis is a genus of flowering plant that includes one or more species. The plant is believed to have originated in the mountainous regions just north-west of the Himalayas in India. Cannabis sativa male plants show evidence of selection for traits that enhance fiber production and seed-oil (for fuel) but the female plant produce seeds (for food) and flower buds that can be used as a psychoactive substance because it has higher levels of the psychoactive delta-9-tetrahydrocannabinol (THC), whereas Cannabis indica was primarily selected for drug production and has relatively higher levels of cannabidiol (CBD) and Cannabinol (CBN) than THC.
Traditional herbal cannabis contains between 1 and 15 per cent of the main psycho-active ingredient, THC. Some of the newer strains, including skunk, contain up to 20 per cent, so can be 3 times as strong as traditional cannabis. It works more quickly, and can produce hallucinations with profound relaxation and elation – along with nervousness, anxiety attacks, projectile vomiting and a strong desire to eat. They may be used by some as a substitute for Ecstasy or LSD. Recent research in Europe, and in the UK, has suggested that people who have a family background of mental illness – so probably have a genetic vulnerability anyway – are more likely to develop schizophrenia if they use cannabis as well.
There is growing evidence that people with serious mental illness, including depression and psychosis, are more likely to use cannabis or have used it for long periods of time in the past. Regular use of the drug has appeared to double the risk of developing a psychotic episode or long-term schizophrenia.
When cannabis is smoked, its compounds rapidly enter the bloodstream and are transported directly to the brain and other parts of the body. The feeling of being ‘stoned’ or ‘high’ is caused mainly by the delta-9-THC binding to cannabinoid receptors in the brain. A receptor is a site on brain cell where certain substances can stick or “bind” for a while. If this happens, it has an effect on the cell and the nerve impulses it produces. Curiously, there are also cannabis-like substances produced naturally by the brain itself – these are called endocannabinoids.
Biochemical Effects :-
The most prevalent psychoactive substance in cannabis is delta-9-tetrahydrocannabinol (commonly called ch9169-THC, or simply THC). In the past two decades, the average content of THC in marijuana sold in North America has increased from about 1% to 3-4% or more.
One of the primary effects of marijuana in humans is the disruption of short-term memory, which is consistent with the abundance of CB1 receptors on the hippocampus. The effects of THC at these receptor sites produce what is called a ‘temporary hippocampal lesion.’ 3 As a result of this lesion, several neurotransmitters like acetylcholine, norepinephrine, and glutamate, are released that trigger a major decrease in neuronal activity in the hippocampus and its inputs. The total duration of cannabis intoxication when smoked is about 1 to 4 hours.
Behavioral effects:-
It is sometimes observed, and generally stereotyped, that systematic changes in a person’s lifestyle, ambitions, motivation, and personality happen when a young person starts smoking marijuana. In fact, in many situations when people are asked to describe the personality traits of a marijuana user, they will most likely portray a person of apathy or loss of effectiveness: a person with diminished capacity or willingness to carry out complex long-term plans, endure frustration, concentrate for long periods, follow routines, or even successfully master new material. Marijuana use can just as easily be seen as the result of such a personality shift as it can be the cause of it. Regardless, studies to raise this and other questions, like the prevalence of such ‘syndrome’ in the population, and proving a biological or psychological connection of the ‘syndrome’ to substance use, have not happened. Instead, a political tug of war has ensued with each point of view claiming their own scientific research as evidence.
Similarity of symptoms:-
There is a classification of psychosis within the DSM-IV called ‘cannabis psychosis’ which is very rare. In susceptible individuals, ingestion of sufficient quantities of the drug can trigger an acute psychotic event. It should be noted that the extent of a subject’s experience with cannabis is a strong factor determining susceptibility.
A Yale research study notes that subjects administered pure delta-9-THC induced transient symptoms which resemble those of schizophrenia ‘ranging from suspiciousness and delusions to impairments in memory and attention’. There were no side effects in the study participants one, three, and six months after the study. Cannabis use appears to be neither a sufficient nor a necessary cause for psychosis. It might be a component cause, part of a complex constellation of factors leading to psychosis, or it might be a correlation without forward causality at all. Similar correlations can be drawn between cannabis usage and cancer, for instance, because those who suffer from cancer may be more likely to use cannabis due to the pain relief it provides.

Introduction: Today I am going to be talking to you about why people over the age of 65 should be required to take a yearly driving test. Have you ever been driving to work, school, the mall or wherever you’re trying to get and you get stuck behind an old person going 20 in a 45? Or have an elder pull right out in front of you? Well same. Many older drivers are not in the proper state to be driving, and they should not be able to drive behind the wheel until they have taken the steps to prove they’re capable to drive on their own.

Main Point 1: Vision Loss
A major cause of elderly accidents are due to vision loss, as you get older it is more difficult for your eyes to adjust to the changes in light. This is especially dangerous at night. States have made it a requirement for drivers to get vision tests at certain ages: Maine and Maryland begin vision testing at age 40, Oregon age 50, Georgia age 64, and Florida are 80. Illinois and New Hampshire require older drivers to retake road test when renewing their license. Michigan however has no older age requirements- just that everyone renews every 4 years. Anyone however may report a potentially unsafe driver to the Secretary Of State office and authorities may require that person to pass a driving or vision test, or any other tests they find necessary.

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Main Point 2: Diseases
Diseases are very common in elders which can really affect their driving. Diseases such as cataracts and glaucoma, which are very common in those over 65, can make it harder to see colors or read signs. This could result in running through a red light, crosswalk, roundabout etc. Weaker muscles, reduced flexibility and limited range of motion restrict senior drivers ability to grip and turn the steering wheel or press the pedal or brake. Since older drivers are more fragile their fatality rates are 17 times higher than those of ages 25-64. Which brings me to my next point.

Main Point 3:


Umbilical Hernia in pediatric age group is very a common finding 1. The incidence of umbilical hernia in general population varies with age, race, gestational age, and coexisting disorders. In the USA, the incidence in African-American children from birth to 1-year-old ranges from 25 58%, whereas Caucasian children in the same age group have an incidence of 2 18.5%. 2, 3
After birth, closure of the umbilical ring is the result of complex interactions of lateral body wall folding in a medial direction, fusion of the rectus abdominis muscles into the linea alba, and umbilical orifice contraction which is aided by elastic fibers from the obliterated umbilical arteries. Fibrous proliferation of surrounding lateral connective tissue plates may also help with natural closure. Failure of these closure processes results in umbilical hernia. 4
Umbilical hernia is considered a benign condition that often disappears spontaneously. Surgical repair is frequently postponed and often not performed because the complications of this condition are rare and the majority of the defects close within 3 years; more than 90% close before the child is 6 years of age. 5, 6 Although umbilical hernias in pediatric are common as stated previously, they are still poorly studied and no existing standard guidelines for their management. The reason behind this, thought to be the straightforward repair with no significant challenges and secondly, the minimal complications of watchful waiting protocol due to their nature of spontaneous resolution.
For this, we performed a review of the existing literature on spontaneous closure of umbilical hernia, complications associated with watchful waiting, and recommendations on timing of operative repair.

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We performed an online literature search of ACP Journal Club, Clinical Evidence, Dynamed, Cochrane library, UpToDate, and PubMed. We targeted publications where pediatric umbilical hernias, recommendations on timing of surgical repair and natural history of spontaneous closure are addressed. Only Studies published in English were included in this review and no publication date limits were placed on the search. We excluded studies examining children older than 14 years, and umbilical hernias associated with other pathologies, medical comorbidities such as cirrhosis, renal failure or ascites, and any abdominal wall defects such as gastroschisis or omphalocele. We then summarized the results and recommendations of these studies and drawn a conclusion of their consensus.

Additionally, we performed our own single institutional retrospective study at Queen Rania Hospital for Children in Amman, Jordan. Medical records of 520 children presented to both outpatient offices and emergency department between 2007 and 2017, aged between 1 month and 14 years old were reviewed. The chief complain was painless umbilical swelling which was diagnosed by our faculties as an asymptomatic umbilical hernia. Size of the umbilical defects were not included in the study. Our goal was to identify the percentage of spontaneous closure within the first
5 years of age versus the rate of operatively repaired hernias beyond this age.


The likelihood of spontaneous closure of umbilical hernias in pediatric was reviewed in seven studies (summarized in Table-1). The overwhelming consensus from these articles was that, the majority of umbilical hernias close spontaneously without surgical intervention before the age of 5 years. The primary danger associated with observation therapy is the possibility of incarceration or strangulation. Studies have shown these complications to be quite rare, with an incidence of less than 0.2%. Also, studies found that methods like pressure dressings or other used devices to keep the hernia reduced do not enhance the closure process and may result in skin irritation and breakdown.

The reviewed studies are 5 prospective studies, 1 retrospective study, and one crosssectional observational study.

In the retrospective cohort study by Woods et al. in 1953 a two hundred and eightythree infants with umbilical hernia have been studied. In this series a frequency of an umbilical hernia of one in six infants has been recorded. The first appearance of the hernia is usually within the first few months of life and rarely after six months. 93 % of children became cured automatically in the first year of life in the absence of any strapping or truss 7.

Mack et al. in 1945 estimates based on prevalence data in a population of African children that 90% of hernias closed spontaneously and that there was a continual curve of healing from infancy to puberty 8.

A prospective study by Heifetz et al. in 1963 found 92.3% hernias over 0.5 cm in diameter closed spontaneously (40% closed with-in 1 year, 65% within 2 years, and 85% by 3 years). This study found that over the first year of life, the diameter of these comparatively large umbilical hernia defects decreased by an average of 18% per month 9.

Hall et al. examined a cross-section of 665 African-American children and found that the prevalence of umbilical hernias at age 11 was approximately half that at age 4 5, suggesting spontaneous closure later in childhood 10.

In a prospective cohort study of South African children in 1980, Blumberg et al. found that hernia prevalence steadily decreased with age, suggesting that even the majority of large hernias tend to close by in 3 4 years of life without surgery 11.

In contrast, a prospective cohort study of African American children in 1967 by Walker et al. found that although 89.1% of hernias closed spontaneously by age 6, larger hernias were less likely to close. This study reported that 95% of hernias (201/211) with a defect 1.5 cm in infancy 12.

A prospective cohort study investigated non-operative umbilical strapping as a method of treating umbilical hernias without surgery. In 2016, Yanagisawa et al. examined 89 children who underwent umbilical strapping. They found that 91% of umbilical hernias treated with adhesive strapping closed in 13 weeks regardless of the diameter of the hernia defect, gestational age, or the timing of treatment and only
2.25% of hernias recurred 13

Our retrospective study of 520 children aged between 1 month and 14 years presented between 2007 and 2017 with umbilical hernias in Queen Rania hospital for Children in Amman, Jordan resulted in that 442 were treated non-operatively and 78 children underwent straightforward surgical repair. Of the 442 cases treated conservatively, 85% closed spontaneously by 1-5 years old irrespective of the defect size upon their presentation. Majority of spontaneous closure was during the first 3 years of life. No incarceration or strangulation were identified.


The current recommendations available on literature in regards to the exact timing of surgical repair for asymptomatic pediatric umbilical hernias show no evidence for a particular management strategy. In contrast to complicated or symptomatic hernias where an immediate repair is frankly recommended.

While reviewing the literature, we found there is a strong consensus that umbilical hernias in pediatric age groups have the predisposition to close spontaneously especially during the first 3 years of life unlike hernias in adult. Our own retrospective cohort study has also the same conclusions.

This natural history of spontaneous closure of umbilical hernias in pediatric has the advantage of avoiding unnecessary operations, and complications of anesthesia and surgeries. This natural trend is also cost effective to health care facilities.

There is significant variability in author recommendations surrounding surgical repair of asymptomatic pediatric umbilical hernias. The majority of studies in this review concluded no increased risk of complication in children less than 6 years old, meanwhile anesthesia literature suggests an increased risk of neurologic and respiratory complications in children less than 6 years of age 14, 15.

The majority of manuscripts recommendation were supporting the watchful waiting over surgical repair for asymptomatic umbilical hernias in children younger than 5 years old. There was no association between size of the defect and likelihood of developing strangulation or incarceration. Although larger defects may be less likely to close and eventually require surgery, several small studies have demonstrated the possibility of spontaneous closure later in childhood.


Asymptomatic umbilical hernias in pediatric are a common pathology that encountered by most of pediatric and many general surgeons in their outpatient offices or in emergency department. Little recommendations were found in literature in regards to timing of surgical repair since the vast majority are resolved spontaneously with very minimal complications on watchful waiting strategy.

We concluded from the reviewed studies and additionally we found from our own experience based on our retrospective study we have done, that no surgical repair is indicated for asymptomatic umbilical hernias in infants and children before the age of 4-5 years irrespective of the defect size. In contrast to symptomatic or complicated hernias, an immediate measurements should be taken in place, this including an operative repair. This guidelines would be of benefits to avoid complications of surgical repair and complications from anesthesia, lessen the burden on medical staff and hospitals and, it is cost effective for health care systems.


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