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Proposed mechanisms by which sudden unexplained death syndrome in epilepsy (SUDEP) occurs include cardiac dysrhythmias. We hypothesized that individuals dying of SUDEP would have enlarged hearts compared with normal, increasing the risk of sudden cardiac death should the autonomic nervous system initiate a dysrhythmia. We performed a retrospective case-control study in a medical examiner population, comparing the mean heart mass in a group of individuals who died of SUDEP to a group of individuals with epilepsy who died suddenly due to some unrelated cause (non-SUDEP). We found no significant difference in the mean heart mass between the 2 groups when analyzing the unadjusted data. Upon stratifying the cases by age, however, we found a significant reduction in the frequency of SUDEP in individuals 40 or more years of age with an increased heart mass compared with those younger. This reduced frequency disappeared when cases where the cause of death was indeterminate between SUDEP and heart disease were reclassified from non-SUDEP to SUDEP. With increasing age, the likelihood of finding a cause of death that competes with the possibility of SUDEP increases, making SUDEP appear to be a phenomenon of the young. The inclusion of seizure deaths evaluated in a medical examiner office in studies of SUDEP would provide the benefit of a more certain diagnosis in each given case. Moreover, the inclusion of cases from the medical examiner population would stem attrition in a clinical study due to loss to follow-up.

The practice of medicine has always depended upon effective communication. The quality of patient care is highest when the patient and physician freely communicate with each other and when attending and consulting physicians freely communicate among themselves. Today patients have an unprecedented ability to educate themselves concerning their health and health care. Any patient with Internet access can search the Medline, seek an explanation of the content of medical reports (including pathology reports), explore the practice history and licensure of his physicians, or look into the feasibility of bringing a malpractice suit. Meanwhile, the nature of the physician–consultant physician relationship is also changing because of telemedicine.

Properly conducted programs in quality control and quality assurance improve the practice of pathology and are, of course, required for accreditation of a pathology laboratory. The laws governing quality control and quality assurance in hospitals vary greatly from state to state, and thus only general points will be discussed here.

Pathologists are physicians, a fact pathologists sometimes remind others of when it suits the pathologist’s purpose. Otherwise, pathologists, who have chosen to toil in the wings, are usually content to be overlooked. Nevertheless, the pathologist is a physician first and a pathologist second. Therefore, pathologists have legal obligations that are common to all physicians. Some of those common obligations, however, do take on a special twist in the practice of pathology.

It is a regrettable truth that some practitioners of medicine are corrupt. Some unscrupulous physicians forsake the practice of sound medicine for new careers as suppliers of pain medications. Other physicians are willing to testify to unsound medicine in court as expert witnesses. What constitutes unethical expert witness testimony, and what can be done about it?

As mentioned in Chapter 2, an expert witness has training and experience beyond that of ordinary human experience, and the expert witness is called upon in court to provide the judge and jury the benefit of his special training and experience so that the best possible judgment can be rendered. An expert witness is allowed to give his opinion in court concerning a matter within his area of expertise. In other words, an expert witness is permitted to use his special training and experience to make his own judgment concerning matters that fall within his area of expertise. Having made his judgment, the expert witness may then pass his personal judgment of the situation on to the judge and jury so that they can use his informed opinion to make their own decision concerning the guilt of the party accused of committing a criminal or civil wrong. That courts should grant such authority to expert witnesses is, in a way, astonishing. In order for an expert witness to function properly, as a teacher to the court, the court assumes that the privilege granted to an expert witness of offering his opinion is balanced by the responsibility of using his special knowledge to assess each question and situation with equanimity.

Both law and medicine are dramatic. Many radio dramas, television shows, and movies are based upon either medicine or law because what physicians and attorneys do is sometimes the stuff of high drama. Court is especially dramatic because a trial is, in a very real sense, a piece of theatre. A trial occurs when two parties who disagree over some matter present themselves before an independent party for a judgment that is binding upon the parties that disagree. The American judicial system arrives at that judgment, called the verdict, through an adversarial trial system. You may think of an adversarial trial system as a civilized version of trial by combat. In order to understand the legal proceedings in a courtroom, it is critically important to understand the theory and practice of the adversarial trial system. The method by which every trial in the United States is conducted hangs on this adversarial approach to justice.

Your first notice of involvement in a legal matter if you are the defendant in a lawsuit will be a summons. If you are a fact witness, your first notice may be a subpoena. If you are serving as an expert witness, then your first notice was being contacted by an attorney to consider taking the case. Notification of a malpractice suit is discussed in Chapter 4; fact and expert witness distinctions are discussed in Chapters 2 and 5. However you became involved in the case, for you this particular legal battle has begun. In order to be an effective part of the legal proceedings, up to and including a trial, you need to prepare yourself. You prepare yourself by reviewing the case and then by reviewing the case and planning for trial with the attorney that you are working with.

Objective: The purpose of this study was to present the epidemiology of homicide among children younger than 6 years of age in Jefferson County, Alabama. This study focused on obtaining great detail on homicides and suspicious deaths occurring within a fixed population. Methods: For purposes of this study, cases included Jefferson County deaths attributed to “homicide” or that were “undetermined” as noted in the coroner files among children younger than 6 years of age who were born and died between January 1, 1988 and December, 31, 1998. Victim and offender characteristics were obtained from the Jefferson County Coroner/Medical Examiner Office records. Environmental factors and circumstances surrounding the death were noted as well. Results: The 53 study subjects were mainly female (55%), Black (69%), younger than 2 years of age (85%), had single mothers (38%), and a history of abuse (53%). Offenders were more likely to be male (64%), Black (73%), and a parent of the victim (53%). Homicides primarily resulted from an angry impulse (61%), with hands the most common weapon (61%). Conclusions: The majority of deaths in this study occurred among children younger than age 2, with a high proportion of fatalities among Black children of unmarried mothers. The offender most often knew the victim, with half of all homicides and two-thirds of all infant homicides involving a parent. More than half of the homicides resulted from an angry impulse, while the most common scenario for deaths with undetermined intent involved the caretaker finding the child unresponsive.

OBJECTIVE: To study the incidence and nature of pelvic fractures in rapidly fatal automobile accidents. DESIGN: Retrospective. SETTING: County Medical Examiner's Office. PATIENTS: The files of 255 consecutive motor vehicle accident fatalities examined at the Jefferson County Coroner/Medical Examiner's office (study period 1996-1998) were reviewed. We correlated this information with our previous findings, derived from a review of 392 such cases (study period 1994-1996). RESULTS: Approximately 25% of decedents involved in rapidly fatal automobile accidents sustained pelvic fractures. In 93% of the cases, postmortem radiographs were available and suitable for scoring according to the Orthopaedic Trauma Association nomenclature. The distribution of pelvic fractures by type was type A, 16%; type B, 32%; and type C, 52%, with the most common pelvic fracture being type C1 (26%). Additionally, pedestrians and motorcyclists were twice as likely to sustain a pelvic fracture, and the severity of pelvic fracture type seemed to correlate with increasing speed of the automobile. No correlation between drug use or direction of impact and incidence or type of pelvic fracture was observed. Compared with published studies on survivors of automobile accidents, our data suggest that pelvic injuries may tend to be more severe in victims who do not survive to hospitalization. CONCLUSIONS: Our data indicate that current estimates about the mortality of pelvic fractures may be faulty due to exclusion of victims who fail to survive to hospitalization. This series suggests that an appreciation of the full spectrum of pelvic ring disruptions requires collaboration between orthopaedic surgeons and forensic pathologists. Language: en

Utilities that supply power are subject to theft of service and theft of hardware used to provide service. Individuals who try to steal from a power utility risk electrocution. We conducted a retrospective study of all individuals examined by the Jefferson County Coroner Medical Examiner Office from January 1981 through December 2001 and found that 8 individuals died trying to steal from a power utility. All decedents were men, with an average age of 33 years. Seven decedents were stealing copper, and 1 was stealing electricity. Only 1 decedent survived long enough to be admitted to a hospital. Five decedents were intoxicated, 3 with ethanol, 1 with cocaine, and 1 with both cocaine and ethanol. Seven decedents sustained electrical burns in keeping with the high voltage to which they were subjected. The unburned decedent died of laceration of the aorta at its origin from the heart, an injury sustained when the decedent fell from the power pole. All 8 decedents attempted their theft during daylight. Items found in the decedent's pockets, the presence of a ladder nearby, or the presence of electrical tools around the body may help to establish the attempted act of theft.

Sudden unexplained death in epilepsy occurs when epilepsy patients die suddenly and unexpectedly in the absence of recent tonic-clonic seizure activity. There is currently no known reliable indicator of acutely lethal seizure activity. Clinical studies record a relationship between recent (within 10-40 minutes) seizure activity and elevated serum prolactin levels, and postictal elevation of prolactin within peripheral vessels has proved clinically useful in determining recent seizure activity. The authors hypothesized that elevated prolactin could be detected in cerebral vessels by immunohistochemical stains, serving as a marker for sudden unexplained death in epilepsy. They conducted a retrospective study of individuals who died in their jurisdiction during the 14 years from 1986 through 1999. The study contained one group of individuals who died of sudden unexplained death in epilepsy, a group with epilepsy who died of some other cause, and a control group whose members died rapidly of a gunshot wound of the torso. Sections of hippocampus and neocortex were obtained and stained with a polyclonal prolactin antibody. No significant difference in the level of immunostaining for prolactin in cerebral vessels was found between the experimental and control groups. A review of the protocols used indicates that revision of certain aspects may provide better immunostaining and more conclusive results.

In Alabama, little is known about the overall characteristics of job-related injuries.We examined fatal occupational injuries that occurred in Jefferson County, Alabama, from 1990 through 1999 using files maintained by the Jefferson County Coroner/Medical Examiner Office. Mortality rates were calculated by sex, age, race, occupation, and industry.There were 186 fatal occupational injuries; 136 were unintentional. The overall fatality rate was 4.45 deaths per 100,000 worker-years. Mortality rates were higher among men than among women, and they increased with advancing age. The homicide rate was higher among black workers than among whites. Mining, manufacturing, and transportation were the industries with the highest fatal injury rates. Transportation-related jobs and manual labor were high-risk occupations.High-risk industries should consider worker-targeted injury prevention programs, and particular attention should be paid to elderly workers.

Interpretation of the concentration of a drug is more difficult when a combination of drugs is present in a decedent's blood. An increase in deaths resulting from co-intoxication with methadone and a benzodiazepine led the authors to perform a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office. They found 101 deaths wherein methadone was detected in the blood. Based on the drugs detected in the blood, these 101 cases were grouped into four categories: (1) pure methadone intoxication, (2) intoxication with methadone and benzodiazepine, (3) intoxication with methadone and other drugs excluding benzodiazepine, and (4) intoxication with methadone, benzodiazepines, and other drugs. Methadone was the sole intoxicant in 15 cases, with a mean concentration of 0.27 mg/L. Benzodiazepines were the most frequently detected co-intoxicant (60 of 101 cases). Benzodiazepine was the only co-intoxicant in 30 cases, and the mean methadone concentration in those 30 cases was 0.599 mg/L. Higher levels of methadone may occur in acute intoxication with methadone and benzodiazepine because benzodiazepines compete with methadone for methadone receptors. Higher levels of methadone may occur with chronic abuse of methadone and benzodiazepines because over time, benzodiazepines inhibit the hepatic enzymes that metabolize methadone.

Pelvic fractures are frequent complications of motor vehicle accidents, and motor vehicle accidents are the most common cause of pelvic fracture. Although pelvic fractures are associated with considerable morbidity and mortality, there has traditionally been no attempt to grade or classify pelvic fractures during postmortem examination. The authors performed a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office from 1994 to 1996, reviewing investigative reports and autopsy findings. Radiographs were examined for the presence and Tile type of pelvic fracture. Pelvic fractures were identified in 88 of 392 cases (23%). In most (89%), the pelvic fracture was readily classified according to Tile type on the basis of radiographs and the inferred mechanism of injury. This study indicates that current estimates of the mortality of pelvic fractures are low because of the exclusion of individuals who do not survive to hospitalization. Furthermore, pelvic fractures in rapidly fatal motor vehicle accidents tend to be more severe than fractures in individuals who have a significant interval of survival. The presence and classification of pelvic fractures may be readily determined by radiographs in most cases. The Tile classification scheme is easy to apply and has important implications in the comparison of study groups.

A 13-year-old girl experienced a fall during gym class that caused immediate unresponsiveness and death. The lone witness reported that the decedent lost her balance as she approached a hurdle and fell, striking her head on a crossbar of the hurdle near the ground. Autopsy revealed no external injury. Internal injury that could be demonstrated anatomically was confined to a contusion within the right semicapitis muscle at the base of the skull. In the absence of an anatomic cause of death, possible explanations of the death include a cardiac dysrhythmia, a vasovagal stimulus, and diffuse axonal injury caused by a concussive force to the junction of the medulla and spinal cord. Animal studies have shown that severe concussion can cause death via profound autonomic dysfunction without leaving anatomic evidence of injury, and that the essential component of concussion is an element of rotational injury to the brain. The authors believe that the blow to the neck caused this death by the transmission of a concussive force through the reticular activating system. The prompt work of police in distinguishing the lone witness from several people in the area who thought they knew what had happened was essential for diagnosis. On reaching our conclusions, the authors notified first the family, then the superintendent of the school system, and finally the news media. The authors told each party in turn that they would be contacting the others.

A 53-year-old Caucasian male victim of suicide was suspected of overdose with sertraline and alprazolam after death-scene investigation. The concentration of sertraline, a selective serotonin reuptake inhibitor, was determined by a gas chromatograph with mass selective detection. The concentration of alprazolam, a triazolobenzodiazepine, was determined by high-performance liquid chromatography. The sertraline concentration was reported at 1.0 mg/L in peripheral blood, which is greater than previously reported in other postmortem cases in which death was attributed to a multiple drug overdose. The N-desmethylsertraline concentration was reported at 0.2 mg/L in peripheral blood, which is far less than in other postmortem cases and suggests acute intoxication in this case. The alprazolam concentration was reported at 33 microg/L in heart blood, which is within the therapeutic range. The cause of death was multiple drug intoxication following acute use of sertraline, the manner of death was suicide, and the mechanism of death is an unexplained drug interaction and/or toxicity.

Understanding the pathogenesis of viral myocarditis is linked to the availability of sensitive assays to detect viruses in clinical material. Recent advances in molecular techniques permit direct detection of viral-specific nucleic acid in tissue samples. This report describes a protocol for DNA extraction and amplification of adenovirus genome from formalin-fixed, paraffin-embedded human tissues that detects as little as 10 copies of viral genome in a background of 0.5 μg of human DNA. This sensitive assay permitted the examination of archived tissues to establish a retrospective diagnosis of adenoviral myocarditis in two pediatric patients.

The following abstracts are compiled from Check Sample exercises published in 2008. These peer-reviewed case studies assist laboratory professionals with continuing medical education and are developed in the areas of clinical chemistry, cytopathology, forensic pathology, hematology, microbiology, surgical pathology, and transfusion medicine. Abstracts for all exercises published in the program will appear annually in AJCP. # 1 Fetal Lung Maturity Testing Clinical Chemistry No. CC 08-1 (CC-367) {#article-title-2} Neonatal respiratory distress syndrome (RDS) is a disorder of pulmonary immaturity with a high mortality characterized by low levels of pulmonary surfactant. Gestational age determines risk based on concentration of pulmonary surfactant, ie, as gestation progresses the concentration of pulmonary surfactant increases. As a result, newborns delivered at fewer than 28 weeks have a more than 60% risk of RDS, whereas those delivered at more than 34 weeks have a less than 5% risk of RDS. In situations where gestational age alone is not sufficient to determine RDS risk and preterm delivery is medically needed, amniotic fluid analysis can be performed to determine pulmonary surfactant concentration. Four common methods are the lecithin-sphingomyelin ratio, phosphatidylglycerol measurement, surfactant-albumin ratio, and lamellar body count. All of these tests have excellent negative predictive values but poor positive predictive values, ie, they are great at confirming maturity but poor at confirming immaturity. # 2 Alkaline Phosphatase Isoenzyme Analysis: Guiding the Differential Diagnosis of Elevated Serum Total Alkaline Phosphatase Clinical Chemistry No. CC 08-2 (CC-368) {#article-title-3} The measurement of alkaline phosphatase (ALP) has long been used in clinical medicine, primarily to aid the diagnosis and monitoring of liver and bone diseases. Its diagnostic utility is limited by the enzyme’s wide tissue distribution and by a variety of potential nonpathologic causes. Isoenzyme analysis is one of several tools available to the clinician hoping to further characterize an elevated total ALP. It provides differentiation among liver, bone, intestinal, placental, and tumor-related forms as the cause of an elevation. The case presents a patient with persistent elevated ALP and atypical bands in the isoenzyme electrophoresis gel. An atypical ALP may be the result of a macroenzyme, which, if present, complicates interpretation of the test result and may cause additional, unnecessary testing or procedures. Recognizing and reporting a macroenzyme is an important service the clinical laboratorian can provide a clinician. # 3 Indirect Phlebotomy: Is It Good Practice? Clinical Chemistry No. CC 08-3 (CC-369) {#article-title-4} Indirect phlebotomy, the collection of blood samples through vascular infusion devices, is a common practice adopted to minimize needle-stick pain and discomfort in hospitalized patients. However, this practice can lead to alteration of the specimen and medical errors associated with misrepresentation of the blood test values. Among the possible problems, dilution or concentration of a particular analyte may occur, depending on the contents of the line’s infusate. Although some studies may indicate that blood collection from lines can be acceptable for isolated laboratory tests, there are insufficient data to demonstrate the reliability of line draws as routine practice. Use of lines for specimen collection should be reserved only for those patients with truly poor vascular access or those patients who require multiple phlebotomies in a short time period. Samples should be collected from lines only under a direct physician order, with careful attention to technique and established protocols that take many variables into account, including the analytes, contents of the line, type of line, discard blood volume, time interval between interruption of infusion and sampling, and catheter size. Even with careful attention to these details, clinicians must remain wary of the potential for medical errors related to misinterpretation of laboratory test results based on such samples.

Dr. Wagner wrote his Color Atlas of the Autopsy for crime scene investigators, law enforcement officials, and other professionals who interact with forensic pathologists during the course of an autopsy. Individuals who lack formal medical training have many questions upon seeing their first autopsy, and Color Atlas of the Autopsy attempts to answer these questions by capturing the process of autopsy examination as it unfolds.

Cranes are machines used to move heavy objects. Cranes are operated by crane operators, usually working in conjunction with an assistant guiding the movements of the crane from his vantage point outside the crane. Few jurisdictions require that crane operators be either licensed or certified. We conducted a retrospective study of those dying of crane-related injuries in our jurisdiction during the 16 years from 1981 to 1996. All ten decedents were male, and the manner of each death was accidental. Neither ethanol nor drugs of abuse were detected in any case. Eight of the ten decedents died due to blunt force injuries, one due to mechanical asphyxia, and one due to thermal burns. Investigation by the Occupational Safety and Health Administration (OSHA) led to fines ranging from $80 to $2700 in six of the ten cases. Nationwide, electrocution is the most common cause of crane-related death, but no crane-related death in Jefferson County was caused by electrocution in our study. The absence of electrocutions was due to the planned, routine suspension of power to electrical lines in the vicinity of a crane during the crane's operation, a practice saving an estimated seven lives. Nevertheless, human error or lack of planning was still responsible for most of the deaths in our study. In addition to careful planning and adherence to safety standards established by planning, we recommend the mandatory licensure and certification of professional crane operators and the assessment of larger fines by OSHA for safety standard violations.

Acute aortic dissections are catastrophic vascular events that have a high rate of mortality. Aortic dissections have been associated with a variety of factors, particularly hypertension. We reviewed 84 medical examiner autopsies on individuals dying from acute aortic dissections with particular emphasis on the role of drugs. Previous case reports have associated aortic dissections with both cocaine and methamphetamine intoxication. We found that seven of the 35 cases tested for drugs of abuse were positive for methamphetamine. Our study had no cases of solely cocaine-related dissection, although one of the cases was positive for both methamphetamine and the cocaine metabolite benzoylecgonine. No significant association was found with any other drugs. As with other studies, we found the most common risk factor to be hypertension. Surprisingly, methamphetamine use was the second most common risk factor. The association between methamphetamine use and aortic dissection is most likely due to its hypertensive effect. Although methamphetamine appears to pose a greater risk than cocaine, both drugs should be considered as possible factors in all aortic dissections.

Sudden unexplained death syndrome (SUDS) in epilepsy is identified as death in an epileptic individual with no anatomic cause found at autopsy. SUDS appears to be associated with subtherapeutic levels of anticonvulsants. Sudden death with no demonstrable cause at autopsy accounts for 5% to 30% of deaths in epileptic individuals. In the majority of cases, however, the cause of death in epileptic individuals can be demonstrated at autopsy. We examined the anti-epileptic drug concentrations in decedents who died as a direct result of epilepsy and compared these findings with those from a control population of epileptic patients who died suddenly due to some unrelated cause. This retrospective study was conducted on all deaths involving patients with epilepsy examined at the Jefferson County Coroner/Medical Examiner office from 1986–95. Out of 115 total cases the underlying cause of death was epilepsy in 60 cases—52 cases of SUDS and 8 deaths caused by an accident precipitated by a seizure. In 44 cases death was unrelated to the decedent's epilepsy. In 11 cases the contribution of epilepsy to death could not be determined. Published articles on SUDS report subtherapeutic anti-epileptic medication levels in 63% to 94% of cases. We found subtherapeutic drug levels in 69% of the 52 cases of SUDS, in 75% of the 8 cases where a seizure precipitated an accident causing death, and in 34% of the control population. The incidence of subtherapeutic anticonvulsants is significantly greater in patients dying as a direct result of their epilepsy than in those dying of an unrelated cause.

With constant improvements in socioeconomic conditions, the people of most industrialized nations are living longer. Most elderly individuals lead productive lives within the community. Unfortunately, when elderly individuals suffer from a debilitating disease or injury, society seems ill-equipped to care for them. The frailty and social isolation that comes with illness or advanced age renders the elderly more vulnerable to crime. This study examines the circumstances that surround homicides of those 65 years of age or older which occurred in Jefferson County, Alabama over a 15 year span. We conducted a retrospective study of all decedents brought to the Jefferson County Coroner/Medical Examiner Office during the 15 years from 1981-1995. A computer search identified 150 homicide victims who were 65 years or older. In these 150 cases the causes of death were as follows: gunshot wound 50%, blunt force injuries 19%, knife wounds 14%, and asphyxiation 10%. Younger homicide victims were much less likely to be killed as the result of a direct physical assault; blunt force injuries and asphyxiation combined caused death in only 7% of the younger population. Robbery was the most common motive for death in the elderly population, which accounted for 37% of cases. The most common location for homicides in the elderly population was in their own residence, which accounted for 71% of cases. Four elderly homicide victims were shot by the police. Three elderly decedents died as a result of abuse.

Sudden, unexpected death can occur following rupture of an artery weakened by aneurysmal dilatation or by medial dissection. In both of these diseases the arterial abnormality is exacerbated by hypertension. This arterial weakness could also be aggravated by the use of drugs with a hypertensive effect. We report seven cases of sudden death in patients abusing methamphetamine--four cases of ruptured berry aneurysms and three cases of aortic dissection with cardiac tamponade. The autopsy findings are reviewed, and various mechanisms are considered by which methamphetamine may contribute to death in such cases.

Two forms of cytochrome P-450 were purified to apparent homogeneity from several different preparations of human liver microsomes. One form, designated P-450DB, had relatively high catalytic activity towards the drugs debrisoquine, sparteine, bufuralol (both the (+)- and (-)-isomers), encainide, and propranolol and appears to be the enzyme involved in the polymorphic distribution of oxidative activities towards these substrates in humans. The other form, designated P-450PA, had relatively high phenacetin O-deethylase activity and appears to be involved in the variation of this activity among humans. Polyclonal antibodies raised to the two enzymes were specific for the antigens as judged by immunoelectrophoresis and immuno-inhibition studies. The two enzymes and their activities were distinguished by chromatographic separation, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, amino acid composition, immuno-inhibition studies, and steady-state kinetic assays. Immunochemical studies suggest that each form represents only a small fraction of the total cytochrome P-450 in human liver microsomes. These biochemical studies provide a basis for better understanding the mechanisms which underlie genetic polymorphisms involving P-450 cytochromes in humans.

Purpose Heroin has a half-life of 2–6 min and is metabolized too quickly to be detected in autopsy samples. The presence of 6-acetylmophine (6-AM) in urine, blood, or other samples is convincing evidence of heroin use by a decedent, but 6-AM itself has a half-life of 6–25 min before it is hydrolyzed to morphine, so 6-AM may not be present in sufficient concentration to detect in postmortem samples. Codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin. Studies report that a ratio of morphine to codeine greater than one indicates heroin use. We hypothesize that the ratio of morphine to codeine in our decedents abusing drugs intravenously will be no different in individuals with 6-AM present than in individuals where no 6-AM is detected, and we report our study of this hypothesis. Methods All accidental deaths investigated by the Jefferson County Coroner/Medical Examiner Office from 2010 to 2013 with morphine detected in blood samples collected at autopsy were reviewed. Five deaths where trauma caused or contributed to death were excluded from the review. The presence or absence of 6-AM and the concentrations of morphine and codeine were recorded for each case. The ratio of morphine to codeine was calculated for all decedents. Any individual in whom no morphine or codeine was detected in a postmortem sample was excluded from further study. Absence or presence of drug paraphernalia or evidence of intravascular (IV) drug use was documented in each case to identify IV drug users. The proportion of the IV drug users with and without 6-AM present in a postmortem sample was compared to the M/C ratio for the individuals. Results Of the 230 deaths included in the analysis, 103 IV drug users with quantifiable morphine and codeine in a postmortem sample were identified allowing for calculation of an M/C ratio. In these IV drug users, the M/C ratio was greater than 1 in 98 % of decedents. When controlling for the absence or presence of 6-AM there was no statistically significant difference in the proportion of IV drug users when compared to non IV drug users with an M/C ratio of greater than 1 (p = 1.000). Conclusion The M/C ratio in IV drug users, if greater than 1, is seen in deaths due to heroin toxicity where 6-AM is detected in a postmortem sample. This study provides evidence that a M/C ratio greater than one in an IV drug user is evidence of a death due to heroin toxicity even if 6-AM is not detected in the blood. Using the M/C ratio, in addition to scene and autopsy findings, provides sufficient evidence to show heroin is the source of the morphine and codeine. Listing heroin as a cause or contributing factor in deaths with evidence of IV drug abuse and where the M/C ratio exceeds 1 will improve identification of heroin fatalities, which will allow better allocation of resources for public health initiatives.

Summary Hooded rodents were tested in an emotionality condition and two competitive “dominance” conditions. It was found that stable rankings of subjects within the test groups could be established for each of the three conditions. Significant negative correlations were also found between a subject's “emotionality” ranking in a group and his ranking in the group in relation to either condition of competitive dominance, while a significant positive correlation was found between a subject's ranking in both of the competitive dominance conditions. These data are taken as evidence for a debilitating effect of high emotionality on one's success in competition.

Exposure of isolated hepatocytes to extracellular ATP, cystamine or ionophore A23187 was associated with an increase in cytosolic Ca2+ concentration, a stimulation of intracellular proteolysis, and the appearance of plasma membrane blebs which preceded the loss of cell viability. Both bleb formation and cell killing were prevented when inhibitors of Ca2+-activated neutral proteases, such as antipain or leupeptin, were included in the incubation medium, whereas inhibitors of lysosomal proteases had no effect. Thus, the activation of a Ca2+-dependent, non-lysosomal proteolytic system appears to be responsible for the plasma membrane blebbing and, ultimately, the cytotoxicity associated with treatment of hepatocytes with agents that disrupt intracellular Ca2+ homeostasis.