Investigation of morphine and morphine glucuronide levels and cytochrome P450 isoenzyme 2D6 genotype in codeine-related deaths

Compared to morphine and morphine-6-glucuronide (M6G), codeine and its other major metabolites codeine-6-glucuronide and norcodeine have weak affinity to opioid μ-receptors. Analgesic effects of codeine are thus largely dependent on metabolic conversion to morphine by the polymorphic cytochrome P450 isoenzyme 2D6 (CYP2D6). How this relates to toxicity and post-mortem whole blood levels is not known. This paper presents a case series of codeine-related deaths where concentrations of morphine, M6G and morphine-3-glucuronide (M3G), as well as CYP2D6 genotype, are taken into account. Post-mortem toxicological specimens from a total of 1444 consecutive forensic autopsy cases in Central Norway were analyzed. Among these, 111 cases with detectable amounts of codeine in femoral blood were identified, of which 34 had femoral blood concentrations exceeding the TIAFT toxicity threshold of 0.3mg/L. Autopsy records of these 34 cases were retrieved and reviewed. In the 34 reviewed cases, there was a large variability in individual morphine to codeine concentration ratios (M/C ratios), and morphine levels could not be predicted from codeine concentrations, even when CYP2D6 genotype was known. 13 cases had codeine concentrations exceeding the TIAFT threshold for possibly lethal serum concentrations (1.6 mg/L). Among these, 8 individuals had morphine concentrations below the toxic threshold according to TIAFT (0.15 mg/L). In one case, morphine as well as M6G and M3G concentrations were below the limit of detection. A comprehensive investigation of codeine-related fatalities should, in addition to a detailed case history, include quantification of morphine and morphine metabolites. CYP2D6 genotyping may be of interest in cases with unexpectedly high or low M/C ratios.     

Can Civil Society Organizations Solve the Crisis of Partisan Representation in Latin America?

This article takes up the question of whether civil society organizations (CSOs) can and do act as mechanisms of representation in times of party crisis. It looks at recent representation practices in Argentina, Bolivia, and Brazil, three countries where political parties have experienced sharp crises after several decades of mixed reviews for their party systems. At such moments, any replacement of parties by CSOs should be especially apparent. This study concludes that the degree of crisis determines the extent that CSOs' representative functions replace partisan representation, at least in the short term. Where systems show signs of re‐equilibration, CSOs offer alternative mechanisms through which citizens can influence political outcomes without seeking to replace parties. Where crisis is profound, CSOs claim some of the basic party functions but do not necessarily solve the problems of partisan representation.     

Y-chromosomal STR haplotypes in a Belgian population sample and identification of a micro-variant with a flanking site mutation at DYS19

Allele frequencies and haplotypes for 12 Y-chromosomal STR loci included in the Powerplex System (Promega, Madison, USA) were determined in a sample of 113 unrelated males of Belgian origin. Ninety-nine different haplotypes were observed with an overall haplotype diversity of 0.997.     

Discovery of decomposed and mummified corpses in the domestic setting--a marker of social isolation?

Mass media reports attribute the occurrence of decomposed or mummified corpses in a domestic setting mainly to an increasing social isolation of elderly people. Not much is known about the demographic and medical conditions under which individuals are found months or even years after death in their homes. For this study, autopsy reports of individuals found dead and mummified or decomposed between 1993 and 1997 with those from 1963 to 1967 were retrospectively analyzed. Between 1993 and 1997, a total number of 320 individuals were found decomposed at home compared to 412 such cases between 1963 and 1967. The proportion of individuals older than 64 years was significantly higher during the 1990s study period. Furthermore, the proportion of deaths attributable to natural causes was significantly lower during the 1990s, whereas the rate of suicides was nearly three times higher.     

Anticoagulant-related iliopsoas muscle bleeding leading to fatal exsanguination: report of two autopsy cases

Two cases of massive iliopsoas muscle bleeding leading to fatal exsanguination are presented. Both patients (two women, 61 and 74 years old, respectively) received oral anticoagulation with phenprocoumon. The intramuscular bleeding occurred spontaneously in women of relatively good physical condition. Intriguingly, phenprocoumon concentrations were within the therapeutic range (1.55 microg/ml and 1.26 microg/ml, respectively) as detected by toxicologic analysis. These cases demonstrate that severe bleeding in the iliopsoas muscle has to be considered in all patients receiving anticoagulant medication, even in those who have coagulation parameters within the therapeutic range. Especially in older patients with a high degree of comorbidity or in patients receiving analgesic drugs, the potential of fatal outcome of iliopsoas muscle bleeding seems to be of clinicopathologic relevance.     

The role of information technology in reducing medical errors

This Article summarizes the discussion at a breakout session held at the American Health Lawyers Association's (Health Lawyers') 2003 Public Interest Colloquium,' Minimizing Medical Errors: Legal Issues in the Debate on Improving Patient Safety, held February 28-March 1, 2003, in Washington, DC. The authors developed a series of core questions identifying relevant legal and policy issues relating to the use of information technology in reducing medical errors, and facilitated the breakout discussion.     

Can Dispersed Practices Be Held Ethically Accountable?

This article offers a positive answer to: can dispersed practices, such as global civil society and the society of democratic states, be held ethically accountable? To clarify this kind of ethical judgement, a contrast is made between the ways we hold individuals ethically accountable within social practices, awarding praise/blame to individuals (individual persons or collective actors such as states), and the way in which we deploy critical theories to hold a dispersed practice ethically responsible for certain consequences flowing from its operation. Such judgements are ironic given that within such practices individual actors are not, from an ethical point of view, doing wrong. The kind of ethical criticism made possible by critical theory in general, and constitutive theory in particular, is a necessary precursor to many political campaigns aimed at transforming the global dispersed social practices within which we are constituted as who we are.     

Sites of repression and resistance: political space in refugee camps in Thailand

Refugee camps are frequently perceived as spaces of emergency and exception. However, they are also spaces where millions of people live their everyday lives, sometimes for extended periods of time. As such, refugee camps are political spaces where struggles over the right to influence life in the camps and shape how they are governed are continuously ongoing. In this context, what are the opportunities for political participation for refugees living in camps? How and to what extent are refugees able to carve out political space where they can engage with and affect their lives and their situations? This paper addresses these questions through an analysis of refugee camps in Thailand. Drawing on Foucauldian analytics, the analysis demonstrates how key strategies employed to govern refugees, namely spatial confinement and development interventions are also creatively subverted by refugees and appropriated as bases for resistance and political mobilization. The article provides new insights into the relationship between power and resistance, demonstrating how specific technologies of governance create opportunities for subversion, reinterpretation, and appropriation.