National Association of Medical Examiners position paper on the certification of cocaine-related deaths

The National Association of Medical Examiners Committee on Cocaine-related Deaths recommends that the following guidelines be applied in the process of documenting, interpreting, and certifying potential cocaine-related fatalities. The committee cautions that the investigation of any drug-related death requires a complete investigation of the circumstances of death, the death scene, and past medical history. It is also necessary to have the results of the forensic toxicological analysis and those of a complete forensic autopsy examination prior to formulating an opinion as to the cause and manner of death. Cocaine should be considered the underlying cause of the death when 1 or more of the following is true: (1). the circumstances surrounding the death can be associated with an acute cocaine exposure and there are no supervening causes of death; (2). the immediate cause of death is directly due to a readily identifiable mechanism or disease such as a gunshot wound or a stroke, yet the acute use of cocaine was the direct underlying cause of the trauma or the disease process; and (3). chronic cocaine use leads to a disease that results in an ultimately fatal pathologic process leading to organ injury and death. The committee further cautions that reported drug levels may not directly relate to the toxic or lethal effects of the drug upon the patient. These guidelines are intended for use by practicing medical examiners and physicians who certify drug deaths, as well as providing education tools for students.     

Pregnancy-related maternal deaths

Pregnancy is a normal biologic process, but because of a variety of physiologic factors, it increases a woman's risk for death. Maternal deaths in pregnancy may be due to conditions unique to pregnancy, conditions associated with pregnancy, or conditions unrelated to but exacerbated by pregnancy. Death may occur during any trimester, during labor/birth, or postpartum. In this report, we present 45 cases of pregnancy-related maternal deaths that were investigated and autopsied at the Dallas County Medical Examiners office between 1977 and 1999, and we review the topic of pregnancy-related maternal death.     

The application of an automated allele concordance analysis system (CompareCalls) to ensure the accuracy of single-source STR DNA profiles

A powerful method for validating a scientific result is to confirm specific results utilizing independent methodologies and processing pathways. Thus, we have designed, developed and validated an automated allele concordance analysis system (CompareCalls, patent pending) that performs comparisons between two independent DNA analysis platforms to ensure the highest accuracy for allele calls. Application of this system in a quality assurance role has shown the potential to eliminate greater than 90% of the STR analysis required of a DNA data analyst. While this system is broadly applicable for use with any two independent STR analysis programs, either prior to or following human data review, we are presenting its application to data generated with the ABI Prism Genotyper software system versus data generated with the SurelockID system. With the automated allele concordance analysis system, the GeneScan DNA fragment data generated from an ABI 377 gel image are analyzed in two independent pathways. In one analysis pathway, the GeneScan data are imported into Genotyper software where STR labels are assigned to the fragment data based upon the criteria of the Kazam 20% macro. The "Kazam" macro provided with the Genotyper program works by labeling all peaks in a category (or locus) and then filtering (or removing) the labels from peaks, such as those in stutter positions, that meet predefined criteria. In the second pathway, the GeneScan data are imported into the SurelockID analysis platform where STR labels and error messages are assigned to the fragment data based upon hard-coded allele calling criteria and quality parameters. The resulting STR allele calls for each analysis platform are then compared, utilizing the automated allele concordance analysis system. Any differences in the STR allele calls between the two systems are flagged in a discordance report for further review by a qualified DNA data analyst. The automated allele concordance analysis system guides the DNA data analyst to the discordant data generated by either analysis platform. Additionally, the analyst is also directed to data that are of less than pristine quality which may have an increased potential for errors in interpretation by either analysis platform or by a human DNA data analyst. Implementation of an automated allele concordance analysis system will yield high-quality data for CODIS and free the human DNA data analyst to perform other critical duties within the laboratory.     

Esophageal and pharyngeal injuries associated with the use of the esophageal-tracheal Combitube

The Combitube is a ventilatory device consisting of a twin lumen tube with proximal and distal inflatable cuffs. The major benefit of the Combitube is that its design and function allow for ventilation through non-laryngoscope-assisted insertion into either the trachea, or esophagus. As with any invasive procedure, intubation using the Combitube carries certain risks and potential complications. The majority of complications are relatively minor; however, a rare and serious complication reported primarily in the anesthesiology literature is laceration of the esophagus. This reportedly rare injury is increasingly seen by medical examiners/coroners in the forensic setting. This paper presents a series of three cases of esophageal laceration and a single case of perforation of the hypopharynx associated with the use of the Combitube, while also exploring potential mechanisms of injury. In addition, this work demonstrates the vital role the medical examiner/coroner plays in identifying existing or potential problems with current or emerging medical devices.     

Mitochondrial DNA and STR analyses of maggot crop contents: effect of specimen preservation technique

DNA analysis of maggot crop contents can be used to identify a missing body or aid entomologists with interpreting evidence used for PMI estimations. Entomological evidence is often collected and preserved to keep identifiable external features intact. The preservation methods currently in use may not be suitable for preserving DNA in the maggot crop for later analysis. In this study, carrion maggots raised on human tissue were preserved under the following 8 preservation conditions: no fluid at -70 degrees C, no fluid at 4 degrees C, no fluid at 24 degrees C, 70% ethanol at 4 degrees C, 70% ethanol at 24 degrees C, 95% ethanol at 24 degrees C, Kahle's solution at 24 degrees C and formaldehyde at 24 degrees C. Maggots were dissected following 2 weeks, 8 weeks and 6 months of preservation. The maggot crops were extracted, human DNA was quantitated, and an attempt was made at amplifying mitochondrial DNA (mtDNA) and short tandem repeat (STR) loci. Both mtDNA and STRs were successfully amplified from maggots stored in ethanol or without any preservation fluid. Formalin-containing preservation solutions reduced the recovery of DNA. The best results were observed from maggots stored without any preservation fluid at -70 degrees C.     

Lay persons' versus psychologists' judgments of psychologically aggressive actions by a husband and wife

Literature assessing knowledge of and attitudes toward social issues has demonstrated that mental health professionals and lay persons often differ greatly. To add to the normative information in the field of psychological abuse and to determine whether the differences previously found between mental health professionals and lay persons extend to this field, a sample from each group rated psychologically aggressive items by a husband toward his wife. For the 102 items, psychologists were more likely to label the behaviors as "psychological abuse," but this tendency was due to psychologists considering the behaviors as either "always" or "possibly" abusive, whereas lay persons demonstrated a bimodal response pattern of rating the behaviors as "always" or "never" psychological abuse. Lay persons were much more likely than psychologists to rate items high in terms of severity level, however. The two groups used different contextual factors for determining that a behavior was psychological abuse when they initially were uncertain that it was abusive.     

Typologies of men who are maritally violent: scientific and clinical implications

Varying levels and types of husband violence may be conceptualized as typologies of maritally violent men. Across studies, batterer subtypes resembling those proposed by Holtzworth-Munroe and Stuart (1994) have been identified and generally found to differ in predicted ways. Longitudinal data from this study suggests that the subgroups continued to differ over three years. Over time, however, the placement of individual men into some subtypes was not stable. Whether to best conceptualize the heterogeneity among maritally violent men as differing subtypes or as variability along dimensions is considered. Clinical issues regarding the typology are discussed, including concern that the use of absolute cut-off points to identify subtypes is premature and consideration of using the typology to predict treatment outcome and to match interventions to subtypes. Regarding future research ideas, it is time to consider more immediate, situational and dyadic, processes leading to violence perpetration within each subtype.