Subdural haemorrhage sustained in a baby-rocker? A biomechanical approach to causation

An unconscious 8 weeks old infant was admitted to hospital and found to have bilateral, subdural and retinal haemorrhages. He died the following day. The explanation for the subdural haemorrhage put forward by his carers was that the infant had been in a baby-rocker and that the carers had seen the rocker being rocked vigorously by their 14 months old daughter on two separate occasions. This paper describes the biomechanics of an infant model in the particular baby-rocker used and determines the maximum forces generated, comparing them with the 'forces' thought to be compatible with the causation of subdural haemorrhage.     

Urine/blood ratios of ethanol in deaths attributed to acute alcohol poisoning and chronic alcoholism

The concentrations of ethanol were determined in femoral venous blood (BAC) and urine (UAC) and the UAC/BAC ratios were evaluated for a large case series of forensic autopsies in which the primary cause of death was either acute alcohol poisoning (N=628) or chronic alcoholism (N=647). In alcohol poisoning deaths both UAC and BAC were higher by about 2g/l compared with chronic alcoholism deaths. In acute alcohol poisoning deaths the minimum BAC was 0.74 g/l and the distribution of UAC/BAC ratios agreed well with the shape of a Gaussian curve with mean+/-standard deviation (S.D.) and median (2.5th and 97.5th centiles) of 1.18+/-0.182 and 1.18 (0.87 and 1.53), respectively. In alcoholism deaths, when the BAC was above 0.74 g/l (N=457) the mean+/-S.D. and median (2.5th and 97.5th centiles) UAC/BAC ratios were 1.30+/-0.29 and 1.26 (0.87 and 2.1), respectively. When the BAC was below 0.74 g/l (N=190), the mean and median UAC/BAC ratios were considerably higher, being 2.24 and 1.58, respectively. BAC and UAC were highly correlated in acute alcohol poisoning deaths (r=0.84, residual S.D.=0.47 g/l) and in chronic alcoholism deaths (r=0.95, residual S.D.=0.41 g/l). For both causes of death (N=1275), the correlation between BAC and UAC was r=0.95 and the residual S.D. was 0.46 g/l. The lower UAC/BAC ratio observed in acute alcohol poisoning deaths (mean and median 1.18:1) suggests that these individuals died before absorption and distribution of ethanol in all body fluids were complete. The higher UAC/BAC ratio in chronic alcoholism (median 1.30:1) is closer to the value expected for complete absorption and distribution of ethanol in all body fluids.     

High prevalence of 6-acetylmorphine in morphine-positive oral fluid specimens

Identification of 6-acetylmorphine, a specific metabolite of heroin, is considered to be definitive evidence of heroin use. Although 6-acetylmorphine has been identified in oral fluid following controlled heroin administration, no prevalence data is available for oral fluid specimens collected in the workplace. We evaluated the prevalence of positive test results for 6-acetylmorphine in 77,218 oral fluid specimens collected over a 10-month period (January-October 2001) from private workplace testing programs. Specimens were analyzed by Intercept immunoassay (cutoff concentration=30 ng/ml) and confirmed by GC-MS-MS (cutoff concentrations=30 ng/ml for morphine and codeine, and 3 ng/ml for 6-acetylmorphine). Only morphine-positive oral fluid specimens were tested by GC-MS-MS for 6-acetylmorphine. A total of 48 confirmed positive morphine results were identified. An additional 107 specimens were confirmed for codeine only. Of the 48 morphine-positive specimens, 32 (66.7%) specimens were positive for 6-acetylmorphine. Mean concentrations (+/-S.E.M.) of morphine, 6-acetylmorphine and codeine in the 32 specimens were 755+/-201, 416+/-168 and 196+/-36 ng/ml, respectively. Concentrations of 6-acetylmorphine in oral fluid ranged from 3 to 4095 ng/ml. The mean ratio (+/-S.E.M.) of 6-acetylmorphine/morphine was 0.33+/-0.06. It is suggested that, based on controlled dose studies of heroin administration, ratios >1 of 6-acetylmorphine/morphine in oral fluid are consistent with heroin use within the last hour before specimen collection. The confirmation of 6-acetylmorphine in 66.7% of morphine-positive oral fluid specimens indicates that oral fluid testing for opioids may offer advantages over urine in workplace drug testing programs and in testing drugged drivers for recent heroin use.     

Improving suicide risk assessment in a managed-care environment

This article describes the quality improvement intervention of a managed behavioral healthcare company to improve the quality of suicide risk assessments by its panel of providers. At-risk cases are identified by the patient's self-reported high frequency of suicidal ideation on a standardized outcome measure. Clinicians also assess severity of suicidal ideation based on clinical interviews. The clinician's assessment is identified as probably erroneous if the patient report indicates a high frequency of suicidal ideation and the clinicians assessment of suicidal ideation is none. The article describes the methods used to encourage clinicians to utilize information from the patient self-report measure as part of the clinical assessment. Probable suicidal ideation assessment errors were subsequently reduced by 29% over a 1-year period of administration.     

Legal Pluralism and the Adjudication of Internet Disputes

No single entity-academic, corporate, governmental or non-profit-administers the Internet. (American Civil Liberties Union v Reno \[E.D. Pa. 1996] 929 F. Supp. 824, 832) The problems of regulation on the Internet are simply stated. First, it allows novel activities: e-mail, electronic discussion groups, simple transfer or viewing of text, images, sound and video. These activities may fall foul of laws of obscenity or defamation in some or all of the jurisdictions in which it is available. Second, the Internet is a distributed system that straddles geographical and jurisdictional boundaries; the regulation of such activities is likely to fall within two or more national 'legal' jurisdictions. It may therefore be difficult to choose an appropriate jurisdiction. Third, the inevitable need to choose a jurisdiction will mean that the values to be imposed upon the dispute will be the values of that jurisdiction, values that may be different from the values of those involved in the dispute. Much has been written on the first two problems and significant developments have been made in the formulation of principles to be applied to the problem of choosing a jurisdiction. In this paper, I will begin to focus on the third problem, the problem of inappropriate values being imposed upon Internet behaviour. The paper will develop the theme that the need for a single jurisdiction and, in consequence, the need for a single set of values to be imposed upon Internet activities is a fiction born out of centralist systems of western jurisprudence. The paper will review how courts have turned against pluralistic approaches in the past when dealing with clashes in cultural and religious values, particularly the clash in the English courts in the case of Salman Rushdie's 'The Satanic Verses'. Western courts have been dismissive of cultural and religious claims either treating them as 'repugnant' or contrary to public policy, or else questioning the validity of the motives of the applicants. It is evident from recent cases in the US, that judges will use similar techniques to impose their own value values upon Internet activity. The concept of legal pluralism is not recognised within westernised systems of law. The paper will then consider whether a more pluralistic strategy would provide a more satisfactory approach to dealing with such disputes on the Internet: an approach that would enable the resolution of the conflict between different cultural and religious values.     

‘twinning’ as a method of sustainable institutional capacity building

‘Twinning’ is the distinctive method employed during the last two decades by the Swedish International Development Co‐operation Agency (Sida) to promote institutional capacity building in development co‐operation. This article reports on a study undertaken to provide evidence which would help Sida to make judgements about the efficacy of the twinning model as a basis for sustainable capacity building, and to explore ways of enhancing the method. The study indicates that the twinning method has potential advantages over other modes of development co‐operation, particularly that it offers enhanced possibilities for organizational learning and sustainable capacity building. However, the study suggests that this potential is not being fully exploited. Twinning arrangements have produced major benefits in professional/technical upgrading, but there is less evidence of outcomes at the level of sustainable institutional capacity building. Contrary to Sida's expectations of its distinctive advantages, in operation, twinning tends to become a rather routine process, viewed by developing country partners as an unexceptional way of delivering aid which presents few fundamental challenges and provides essentially the same benefits as alternative methods. It appears that institutional development and organizational learning are generally not issues of major significance for partner organizations in twinning arrangements. Even at the individual level the focus is on training rather than learning, which results in the usual emphasis on formal off‐job training rather than seeking opportunities for learning from work. The article presents ideas on how the current twinning approach might be renovated, and considers how agencies such as Sida might enhance their development co‐operation in the realm of governance by moving beyond twinning. Copyright © 1999 John Wiley & Sons, Ltd.