Fatal case of BOTOX-related anaphylaxis?

Anaphylactic drug reactions are rare and often serious events. The Botulinum toxin A, marketed as BOTOX, was recently approved by the Food and Drug Administration for cervical dystonia and glabellar wrinkles, after its approved use and success with blepharospasm, strabismus, and disorders of the 7th cranial nerve. It has been well received due to its efficacy in improving facial lines. This case report documents the first death associated with a Botox-lidocaine mixture given to a woman for chronic neck and back pain. Based on the medical records, autopsy, and laboratory findings, the cause of death was determined to be anaphylaxis to the Botox-lidocaine mixture. The history, indications, off-label uses and possible future applications of Botox are reviewed as well as the uses and complications of lidocaine. Although the anaphylaxis cannot be definitively proven to be due to Botox alone, this case warns of an adverse reaction related to Botox, a drug that is rapidly expanding in range of use as well as increased usage.     

When methods meet politics: how risk adjustment became part of Medicare managed care

Health-based risk adjustment has long been touted as key to the success of competitive models of health care. Because it decreases the incentive to enroll only healthy patients in insurance plans, risk adjustment was incorporated into Medicare policy via the Balanced Budget Act of 1997. However, full implementation of risk adjustment was delayed due to clashes with the managed care industry over payment policy, concerns over perverse incentives, and problems of data burden. We review the history of risk adjustment leading up to the Balanced Budget Act and examine the controversies surrounding attempts to stop or delay its implementation during the years that followed. The article provides lessons for the future of health-based risk adjustment and possible alternatives.     

A friend in need: the role of friendship quality as a protective factor in peer victimization and bullying

This study examined friendship quality as a possible moderator of risk factors in predicting peer victimization and bullying. Children (50 boys and 49 girls, ages 10 to 13 years) reported on the quality of their best friendship, as well as their bullying and victimization tendencies. Parents reported on their child's internalizing and externalizing behaviors, in addition to bullying and victimization tendencies. Results indicated that externalizing problems were related to bullying behavior; however, friendship quality moderated this relation such that among children with externalizing behaviors, a high-quality friendship significantly attenuated bullying behavior. Internalizing problems and low friendship quality were significantly related to victimization; however, friendship quality did not moderate the relation between internalizing problems and victimization. Implications for interventions based on these findings are discussed.     

Application of the BioMek 2000 Laboratory Automation Workstation and the DNA IQ System to the extraction of forensic casework samples

Robotic systems are commonly utilized for the extraction of database samples. However, the application of robotic extraction to forensic casework samples is a more daunting task. Such a system must be versatile enough to accommodate a wide range of samples that may contain greatly varying amounts of DNA, but it must also pose no more risk of contamination than the manual DNA extraction methods. This study demonstrates that the BioMek 2000 Laboratory Automation Workstation, used in combination with the DNA IQ System, is versatile enough to accommodate the wide range of samples typically encountered by a crime laboratory. The use of a silica coated paramagnetic resin, as with the DNA IQ System, facilitates the adaptation of an open well, hands off, robotic system to the extraction of casework samples since no filtration or centrifugation steps are needed. Moreover, the DNA remains tightly coupled to the silica coated paramagnetic resin for the entire process until the elution step. A short pre-extraction incubation step is necessary prior to loading samples onto the robot and it is at this step that most modifications are made to accommodate the different sample types and substrates commonly encountered with forensic evidentiary samples. Sexual assault (mixed stain) samples, cigarette butts, blood stains, buccal swabs, and various tissue samples were successfully extracted with the BioMek 2000 Laboratory Automation Workstation and the DNA IQ System, with no evidence of contamination throughout the extensive validation studies reported here.     

Measurement of chemical analytes in vitreous humor: stability and precision studies

The analytic accuracy and precision for measurement of chemical analytes in vitreous humor (VH) are critical if results are to be used in forensic pathology. The purpose of our study was to demonstrate the stability and the reproducibility of VH sodium, potassium, chloride, glucose, urea nitrogen, acetone, and beta-hydroxybutyrate in specimens obtained from both eyes in medical examiner cases. We also compared with calculated VH osmolalities. Small but significant increases were observed in VH electrolyte concentrations in specimens refrigerated 6-12 months: sodium pre 144 mmol/L, post 151 mmol/L; potassium pre 12.0 mmol/L, post 12.8 mmol/L; chloride pre 121 mmol/L, post 123 mmol/L. No differences were observed between eyes, and within-day precision for all electrolyte measurements were excellent, (<1%). Frozen specimens showed significantly higher measured (439 mOsmol/kg) as compared with calculated osmolality (305 mOsmol/kg), with 1% within-day precision and no significance between eye variation for glucose and urea nitrogen. In 20 of 24 medical cases selected for possible ketoacidosis, measurement of beta-hydroxybutyrate concentrations appears to be a promising diagnostic biomarker for confirming suspected ketosis in medical examiner cases by means of VH analysis.     

The Design and Implementation of Cross-Sector Collaborations: Propositions from the Literature

People who want to tackle tough social problems and achieve beneficial community outcomes are beginning to understand that multiple sectors of a democratic society—business, nonprofits and philanthropies, the media, the community, and government—must collaborate to deal effectively and humanely with the challenges. This article focuses on cross-sector collaboration that is required to remedy complex public problems. Based on an extensive review of the literature on collaboration, the article presents a propositional inventory organized around the initial conditions affecting collaboration formation, process, structural and governance components, constraints and contingencies, outcomes, and accountability issues.     

Results of the 2003-2004 GEP-ISFG collaborative study on mitochondrial DNA: focus on the mtDNA profile of a mixed semen-saliva stain

We report here a review of the seventh mitochondrial DNA (mtDNA) exercise undertaken by the Spanish and Portuguese working group (GEP) of the International Society for Forensic Genetics (ISFG) corresponding to the period 2003-2004. Five reference bloodstains from five donors (M1-M5), a mixed stain of saliva and semen (M6), and a hair sample (M7) were submitted to each participating laboratory for nuclear DNA (nDNA; autosomal STR and Y-STR) and mtDNA analysis. Laboratories were asked to investigate the contributors of samples M6 and M7 among the reference donors (M1-M5). A total of 34 laboratories reported total or partial mtDNA sequence data from both, the reference bloodstains (M1-M5) and the hair sample (M7) concluding a match between mtDNA profiles of M5 and M7. Autosomal STR and Y-STR profiling was the preferred strategy to investigate the contributors of the semen/saliva mixture (M6). Nuclear DNA profiles were consistent with a mixture of saliva from the donor (female) of M4 and semen from donor M5, being the semen (XY) profile the dominant component of the mixture. Strikingly, and in contradiction to the nuclear DNA analysis, mtDNA sequencing results yield a more simple result: only the saliva contribution (M4) was detected, either after preferential lysis or after complete DNA digestion. Some labs provided with several explanations for this finding and carried out additional experiments to explain this apparent contradictory result. The results pointed to the existence of different relative amounts of nuclear and mtDNAs in saliva and semen. We conclude that this circumstance could strongly influence the interpretation of the mtDNA evidence in unbalanced mixtures and in consequence lead to false exclusions. During the GEP-ISFG annual conference a validation study was planned to progress in the interpretation of mtDNA from different mixtures.     

Exposure to interpersonal violence as a predictor of PTSD symptomatology in domestic violence survivors

This study examines the interrelationships between childhood abuse, exposure to maternal domestic violence, and posttraumatic stress disorder (PTSD) symptomatology in a multiethnic sample of 111 adult female residents of a domestic violence (DV) shelter. Participants completed structured interviews about the DV and their prior violence exposure, as well as the Impact of Event Scale-Revised. As hypothesized, there was high co-occurrence between exposure to maternal DV and childhood physical and sexual abuse, and the frequency of lifetime violence exposure predicted PTSD symptomatology. A series of multiple regressions indicated a more complex pattern of relationships, in which specific forms of prior violence exposure predicted different PTSD symptom dimensions. A history of witnessing maternal DV predicted intrusion symptoms, and a history of childhood sexual abuse predicted hyperarousal symptoms. Ethnicity was not related to levels of violence exposure or to PTSD symptoms. Clinical implications of the findings are discussed.     

Becoming better health care providers: outcomes of a primary care service-learning project in medical school

Medical educators have begun to embrace service-learning as a method for teaching medical students to be more socially responsible, patient-oriented practitioners. However, research documenting the learning outcomes of service-learning in medical education is limited. In this paper, written documents generated through evaluation of a mandatory, structured community service-learning experience were analyzed qualitatively to discover the diverse learning outcomes among 24 students who participated in the experience. Preliminary findings indicate that students developed skills and attitudes directly related to competencies of concern in most U.S. medical programs. These preliminary findings may help other programs articulate learning outcomes for their service-learning programs. Further, these preliminary findings may stimulate more systematic research (qualitative and quantitative) in this area.     

Investigation of Italy's deadliest building collapse: forensic aspects of a mass disaster

We describe the investigation of the 1999 collapse of an apartment building in Foggia, Italy. Sixty-one victims were recovered in the rubble of the building, and five people were unaccounted for. All the bodies were well preserved except for two who had been burned. The majority of the victims were identified visually or by comparing body features, clothing, or personal effects with information collected from relatives or friends. Positive identifications of the two victims who were burned were obtained by dental comparison and DNA analysis. Approximately half of the victims (51.6%) sustained fatal injuires, while the remainder died from asphyxia. The injuries were characterized using the Abbreviated Injury Scale (AIS) and the New Injury Severity Score (NISS) systems. Injury severity associated with the location of victims inside the apartment may provide useful information for those involved in building design and/or search and rescue operations. Engineers determined that the collapse was the result of the use of inappropriate foundation material.