Detection of ketosis in vitreous at autopsy after embalming

Ketosis occurs in ketoacidosis or malnourishment. When either is suspected in relation to a death, it may be important to analyze for ketosis at autopsy. We encountered a case where starvation was suspected in a deceased nursing home resident, where the body had been embalmed prior to autopsy. Gas chromatography (GC) was unable to separate acetone from formaldehyde, a component of embalming fluid. The Acetest is a simple test that can detect acetone and acetoacetate in body fluids. We validated the Acetest with GC on vitreous. The Acetest and GC were consistent except at very low levels of acetone or acetoacetate. The sensitivity of the Acetest for acetoacetate in vitreous was 10 mg/dL, consistent with early starvation. Significant interference from embalming fluid did not occur. The Acetest was negative in the described case. The Acetest is a simple and useful test for the detection of ketosis in embalmed autopsies.     

Collaboration and Leadership for Effective Emergency Management

Collaboration is a necessary foundation for dealing with both natural and technological hazards and disasters and the consequences of terrorism. This analysis describes the structure of the American emergency management system, the charts development of the Federal Emergency Management Agency, and identifies conflicts arising from the creation of the Department of Homeland Security and the attempt to impose a command and control system on a very collaborative organizational culture in a very collaborative sociopolitical and legal context. The importance of collaboration is stressed, and recommendations are offered on how to improve the amount and value of collaborative activities. New leadership strategies are recommended that derive their power from effective strategies and the transformational power of a compelling vision, rather than from hierarchy, rank, or standard operating procedures.     

Who Wants to Work for the Government?

In an era when everyone wants to be a millionaire, governments struggle to attract and retain highly qualified employees, making it more important than ever to understand what attracts people to the public service. Using contingency table analysis and logistic regression on the 1989 and 1998 General Social Surveys, we explore how individuals' demographic characteristics and the importance they place on various job qualities influence their preference for and employment in the public sector. Job security may still be the strongest attraction of government jobs, but high income and the opportunity to be useful to society also attract some Americans to the public service. Minorities, veterans, Democrats, and older Americans preferred public-sector jobs more than whites, nonveterans, Republicans, and younger Americans, who were otherwise similar. Women and college graduates were more likely than comparable men and less-educated respondents to have government jobs, but no more likely to prefer them. Overall, desire for government jobs declined markedly between 1989 and 1998.     

Correlation of the incidence of cocaine and cocaethylene in hair and postmortem biologic samples

Hair samples are useful as a matrix for drug testing because drugs can be detected in hair for longer periods than in blood or urine. The authors report a prospective comparison of the detection of cocaine and cocaethylene in routine postmortem biologic specimens to the detection of cocaine and cocaethylene in hair. The authors collected hair samples from various areas of the head in 53 autopsy cases, prepared them, and analyzed them by gas chromatography/mass spectrometry (GC/MS) for cocaine and cocaethylene. The authors compared the results of hair analysis with the results of toxicologic analysis performed on routine postmortem samples by enzyme multiplied immunoassay technique and GC/MS. Cocaine was found in either biologic fluids or in hair in 16 of 53 samples tested. Nine samples were positive for cocaine in both biologic fluids and hair. Five samples contained cocaine only in biologic fluids, and two contained cocaine only in hair. Cocaethylene was present in two cases. Drug screening of hair provides additional information in some autopsy cases, but the authors have not made hair analysis a routine practice. It may prove useful to save hair samples in all cases for later analysis if warranted by additional history or autopsy findings.     

Reducing violence in serious juvenile offenders using intensive treatment

This study reports on the reduction in violent offending in a population of serious and violent juvenile offenders following an intensive institutional treatment program. The treatment group (N=101) is compared to a similar group that was assessed but not treated (N=147). All youth were sent to the program from a juvenile corrections institution where they had received the customary rehabilitation services. The results show a significant reduction in the prevalence of recidivism in the treated group after controlling for time at risk in the community and other covariates. The effects of non-random group assignment were reduced by including a propensity score analysis procedure in the outcome analysis. Untreated comparison youth appeared to be about twice as likely to commit violent offenses as were treated youth (44% vs. 23%). Similarly, treated youth had significantly lower hazard ratios for recidivism in the in the community than the comparison youth, even after accounting for the effects of non-random group assignment.     

The interplay between economic and political logics: path dependency in health care in England

The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.     

Polydrug fatality involving metaxalone

A 29-year old female with a history of depression was found dead in a hotel room. The death scene investigation found empty pill bottles and an empty liter bottle of wine. Metaxalone, a centrally acting muscle relaxant, along with citalopram, ethanol, and chlorpheniramine were identified in the postmortem samples and quantitated by gas chromatography-mass spectrometry. The concentration of metaxalone in femoral vein blood was 39 mg/L. The heart blood concentration was 54 mg/L. Femoral vein blood concentrations of citalopram and chlorpheniramine were 0.77 mg/L and 0.04 mg/L, respectively. Ethanol levels were 0.13 g/dL in vitreous and 0.08 g/dL in heart blood. Other tissue samples were also analyzed. The authors consider the metaxalone concentrations toxic and potentially fatal. The citalopram concentrations were lower than those reported in fatal cases for this drug alone. Death was ascribed to polydrug abuse/overdose with metaxalone a major contributor. This represents the first reported case to our knowledge in which a metaxalone overdose significantly contributed to death.