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.     

In Search of Co‐variance,Causal Mechanisms or Congruence? Towards a Plural Understanding of Case Studies

Methodological reflections about case study research have increased within recent years. According to our account, there are three distinct approaches to case studies: co‐variational, causal process tracing, and congruence analysis. The main goals of this article are to lay out the distinct ways in which causal inferences are drawn for the cases under study and to scrutinize the different understandings and directions of generalization within these three approaches. By doing so we highlight two aspects: First, causal process tracing and congruence analysis should be seen as two distinct alternatives to the dominant co‐variational template. Second, the main characteristics of case studies, their thickness, provides only an unavoidable dilemma if we aim to generalize the findings towards a wider population of similar cases as in the co‐variational template. If we would like to get deeper insights â‐“ as the causal process tracing approach does â‐“ or if we would like to use the empirical evidence for a broader theoretical discourse â‐“ as the congruence analysis does â‐“ case studies do not face a trade‐off.     

A profile of children with disabilities receiving SSI: highlights from the National Survey of SSI Children and Families

This article provides a nationally representative profile of noninstitutionalized children 0 to 17 years of age who were receiving support from the Supplemental Security Income (SSI) program because of a disability. To assess the role of the SSI program in providing assistance to low-income children with disabilities and their families, it is important to obtain detailed information on demographic characteristics, income and assets, health and disabilities, and health care utilization. Yet administrative records of the Social Security Administration do not contain many of the relevant data items, and the records provide only an incomplete picture of the family relationships affecting the lives of children with disabilities. The National Survey of SSI Children and Families fills this gap. This summary article is based on survey interviews conducted between July 2001 and June 2002 and provides some highlights characterizing children with disabilities who were receiving SSI and their families. Most children receiving SSI (hereafter referred to as "SSI children") lived in a family headed by a single mother, and less than one in three lived with both parents. A very high proportion, about half, were living in a household with at least one other individual reported to have had a disability. About 70 percent of children received some kind of special education. SSI support was the most important source of family income, with earnings a close second. On average, SSI payments accounted for nearly half of the income for the children's families, and earnings accounted for almost 40 percent. When all sources of family income were considered, slightly more than half (54 percent) of SSI children lived in families above the poverty threshold, a notable fact given that the federal SSI program guarantees only a subpoverty level of income. However, beyond these averages there was substantial variation, with some children living in families with income well below the poverty threshold and others having income well over 200 percent of the poverty threshold. About one-third of SSI children lived in families owning a home, two-thirds lived with parents or guardians with at least one car, and about 40 percent lived with parents or guardians with zero liquid assets. Less than 4 percent lived with adults who owned stocks, mutual funds, notes, certificates of deposit, or savings bonds. The Social Security Administration's administrative records contain only a limited amount of information about disability diagnoses. The National Survey of SSI Children and Families supplements those records with data from an array of questions on functional limitations, self-reported health, and the perceived severity of disabilities. The data suggest that a great degree of variation in severity exists within the childhood caseload, as reflected in reports of the presence or absence of six functional limitations, perceived overall health status, and perceived impact of disability on the child's ability to do things. Overall, 36 percent of the children were reported to have had disabilities that affected their abilities to do things "a great deal," and for 21 percent their difficulties had very little or no impact. Physical disabilities were most common among children aged 0 to 5, and mental disabilities dominated the picture for the other two age groups: 6 to 12 and 13 to 17. Virtually all SSI children are covered by some form of health insurance, with Medicaid being by far the most common source of health insurance coverage. Just as in the case of the severity of disabilities, substantial variation was reported in health care utilization among SSI children. Almost 30 percent of children had two or fewer doctor visits during the 12 months preceding the interview, and close to 50 percent had five or more doctor visits. About four-fifths of the children had no reported hospitalizations or surgeries during the previous year. More than 40 percent of the children visited an emergency room during the previous year, most of them more than once. Importantly, no out-of-pocket costs associated with medical care were reported for more than two-thirds of the children, and only about 3 percent had annual expenses exceeding $1,000 for physical and mental health care. This finding suggests that SSI payments are not used to cover medical expenses for the overwhelming majority of children. The use of supportive therapies varied widely among SSI children: more than half reported having used physical, occupational, or speech therapy; only 8 percent used respite care for the parents or other family members. An analysis of the perception of the survey respondents shows that more than one-third of children had unmet needs for mental health counseling services, and about three-quarters of families had unmet needs for respite care. In several service categories, the proportion perceived to have had unmet service needs was around 10 percent or less. In the dominant service category of physical, occupational, and speech therapy, only 11 percent perceived to have had unmet service needs.     

Die Institutionalisierung Indischer Parteien

Party systems are considered as institutionalized, when they have strong roots in the society, when they are stable (= moderate electoral volatility, fragmentation and polarisation of the party system), are regarded as legitimate vehicles of political competition and organizationally strong. Compared to these criteria, the Indian party system fares better, than quite a few critical survey indicate. Indian parties have strong, but specific roots in the society, party polarization is moderate and high fragmentation is only a consequence of unsuccessful aggregation of different subnational party systems in the Lower House. On the other hand Indian parties reflect specific social cleavages, more exactly, they are themselves prime actors in the social construction of cleavages. They also suffer from lack of internal democracy and cohesion. These deficits are related to the patronage character of Indian democracy and decisions of rational voter groups and parties in an extremely plural, and politically increasingly mobilized society. On the other hand, institutional shortcomings of parties have some positive effects on the political participation and on social emancipation of underprivileged groups. This seems to indicate, that institutionalization criteria won by the observation of Western parties, might be only partly helpful in the Indian context.     

Domestic accident or child abuse?

While playing, a 33/4-year-old girl was hiding in a tumble dryer, which had been running before and started the drying process with rotation of the drum again after the girl had climbed into the machine and shut the door. The child suffered multiple haematomas, especially on the back and the lower arms, as well as second-degree burns on body regions not covered by the clothing. The injury pattern was consistent with the properties of the appliance, and the initial suspicion that the child had been physically abused could not be maintained.     

Discussion Law & Society Review at Fifty: A Debate on the Future of Publishing by the Law & Society Association

This contribution presents a series of statements on the future of publishing by the Law & Society Review and the Law & Society Association generally. Framed by the first author's introductory and concluding comments are contributions by Halliday, Liu, Morrill, Seron, and Silbey. This debate, based on a LSR 50th anniversary panel held at the 2016 Annual Meeting of the LSA, is intended to open up a broader conversation among members of the Association. Positions by individual contributors can only be linked to them and not to the group of contributors.     

Lassen sich Signifikanztests auf Vollerhebungen anwenden? Einige essayistische Anmerkungen

The question whether it is allowed to use methods of statistical inference in the study of entire populations is disputed in the scientific community. Such a procedure can be justified only if the generation of the data of the population can be regarded as the realisation of a stochastic data generating process, analogously to drawing a sample out of a population by random. This article specifies under which circumstances these conditions can be regarded as given. Furthermore, it shows under which circumstances we should be at least careful, if not reluctant, to interpret the results of significance tests in the usual manner.