Detection of Acetaminophen-Protein Adducts in Decedents with Suspected Opioid-Acetaminophen Combination Product Overdose.

Acetaminophen overdose is a leading cause of drug-induced liver failure in the United States. Acetaminophen-protein adducts have been suggested as a biomarker of hepatotoxicity. The purpose of this study was to determine whether protein-derived acetaminophen-protein adducts are quantifiable in postmortem samples. Heart blood, femoral blood, and liver tissue were collected at autopsy from 22 decedents suspected of opioid-acetaminophen overdose. Samples were assayed for protein-derived acetaminophen-protein adducts, acetaminophen, and selected opioids found in combination products containing acetaminophen. Protein-derived APAP-CYS was detected in 17 of 22 decedents and was measurable in blood that was not degraded or hemolyzed. Heart blood concentrations ranged from 11 ng/mL (0.1 µM) to 7817 ng/mL (28.9 µM). Protein-derived acetaminophen-protein adducts were detectable in liver tissue for 20 of 22 decedents. Liver histology was also performed for all decedents, and no evidence of centrilobular hepatic necrosis was observed.

Risk factors for prescription opioid-related death, Utah, 2008-2009.

OBJECTIVE: Utah prescription opioid death rates increased nearly fivefold during 2000-2009. Inadequate understanding of risk factors hinders prevention. The goal of this study was to determine risk factors for prescription opioid death in Utah. DESIGN: Case-control study. Cases were 254 Utah decedents with ≥1 prescription opioid causing death during 2008-2009 with nonintentional manner of death (information obtained via next-of-kin interviews). Controls were 1,308 Utah 2008 Behavioral Risk Factor Surveillance System respondents who reported prescription opioid use during the previous year. OUTCOME MEASURES: Exposure prevalence ratios (EPRs) for selected characteristics and confidence intervals (CIs) were calculated. RESULTS: Decedents were more likely than the comparison group to have used prescription pain medication more than prescribed (52.9% vs 3.2%; EPR, 16.5; 95% CI, 9.3-23.7), obtained prescription pain medication from nonprescription sources (39.6% vs 8.3%; EPR, 4.8; 95% CI, 3.6-6.0), smoked daily (54.5% vs 9.7%; EPR, 5.6; 95% CI, 4.4-6.9), not graduated high school (18.5% vs 6.2%; EPR, 3.0; 95% CI, 2.0-3.9), and been divorced or separated (34.6% vs 9.4%; EPR, 3.7; 95% CI, 3.0-4.4). Decedents were more likely to have had chronic pain than the comparison group (94.2% vs 31.6%; EPR, 3.0; 95% CI, 2.7-3.3). CONCLUSIONS: Use of pain medication outside prescription bounds was a risk factor for death. However, decedents were more likely to have had chronic pain, and the majority of both groups had obtained pain medication by prescription. Other factors (e.g., smoking status) might also play important roles in prescription opioid-related death. Prescribers should screen chronic pain patients for risk factors.

Best practices: the Utah Youth Suicide Study: best practices for suicide prevention through the juvenile court system.

Utah is among a group of Western Mountain states in which suicide rates among youths are consistently high. The Utah Youth Suicide Study incorporated data from every government agency in Utah, utilizing a statewide Office of the Medical Examiner. A key finding was that 63% of suicide decedents had contact with the juvenile courts. The group developed a best practices model within the juvenile court system for early mental health intervention. Significant cost savings were demonstrated. The model includes screening at-risk teenagers with the Youth Outcome Questionnaire. Treatment includes both psychiatric care and in-home behavioral intervention. Services were effectively delivered on a large scale.

The skull and cervical spine radiographs of Tutankhamen: a critical appraisal.

BACKGROUND AND PURPOSE: Tutankhamen, the last pharaoh of the XVIIIth dynasty, died unexpectedly at approximately age 18 years. A cause of death has never been established, but theories that the young king was murdered by a blow to the head have been proposed based on skull radiographs obtained by a team from the University of Liverpool in 1968. We recently had the opportunity to evaluate the skull and cervical spine radiographs of Tutankhamen. The purpose of this study was to report our critical appraisal of the radiographs of Tutankhamen regarding the findings alleged to indicate traumatic death. METHODS: Copies of lateral, anteroposterior, and submental vertex skull radiographs of Tutankhamen were reviewed with special attention to the claims of a depressed skull fracture, intracranial bone fragments, and calcified membrane of a posterior fossa subdural hematoma. A phantom skull was radiographed to reproduce the appearance of the floor of the posterior fossa in the lateral projection. RESULTS: The skull radiographs of Tutankhamen show only postmortem artifacts that are explainable by an understanding of the methods of mummy preservation used at the time of his death. Some findings also relate to trauma inflicted by an autopsy performed in 1925. The alleged calcified membrane of a posterior fossa subdural hematoma is easily reproduced with a skull phantom. CONCLUSION: Our critical review of the skull and cervical spine radiographs of Tutankhamen does not support proposed theories of a traumatic or homicidal death.