Reclaiming the Autopsy as the Practice of Medicine: A Pathway to Remediation of the Forensic Pathology Workforce Shortage?

The historically constricted forensic pathology workforce pipeline is facing an existential crisis. Pathology residents are exposed to forensic pathology through the American Council of Graduate Medical Education autopsy requirement. In 1950, autopsies were conducted in one half of the patients dying in American hospitals and 90% in teaching hospitals, but they have dwindled to fewer than 5%. Elimination of funding for autopsies is a major contributor to the lack of support for autopsies in departments of pathology. Funding may require reclaiming the autopsy as the practice of medicine. Funding of autopsies would rekindle interest in hospital autopsies and strengthen the forensic pathology workforce pipeline.

4F-MDMB-BINACA: A New Synthetic Cannabinoid Widely Implicated in Forensic Casework.

This is the first report regarding the characterization of the new synthetic cannabinoid 4F-MDMB-BINACA. 4F-MDMB-BINACA was first analytically confirmed in seized drug material using gas chromatography-mass spectrometry (GC-MS), liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF), and nuclear magnetic resonance (NMR) spectroscopy. Subsequent to this characterization, 4F-MDMB-BINACA was detected in biological specimens collected as part of forensically relevant casework, including medicolegal death investigations and drug impaired driving investigations, from a variety of regions in the United States. Further analysis of biological specimens resulted in the identification of the metabolites 4F-MDMB-BINACA 3,3-dimethylbutanoic acid and 4-OH-MDMB-BINACA. 4F-MDMB-BINACA is appearing with increasing frequency as a contributory factor in deaths, creating morbidity and mortality risks for drug users. Laboratories must be aware of its presence and impact, incorporating 4F-MDMB-BINACA into workflows for detection and confirmation.

The Opioid Epidemic: Moving Toward an Integrated, Holistic Analytical Response.

In many jurisdictions, public safety and public health entities are working together to enhance the timeliness and accuracy of the analytical characterization and toxicology testing of novel synthetic opioids. The improved sharing and early detection of these analytical data are intended to inform surveillance, interdiction efforts, patient intervention and treatment, all of which are critical to curbing the opioid epidemic. Forensic practitioners working to identify novel synthetic opioids struggle to provide timely results when encountering new or unknown substances, such as the fentanyl analogs. These compounds, which mimic heroin in pharmacologic effect but can be far more potent, are inconsistently present in chemical identification libraries, and are currently largely unavailable as reference materials for analytical comparison. Additionally, federal, state and local governments as well as nongovernmental organizations require potency, toxicity and potential-for-abuse data to evaluate the potential health risks of emerging drug threats. Subsequent scheduling efforts and criminal prosecutions also require these thorough drug characterization studies. Pilot programs have demonstrated that early communication of real-time drug toxicity and analytical data significantly impacts the successful response to emerging opioids. High-quality, real-time, national-level data on chemical composition, toxicological test data, drug toxicity and overdoses, and analysis of seized materials by law enforcement are needed to track drug trends. However, the USA still lacks a national system to coordinate and communicate toxicology, medical and medical examiner and coroner data with the broader medical and law enforcement communities. Opportunities to address these gaps as well as recent advancements collected through interagency efforts and technical workshops in the toxicology and analytical chemistry communities are presented here. Opportunities for partnership, increased communication and expanding best practices to move toward an integrated, holistic analytical response are also explored.

La prueba de cribado del inventario de desarrollo de Battelle para la detección precoz de alteraciones del desarrollo en parálisis cerebral / The Battelle developmental inventory screening test for early detection of developmental disorders in cerebral palsy

Introducción: La parálisis cerebral (PC) está frecuentemente asociada a trastornos en diversas funciones (movilidad, lenguaje y capacidades cognitivas entre otras), que provocan deficiencias en las habilidades de la vida diaria, sociales, académicas y de independencia personal. La detección precoz de estos déficits en el ámbito clínico es esencial para prever y dotar al sujeto de los apoyos necesarios para la adaptación a su entorno en todos los ámbitos. El objetivo principal de este estudio demostrar que estos déficits se pueden objetivar a edades muy tempranas y de modo amplio mediante el uso de una escala breve de desarrollo. Material y métodos: Se estudió a 100 niños de entre 4 y 70 meses de edad, la mitad de los cuales presentan PC y la otra mitad no padece ningún tipo de trastorno. Todos los sujetos fueron evaluados mediante la prueba de cribado del inventario de desarrollo de Battelle (BDI), de lo cual se obtuvieron cocientes de desarrollo que fueron comparados entre ambos grupos y entre los sujetos con diferentes alteraciones motoras mediante un diseño ex post facto prospectivo simple. Resultados: La prueba detecta las diferencias entre ambos grupos de estudio en todos los niveles de edad y entre los sujetos con tetraplejía y el resto de trastornos motores, no encontrándose diferencias en función del sexo. Conclusiones: Los déficits en el desarrollo asociados a la PC se pueden objetivar a edades muy tempranas mediante el uso de una escala breve de desarrollo, por lo que la implantación sistemática de este método de detección sería de gran ayuda para su tratamiento e intervención temprana. Esto permitiría prever y anticipar los medios necesarios para la intervención multidisciplinar, proporcionar orientación a otros profesionales de la salud y adecuar el apoyo escolar, social y familiar (AU)

Introduction: Cerebral palsy is usually associated with motor, cognitive, and language deficits, and with other disorders that cause disability in daily living skills, personal independence, social interaction and academic activities. Early detection of these deficits in the clinical setting is essential to anticipate and provide the child with the necessary support for adapting to the environment in all possible areas. The main objective of this study is to demonstrate that these deficits can be detected at an early age and comprehensively through the use of a brief development scale. Methods: We studied 100 children between 4 and 70 months old, half of them with cerebral palsy and the other half without any disorder. All subjects were evaluated using the Battelle Developmental Inventory screening test. We compared the developmental quotients in both groups and between the subjects with different motor impairments, using a simple prospective ex post facto design. Results: The test detected statistically significant differences between the clinical group and the control group at all age levels. Statistically significant differences were also found between tetraplegia and other motor disorders. There were no differences by gender. Discussion: The deficit in development associated with cerebral palsy can be quantified at early ages through the use of a brief development scale, thus we propose that the systematic implementation of protocols with this screening tool would be helpful for treatment and early intervention. This would also help in anticipating and establishing the means for the multidisciplinary actions required, and could provide guidance to other health professionals, to provide adequate school, social, and family support (AU)

[The Battelle developmental inventory screening test for early detection of developmental disorders in cerebral palsy]. / La prueba de cribado del inventario de desarrollo de Battelle para la detección precoz de alteraciones del desarrollo en parálisis cerebral.

INTRODUCTION: Cerebral palsy is usually associated with motor, cognitive, and language deficits, and with other disorders that cause disability in daily living skills, personal independence, social interaction and academic activities. Early detection of these deficits in the clinical setting is essential to anticipate and provide the child with the necessary support for adapting to the environment in all possible areas. The main objective of this study is to demonstrate that these deficits can be detected at an early age and comprehensively through the use of a brief development scale. METHODS: We studied 100 children between 4 and 70 months old, half of them with cerebral palsy and the other half without any disorder. All subjects were evaluated using the Battelle Developmental Inventory screening test. We compared the developmental quotients in both groups and between the subjects with different motor impairments, using a simple prospective ex post facto design. RESULTS: The test detected statistically significant differences between the clinical group and the control group at all age levels. Statistically significant differences were also found between tetraplegia and other motor disorders. There were no differences by gender. DISCUSSION: The deficit in development associated with cerebral palsy can be quantified at early ages through the use of a brief development scale, thus we propose that the systematic implementation of protocols with this screening tool would be helpful for treatment and early intervention. This would also help in anticipating and establishing the means for the multidisciplinary actions required, and could provide guidance to other health professionals, to provide adequate school, social, and family support,.

Genetic polymorphism of N-acetyltransferase-2, glutathione S-transferase-M1, and cytochromes P450IIE1 and P450IID6 in the susceptibility to head and neck cancer.

AIMS: To analyse the allele frequencies of DNA polymorphisms at the genes for cytochromes P450IIE1 and P450IID6, N-acetyltransferase-2, and glutathione S-transferase-M1 in patients with head and neck squamous cell carcinoma, in an attempt to define genetic factors involved in the susceptibility to this cancer, which is strongly associated with tobacco consumption. METHODS: Determination of restriction fragment length polymorphism (RFLP) at cytochromes P450IIE1/P450IID6 and NAT2 genes, and the presence of homozygous deletion of the GSTM1 gene, in 200 controls and 75 head and neck cancer patients. Allelic frequencies between the two groups were compared using a chi 2 test, and odds ratio with 95% confidence intervals were calculated. RESULTS: There was no evidence of an association between alleles of CYP2D6 and CYP2E1 and head and neck cancer in our population. Similarly, frequencies of individuals lacking the GSTM1 gene did not differ between controls and patients. However, individuals with the NAT2-SA phenotype were at higher risk of developing head and neck cancer. The frequencies of the most common SA genotype (homozygous for the NAT2*5 allele) were higher in patients than in controls (27% v 15%, respectively). Slow acetylators homozygous for the NAT2*6 allele, the second most common SA allele, were also more common in patients than in controls (11% v 5%, respectively). CONCLUSIONS: Slow NAT2 activity is a risk factor possibly leading to the development of head and neck cancer in response to tobacco carcinogens.

A family with a milder form of adult dominant polycystic kidney disease not linked to the PKD1 (16p) or PKD2 (4q) genes.

Autosomal dominant polycystic kidney disease (ADPKD) is a genetically heterogeneous disease. Most families show positive linkage to polymorphic markers around the PKD1 (16p13.3) or PKD2 (4q21-23) loci. The PKD1 and PKD2 genes have been cloned and mutations defined in a number of patients. Several clinical studies have described a milder phenotype for PKD2 patients. More recently, evidence for a third genetic locus has been found in one Portuguese, one French-Canadian, and one Italian family. We identified a Spanish family with negative linkage to the PKD1 and the PKD2 loci. This family showed a very mild clinical phenotype compared to the other forms of ADPKD, including the non-PKD1/non-PKD2 families previously described.

Deletion and methylation of the tumour suppressor gene p16/CDKN2 in primary head and neck squamous cell carcinoma.

AIMS: To study the homozygous deletion and methylation status of the 5' CpG island of the p16 and p15 genes (9p21) in a set of primary advanced head and neck squamous cell carcinomas (SCC) and to test whether inactivation of these genes by these mechanisms contributes to head and neck SCC development. METHODS: DNA was extracted from fresh tumours. Homozygous deletion was determined by the polymerase chain reaction (PCR) followed by hybridisation with the corresponding probe, radioactively labelled by the random priming method. Methylation status of the CpG island of the 5' region of these genes was assessed by digestion with the appropriate restriction enzymes followed by PCR and subsequent hybridisation with the corresponding probe. The presence of point mutations was determined by PCR-SSCP (single strand conformation polymorphism). RESULTS: The p16 and p15 genes were homozygously deleted in 20% and 10% of the tumours, respectively. No point mutations were found at p16 and p15. The 5' CpG island at the p16 gene was methylated in 20% of the cases. CONCLUSIONS: The tumour suppressor gene p16 is inactivated through homozygous deletion or methylation in a significant proportion of cases of head and neck SCC.

Mutation analysis of the p53, APC, and p16 genes in the Barrett's oesophagus, dysplasia, and adenocarcinoma.

AIMS: To study the loss of heterozygosity and the presence of mutations at the p53, p16/CDKN2, and APC genes in Barrett's oesophagus, low grade dysplastic oesophageal epithelium, and adenocarcinoma of the oesophagus; to relate the presence of alterations at these genes with the progression from Barrett's oesophagus to adenocarcinoma. METHODS: DNA was extracted from paraffin blocks containing tissue from Barrett's oesophagus (12 samples), low grade dysplasia (15 cases), and adenocarcinoma (14 cases). Loss of heterozygosity (LOH) at the p53, p16, and APC genes was determined by comparing the autoradiographic patterns of several microsatellite markers between the normal tissue and the malignant tissue counterpart. SSCP was used to determine the presence of mutations at p53 (exons 5 to 8), p16 (exon 2), and APC. Homozygous deletion of the p16 gene was defined through polymerase chain reaction followed by Southern blot. RESULTS: LOH at the p53, p16, and APC genes was not observed in Barrett's oesophagus without dysplasia, and increased to 90% (p53), 89% (p16), and 60% (APC) in the adenocarcinomas. The p53 gene was mutated in only two adenocarcinomas (codons 175 and 245). In one case a mutation at the APC gene (codon 1297) was found. No patient had mutation at the second exon of p16. However, this gene was homozygously deleted in three of the 12 adenocarcinomas. CONCLUSIONS: The tumour suppressor genes p53, p16, and APC are often deleted in adenocarcinomas derived from Barrett's oesophagus. Mutations at these genes are also found in the adenocarcinomas, including the homozygous deletion of the p16 gene. However, the absence of genetic alterations in the Barrett's oesophagus and the low grade dysplastic epithelia suggest that mutations at these genes develop later in the progression from Barrett's oesophagus to adenocarcinoma.

Factor V Leiden (R506Q) and risk of venous thromboembolism: a case-control study based on the Spanish population.

Resistance to activated protein C (APC) is a frequent cause of thrombophilia. Most patients showing APC-resistance have a G to A mutation at codon 506 of the factor V that converts arginine to glutamine. This mutation is present in populations worldwide with frequencies ranging from 0.01 to 0.05. Genotyping of 150 control individuals from the Spanish population showed that 3.33% of them carried the mutation. Several studies have measured resistance to APC (following a classical functional assay) and have determined the factor V genotype in a number of thrombophilic patients, in an attempt to compare the predictive value of both laboratory methods. To assess the incidence of the factor V mutation among Spanish thrombophilic patients, we genotyped 51 of these. The frequency of mutation carriers rose from 3.33% in the controls to 53% in the patients. We found significant differences for the thrombosis-free survival curves and for the age at the first thrombotic event between patients who carried or did not carry the mutation. Analysis of relatives of 16 patients who carried the factor V mutation suggests the existence of additional genes that modulate the effect of the factor V gene in the development of venous thrombosis among carriers of the G to A mutation.

[Evaluation of the urinalysis of the diabetic patient in primary care]. / Evaluación del uroanálisis del diabético en atencion primaria.

OBJECTIVE: To study the level of concordance between the reactive strip, urine sediment and culture, and their sensitivity, specificity and predictive values. DESIGN: Crossover study. SETTING: Sotrondio and Laviana Health Centres, Asturias. PARTICIPANTS: Diabetics of 14 or over included in the procedure. MEASUREMENTS AND MAIN RESULTS: A total of 165 analytical samples of blood and urine were studied. The variables were: age, sex, reactive strip (RS) of urine, sediment (S), binomial concordance of reactive strip-sediment (RS-S), culture (C) and metabolic control. The level of concordance between the variables was found through the Kappa index. Very high concordance was obtained in the RS-S and C comparisons (K = 0.49). The analysis of the variable RS-S displayed sensitivity of 66% and specificity of 87%. CONCLUSIONS: Finding a low concordance between reactive strip, sediment and culture suggests their non-exclusive character. The importance of requesting urine sediment instead of the reactive strip for diabetics is indicated. Urine culture could well be included in the diabetic protocol.

[Detection of visual acuity disorders and amblyopia in preschool children]. / Detección de trastornos de agudeza visual y ambliopía en preescolares.

OBJECTIVE: To call attention to the visual sharpness disorders which pre-school children on a determined paediatric list present. DESIGN: A descriptive study. SETTING: Riaño Health Centre, Langreo, Asturias. PARTICIPANTS: Pre-school children aged 4 and 5 at the study date (1994). MEASUREMENTS AND MAIN RESULTS: A total of 155 children captured for the study through the nursing child programme were evaluated. Data were collected from their corresponding clinical histories. Evaluation was performed by Paediatrics and Ophthalmology specialists and second-year interns in Family and Community Medicine at the Valle del Nalón hospital. To check ocular alignment, the Hirschberg test was used; and to explore visual sharpness, the Pigassou optotype was applied. Disturbance of ocular alignment was suspected in 40.6% of cases and pathology was confirmed in 58.3%; whereas in 44% of cases referral to the ophthalmologist was due to errors in the visualisation of the optotype, with 50% presenting pathology. Amblyopia was found in 5.4% of the total population studied. In the breakdown of ophthalmic pathology it was observed that compound astigmatism was the most common finding (25%). CONCLUSIONS: 1. The high prevalence of Amblyopia found underlines the importance of considering it as a priority objective in prevention programmes. 2. The Hirschberg test and early use of optotypes should be considered elementary routine exploration tests in the scheduled check-ups. 3. It would be useful to strengthen training within the population as a whole as well as improve the linking of Primary and Specialist Care.

Loss of heterozygosity and mutation analysis of the p16 (9p21) and p53 (17p13) genes in squamous cell carcinoma of the head and neck.

We analyzed allelic loss at the p53 gene (17p13) and at chromosome region 9p21 in 35 primary head and neck squamous cell carcinomas. Loss of heterozygosity (LOH) at p53 and 9p21 was found in 50 and 75% of informative cases, respectively. LOH at the p53 gene did not increase significantly with tumor stage, but was more frequent in moderately and poorly differentiated tumors than in well-differentiated tumors. LOH plus mutation or homozygous deletion of p53 was limited to advanced stage and poorly differentiated tumors. Allelic loss at 9p21 is frequent in early stage head and neck squamous cell carcinoma and is not significantly associated with LOH at p53. The second exon of the p16/MTS1/CDKN2 gene was found to be homozygously deleted in 1 of 19 cases showing LOH at 9p21, but direct sequencing did not show mutations in the remaining 18 cases. This suggests that p16 plays a limited role in the development of head and neck squamous cell carcinoma.

PCR-based study of the presence of Y-chromosome sequences in patients with Ullrich-Turner syndrome.

The presence of Y chromosome sequences in Ullrich-Turner syndrome (UTS) patients has been suggested in previous work. Karyotype analysis estimated at about 60% of patients with a 45, X constitution and molecular analysis (Southern blot analysis with several Y chromosome probes and PCR of specific sequences) identified the presence of Y chromosome material in about 40% of 45, X patients. We have developed a very sensitive, PCR-based method to detect Y specific sequences in DNA from UTS patients. This protocol permits the detection of a single cell carrying a Y sequence among 10(5) Y-negative cells. We studied 18 UTS patients with 4 Y-specific sequences. In 11 patients we detected a positive amplification for at least one Y sequence. The existence of a simple and sensitive method for the detection of Y sequences has important implications for UTS patients, in view of the risk for some of the females carrying Y-chromosome material of developing gonadoblastoma and virilization. Additionally, some of the UTS associated phenotypes, such as renal anomalies, could be correlated with the presence of Y chromosome specific sequences.

DNA microsatellite analysis of families with autosomal dominant polycystic kidney disease types 1 and 2: evaluation of clinical heterogeneity between both forms of the disease.

We studied 17 large families affected by adult dominant polycystic kidney disease (ADPKD). Ultrasonographic analysis was performed on all the family members. DNA microsatellite markers closely linked to PKD1 on 16p13.3 were analysed, and linkage of the disease to this locus was determined. Families showing a negative linkage value were evaluated for linkage to the PKD2 locus on 4q. Five of the 17 families showed negative linkage for the 16p13.3 markers. In these families significant linkage to 4q was obtained. Renal cysts developed at an earlier age in PKD1 mutation carriers, and end stage renal failure occurred at an older age in people affected with PKD2. Analysis of large families with ADPKD in a Spanish population indicates that this is a genetically heterogeneous disorder, but mutations at only two loci are responsible for the development of the disease in most if not all the families. Clinicopathological differences between both forms of the disease occur, with subjects with ADPKD2 having a better prognosis than those with mutations at PKD1.

[Cystic fibrosis in Asturias: an elevated frequency of the delta F508 mutation]. / Fibrosis quística en Asturias: elevada frecuencia de la mutación delta F508.

BACKGROUND: Cystic fibrosis (CF) is the most common autosomic-recessive inherited disorder. More than 300 different mutations in the CF gene (CFTR) have been described, being delta F508 and G542X the most common in the Spanish population. The frequencies of these mutations vary between the different European populations. METHODS: We have studied the delta F508 and G542X mutations in 20 CF-patients from Asturias. These mutations were analysed through the polymerase chain reaction (PCR). RESULTS: The frequency of the delta F508 mutation in Asturias was 77.5%, higher than those found in most of the other Spanish populations. The frequency found in Asturias is close to the frequency described for the Basque Country population. Patients homozygous for the delta F508 mutation showed clinical symptoms similar to those described in studies on other populations. CONCLUSIONS: The high frequency of two mutations in the CFTR gene in Asturias makes possible the direct diagnostic in most families. The delta F508 mutation is associated to severe clinical manifestations, like early pancreatic insufficiency and Pseudomonas infection.

Role of iron metabolism in absorption and cellular uptake of aluminum.

The effect of iron status on aluminum (Al) absorption was investigated in this study in vivo using an animal model and in vitro using an intestinal mucosal cell line. In the in vivo model rats were rendered iron overloaded by intraperitoneal injection of iron dextran (5 mg/48 hr) or iron deficient by phlebotomy (2.5 to 3 ml blood/week). These rats, and normal controls, were then dosed with Al(OH)3 (40 mg/day) for 30 days. Urinary excretion of Al was significantly greater in the iron deficient group than in the other two groups throughout the study period, and brain Al at the end of the experiment was significantly increased in the iron depleted group (1.93 micrograms/g) and decreased in the iron overloaded group (0.73 microgram/g) compared with controls (1.42 micrograms/g). The brain Al levels in iron overloaded rats were no higher than those in normal rats that had not been dosed with Al(OH)3 (0.61 microgram/g). No significant differences were found in serum Al levels. In the in vitro experiments cultures of the rat intestinal cell line RIE1 were iron overloaded by addition of iron nitrilotriacetate (0.1 mM) or iron depleted with desferrioxamine (5 micrograms/ml) for 20 days prior to pulsing with Al transferrin (0.5 mg/ml) for 24 hours. Uptake of Al was significantly greater in the iron depleted cells (2.3 ng/micrograms cell DNA) than in iron overloaded (0.81 ng) or untreated (0.83 microgram) cells. These studies show that iron depletion markedly increases absorption and cellular uptake and suggest that susceptible individuals, such as renal failure patients, run an increased risk of toxicity if they are iron deficient.