Cause and manner of death and phase of the blood alcohol curve.

In a large number of forensic autopsies (N = 28,184) the concentrations of ethanol in femoral blood and bladder urine were determined and the urine-to-blood concentration ratios of ethanol were calculated. Based on the differences in ethanol concentration between urine and blood, the deaths were classified as having occurred during the absorptive, the peak or the post-absorptive phase of the blood­alcohol curve. Most people died in the post-absorptive phase, N = 24,223 (86%), whereas 1538 individuals (5.5%) were still absorbing alcohol and 2423 (8.6%) were at or close to the peak BAC at time of death. Both blood­alcohol concentration (BAC) and urine­alcohol concentration (UAC) were significantly higher in the post-absorptive phase (p < 0.001). The proportions of people dying in the absorptive and peak phases increased with advancing age. The cause of death (CoD) and manner of death (MoD) according to death certificates were compared with phase of the blood­alcohol curve using a multinomial regression model with and without making adjustment for possible effects of age, gender and BAC. The relative risk (RR) and relative risk ratios (RRR) showed some associations between CoD and phase of the blood­alcohol curve. Undetermined MoD was significantly higher in the absorptive phase compared with the post-absorptive phase (RRR = 2.12). Deaths related to esophagus, stomach and duodenum (RRR = 2.04) and alcoholic liver diseases (RRR = 1.85) were significantly higher at or close to peak phase compared to the post-absorptive phase. Road-traffic fatalities were more prevalent in the peak BAC phase (RRR = 1.33) and deaths by accidental falls were less in the absorptive phase (RRR = 0.58) compared with the post-absorptive phase. The phase of alcohol intoxication seems relevant to consider by forensic experts when alcohol-related deaths are investigated.

Blood-positive illicit-drug findings: implications for cause-of-death certification, classification and coding.

National cause-of-death data are important for national health administration, international comparisons and epidemiological research. The process of compiling mortality statistics starts with determination of causes of death, continues with medical death certification and concludes in coding of causes and selection of the underlying cause of death at statistical office. This study assesses how unequivocally and specifically the toxicologically verified intoxication of cannabinoids, opiates, amphetamines and cocaine is represented in diagnostic entries on death certificates and the national cause-of-death database and, ultimately, in the cause-of-death statistics. Drug-positive deaths, i.e. deaths with blood-positive drug finding(s), the corresponding death certificates and the information entered in Statistics Finland's cause-of-death database were reviewed for the entire years of 2000, 2002 and 2004. Drug influence at the time of death may or may not be related to death. A drug-related condition was reported as the cause of death in 52% of cannabinoid-positive, in 81% of amphetamine-positive, in 98% of opiate-positive and in 100% of cocaine-positive deaths, calculated from the combined three-year material. At Statistics Finland, after validation of the reported information, the distribution was practically the same. From the cause-of-death database, the specific drug-related diagnosis could be identified in 21% of cannabinoid-positive, in 89% of opiate-positive and in 57% of amphetamine-positive deaths. The corresponding proportions of specific drug-related underlying causes in the cause-of-death statistics were even smaller for cannabinoids and amphetamines, 10% and 39%, respectively. In multiple-drug cases, identification was possible only if each drug had been assigned an additional drug-specific code from "T categories" of ICD-10 Chapter XIX. What is noteworthy, however, is that a third of cannabinoid-related and a quarter amphetamine-related cause-of-death diagnoses were assigned unspecific categories of ICD-10 in the multiple-cause database and, more notably, in cause-of-death statistics based on selected underlying causes. For the better specification of drug-related causes of death, we propose that the next ICD revision provide each drug with the code of its own, e.g. one comparable to ATC (Anatomical Therapeutic Chemical Classification Index) codes, to be used for its specification in all positions and combinations, or at least provide compatibility with the ATC's coding system. For classification and describing the trends of drug-related deaths, equal and specific definitions for drug-related deaths would also be needed.

Stimulating and inhibitory effects of the dopamine "stabilizer" (-)-OSU6162 on dopamine D2 receptor function in vitro.

The effect of (-)-OSU6162 on the incorporation of GTPgammaS(35) in the membranes of hD(2l)-transfected CHO cells was investigated. In the absence of dopamine the compound exerted a slight but significant stimulating action, suggesting a weak partial agonism. In the presence of dopamine, low concentrations (10 to 100 nM) enhanced the stimulating action of dopamine. This enhancing effect was reversed by higher concentrations of (-)-OSU6162 in a complex biphasic manner. The dopamine-enhancing action is proposed to be mediated by binding to an allosteric site with high affinity and the inhibitory component by a low-affinity binding to the orthosteric site of the dopamine receptor.

Fatal drug poisonings: medico-legal reports and mortality statistics.

The entire fatal drug poisoning panorama in Finland is considered in terms of three catergories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding "to the medicinal agent when combined with alcohol"; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner's evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.

Cause-of-death query in validation of death certification by expert panel; effects on mortality statistics in Finland, 1995.

The correctness of selection, coding and registration of underlying cause-of-death is important for the quality of mortality statistics. One measure to improve quality is the query to the certifier for verification of the underlying cause-of-death. In Finland, 3478 death certificates, 7.1% of total 49074 certifications in 1995, were considered questionable by statisticians. The expert panel at Statistics Finland was able to resolve 2813 (80.9%) of them. However, 665 (19.1%) certificates needed to be further queried from the certifier. Of these, 318 (47.8%) were re-assigned to another ICD-9 category or to the applicable three-digit category within the main category of heart and vascular diseases, resulting in changes from a 17.00-fold increase in rheumatic heart diseases (ICD-9 codes 390-398) to a decrease of about one-half (0.45-fold change) in unspecified neoplasms (codes 235-239). However, a statistically significant impact on national mortality statistics was not observed in any of applied ICD categories. Among all questionable death certificates, most prone to query of the certifier, and with a statistical significance of P<0.05, were those with no cause-of-death specified, those stating underlying cause-of-death as non-specified neoplasms (with a observed/expected ratio, O/E, of 1.69), and heart and vascular diseases (1.45), with its subcategories of ischaemic heart diseases (1.33) and other heart diseases (2.92). Death certificate validation, by expert panel consultations and query to the certifiers, and the importance of estimation of the validity of cause-of-death information on death certificates are strongly pointed out in a continuous strive for correct and reliable mortality statistics.

Fatal alcohol poisoning: medico-legal practices and mortality statistics.

Compilation of mortality statistics from death certificate data is based on international and national conventions which in certain situations result in the underlying cause-of-death other than that established and reported by the physician. The present study compares all fatal alcohol poisonings in 1997 as registered on forensic toxicological grounds at the accredited central laboratory and as presented in the national cause-of-death statistics, according to the underlying cause-of-death, by applying international statistical rules and principles in ICD-10. Four groups were formed, and case frequencies in each group were obtained from forensic toxicological data, group "T51" for acute poisonings due to alcohol alone, and group "Comb" for acute alcohol poisonings combined with some drug, medicament or other biological substance, and from cause-of-death statistics data, group "X45", for deaths from alcohol poisoning, and group "F102" for those medico-legal fatal alcohol poisoning deaths which at the statistics office were inferred to be due to alcoholism. The study shows that in Finland the officially compiled statistics on fatal alcohol poisonings, when compared with medico-legal statements based on forensic toxicological examinations, were underrepresented by 31.4% in 1997. About two-thirds of this underrepresentation is explained by preferring, as the underlying cause-of-death, alcoholism to acute alcohol poisoning, and about one-third by preferring, in cases of acute combined poisonings, the drug component to the alcohol. From 1998 onwards, more emphasis has been put on the alcohol component when coding medico-legally proven accidental deaths from simultaneous poisoning with alcohol and a medicinal agent. This change in coding practices presumably explains the subsequent decline in the annual underrepresentation rate of alcohol poisoning in mortality statistics to the level of 15-16%. It is concluded that the present ICD rules inevitably lead to underrepresentation of alcohol poisonings in the mortality statistics, and conceptual and practical proposals for future procedures are made.

The validity of death certificates: routine validation of death certification and its effects on mortality statistics.

The 3478 death certificates (7.1% of all annual death certificates) of this study comprise those national death certificates in 1995 submitted for validation to the panel representing both medical and nosological expertise. As such, it is highly selected and represents, from the nosological point of view, the most inconsistently filled-in portion of Finnish death certificates. The routine validation procedure is essentially based on exploitation of the extra medical information, i.e. the case history, on the Finnish death certificate form. Altogether, 2813 (80.9%) out of 3478 certificates could be adjusted at the primary panel session; the rest required further clarification. The re-assignment of cause of death by the panel and the impact of panel adjustments on the national mortality statistics is assessed here by comparing the initial death certification and the finally registered underlying cause of death grouped into ICD-9 major categories with special reference to the subcategories of neoplasm, cardiovascular disease (HVD) and unnatural death. A statistically significant decline (p<0.0001) in deaths, both in the category of symptoms, signs and ill-defined conditions and in the pulmonary circulation disease subcategory of HVD with 37.6 and 35.1%, respectively, was observed. The decrease of 11.1% in the benign or NUD neoplasm subcategory and the increase of 8.6 and 7.0% in the categories of endocrine disease, and musculo-skeletal and connective tissue disease, respectively, are essential observations as to the quality of the cause of death register. The effect on the HVD major category was practically nil. At the HVD-subcategorial level, a decrease of 14.0% for diseases of the veins and lymphatics and other circulatory diseases and an increase of 3.5% for hypertensive diseases (HYP) were the two next most obvious alterations to the diseases of the pulmonary circulation, but were without statistical significance. For ischaemic heart disease and other subcategories, the effects were minor. The unnatural deaths as a whole increased in the final statistics with only 0.9%. In the study data, categorial changes ranged from the decrease of 75.2% for symptoms, signs and ill-defined conditions to the increase of 77.3% for endocrine diseases. In conclusion, the Finnish death certificate form, death certification practices and cause of death validation procedure seem to serve the coding of causes of death for mortality statistics appropriately. The results of the study form a relevant reference background to evaluation of epidemiological studies on mortality.

Effect of amphetamine, alpha-methyl-p-tyrosine (alpha-MPT) and antipsychotic agents on dopamine D2-type receptor occupancy in rats.

1. EEDQ inactivates unoccupied receptors in vivo in brain tissue and is useful in determining which receptors are occupied by a drug treatment. 2. alpha-MPT, inhibits the synthesis of dopamine, reducing D2-type receptor occupancy by dopamine and enhances the amount of receptor inactivation by EEDQ. 3. Amphetamine releases dopamine resulting in increased occupancy of dopamine D2-type receptors and we have shown that it protects those receptors from EEDQ. 4. Clozapine and remoxipride, two antipsychotic agents, occupied the dopamine receptors in both the caudate and cortex. 5. These findings are important because they substantiate other results obtained with amphetamine and SPECT, which demonstrated an exaggerated dopamine neurotransmission in schizophrenic patients versus normal controls.

Direct determination of dopamine D4 receptors in normal and schizophrenic postmortem brain tissue: a [3H]NGD-94-1 study.

Using an indirect subtraction binding technique and human postmortem tissue, several laboratories reported finding increases in dopamine D4 receptors in caudate nuclei of schizophrenic patients, although others have not replicated these findings. NGD-94-1 is a selective D4 antagonist with low affinity for the D2 and D3 receptors. [3H]NGD-94-1 has been used in this study to directly determine the density of D4 receptors in normals (n = 13) and schizophrenic subjects (n = 7) off antipsychotic drugs for at least 3 months prior to death, or on antipsychotic (n = 7) drugs at the time of death. Human postmortem coronal brain sections were incubated with [3H]NGD-94-1 and autoradiograms developed; and binding in pertinent regions was quantified. In normals, the highest density of [3H]NGD-94-1 binding was in the hippocampus (68 fmol mg(-1), temporal (33), insular (30), and entorhinal cortices (24.9). Significant increases in [3H]NGD-94-1 density in schizophrenics (n = 14) vs normals (n = 13) were observed in the entorhinal cortex (46%) at both low and high magnifications. The increases observed in the schizophrenics were found in both schizophrenics off antipsychotic drugs for at least 3 months prior to death and those on antipsychotic drugs at the time of death. Thus, the changes may be disease-related and not a consequence of pharmacological treatment. No significant differences were found between the two schizophrenic groups in any brain area studied.

[3H]Neurotensin receptor densities in human postmortem brain tissue obtained from normal and schizophrenic persons. An autoradiographic study.

[3H]Neurotensin binding and autoradiographic techniques were used to determine the distribution and density of neurotensin receptors in normal and schizophrenic postmortem brain tissue. Coronal hemi-brain blocks of tissue were cut at the level of the caudate and hippocampus from frozen brain tissue obtained from normal individuals with no known psychiatric or neurologic illnesses and from schizophrenic subjects off- or on-antipsychotic drugs at the time of death. Each hemi-block was further divided, sectioned, thaw mounted on to slides, incubated with [3H]neurotensin and apposed to film. Digitized images were analyzed for binding densities. Areas of intense binding include the substantia nigra, the entorhinal cortex, superficial layers of the cingulate, middle frontal, and insular cortices; and with moderate binding in nucleus accumbens, and caudate. Schizophrenic patients off- (3 months or more) or on-antipsychotic drugs at the time of death were tested; all patients showed a reduced level of neurotensin receptors in the caudate (68% of normals), cingulate (34%) and prefrontal cortices (25%).

Exploitation of autopsy in determining natural cause of death: trends in Finland with special reference to the diagnostics of ischemic heart diseases and cerebrovascular diseases in middle-aged males, 1974-1993.

Finnish mortality statistics show a marked decrease in coronary disease mortality especially among middle-aged males during the last 20 to 25 years. At the same time, the overall autopsy rate in deaths due to natural, non-violent causes has diminished in Finland. National mortality statistics are based on medical information given in death certificates. How often are the causes of death based on autopsy and is there any definitive trend? Possible changes in cause-of-death determination practices may have contributed to the mortality changes observed. In this study, deaths due to ischemic heart diseases (IHD) and cerebrovascular diseases (CVD) from 1974 to 1993 in Finland were compared with natural deaths, i.e. all of the deaths due to natural causes, in regard to use of autopsy. It was found that IHD-diagnosis as the underlying cause-of-death was, unlike natural deaths and CVD in particular, increasingly based on autopsy. It is thus concluded that the recent decline in coronary disease mortality among middle-aged men in Finland cannot be explained by any deterioration in cause-of-death examination practices.

Antipsychotic properties of the partial dopamine agonist (-)-3-(3-hydroxyphenyl)-N-n-propylpiperidine(preclamol) in schizophrenia.

BACKGROUND: In an ongoing effort to characterize the clinical pharmacologic profile of the partial dopamine agonist (-)-3-(3-hydroxyphenyl)-N-n-propylpiperidine [(-)-3PPP], we administered it to drug-free schizophrenic patients in two consecutive studies. METHODS: In a preliminary dose-finding study, 9 patients were treated using a 6-week placebo-controlled crossover design. Then, to properly demonstrate the antipsychotic effect, we carried out an early efficacy study; here 10 patients received (-)-3PPP, 300 mg B.I.D., in a 1-week placebo-controlled crossover study. RESULTS: Dose-Finding Study: (-)-3PPP showed apparent antipsychotic effect in repeated dosing, with 300 mg B.I.D. being the most effective dose for antipsychotic action; however, the apparent antipsychotic action was not sustained for longer than 1 week, presumably because of desensitization of the receptor by the agonist. Early Efficacy Study: Positive symptoms as measured by the Psychosis Change Scale decreased in 1 week by 30% with (-)-3PPP compared to placebo, and negative symptoms measured with the Brief Psychiatric Rating Scale Withdrawal subscale decreased by 28% with the drug. In both studies, (-)-3PPP lacked any evidence of motor side effects. CONCLUSIONS: These data show that psychotic symptoms decrease with (-)-3PPP and suggest that the treatment of schizophrenia with partial dopamine agonist is a promising strategy. Future attention will be directed toward testing techniques to diminish the tachyphylaxis to allow an ongoing therapeutic effect.

D2-type dopamine receptors in postmortem human brain sections from normal and schizophrenic subjects.

The density of the presumed dopamine D4 receptor ([3H]YM-09151-2 minus [3H]raclopride), as well as the densities of the two ligands themselves were compared in various areas of cerebral tissue from normal versus schizophrenic subjects off or on antipsychotic drugs at the time of death. Using autoradiographic techniques, and analyzing various brain areas, no differences were found in the density of the D4 receptor, nor were differences found between the groups, in any brain region, in the amount of bound [3H]YM-09151-2 or [3H]raclopride. There were, therefore, no differences in the density of the D3-type receptors, including the D4 receptor, in normal and schizophrenic subjects off or on antipsychotic drugs at the time of death.

Affinities and intrinsic activities of dopamine receptor agonists for the hD21 and hD4.4 receptors.

The affinity and intrinsic activity of dopamine receptor agonists were determined at the human dopamine hD21 and hD4.4 receptors. (-)-3-Hydroxy-N-n-propylpiperidine ((-)3-PPP) had an intrinsic activity of 46% and 83%, whereas (+)-N-propylnorapomorphine ((+)-NPA) had intrinsic activities of 61% and 58% at the dopamine hD21 and hD4.4 receptors, respectively. Affinities also varied. A single, or multiple, dopamine D2-type receptor(s) may be involved in schizophrenia and agonists are being tested as therapy. Understanding their properties at the individual dopamine D2-family receptors is important.

D2-family receptor distribution in human postmortem tissue: an autoradiographic study.

The distribution throughout the normal human brain of the dopamine D2-family of receptors were investigated autoradiographically. Three ligands were used, [3H]-YM-09151-2 to define the D2, D3, D4 receptors; [3H]raclopride the D2 D3 receptors; and [3H](+)-7-OH-DPAT, in the presence of GTP, demonstrates D3 distribution. [3H]-YM-09151-2 and [3H]raclopride binding were highest in caudate (121 vs 130 fmol mg(-1)), putamen (96 vs 136 fmol mg(-1)), and nucleus accumbens (113 vs 120 fmol mg(-1)). [3H]-YM-09151-2 also displayed significant binding in several cortical areas (56-39 fmol mg(-1)) and hippocampus (27 fmol mg-1). [3H](+)-7-OH-DPAT was highest in the nucleus accumbens. Based upon the ligands properties it is inferred that D2 distribution is highest in putamen, caudate and nucleus accumbens; D3 in the nucleus accumbens; D4 receptor in cortical areas and hippocampus.

Growth of Chinese hamster ovary (CHO) cells expressing the 5-HT2 serotonin receptor in suspension culture: an efficient method for large-scale acquisition of membrane protein for drug evaluation.

Chinese hamster ovary (CHO) cells expressing the rat 5-HT2 serotonin receptor were grown and evaluated in suspension culture to provide an efficient method of producing membrane-bound receptors for drug discovery. Expression of the 5-HT2 receptor in cells grown in batch suspension culture fluctuated as a function of culture age. Both receptor expression and receptor G-protein coupling were the highest early (1.9 pmol/mg membrane protein) but declined rapidly as the culture increased in age. However, addition of fresh serum-containing medium to stationary-phase cells reversed the decline and, after 24 h of growth, resulted in maximal receptor density and G-protein coupling. This serum response was found to be reproducible and lead to the establishment of a semi-continuous batch culture system in which cells were maintained in a growth state that supported high levels of membrane-incorporated and G protein-coupled receptors. In this system, 50% of the culture volume could be removed at 24-h intervals for membrane preparation and the lost volume replenished with fresh medium, resulting in a continuous supply of high-quality membrane preparations.

Pharmacology of a mixed 5-hydroxytryptamine1A/dopamine agonist.

U-67413B (4-hydroxydipropylaminodihydrophenalene) bound with high affinity to both 5-hydroxytryptamine (HT)1A and D2-dopamine (DA) receptor sites. U-67413B depressed 5-HT and DA cell firing rates and depressed synthesis of both neurotransmitters. The drug depressed mouse body temperatures by an amount similar to that for buspirone, gepirone and ipsapirone, but less than that for 8-hydroxy-N,N-dipropyl-2-aminotetralin. In rats, it produced the 5-HT1A behavioral syndrome. In contrast to 5-HT1A agonists having DA antagonist effects, U-67413B mildly depressed rather than stimulated firing rates of noradrenaline (NA) neurons in the locus ceruleus by a non-alpha-2 receptor mechanism. In behavioral tests designed to measure anxiolytic activities, U-67413B was a slightly more effective anxiolytic than standard 5-HT1A anxiolytics (buspirone, gepirone and ipsapirone). The data are consistent with the hypothesis that effects of 5-HT1A agonists on NA neuron activity are mediated through effects on dopaminergic mechanisms, and that effects on NA neurons could modulate anxiolytic activities of 5-HT1A agonists.