Evaluation of 4-fluoroisobutyrylfentanyl in blood samples from 247 authentic cases submitted to the New York City Office of Chief Medical Examiner in 2017–2018

Purpose

4-Fluoroisobutyrylfentanyl (FIBF) was first identified at the New York City Office of Chief Medical Examiner (OCME) in May 2017 and was reported qualitatively due to the constant changes in “fentalogs” (analogs of fentanyl) identified. However, by the year’s end, FIBF was the fifth most common non-methadone synthetic opioid detected and a quantitative method was developed to better understand the significance of this compound.

Methods

A full quantitative validation was performed utilizing liquid chromatography–tandem mass spectrometry (LC–MS/MS). All cases submitted between May 2017 and December 2018 that tested positive for FIBF qualitatively were chosen for quantitation. In addition to compiling FIBF concentrations, user demographics and concurrent drug use were also investigated.

Results

There were 247 FIBF-positive cases that were tested with blood concentrations ranging from <?0.1 to 331 ng/mL. The most commonly detected drugs in conjunction with FIBF were other opioids, benzodiazepines, cocaine, cannabinoids and ethanol. The most frequent users were male, White, and between 35 and 54 years of age. The concentrations of FIBF varied widely and showed no clear distinction when considering various case types. Although most often used in tandem with other drugs of abuse, the danger of this compound was demonstrated by the fact that FIBF was also reported as the sole intoxicant responsible for death.

Conclusions

The development of a quantitative method for FIBF has been beneficial at the OCME due to the significant number of positive cases reported and the current lack of sufficient published information on this analog. To our knowledge, there are only two papers that include FIBF concentrations in four cases; this article gives the largest number (247 cases) of FIBF levels in blood samples of its users to aid in the interpretation and analysis of significance of this compound.

     

Veterans' health and access to care in the year after September 11, 2001

OBJECTIVE: The goal was to explore veterans' perceptions of their health care in the year after September 11, 2001. METHODS: A random sample of outpatients seen at a Manhattan (New York City) or Midwestern Veterans Affairs facility between September 12, 2001, and September 30, 2002, received a mailed questionnaire. Regression assessed the effects of site, demographic features, military service, and symptoms of post-traumatic stress disorder (PTSD) on health status, care-seeking, and satisfaction with health care among 490 patients. RESULTS: Veterans from New York City reported better health and more satisfaction that their providers listened to them. Patients with more PTSD symptoms reported poorer health, more September 11-related symptoms, and less satisfaction with care and were more likely to seek care outside the Veterans Affairs system. CONCLUSIONS: Proximity to the September 11 terrorist attacks had little relationship to patients' perceptions of their health and health care, whereas PTSD symptoms had a pervasive effect. Patients with PTSD symptoms may require outreach programs to assist them in dealing with catastrophic events, regardless of their proximity to the events.     

Validation of a DNA mixture statistics tool incorporating allelic drop-out and drop-in

DNA mixture analysis is a current topic of discussion in the forensics literature. Of particular interest is how to approach mixtures where allelic drop-out and/or drop-in may have occurred. The Office of Chief Medical Examiner (OCME) of The City of New York has developed and validated the Forensic Statistical Tool (FST), a software tool for likelihood ratio analysis of forensic DNA samples, allowing for allelic drop-out and drop-in. FST can be used for single source samples and for mixtures of DNA from two or three contributors, with or without known contributors. Drop-out and drop-in probabilities were estimated empirically through analysis of over 2000 amplifications of more than 700 mixtures and single source samples. Drop-out rates used by FST are a function of the Identifiler^® locus, the quantity of template DNA amplified, the number of amplification cycles, the number of contributors to the sample, and the approximate mixture ratio (either unequal or approximately equal). Drop-out rates were estimated separately for heterozygous and homozygous genotypes. Drop-in rates used by FST are a function of number of amplification cycles only.FST was validated using 454 mock evidence samples generated from DNA mixtures and from items handled by one to four persons. For each sample, likelihood ratios (LRs) were computed for each true contributor and for each profile in a database of over 1200 non-contributors. A wide range of LRs for true contributors was obtained, as true contributors’ alleles may be labeled at some or all of the tested loci. However, the LRs were consistent with OCME's qualitative assessments of the results. The second set of data was used to evaluate FST LR results when the test sample in the prosecution hypothesis of the LR is not a contributor to the mixture. With this validation, we demonstrate that LRs generated using FST are consistent with, but more informative than, OCME's qualitative sample assessments and that LRs for non-contributors are appropriately assigned.     

腹腔镜辅助与开腹全结肠系膜切除术治疗老年人右半结肠癌疗效和安全性的比较

 目的 分析比较腹腔镜辅助全结肠系膜切除(laparoscopy-assisted complete mesocolic excision, LCME)与开腹全结肠系膜切除(open complete mesocolic excision, OCME)治疗老年人右半结肠癌的可行性、安全性及临床疗效观察。方法 回顾性分析河北大学附属医院2011-04至2015-09收治的老年右半结肠癌170例的临床资料,其中LCME组和OCME组各85例,比较两组患者的术中、术后临床资料及随访资料。结果 两组患者的术中出血量、初次排气时间、初次进流食时间、平均住院时间,LCME组患者明显少于OCME组,差异有统计学意义(均P<0.05)。两组患者手术质量分级、手术时间、清扫淋巴结数目、术后心脑血管意外发生率及未见统计学差异(均P>0.05)。术后随访时间为48个月,两组患者的复发率和转移率差异无统计学意义。结论 腹腔镜辅助全结肠系膜切除术(LCME)治疗老年患者右半结肠癌的安全性、可行性、根治性,以及短期生存均不逊于传统开腹手术。     

Genetic testing in sudden unexpected natural death in the young: New York City Office of Chief Medical Examiner’s experience and perspective

Postmortem genetic testing is a diagnostic tool that is becoming increasingly utilized. The benefits and limitations of genetic testing in cases of sudden, unexpected death in the young (≤ 40 years old) are reviewed from the perspective of the Office of Chief Medical Examiner of the City of New York, whose Molecular Genetics Laboratory, accredited by College of American Pathologists, has had 15 years of postmortem testing experience. Challenges to the interpretation and communication of testing results are highlighted, and opportunities for improving testing yield are discussed for age groups across the lifespan, from infancy to adulthood.     

Brief communication: A radiology resident's experience with COVID-19 in New York City

The COVID-19 pandemic impacted New York City severely. As a radiology resident, I was unsure how my role would change as the pandemic unfolded. Like many hospital systems in New York City, my department was asked to assist in the clinical care of patients during the dramatic surge of admissions related to COVID-19. I placed invasive central lines for critically ill patients in the intensive care unit to help reduce the workload on already overwhelmed critical care teams. I also performed direct patient care within dedicated COVID-19 inpatient floors.     

Lessons Learned From the COVID-19 Response in a Major New York City Hot Zone

The COVID-19 pandemic had significant impact on radiology departments across the United States. Radiology departments have adjusted to the effects of the pandemic. This article presents the changes made by the Radiology department at the Montefiore Medical Center (MMC) of the Albert Einstein College of Medicine located in the Bronx, New York City which is one of the major hot spots of the COVID-19 pandemic.     

Risk stratification in heart failure using ¹²³I-MIBG

Heart failure is a progressive, heterogeneous form of cardiovascular disease that requires treatment to be individualized depending on the presenting symptoms. A decision to use an implantable cardioverter-defibrillator (ICD) is based on chronic heart failure patients presenting with a New York Heart Association classification of II or III and a left ventricular ejection fraction (LVEF) less than or equal to 30%-35%. A large percentage of ICD devices, however, never deliver therapy during their lifetime, and as many as 33% of patients ineligible for an ICD (LVEF > 35%) die of sudden cardiac death. (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy identifies sympathetic nervous system dysfunction and has been shown to lead to better patient stratification. This article reviews the role of planar (123)I-MIBG global quantitation in improving differentiation of heart failure, regardless of the LVEF, to better identify those in whom an ICD is more likely to reap benefits. It goes on to explore the potential incremental benefit of SPECT-based regional quantitation to risk stratification and provides a case example in which (123)I-MIBG SPECT was used to inform a decision to not use an ICD in a patient eligible under the standard criteria.     

DNA analyses of the remains of the Prince Branciforte Barresi family

The five skeletons found buried in the church of Militello di Catania, Sicily, were tentatively identified by morphological analysis and historical reports as the remains of Prince Branciforte Barresi, two of his children, his brother and another juvenile member of the family (sixteenth and seventeenth centuries). In order to attempt to clarify the degree of relationships of the five skeletons, sex testing and mitochondrial DNA (mtDNA) sequence analysis of the hypervariable segments I and II (HV1 and HV2) of control region were performed. Moreover, the 9 bp-deletion marker of region V (COII/tRNA ^lys) was examined. Molecular genetic analyses were consistent with historical expectations, although they did not directly demonstrate that these are in fact the remains of the Prince and his relatives, due to the impossibility of obtaining DNA from living maternal relatives of the Prince. Received: 6 April 1999 / Accepted: 27 September 1999     

Estimating post-mortem interval using accumulated degree-days and a degree of decomposition index in Australia: a validation study

The development of new and more accurate methods for estimating post-mortem interval (PMI), which can be applied universally, are gaining in popularity. However, given the geographically specific nature of soft tissue decomposition, these methods need to be tested for their accuracy and applicability in a variety of regions before being applied to police and forensic investigations. This study tested two methods for PMI estimations to validate their applicability when used in the Hawkesbury region of New South Wales, Australia. The first method, referred to as the ‘Accumulated degree day (ADD)’ method, was proposed by Megyesi et al.¹ in 2005 and the second method, referred to as the ‘Degree of decomposition index (DDI)’ method, was proposed by Fitzgerald and Oxenham² in 2009. Four adult pig carcasses were placed on a soil surface and left to decompose undisturbed from July–September, 2013. The ADD and DDI methods were applied to the remains during this post-mortem interval. Results show that both methods under-estimated the time since death of the remains; however, the ADD method did have the potential to be effective when remains were in the advanced decomposition stages. Failure to validate these methods likely occurred because they could not account for the underlying factors affecting decomposition in this specific environment. An alternative equation was created for these methods, using data collected from the decomposition site in the Hawkesbury region and further validation is being carried out to account for inter- and intra-year variation.     

Incidental findings in the use of DNA to identify human remains: An ethical assessment

DNA analysis is increasingly used to identify the remains of victims of conflicts and disasters. This is especially true in cases where remains are badly damaged and fragmented, or where antemortem records are unavailable. Incidental findings (IFs)—that is, genetics-related information for which investigators were not looking—may result from these identification efforts employing DNA analysis. Because of the critical role played by family members of the missing in identification efforts, as well as the familial nature of DNA, identification initiatives employing DNA analysis are particularly prone to reveal IFs about familial relationships, such as misattributed paternity or false beliefs about sibling relationships. Despite forensic scientists’ widespread awareness of the possibility of generating IFs, to date there has been relatively little explicit guidance about their management. This paper fills that gap. It offers substantive guidance about the ethical management of IFs in this context. To ensure that the analysis addresses actual needs and practices in the field, one author (JDA) conducted semi-structured interviews with key informants from six regionally diverse organizations involved in post-conflict or post-disaster identification efforts. The paper first describes how methods of DNA analysis give rise to IFs. Next, it explains the importance of developing an ethically justified general policy for managing IFs and discusses features of DNA identification efforts that are relevant to such a policy. Then it presents an argument in support of a general policy of nondisclosure—specifically, that considerations of fair access to the individual and social benefits of identification efforts, and the concern to minimize and fairly distribute the risks of participation, support a policy of nondisclosure. It concludes by considering some implications of this argument for the choice among scientific practices involved in using DNA analysis to identify human remains, as well as for managing non-genetic incidental findings.     

Lessons learned during the COVID-19 pandemic: a single institution radiology chief resident experience

Coronavirus Disease 2019 (COVID-19) has posed incredible new challenges for radiology residency programs, including resident training under tenuous and uncertain conditions, barriers to communication, deployment-induced anxiety, and social isolation. Chief residents and program leadership play a critical role in guiding radiology residents through these unprecedented times. Best practices and creative approaches experienced in a single institution's residency program located in New York City are shared in an effort to encourage other programs struggling with similar obstacles to prioritize resident education and wellness.     

Accuracy in certification of cause of death in a tertiary care hospital – A retrospective analysis

Every physician is duty bound to issue a “Cause of Death” certificate in the unfortunate event death of his/her patient. Incomplete and inaccurate entry in these certificates poses difficulty in obtaining reliable information pertaining to causes of mortality, leads to faulty public health surveillance, and causes hindrance in research. This study intends to evaluate the completeness and accuracy of Medical Certification of Cause of Death in our Institute and to formulate strategy to improve the quality of reporting of cause of death. During the period from January 2012 to December 2012, a total of 151 certificates of cause of death were issued by the faculty members of various departments. Maximum number of death certificates were issued for patients in the extremes of the age <10 years (n = 42, 27.82%) and in >60 years (n = 46, 30.46%). The various inadequacies observed by us are as follows: 40 (26.49%) cases had inaccurate cause of death, interval between onset and terminal event was missing in 94 (62.25%) cases, in 68 (45.03%)cases the seal with registration number of the physician was not available on the certificate, incomplete antecedent & underlying cause of death was found in 35 (23.18%) & 84 (55.63%) cases, in 66 (43.71%) cases there was use of abbreviations and the handwriting was illegible in 79(52.32%) cases.     

Ewing's sarcoma of humerus with epithelial differentiation

This case was originally presented at the closed meeting of the International Skeletal Society in New York, September 1989     

Case report 787

Presented at the 16th Meeting of the International Skeletal Society in New York, NY, USA, September 1989     

Availability of death review of children using death certificates and forensic autopsy results

The Model Project for Child Death Review (CDR) was initiated in Japan, but parental consent is required for detailed investigations. We proposed an alternative method to review child deaths using death certificates and forensic autopsy results when parental consent is not provided. We extracted and reviewed death certificates for the deceased younger than 18 years from among all certificates submitted in Shiga Prefecture between 2015 and 2017. In addition, we analyzed autopsy records in cases that underwent forensic autopsy. The prevalence of each cause of death was compared among age groups. The situation and circumstances of unnatural deaths were analyzed in detail. Of 131 certificates, unnatural deaths accounted for 29.7 %. The prevalence of each cause of death significantly differed among age groups. Malignant disease and suicide were most common in school-aged children and congenital disease was most common in infants. Suicide was the leading cause of unnatural death, followed by suffocation, which was most common in infants. Situations where suffocation was reported included co-sleeping with the mother and breastfeeding. Despite parental consent not being obtained, the trends of regional child deaths and the circumstances of accidental deaths were clarified by the present method. However, the results of detailed investigation were lacking. This study provided basic information for implementing detailed methods and procedures for CDR at the governmental level. To perform optimal CDR, legislation for collecting detailed information without parental consent is required.     

Deaths attributed to X-ray contrast media on U.S. death certificates

OBJECTIVE: The objectives of our study were to determine the number, rate, and types of deaths attributed to specific X-ray contrast media on the basis of U.S. death certificates and to attempt to assess the comparative safety of commonly used diagnostic X-ray contrast agents using death certificate information. CONCLUSION: From 1999 through 2001, deaths attributed to the International Classification of Diseases (ICD) code for contrast media occurred at the rate of 1.1-1.2 per million contrast media packages distributed. An analysis of 1999 death certificates indicated that most deaths attributed to contrast media predictably were associated with renal failure or nephropathy and anaphylaxis or allergic reactions. Risk assessment of the comparative safety of classes or agents was limited by lack of specific contrast media names. Names of administered contrast agents should be recorded in patients' medical records and communicated to primary care physicians and certifiers of death in the event of serious sequelae after an identified recent radiologic procedure.     

International conference on the relationship between disarmament and development

The first International Conference on the Relationship between Disarmament and Development was held at the United Nations, in New York, from 24 August to 11 September, 1987.     

Cardiac 123 I-MIBG imaging and clinical variables in risk stratification in patients with heart failure treated with beta blockers

Both myocardial m-[123I]iodobenzylguanidine (123I-MIBG) uptake and plasma norepinephrine are markers of sympathetic activation in heart failure and have been shown to portend a poorer prognosis. However, these observations were noted before treatment with beta blockers became part of standard clinical practice. Fifty-eight patients with chronic heart failure (New York Heart Association functional class II and III, ejection fraction <35%; 53% ischaemic cardiomyopathy) were prospectively studied with a mean follow-up of 36 months. During the observational period, 17 patients (29.3%) had a predefined event (death and heart transplantation). All prognostic parameters were obtained before beta blocker therapy was initiated. In both uni- and multivariate analysis, the heart-mediastinum ratio of 123I-MIBG uptake did not correlate with cardiovascular mortality. In the multivariate Cox regression analysis, plasma norepinephrine, peak oxygen consumption, end-diastolic volume as measured by echocardiography and exercise performance during bicycling and walking had prognostic significance in patients with heart failure treated with beta blockers in addition to angiotensin-converting enzyme inhibitors.