Rapid Deaths Research Articles

Experience of a health day at the university of Namibia: A community service

The School of Nursing and Public Health conducted an annual health day at the main campus in Windhoek. The clinic on campus was not operational, at this time. This service is much appreciated by students and staff. The Community Health Nursing lecturers and second year diploma students participated in the Health day. The services that were rendered included blood pressure; weight and height and body mass index; blood-glucose test; eye test; neck massage. Health education on HIV/AIDS and cancer prevention was given to those who took part. The health day targeted non-communicable diseases (NCD) in order to promote prevention strategies. NCD is a medical condition or disease that can be defined as non-infectious and non-transmissible among people. It is further described as chronic diseases which last for long periods of time and progress slowly. Sometimes, NCDs result in rapid deaths as seen in certain types of diseases such as autoimmune diseases, heart diseases, stroke, most cancers, asthma, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and many more (World Health Organization (WHO).Aim: The health day was done to promote and to provide necessary information and to raise awareness to students and staff on their health and on how to prevent non –communicable diseases.Method: No actual research was done.Results: Data analysis was done based on the findings from the users of the service. The total number of the people who used the blood pressure service were 161. Of which 38 were found to have high blood pressure while 10 were found with low blood pressure and were advised to visit the hospital or clinic and 113 had normal blood pressure. Many people, who were detected with high blood pressure, or hypertension, had no idea of having it. The people who came for weight were 130 out of which 63 had normal weight, 32 were overweight, 16 were obese, and 15 were underweight. Health education was given on nutrition, specifically on balance diet. 20 people were found with high blood-glucose level ranging between 7-21.8 mml. Total number of people who attend eye test were 63 of which 4 had poor vision and were referred to eye clinic. Neck massage attracted many people, and they enjoyed it.Conclusion: The results of health day indicated the need of such services in order to detect abnormalities and to improve the knowledge and understanding of the community members on non-communicable diseases and how to prevent them.

The future of global health after the Ebola outbreak

Background: This article aims to address the future of Global Health after the Ebola outbreak in West Africa. It analyzes the effectiveness of the response provided from the beginning of the epidemic to its remission.Methods:The article is both retrospective and prospective. It is analytic. It is based on factual considerations rather than clinical trials. The article provides the last statistics provided by the World Health Organization. It discusses the rapid involvement of the scientific and the international community in the production of the vaccine against the Ebola virus. It briefly focuses on the cycle of the production of a vaccine which has not been respected in the case of the Ebola outbreak.Results: The Republic of Guinea recorded its first patients in March 2014. The authorities; at that beginning, remained slow in their response. That negligence resulted in hundreds of deaths in the community. The deadly virus killed thousands of people; mainly in Guinea, Sierra Leone and Liberia. Some of the countries that were previously affected by the virus are now declared free of Ebola, while Guinea continues to record some sporadic cases.Conclusions:It appears that the concept of global health was not working in the proper sense from 1976 to 2014. The concept started to work after noticing the rapid deaths of thousands of people in Guinea, Sierra-Leone, and Liberia. Also, the involvement of the United States of America has accelerated the process of the global response to the Ebola outbreak. Rapidly, a vaccine was developed with 100% effectiveness. The conclusion summarizes the future of Global Health in the World; mainly in Africa. The future of modern medicine will pass by the knowledge of the concept of Global Health which is an inclusive part of the Public Health. For example, Global Health is now taught in developed countries. After the Ebola outbreak, universities in Africa and around the world must include the teaching of Global Health in their curriculum.

Pinnatoxin G is responsible for atypical toxicity in mussels (Mytilus galloprovincialis) and clams (Venerupis decussata) from Ingril, a French Mediterranean lagoon

Following a review of official control data on shellfish in France, Ingril Lagoon had been identified as a site where positive mouse bioassays for lipophilic toxins had been repeatedly observed. These unexplained mouse bioassays, also called atypical toxicity, coincided with an absence of regulated toxins and rapid death times in mice observed in the assay.The present study describes pinnatoxin G as the main compound responsible for the toxicity observed using the mouse bioassay for lipophilic toxins. Using a well-characterised standard for pinnatoxin G, LC-MS/MS analysis of mussel samples collected from 2009 to 2012 revealed regular occurrences of pinnatoxin G at levels sufficient to account for the toxicity in the mouse bioassays. Baseline levels of pinnatoxin G from May to October usually exceeded 40 μg kg−1 in whole flesh, with a maximum in September 2010 of around 1200 μg kg−1. These concentrations were much greater than those at the other 10 sites selected for vigilance testing, where concentrations did not exceed 10 μg kg−1 in a 3-month survey from April to July 2010, and where rapid mouse deaths were not typically observed. Mussels were always more contaminated than clams, confirming that mussel is a good sentinel species for pinnatoxins. Profiles in mussels and clams were similar, with the concentration of pinnatoxin A less than 2% that of pinnatoxin G, and pteriatoxins were only present in non-quantifiable traces. Esters of pinnatoxin G could not be detected by analysis of extracts before and after alkaline hydrolysis. Analysis with a receptor-binding assay showed that natural pinnatoxin G was similarly active on the nicotinic acetylcholine receptor as chemically synthesized pinnatoxin G. Culture of Vulcanodinium rugosum, previously isolated from Ingril lagoon, confirmed that this alga is a pinnatoxin G producer (4.7 pg cell−1). Absence of this organism from the water column during prolonged periods of shellfish contamination and the dominance of non-motile life stages of V. rugosum both suggest that further studies will be required to fully describe the ecology of this organism and the accumulation of pinnatoxins in shellfish.

Birth month and longevity: birth month of victims of sudden (SCD, ≤1 h) and rapid (RCD, ≤24 h) cardiac deaths

After a publication of a study in the Proceedings of the National Academy of Sciences USA in 2001, we published three studies related to birth month and morbidity of patients that can affect longevity. The aim of this study is to check two groups of cardiac deaths, consisting of more than 50% of cardiovascular mortality in the industrial world, to examine this paradigm. Patients suffering rapid cardiac death (RCD) (≤24 h) and sudden cardiac death (SCD) (≤1 h) in Lithuanian Medical Science University hospital, a tertiary 3000-bed facility, in 2000-2010 were studied. In total, 1239 RCDs and 324 SCDs were included in this study. Monthly, quarterly, trimester and half-year comparisons of the patients' birth month population were studied. A difference in birth month distribution of the study patients was observed. For RCDs (≤24 h), the highest numbers were found for January (11.0%) and May (10.3%), whereas for the SCDs (≤1 h), April (13.3%) and January (10.5%) dominated. The least numbers were in November (SCD, 5.6%; RCD, 6.2%) and December (5.2-6.1%). Those born in the first and second quarter and first trimester were significantly more than those born in the fourth quarter (I/IV, p=0.0023; I/III, p=0.0074; II/IV, p=0.047) or trimester [I/II, p=0.09 (trend); I/III p=0.014; II/III, p=0.079 (trend)]. In another study at the same location (number of newborns n=286,963), significant correlation between monthly newborn number and month of the year was not found. possible environmental effects related to the different monthly birth distributions of the studied group are discussed. Victims of SCD and RCD are unequally distributed according to month of birth. The highest numbers were found for January and March to May. The numbers are higher for the first and second quarter and first trimester in comparison with the months at the end of the year. The lowest numbers of study patients were born in November, December and October. This is in accord with the birth months of American centenarians (100-112 years old) found by colleagues from the University of Chicago. Possible mechanisms for predisposition to SCD and RCD need further elucidation. Our findings support the paradigm linking birth month and longevity.

Distribution of opiates in femoral blood and vitreous humour in heroin/morphine-related deaths

The distribution of free morphine (FM), codeine and 6-acetylmorphine (6AM) in vitreous humour (VH) and femoral blood (FB) was measured in 70 cases involving heroin/morphine. The relationship between tissue drug concentrations was assessed with respect to case circumstances. Total morphine (TM) concentrations in FB are also reported. The relative concentrations of FM in VH and FB were influenced by survival time. In rapid deaths (<3h after drug intake; n=34) the median FM concentration in VH (0.13mg/L) was significantly lower than the corresponding result for FB (0.25mg/L; p<.01). In delayed deaths (>3h; n=12) the VH concentration (median 0.15mg/L) was higher than in FB (0.092mg/L; p>.05). Free morphine VH/FB ratios were significantly higher in delayed (median 1.3) compared to rapid deaths (0.64). Although these findings indicate a lag in the distribution of morphine into the VH, overlaps were observed in the VH/FB ratio in rapid and delayed death groups which limits the interpretive use of VH/FB ratios. Codeine and 6AM appeared to distribute more rapidly into the VH. Despite the observation that all opiate analytes were correlated between FB and VH (rs≥61; p<.01), our results indicate that in the absence of a blood sample, blood concentrations cannot be reliably inferred from that measured in the VH. In the absence of additional toxicological evidence, the use of FM to TM ratios in blood as an indicator of survival time is not advised.

Rapid death after admission to palliative care

Palliative care units provide non-curative treatment and support to patients with terminal illness. Brief end-of-life admissions are disruptive for patients and their families, and increase staff stress. Extremely rapid deaths (survival <24 h from admission) are particularly challenging for all involved. From 1 January 2010 to 23 August 2011, 256 patients died on the Palliative Care Unit (Caritas Christi) at St Vincent's Hospital Melbourne. Forty-two died within 24 h (16%), while 214 survived beyond 24 h (84%). A retrospective chart audit was conducted, aiming to identify factors characterising those patients who died within 24 h. Groups were compared for age, gender, country of birth, preferred language, ward of origin, primary pathology, time trends, whether an emergency code was called, Palliative Care Outcomes Collaboration (PCOC) phase, modified Karnofsky score and commencement of a syringe driver for medication. Results showed that admission from neurosurgery (P= 0.0001), a vascular or infective pathology (P= 0.0001), PCOC phase ≥ 3 (P= 0.0001), modified Karnofsky score ≤ 20% (P= 0.0001), and commencement of a syringe driver prior to or at admission (P= 0.0001) were all significantly associated with death within 24 h of admission. On binary logistic regression, the only independent predictor of patients likely to die in <24 h from admission was PCOC phase ≥ 3 (P= 0.002).

Investigation of causes of rapid death after rescue among patients suffering crush injury after Wenchuan earthquake

Objective To investigate the causes of rapid death after rescue among patients suffering crush injury after Wenchuan earthquake. Method A retrospective analysis of the medical records of 417 earthquake victims who remedied and transferred by our medical team was made. All patients were salvaged at scene according to the situation at that time and severe patients were transferred to undamaged peripheral general hospitals for continued treatment. Results A total of 417 patients (355 adults and 62 children) with earthquake related injuries and illness were admitted to our medical team. The mean age was (37± 9.6) years. There were 117 crush injury patients (79 male and 38 female) among those patients. The mortality of crush injury was 11.1% (13/117). Among the dead cases, five died of severe primary injury and the other 8 patients with sudden rapid death within 1 h after removal of compressive forces. Conclusions Hyperkalemia and its associated cardiotoxicity were the most common cause of rapid deaths after rescue among patients suffering crush injury after earthquake. Effective treatment of crush injury patients remains one of the most important measures in decreasing earthquake-related death rate. Key words: Earthquake; Crush injury; Crush syndrome; Hyperpotassemia

Four nonfatal and six fatal cases of opiate use: utility of morphine, its metabolites, and their ratios in blood specimens

Four nonfatal and six fatal cases of opiate use are presented with careful toxicological analysis. Levels of morphine (M), 6-monoacetylmorphine (6-MAM), morphine-6-glucuronide (M6G), and morphine-3-glucuronide (M3G) in blood specimens were measured by the sophisticated method of liquid chromatography (LC)-electrospray ionization (ESI)-tandem mass spectrometry (MS-MS). Fatal cases were characterized by much higher levels of free M than the nonfatal cases; this caused lower ratios of M6G/M and M3G/M in the fatal cases when compared with the nonfatal cases. Among the six fatal cases, the M6G/M ratios were especially low in four cases, in which rapid deaths were estimated. The present data are compared with data previously reported by other groups, and we discuss the utility of the levels of M, M6G, and M3G in blood and their ratios for estimating the antemortem status of each individual.

Enterite necrótica aviária

A Enterite Necrótica Aviária (ENA) é uma enterotoxemia aguda que aparece subitamente e provoca morte rápida, afetando principalmente animais jovens. Embora seu impacto negativo na produção, devido ao aumento da conversão alimentar e da condenação de carcaças seja já conhecido, questões relacionadas à etiologia, à patogenia e ao controle desta importante enfermidade necessitam de maiores esclarecimentos. Nos últimos anos, o controle da ENA baseou-se na aplicação de antibióticos na ração animal, prática banida pelo mercado consumidor, que exigiu o desenvolvimento de novas estratégias de controle. Esta revisão aborda informações sobre a etiologia, a epizootiologia, a patogenia, o diagnóstico e o controle da doença, em especial a utilização de probióticos e vacinas como alternativas de controle da ENA.

End‐stage Liver Disease and Liver Transplant: Current Situation and Key Issues

The aim of this article is to identify the current challenges in pediatric OLT. It is directed to all physicians who care for pediatric patients from the early prospect of liver transplant to posttransplant life. Besides assessing current information on transplant results, the coauthors of this article have identified a number of issues that they consider as the most important that need to be addressed in 2008. Some are only an update of old questions, and others are newly identified problems. The recommendations from the group are summarized at the end of each specific issue and in the consensus guidelines.

Cloning, characterization and phylogenetic analyses of members of three major venom families from a single specimen of Walterinnesia aegyptia,

Walterinnesia aegyptia is a monotypic elapid snake inhabiting in Africa and Mideast. Although its envenoming is known to cause rapid deaths and paralysis, structural data of its venom proteins are rather limited. Using gel filtration and reverse-phase HPLC, phospholipases A 2 (PLAs), three-fingered toxins (3FTxs), and Kunitz-type protease inhibitors (KIns) were purified from the venom of a single specimen of this species caught in northern Egypt. In addition, specific primers were designed and PCR was carried out to amplify the cDNAs encoding members of the three venom families, respectively, using total cDNA prepared from its venom glands. Complete amino acid sequences of two acidic PLAs, three short chain 3FTxs, and four KIns of this venom species were thus deduced after their cDNAs were cloned and sequenced. They are all novel sequences and match the mass data of purified proteins. For members of each toxin family, protein sequences were aligned and subjected to molecular phylogenetic analyses. The results indicated that the PLAs and a Kunitz inhibitor of W. aegyptia are most similar to those of king cobra venom, and its 3FTxs belongs to either Type I α-neurotoxins or weak toxins of orphan-II subtype. It is remarkable that both king cobra and W. aegyptia cause rapid deaths of the victims, and a close evolutionary relationship between them is speculated.

Acute Deaths in Nonpregnant Adults Due to Invasive Streptococcal Infections

Streptococcal organisms, part of the normal human bacterial flora, occasionally become infectious pathogens responsible for a wide array of clinical syndromes, ranging from mild pharyngitis to death. Notably, infections due to group A and group B beta-hemolytic strains are well known for causing invasive disease leading to death. These deaths, while often suspected clinically, occasionally are not diagnosed until autopsy. We present 3 rapid deaths, with very different presentations, due to streptococcal infection. Two decedents experienced sudden deaths due to pneumonia and severe meningoencephalitis caused by group B beta-hemolytic streptococcal infection, a common cause of neonatal meningitis but only rarely reported in nonpregnant adults. The final case involves a 69-year-old male who presented to the emergency room with a complaint of shoulder pain but over the next several hours developed signs of necrotizing fasciitis, became septic, and died. While antemortem cultures were negative, owing to antibiotic administration, postmortem cultures of bone and deep soft tissue were positive for group A beta-hemolytic Streptococcus sp. Acute and sudden deaths due to infectious etiology represent an uncommon yet well-documented occurrence. The importance of appropriate postmortem cultures in these situations and a review of the literature will be discussed.

First report in a river in France of the benthic cyanobacterium Phormidium favosum producing anatoxin-a associated with dog neurotoxicosis

The first identification of anatoxin-a in a French lotic system is reported. Rapid deaths of dogs occurred in 2003 after the animals drank water from the shoreline of the La Loue River in eastern France. Sediments, stones and macrophytes surfaces at the margin of the river were covered by a thick biofilm containing large quantities of several benthic species of filamentous, non-heterocystous cyanobacteria. Known cyanotoxins, such as microcystins, saxitoxins and anatoxins were screened from biofilm samples by biochemical and analytical assays. A compound with similar UV spectra to the anatoxin-a standard was detected by high-performance liquid chromatography (HPLC) coupled with photo-diode array detector. This toxin was further identified by HPLC coupled with a UV detector and by electrospray ionisation-Quadrupole-Time-Of-Flight mass spectrometer, and confirmed by tandem mass spectrometry. These two techniques were necessary to discriminate anatoxin-a in phenylalanine-containing matrices such as liver samples of poisoned dogs. The toxin and the aromatic amino acid, phenylalanine, present the same pseudomolecular ion at m/ z 166, but have differing fragmentation patterns, retention times and UV spectra. Finally, several cyanobacterial strains were isolated from the green biofilm and tested for anatoxin-a production. Phormidium favosum was identified as a new anatoxin-a producing species.

Enterovirus 71 outbreaks, Taiwan: occurrence and recognition.

Enterovirus 71 (EV71) caused a large outbreak in Taiwan in 1998 with 78 deaths, and smaller outbreaks recurred in 2000 and 2001. The outbreak was recognized because of a large number of hand, foot, and mouth disease cases and the rapid deaths of children with the disease. Virologic and pathologic studies indicated that EV71 was the most important agent related to severe and fatal cases and that a neurogenic inflammatory response was involved in the pathogenesis of cardiopulmonary collapse resulting from fulminant EV71 infection. Seroepidemiologic study suggested that EV71 had circulated for at least 16 years and that the accumulation of susceptible hosts might have triggered the 1998 outbreak. However, a change in EV71 neurovirulence and host genetic susceptibility may also have affected the clinical outcome. The Taiwan outbreak shows that worldwide attention should be paid to such outbreaks, new antiviral drugs should be developed, and that vaccination of children under 5 years of age may be warranted.

Prolactin levels in sudden unexpected death in epilepsy.

To assess serum prolactin levels in sudden unexpected death in epilepsy (SUDEP) and control groups to test the hypothesis that if seizures occur routinely as a terminal event in SUDEP, then raised prolactin levels may be an indicator of terminal seizure. Blood was taken for measurement of prolactin levels from subjects with SUDEP and three control groups. The control groups were those with epilepsy dying from causes other than epilepsy (e.g., ischemic heart disease or injuries), physiologically stressed individuals without epilepsy (they were admitted to the hospital after an acute illness and died after several hours to 3 days), and nonepileptic rapid deaths (these people collapsed suddenly and died at the scene). In the SUDEP group, evidence for terminal seizure was considered to be at least one of the following: body found half on, half off the bed, or urinary incontinence at the scene, or bitten lips or tongue at autopsy. There was evidence for terminal seizure at the scene or at autopsy in four of the 10 SUDEP cases. Serum prolactin levels were not significantly increased in the SUDEP group compared with the controls. None of the SUDEP subjects, including those with clinical evidence of a terminal seizure, had high prolactin levels characteristic of those observed after seizures in living subjects. Prolactin levels are not raised in SUDEP, even if there is evidence of terminal seizure. As prolactin takes 15-20 min to peak after a seizure in life, there may be insufficient time for a prolactin increase to occur in SUDEP. Thus prolactin levels cannot be used to determine if a deceased individual with epilepsy had a seizure or to answer the broad question whether SUDEP is always associated with a terminal seizure.

Screening strategies for early detection of lung cancer: the time is now.

CURRENT KNOWLEDGE AND AVAILABLE TECHNOL -ogy could change the outcome of lung cancer. But screening and even case finding in patients at high risk is still not recommended. No major medical organization in the United States recommends any form of screening for lung cancer. For this reason, lung cancer is not diagnosed until it is symptomatic and usually when it is in advanced and incurable stages. Assume that the following facts are true: In the year 2000, approximately 172 000 patients will be diagnosed as having lung cancer, which represents the most common fatal malignancy in both men and women in the United States (based on 1996 data),' and the 5-year survival rate will be only 15%, which is a generous estimate. Simple arithmetic results in 25800 patients who will survive and 146200 patients who will have progressive, rapid, and painful deaths from lung cancer, often with bone and brain metastases. However, the survival rate in early-stage lung cancer, that is, in situ and stage IA, is 60%, which also is a conservative estimate. Thus, if all 172000 patients could be diagnosed at this early stage, this would result in 103200 survivors and 68800 deaths in 2000. Diagnosing and treating lung cancer in the early stages of the disease could save tens of thousands of lives each year.

Acute pit gas (hydrogen sulfide) poisoning in confinement cattle.

Rapid deaths in confinement cattle caused by exposure to hydrogen sulfide (H2S) gas from manure pits has not been reported in the USA. In 1997, 158 cattle in 2 confinement pens were exposed to H2S gas as the manure in the pits under a slatted floor was agitated prior to pumping. Approximately 35 of the cattle were lying on the floor when the upper agitator was turned on. Within 5 minutes, many these cattle were down on their sides and paddling. Of these, 26 died within a few minutes. The survivors were treated and sent to slaughter. Cattle that did not show immediate signs of toxicosis remained clinically unaffected. Two steers that were near death were brought to the Purdue Animal Disease Diagnostic Laboratory for clinical evaluation, euthanasia, and necropsy. They were recumbent and unresponsive to visual and auditory stimuli. Necropsy examination yielded no significant gross lesions. No evidence of viral or bacterial infection was found. Ocular fluid nitrate concentrations were within normal limits, and no lead was detected in either animal. Microscopic examination revealed lesions consistent with H2S-induced central nervous system anoxia. Histologically, sections of brain demonstrated massive, diffuse cerebral cortical laminar necrosis and edema. Portions of the outer lamina contained hypereosinophilic and shrunken neurons. The subcortical white matter was vacuolated in some areas. The history, clinical signs, and histologic lesion of cerebral laminar necrosis led to a diagnosis of H2S toxicosis in these cattle.

Winter accumulation of paralytic shellfish toxins in digestive glands of mussels from Arcachon and Toulon (France) without detectable toxic plankton species revealed by interference in the mouse bioassay for lipophilic toxins

Since January 1993, neurological symptoms and rapid deaths (5 to 10 min) were typically observed in the mouse bioassay of acetone extracts of digestive glands from Arcachon and Toulon (France) during the winter season. It was assumed initially that a new lipophilic toxin was present because tests using the AOAC mouse bioassay for paralytic shellfish toxins on acid extracts of whole shellfish meat were negative, no known lipophilic toxins were detected and no toxic phytoplankton species were observed in the area during the poisoning events. In this study, however, preparative isolation of the toxic factor from toxic mussel digestive glands has revealed the presence of paralytic shellfish toxins, the principal ones being gonyautoxins-2 and -3 at Arcachon and gonyautoxins-1, -4, -2 and -3 at Toulon. The toxin concentrations recorded were below levels harmful to consumers and therefore represent a false positive in the mouse bioassay for lipophilic toxins based upon acetone extraction. The origin of the toxins remains to be determined. Copyright © 1999 John Wiley & Sons, Ltd.

Winter accumulation of paralytic shellfish toxins in digestive glands of mussels from Arcachon and Toulon (France) without detectable toxic plankton species revealed by interference in the mouse bioassay for lipophilic toxins.

Since January 1993, neurological symptoms and rapid deaths (5 to 10 min) were typically observed in the mouse bioassay of acetone extracts of digestive glands from Arcachon and Toulon (France) during the winter season. It was assumed initially that a new lipophilic toxin was present because tests using the AOAC mouse bioassay for paralytic shellfish toxins on acid extracts of whole shellfish meat were negative, no known lipophilic toxins were detected and no toxic phytoplankton species were observed in the area during the poisoning events. In this study, however, preparative isolation of the toxic factor from toxic mussel digestive glands has revealed the presence of paralytic shellfish toxins, the principal ones being gonyautoxins-2 and -3 at Arcachon and gonyautoxins-1, -4, -2 and -3 at Toulon. The toxin concentrations recorded were below levels harmful to consumers and therefore represent a false positive in the mouse bioassay for lipophilic toxins based upon acetone extraction. The origin of the toxins remains to be determined.

Disposition of heroin and its metabolites in heroin-related deaths.

Although many deaths occur annually from heroin intoxication, the presence of heroin has not been reported in postmortem tissues. Recognizing heroin's susceptibility to rapid chemical and metabolic hydrolysis, extraction procedures were developed for the efficient recovery of heroin, 6-acetylmorphine, and morphine from postmortem tissue utilizing solid-phase extraction coupled with gas chromatography/mass spectrometry. From heroin-related deaths, 21 sets of blood and urine specimens were collected. The mode of death in these cases was categorized as rapid, delayed, or undetermined. Compared with delayed deaths, rapid deaths were characterized by the following trends: higher mean concentrations of 6-acetylmorphine, free morphine, and total opiates in blood; a higher ratio of free morphine concentrations to total opiate concentrations in blood; lower mean concentrations of 6-acetylmorphine and morphine in urine; greater likelihood of 6-acetylmorphine detection in blood; and lesser likelihood of heroin detection in urine. The study also included analysis of multiple tissue specimens from two subjects who died of heroin intoxication. Heroin was identified in urine and injection-site tissue. Concentrations of 6-acetylmorphine in cerebrospinal fluid, spleen, and brain were substantially higher than in blood, liver, lung, and kidney. All specimens were positive for morphine. Heroin metabolites were detected in hair specimens. The identification of heroin and 6-acetylmorphine in biological tissues effectively established the presence of heroin in cases of acute narcotic intoxication. These studies demonstrated that measurement of heroin and its metabolites provides useful information for the differential diagnosis of heroin-related deaths.