Cathinone derivatives (bath salts) have emerged as the latest drugs of abuse. 3,4-methylenedioxypyrovalerone (MDPV) is the primary active ingredient in bath salts used in this country. This article presents the second reported cause of death by MDPV intoxication alone. In April 2011, a delusional man was emergently brought to a hospital, where he self-reported bath salt usage. He became agitated, developed ventricular tachycardia, hyperthermia, and died. Comprehensive alcohol and drug testing was performed. Using the alkaline drug screen, heart blood contained 0.7 mg/L MDPV and peripheral blood contained 1.0 mg/L MDPV. His bizarre behavior with life-threatening hyperthermia was consistent with an MDPV-induced excited delirium state. MDPV is not yet found by routine immunoassay toxicology screens. Testing for MDPV should be considered in cases with a history of polysubstance abuse with stimulant type drugs, report of acute onset of psychogenic symptoms, excited delirium syndrome, or presentation in a hyperthermic state.

Cause of death rulings in cases when the concentration of a drug or drugs is higher than observed following therapeutic use are generally straightforward "drug deaths." However, when toxicology testing identifies drug concentrations consistent with therapeutic use or detects no drugs at all, then the cause of death determination is more complicated. Given the rapidity and protean manifestations of anaphylaxis, it should be considered in deaths where no other cause of death is apparent in a suspected drug death. This article reports two cases where an anaphylactic reaction was observed following either the actual or alleged use of therapeutic formulations of buprenorphine intravenously.

Maintenance of certification (MOC) is a current hot topic in all disciplines of medicine, and no less so in pathology and forensic pathology, specifically. The extent of physician discontent with MOC has risen to a fevered pitch over the past few years, with reporting on specialty board activities and physicians' reactions reaching the popular media. This invited review authored by several of the members of the National Association of Medical Examiners Education Subcommittee on the Development of Self-Assessment Modules provides an overview of MOC as it relates to forensic pathology. We address the history of MOC and its value as stated by the certifying bodies that created, promote, and administer MOC, including the American Board of Medical Specialties and American Board of Pathology. We further provide an analysis of the existing medical literature proposed as an evidence base for MOC, which is somewhat limited in its scope, particularly nonrobust in pathology, and nonexistent in forensic pathology. We discuss recent changes that medical specialties have made to prescribed MOC programs, potential alternatives to MOC, and the impact that MOC in its current and potential future forms may have on the field of forensic pathology, including effects on the workforce, courts of law, and training pathways.