The discovery of insulin fifty years ago enabled doctors to successfully treat an eleven year old boy dying from diabetes mellitus and thereby ushered in a new medical era. While millions of subsequent patients were thus able to lead productive lives, others tunred this miraculous substance into self-destructive purposes, while a few attempted (and possibly succeeded in) carefully concealed homicidal undertakings. The first “murder by insulin” case, prosecuted with a conviction in Great Britain fifteen years ago, employed a laborious bioassay method to demonstrate the hormone at the site of injection [1]. A recent series of insulin poisonings in California was dependent on pathologi changes in the brain from anoxia (hypoglycemia) coupled with history and investigation rather than chemical measurements, although an immunoassay method was used for confirmation in the final case [2]. Instances of suicidal attempts by self-administered insulin have been reported with analyses performed by radioimmunoassay, now employed in clinical laboratories to measure many hormonal and therapeutic substances [3]. We have applied this principle from pathologic and toxicologic aspects in an effort to enhance the diagnostic capability of the forensic pathologist, who must examine and properly certify such deaths.

The detection and evaluation of digitalis glycosides in autopsy specimens has been a serious problem for both medical examiners and toxicologists alike. Methods utilizing thin-layer chromatography or colorimetric techniques depended on a significant quantity of this drug remaining unabsorbed in the stomach or excreted into the urine. Digoxin, the most potent drug of this group and the form prescribed most frequently, is effective therapeutically in a dose range from 0.25 to 0.50 milligrams per day. This dose gives rise to therapeutic blood concentrations of 1.0 to 1.4 nanograms per millilitre [1]. Toxic effects of digoxin often begin to appear at 2.0 ng/ml. In view of these extremely low concentrations, even after an overdose with digitalis, detection of this drug in blood by conventional techniques could not be accomplished. The introduction of radioimmunoassay tests for these substances has provided an answer to this problem. Blood values of digoxin as low as 0.2 ng/ml can now be detected and measured reliably.

Background:Primary hyperparathyroidism (PHPT) is characterized by inappropriately elevated serum parathyroid hormone (PTH) level despite elevated serum calcium. Insulin resistant is the basic pathophysiology, behind the higher prevalence of diabetes mellitus in patients with PHPT. However, the improvement in insulin resistance (IR) after curative parathyroidectomy (CPTX) has not been established yet, as the study results are conflicting.Materials and Methods:In this prospective interventional study, ten patients with mild PHPT (Group 1) and another ten patients with moderate to severe PHPT (Group 2) were undergone CPTX. The IR was assessed by homeostasis model assessment-IR (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), fasting plasma glucose (FPG), and fasting serum insulin (FSI), before and 3 months after CPTX.Results:There was no significant change of FPG and FSI, before and after CPTX in Group 1 (P = 0.179 and P = 0.104) and Group 2 (P = 0.376 and P = 0.488). Before surgery, HOMA-IR was higher, and QUICKI was significantly lower, in both Group 1 (P = 0.058 and P = 0.009) and Group 2 (P = 0.023 and P = 0.005) as compared to published normal reference mean, with no significant difference between the groups. Three months after surgery HOMA-IR increased further and QUICKI remained unchanged as compared to baseline, in both Group 1 (P = 0.072 and 0.082) and Group 2 (P = 0.54 and 0.56), but statistically insignificant.Conclusion:IR remained unchanged after CPTX in mild as well as moderate to severe PHPT. Asymptomatic PHPT with abnormal IR should not be used as criteria for parathyroidectomy.

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