To the Editor:
We would like to thank Barbería-Marcalain et al for the comments and opinions which we also share. The limitations of our study were explained in detail in the article in which we describe sudden death syndrome in young males following police arrest.1 We would like to point out that we only included sudden, unexplained deaths that occur in the first 24 hours following police arrest, of which nearly a third actually take place at the time of arrest; this is what distinguishes them from other deaths in custody. Therefore, we do not consider deaths secondary to trauma or drug intoxication, for example, to be unexplained, and we did not include them in our series.
Although there has been talk of the need in Spain for creating a record of all deaths in custody,2 such a record is not available at present. It is for this reason that our article stated that "we cannot rule out the possibility that there have been more sudden and unexplained deaths following police arrest than those described."1 The magnitude of the problem is unknown, but an indication that the problem may not be infrequent is found in a French medical-legal study of 49 autopsies for stress-related sudden deaths in which 4 cases (8.2%) were triggered by police arrest. Our hypothesis is that these arrests produce an abrupt increase in catecholamine levels. High levels of these substances are associated with stress-induced myocardiopathy4 and in young males, this may trigger sudden death more easily. We agree that some factors in detainees (such as history and recent consumption of drugs) can contribute to the onset of the syndrome, but we do not agree that they are necessary in order for it to occur.