Buprenorphine withdrawal syndrome in a newborn

A pregnant woman who was addicted to heroin rapidly withdrew from illicit drugs after the onset of a 4 mg/day buprenorphine treatment. In the newborn's blood, urine, and meconium 20 hours after birth, high concentrations of buprenorphine and its metabolite norbuprenorphine were detected, with a higher buprenorphine/norbuprenorphine ratio than in adults, possibly as a consequence of immature hepatic function; no illicit drugs were found. The child had a weak withdrawal syndrome on the second day of life and recovered rapidly. The measured buprenorphine daily dose ingested by the newborn through mother's milk was very low (3.28 micrograms) and probably had little pharmacologic effect because no withdrawal signs could be noted when maternal feeding was later abruptly interrupted. Further investigations are required to determine whether buprenorphine can be considered to be a good alternative to methadone in the treatment of pregnant heroin addicts to prevent marked withdrawal syndromes in newborns.

Simultaneous determination of amphetamine and its analogs in human whole blood by gas chromatography-mass spectrometry

A sensitive and specific gas chromatography-mass spectrometry (GC-MS) method for the determination of amphetamine (AM), methamphetamine (MA), methylenedioxyamphetamine (MDA), methylenedioxymethamphetamine (MDMA) and methylenedioxyethylamphetamine (MDEA) in whole blood was designed, using the respective pentadeuterated analogs of the analytes as internal standards (I.S.). After alkalinisation of blood samples, the amphetamines were extracted using diethyl ether, derivatized with heptafluorobutyric anhydride, then purified by successive washings with deionized water and 4% NH4OH. Extraction recoveries were 85.2% for AM, 90.9% for MA, 76.5% for MDA, 84.1% for MDMA and 63.6% for MDEA. Chromatographic separation was performed on a non-polar 30 m x 0.32 mm HP 5 MS capillary column using a temperature program. Detection was carried out in the electron-impact, selected ion-monitoring mode, using three mass-to-charge ratios for each analyte and one for each I.S. Limits of detection ranged from 0.5 to 8 ng/ml and limits of quantification were 10 ng/ml for AM, MDMA and MDEA; 20 ng/ml for MA; and 50 ng/ml for MDA. The method was linear from this limit up to 1000 ng/ml for all analytes, with good intra-assay precision and good intermediate precision and accuracy over these ranges. There was no interferences from other sympathomimetic drugs such as ephedrine, norephedrine or methoxyphenamine. This method is thus suitable for clinical and forensic toxicology, as well as for doping control.

Sensitive microanalysis of imipramine and desipramine in single rat thyroids by gas chromatography-mass spectrometry

A new sensitive method for the quantitative determination of imipramine and desipramine in single rat thyroids using gas chromatography-mass spectrometry with selected ion monitoring, after enzymatic hydrolysis and liquid-liquid extraction has been developed. The technique was deemed suitable for microanalysis of single rat thyroids and for other solid tissues, using smaller sample sizes than usually required for traditional determination methods. The quantification was linear from 10 to 200 nmol/l (i.e., from 0.25 to 5 microg/g) for imipramine and from 100 nmol/l to 2000 nmol/l (i.e., from 2.4 to 47 microg/g) for desipramine, and the limits of detection (less than 25 ng/g tissue for both compounds) were better than those previously reported. Recoveries, repeatability and reproducibility of this technique were satisfactory. It has been successfully applied in a preliminary study of the concentration-time profiles of imipramine and desipramine in the thyroid of rats treated with either of these drugs.

Determination of LSD and N-demethyl-LSD in urine by liquid chromatography coupled to electrospray ionization mass spectrometry

A sensitive and highly specific method for the determination of LSD and N-demethyl-LSD in urine, using combined liquid chromatography and mass spectrometry (LC-MS) with electrospray ionization, has been developed. Extrelut-3 extraction cartridges were used for a basic sample clean-up. Elution was obtained by toluene-diethyl ether (60:40, v/v). A Nucleosil C18 (150 X 1 mm I.D.) reversed-phase column was used for the chromatographic separation, together with a mixture of 2 mM ammonium formate buffer (pH 3) and acetonitrile (70:30, v/v) as mobile phase. Recoveries were 93 and 80%, detection limits 0.025 and 0.035 ng/ml for LSD and N-demethyl-LSD, respectively. Intra-assay precision, studied at four concentrations, was better than 9% at the ng/ml range and better than 14% at 0.10 ng/ml for both compounds. Limits of quantitation were 0.05 and 0.10 ng/ml for LSD and N-demethyl-LSD, respectively. Reproducibility was good and linearity excellent for LSD in the range from 0.05 to 20 ng/ml (r>0.9999, n=7).

Tungsten determination in biological fluids, hair and nails by plasma emission spectrometry in a case of severe acute intoxication in man

A healthy 19-year-old recruit in a French artillery regiment drank 250 mL of a mixture of beer and wine that had rinsed in a hot 155-mm gun-barrel. Fifteen minutes later, he complained of nausea followed by seizures. He was comatose for 24 h, presenting signs of encephalopathy. A moderate renal failure was noted initially and worsened to an extensive tubular necrosis with anuria on the day after the incident. The first toxicological investigations only showed a 0.31 g/L blood ethanol. Then inductively-coupled plasma (ICP) emission-spectrometry revealed very high concentrations of tungsten in the "beverage" as well as in gastric content, blood and urine (1540 mg/L, 8 mg/L, 5 mg/L, and 101 mg/L, respectively). The nature of the metal was confirmed by ICP coupled to mass spectrometry. A simple and reliable ICP quantitative assay of tungsten in biological fluids, hair and nails was then developed. It showed high blood levels (> 0.005 mg/L) until day 13 in spite of six hemodialyses, and in urine until D33. Tungsten was also incorporated in hair and nails. To the best of our knowledge, such an intoxication has never been reported before though this drinking seems to be traditional in the French Artillery. It has probably been favored by the unusually high volume of beverage absorbed and by the new alloy of the gun, containing tungsten. The clinical evolution was satisfactory over weeks and the patient was declared totally cured after five months.

Simultaneous determination of lidocaine and bupivacaine in human plasma: application to pharmacokinetics

High-performance liquid chromatography has been applied to the simultaneous determination of lidocaine and bupivacaine levels in human plasma, using etidocaine as internal standard. The method was found to be linear in the range 10-2,000 micrograms/l for lidocaine and 20-1,000 micrograms/l for bupivacaine. Within-day and day-to-day coefficients of variation were generally lower than 12%. The method was applied to a pharmacokinetic study of lidocaine and bupivacaine during peribulbar anesthesia in ocular surgery. Both compounds displayed a slow apparent elimination rate. The method described here permitted the determination of the complete pharmacokinetic profiles of the two anesthetics, although they were administered at quite different doses.

Determination of buprenorphine and norbuprenorphine in whole blood by liquid chromatography-mass spectrometry

A sensitive and highly specific method for the determination of buprenorphine and norbuprenorphine in postmortem and hemolyzed whole blood using combined liquid chromatography and mass spectrometry (LC-MS) with electrospray ionization was developed. After enzymatic hydrolysis and deproteinization with acetonitrile, Extrelut-3 cartridges were used for a preliminary basic sample cleanup. Elution by toluene-ether (50:50, v/v) was followed by an acid wash with 0.05M H3PO4 and a basic re-extraction into ether. A Nucleosil C18 (150 x 1-mm i.d.) reversed-phase column was used for the chromatographic separation together with a mixture of 2mM ammonium formate buffer (pH 3) and acetonitrile (55:45, v/v) as the mobile phase. Recoveries were between 56 and 60%, and detection limits were 0.05 ng/mL for both analytes. The coefficient of variation for repeatability was lower than 4%. Limits of quantitation were 0.1 ng/mL for buprenorphine and norbuprenorphine. Reproducibility was good, and linearity was excellent in the range of 0.1 to 100 ng/mL (r > 0.9999, n = 7).

Applications of liquid chromatography--mass spectrometry in analytical toxicology: a review

Liquid chromatography-mass spectrometry (LC-MS), after long-term development that has introduced seven major interfacing techniques, is finally suitable for application in the field of analytical toxicology. Various compound classes can be analyzed, and sensitivities for more or less polar analytes that are as good as or better than those of gas chromatography-mass spectrometry can be obtained with modern interfaces. In addition, because ionization is often softer than classical electron impact, some LC-MS interfaces are able to handle fragile species that are otherwise not amenable to MS. This review is intended to present LC-MS to less familiarized readers and to give an extensive overview of the application of the different coupling techniques to doping agents, drugs of abuse, forensic analysis, toxic compounds of various nature, and several toxicologically relevant therapeutic drugs. Experimental parameters such as the interfaces used, ionization methods, detection limits, and experimental details for exemplary applications are given.

Determination of haloperidol and its reduced metabolite in human plasma by liquid chromatography-mass spectrometry with electrospray ionization

A sensitive and accurate liquid chromatographic-electrospray mass spectrometric (LC-ES-MS) method for the determination of haloperidol (H) and reduced haloperidol (RH) in human plasma is presented, using chlorohaloperidol as the internal standard. A 2-ml volume of plasma was subjected to basic (NaOH) extraction, acid (HCl) back-extraction, acid wash and basic (NaOH) re-extraction. The extraction solvent was hexane-isoamyl alcohol (99:1, v/v) for the whole procedure. A Nucleosil C18 column (150 x 1 mm) was used for high-performance liquid chromatography, together with 2 mM HCOONH4-acetonitrile (55:45, v/v; pH 3.0) as the mobile phase. For each drug, four characteristic ions were monitored. Linearity was assessed in the ranges 0.1-50 and 0.25-50 ng/ml for H and RH, respectively. Recoveries were 58 and 70% and detection limits were 0.075 and 0.100 ng/ml for H and RH, respectively. Correlation coefficients were better than 0.999 for both compounds. R.S.D.s for repeatability and reproducibility at 0.25 ng/ml were 11.1 and 8.5% for H and 9.4 and 11.2% for RH, respectively. One of the main advantages of (LC-ES-MS) over other detection systems is the increase in selectivity obtained by monitoring three ions of confirmation for each of the drugs.

Population pharmacokinetics of amikacin in geriatric patients studied with the NPEM-2 algorithm

The population pharmacokinetics of amikacin were studied in 40 geriatric medicine patients (aged 59-95 years, average 78 years) by the NPEM-2 algorithm, using a 2-compartment model. The fitted parameters were: renal clearance of amikacin, expressed as a fraction of creatinine clearance (CLS) and volume of the central compartment, expressed as a fraction of body weight (VS). The nonrenal clearance of amikacin (CLi) and the transfer constants between the 2 compartments (k12 and k21) were held constant. The distribution of each pharmacokinetic parameter was characterized by the median and the 50% dispersion factor (DF50) which is the interval between the 25th and 75th percentiles, divided by 1.32. The parameters were thus estimated by the following values: CLs = 0.91 +/- 0.45 and Vs = 0.29 +/- 0.10 l x kg-1. The volume of distribution was increased with respect to the usual value of 0.20 l x kg-1. The interindividual variability was high, particularly for clearance. Although the median value of CLs was close to unity, indicating that for most patients the elimination kinetics of amikacin followed that of creatinine, there was a slight probability to observe much higher values of CLs (up to 5), indicating that for some aged patients the elimination of amikacin was less altered than that of creatinine. These parameters were used as reference population values to estimate the pharmacokinetics of amikacin in a second group of 20 patients by the Bayesian method, with 2 blood samples per patient. For each patient the fitted parameters were able to predict the plasma concentrations of amikacin during the next 72 hours with no significant bias and a precision of 3.5 mg x 1(-1). This study confirms the ability of the NPEM-2 algorithm to provide reference population values for use in Bayesian monitoring of aminoglycoside therapy.

Role of tissue structure in photon migration through breast tissues

Photon migration has been investigated experimentally in vitro on human breast tissues, bovine liver, tissue phantoms, and theoretically by Monte Carlo simulations and diffusion theory. The spatial intensity profiles have been measured at the output surface of a sample illuminated by a collimated beam. Experimental results have then been compared with simulations that assume the sample to be homogeneous. Measurements on phantoms, i.e., fat emulsion and microspheres suspension, and on liver are in good agreement with theory. On the other hand, the width of the intensity profiles measured on breast tissues (adipose and fibrous) are systematically larger than those measured on phantoms or calculated by simulations. The structure of these samples, not considered in simulations and not present in phantoms, explains these differences.

Serotonin syndrome due to an overdose of moclobemide and clomipramine. A potentially life-threatening association

The serotonin syndrome is frequently characterized by minor neurologic manifestations that regress rapidly (such as confusion, tremor, ...). Many medications including tricyclic antidepressants, serotonin reuptake inhibitors, tryptophan and the association of monoamine oxidase inhibitors together with a serotoninergic agent have been implicated in this syndrome. In certain cases, and for poorly understood reasons, clinical manifestations can include circulatory collapse, malignant hyperthermia, convulsions and rhabdomyolysis. These forms are often fatal. Treatment, other than the withdrawal of the offending drug, is symptomatic. Dialysis may be of value in withdrawing the drug from the circulatory system. We report a patient with the serotonin syndrome of favorable outcome due to an overdose of moclobemide and clomipramine.

A screening procedure for the determination of 13 oral anticoagulants and rodenticides

A technique for the simultaneous identification and quantitation of 13 hydroxycoumarin and indandione anticoagulant drugs and rodenticides from human serum by reversed-phase liquid chromatography with diode-array detection has been developed. High-performance liquid chromatography was performed using gradient elution with an acetonitrile and phosphate buffer on a Nucleosil ODS column. Ultraviolet spectra from 200 to 400 nm were recorded on-line during the analysis and compared with spectra stored in a library. For the spiked 2 mL of serum, acidic and alkaline liquid-liquid double extraction with diethylether-ether acetate (50:50, v/v) was conducted, and recoveries greater than 60% for most compounds were found. The detection limit was approximately 25 or 50 ng/mL for all components except for difethialone and fluindione, for which it was approximately 100 ng/mL. The standard calibration curves were linear from the detection limit to 5000 ng/mL. The within-run precision coefficient of variation (CV) was less than 10%, and the between-run precision CV was less than 20%.

Analytical findings in a suicide involving sodium azide

A 47-year-old laboratory assistant ingested approximately 9 g of sodium azide powder and died 4 h later at a hospital. A high-performance liquid chromatographic method using diode-array detection has been developed for the determination of an azide benzoyl derivative in blood (after a simple deproteinization) and in several tissues (after homogenization in a neutral buffer and deproteinization of the supernatant). The blood concentration in this case was lower than those previously published. The highest azide concentration was found in lung tissue. A complete toxicological screening revealed the presence of cyanide in blood, which has been previously reported twice, but for the first time, it was confirmed by mass spectrometry. Whether the production of cyanide in the presence of azide took place in vivo or postmortem remains unknown; the nature of the metabolic pathway involved also remains unknown.

A screening procedure for the determination of 13 oral anticoagulants and rodenticides

A technique for the simultaneous identification and quantitation of 13 hydroxycoumarin and indandione anticoagulant drugs and rodenticides from human serum by reversed-phase liquid chromatography with diode-array detection has been developed. High-performance liquid chromatography was performed using gradient elution with an acetonitrile and phosphate buffer on a Nucleosil ODS column. Ultraviolet spectra from 200 to 400 nm were recorded on-line during the analysis and compared with spectra stored in a library. For the spiked 2 mL of serum, acidic and alkaline liquid-liquid double extraction with diethylether-ether acetate (50:50, v/v) was conducted, and recoveries greater than 60% for most compounds were found. The detection limit was approximately 25 or 50 ng/mL for all components except for difethialone and fluindione, for which it was approximately 100 ng/mL. The standard calibration curves were linear from the detection limit to 5000 ng/mL. The within-run precision coefficient of variation (CV) was less than 10%, and the between-run precision CV was less than 20%.

Acoustic properties of the normal chest

Laënnec invented the stethoscope in 1816 and published a treatise on auscultation in 1819. We then had to wait until the 1950s to observe development of modern devices and methods of recording and signal-processing, which allowed objective studies of lung sounds in time and frequency fields. Tracheobronchial sounds generated by ventilation originate in the upper airways, the frequency content of these sounds has led to extensive research. Consolidated lungs act as more efficient sound conductors to the chest wall (bronchial breathing murmur). Tracheobronchial sounds contain higher frequency components compared to vesicular lung sounds. The origin of vesicular lung sounds has been becoming progressively clear for about 10 yrs. It is at least partly produced locally, deep, and probably intralobular. Clearly, further studies need to be performed in order to elucidate the true mechanisms involved in generating vesicular lung sounds, the redistribution of intrapulmonary gas or vibrations caused by the stretching of lung tissue. The devices developed are already useful for monitoring the state of patients in intensive care. Sooner or later, real time analysis and automated diagnosis will become available.

Comparison of 2- and 3-compartment models for the Bayesian estimation of methotrexate pharmacokinetics

Moderate and high-dose methotrexate was given by a 4-h infusion to 10 patients. The pharmacokinetics of methotrexate, determined by fluorescence polarization immuno-assay, was successively described by a 2- and a 3-compartment open model with elimination from the central compartment. Population pharmacokinetic parameters were obtained by non-linear regression from 8 data points for each course and were subsequently used to fit the same data by the Bayesian estimation method. According to Akaike's information criterion, the 3-compartment model was found statistically superior in 7 patients out of 10. Using this model clearance was well predicted (+/- 5%) by the Bayesian method with only 2 points taken at the end of the infusion and 24 h after. The prediction was less good for the steady-state volume of distribution (+/- 18%) and the half-lives (+/- 20-30%). This procedure enables a good estimation of individual pharmacokinetic parameters for methotrexate, specially with clearance, at minimal cost and minimal disturbance for the patient.

Population pharmacokinetics of amikacin in intensive care unit patients studied by NPEM algorithm

The population pharmacokinetics of amikacin was studied in 40 intensive care unit patients (212 plasma concentrations) by NPEM algorithm using a one-compartment model. The population was best characterized by the following pharmacokinetic parameters: renal clearance relative to creatinine clearance (Cs = 0.96 +/- 0.33), and either the total volume of distribution (Vd = 23.9 +/- 7.0 l) or the volume of distribution relative to body weight (Vs = 0.36 +/- 0.10 l.kg-1. The volume of distribution was increased with respect to the usual value of 0.25 l.kg-1. The statistical distribution of these pharmacokinetic parameters was approximately gaussian, with no significant correlation between volume of distribution and clearance. The medians and standard deviations of Cs and Vs were used as reference population values to estimate the pharmacokinetics of amikacin in a second group of 29 patients by the bayesian method, with two blood samples per patient. For each patient, the fitted parameters were able to predict the plasma concentrations of amikacin during the next 72 h with no significant bias and good precision (2.9 mg.l-1 for peaks and 0.5 mg.l-1 for troughs). This study confirms the ability of the NPEM algorithm to provide reference population values for use in bayesian monitoring of aminoglycoside therapy.

[Blood lactate in the steeplechase horse: triangular and rectangular series of steps during short duration races]

Five steeplechase race horses were observed during incremental and constant-load exercises with the aim of separating effects of work rate and time on blood lactate. Each independent exercise (an incremental and three constant load tests) was a sequence of three two-minute runs, separated by two one-minute rest intervals for jugular blood sampling. The following observations were made: 1. During constant load exercises, in the five horses, blood lactate stabilized below 4 mmol.l-1: lactatemia critical velocity (LVC) = 3.33 +/- 0.16 mmol.l-1. Nevertheless, VCL, critical lactate velocity inducing LVC, was not statistically different from VS4, velocity inducing a 4 mmol.l-1 blood lactate during incremental tests. Remaining reticent on the meaning of "lactate threshold" often attributed to VS4, an incremental exercise thus seemed pertinent for routine long-term surveys of endurance. 2. If delta L is the blood lactate increase within a single short run, delta L increases linearly with running velocity for an incremental test, allowing the calculation of a "null" velocity, the highest velocity for which there is no significant lactate increase. For independent runs, delta L increased exponentially with velocity, with noticeable differences between horses. This individual short-term functional adaptation variability could be considered in assessment and follow-up of race horse fitness.

Pharmacokinetics of vinorelbine in man

The pharmacokinetics of vinorelbine has been investigated by a new HPLC method in 8 cancer patients receiving 8 weekly doses (30 mg.m-2) administered by brief infusion (15 min). The plasma concentration-time curves showed a tri-exponential decay with a long terminal half-life (44.7 h) and a high volume of distribution (Vz = 75.61.kg-1). The concentrations after the 8th infusion were significantly lower than after the 1st infusion, but without significant modification of CL (1.28 l.h-1.kg-1) or AUC (0.80 mg.l-1.h). The pharmacokinetic parameters exhibited wide interindividual variations. The results are consistent with those of previous RIA studies, although the HPLC method appears to be more specific and more precise.