1
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Yu Z, Yuan Y, Zhang J, Li Y, Wang Z, Wang Y, Duan Y, Zhou Y. Review of the lethal mechanism of insulin poisoning and the characteristic of forensic identification. Leg Med (Tokyo) 2024; 70:102478. [PMID: 38959585 DOI: 10.1016/j.legalmed.2024.102478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/10/2024] [Accepted: 06/22/2024] [Indexed: 07/05/2024]
Abstract
Insulin, as the only hypoglycemic hormone in the body, plays a key role in blood sugar control. However, excessive insulin intake can lead to insulin poisoning and even death, which often occurs in clinical and forensic work. At present, some researches on insulin poisoning have been carried out at home and abroad, however, it seems that the mechanism and forensic characteristics of insulin poisoning are not clear and complete. Therefore, in this paper, we reviewed the potential mechanism of insulin poisoning, the methods of insulin detection and the forensic identification of poisoning cases, aiming at providing services for the forensic identification of insulin poisoning.
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Affiliation(s)
- Zhonghao Yu
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yuhao Yuan
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Jiaxin Zhang
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yiling Li
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Zhaoxuan Wang
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yubei Wang
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yijie Duan
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yiwu Zhou
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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2
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Yuan Y, Yu Z, Tong F, Zhao S, Li Y, Shi Q, Zhou Y. A retrospective study of 29 fatal cases of insulin overdose. Forensic Sci Int 2024; 361:112126. [PMID: 38954875 DOI: 10.1016/j.forsciint.2024.112126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To summarize recent cases of fatal insulin poisoning both domestically and internationally, thereby offering valuable insights for the forensic identification of insulin overdose cases. METHODS Literature published since 2000 on fatal insulin overdose were systematically searched and screened. Data encompassing variables such as year, age, sex, cause of death, scene conditions, occupations, medical histories of victims and perpetrators, autopsy timing, dosage and administration methods, forensic pathology, and toxicological analysis, were compiled for rigorous statistical analysis. RESULTS Among the 29 fatal cases of insulin poisoning, suicides and homicides accounted for 55.2 % and 41.4 %, respectively. Precisely 34.5 % of victims or perpetrators were associated with the medical industry, 27.6 % had diabetes, and 24.1 % had mental illnesses such as depression. Intravenous injection resulted in quicker death than did subcutaneous injection. In some cases, immunohistochemical staining of insulin and protamine at injection sites yielded positive results. The average molar ratio of insulin to C-peptide in post-mortem blood was 13.76 ± 5.167, indicating a significant diagnostic value for insulin poisoning. CONCLUSION Assessment of cases of fatal insulin overdose should be thorough, incorporating case investigation, scene examination, medical records review, autopsy findings, pathological examinations, and laboratory tests, alongside considering the condition of the body and timing of death autopsy. Using mass spectrometry to detect insulin proves valuable, particularly in cases of poor body preservation.
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Affiliation(s)
- Yuhao Yuan
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Zhonghao Yu
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Fang Tong
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Shuquan Zhao
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Yiling Li
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Qing Shi
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China
| | - Yiwu Zhou
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, No. 13 Hangkong Road, Wuhan 430030, People's Republic of China.
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3
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Arbouche N, Farrugia A, Gheddar L, Ameline A, Blanchot A, Raul JS, Kintz P. Is it really possible to kill with insulin without leaving traces? From lifesaver to killer, the issues surrounding the analytical characterization of postmortem insulin illustrated by an exemplary case. J Forensic Sci 2024; 69:1106-1113. [PMID: 38481368 DOI: 10.1111/1556-4029.15501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/19/2024] [Accepted: 02/29/2024] [Indexed: 04/26/2024]
Abstract
Evidence of an insulin overdose is very complicated in the medico-legal field. The analysis and subsequent interpretation of results is complex, especially when treating postmortem blood samples. The instability of insulin, the special pre-analytical conditions and the absence of specific analytical methods has led most laboratories not to analyze insulin in their routine with a consequent underestimation of cases. This paper aims to assess the difficulties associated with the analytical characterization of insulin by describing a case that typically represents most of the inconveniences encountered following a suspected insulin overdose. The case concerns a man found dead at home by his brother. After an external examination, which did not reveal a specific cause of death, toxicological analysis was requested which did not reveal any substance of toxicological interest. Only 9 months later, it was reported to the toxicologist that the subject was diabetic, on insulin lispro treatment and that three empty syringes were found next to his body. Following analysis by LC-high-resolution mass spectrometry, the presence of insulin lispro at a concentration of 1.1 ng/mL, a therapeutic concentration, was evidenced. Despite the low concentration found, overdose cannot be excluded and this paper will describe the criteria evaluated to reach this conclusion. This case highlights that the interpretation of a postmortem insulin concentration is very complex and requires the evaluation of various elements including the circumstances of death, the subject's medical history, the interval between death and sampling and the sample storage.
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Affiliation(s)
| | | | | | | | | | | | - Pascal Kintz
- Institut de Médecine Légale, Strasbourg, France
- X-Pertise Consulting, Mittelhausbergen, France
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4
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Bian C, He X, Wang Q, Zheng Z, Zhang Y, Xiong H, Li Y, Zhao M, Li J. Biochemical Toxicological Study of Insulin Overdose in Rats: A Forensic Perspective. TOXICS 2023; 12:17. [PMID: 38250973 PMCID: PMC10819875 DOI: 10.3390/toxics12010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Due to nonspecific pathological changes and the rapid degradation of insulin in postmortem blood samples, the identification of the cause of death during insulin overdose has always been a difficulty in forensic medicine. At present, there is a lack of studies on the toxicological changes and related mechanisms of an insulin overdose, and the specific molecular markers of insulin overdose are still unclear. In this study, an animal model of insulin overdose was established, and 24 SD rats were randomly divided into a control group, insulin overdose group, and a recovery group (n = 8). We detected the biochemical changes and analyzed the toxicological mechanism of an insulin overdose. The results showed that after insulin overdose, the rats developed irregular convulsions, Eclampsia, Opisthotonos, and other symptoms. The levels of glucose, glycogen, and C-peptide in the body decreased significantly, while the levels of lactate, insulin, and glucagon increased significantly. The decrease in plasma K+ was accompanied by the increase in skeletal muscle K+. The PI3K-AKT signaling pathway was significantly activated in skeletal muscle, and the translocation of GLUT4/Na+-K+-ATPase to sarcolemma was significantly increased. Rare glycogenic hepatopathy occurred in the recovery group after insulin overdose. Our study showed that insulin overdose also plays a role in skeletal muscle cells, mainly through the PI3K-Akt signaling pathway. Therefore, the detection of signaling pathway proteins of the skeletal muscle cell membrane GLUT4 and Na+-K+-ATPase has a certain auxiliary diagnostic value for forensic insulin overdose identification. Glycogen detection in the liver and skeletal muscle is important for the diagnosis of insulin overdose, but it still needs to be differentiated from other causes of death. Skeletal muscle has great potential for insulin detection, and the ratio of insulin to the C-peptide (I:C) can determine whether an exogenous insulin overdose is present.
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Affiliation(s)
- Cunhao Bian
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Xin He
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Qi Wang
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Zhe Zheng
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Yongtai Zhang
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Hongli Xiong
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Yongguo Li
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Mingzhu Zhao
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
| | - Jianbo Li
- Department of Forensic Medicine, Faculty of Basic Medical Sciences, Chongqing Medical University, Chongqing 400016, China; (C.B.); (X.H.); (Q.W.); (Z.Z.); (Y.Z.); (H.X.); (Y.L.); (M.Z.)
- Chongqing Engineering Research Center of Criminal Investigation Technology, Chongqing 400016, China
- Chongqing Key Laboratory of Forensic Medicine, Chongqing 400016, China
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5
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Zhao S, Liu Z, Ma L, Yin M, Zhou Y. Potential biomarkers in hypoglycemic brain injury. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00681-8. [PMID: 37466819 DOI: 10.1007/s12024-023-00681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 07/20/2023]
Abstract
Oxidative stress is a major underlying mechanism in hypoglycemic brain injury. Several oxidative stress-related proteins were identified through previous proteomics and literature review. The aim of the present study was to evaluate the potential of these proteins as biomarkers in hypoglycemic brain injury. Forty male Sprague Dawley rats were randomly and equally divided into four groups: control, acute hypoglycemia, hypoglycemia resuscitation 24 h, and hypoglycemia resuscitation 7 days. The hypoglycemic brain injury rat model was successfully constructed according to the Auer model. Real-time fluorescent quantitative polymerase chain reaction, western blot analysis, and immunohistochemical staining were used to quantify the expression of oxidative stress-related proteins. We also verified the expression level of selected protein in the brain samples of fatal insulin overdose cases. The expression of oxidative stress-related proteins PEX1/5/12 was down-regulated in hypoglycemic brain injury (P < 0.05), while the expressions of DJ-1 and NDRG1 were up-regulated (P < 0.05). Compared with the control group, the serum oxidative stress indexes SOD and MDA in the acute hypoglycemia group were significantly different (P < 0.01). The expressions of DJ-1 and NDRG1 in the hippocampus, cortex, and hypothalamus of rats were increased (P < 0.05). The expressions of DJ-1 and NDRG1 proteins in the cortex of the autopsy samples of insulin overdose were increased (P < 0.05). Oxidative stress-related proteins showed potential value as specific molecular markers in hypoglycemic brain injury, but further confirmatory studies are needed.
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Affiliation(s)
- Shuquan Zhao
- Department of Forensic Pathology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Sun Yat-Sen university, Guang zhou, China
| | - Zihao Liu
- Evidence Identification Center, Chongqing Public Security Bureau, Chongqing, China
| | - Longda Ma
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Yin
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiwu Zhou
- Guangdong Province Translational Forensic Medicine Engineering Technology Research Center, Sun Yat-Sen university, Guang zhou, China.
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6
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Nagasawa S, Yamaguchi R, Chiba F, Torimitsu S, Iwase H. Identification, measurement, and evaluation of blood concentrations of insulin glargine and insulin lispro by UPLC-MS-MS in a dead body suspected of insulin overdose. J Forensic Sci 2023; 68:704-710. [PMID: 36762764 DOI: 10.1111/1556-4029.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
Insulin preparations, which are drug treatments for diabetes, cause fatal hypoglycemia when an overdose is administered. Cases of homicide and suicide using these preparations have been reported and are of great forensic interest. However, there are few reports assessing the postmortem concentration of insulin preparations, and it is often difficult to determine the cause of death. In the present study, we report a case of a suspected insulin glargine and insulin lispro overdose for suicide. A woman in her 30s had a history of mental illness and diabetes. The day before her death, she reported to her boyfriend that she had taken large doses of insulin preparations and prescription drugs. An autopsy revealed no fatal injuries or lesions. Drug screening tests revealed several prescription drugs, none of which showed toxic concentrations. Analysis using LC-MS/MS detected insulin glargine in the peripheral and cardiac blood at 429 μU/mL and 1362 μU/mL, respectively, whereas insulin lispro was detected in both the peripheral and cardiac blood at levels below the lower limit of quantification (LLOQ; <50 μU/mL). The cause of death was considered likely to be hypoglycemia caused by an overdose of insulin glargine. Insulin glargine is rapidly metabolized after subcutaneous administration and is rarely detected in the blood when used at therapeutic doses. There are no other reports on the quantification of insulin glargine parent compounds in postmortem samples, and this case provides important data on postmortem blood concentrations of insulin glargine intoxication.
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Affiliation(s)
- Sayaka Nagasawa
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.,Laboratoly of Forensic Toxicology, Graduate School of Pharmaceutical, Chiba University, Chiba, Japan
| | - Rutsuko Yamaguchi
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Japan
| | - Fumiko Chiba
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.,Laboratoly of Forensic Toxicology, Graduate School of Pharmaceutical, Chiba University, Chiba, Japan
| | - Suguru Torimitsu
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Japan
| | - Hirotaro Iwase
- Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.,Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-Ku, Japan
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7
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Insulin murder and the case of Colin Norris. J Forensic Leg Med 2023; 94:102483. [PMID: 36680946 DOI: 10.1016/j.jflm.2023.102483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
Although insulin is an essential medicine and a life-saving drug, it has also been incriminated in many poisoning deaths; accidental, suicidal and some with malicious intent. Overdosing with insulin precipitates a life-threatening state of hypoglycemia and if untreated leads to coma, irreversible brain damage and death. Normally, the pancreatic β-cells secrete equimolar amounts of insulin and C-peptide into the portal venous blood, although under physiological conditions the plasma concentration ratio (insulin/C-peptide) is less than unity, because insulin is more susceptible to hepatic first-pass metabolism. A high ratio of insulin/C-peptide in plasma from a poisoned patient is compelling evidence that pharmaceutical insulin was administered, which does not contain C-peptide. The analysis of insulin and C-peptide was traditionally done by immunoassay methods (RIA and/or ELISA), although high resolution LC-MS/MS is more suitable for forensic purposes and permits the identification of insulin analogues. Use of insulin as a murder weapon is exemplified by the case of Colin Norris, a male nurse found guilty of murdering four elderly patients and the attempted murder of a fifth by injecting them with insulin. However, the prosecution evidence against Norris was mainly circumstantial and hearsay. Toxicological evidence against Norris consisted of a high insulin/C-peptide concentration ratio in plasma from one of the victims. This analysis was done by an immunoassay method at a clinical laboratory and not a forensic laboratory. Analytical procedures, including chain-of-custody routines, are more stringent at forensic laboratories. Since his conviction, some of the medical evidence against Norris has been called into question, especially the prevalence of spontaneous attacks of hypoglycemia in elderly and frail patients with co-morbidities.
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8
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Stephenson L, van den Heuvel C, Humphries M, Byard RW. Characteristics of fatal insulin overdoses. Forensic Sci Med Pathol 2022; 18:429-441. [PMID: 35943711 PMCID: PMC9636090 DOI: 10.1007/s12024-022-00511-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 12/14/2022]
Abstract
This study was undertaken to review fatal cases of insulin overdose in South Australia (SA) over a 20-year period to assess rates and characteristics of insulin-related deaths among insulin-dependent diabetics and non-diabetics for all manners of death. Records from the National Coronial Information System (NCIS) and Forensic Science SA (FSSA) were searched for all cases of fatal insulin overdose in South Australia (SA) between 2000 and 2019. Collected variables included age, sex, cause of death, scene findings, manner of death, decedent medical and personal histories, biochemistry, toxicology, histopathology, and autopsy findings. Statistical analyses were performed using R (version 4.1.2). Forty cases of insulin overdose were identified in SA between 2000 and 2019. Twenty-nine cases (72.5%) were suicides, with the remaining cases classified as accidental or undetermined intent. Thirteen of the 22 insulin-dependent diabetics (59%) had a history of depression, 10 of whom had previously demonstrated suicidal ideation. The current study has shown that suicides using insulin among insulin-dependent diabetics are equally as prevalent, if not more so than fatal accidental insulin overdoses. This can largely be attributed to insulin-dependent diabetic access to a potentially lethal substance. Suicide prevention strategies should focus on insulin-dependent diabetics with a history of depression, particularly for those with access to rapid-acting insulin.
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Affiliation(s)
- Lilli Stephenson
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, 5000, Australia.
| | - Corinna van den Heuvel
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, 5000, Australia
| | - Melissa Humphries
- School of Mathematical Sciences, The University of Adelaide, Adelaide, South Australia, 5000, Australia
| | - Roger W Byard
- School of Biomedicine, The University of Adelaide, Adelaide, South Australia, 5000, Australia
- Forensic Science SA (FSSA), Adelaide, South Australia, 5000, Australia
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9
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Laugesen SH, Chou DHC, Safavi-Hemami H. Unconventional insulins from predators and pathogens. Nat Chem Biol 2022; 18:688-697. [PMID: 35761080 DOI: 10.1038/s41589-022-01068-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/18/2022] [Indexed: 11/09/2022]
Abstract
Insulin and its related peptides are found throughout the animal kingdom, in which they serve diverse functions. This includes regulation of glucose homeostasis, neuronal development and cognition. The surprising recent discovery that venomous snails evolved specialized insulins to capture fish demonstrated the nefarious use of this hormone in nature. Because of their streamlined role in predation, these repurposed insulins exhibit unique characteristics that have unraveled new aspects of the chemical ecology and structural biology of this important hormone. Recently, insulins were also reported in other venomous predators and pathogenic viruses, demonstrating the broader use of insulin by one organism to manipulate the physiology of another. In this Review, we provide an overview of the discovery and biomedical application of repurposed insulins and other hormones found in nature and highlight several unique insights gained from these unusual compounds.
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Affiliation(s)
| | - Danny Hung-Chieh Chou
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University, Stanford, CA, USA
| | - Helena Safavi-Hemami
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark. .,Department of Biochemistry, University of Utah, Salt Lake City, UT, USA. .,School of Biological Sciences, University of Utah, Salt Lake City, UT, USA.
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10
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The Other Face of Insulin—Overdose and Its Effects. TOXICS 2022; 10:toxics10030123. [PMID: 35324747 PMCID: PMC8955302 DOI: 10.3390/toxics10030123] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
Insulin is the most effective glycemic-lowering drug, and for people suffering from type 1 diabetes it is a life-saving drug. Its self-dosing by patients may be associated with a higher risk of overdose, both accidental and deliberate. Insulin-induced hypoglycemia causes up to 100,000 emergency department calls per year. Cases of suicide attempts using insulin have been described in the literature since its introduction into therapy, and one of the important factors in their occurrence is the very fact of chronic disease. Up to 90% of patients who go to toxicology wards overdose insulin consciously. Patients with diabetes are burdened with a 2–3 times higher risk of developing depression compared to the general population. For this reason, it is necessary to develop an effective system for detecting a predisposition to overdose, including the assessment of the first symptoms of depression in patients with diabetes. A key role is played by a risk-conscious therapeutic team, as well as education. Further post-mortem testing is also needed for material collection and storage, as well as standardization of analytical methods and interpretation of results, which would allow for more effective detection and analysis of intentional overdose—both by the patient and for criminal purposes.
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Bottinelli C, Bévalot F, Cartiser N, Fanton L, Guitton J. Detection of insulins in postmortem tissues: an optimized workflow based on immunopurification and LC-MS/HRMS detection. Int J Legal Med 2021; 135:1813-1822. [PMID: 33932171 DOI: 10.1007/s00414-021-02598-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/05/2021] [Indexed: 12/22/2022]
Abstract
Diabetes is a worldwide disease in perpetual expansion. Type 1 and sometimes type 2 diabetic patients require daily human insulin (HI) or analog administration. Easy access to insulins for insulin-treated diabetics, their relatives, and medical professionals can enable abuse for suicidal or homicidal purpose. However, demonstrating insulin overdose in postmortem blood is challenging. Tissue analyses are contributive, as insulins can accumulate before death or undergo only limited degradation. The present study describes an assay for HI and synthetic analogs (lispro, aspart, glulisine, detemir and degludec, glargine and its main metabolite (M1)) in liver, kidney, muscle, and injection site samples. It is based on a 5-step sample preparation (reduction of tissue sample size, homogenization, extraction, concentration, and immunopurification) associated with liquid chromatography coupled to high-resolution mass spectrometry (LC-MS/HRMS). Selectivity and limit of detection (LOD) for all target analogs were assessed in the above matrices. LOD was determined at 25 ng/g for HI and for analogs except detemir and degludec, where LOD was 50 ng/g in kidney and injection site samples and 80 ng/g in the liver and muscle. The method was applied to13 forensic cases in which insulin use was suspected.
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Affiliation(s)
- Charline Bottinelli
- LAT LUMTOX Laboratory, 32 Rue du 35ème Régiment d'Aviation 69500, Bron, France.
| | - Fabien Bévalot
- LAT LUMTOX Laboratory, 32 Rue du 35ème Régiment d'Aviation 69500, Bron, France
| | - Nathalie Cartiser
- Department of Forensic Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Fanton
- Department of Forensic Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Faculty of Medicine Lyon-Est, University of Lyon, UCBL1, Lyon, France
| | - Jérôme Guitton
- Toxicology Laboratory, ISPB Faculty of Pharmacy, University of Lyon, UCBL1, Lyon, France.,Pharmacology-Toxicology Laboratory, Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
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12
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Bottinelli C, Nicoli R, Bévalot F, Cartiser N, Roger C, Chikh K, Kuuranne T, Fanton L, Guitton J. Development and validation of a method for quantification of human insulin and its synthetic analogues in plasma and post-mortem sera by LC-MS/HRMS. Talanta 2020; 225:122047. [PMID: 33592769 DOI: 10.1016/j.talanta.2020.122047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/28/2022]
Abstract
Analysis of human insulin and its synthetic analogues is increasingly requested for clinical monitoring, for anti-doping purposes, but also for forensic cases. Indeed, insulin analogues may be abused for suicide or homicide - whence their forensic interest. Collection and storage conditions, as well as the phenomenon of degradation make post-mortem serum samples analytically challenging and consequently, the rate of exogenous insulin administration as cause of death is undoubtedly underestimated. However, with recent technological advances and the development of new extraction techniques particularly for anti-doping analyses, detection of insulins in post-mortem samples seems to be achievable. This study describes the first validated quantitative method for analysis human insulin and its six analogues (lispro, aspart, glulisine, glargine, detemir and degludec) in plasma and post-mortem sera. Various extraction processes, namely precipitation + solid phase extraction (SPE), filtration + SPE, precipitation + SPE + immunopurification, and filtration + immunopurification, were assessed to evaluate the lowest limit of detection for all target analogues. The selected sample preparation consists of filtration step followed by immunopurification extraction with an anti-body precoated ELISA plate for plasma. For post-mortem sera, the first step of precipitation was added to remove matrix interferences. The extracts were analyzed by ultra-high-performance liquid chromatography-high resolution mass spectrometry (LC-HRMS), interfaced by electrospray (ESI). The method was validated with respect linearity, precision, accuracy, recovery, matrix effect, dilution and carryover. The limit of quantification (LOQ) in plasma was 0.5 ng/mL for human insulin and rapid-acting insulins, 1.0 ng/mL for glargine, 2.5 ng/mL for degludec and 10 ng/mL for detemir. Two types of post-mortem sera were studied based on the post-mortem interval (PMI): inferior or superior to 48 h. The obtained LOQ were the same for each analogue, independent from the PMI: 1.0 ng/mL for human insulin and rapid-acting insulins, 1.0 ng/mL for glargine, 2.5 ng/mL for degludec and 10 ng/mL for detemir. At the LOQ level, for all insulins and all samples, accuracy was between 70 and 130% and precision inferior to 30%. The validated method was applied to five subjects participating in therapeutic monitoring of insulin and to seven post-mortem cases.
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Affiliation(s)
- C Bottinelli
- LAT LUMTOX Laboratory, 32 Rue Du 35(ème) Régiment D'Aviation, 69500, Bron, France.
| | - R Nicoli
- Swiss Laboratory for Doping Analyses, University Center of Legal Medicine, Lausanne and Geneva, Lausanne University Hospital and University of Lausanne, Switzerland
| | - F Bévalot
- LAT LUMTOX Laboratory, 32 Rue Du 35(ème) Régiment D'Aviation, 69500, Bron, France
| | - N Cartiser
- Hospices Civils de Lyon, Edouard Herriot Hospital, Service of Forensic Medicine, France
| | - C Roger
- Biochemistry Laboratory, Lyon-Sud Hospital, Hospices Civils de Lyon, France
| | - K Chikh
- Biochemistry Laboratory, Lyon-Sud Hospital, Hospices Civils de Lyon, France
| | - T Kuuranne
- Swiss Laboratory for Doping Analyses, University Center of Legal Medicine, Lausanne and Geneva, Lausanne University Hospital and University of Lausanne, Switzerland
| | - L Fanton
- Hospices Civils de Lyon, Edouard Herriot Hospital, Service of Forensic Medicine, France; University of Lyon, UCBL1, Faculty of Medicine Lyon-Est, France
| | - J Guitton
- Toxicology Laboratory, ISPB Faculty of Pharmacy, University of Lyon, UCBL1, France; Pharmacology-Toxicology Laboratory, Lyon-Sud Hospital, Hospices Civils de Lyon, France
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13
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Beckett N, Tidy R, Douglas B, Priddis C. Detection of intact insulin analogues in post-mortem vitreous humour-Application to forensic toxicology casework. Drug Test Anal 2020; 13:604-613. [PMID: 33197145 DOI: 10.1002/dta.2974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/04/2020] [Accepted: 11/11/2020] [Indexed: 11/11/2022]
Abstract
The application of proteomic techniques to forensic science widens the range of analytical capabilities available to forensic laboratories when answering complex toxicology problems. Currently, these techniques are underutilised in post-mortem toxicology because of the historic focus on smaller (<1,000 amu) drug molecules. Definitive confirmation of an insulin overdose by analysis of post-mortem biological matrices is rare and challenging, however can assist coronial investigations pertaining to accidental or intentional overdoses in both diabetic and nondiabetic populations. A semiautomated micro-solid phase extraction paired with mass spectrometry-based insulin methodology was developed and validated for routine use in a Forensic Coronial Toxicology Laboratory. This resulting work reports the first Australian cases where synthetic insulins were confirmed by mass spectrometry in the vitreous humour of Type 1 diabetics who intentionally or accidentally overdosed on their prescription medication glargine and aspart. The detection of glargine M1 in Case 1, aspart in Case 2 and glargine M1 was indicated in Case 3. This paper highlights advancements in forensic coronial toxicology and the promising potential of proteomic analysis in a forensic context.
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Affiliation(s)
- Nicola Beckett
- Forensic Toxicology Laboratory, ChemCentre, Bentley, Western Australia, Australia
| | - Rebecca Tidy
- Forensic Toxicology Laboratory, ChemCentre, Bentley, Western Australia, Australia
| | - Bianca Douglas
- Forensic Toxicology Laboratory, ChemCentre, Bentley, Western Australia, Australia
| | - Colin Priddis
- Forensic Toxicology Laboratory, ChemCentre, Bentley, Western Australia, Australia
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14
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Judák P, Coppieters G, Lapauw B, Van Eenoo P, Deventer K. Urinary detection of rapid‐acting insulin analogs in healthy humans. Drug Test Anal 2020; 12:1629-1635. [DOI: 10.1002/dta.2817] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Péter Judák
- Department of Diagnostic Sciences, Doping Control Laboratory Ghent University Zwijnaarde Belgium
| | - Gilles Coppieters
- Department of Diagnostic Sciences, Doping Control Laboratory Ghent University Zwijnaarde Belgium
| | - Bruno Lapauw
- Department of Endocrinology Ghent University Hospital Ghent Belgium
| | - Peter Van Eenoo
- Department of Diagnostic Sciences, Doping Control Laboratory Ghent University Zwijnaarde Belgium
| | - Koen Deventer
- Department of Diagnostic Sciences, Doping Control Laboratory Ghent University Zwijnaarde Belgium
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15
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Bottinelli C, Cartiser N, Bévalot F, Fanton L, Guitton J. Is insulin intoxication still the perfect crime? Analysis and interpretation of postmortem insulin: review and perspectives in forensic toxicology. Crit Rev Toxicol 2020; 50:324-347. [PMID: 32458714 DOI: 10.1080/10408444.2020.1762540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Insulin is an anabolic hormone essential to glucose homeostasis. Insulin therapy, comprising human insulin (HI) or biosynthetic analogs, is critical for the management of type-1 diabetes and many of type-2 diabetes. However, medication error including non-adapted dose and confusion of insulin type, and misuse, such as massive self-administration or with criminal intent, can have lethal consequences. The aim of this paper is to review the state of knowledge of insulin analysis in biological samples and of the interpretation of insulin concentrations in the situation of insulin-related death investigations. Analytic aspects are considered, as quantification can be strongly impacted by methodology. Immunoanalysis, the historical technique, has a prominent role due to its sensitivity and ease of implementation. Recently, liquid chromatography coupled to mass spectrometry has provided indispensable selectivity in forensic contexts, distinguishing HI, analogs, and degradation products. We review the numerous antemortem (dose, associated pathology, injection-to-death interval, etc.) and postmortem parameters (in corpore degradation, in vitro degradation related to hemolysis, etc.) involved in the interpretation of insulin concentration. The interest and limitations of various alternative matrices providing a valuable complement to blood analysis are discussed. Vitreous humor is one of the most interesting, but the low diffusion of insulin in this matrix entails very low concentrations. Injection site analysis is relevant for identifying which type of insulin was administered. Muscle and renal cortex are matrices of particular interest, although additional studies are required. A table containing most case reports of fatal insulin poisoning published, with analytical data, completes this review. A logic diagram is proposed to highlight analytical issues and the main parameters to be considered for the interpretation of blood concentrations. Finally, it remains a challenge to provide reliable biological data and solid interpretation in the context of death related to insulin overdose. However, the progress of analytical tools is making the "perfect crime" ever more difficult to commit.
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Affiliation(s)
| | - Nathalie Cartiser
- Département de médecine légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Laurent Fanton
- Département de médecine légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France.,Faculté de médecine Lyon Est, Institut de Médecine Légale, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jérôme Guitton
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.,Hospices Civils de Lyon, Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Lyon-Sud, Pierre Bénite Cedex, France
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16
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Matrix-assisted laser desorption/ionization in-source decay mass spectrometry analysis of human insulin and insulin analogues for the identification of insulin from insulin preparations. Forensic Toxicol 2020. [DOI: 10.1007/s11419-020-00532-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Thevis M, Thomas A. Nachweis synthetischer Insuline in Doping-Analytik und Forensik. Rechtsmedizin (Berl) 2019. [DOI: 10.1007/s00194-019-00347-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Bugelli V, Campobasso CP, Angelino A, Focardi M, Pinchi V. CLEIA of humor vitreous in a case of suicidal insulin overdose. Leg Med (Tokyo) 2019; 40:22-25. [DOI: 10.1016/j.legalmed.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 05/07/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
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19
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Thomas A, Thevis M. Analysis of insulin and insulin analogs from dried blood spots by means of liquid chromatography–high resolution mass spectrometry. Drug Test Anal 2018; 10:1761-1768. [DOI: 10.1002/dta.2518] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Andreas Thomas
- Institute of Biochemistry/Center for Preventive Doping ResearchGerman Sport University Cologne Cologne Germany
| | - Mario Thevis
- Institute of Biochemistry/Center for Preventive Doping ResearchGerman Sport University Cologne Cologne Germany
- European Monitoring Center for Emerging Doping Agents (EuMoCEDA) Cologne/Bonn Germany
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20
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Tong F, Wu R, Huang W, Yang Y, Zhang L, Zhang B, Chen X, Tang X, Zhou Y. Forensic aspects of homicides by insulin overdose. Forensic Sci Int 2017; 278:9-15. [DOI: 10.1016/j.forsciint.2017.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 06/10/2017] [Accepted: 06/14/2017] [Indexed: 11/30/2022]
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21
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Robinson SD, Safavi-Hemami H. Insulin as a weapon. Toxicon 2016; 123:56-61. [DOI: 10.1016/j.toxicon.2016.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/08/2016] [Accepted: 10/18/2016] [Indexed: 12/26/2022]
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22
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Thomas A, Brinkkötter PT, Schänzer W, Thevis M. Simultaneous determination of insulin, DesB30 insulin, proinsulin, and C-peptide in human plasma samples by liquid chromatography coupled to high resolution mass spectrometry. Forensic Toxicol 2016. [DOI: 10.1007/s11419-016-0343-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Labay LM, Bitting CP, Legg KM, Logan BK. The Determination of Insulin Overdose in Postmortem Investigations. Acad Forensic Pathol 2016; 6:174-183. [PMID: 31239889 DOI: 10.23907/2016.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/19/2016] [Accepted: 05/24/2016] [Indexed: 01/17/2023]
Abstract
The analysis of biological specimens for the presence of exogenous insulin is of special interest in select postmortem investigations. Insulin analogues are primarily used to mediate the regulation of blood glucose concentrations; however, their use has also been implicated or suspected as a cause of death in suicides, accidents, and homicides. Toxicological analysis for these compounds is challenging due to the large molecular weight, the limited stability of insulin in whole blood, and complexities associated with sample preparation and instrumental testing. As a consequence, determination of insulin in postmortem specimens is not routinely offered by most forensic toxicology laboratories. Forensic death investigation is further complicated by interpretative difficulties such as the frequent absence of anatomical findings, concentration interpretation in known insulin users, and addressing the impact of chemical instability and postmortem redistribution. There are ongoing efforts, however, to develop and validate robust methods that may be used for this analysis on these challenging samples and that are capable of withstanding scientific and legal scrutiny for forensic use. In this regard, in recent years, methods for the detection of exogenous insulin in postmortem samples have been reported and results of this testing has been published in a handful of cases. The purpose of this article is to review the primary functions of insulin, the disease states associated with the therapeutic use of exogenous insulin, the current state of laboratory testing, and to provide case summaries that summarize the timeline of advancements and underscore the importance of this work.
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Affiliation(s)
| | | | - Kevin M Legg
- Center for Forensic Science Research and Education
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24
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Belsey SL, Flanagan RJ. Postmortem biochemistry: Current applications. J Forensic Leg Med 2016; 41:49-57. [PMID: 27131037 DOI: 10.1016/j.jflm.2016.04.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/31/2016] [Accepted: 04/10/2016] [Indexed: 11/26/2022]
Abstract
The results of biochemical analyses in specimens obtained postmortem may aid death investigation when diabetic and alcoholic ketoacidosis is suspected, when death may have been the result of drowning, anaphylaxis, or involved a prolonged stress response such as hypothermia, and in the diagnosis of disease processes such as inflammation, early myocardial infarction, or sepsis. There is often cross-over with different disciplines, in particular with clinical and forensic toxicology, since some endogenous substances such as sodium chloride, potassium chloride, and insulin can be used as poisons. The interpretation of results is often complicated because of the likelihood of postmortem change in analyte concentration or activity, and proper interpretation must take into account all the available evidence. The unpredictability of postmortem changes means that use of biochemical measurements in time of death estimation has little value. The use of vitreous humour is beneficial for many analytes as the eye is in a physically protected environment, this medium may be less affected by autolysis or microbial metabolism than blood, and the assays can be performed with due precaution using standard clinical chemistry analysers. However, interpretation of results may not be straightforward because (i) defined reference ranges in life are often lacking, (ii) there is a dearth of knowledge regarding, for example, the speed of equilibration of many analytes between blood, vitreous humour, and other fluids that may be sampled, and (iii) the effects of post-mortem change are difficult to quantify because of the lack of control data. A major limitation is that postmortem vitreous glucose measurements are of no help in diagnosing antemortem hypoglycaemia.
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Affiliation(s)
- S L Belsey
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK.
| | - R J Flanagan
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK; Toxicology Unit, Dept of Pathology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
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25
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Thomas A, Brinkkötter P, Schänzer W, Thevis M. Metabolism of human insulin after subcutaneous administration: A possible means to uncover insulin misuse. Anal Chim Acta 2015; 897:53-61. [DOI: 10.1016/j.aca.2015.09.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/17/2015] [Accepted: 09/19/2015] [Indexed: 12/15/2022]
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26
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Sunderland N, Wong S, Lee CK. Fatal Insulin Overdoses: Case Report and Update on Testing Methodology. J Forensic Sci 2015; 61 Suppl 1:S281-4. [DOI: 10.1111/1556-4029.12958] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/05/2015] [Accepted: 03/22/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - Sophia Wong
- University of British Columbia; Vancouver BC Canada
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27
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Palmiere C, Sabatasso S, Torrent C, Rey F, Werner D, Bardy D. Post-mortem determination of insulin using chemiluminescence enzyme immunoassay: preliminary results. Drug Test Anal 2015; 7:797-803. [DOI: 10.1002/dta.1775] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/19/2014] [Accepted: 01/02/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Sara Sabatasso
- CURML; chemin de la Vulliette 5; Lausanne 1000 Switzerland
| | - Céline Torrent
- Laboratory of Clinical Chemistry; Lausanne VD Switzerland
| | - François Rey
- Laboratory of Clinical Chemistry; Lausanne VD Switzerland
| | | | - Daniel Bardy
- Laboratory of Clinical Chemistry; Lausanne VD Switzerland
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28
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Thomas A, Schänzer W, Thevis M. Determination of human insulin and its analogues in human blood using liquid chromatography coupled to ion mobility mass spectrometry (LC-IM-MS). Drug Test Anal 2014; 6:1125-32. [DOI: 10.1002/dta.1710] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/14/2014] [Accepted: 07/27/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Andreas Thomas
- Center for Preventive Doping Research and Institute of Biochemistry; German Sport University Cologne; Am Sportpark Müngersdorf 6 50933 Cologne Germany
| | - Wilhelm Schänzer
- Center for Preventive Doping Research and Institute of Biochemistry; German Sport University Cologne; Am Sportpark Müngersdorf 6 50933 Cologne Germany
| | - Mario Thevis
- Center for Preventive Doping Research and Institute of Biochemistry; German Sport University Cologne; Am Sportpark Müngersdorf 6 50933 Cologne Germany
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29
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Wunder C, Kauert GF, Toennes SW. Factors leading to the degradation/loss of insulin in postmortem blood samples. Forensic Sci Int 2014; 241:173-7. [DOI: 10.1016/j.forsciint.2014.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 05/29/2014] [Accepted: 06/05/2014] [Indexed: 10/25/2022]
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30
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Chambers EE, Fountain KJ, Smith N, Ashraf L, Karalliedde J, Cowan D, Legido-Quigley C. Multidimensional LC-MS/MS Enables Simultaneous Quantification of Intact Human Insulin and Five Recombinant Analogs in Human Plasma. Anal Chem 2013; 86:694-702. [DOI: 10.1021/ac403055d] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Erin E. Chambers
- Institute
of Pharmaceutical Sciences, King’s College London, Franklin-Wilkins
Building, 150 Stamford Street, London SE1 9NH, United Kingdom
- Waters Centre for Innovation in Separation Science, Analytical & Environmental Science Division, King’s College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, United Kingdom
| | - Kenneth J. Fountain
- Waters Corporation, 34 Maple
Street, Milford, Massachusetts 01757, United States
| | - Norman Smith
- Waters Centre for Innovation in Separation Science, Analytical & Environmental Science Division, King’s College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, United Kingdom
| | - Leah Ashraf
- Cardiovascular
Division, King’s College London, Franklin-Wilkins Building, 150 Stamford
Street, London SE1 9NH, United Kingdom
| | - Janaka Karalliedde
- Cardiovascular
Division, King’s College London, Franklin-Wilkins Building, 150 Stamford
Street, London SE1 9NH, United Kingdom
| | - David Cowan
- Drug Control Centre, Analytical & Environmental Science Division, King’s College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, United Kingdom
| | - Cristina Legido-Quigley
- Institute
of Pharmaceutical Sciences, King’s College London, Franklin-Wilkins
Building, 150 Stamford Street, London SE1 9NH, United Kingdom
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31
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Ojanperä I, Sajantila A, Vinogradova L, Thomas A, Schänzer W, Thevis M. Post-mortem vitreous humour as potential specimen for detection of insulin analogues by LC–MS/MS. Forensic Sci Int 2013; 233:328-32. [DOI: 10.1016/j.forsciint.2013.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/26/2013] [Accepted: 10/05/2013] [Indexed: 10/26/2022]
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Abstract
Insulin or, more appropriately, hypoglycaemia gives rise to a wide variety of interactions with the law. In most cases its role is not seriously open to question occasionally however, it is. This is especially true of situations in which insulin is suspected of having been used inappropriately or maliciously. The major differences between investigation of hypoglycaemia in clinical and forensic situation are that in the latter the history is often unreliable, appropriate samples for analysis were not collected, preserved or labelled correctly and analytical results are likely to be challenged on grounds of specificity, accuracy and interpretation. Immunoassay remains the mainstay of clinical investigation of hypoglycaemia but likely to become displaced by mass-spectrometry in the forensic situation especially now that human insulin is being replaced by synthetic insulin analogues for the treatment of diabetes.
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Affiliation(s)
- Vincent Marks
- Post Graduate Medical School, University of Surrey, Guildford, UK.
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33
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Hess C, Madea B, Daldrup T, Musshoff F. Determination of hypoglycaemia induced by insulin or its synthetic analogues post mortem. Drug Test Anal 2013; 5:802-7. [DOI: 10.1002/dta.1500] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 03/28/2013] [Accepted: 04/25/2013] [Indexed: 11/12/2022]
Affiliation(s)
- C. Hess
- Institute of Forensic Medicine; University Hospital Bonn; Stiftsplatz 12; 53111; Bonn; Germany
| | - B. Madea
- Institute of Forensic Medicine; University Hospital Bonn; Stiftsplatz 12; 53111; Bonn; Germany
| | - T. Daldrup
- Institute of Forensic Medicine; University Hospital Düsseldorf; Moorenstraße 5; 40225; Düsseldorf; Germany
| | - F. Musshoff
- Institute of Forensic Medicine; University Hospital Bonn; Stiftsplatz 12; 53111; Bonn; Germany
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34
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Nirantharakumar K, Marshall T, Hodson J, Narendran P, Deeks J, Coleman JJ, Ferner RE. Hypoglycemia in non-diabetic in-patients: clinical or criminal? PLoS One 2012; 7:e40384. [PMID: 22768352 PMCID: PMC3388042 DOI: 10.1371/journal.pone.0040384] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/05/2012] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIM We wished to establish the frequency of unexpected hypoglycemia observed in non diabetic patients outside the intensive care unit and to determine if they have a plausible clinical explanation. METHODS We analysed data for 2010 from three distinct sources to identify non diabetic hypoglycaemic patients: bedside and laboratory blood glucose measurements; medication records for those treatments (high-strength glucose solution and glucagon) commonly given to reverse hypoglycemia; and diagnostic codes for hypoglycemia. We excluded from the denominator admissions of patients with a diagnosis of diabetes or prescribed diabetic medication. Case notes of patients identified were reviewed. We used capture-recapture methods to establish the likely frequency of hypoglycemia in non-diabetic in-patients outside intensive care unit at different cut-off points for hypoglycemia. We also recorded co-morbidities that might have given rise to hypoglycemia. RESULTS Among the 37,898 admissions, the triggers identified 71 hypoglycaemic episodes at a cut-off of 3.3 mmol/l. Estimated frequency at 3.3 mmol/l was 50(CI 33-93), at 3.0 mmol/l, 36(CI 24-64), at 2.7 mmol/l, 13(CI 11-19), at 2.5 mmol/l, 11(CI 9-15) and at 2.2 mmol/l, 8(CI 7-11) per 10,000 admissions. Admissions of patients aged above 65 years were approximately 50% more likely to have an episode of hypoglycemia. Most were associated with important co-morbidities. CONCLUSION Significant non-diabetic hypoglycemia in hospital in-patients (at or below 2.7 mmol/l) outside critical care is rare. It is sufficiently rare for occurrences to merit case-note review and diagnostic blood tests, unless an obvious explanation is found.
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35
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Thevis M, Thomas A, Schänzer W, Östman P, Ojanperä I. Measuring insulin in human vitreous humour using LC-MS/MS. Drug Test Anal 2011; 4:53-6. [DOI: 10.1002/dta.368] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 08/13/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Mario Thevis
- Institute of Biochemistry - Center for Preventive Doping Research; German Sport University Cologne; Am Sportpark Müngersdorf 6; 50933; Cologne; Germany
| | - Andreas Thomas
- Institute of Biochemistry - Center for Preventive Doping Research; German Sport University Cologne; Am Sportpark Müngersdorf 6; 50933; Cologne; Germany
| | - Wilhelm Schänzer
- Institute of Biochemistry - Center for Preventive Doping Research; German Sport University Cologne; Am Sportpark Müngersdorf 6; 50933; Cologne; Germany
| | - Pekka Östman
- Hjelt Institute, Department of Forensic Medicine; University of Helsinki; PO Box 40 (Kytösuontie 11); 00014; Helsinki; Finland
| | - Ilkka Ojanperä
- Hjelt Institute, Department of Forensic Medicine; University of Helsinki; PO Box 40 (Kytösuontie 11); 00014; Helsinki; Finland
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Palmiere C, Mangin P. Postmortem chemistry update part I. Int J Legal Med 2011; 126:187-98. [PMID: 21947676 DOI: 10.1007/s00414-011-0625-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 09/09/2011] [Indexed: 11/30/2022]
Abstract
Postmortem chemistry is becoming increasingly essential in the forensic pathology routine and considerable progress has been made over the past years. Biochemical analyses of vitreous humor, cerebrospinal fluid, blood and urine may provide significant information in determining the cause of death or in elucidating forensic cases. Postmortem chemistry may essentially contribute in the determination of the cause of death when the pathophysiological changes involved in the death process cannot be detected by morphological methods (e.g. diabetes mellitus, alcoholic ketoacidosis and electrolytic disorders). It can also provide significant information and useful support in other forensic situations, including anaphylaxis, hypothermia, sepsis and hormonal disturbances. In this article, we present a review of the literature that covers this vast topic and we report the results of our observations. We have focused our attention on glucose metabolism, renal function and electrolytic disorders.
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Affiliation(s)
- Cristian Palmiere
- University Centre of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011, Lausanne, Switzerland.
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37
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Thevis M, Trevorrow P. Special issue-murders by drugs. Drug Test Anal 2010; 1:149. [PMID: 20355190 DOI: 10.1002/dta.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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