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Agarwal R, Kumar A, Pandey T, Chayal NK, Verma KS, Kumar D, Kumar K, Aryal S, Singh P, Ali M, Srivastava A, Singh M, Ghosh AK. High lead contamination in Mother's breastmilk in Bihar (India): Health risk assessment of the feeding children. CHEMOSPHERE 2024; 364:143064. [PMID: 39142396 DOI: 10.1016/j.chemosphere.2024.143064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/23/2024] [Accepted: 08/08/2024] [Indexed: 08/16/2024]
Abstract
Lead poisoning in the recent times has caused serious health threats in the exposed human population. It is estimated that about 815 million people are exposed to lead poisoning worldwide and in India total 275 million children are exposed to blood lead contamination. The present study was carried outed in 6 districts of Bihar to know the extent of lead exposure in the children through their mother's breastmilk. The biological samples such as breastmilk, mother's urine, child's urine, and mother's blood samples were collected for quantitative lead estimation. Moreover, the selected household water sources (handpump) and the food consumed by the individuals-wheat, rice and potato samples were also collected for lead quantification. The study reveals that the breastmilk had high lead content in 92% of the samples (highest value 1309 μg/L), in blood presence of lead was observed in 87% studied samples (highest value 677.2 μg/L). In mother's urine the highest lead value was 4168 μg/L (62%) and in child's urine the highest value was 875.4 μg/L (62%) respectively of the studied samples. Moreover, in the studied food samples, wheat had lead content in 45% the studied samples (highest value 7910 μg/kg). In rice in 40% of the studied samples (highest value 6972 μg/kg) and in potato 90% of the studied samples (highest value = 13786 μg/kg) were found with elevated lead content respectively. The hazard quotient (HQ) and the cancer risk (CR) for lead contamination was very much higher in mothers followed by their children. The entire study indicated that lead exposure through food (wheat, rice and potato) has reached the mother's breastmilk and from their it has reached their child's body. This could cause serious hazards in the exposed children causing serious neurological damages, low IQ, low memory, and low mental growth in them. Therefore, a strategic action is required to control the present problem.
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Affiliation(s)
- Radhika Agarwal
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India; Lovely Professional University, Punjab, India
| | - Arun Kumar
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India.
| | | | | | | | - Dhruv Kumar
- UPES University, Dehradun, Uttarakhand, India
| | - Kanhaiya Kumar
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India
| | - Siddhant Aryal
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India
| | - Pratima Singh
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India
| | - Mohammad Ali
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India
| | | | - Manisha Singh
- Mahavir Cancer Sansthan & Research Centre, Patna, Bihar, India
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McMillin GA, Morad AW, Boyd JM, Johnson-Davis KL, Metz TD, Smid MC, Krasowski MD. Biological Testing and Interpretation of Laboratory Results Associated with Detecting Newborns with Substance Exposure. Clin Chem 2024; 70:934-947. [PMID: 38549034 DOI: 10.1093/clinchem/hvae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Substance use during pregnancy is common, as is biological testing that is intended to help identify prenatal exposures. However, there is no standardized requirement for biological testing with either maternal or newborn specimens, nor is there standardization related to when testing occurs, how frequently testing occurs, what specimen(s) to test, what substances to test for, or how to perform testing. CONTENT We review common specimen types tested to detect maternal and newborn substance exposure with a focus on urine, meconium, and umbilical cord tissue. We also review common analytical methods used to perform testing, including immunoassay, and mass spectrometry platforms. Considerations regarding the utilization of testing relative to the purpose of testing, the drug analyte(s) of interest, the specific testing employed, and the interpretation of results are emphasized to help guide decisions about clinical utilization of testing. We also highlight specific examples of unexpected results that can be used to guide interpretation and appropriate next steps. SUMMARY There are strengths and limitations associated with all approaches to detecting substance exposure in pregnant persons as well as biological testing to evaluate a newborn with possible substance exposure. Standardization is needed to better inform decisions surrounding evaluation of substance exposures in pregnant people and newborns. If biological sampling is pursued, testing options and results must be reviewed in clinical context, acknowledging that false-positive and -negative results can and do occur.
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Affiliation(s)
- Gwendolyn A McMillin
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Anna W Morad
- Department of Pediatrics, Academic General Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Jessica M Boyd
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Kamisha L Johnson-Davis
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
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Brown HM, Roper SM, Dietzen DJ, Crews BO. High-sensitivity neonatal urine drug testing has similar positivity rates to meconium for detecting in utero exposure to methamphetamine and cocaine. J Anal Toxicol 2024; 48:99-103. [PMID: 37952088 DOI: 10.1093/jat/bkad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
Current guidelines recommend universal screening for substance use disorders in obstetric patients, and neonatal drug testing is also frequently performed. Meconium is often the preferred specimen type to detect neonatal drug exposure due to a longer window of detection compared to urine, but most laboratories send out meconium testing to specialized reference laboratories, which can delay results for several days or more. Here, we evaluate a rapid and definitive liquid chromatography-tandem mass spectrometry method for neonatal urine drug testing and compare results obtained using this method to paired meconium drug testing in 1,424 neonates for amphetamines, cocaine, cannabinoids, opiates, oxycodone and phencyclidine. Urine testing showed equivalent sensitivity to current meconium methods for detecting in utero exposure to amphetamines and cocaine.
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Affiliation(s)
- Hannah M Brown
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Stephen M Roper
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Bridgit O Crews
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
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Midthun KM. Umbilical Cord Tissue: From Antemortem Monitoring to Postmortem Possibilities. Am J Forensic Med Pathol 2024; 45:67-71. [PMID: 38064344 DOI: 10.1097/paf.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
ABSTRACT Umbilical cord tissue (UCT) traditionally has been used as an antemortem matrix for identifying and monitoring fetal exposure to drugs suspected to have been used during pregnancy. The specimen offers several advantages as a testable tissue, including accessibility and ease of collection, ample sample volume, a long window of detection, and ability to detect for a wide range of drugs. Despite these advantages, little to no research exists on the use of UCT as a postmortem forensic toxicology specimen. This article aims to provide insights into UCT toxicological testing and infer potential applications for postmortem use, such as investigations into stillbirths and infant abandonment. Umbilical cord tissue offers several benefits as a postmortem toxicological specimen. Importantly, it can be collected with or without an autopsy being performed and may help explain factors that contribute to the underdevelopment and death of the neonate. With the limited sample volumes present in infant investigations, toxicological analysis of UCT could become a valuable tool for neonatal medicolegal death investigations.
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Bandoli G, Anunziata F, Bogdan R, Zilverstand A, Chaiyachati BH, Gurka KK, Sullivan E, Croff J, Bakhireva LN. Assessment of substance exposures in nail clipping samples: A systematic review. Drug Alcohol Depend 2024; 254:111038. [PMID: 38041982 PMCID: PMC11059950 DOI: 10.1016/j.drugalcdep.2023.111038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Studies of prenatal substance exposure often rely on self-report, urine drug screens, and/or analyses of blood or meconium biomarkers. Accuracy of these measures is limited when assessing exposure over many weeks or months of gestation. Nails are increasingly being considered as a matrix from which to assess substance exposure. This systematic review synthesizes data on the validity of detecting alcohol, nicotine, cannabis, and opioid from nail clippings, with an emphasis on prenatal exposure assessment. METHODS The systematic review was conducted using PRISMA 2020 guidelines. Seven databases were searched with keywords relevant to the four substances of interest. Results were summarized grouping manuscripts by the exposure of interest with focus on accuracy and feasibility. RESULTS Of 2384 papers initially identified, 35 manuscripts were included in our qualitative synthesis. Only a few studies specifically looked at pregnant individuals or mother-child dyads. Across the four substances, many studies demonstrated a dose-response relationship between exposure and concentration of analytes in nails. Nail assays appear to detect lower level of exposure compared to hair; however, sample insufficiency, especially for multi-substance assays, remains a limitation. CONCLUSIONS Based on the reviewed studies, nail clippings are an acceptable and potentially preferable matrix for the evaluation of these four prenatal substances when sampling frequency and/or study design necessitates assessment of past exposures over an extended period. Nails have the advantage of infrequent sampling and minimal invasiveness to assess a broad exposure period. Future studies should examine validity of analytes in toenail versus fingernail clippings.
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Affiliation(s)
- Gretchen Bandoli
- Department of Pediatrics, University of California, La Jolla, San Diego, CA 92093, USA.
| | - Florencia Anunziata
- Department of Pediatrics, University of California, La Jolla, San Diego, CA 92093, USA
| | - Ryan Bogdan
- Department of Psychological & Brain Sciences, Washington University, St. Louis, MO 63130, USA
| | - Anna Zilverstand
- Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis MN 55455, USA
| | | | - Kelly K Gurka
- Department of Epidemiology, Colleges of Public Health & Health Professions and Medicine, University of Florida, Gainesville FL, 32611 USA
| | - Elinor Sullivan
- Department of Psychiatry, Oregon Health & Science University, Portland, OR 97239, USA
| | - Julie Croff
- Department of Rural Health, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
| | - Ludmila N Bakhireva
- Department of Pharmacy Practice & Administrative Sciences, University of New Mexico Health and Health Sciences, Albuquerque, NM 87131, USA
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Gersch H, Shah D, Chroust A, Bailey B. Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome? J Matern Fetal Neonatal Med 2023; 36:2211706. [PMID: 37183045 DOI: 10.1080/14767058.2023.2211706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE This study evaluated maternal urine drug screen (UDS) at delivery and umbilical cord drug testing and its association with neonatal opioid withdrawal syndrome (NOWS) diagnosis and severity following opioid exposed pregnancy. METHODS A retrospective chart review of 770 mother-infant dyads at five birthing hospitals in the United States Appalachian region for a five-year period was performed. Variables of interest included dyad demographics, results of maternal UDS at delivery and umbilical cord drug testing, and three neonatal outcomes: NOWS diagnosis, pharmacologic treatment administered for NOWS, and length of hospital stay (LOS) of the newborn. RESULTS Opioid-positivity was between 8.5% and 66.3% based on maternal UDS at delivery or umbilical cord testing. Odds of NOWS diagnosis and increased infant LOS was best associated with opioid detection in maternal UDS alone (OR = 5.62, 95% CI [3.06, 10.33] and OR = 8.33, 95% CI [3.67, 18.89], respectively). However, odds of pharmacologic treatment for NOWS was best associated with opioid detection in both maternal UDS and umbilical cord testing on the same dyad (OR = 3.22, 95% CI [1.14, 9.09]). CONCLUSION Maternal UDS is a better option compared to umbilical cord testing for evaluation of opioid-exposed infants and risk of NOWS diagnosis and increased infant LOS.
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Affiliation(s)
- Hannah Gersch
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Darshan Shah
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Alyson Chroust
- Department of Psychology, College of Arts and Sciences, East Tennessee State University, Johnson City, TN, USA
| | - Beth Bailey
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA
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Bertaso A, Gottardo R, Murari M, Mazzola M, Porpiglia NM, Taus F, Beghini R, Gandini F, Bortolotti F. Hair testing applied to the assessment of in utero exposure to drugs: Critical analysis of 51 cases of the University Hospital of Verona. Drug Test Anal 2023; 15:980-986. [PMID: 37154073 DOI: 10.1002/dta.3515] [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: 01/08/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
The work discusses the results of hair and urine testing performed in 51 cases of suspected in utero drug exposure handled at the University Hospital of Verona from 2016 to 2022. On the day of birth or the day after birth, urine from mother and newborn (UM and UN) and hair from mother (HM), newborn (HN) and father (HF), if possible, were collected. Urine underwent immunoassay and GC-MS analysis, whereas hair underwent LC-MS/MS and GC-MS/MS analysis. In 50 out of 51 cases, HM and/or HN were available. In 92% of them, hair testing resulted in a positive, often (>50% cases) for more than one class of substance. The most detected substances were cocaine, opiates, methadone and cannabinoids. Maternal segmental analysis showed a prevalent decreasing concentration trend during pregnancy in case of positivity for one class of substances, whereas, as expected, a neatly prevalent increasing trend in the case of positivity for more than one class of substances. In nine cases, HF was also available, resulting in all being positive, usually for the same classes of substances identified in HM, thus questioning parental responsibility. In 33 cases, urine samples from the mother or newborn were also collected. Of them, 27 cases (82%) tested positive, showing peri-partum drug consumption and then confirming the severity of the addiction. Hair testing showed to be a reliable diagnostic tool to investigate in utero drug exposure because of the possibility of obtaining a complete picture of maternal addictive behaviour and family background, thanks to segmental maternal hair analysis and father hair testing.
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Affiliation(s)
- Anna Bertaso
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Rossella Gottardo
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Matilde Murari
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Mara Mazzola
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Nadia Maria Porpiglia
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
| | - Francesco Taus
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
- Department of Diagnostic and Public Health, Unit of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Renzo Beghini
- Department of Pediatrics, Verona University Hospital, Verona, Italy
| | - Fabio Gandini
- Social Services, Verona University Hospital, Verona, Italy
| | - Federica Bortolotti
- Department of Diagnostic and Public Health, Unit of Forensic Medicine, University of Verona, Verona, Italy
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Cohen S, Nielsen T, Chou JH, Hoeppner B, Koenigs KJ, Bernstein SN, Smith NA, Perlman N, Sarathy L, Wilens T, Terplan M, Schiff DM. Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals. Acad Pediatr 2023; 23:1268-1275. [PMID: 36754165 DOI: 10.1016/j.acap.2023.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement. METHODS Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression. RESULTS Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement. CONCLUSIONS Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.
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Affiliation(s)
- Samuel Cohen
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass; Department of Pediatrics, Boston Medical Center (S Cohen), Boston, Mass.
| | - Timothy Nielsen
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney (T Nielsen), Sydney, Australia
| | - Joseph H Chou
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Bettina Hoeppner
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | - Kathleen J Koenigs
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Sarah N Bernstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital (SN Bernstein), Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital (NA Smith), Boston, Mass
| | - Nicola Perlman
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Leela Sarathy
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Timothy Wilens
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | | | - Davida M Schiff
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
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Peters FT, Wissenbach D. Current state-of-the-art approaches for mass spectrometry in clinical toxicology: an overview. Expert Opin Drug Metab Toxicol 2023; 19:487-500. [PMID: 37615282 DOI: 10.1080/17425255.2023.2252324] [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: 05/16/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Hyphenated mass spectrometry (MS) has evolved into a very powerful analytical technique of high sensitivity and specificity. It is used to analyze a very wide spectrum of analytes in classical and alternative matrices. The presented paper will provide an overview of the current state-of-the-art of hyphenated MS applications in clinical toxicology primarily based on review articles indexed in PubMed (1990 to April 2023). AREAS COVERED A general overview of matrices, sample preparation, analytical systems, detection modes, and validation and quality control is given. Moreover, selected applications are discussed. EXPERT OPINION A more widespread use of hyphenated MS techniques, especially in systematic toxicological analysis and drugs of abuse testing, would help overcome limitations of immunoassay-based screening strategies. This is currently hampered by high instrument cost, qualification requirements for personnel, and less favorable turnaround times, which could be overcome by more user-friendly, ideally fully automated MS instruments. This would help making hyphenated MS-based analysis available in more laboratories and expanding analysis to a large number of organic drugs, poisons, and/or metabolites. Even the most recent novel psychoactive substances (NPS) could be presumptively identified by high-resolution MS methods, their likely presence be communicated to treating physicians, and be confirmed later on.
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Affiliation(s)
- Frank T Peters
- Institute of Forensic Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Daniela Wissenbach
- Institute of Forensic Medicine, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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Hughs M, Kish-Trier E, O'Brien A, McMillin GA. Analysis of Mitragynine and Speciociliatine in Umbilical Cord by LC-MS-MS for Detecting Prenatal Exposure to Kratom. J Anal Toxicol 2023; 46:957-964. [PMID: 36047661 DOI: 10.1093/jat/bkac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/22/2022] [Accepted: 08/30/2022] [Indexed: 01/26/2023] Open
Abstract
Kratom is an herbal drug that is legal in the USA. While it is marketed as a safer alternative to opioids, it can cause opioid-like withdrawal symptoms when discontinued after regular use. Several case studies have shown that kratom exposure in utero can lead to symptoms in newborns consistent with neonatal abstinence syndrome. Here, we present a validated method for the detection of kratom in umbilical cord by liquid chromatography--tandem mass spectrometry. The umbilical cord is homogenized in solvent and kratom analytes are purified by solid phase extraction (strong cation exchange). Diastereomeric kratom alkaloids mitragynine (MG), speciociliatine (SC), speciogynine and mitraciliatine are separated by reverse phase chromatography on a phenyl-hexyl column. Applying this method to residual umbilical cords submitted to our laboratory for drug testing, 29 positive specimens exhibiting varied kratom analyte distributions were observed. MG and SC were the most abundant kratom analytes and were selected as biomarkers of kratom exposure. A cutoff concentration of 0.08 ng/g was established for both MG and SC.
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Affiliation(s)
- Melissa Hughs
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Erik Kish-Trier
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Aidin O'Brien
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Gwendolyn A McMillin
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA.,Department of Pathology, University of Utah School of Medicine, 15 North Medical Drive, East Street #1100, Salt Lake City, UT 84112, USA
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Albano GD, La Spina C, Pitingaro W, Milazzo V, Triolo V, Argo A, Malta G, Zerbo S. Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues. TOXICS 2023; 11:toxics11010062. [PMID: 36668788 PMCID: PMC9866828 DOI: 10.3390/toxics11010062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 06/01/2023]
Abstract
Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.
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Langman LJ, Rushton AM, Thomas D, Colbourne P, Seiden-Long I, Brun MM, Colantonio D, Jannetto PJ. Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation. Clin Biochem 2023; 111:1-10. [PMID: 36379240 DOI: 10.1016/j.clinbiochem.2022.11.002] [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: 08/22/2022] [Revised: 10/21/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.
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Affiliation(s)
- Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Alysha M Rushton
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Dylan Thomas
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penny Colbourne
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Miranda M Brun
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Colantonio
- Eastern Ontario Regional Laboratory Association and Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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13
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Midthun KM, Nelson BN, Strathmann FG, Browne T, Logan BK. Analysis of umbilical cord tissue as an indicator of in utero exposure to toxic adulterating substances. Front Pediatr 2023; 11:1127020. [PMID: 37025298 PMCID: PMC10070803 DOI: 10.3389/fped.2023.1127020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/27/2023] [Indexed: 04/08/2023] Open
Abstract
In utero drug exposure is a significant public health threat to the well-being and normal development of the neonate. Recently, testing of umbilical cord tissue (UCT) has been employed to measure illicit drug exposure, as drugs used by the mother during the third trimester may be retained in the UCT. Focus has also been given to potential adverse health effects among drug users, resulting from exposure to pharmacologically active adulterants and cutting agents in the street drug supply. The in utero effects of these substances have not been well studied in humans, nor has their presence been demonstrated as a means for assessing adverse health effects in the neonate. Here, we describe the application of a novel test method to analyze UCT for the presence of more than 20 common adulterating/cutting substances via LC/Q-TOF. In total, 300 de-identified UCT samples were analyzed-all had previously tested positive for cocaine or opiates. Generally, the positivity rates of individual compounds were similar between the Cocaine and Opiates Subgroups, apart from levamisole, xylazine, dipyrone (metabolites), and promethazine. Many of the adulterants used in the street drug supply do have legitimate medicinal/therapeutic uses, including several of the compounds most frequently detected in this study. Caffeine and lidocaine were the most frequently identified compounds both individually (>70% each) and in combination with each other. Alternatively, levamisole, an adulterant with no legitimate therapeutic use, was present in 12% of cases. Importantly, this data demonstrates that the detection of traditional drugs of abuse may serve as indicators of potential in utero exposure to toxic adulterating substances during gestation. While there is cause for concern with respect to any unintentional drug exposure, illicit drug use during pregnancy, including uncontrolled dosing, poly-adulterant consumption, and the interactions of these drug mixtures, produces a significant public health threat to the neonate which warrants further study.
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Affiliation(s)
- Kari M. Midthun
- NMS Labs, Horsham, PA, United States
- Correspondence: Kari M. Midthun
| | | | | | - Thom Browne
- Colombo Plan Secretariat, Colombo, Sri Lanka
| | - Barry K. Logan
- NMS Labs, Horsham, PA, United States
- Center for Forensic Science Research and Education (CFSRE) at the Fredric Rieders Family Foundation, Willow Grove, PA, United States
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14
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Cai FS, Tang B, Zheng J, Yan X, Luo WK, He M, Luo XJ, Ren MZ, Yu YJ, Mai BX. Fetal exposure to organic contaminants revealed by infant hair: A preliminary study in south China. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 316:120536. [PMID: 36367513 DOI: 10.1016/j.envpol.2022.120536] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 10/16/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
Fetal exposure to multiple organic contaminants (OCs) is a public concern because of the adverse effects of OCs on early life development. Infant hair has the potential to be used as an alternative matrix to identify susceptible fetuses, owing to its reliability, sensitivity, and advantages associated with sampling, handling, and ethics. However, the applicability of infant hair for assessing in utero exposure to OCs is still limited. In this study, 57 infant hair samples were collected in Guangzhou, South China, to evaluate the levels and compositions of typical OCs in the fetus. Most of the target OCs were detected in infant hair, with medians of 144 μg/g, 17.7 μg/g, 192 ng/g, 46.9 ng/g, and 1.36 ng/g for phthalate esters (PAEs), alternative plasticizers (APs), organophosphorus flame retardants (OPFRs), polybrominated diphenyl ethers (PBDEs), and organochlorine pesticides (OCPs), respectively. Meanwhile, paired maternal hair (0-9 cm from the scalp) was collected to examine the associations between maternal and infant hair for individual compounds. Low-brominated PBDEs tended to deposit in infant hair, with median concentrations approximately two times higher than those in maternal samples. Levels of PBDEs and 4,4'-dichlorodiphenyldichloroethylene (p,p'-DDE) in paired maternal and infant hair showed strong positive correlations (p < 0.05), while most plasticizers (PAEs and APs) were poorly correlated between paired hair samples. Exposure sources were responsible for the variation in correlation between OC levels in the paired infant and maternal samples. Crude relationships between fetal exposure to OCs and birth size were examined using the Bayesian kernel machine regression (BKMR) model. BDE-28 was found to be adversely associated with the birth size. This study provides referential information for evaluating in utero exposure to OCs and their health risks based on infant hair.
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Affiliation(s)
- Feng-Shan Cai
- State Key Laboratory of Organic Geochemistry, Guangdong Provincial Key Laboratory of Environmental Protection and Resources Utilization, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou, 510640, PR China; State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China; University of Chinese Academy of Sciences, Beijing, 100049, PR China
| | - Bin Tang
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China
| | - Jing Zheng
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China; School of Public Health, Key Laboratory of Environmental Pollution and Disease Monitoring of Ministry of Education, Guizhou Medical University, Guiyang, 550000, PR China.
| | - Xiao Yan
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China; School of Public Health, Key Laboratory of Environmental Pollution and Disease Monitoring of Ministry of Education, Guizhou Medical University, Guiyang, 550000, PR China
| | - Wei-Keng Luo
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China
| | - Mian He
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518107, PR China
| | - Xiao-Jun Luo
- State Key Laboratory of Organic Geochemistry, Guangdong Provincial Key Laboratory of Environmental Protection and Resources Utilization, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou, 510640, PR China; Guangdong-Hong Kong-Macao Joint Laboratory for Environmental Pollution and Control, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou, 510640, PR China
| | - Ming-Zhong Ren
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China
| | - Yun-Jiang Yu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou, 510655, PR China
| | - Bi-Xian Mai
- State Key Laboratory of Organic Geochemistry, Guangdong Provincial Key Laboratory of Environmental Protection and Resources Utilization, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou, 510640, PR China; Guangdong-Hong Kong-Macao Joint Laboratory for Environmental Pollution and Control, Guangzhou Institute of Geochemistry, Chinese Academy of Sciences, Guangzhou, 510640, PR China
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15
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Bithi N, Merrigan SD, McMillin GA. Does Labetalol Trigger False Positive Drug Testing Results? J Addict Med 2022:01271255-990000000-00117. [PMID: 36645208 DOI: 10.1097/adm.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Labetalol, an α- and β-adrenergic antagonist used to treat hypertension in pregnancy has been blamed for causing false-positive amphetamine and methamphetamine results. In this study, we tested 3 concentrations of labetalol prepared with 4 specimen types (urine, plasma, meconium, and umbilical cord tissue), for amphetamine, methamphetamine, and several other drugs with screen and confirmation tests. METHODS Residual drug-free specimens were pooled. Labetalol hydrochloride dissolved in methanol was used to prepare spikes in triplicate per specimen type (2.7, 50, and 100 μM), which were tested with 41 previously validated drug tests performed by immunoassay or liquid chromatography tandem mass spectrometry (LC-MS/MS). RESULTS Labetalol triggered false-positive amphetamine and methamphetamine results by immunoassay in meconium but did not trigger positive results for any of the targeted drugs or drug metabolites tested by LC-MS/MS. No positive results were generated by any immunoassay or LC-MS/MS test included in the study, when challenged with high concentrations of labetalol in urine, plasma, or umbilical cord tissue. CONCLUSIONS In summary, false-positive results can be generated by labetalol when tested by immunoassay, but false-positive results are not expected when testing is performed by highly specific analytical approaches such as LC-MS/MS.
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Affiliation(s)
- Nazmin Bithi
- From the Department of Pathology, University of Utah, Salt Lake City, UT (NB, GAM); ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT (SDM, GAM)
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16
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Jones MJ, Lotfi A, Lin A, Gievers LL, Hendrickson R, Sheridan DC. Prenatal marijuana exposure and neonatal outcomes: a retrospective cohort study. BMJ Open 2022; 12:e061167. [PMID: 36171027 PMCID: PMC9528601 DOI: 10.1136/bmjopen-2022-061167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Previous literature on the effects of marijuana exposure on neonatal outcomes has been limited by the reliance on maternal self-report. The objective of this study was to examine the relationship of prenatal marijuana exposure on neonatal outcomes in infants with marijuana exposure confirmed with meconium drug testing. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Meconium drug screens obtained on infants born in a hospital system in the Pacific Northwest in the USA over a 2.5-year period. 1804 meconium drug screens were initially obtained, with 1540 drug screens included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES Neonates with meconium drug screens positive for delta-9-tetrahydrocannabinol (THC) only were compared with neonates with negative drug screens. The following neonatal outcomes were examined: gestational age, preterm birth (<37 weeks), birth weight, low birth weight (defined as birth weight <2.5 kg), length, head circumference, Apgar scores and admission to the neonatal intensive care unit (NICU). Using multivariable logistical and linear regression, we controlled for confounding variables. RESULTS 1540 meconium drug screens were included in the analysis, with 483 positive for delta-9-THC only. Neonates exposed to delta-9-THC had significantly lower birth weight, head circumference and length (p<0.001). Neonates with THC exposure had 1.9 times the odds (95% CI 1.3 to 2.7, p=0.001) of being defined as low birth weight. Birth weight was on average 0.16 kg lower (95% CI 0.10 to 0.22, p<0.001) in those exposed to THC. CONCLUSIONS Prenatal marijuana exposure was significantly associated with decreases in birth weight, length and head circumference, and an increased risk of being defined as low birth weight. These findings add to the previous literature demonstrating possible negative effects of prenatal marijuana use on neonatal outcomes.
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Affiliation(s)
- Michael James Jones
- Department of Pediatrics, Sacred Heart Medical Center at RiverBend, Springfield, Oregon, USA
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Asma Lotfi
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Amber Lin
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ladawna L Gievers
- Department of Pediatrics, Division of Neonatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Hendrickson
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
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17
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Smid MC, Allshouse AA, McMillin GA, Nunez K, Cavin T, Worden J, Buchi K, Muniyappa B, Varner MW, Cochran G, Metz TD. Umbilical Cord Collection and Drug Testing to Estimate Prenatal Substance Exposure in Utah. Obstet Gynecol 2022; 140:153-162. [PMID: 35852263 PMCID: PMC9373719 DOI: 10.1097/aog.0000000000004868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our primary objective was to estimate statewide prenatal substance exposure based on umbilical cord sampling. Our secondary objectives were to compare prevalence of prenatal substance exposure across urban, rural, and frontier regions, and to compare contemporary findings to those previously reported. METHODS We performed a cross-sectional prevalence study of prenatal substance exposure, as determined by umbilical cord positivity for 49 drugs and drug metabolites, through the use of qualitative liquid chromatography-tandem mass spectrometry. All labor and delivery units in Utah (N=45) were invited to participate. Based on a 2010 study using similar methodology, we calculated that a sample size of at least 1,600 cords would have 90% power to detect 33% higher rate of umbilical cords testing positive for any substance. Deidentified umbilical cords were collected from consecutive deliveries at participating hospitals. Prevalence of prenatal substance exposure was estimated statewide and by rurality using weighted analysis. RESULTS From November 2020 to November 2021, 1,748 cords (urban n=988, rural n=384, frontier n=376) were collected from 37 hospitals, representing 92% of hospitals that conduct 91% of births in the state. More than 99% of cords (n=1,739) yielded results. Statewide, 9.9% (95% CI 8.1-11.7%) were positive for at least one substance, most commonly opioids (7.0%, 95% CI 5.5-8.5%), followed by cannabinoid (11-nor-9-carboxy-delta-9-tetrahydrocannabinol [THC-COOH]) (2.5%, 95% CI 1.6-3.4%), amphetamines (0.9%, 95% CI 0.4-1.5), benzodiazepines (0.5%, 95% CI 0.1-0.9%), alcohol (0.4%, 95% CI 0.1-0.7%), and cocaine (0.1%, 95% CI 0-0.3%). Cord positivity was similar by rurality (urban=10.3%, 95% CI 8.3-12.3%, rural=7.1%, 95% CI 3.5-10.7%, frontier=9.2%, 95% CI 6.2-12.2%, P=.31) and did not differ by substance type. Compared with a previous study, prenatal exposure to any substance (6.8 vs 9.9%, P=.01), opioids (4.7 vs 7.0% vs 4.7%, P=.03), amphetamines (0.1 vs 0.9%, P=.01) and THC-COOH (0.5 vs 2.5%, P<.001) increased. CONCLUSION Prenatal substance exposure was detected in nearly 1 in 10 births statewide.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, the Department of Pathology, and the Department of Pediatrics, University of Utah Health, the Division of Maternal Fetal Medicine, Women and Newborns Clinical Program, Intermountain Healthcare, the Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, and ARUP Laboratories, Salt Lake City, Utah
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18
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Pandya V, Wilker C, McMillin GA. Can Umbilical Cord and Meconium Results Be Directly Compared? Analytical Approach Matters. J Anal Toxicol 2022; 47:96-105. [PMID: 35707888 PMCID: PMC9942436 DOI: 10.1093/jat/bkac037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 12/26/2022] Open
Abstract
Maternal drug use during pregnancy is a significant concern. Drug-exposed newborns are often born premature and may suffer from birth defects, neonatal abstinence syndrome and cognitive and developmental delays. Because of this, testing of neonatal specimens is carried out to assess fetal drug exposure during pregnancy. Umbilical cord tissue (UC) and meconium are commonly used specimens for this purpose. However, comprehensive studies comparing drug positivity rates and concentration in the two specimen types are lacking. To this end, 4,036 paired UC and meconium specimens originating from 13 states within the USA were identified, and retrospective analysis of drug positivity rates and drug concentration was performed for 31 analytes in 5 drug classes. Testing for 11-Nor-9-carboxy-tetrahydrocannabinol (THC-COOH) is a separate orderable for UC specimen at our laboratory, so a second data set was created for evaluation of this drug analyte with 2,112 paired UC and meconium specimens originating from 11 states. Testing of UC was performed by semi-quantitative liquid chromatography-tandem mass spectrometry (LC-MS-MS) assays, whereas, for meconium, an immunoassay-based screening preceded LC-MS-MS confirmation tests. Results generated for UC and meconium specimens were therefore compared for a total of 32 drug analytes from 6 drug classes. Drug concentrations for analytes were higher in meconium compared to UC, with the exception of phencyclidine. Despite this, the positivity rates for individual analytes were higher in UC, with the exception of THC-COOH and cocaine. Furthermore, analysis for multidrug positivity revealed that THC-COOH and opioids were the most common multidrug combination detected in both matrices. In conclusion, this study suggests that for most drug compounds, UC was more analytically sensitive to assess neonatal drug exposure by current methodologies. Additionally, by demonstrating that meconium has higher drug concentrations for most compounds, this study sets the stage for developing more sensitive assays in meconium.
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Affiliation(s)
- Vrajesh Pandya
- Department of Pathology, University of Utah Health, Salt Lake City, UT 84112, USA,ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Chase Wilker
- ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA,ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
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19
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Alternative matrices in forensic toxicology: a critical review. Forensic Toxicol 2021; 40:1-18. [DOI: 10.1007/s11419-021-00596-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/19/2021] [Indexed: 12/12/2022]
Abstract
Abstract
Purpose
The use of alternative matrices in toxicological analyses has been on the rise in clinical and forensic settings. Specimens alternative to blood and urine are useful in providing additional information regarding drug exposure and analytical benefits. The goal of this paper is to present a critical review on the most recent literature regarding the application of six common alternative matrices, i.e., oral fluid, hair, sweat, meconium, breast milk and vitreous humor in forensic toxicology.
Methods
The recent literature have been searched and reviewed for the characteristics, advantages and limitations of oral fluid, hair, sweat, meconium, breast milk and vitreous humor and its applications in the analysis of traditional drugs of abuse and novel psychoactive substances (NPS).
Results
This paper outlines the properties of six biological matrices that have been used in forensic analyses, as alternatives to whole blood and urine specimens. Each of this matrix has benefits in regards to sampling, extraction, detection window, typical drug levels and other aspects. However, theses matrices have also limitations such as limited incorporation of drugs (according to physical–chemical properties), impossibility to correlate the concentrations for effects, low levels of xenobiotics and ultimately the need for more sensitive analysis. For more traditional drugs of abuse (e.g., cocaine and amphetamines), there are already data available on the detection in alternative matrices. However, data on the determination of emerging drugs such as the NPS in alternative biological matrices are more limited.
Conclusions
Alternative biological fluids are important specimens in forensic toxicology. These matrices have been increasingly reported over the years, and this dynamic will probably continue in the future, especially considering their inherent advantages and the possibility to be used when blood or urine are unavailable. However, one should be aware that these matrices have limitations and particular properties, and the findings obtained from the analysis of these specimens may vary according to the type of matrix. As a potential perspective in forensic toxicology, the topic of alternative matrices will be continuously explored, especially emphasizing NPS.
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20
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Nelson HA, Wood KE, McMillin GA, Krasowski MD. Umbilical Cord Drug Screening in Multiple Births: Experience from a Reference Laboratory and Academic Medical Center. J Anal Toxicol 2021; 46:611-618. [PMID: 34165142 DOI: 10.1093/jat/bkab077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to review the results of umbilical cord drug screening in twins and triplets (multiples) to compare drug(s) and/or drug metabolite(s) detected. Results that did not agree between multiples were considered mismatched and were investigated. A retrospective analysis was conducted using de-identified data from a national reference laboratory, and results were compared with data from an academic medical center, where detailed medical chart review was performed. Umbilical cord was analyzed for stimulants, sedatives, opioids, and other drugs and metabolites. For the reference laboratory dataset, 23.3% (n=844) of 3,616 umbilical cords from twins (n=3,550) or triplets (n=66) were positive for one or more drugs and/or metabolites. Of these, mismatched results were identified for thirty-seven sets of twins (2.1%) and no sets of triplets. The most frequent mismatches were found in opioids (n=24), with morphine (n=5) being the most mismatched of any single analyte in the panel. Mismatches for the marijuana metabolite 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (9-COOH-THC) in the reference laboratory dataset occurred in six of 737 sets of twins (0.8%) and no triplets. For the academic medical center dataset, 21.9% (n=57) of 260 umbilical cords tested positive for one or more drugs and/or metabolite(s). Of these, 4 mismatches (3.2%) were identified, including 9-COOH-THC (n=2), phentermine (n=1), and oxycodone (n=1), all involving twins. All involved cases where the discrepant analyte was likely present in the negative twin but either slightly below reporting cutoff threshold, or failed analytical quality criteria. Mismatched results of umbilical cord drug screening occur in less than 4% of twins and most often occur when the analyte is slightly above the reporting cutoff in just one infant.
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Affiliation(s)
- Heather A Nelson
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - Kelly E Wood
- Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, 52242, USA
| | - Gwendolyn A McMillin
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA.,ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
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21
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Gesseck AM, Nanco CR, Hendricks-Muñoz KD, Xu J, Wolf CE, Poklis JL, Peace MR. Neonatal Exposure to Tramadol through Mother's Breast Milk. J Anal Toxicol 2021; 45:840-846. [PMID: 34037761 DOI: 10.1093/jat/bkab055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 12/27/2022] Open
Abstract
Tramadol is an opioid used in the treatment of moderate to moderately severe pain. Tramadol's use during pregnancy is generally avoided and may cause some reversible withdrawal effects in neonates and its use during lactation is not licensed by the manufacturer. A small clinical trial reported infants were exposed to < 3% of a mother's tramadol dose though breast milk with no evidence of harmful effects. Presented is a case study of breast milk, neonatal urine, and neonatal oral fluid for the analysis of tramadol and its metabolites, along with the validation of a method for the analysis of tramadol, O-desmethyltramadol, and N-desmethyltramadol in breast milk. Tramadol and its metabolites were extracted by solid-phase extraction (SPE) after saponification of breast milk to remove lipids. Samples were analyzed by ultra-pressure liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). To the author's knowledge, this is the first report of tramadol and its metabolites in neonatal oral fluid. The breast milk concentrations were 63, 22, and 76 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively on day of life 12. On day of life 20, the breast milk concentrations were 1,254, 388, and 937 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively. Oral fluid concentrations were 1,011, 1,499, and 406 ng/mL tramadol, O-desmethyltramadol and N-desmethyltramadol, respectively on day of life 20. Oral fluid concentrations were similar to breast milk for tramadol, almost four times higher for O-desmethyltramadol, and less than half for N-desmethyltramadol. The absolute infant dose was calculated to be 10 μg/kg/day and 294 μg/kg/day tramadol on day of life 12 and 20, respectively.
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Affiliation(s)
- Ashley M Gesseck
- Integrative Life Sciences Doctoral Program, Virginia Commonwealth University, Richmond, VA.,Departments of Forensic Science, Virginia Commonwealth University, Richmond, VA
| | - Carrol R Nanco
- Departments of Pathology, Virginia Commonwealth University, Richmond, VA
| | - Karen D Hendricks-Muñoz
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Jie Xu
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Carl E Wolf
- Departments of Pathology, Virginia Commonwealth University, Richmond, VA
| | - Justin L Poklis
- Departments of Pharmacology & Toxicology, Virginia Commonwealth University, Richmond, VA
| | - Michelle R Peace
- Departments of Forensic Science, Virginia Commonwealth University, Richmond, VA
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Okoye NC, McMillin GA. Patterns of Neonatal Co-Exposure to Gabapentin and Commonly Abused Drugs Observed in Umbilical Cord Tissue. J Anal Toxicol 2021; 45:506-512. [PMID: 32860706 DOI: 10.1093/jat/bkaa118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/18/2020] [Accepted: 08/25/2020] [Indexed: 01/10/2023] Open
Abstract
Gabapentin was thought to have low abuse potential, but it is increasingly being abused by people with substance use disorder in an attempt to potentiate the euphoric effects from opioids and other CNS depressants. Additionally, infants co-exposed to gabapentin and opioids during pregnancy tend to exhibit prolonged and more severe neonatal abstinence syndrome. In this study, we describe positivity rates among commonly abused drugs and rates of co-medication with gabapentin in a large dataset of umbilical cord tissue specimens (n = 25,422) submitted for routine newborn drug testing at a national clinical reference laboratory (ARUP Laboratories, Salt Lake City, UT, USA). Detection of prenatal drug exposure in umbilical cord tissue specimens was accomplished using a semi-quantitative liquid chromatography-tandem mass spectrometry assay designed to detect 47 specific drugs and drug metabolites including opioids, stimulants, sedative-hypnotics and hallucinogens. A positive result for at least one of the measured drugs or drug metabolites was reported in 7,054 (28%) of the umbilical cord tissues analyzed. Gabapentin had a positivity rate of ~2% with 562 positive results. Of the 562 gabapentin-positive samples, 395 (70%) also had a positive result for at least one other drug or drug metabolite, with the highest co-positivity rate observed for norbuprenorphine (32%, n = 182) followed by amphetamine (15%, n = 84), buprenorphine (13%, n = 74), methamphetamine (12%, n = 68), morphine (11%, n = 64), fentanyl (10%, n = 54) and naloxone (10%, n = 54). Notably, the concentration of gabapentin in gabapentin-positive umbilical cord specimens was higher in buprenorphine-containing specimens as compared to specimens containing other opioids, stimulants or benzodiazepines. Identification of neonatal co-exposure to gabapentin and opioids, particularly buprenorphine, may guide clinicians in rapid initiation of monitoring and intervention for neonatal abstinence syndrome.
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Affiliation(s)
- Nkemakonam C Okoye
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gwendolyn A McMillin
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA.,ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah, USA
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Drug Exposure in Newborns: Effect of Selected Drugs Prescribed to Mothers During Pregnancy and Lactation. Ther Drug Monit 2021; 42:255-263. [PMID: 32068668 DOI: 10.1097/ftd.0000000000000747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The number of newborns exposed to therapeutic drugs during pregnancy is growing because of the increased use of drugs during pregnancy. In recent years, advances in our understanding of drug placental transfer have augmented the likelihood of a healthy baby in mothers with chronic diseases needing drug therapy. Globally, for example, more than 1.4 million pregnancies in 2015 have been burdened with antiretroviral drugs due to an increasing number of HIV-positive women treated with these drugs, particularly in low- and middle-income countries. In most cases, the fetus is exposed to much higher drug doses in utero than the newborn nursed by the mother. Drug transfer through the placenta takes place by passive diffusion, active transport, or facilitated transport, and drug concentrations in the fetal circulation may be comparable to that in the mother's blood concentration. The excretion of drugs into breastmilk predominantly occurs by passive diffusion, allowing only the non-protein-bound fraction of the blood drug concentration to penetrate. Drug agencies in the United States and Europe highly recommend performing clinical trials in pregnant or breastfeeding women. However, only a few drugs have reported statistically sound data in these patient groups. Most available results concerning pregnancy are obtained from observational studies after birth, assessing outcomes in the newborn or by measuring drug concentrations in the mother and umbilical cord blood. In the case of the lactation period, some studies have evaluated drug concentrations in breastmilk and blood of the mother and/or infant. In this review, exposure to antiretrovirals, immunosuppressants used after solid organ transplantation, and antiepileptics during pregnancy and lactation has been discussed in detail.
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Mark K, Pace L, Temkin SM, Crimmins S, Terplan M. Concordance and discordance between maternal and newborn drug test results. Am J Obstet Gynecol MFM 2021; 3:100366. [PMID: 33831588 DOI: 10.1016/j.ajogmf.2021.100366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal. OBJECTIVE This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery. STUDY DESIGN This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared. RESULTS Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other. CONCLUSION There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.
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Affiliation(s)
- Katrina Mark
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins).
| | - Lauren Pace
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | | | - Sarah Crimmins
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | - Mishka Terplan
- Friend Social Research Institute, Baltimore, MD (Dr Terplan)
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25
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Abstract
BACKGROUND/SIGNIFICANCE Intrauterine opioid drug exposure is associated with an increased risk of preterm birth. Preterm infants may not exhibit the same withdrawal symptoms as term infants diagnosed with neonatal abstinence syndrome (NAS). There are no current standards for how to screen, assess, or treat NAS in preterm infants. PURPOSE This study explored the current state of practice for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids. METHODS This was a descriptive cross-sectional study of NAS practice in preterm infants born at less than 34 weeks of gestational age in neonatal intensive care units (NICUs) in the United States and Canada. The study was conducted May through September 2018. All respondents cared for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine drugs. RESULTS There were 70 respondents representing 67 hospitals in the United States and 1 in Canada. Level III NICUs represented 69% of respondents. Ninety-three percent reported neonatal triggers for further evaluation. Review of maternal history and maternal urine testing was the most consistent practice across NICUs. A modified Finnegan scoring tool was used for both preterm and term infants. Morphine was reported as the most common first-line drug used for treatment. IMPLICATIONS FOR PRACTICE Great variability in NAS practice for preterm infants born at less than 34 weeks of gestational age across the multiple NICUs supports the need for a validated preterm infant assessment tool and development of appropriate treatment strategies. IMPLICATIONS FOR RESEARCH Future research describing the NAS symptomatology of preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids is warranted.
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McMillin GA, Johnson-Davis KL, Kelly BN, Scott B, Yang YK. Impact of the Opioid Epidemic on Drug Testing. Ther Drug Monit 2021; 43:14-24. [PMID: 33230043 DOI: 10.1097/ftd.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a description of how the opioid epidemic has impacted drug testing. METHODS Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.
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Affiliation(s)
| | | | - Brian N Kelly
- Department of Pathology, University of Utah and ARUP Laboratories; and
| | | | - Yifei K Yang
- Department of Pathology, University of Utah and ARUP Laboratories; and
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27
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Advances in drugs of abuse testing. Clin Chim Acta 2020; 514:40-47. [PMID: 33333045 DOI: 10.1016/j.cca.2020.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/06/2020] [Accepted: 12/07/2020] [Indexed: 01/04/2023]
Abstract
Drugs of abuse testing is widely used clinically and forensically. Urine is the preferred type of specimen for drugs of abuse screening, but saliva, sweat, hair, and meconium are emerging types of specimens. GC-MS has been used as a gold standard for confirmatory drug testing, but LC-tandem-MS can analyze more diverse types of analytes than GC-MS. Thus, LC-tandem-MS becomes a new gold standard for confirmatory drug testing. Unlike GC-MS, LC-tandem-MS is not suited for non-targeted comprehensive drug screening. But with the advent of high-resolution-MS such as Tof-MS, which can discriminate the compounds of similar molecular masses but with different formulas, LC-hybrid-Tof-MS is usable for non-targeted comprehensive drug screening. Another technical advancement is the advent of miniature ambient ionization MS, which can analyze biological specimens including urine within one minute. Thus these mass spectrometers are promising for rapid drugs of abuse testing in a POC setting.
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Abstract
The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.
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Affiliation(s)
- Stephen W Patrick
- Division of Neonatology, Department of Pediatrics and Health Policy, School of Medicine, Vanderbilt University and Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Wanda D Barfield
- Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Brenda B Poindexter
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Medical Hospital Center, Cincinnati, Ohio
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Gesseck AM, Poklis JL, Wolf CE, Xu J, Bashir A, Hendricks-Muñoz KD, Peace MR. A Case Study Evaluating the Efficacy of an Ad Hoc Hospital Collection Device for Fentanyl in Infant Oral Fluid. J Anal Toxicol 2020; 44:741-746. [PMID: 32591773 PMCID: PMC7549304 DOI: 10.1093/jat/bkaa069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/17/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022] Open
Abstract
Neonatal drug exposure is currently assessed using meconium, urine, blood, hair, or umbilical cord tissue/blood. Due to the invasiveness, challenges, and limitations of collection, and/or analytical difficulties of these matrices, oral fluid may be a more desirable matrix in diagnosing opioid exposure and risk for opioid withdrawal in neonatal abstinence syndrome. Traditional oral fluid collection devices are not viable options as they are too large for neonates' mouths and may contain chemicals on the collection pad. Unstimulated and stimulated infant oral fluid samples have been used for therapeutic drug monitoring as an alternative matrix to blood. The objective of this study was to assess the viability of a simple oral fluid collection system using a sterile foam-tipped swab rinsed in phosphate-buffered saline. Two infants were administered fentanyl for post-operative pain relief while hospitalized in the Neonatal Intensive Care Units at the Children's Hospital of Richmond of Virginia Commonwealth University. Oral fluid samples were collected at 16 h, 2 days, and/or 7 days following the start of intravenous infusion of fentanyl. Samples were analyzed by ultra-high-pressure liquid chromatography-tandem mass spectrometry for fentanyl and norfentanyl after solid-phase extraction. In one of the three samples tested, fentanyl and norfentanyl were detected at concentrations of 28 and 78 ng/mL, respectively. Based on the infusion rate, the theoretical oral fluid fentanyl concentration at steady state was calculated to be 33 ng/mL.
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Affiliation(s)
- Ashley M Gesseck
- Integrative Life Sciences Doctoral Program, Virginia Commonwealth University, PO Box 84230, Richmond, VA 23284-0203, USA
- Department of Forensic Science, Virginia Commonwealth University, PO Box 843079, Richmond, VA 23284-3079, USA
| | - Justin L Poklis
- Department of Pharmacology & Toxicology, Virginia Commonwealth University, PO Box 980613, Richmond, VA 23298-0613, USA
| | - Carl E Wolf
- Department of Forensic Science, Virginia Commonwealth University, PO Box 843079, Richmond, VA 23284-3079, USA
- Department of Pathology, Virginia Commonwealth University, PO Box 980662, Richmond, VA 23298-0662, USA
| | - Jie Xu
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine, PO Box 980646, Richmond, VA 23298-0646, USA
| | - Aamir Bashir
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine, PO Box 980646, Richmond, VA 23298-0646, USA
| | - Karen D Hendricks-Muñoz
- Division of Neonatal Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Virginia Commonwealth University School of Medicine, PO Box 980646, Richmond, VA 23298-0646, USA
| | - Michelle R Peace
- Department of Forensic Science, Virginia Commonwealth University, PO Box 843079, Richmond, VA 23284-3079, USA
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30
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Puthenpura V, Gueye-Ndiaye S, Joshi S, Puvabanditsin S, Carayannopoulos MO. Social and legal implications of urine drug screen analysis in the neonate: A case of suspected specimen mishandling. Clin Chim Acta 2020; 511:104-106. [PMID: 33002470 DOI: 10.1016/j.cca.2020.09.032] [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: 10/25/2019] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The legal implications associated with illicit drug use during pregnancy are significant, as providers are required to notify child protective services when a drug-exposed infant is identified. CASE REPORT The case presented involves possible specimen mishandling in two infants at risk for in utero drug exposure and describes alternative methodologies available to confirm specimen identity. CONCLUSIONS It is critical that institutions establish and adhere to stringent procedures when screening newborns.
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Affiliation(s)
- Vidya Puthenpura
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Seyni Gueye-Ndiaye
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Sonali Joshi
- Robert Wood Johnson University Hospital, New Brunswick, NJ, United States
| | - Surasak Puvabanditsin
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Mary O Carayannopoulos
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.
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31
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Jussila H, Pajulo M, Ekholm E. A Novel 4D Ultrasound Parenting Intervention for Substance Using Pregnant Women in Finland: Participation in Obstetric Care, Fetal Drug Exposure, and Perinatal Outcomes in a Randomized Controlled Trial. Matern Child Health J 2020; 24:90-100. [PMID: 31250239 PMCID: PMC6957471 DOI: 10.1007/s10995-019-02773-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives The aim of the study was to explore the effect of a new prenatal intervention on participation in obstetric care, fetal drug exposure, and perinatal outcomes among substance using pregnant women in Finland. Methods The participants were 90 women referred to a hospital obstetric outpatient clinic due to current or recent substance use. The intervention group (n = 46) was offered three interactive ultrasounds at 24, 30 and 34 gestational weeks and a pregnancy diary accompanied by three prenatal infant mental health consultations. The intervention elements were designed to enhance parental mentalization and prenatal attachment. A randomized control group (n = 44) design was used. All participants were offered treatment-as-usual in the obstetric tertiary setting. Medical record data and meconium toxicology were analyzed. Results The retention rate in the whole sample was 89%. Retention was higher in the intervention group (96% vs. 82%, p < 0.05), of which 74% attended all three ultrasound sessions. However, the pregnant women in the intervention group participated less often in all the scheduled obstetric standard care visits (59% vs. 83%, p = 0.02). Fetal drug exposure and perinatal outcomes were similar in both groups. Within the whole sample, 13% of the neonates were preterm, 12% small for gestational age and 7% had exposure to drugs. Conclusions for Practice Retention in the intervention was very good. Watching the fetus with parenting focus seemed to motivate these high-risk women. Interestingly, the pregnant women in the intervention group tended to prefer the intervention sessions to the routine care. Clinical implications of this finding are discussed. Trial Registry The trial registration number in ClinicalTrials.gov: NCT03413631.
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Affiliation(s)
- Heidi Jussila
- Doctoral Programme of Clinical Investigation, Department of Child Psychiatry, University of Turku, 20014 Turku, Finland
- Department of Child Psychiatry, Turku University Hospital, Kiinamyllynkatu 4-8, PL 52, 20521 Turku, Finland
| | - Marjukka Pajulo
- Department of Child Psychiatry and The FinnBrain, University of Turku, 20014 Turku, Finland
| | - Eeva Ekholm
- Department of Obstetrics and Gynecology, Turku University Hospital, Kiinamyllynkatu 4-8, PL 52, 20521 Turku, Finland
- Department of Obstetrics and Gynecology, University of Turku, 20014 Turku, Finland
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32
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Screening for Opioid and Stimulant Exposure In Utero Through Targeted and Untargeted Metabolomics Analysis of Umbilical Cords. Ther Drug Monit 2020; 42:787-794. [PMID: 32142018 DOI: 10.1097/ftd.0000000000000753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome is an array of signs and symptoms experienced by a newborn due to abrupt discontinuation of intrauterine exposure to certain drugs, primarily opioids. In the United States, the incidence of neonatal abstinence syndrome has tripled over the past decade. The current standard of care for drug testing includes the analysis of infant urine and meconium. Sample collection is associated with several limitations, including diaper media interferences, limited sample amount, sample heterogeneity, and the need for professional staff for collection. Umbilical cord tissue has emerged as a convenient sample matrix for testing owing to its universal availability. The purpose of this study was to examine umbilical cords using an untargeted metabolomics approach to determine the detected drugs and validate an analytical method to confirm and quantify the identified drugs. METHODS A metabolomics analysis was performed with 21 umbilical cords to screen for drugs and drug metabolites by liquid chromatography-mass spectrometry. Drugs were identified using the National Institute of Standards and Technology database, and an analytical method was developed and validated using secondary liquid chromatography-mass spectrometry instrument for positive confirmation and quantitative analysis. RESULTS Twenty-one random umbilical cords from women were tested: 4 were positive for cocaine and the primary and secondary metabolites; one was positive for methadone, the primary metabolite; 3 were positive for cotinine, the metabolite of nicotine; and 5 were positive for acetyl norfentanyl. CONCLUSIONS Our research is a prospective method development study using untargeted and targeted approaches to characterize steady-state drug metabolite levels in the umbilical cord matrix at the time of delivery. By characterizing drug type and concentration, this methodology can be used to develop a reliable complementary testing method for meconium toxicology screens.
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Price HR, Chehroudi C, Knight SJ, Smith AD, Lai D, Kim H, Wright TE, Coughtrie MW, Collier AC. Umbilical cord as an analytical matrix - A technical note. Placenta 2019; 90:42-44. [PMID: 32056550 DOI: 10.1016/j.placenta.2019.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 01/19/2023]
Abstract
The umbilical cord (UC) connects the fetal blood supply to the placenta, so is exposed to all systemic endo- and xenobiotics. We have extensive experience using UC as an analytical matrix for detecting and/or quantitating drugs, chemicals and endogenous compounds. This technical note describes advantages (large amount available, ease of collection, small sample needed for use, rapid availability) and challenges (clinical relationships, processing difficulties, matrix effects on analytes and detection technologies) of UC as an analytical matrix in ELISA and LC/MS platforms, and provides guidance for successfully working with this tissue.
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Affiliation(s)
- Hayley R Price
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Camron Chehroudi
- Centre for Blood Research, 2350 Health Sciences Mall, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada; Faculty of Dentistry, 2199 Wesbrook Mall, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada; Department of Biochemistry and Molecular Biology, 2350 Health Sciences Mall, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Stuart J Knight
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Alexander D Smith
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Dickson Lai
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Hugh Kim
- Centre for Blood Research, 2350 Health Sciences Mall, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada; Faculty of Dentistry, 2199 Wesbrook Mall, The University of British Columbia, Vancouver, BC, V6T 1Z3, Canada; Department of Biochemistry and Molecular Biology, 2350 Health Sciences Mall, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Tricia E Wright
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, 94115, USA
| | - Michael Wh Coughtrie
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Abby C Collier
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
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34
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Jensen TL, Wu F, McMillin GA. Detection of in utero Exposure to Cannabis in Paired Umbilical Cord Tissue and Meconium by Liquid Chromatography-Tandem Mass Spectrometry. CLINICAL MASS SPECTROMETRY 2019; 14 Pt B:115-123. [DOI: 10.1016/j.clinms.2019.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
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Wood KE, McMillin GA, Krasowski MD. Risk-Based Newborn Drug Testing in a Setting With a Low Prevalence of Maternal Drug Use. Hosp Pediatr 2019; 9:593-600. [PMID: 31278167 DOI: 10.1542/hpeds.2018-0256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Our objective in this study was to determine the predictive value of an institutional risk-based newborn drug-testing tool for detecting maternal drug use during pregnancy. METHODS For 5.5 months, the umbilical cords of all newborns born at the study institution were collected and analyzed at a national reference laboratory. In the context of usual clinical care, the decision to perform newborn drug testing is based on an institutional risk assessment tool. For the cohort without clinical indication for testing, cords were deidentified during the study period. Chart review was not performed. Study data were compared with a national data set during the same time period and to previous institutional data. RESULTS We tested 857 newborns, 257 of which had 1 or more identified risk factors. There were no drugs or drug metabolites that were significantly more common in the cohort without risk factors than in the clinical cohort. Alprazolam, methamphetamine, hydrocodone, and oxycodone were all significantly more commonly found in the risk-identified cohort. Amphetamine, methamphetamine, and cocaine were not detected in umbilical cords from any of the 600 newborns that would not have been identified for testing. Tetrahydrocannabinol (1.0%; n = 6) was the only illegal substance in the institution's state that would not have been detected. CONCLUSIONS Performing universal newborn drug testing in the study population would have identified an additional 6 newborns who were exposed prenatally to tetrahydrocannabinol out of 600 who were additionally tested. In areas with a low prevalence of maternal drug use, universal testing may not be cost-effective.
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Affiliation(s)
- Kelly E Wood
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa;
| | - Gwendolyn A McMillin
- Department of Pathology, University of Utah School of Medicine, ARUP Laboratories, Salt Lake City, Utah; and
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36
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Negrusz A, Jones J. Testing umbilical cord tissue for drugs: Lower analytical limits, better concordance with meconium results. J Pediatr 2019; 209:258-259. [PMID: 30723018 DOI: 10.1016/j.jpeds.2019.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Adam Negrusz
- United States Drug Testing Laboratories, Inc, Des Plaines, Illinois
| | - Joseph Jones
- United States Drug Testing Laboratories, Inc, Des Plaines, Illinois
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37
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Guimarães MF, Rabelo FA, Figueiredo I. Knowledge about Neonatal Screening among Postpartum Women and Complexity Level of Birthing Facilities. Int J Neonatal Screen 2019; 5:8. [PMID: 33072968 PMCID: PMC7510197 DOI: 10.3390/ijns5010008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/20/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To ascertain the degree of knowledge of postpartum women about important aspects related to the neonatal screening process and whether differences of opinion exist between those who deliver in low-complexity versus high-complexity health facilities (low-risk versus high-risk pregnancies, respectively). METHODS This was a prospective, cross-sectional, questionnaire-based study. The sample consisted of postpartum women recruited from 2013 to 2015 at public maternity hospitals in the city of Niterói, Brazil. Participants were divided into two groups and completed a questionnaire consisting of Likert-scored items. Continuous variables were analyzed with the Mann-Whitney test, and categorical variables, with Fisher's test. A confirmatory factor analysis of participants' answers was performed. RESULTS Of 188 women enrolled, 54 (28.7%) had incomplete elementary education; 119 (62.2%) had attended more than six antenatal care visits. The mean age was 25.57 years. Nearly all women (n = 179, 95.2%) were roomed-in with their infants. Knowledge of neonatal screening was very similar in the high-complexity and low-complexity groups. Divergences were limited to items regarding the risks of neonatal screening. CONCLUSIONS The degree of knowledge among postpartum women was similar among high- and low-complexity facilities. Those who attended high-complexity facilities had longer hospital stays and greater adherence to ethical issues regarding neonatal screening.
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Affiliation(s)
- Mariana F. Guimarães
- Departamento Materno-Infantil, Faculdade de Medicina, Hospital Universitário Antonio Pedro, Universidade Federal Fluminense, Niterói 24033-900, Brasil
| | | | - Israel Figueiredo
- Departamento Materno-Infantil, Faculdade de Medicina, Hospital Universitário Antonio Pedro, Universidade Federal Fluminense, Niterói 24033-900, Brasil
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Colby JM, Adams B, Morad A, Presley L, Patrick SW. Umbilical Cord Tissue and Meconium May Not Be Equivalent for Confirming in Utero Substance Exposure. J Pediatr 2019; 205:277-280. [PMID: 30342870 PMCID: PMC6348119 DOI: 10.1016/j.jpeds.2018.09.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/22/2018] [Accepted: 09/14/2018] [Indexed: 12/14/2022]
Abstract
In a retrospective study of 501 neonates with potential in utero substance exposure, the drug detection performance of a commercially available umbilical cord tissue toxicology test was evaluated against a commercially available gold standard meconium toxicology test. Drugs detected in paired meconium and umbilical cord tissue samples were often discordant.
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Affiliation(s)
- Jennifer M. Colby
- Departments of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Brad Adams
- Enterprise Analytics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna Morad
- Departments of Pediatrics, Vanderbilt University, Nashville, TN, USA
| | - Lauren Presley
- Departments of Pediatrics, Vanderbilt University, Nashville, TN, USA
| | - Stephen W. Patrick
- Departments of Pediatrics, Vanderbilt University, Nashville, TN, USA,Departments of Health Policy, Vanderbilt University, Nashville, TN, USA,Vanderbilt Center for Child Health Policy, Nashville, TN, USA
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39
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Price HR, Collier AC, Wright TE. Screening Pregnant Women and Their Neonates for Illicit Drug Use: Consideration of the Integrated Technical, Medical, Ethical, Legal, and Social Issues. Front Pharmacol 2018; 9:961. [PMID: 30210343 PMCID: PMC6120972 DOI: 10.3389/fphar.2018.00961] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/03/2018] [Indexed: 01/01/2023] Open
Abstract
North America is currently suffering from one of the worst epidemics of illicit drug use in recent history: the opioid crisis. Pregnant women are not immune to the ravages of substance misuse which affects themselves, their pregnancies, and the wider community. The prevalence of drug misuse in pregnancy is not well quantified due to the lack of good validated tests, cooperation between clinicians and scientists developing tests, and consensus as to who should be tested and how results should be used. A wide range of tissues can be tested for drug use, including maternal blood, urine, and hair; neonatal meconium, urine, and hair; and placenta and umbilical cord tissues. Testing methods range from simple spectrophotometry and clinical chemistry to sophisticated analytical HPLC or mass spectrometry techniques. The drive for ever greater accuracy and sensitivity must be balanced with the necessities of medical practice requiring minimally invasive sampling, rapid turnaround, and techniques that can be realistically utilized in a clinical laboratory. Better screening tests have great potential to improve neonatal and maternal medical outcomes by enhancing the speed and accuracy of diagnosis. They also have great promise for public health monitoring, policy development, and resource allocation. However, women can and have been arrested for positive drug screens with even preliminary results used to remove children from custody, before rigorous confirmatory testing is completed. Balancing the scientific, medical, public health, legal, and ethical aspects of screening tests for drugs in pregnancy is critical for helping to address this crisis at all levels.
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Affiliation(s)
- Hayley R Price
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Abby C Collier
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Tricia E Wright
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, United States.,Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, United States
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