Collection of biological samples in forensic toxicology

Use of innovative sample dryer for effective sample drying in forensic investigations: An experimental study

BACK GROUND

The sample collection and preservation before transportation to a Forensic Science Laboratory in a medicolegal case in India is a crucial step in establishing a link between accused, victim, crime scene and the weapon. This paper discusses pioneering advancement in health technology-a state-of-the-art sample dryer developed to preserve biological samples during Forensic investigations. This unique design has been officially registered with the design office in India as a copy right.

AIMS AND OBJECTIVES

The primary goal of the sample dryer is to augment the preservation of biological evidence by removing moisture content through air drying before packaging, sealing and its transportation to a Forensic Science Laboratory.

MATERIAL AND METHODS

The process of air drying of biological samples by variety of experiments conducted in sample's dryer designed for the purpose which employs a range of air movement techniques including horizontal, vertical, and circular laminar flows to swiftly extract moisture from the samples. The drying duration for each experimental sample was documented upon manual confirmation of complete drying.

RESULTS

The results were extraordinary, showcasing that the sample's dryer reduced the drying time drastically by up to 27 times lesser in comparison to conventional methods for identical samples. The diverse airflow patterns generated by the sample dryer unequivocally demonstrated it's utility in achieving superior sample preservation through efficient air drying.

CONCLUSION

Given the exceptional outcomes observed in the experimental phase, the authors strongly advocate for the widespread adoption of this innovative sample's dryer equipment to ensure effective air drying of biological samples and their efficient sample preservation to enable successful forensic analysis as expected.

"Not everything that can be counted counts" in ethanol toxicological results: an antemortem and postmortem technical interpretation focusing on driving under the influence

Ethanol blood analysis is the most common request in forensic toxicology, and some studies point to positive results in approximately one-third of all unnatural deaths. However, distinguishing sober deaths from drunk deaths is not as simple as it may seem. This technical, clinical, and forensic interpretation is proposed to interpret the ethanol toxicological results, discussing several artefacts and pitfalls that must be considered, namely focusing on driving under the influence. This work is presented with a practical and objective approach, aiming to alleviate the complexities associated with clinical, physiological, pathophysiological, and toxicological aspects to enhance comprehension, practicality, and applicability of its content, especially to courts. Particularly the physical integrity of the body, the postmortem interval, putrefactive signs, anatomic place of blood collection, alternative samples such as vitreous humour and urine, the possibility of postmortem redistribution, the inclusion of preservatives in containers, and optimal temperature conditions of shipment are among some of the aspects to pay attention. Although several biomarkers related to postmortem microbial ethanol production have been proposed, their translation into forensic routine is slow to be implemented due to the uncertainties of their application and analytical difficulties. Specifically, in the interpretation of ethanol toxicological results, "not everything that can be counted counts and not everything that counts can be counted" (attributed to Albert Einstein).

Towards an integrative approach to the biological profile

One of the most important tasks in forensic anthropology is the construction of the biological profile, classically defined as a set of four basic biological descriptors: biological sex, age-at-death, ancestry, and stature. Yet, our empirical and technological abilities in reconstructing the life experiences and health from skeletal remains far exceed these four parameters and forensic anthropology could benefit from further descriptors in the search for an identity. In this paper, we propose the inclusion of two other investigations to forensic anthropology practice to implement the already known biological profile: the interpretation of bone disease and lesions, and forensic toxicology on unconventional biological matrices. These analyses can provide information regarding health, habits, and disease burden, and by implementing them in our practice of forensic anthropology, they have the potential to improve the biological profile. We also propose a new term that can include not only the classical biological profile but also further descriptors, namely, the "biocultural profile".

Analytical methods and biomonitoring results in hair for the assessment of exposure to endocrine-disrupting chemicals: A literature review

Endocrine-disrupting chemicals (EDC) are compounds that alter functions of the endocrine system due to their ability to mimic or antagonize endogenous hormones, or that alter their synthesis and metabolism, causing adverse health effects. Human biomonitoring (HBM) is a reliable method to assess human exposure to chemicals through measurement in human body fluids and tissues. It identifies new sources of exposure and determines their distribution, thereby enabling detection of the most exposed populations. Blood and urine are commonly used for HBM of EDC, but their interest is limited for compounds presenting short half-lives. Hair appears as an interesting alternative insofar as it provides a large exposure window. For the present study, we evaluated the relevance of hair in determining EDC exposure. With this in mind, we undertook a literature review focusing on the bioanalytical aspects and performances of methods developed to determine EDC in hair. The literature review was performed through methodical bibliographical research. Relevant articles were identified using two scientific databases: PubMed and Web of Science, with search equations built from a combination of keywords, MeSH terms and Boolean operators. The search strategy identified 2949 articles. After duplicates were removed, and following title, abstract, and full-text screenings, only 31 were included for qualitative synthesis. Hair collection was mainly performed in the back of the head and preparation involved two processes: cutting into small pieces or grounding to powder. The off-line LC-MS/MS method remains the main technique used to assess EDC through hair. Differences regarding the validation of analytical methods and interpretation of HBM results were highlighted, suggesting a need for international harmonisation to obtain reliable and comparable results. External contamination of hair was identified as a main limitation in the interpretation of results, highlighting the need to better understand EDC transfers through hair and to develop relevant hair decontamination processes.

Applicability of a Chemiluminescence Immunoassay to Screen Postmortem Bile Specimens and Its Agreement with Confirmation Analysis

Bile has emerged as an alternative matrix for toxicological investigation of drugs in suspected forensic cases of overdose in adults and intoxications in children. Toxicological investigation consists in screening and, subsequently, confirming the result with specific techniques, such as liquid chromatography with tandem mass spectrometry (LC-MS/MS). As there is no screening test on the market to test postmortem bile specimens, the novelty of this study was in investigating the applicability of a chemiluminescence immunoassay, designed for other matrices and available on the market, on bile and validate its use, testing the agreement with LC-MS/MS analysis. Bile specimens were obtained from 25 forensic cases of suspected death from overdose and intoxication. Sample preparation for bile screening consists simply in centrifugation and dilution. Confirmation analysis allows simultaneous identification of 108 drugs and was validated on bile. Kappa analysis assessed a perfect agreement (0.81-1) between the assays for benzodiazepines, methadone, opiates, cocaine, oxycodone, cannabinoids, buprenorphine and pregabalin; a substantial agreement (0.41-0.6) was reported for barbiturates. No agreement was assessed for amphetamines, due to an abundance of putrefactive amines in postmortem specimens. In conclusion, this fast and easy immunoassay could be used for initial screening of bile specimens, identifying presence of drugs, except amphetamines, with reliability.

Unusual concentration of tramadol detected in cadaver in the last stage of decomposition and in fly larvae in the immediate vicinity: case report and literature review

Determination of the manner and cause of death from skeletal remains is almost always very difficult and can be a challenge for medical examiners. At the end also on skeletal remains, it is possible to assess mechanical, chemical, and thermal injuries, although it can be usually impossible. Possibilities to analyze biological material for the presence of drugs are also limited. The present study describes a case of a homeless man's skeletal remains on which a large number of fly larvae were found. Unusually high concentration of tramadol (TML) in the bone marrow (BM) = 4530 ng/g, muscle (M) = 4020 ng/g, and fly larvae (FL) = 280 ng/g was detected using a validated GC/MS method. In all analyzed samples, caffeine and N-desmethyltramadol (except BM) were qualitatively determined. Autopsy findings and toxicological analyses of the BM suggested that the cause of death could probably be intoxication by TML. It is apparent from the reviewed literature that analysis of TML in the late stages of decomposition of human body is rarely performed. Literature is predominantly focused on animal studies. Thus, TML concentrations analyzed in BM, M, or FL could be found helpful in relation to evaluation of intoxication by this substance. However, the significance of the results obtained in the presented study should be confirmed by further analyses of BM, M, or FL, where TML would be proved in lethal concentration in the blood.

Preanalytical factors influencing the results of ethanol analysis in postmortem specimens

Excessive drinking and drunkenness are underlying factors in many fatal accidents, which make the quantitative determination of ethanol in postmortem (PM) specimens an essential part of all unnatural death investigations. The same analytical methods are used to determine ethanol in blood taken from living and deceased persons although the interpretation of the results is more complicated in medical examiner cases owing to various preanalytical factors. The biggest problem is that under anaerobic conditions ethanol can be produced naturally in decomposed bodies by microbial activity and fermentation of blood glucose. Ways are needed to differentiate antemortem ingestion of ethanol from PM synthesis. One approach involves the determination of ethanol in alternative specimens, such as bile, cerebrospinal fluid, vitreous humor and/or urine, and comparison of results with blood alcohol concentration (BAC). Another approach involves the analysis of various alcohol biomarkers, such as ethyl glucuronide, ethyl sulfate and/or phosphatidylethanol or the urinary metabolites of serotonin 5-hydroxytryptophol/5-hydroxyindoleacetic acid (5-HTOL/5-HIAA). If ethanol had been produced in the body by microbial activity, the blood samples should also contain other low-molecular volatiles, such as acetaldehyde, n-propanol and/or n-butanol. The inclusion of 1-2% w/v sodium or potassium fluoride, as an enzyme inhibitor, in all PM specimens is essential to diminish the risk of ethanol being generated after sampling, such as during shipment and storage prior to analysis. Furthermore, much might be gained if the analytical cut-off for reporting positive BAC was raised from 0.01 to 0.02 g% when PM blood is analyzed. During putrefaction low BACs are more often produced after death than high BACs. Therefore, when the cadaver is obviously decomposed, a pragmatic approach would be to subtract 0.05 g% from the mean analytical result. Any remaining BAC is expected to give a more reliable indication of whether alcohol had been consumed before death.

Optimization of biochip assay for illegal substances on drug abusers' whole blood: Randox Evidence vs LC-MS/MS

Immunoassay tests are used in clinical and forensic toxicology laboratories to determine illicit drug use in biological samples. Therefore, this study aims to optimize the cutoff concentrations of DOA I Plus in the blood and compare the LC-MS/MS results. 680 authentic forensic whole blood specimens with Randox Evidence DOA I Plus array were screened for drug of abuse and confirmed by LC-MS/MS. Regarding the manufacturer recommended threshold values, 139 out of 680 authentic blood samples were positive for one or more analytes, while 541 were negative. Nearly all of the 139 positive blood samples confirmed by LC-MS/MS were true positive for one or more analytes, while 522 of the 541 negative blood samples were true negative. The overall sensitivity and the specificity were 87.8% and 99.6%, respectively. THC was considered in detail, and a receiver operator characteristic curve analysis was performed to determine the optimum cutoff for THC, as it accounts for 78% of all positive results according to the manufacturer's recommended thresholds. The optimal threshold value for THC was determined at a concentration of 23 ng/mL, while these values for other parameters were defined as recommended by the manufacturer.

Water-related atmospheric agents and solubility: two parameters of validation in toxicological screening on clothing worn by skeletal remains

In forensic toxicology, when conventional matrices are no longer available, alternative matrices can be used to assess toxicological investigations. Clothes worn by skeletal remains may be a good unconventional matrix for toxicological analyses considering that they have absorbed decomposition fluids and blood from a body. We hypothesized a scenario in which a skeleton, wearing clothes, was discovered in an open environment. From this starting point, an experimental study was developed on different textiles (cotton, wool, and polyester) to evaluate whether water-related atmospheric agents and molecule solubility can largely influence the detection of molecules of toxicological interest on this specific matrix, together with the characteristics of different garments chosen. The experimental study was performed on blood spots, previously spiked with 6-monoacetylmorphine and morphine, accurately placed on different textiles and washed with different quantities of deionized water adjusted at pH 5.6 with formic acid to simulate different rainfall conditions. Toxicological analyses were performed via Solid-Phase Extraction and High-Performance Liquid Chromatography-Tandem Mass Spectrometry analyses (Thermo Scientific™ TSQ Fortis™ II Triple-Quadrupole Mass Spectrometer). From the experimental study morphine could not be detected on 100% cotton and 100% wool fabric after the passing of 500 mL of deionized water and in 100% synthetic polyester textile after washing with 250 mL of deionized water. In conclusion, when toxicological analyses are carried out on unconventional matrices as textiles worn by corpses exposed to different environmental conditions, it is of great importance, in using such substrates as evidence for the presence of molecules of toxicological interest, to evaluate chemical-physical characteristics of each analyte under investigation in order to correctly interpret the toxicological data obtained.

Papaver somniferum in seventeenth century (Italy): archaeotoxicological study on brain and bone samples in patients from a hospital in Milan

In this paper, we present the results of toxicological analyses of preserved brain tissue and bone samples from the remains of the seventeenth century patients of the Ospedale Maggiore, the main hospital in Milan and one of the most innovative hospitals in Europe from the Renaissance period. Beneath it, the crypt functioned as the burial place for the deceased of the hospital. In this multidisciplinary study of the remains, toxicological analyses in particular were performed with HPLC-MS/MS on different biological samples from nine individuals. Anthropological, paleopathological, histological, radiological examinations and radiocarbon dating were also carried out. As a result, archeotoxicological analyses revealed the presence of codeine, morphine, noscapine and papaverine, derived from Papaver somniferum, a plant present in the hospital pharmacopeia used as a narcotic, analgesic, astringent, coagulant, and antitussive agent. Such analyses have shed light on the pharmacological therapies administered to the patients near the time of death and have implemented our knowledge of medical treatment and drug administration in the 1600's.

One image is worth more than a thousand words: producing an atlas of medical signs for teaching clinical and forensic toxicology

Clinical and forensic toxicology are critically involved in the acquisition of basic skills to correctly suspect intoxication, collect biological and non-biological materials for toxicological analysis, comprehend the complexities inherent to laboratory activity, and understand the fundamentals of toxicokinetics and toxicodynamics that underlie the interpretation of results. This works presents a pedagogical innovation proposal for the teaching of clinical and forensic toxicology based on a compilation of more than 3 000 cases where the image was fulcra for suspicion. The experience in this article follows the model practiced in bachelors, masters, and PhD degrees, as well as in other continuing training courses, where we are teaching toxicology for more than 15 years. All these levels of education are considered fundamental to the sound development of this science. This approach aims also to offer strength to the intervention of the true toxicologist in all the toxicological phases, besides the classic analytical chemistry. Indeed, it is impossible to provide effective clinical and forensic toxicological interpretations without a proper and broad education, and not thinking exclusively in terms of laboratory techniques. In the future, it will be interesting to evaluate knowledge retention and to propose a database of videos of signs related to intoxications.

Postmortem forensic toxicology cases: A retrospective review from Milan, Italy

We are presenting a study on 136 cases performed in a 2-year period (2018-2019) at the Bureau of Legal Medicine of the University of Milan for which toxicological analyses were requested and we are making a detailed interpretation of clinical records and discussing toxicological results from each case included in the study. Total number of autopsies was 1323 and in 10.3% of the cases, toxicological analyses were requested to obtain further information. Analyses were assessed with High-Performance Liquid Chromatography-Mass Spectrometry system and Gas Chromatography-Mass Spectrometry analyses. Additionally, Blood Alcohol Concentration and detection of volatile substances were obtained with Head Space-Gas Chromatography-Mass Spectrometry system. From these analyses, 101 cases out of 136 provided positive results (74.3%). Main substances detected were cocaine, diazepam, morphine, and ethanol. The most representative profiles of individuals that emerged from this study were: a Caucasian male, age 41-50, that died for cocaine acute intoxication or was killed; a Caucasian male or female with a range-of-age of 31-50 deceased for simple suicide caused by acute intoxication or by complex suicide caused by acute intoxication and suffocation; and finally, a Caucasian male with a range-of-age 21-40 that died in a car accident without any toxicological evidence. From the results, acute intoxication at the time of death was confirmed in 54 cases and in 57 cases the toxicological analyses helped in the determination of the cause and manner of death. From this study, the importance of toxicological data among forensic sciences is confirmed.

Pesticides analysis in alternative biological matrices

This review aims to bring together the works on pesticide analysis in alternative biological matrices, such as hair, breast milk, meconium, and placenta. Much is known about the harmful effects of the use and indirect consumption of pesticides; however, the assessment of long-term contamination is still unclear. In this sense, the use of hair as an alternative biological matrix has some advantages, such as segmentation, which makes it possible to assess the presence of xenobiotics to which individuals have been exposed over the years, and possibly relate this exposure to symptoms or diseases that may affect them. Complementarily, the other matrices discussed are able to provide information about the exposure of mothers and newborn children, who may have been indistinctly exposed to pesticides while in the womb. Through the analysis of studies already performed, it can be observed that organochlorine pesticides (OCPs) are the most likely to be found within the biological matrices discussed here, due to the lipophilic characteristics of these compounds. For the other classes, biotransformation products are more easily detected.

A Forensic Diagnostic Algorithm for Drug-Related Deaths: A Case Series

The best evidence provided in the literature worldwide suggests the importance of harmonizing the investigation in drug-related fatalities. In this study, the application of a multidisciplinary approach in eight cases of drug-related deaths is presented. Although death scene findings could be highly suggestive of drug intoxication, external examination and toxicological screening test alone are insufficient. There are several variables, and it is not always easy to give the proper interpretation of the drug detection. A complete autopsy is necessary to correctly complete organ and tissues sampling for further histological and toxicological studies and obtain body fluids. The use of peripheral blood is recommended to avoid artifacts. The collection of many specimens is warranted to get more responses. The sampling aims to provide a picture of the distribution of the substance in the body. The sample and the selection of the drugs and the matrices to investigate are case-dependent. The presented diagnostic algorithm provides the coroner with all the elements to investigate drug-related deaths and cooperate with toxicologists. Toxicological forensic diagnosis is still extremely heterogeneous in regional and national contexts. Funding for method development, research, networking, facilities, and technologies improvement is mandatory to standardize the toxicological investigation.

Virtual Autopsy in COVID19 Positive Sudden Death of a Young Adult Male; A Forensic Case Report

COVID-19 pandemic has changed the way medical professionals worked earlier. Every branch of medicine has revised its protocols to minimize transmission of infection among healthcare workers, and the branch of forensic pathology is no different. Conventional autopsies are generally not recommended in COVID cases as they pose the risk of transmission due to aerosol-generating procedures. However, there have been more than one occasion where the above recommendation has created ethical dilemmas in medicolegal autopsies. To the best of the author’s knowledge, this is the first known case of COVID-19 sudden death being investigated through a virtual autopsy in the Indian setting. The case further strengthens the notion of the virtual autopsy being sufficient in demonstrating the relevant findings for the purpose of the cause of death in a certain category of medicolegal cases.

Histological paraffin-embedded block: a good alternative specimen to detect the use of opiates at least 20 years ago

PURPOSE

Since the solely certain remnants of a performed autopsy are formalin-fixed paraffin-embedded (FFPE) samples, stored in the archives of every institute of legal medicine, we managed to extract molecules of toxicological interest from these specimens.

METHODS

We assessed the analysis of ten fresh liver samples collected from heroin-related deaths and then histologically processed the same samples. The embedded blocks were then extracted by means of a new extracting method and the eluates were measured. We also selected five toxicological cases of heroin-related fatalities that were examined 20 years ago, collected the toxicological result documents of the analysis that were carried out at the time and then processed the corresponding FFPE liver samples that were stored in the archives.

RESULTS

We managed to isolate heroine-related metabolites from 20-year-old paraffin-embedded blocks and calculated ratios to evaluate the performance of our new extraction.

CONCLUSIONS

According to our study, it is feasible to carry out a toxicological examination on old histological samples and, therefore, this matrix can be considered as a new alternative specimen for chemical-analytical evaluations of past cases or when fresh samples are not available anymore. The new extractive method was evaluated as efficient in treating these complex, paraffin-embedded samples. It was surprising that the target compounds could be quantitated from FFPE bocks created as long as 20 years ago.

Evidentiary discrepancies in sexual assault casework within the US

In recent years, a significant number of investigations have discovered up to 200 000 unsubmitted sexual assault kits (SAKs) in the US. While the public outcry was largely directed towards DNA analysis, the SAKs also contained biological specimens specifically designated for toxicological analysis. Due to the sensitivity of analytes in potential drug facilitated sexual assaults, the preservation and maintenance of the specimens is crucial in providing accurate toxicological measurements. The investigations into the unsubmitted SAKs have identified subjective law enforcement officer (LEO) rationale for the unsubmitted kits, however the impact on toxicological specimens has not been examined. This brief review of policies and guidelines with respect to forensic specimens has identified potential sources of evidentiary degradation, despite the use of chemical preservatives. With respect to temperature-controlled environments, the variation in SAK submission policies established throughout the US are potentially detrimental to the preservation of toxicological evidence. Degradation as a result of time-delayed collection and poorly maintained storage temperatures plays a crucial role for/in the interpretation of qualitative and quantitative toxicological results. This review finds these delays can be addressed through modernisation of facilities; electronic tracking of unsubmitted SAKs; mandated transfer of biological evidence within 72 h; and documentation of temperature within the chain of custody or other records. Without identifying the range of temperatures in which the evidence was exposed, forensic toxicologists may unintentionally provide erroneous interpretations of toxicological analyses – potentially casting doubt on the survivor’s recall of events and negatively impacting future sexual assault investigations.

Cerebrospinal fluid in forensic toxicology: Current status and future perspectives

In forensic toxicology, alternative biological materials are very useful and important, e.g. in the case of lack of basic body fluids. One alternative biological material is cerebrospinal fluid (CSF). The procedures of the collection of biological material during the autopsy are performed in accordance with local, usually national recommendations, which most often require updating. It is very difficult to assess the possibility of using CSF as an alternative biological material for toxicological studies for the presence of drugs, intoxicants, including new psychoactive substances (commonly known as designer drugs), psychotropic substances, and ethyl alcohol, based on current data. Previous research suggests that CSF may be useful in toxicological studies, but these aspects need to be investigated more carefully because studies have collected CSF from different sites and often the results of different authors are not comparable. It would be necessary to prepare guidelines, e.g. the site of CSF collection that may influence the results of quantitative analysis. It would also be necessary to replicate some studies with a different collection site or a more recent analytical technique, e.g. for comparative testing of blood ethanol and cerebrospinal fluid. Cerebrospinal fluid can be a valuable information carrier in the absence of classic biological material from an autopsy. Investigating these aspects in more detail could allow the future use of this alternative material for routine toxicology analyzes in a forensic laboratory.

Proteomics in Forensic Analysis: Applications for Human Samples

Proteomics, the large-scale study of all proteins of an organism or system, is a powerful tool for studying biological systems. It can provide a holistic view of the physiological and biochemical states of given samples through identification and quantification of large numbers of peptides and proteins. In forensic science, proteomics can be used as a confirmatory and orthogonal technique for well-built genomic analyses. Proteomics is highly valuable in cases where nucleic acids are absent or degraded, such as hair and bone samples. It can be used to identify body fluids, ethnic group, gender, individual, and estimate post-mortem interval using bone, muscle, and decomposition fluid samples. Compared to genomic analysis, proteomics can provide a better global picture of a sample. It has been used in forensic science for a wide range of sample types and applications. In this review, we briefly introduce proteomic methods, including sample preparation techniques, data acquisition using liquid chromatography-tandem mass spectrometry, and data analysis using database search, spectral library search, and de novo sequencing. We also summarize recent applications in the past decade of proteomics in forensic science with a special focus on human samples, including hair, bone, body fluids, fingernail, muscle, brain, and fingermark, and address the challenges, considerations, and future developments of forensic proteomics.

Potential significance of medicinal plants in forensic analysis: A review

Medicinal plants are a two-edged sword that might be exploited as a treatment specific dosage, and as deadly poisonous substances to commit murder or suicide when administered in high doses. Forensic experts can collect traces and residual materials from these toxic medicinal plants at a crime scene as forensic evidence. Further, more investigations need to be deeply implemented to in the future to understand the significance of medicinal plants in forensic investigations to detect these criminal offenses. Additionally, to provides a deep understanding of chemical substances that can impact human life positively or negatively with different doses as well as identifying the optimal or overdose concentrations for either treatments or poisonous effects using recent biotechnological approaches. This review aims to illustrate different contributions and the significance of medicinal plants in the field and further employment in the context of forensic science, especially in the Kingdom of Saudi Arabia.

Towards Extending the Detection Window of Gamma-Hydroxybutyric Acid-An Untargeted Metabolomics Study in Serum and Urine Following Controlled Administration in Healthy Men

In forensic toxicology, gamma-hydroxybutyrate (GHB) still represents one of the most challenging drugs of abuse in terms of analytical detection and interpretation. Given its rapid elimination, the detection window of GHB in common matrices is short (maximum 12 h in urine). Additionally, the differentiation from naturally occurring endogenous GHB, is challenging. Thus, novel biomarkers to extend the detection window of GHB are urgently needed. The present study aimed at searching new potential biomarkers of GHB use by means of mass spectrometry (MS) metabolomic profiling in serum (up to 16.5 h) and urine samples (up to 8 h after intake) collected during a placebo-controlled crossover study in healthy men. MS data acquired by different analytical methods (reversed phase and hydrophilic interaction liquid chromatography; positive and negative electrospray ionization each) were filtered for significantly changed features applying univariate and mixed-effect model statistics. Complementary to a former study, conjugates of GHB with glycine, glutamate, taurine, carnitine and pentose (ribose) were identified in urine, with particularly GHB-pentose being promising for longer detection. None of the conjugates were detectable in serum. Therein, mainly energy metabolic substrates were identified, which may be useful for more detailed interpretation of underlying pathways but are too unspecific as biomarkers.

Dynamic Distribution and Postmortem Redistribution of Tramadol in Poisoned Rats

In the past dozen years, the cases of tramadol intoxication have become frequent in many countries. Most previous studies focused on tramadol's pharmacology, such as pharmacokinetics, pharmacodynamics and pharmacogenetics. However, the dynamic distribution and postmortem redistribution (PMR) of tramadol remain unclear. Our study aimed to investigate these two issues systematically in various specimens of 216 poisoned male rats. A validated gas chromatography-mass spectrometry method was used in this study to measure the concentrations of tramadol. In the first part, 66 tramadol poisoned rats were sacrificed at 11 different time points and their organs were collected separately for the study of tramadol's dynamic distribution, which made it feasible to investigate its PMR later on. The results of this part showed that tramadol's concentrations varied according to the organ and time, and peaked 2 h after intragastric administration in the specimens of liver, kidney, spleen, lung, brain and heart-blood (except stomach and heart). Based on the results of the first part, the concentration of tramadol peaked 2 h in most tissues. Therefore, this time point was used for the study of tramadol's PMR. In the second part, the remaining 150 rats were sacrificed 2 h after intragastric administration of tramadol, and the carcasses were stored under three different conditions (-20, 4 and 20°C). The autopsy was carried out at eight different time points and their organs were collected separately. The results of this part showed that under storage temperatures of -20 and 4°C, the concentrations of tramadol in individual organs showed no significant changes at different time points whereas under a storage temperature of 20°C, the concentrations in certain organs (liver, kidney, spleen, lung, brain and heart-blood) increased significantly at the last few time points. PMR of tramadol was therefore confirmed. The process of PMR of tramadol could be slowed or stopped at lower storage temperatures (-20 or 4°C), which is significant in cases of suspected tramadol poisoning.

Inferences and Legal Considerations Following a Blood Collection Tube Recall

In mid-2019, medical, forensic and legal communities were notified that a certain shipment of evacuated blood sampling tubes were recalled by the manufacturer. This recall order described that the preservative sodium fluoride (100 mg) and anticoagulant potassium oxalate (20 mg) were missing from a small batch of 10-mL evacuated tubes. This gave cause for concern for possible implications in criminal justice (e.g., in drink-driving offenses) when blood-alcohol concentrations are interpreted. In reality, the lack of an anticoagulant would have been immediately obvious during sample preparation, owing to the formation of a large clot in the tube when received. Certain impairing drugs (e.g., cocaine and 6-acetylmorphine) are unstable in blood and tend to degrade without an enzyme inhibitor, such as sodium fluoride, present. In reviewing available literature related to current practices and the stability of ethanol in stored blood samples, there does not appear to be a clear consensus regarding the amount of sodium fluoride preservative necessary, if any at all, when blood is taken from living subjects under sterile conditions for typical forensic ethanol analysis.

Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

Impact of poor evidence management on DNA profiling in sexual assault and homicide: A case report

Increasing numbers of female victims of violent sexual assaults are being murdered with the aim of concealing the identity of the perpetrator. Proper handling and analysis of evidence is very important in gaining a conviction in many criminal cases. After evidence is collected, due precautions must be taken to ensure that the integrity of the sample is maintained, and chances of contamination are minimised. This paper presents a case study where improper handling of biological evidence led to loss of evidentiary value, and the semen could not be located on the vaginal swabs and victim's garments due to improper preservation of samples. However, the DNA from the nail of a decomposed finger helped identify the victim, and the suspect was apprehended based on the clues given by her family.

Detecting drugs in dry bone: a pilot study of skeletal remains with a post-mortem interval over 23 years

In decomposed or skeletonized bodies, conventional matrices used in forensic toxicology may no longer be available for analysis. The aim of this paper was to test the survival and detection of toxicological substances in dry bone samples with over 23 years of post-mortem interval. In this perspective, bone samples from the cranium, ribs, and vertebrae of seven skeletons from the CAL Milano Cemetery Skeletal Collection, buried for over 23 years, fully decomposed and altered by taphonomic factors were selected based on their ante-mortem data, which included verified or suspected drug addictions or overdose. Qualitative and quantitative analyses were performed with Dionex™ ASE™ 350 Accelerated Solvent Extractor and Q-Exactive Orbitrap-mass spectrometry with a HPLC system. Positive results were obtained in six of the seven cases, and different psychoactive drugs (and in some cases their active metabolites) were detected, including analgesic (two opioids: methadone and buprenorphine) and anxiolytic drugs (benzodiazepines, in particular delorazepam, diazepam, nordiazepam, and lorazepam), a cannabinoid metabolite (THCCOOH) as well as metabolites of stimulants (benzoylecgonine and MDA). Consequently, this research shows that toxicological substances may be found in bone tissue after over 23 years of post-mortem interval.

Stability of synthetic cathinones in clinical and forensic toxicological analysis-Where are we now?

Understanding the stability of analyzed drugs in biological samples is a crucial part for an appropriate interpretation of the analytical findings. Synthetic cathinones, as psychoactive stimulants, belong to a major class of new psychoactive substances. As they are subject to several degradation pathways, they are known to clinical and forensic toxicologists as unstable analytes in biological samples. When interpreting analytical data of synthetic cathinones in biological samples, analysts must be aware that the concentration of analytes may not accurately reflect the levels at the time they were acquired owing to many factors. This review provides (i) an overview of the current scientific knowledge on the stability of synthetic cathinones and/or metabolites in various human biological samples with a focus on factors that may deteriorate their stability-such as storage temperature, length of storage, matrix, pH, type of preservatives, concentration of analytes, and the chemistry of the analytes-and (ii) possible solutions on how to avoid such degradation. The PubMed database as well as Google Scholar was thoroughly searched to find published studies on the stability of synthetic cathinones since 2007 by searching specific keywords. A total of 23 articles met the inclusion criteria and were included in this review. Synthetic cathinones that carry methylenedioxy or N-pyrrolidine ring showed higher degradation resistance over other substituted groups. Acidification of samples pH plays a crucial role at increasing the stability of cathinones even with analytes that were frequently considered as poorly stable. This review also provides several recommendations for best practice in planning the experimental design, preservation, and storage conditions in order to minimize synthetic cathinones' degradation in human biological samples.

A Comparative Study of Ethanol Concentration in Costal Cartilage in Relation to Blood and Urine

Blood is not always available in forensic autopsies, therefore, the search for alternative sampling materials is needed. This study aimed at examining if ethanol can be detected in costal cartilage and to investigate if different forms of costal cartilage can give accurate information about ethanol concentration in the blood or urine of human cadavers (n = 50). Ethanol concentration in samples of unground costal cartilage (UCC), ground costal cartilage (GCC), femoral venous blood, and urine was analyzed using a gas chromatography-flame ionization detector (GC-FID). Due to Polish law, we used two different cut-off points: the blood alcohol concentration >0.2 mg/mL defined as the ‘after use’ condition, and the blood alcohol concentration >0.5 mg/mL defined as the ‘state of insobriety’. Based on the constructed receiver operating characteristics (ROC) curves, the optimal cut-off point for ethanol content as the ‘after use’ condition was 0.273 mg/g for the UCC method and 0.069 mg/g for the GCC method. Analysis of the Areas under a ROC Curve (AUC) showed that both methods present excellent diagnostic accuracy (AUCUCC = 0.903; AUCGCC = 0.984). We demonstrated that it is possible to detect ethanol in the costal cartilage and showed that ethanol concentrations are determined in GCC samples with greater accuracy.

Drugs in bone: Detectability of substances of toxicological interest in different states of preservation

In forensic contexts of advanced decomposition, when conventional matrices are no longer available for toxicological analyses, finding alternative matrices is necessary. The skeleton, which is fundamental for anthropologists and geneticists, could be useful also for toxicological purposes. The present study aims to examine what kind of information toxicological analysis performed on bones (the cranium and the ribs) in different states of preservation could provide to the forensic practitioner. Thirty cadavers with known pharmacological history, subjected to forensic autopsy at the Institute of Legal Medicine of Milan, were selected. Rib and cranium samples were collected from each body and separated into two parts in order to create two different states of preservation: One was cleaned from soft tissues and analyzed as a well-preserved bone sample; the other was submitted to a long maceration process, simulating complete skeletonization. All specimens were then processed with accelerated solvent extraction and the eluates analyzed using Q-Exactive™ Orbitrap™ Mass Spectrometer. The analysis of blood and skeletal matrices showed positive results for the tested substances in 63% of cases, mainly benzodiazepines, antidepressants, and drug abuse. Significant Pearson correlations were observed between non-macerated vs. macerated bone samples: r = 0.79 for rib samples, r = 0.61 for cranium samples, and r = 0.69 for all bone samples. As a consequence, the positive results confirm the potential of the bone tissue as an alternative matrix in forensic toxicology, even in cases of extremely decomposed bodies. This study also highlighted important elements for reconstructing the biological profile in cases of forensic anthropological concern.

Evaluation and review of ways to differentiate sources of ethanol in postmortem blood

Accurate determination of a person's blood alcohol concentration (BAC) is an important task in forensic toxicology laboratories because of the existence of statutory limits for driving a motor vehicle and workplace alcohol testing regulations. However, making a correct interpretation of the BAC determined in postmortem (PM) specimens is complicated, owing to the possibility that ethanol was produced in the body after death by the action of various micro-organisms (e.g., Candida species) and fermentation processes. This article reviews various ways to establish the source of ethanol in PM blood, including collection and analysis of alternative specimens (e.g., bile, vitreous humor (VH), and bladder urine), the identification of non-oxidative metabolites of ethanol, ethyl glucuronide (EtG) and ethyl sulfate (EtS), the urinary metabolites of serotonin (5-HTOL/5-HIAA), and identification of n-propanol and n-butanol in blood, which are known putrefaction products. Practical utility of the various biomarkers including specificity and stability is discussed.

Suicide by inhalation of butane gas through a homemade adaptation of a continuous positive airway pressure (CPAP) face mask

Fatal poisoning due to butane inhalation has been described in the clinical and forensic literature. We report the first case of a seventy-year-old obese man with a history of sleep apnea and depression, who was found dead in bed after inhaling butane gas through a homemade adaptation of his own continuous positive airway pressure (CPAP) face mask. The death scene investigation, autopsy findings and toxicological results are described. The cause of death was suspected to be due to asphyxia through butane inhalation.

Abuse of Licit and Illicit Psychoactive Substances in the Workplace: Medical, Toxicological, and Forensic Aspects

About one-third of adult life is spent in the workplace. The use of psychoactive substances is a major preventable cause of morbidity and mortality. The consumption of psychoactive substances during or outside working hours greatly increases the frequency and severity of labor accidents, as well as the workers’ poor general state of health and productivity, implying higher costs for enterprises. It is the responsibility of organizations to ensure the safety and health of their workers. These cannot be limited to traditional routine clinical exams, as other aspects also have an impact on health. Thus, prevention and intervention in the consumption of psychoactive substances (e.g., ethanol, opioids, central nervous system stimulants or depressants, hallucinogens, Cannabis derivatives, dissociative substances, and inhalants) in labor activity should be considered as an investment of organizations and not as a cost, in view of the professional, personal, and family advantages for workers and employers, with a potential impact on productivity, security, health, and quality of life at work. Despite the extensive literature on the subject, each article generally focuses on one or another aspect of a very specific nature, not tackling the problem in a holistic way by confronting clinical, safety, and legal issues. This article presents a reflection on the legal, laboratorial, clinical, ethical, forensic, and safety concerns related to the consumption of psychoactive substances in the workplace, and can be a cross-cutting contribution to occupational medicine, forensic medicine, and insurance medicine, as well as for entrepreneurs, lawyers, judges, workers, and technicians from the public and private sectors that develop projects in this area. This discussion is based on general principles established internationally and highlights the role of the occupational healthcare system and other decision-making actors in the prevention and supervision of workplace psychoactive consumption.

New strategy for carbon monoxide poisoning diagnosis: Carboxyhemoglobin (COHb) vs Total Blood Carbon Monoxide (TBCO)

Diagnosis of carbon monoxide (CO) poisonings has always been a challenging task due to the susceptibility to alterations of the optical state and degradation of blood samples during sampling, transport and storage, which highly affects the analysis with spectrophotometric methods. Methodological improvements are then required urgently because of increased reports of cases with discrepancies between results of the measured biomarker carboxyhemoglobin (COHb) and reported symptoms. Total blood CO (TBCO) measured chromatographically was thus proposed in a previous study as alternative biomarker to COHb. This approach was investigated in this study by comparing the two biomarkers and assessing the effects of various storage parameters (temperature, preservative, time, tube headspace (HS) volume, initial saturation level, freeze- and thaw- and reopening-cycles) over a period of one month. Results show that while for TBCO, concentrations are relatively stable over the observation period regardless of parameters such as temperature, time and HS volume, for COHb, concentrations are altered significantly during storage. Therefore, the use of TBCO as alternative biomarker for CO poisonings has been proposed, since it provides more valid results and is more stable even under non-optimal storage conditions. Additionally, it can be used to predict COHb in cases where sample degradation hinders optical measurement. Furthermore, a correction formula for COHb and TBCO is provided to be used in laboratories or circumstances where optimal storage or analysis is not possible, to obtain more accurate results.

[Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice]

Knockout Drugs: Diagnostics in the Emergency Unit and Clinical Practice Abstract. Every now and then, physicians are challenged with date rape drugs. If there is a suspicion of substance administration, the question of involving forensic medicine is commonly raised. In obscure situations or questionable offences, however, patients may wish for an initial diagnosis in the emergency department or the private practice. The physicians are often greatly challenged by the variety of substances, the limited analytical methods and difficulties with the interpretion of results. The major goal of this article is to present diagnostic options including their limitations. An overview of frequently involved substances is provided. Particular focus will be placed on practical aspects, including questions regarding pre-analytics and health insurance coverage.

Interpreting γ-hydroxybutyrate concentrations for clinical and forensic purposes

INTRODUCTION

γ-Hydroxybutyric acid is an endogenous substance, a therapeutic agent, and a recreational drug of abuse. This psychoactive substance acts as a depressant of the central nervous system and is commonly encountered in clinical and forensic practice, including impaired drivers, poisoned patients, and drug-related intoxication deaths.

OBJECTIVE

The aim of this review is to assist clinical and forensic practitioners with the interpretation of γ-hydroxybutyric acid concentrations in blood, urine, and alternative biological specimens from living and deceased persons.

METHODS

The information sources used to prepare this review were PubMed, Scopus, and Web-of-Science. These databases were searched using keywords γ-hydroxybutyrate (GHB), blood, urine, alternative specimens, non-conventional biological matrices, saliva, oral fluid, sweat, hair, vitreous humor (VH), brain, cerebrospinal fluid (CSF), dried blood spots (DBS), breast milk, and various combinations thereof. The resulting 4228 references were screened to exclude duplicates, which left 1980 articles for further consideration. These publications were carefully evaluated by taking into account the main aims of the review and 143 scientific papers were considered relevant. Analytical methods: The analytical methods used to determine γ-hydroxybutyric acid in blood and other biological specimens make use of gas- or liquid-chromatography coupled to mass spectrometry. These hyphenated techniques are accurate, precise, and specific for their intended purposes and the lower limit of quantitation in blood and other specimens is 0.5 mg/L or less. Human pharmacokinetics: GHB is rapidly absorbed from the gut and distributes into the total body water compartment. Only a small fraction of the dose (1-2%) is excreted unchanged in the urine. The plasma elimination half-life of γ-hydroxybutyric acid is short, being only about 0.5-0.9 h, which requires timely sampling of blood and other biological specimens for clinical and forensic analysis. Endogenous concentrations of GHB in blood: GHB is both an endogenous metabolite and a drug of abuse, which complicates interpretation of the laboratory results of analysis. Moreover, the concentrations of GHB in blood and other specimens tend to increase after sampling, especially in autopsy cases. This requires the use of practical "cut-off" concentrations to avoid reporting false positive results. These cut-offs are different for different biological specimen types. Concentrations of GHB in clinical and forensic practice: As a recreational drug GHB is predominantly used by young males (94%) with a mean age of 27.1 years. The mean (median) and range of concentrations in blood from apprehended drivers was 90 mg/L (82 mg/L) and 8-600 mg/L, respectively. The concentration distributions in blood taken from living and deceased persons overlapped, although the mean (median) and range of concentrations were higher in intoxication deaths; 640 mg/L (280 mg/L) and 30-9200 mg/L, respectively. Analysis of GHB in alternative specimens: All biological fluids and tissue containing water are suitable for the analysis of GHB. Examples of alternative specimens discussed in this review are CSF, saliva, hair strands, breast milk, DBS, VH, and brain tissue.

CONCLUSIONS

Body fluids for the analysis of GHB must be obtained as quickly as possible after a poisoned patient is admitted to hospital or after a person is arrested for a drug-related crime to enhance chances of detecting the drug. The sampling of urine lengthens the window of detection by 3-4 h compared with blood samples, but with longer delays between last intake of GHB and obtaining specimens, hair strands, and/or nails might be the only option. In postmortem toxicology, the concentrations of drugs tend to be more stable in bladder urine, VH, and CSF compared with blood, because these sampling sites are protected from the spread of bacteria from the gut. Accordingly, the relationship between blood and urine concentrations of GHB furnishes useful information when drug intoxication deaths are investigated.

Cocaine toxicological findings in cases of violent death in Sao Paulo city - Brazil

Violence is a dreadful phenomenon spread throughout the world, resulting in unfortunate events that can ultimately cause death. It is known that some countries play a much worrying role in this scenario than others. Brazil is one of them. The present work has focused on identifying the use of cocaine in 105 postmortem cases arriving at the Institute of Legal Medicine of Sao Paulo (IML-SP), the largest Brazilian city. Both blood and hair samples have been analyzed through ultra-performance liquid chromatography coupled to electrospray ionization tandem mass spectrometry (UPLC-ESI-MS/MS) in order to distinguish between recent or chronic cocaine use. The purpose of this work was to evaluate the proportion of cocaine use amongst violent individuals whose violence has ultimately led to their death. In order to do so, two previous methods, validated in-house, based on methanolic extraction for hair and protein precipitation for blood, have been used for this purpose and the final residue was analyzed through UPLC-ESI-MS/MS system. When looking at the demographics from the 105 postmortem cases analyzed, the results have shown the most critical age range to be between 18 and 25 years old and the least frequent between 37 and 45 years old. Gender wise, a rather extreme difference was found as 97 of the individuals were men and finally, considering the manner of death, the four-category criteria established appear to be fairly similar with 34 cases related to general violence and risk behavior, 26 to drug abuse suspicion, 23 to homicide resulting from opposition to police intervention and 22 to possible suicide.

Determination of benzodiazepines in pericardial fluid by gas chromatography-mass spectrometry

In Forensic Toxicology it is sometimes impossible to obtain a valid blood sample to perform toxicological analysis due to several factors like advanced state of decomposition, severe burns, bleed to death…. Pericardial Fluid has already been studied during the last years and has been proposed as a valid specimen for toxicological tests. Over the years, the consumption of benzodiazepines spread among the drug dependent population and became noticeable in drug facilitated assault cases and road accidents. Improvement of the analytical methodology required for detecting the presence of these drugs in biological samples is of great importance for forensic toxicology, in order to correctly diagnose an exposure or a poisoning. In this study, 9 benzodiazepines (diazepam, nordiazepam, midazolam, bromazepam, oxazepam, temazepam, lorazepam, clonazepam and alprazolam) have been determined in pericardial fluid. For this purpose a solid phase extraction (SPE) was carried out using Bond Elut Certify cartridges. After the derivatization of six of the nine benzodiazepines, gas chromatography coupled to a selective mass detector was used as the technique for the separation of the analytes. The method developed was fully validated for the 9 analytes and was applied to real samples of pericardial fluid received at the Forensic Toxicology Service of the University of Santiago de Compostela. Finally, they were compared with blood results looking for the existence of a possible correlation between both biological samples.

Quantification of Methadone and Main Metabolites in Nails

The quantification of drugs of abuse in keratinized matrices is becoming of special relevance for monitoring consumption and for post-mortem investigations. We aimed to implement an analytical method for the simultaneous detection of morphine (MORF), 6-monoacetylmorphine (6-MAM), methadone (MET), 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) and 2-ethyl-5-methyl-3,3-diphenylpyrrolidine (EMDP) in nails. After decontamination, the nail samples (30 mg) were submitted to an alkaline digestion followed by a two-step liquid-liquid and SPE extraction using mixed-mode cation exchange cartridges. The analytes were eluted with 5% NH4OH/methanol. After derivatization with N-methyl-N-(trimethylsilyl) trifluoroacetamide, the analytes were quantified by gas chromatography-mass spectrometry. The method was optimized and fully validated only for MET, EDDP and EMDP, since for MOR and 6-MAM it was not possible to obtain adequate recovery rates after extraction, although detection of MOR was still possible. The method was selective, accurate and precise. Regression analysis demonstrated linearity over a concentration range of 20.8-333.3 ng/mg for MET and 10.4-166.7 ng/mg for EDDP and EMDP. Limits of detection and quantification values ranged from 3.3 to 6.0 ng/mg and 10.4 to 20.8 ng/mg, respectively, and recovery rates ranged from 82% to 98%. The applicability of the method was demonstrated by analyzing nail and urine samples obtained from heroin consumers under substitution therapy with MET.