EtG Quantification in Hair and Different Reference Cut-Offs in Relation to Various Pathologies: A Scoping Review

A Comprehensive Review on Alcohol Abuse Disorder Fatality, from Alcohol Binges to Alcoholic Cardiomyopathy

Frequent and excessive consumption of alcohol, be it episodic or sustained misuse, ranks among the top causes of mortality globally. This comprehensive analysis seeks to elucidate how alcohol misuse precipitates death, with a particular focus on associated cardiac anomalies. Notably, the phenomenon of "Holiday Heart Syndrome", linked to binge drinking, is recognized for inducing potentially fatal cardiac arrhythmias. Moreover, persistent alcohol consumption is implicated in the development of alcoholic cardiomyopathy, a condition that underlies heart failure and arrhythmic disturbances of the heart. Additionally, individuals undergoing withdrawal from alcohol frequently exhibit disruptions in normal heart rhythm, posing a risk of death. This review further delves into additional alcohol-related mortality factors, including the heightened likelihood of hypertension, cerebrovascular accidents (strokes), and the connection between excessive alcohol use and Takotsubo syndrome.

Brief history of the alcohol biomarkers CDT, EtG, EtS, 5-HTOL, and PEth

This article traces the historical development of various biomarkers of acute and/or chronic alcohol consumption. Much of the research in this domain of clinical and laboratory medicine arose from clinics and laboratories in Sweden, as exemplified by carbohydrate deficient transferrin (CDT) and phosphatidylethanol (PEth). Extensive studies of other alcohol biomarkers, such as ethyl glucuronide (EtG), ethyl sulfate (EtS), and 5-hydroxytryptophol (5-HTOL), also derive from Sweden. The most obvious test of recent drinking is identification of ethanol in a sample of the person's blood, breath, or urine. However, because of continuous metabolism in the liver, ethanol is eliminated from the blood at a rate of 0.15 g/L/h (range 0.1-0.3 g/L/h), so obtaining positive results is not always possible. The widow of detection is increased by analysis of ethanol's non-oxidative metabolites (EtG and EtS), which are more slowly eliminated from the bloodstream. Likewise, an elevated ratio of serotonin metabolites in urine (5-HTOL/5-HIAA) can help to disclose recent drinking after ethanol is no longer measurable in body fluids. A highly specific biomarker of hazardous drinking is CDT, a serum glycoprotein (transferrin), with a deficiency in its N-linked glycosylation. Another widely acclaimed biomarker is PEth, an abnormal phospholipid synthesized in cell membranes when people drink excessively, having a long elimination half-life (median ~6 days) during abstinence. Research on the subject of alcohol biomarkers has increased appreciably and is now an important area of drug testing and analysis.

Non-invasive tests for alcohol-associated liver disease

Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.

Systematic Review of Fatal Sodium Nitrite Ingestion Cases: Toxicological and Forensic Implications

Documented cases of sodium nitrite toxicity are almost exclusively caused by accidental ingestion; however, self-poisoning with sodium nitrite represents an increasing trend in nitrate-related deaths. This systematic review summarizes the most crucial evidence regarding the fatal toxicity of sodium nitrite. It identifies gaps and differences in the diagnostic forensic approaches and the detection methods of sodium nitrite intoxication. A total of eleven research articles were selected for qualitative and quantitative data. Most of the studies (6/11) were case reports. Fifty-three cases of fatal intoxication with sodium nitrite were chosen for the review. More research is required to develop cost-effective techniques and uniform cutoffs for blood nitrite and nitrate levels in the event of deadly sodium nitrite poisoning. There is still a lack of critical information on other matrices and the impact of time since death on toxicological results in such situations. The available evidence provides useful recommendations for forensic pathologists and health practitioners engaged in instances of sodium nitrite poisoning or death. The data should also set off alarm bells in the public health system, in prosecutor's offices, and for policymakers so that they may undertake preventative measures to stop and restrict the unregulated market for these substances.

Alcohol Consumption Assessed by a Biomarker and Self-Reported Drinking in a Sample of Pregnant Women in the South of Europe: A Comparative Study

(1) Background: Alcohol consumption during pregnancy is a major concern, particularly in Europe and North America. Its prevalence has so far been under-researched. In most studies, the determination of this consumption may be underestimated, as it is based on the information obtained from questionnaires rather than from biomarkers, which will provide a much more reliable approach. The main objective of this study was to compare the prevalence of consumption during pregnancy as assessed by a questionnaire and a hair biomarker. (2) Method: A cross-sectional study with a random sample of 425 pregnant women treated in public hospital consultations in Seville (Spain) and in the 20th week of their pregnancy, orally interviewed using an elaborated ad hoc questionnaire that evaluated variables of sociodemographic, obstetric, and alcohol consumption. Furthermore, the ethyl glucuronide metabolite (EtG) was tested on a hair sample in 252 pregnant women who agreed to facilitate it. Once the data obtained through the questionnaire and hair test were analyzed, the level of metabolites and self-reported alcohol consumption were compared. (3) Results: The prevalence of self-reported alcohol consumption (questionnaire) was 20.7%, and the real consumption (metabolite analysis) was 20.2%. In 16.8% of pregnant women who declared not consuming alcohol during their pregnancy, noticeable consumption was detected according to the metabolite test. No relevant level of variability in estimated alcohol consumption was detected in the biomarker with respect to the sociodemographic and obstetric variables studied. (4) Conclusions: The prevalence of alcohol consumption during pregnancy obtained through both questionnaires and metabolite analyses was similar and high. There is no association between consumption and sociodemographic factors in this sample. The determination of consumption through biomarkers allows for a more accurate approximation of the prevalence of consumption than estimated through questionnaires. Larger sample-sized studies are needed to determine consumption patterns and thus guide the adoption of more precise policies fostering abstinence from alcohol consumption since the preconception period.

Assessment of alcohol consumption in mexican pregnant women by hair testing of ethyl glucuronide

There are no studies that have utilized both biomarkers and self-reported data to evaluate maternal alcohol use during pregnancy in Mexico. Therefore, we aimed to describe the prevalence of alcohol consumption in a cohort of 300 Mexican pregnant women. We used a validated ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to measure hair ethyl glucuronide (EtG) in hair segments that corresponded to the first and second half of pregnancy. We compared the hair EtG values to a self-reported questionnaire on maternal drinking habits and evaluated whether the gestational alcohol use was associated with psychotropic drug use. Based on the EtG measurements, 263 women (87.7%) were alcohol-abstinent during the entire pregnancy, while 37 (12.3%) had used alcohol at least once during the pregnancy. Of these, only two women were found to have problematic alcoholic behavior during the entire pregnancy. No significant differences in sociodemographic characteristics were observed between alcohol-abstinent women and women with drinking habits. The self-reporting data and hair EtG gave heterogeneous results: although 37 women had self-reported alcohol use during pregnancy, only 54.1% of these women tested positive for hair EtG. Of the women who tested positive for hair EtG, 54.1% tested positive for psychoactive substances. In our cohort, the use of drugs of abuse was independent of gestational drinking. This study provided the first objective evidence of prenatal ethanol consumption in a cohort of Mexican pregnant women.

Toxicological Analysis in Tissues Following Exhumation More Than Two Years after Death (948 Days): A Forensic Perspective in a Fatal Case

Exhumations are performed in accordance with a court order and are crucial instruments in the investigation of death allegations. When a death is thought to be the result of drug misuse, pharmaceutical overdose, or pesticide poisoning, this process may be used on human remains. However, after a protracted postmortem interval (PMI), it might be difficult to detect the cause of death by looking at an exhumed corpse. The following case report reveals problems associated with postmortem drug concentration changes following exhumation more than two years after death. A 31-year-old man was found dead in a prison cell. Onan inspection of the place, two blister packs, one with a tablet and the other empty, were taken and kept by the police officers. The evening before, the deceased would have taken cetirizine and food supplements consisting of carnitine-creatine tablets. No relevant autopsy findings have been observed. The toxicological analysis was performed by gas chromatography coupled to mass spectrometry and was negative for substances of abuse. Proteomic analysis was positive for creatine detection and negative for other drugs (clarithromycin, fenofibrate, and cetirizine). The presented case shows the methods, the findings, and the limitations of toxicological analysis in an exhumation case with a long postmortem interval (PMI).

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

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.