Pediatric poisoning management: How clinical practice can benefit from forensic approach

Pediatric population represents the most vulnerable and at risk for unintentional poisoning, with children younger than 6 years old accounting for nearly half of poison exposures. Poisoning is a time-dependent emergency. The need to reach a scientific agreement on diagnostic protocol and treatment seems to be crucial to reduce morbidity and mortality. Starting from a buprenorphine pediatric intoxication case, this article highlights the limits and pitfalls of the traditional diagnostic approach. Diagnosis of drug intoxication was achieved after several days when an in-depth diagnostic investigation became necessary and complete forensic toxicological analyses were performed. Results evidenced an alarming lack of an unequivocal diagnostic protocol in case of suspect intoxication in structures not provided with a forensic toxicological service/unit. Collection of biological specimens according to forensic protocols at hospitalization plays a paramount role in the definitive diagnosis of intoxication. A diagnostic algorithm that focuses on medical history and biological specimen collection timing is herein proposed, in order to unify emergency approaches to the suspected poisoned child.

Diquat Poisoning: Care Management and Medico-Legal Implications

Acute chemical intoxication represents one of the major causes of Emergency Room admittance, and possible errors in diagnosis are extremely frequent, especially when patients present generic and non-specific symptoms. Diquat, a bipyridyl class of herbicides, exerts high intrinsic toxicity as a consequence of free oxygen radicals, leading to cellular death and organ dysfunctions. Following ingestion, with the major source of absorption for suicidal purposes, the chemical induces local irritating effects; systemic symptoms appear later, while specific symptoms can occur in the following 48 h. A smoker and hypertensive 50-year-old man arrives at the E.R., reporting that an episode of herbicide inhalation occurred few hours earlier. Physical examination evidenced alkalosis with hypoxemia, leucocytosis, mild hyperglycaemia and moderate increase in creatine kinase and myoglobin. Despite blood creatine kinase and myoglobin values that were higher than normal, he was prescribed with hydration and anti-pain therapy. During the night, the man left the hospital; he returned the next morning at 8:45 a.m., with cardiorespiratory arrest, medium fixed non-reactive mydriasis, diffused cyanosis of the skin and of the mucous membranes, as well as imperceptible pulse and peripheral pressure. Despite resuscitation attempts, the patient died at 9:30 a.m.; the body was immediately transferred to the morgue. Autopsy and toxicological analyses were carried out nine days later, evidencing paraquat ingestion for suicidal purposes. GC/MS analyses to verify the presence of diquat were performed on body fluids and gastric and colon contents; all specimens resulted positive, thus confirming the cause of death as herbicide ingestion (blood diquat concentration of 1.2 mg/L; more than twice the minimum to observe a systemic poisoning). The procedure followed for patient management resulted to be not in line with the provisions of both guidelines and good clinical practices. Staff did not perform clinical-diagnostical monitoring of the patient’s condition or ask for more specific analyses (i.e., serum creatine phosphokinase monitoring). This misconduct led to a decrease in the patient’s chances to survive.

Forensic Toxicological and Medico-Legal Evaluation in a Case of Incongruous Drug Administration in Terminal Cancer Patients

Background: In most cases, palliative care is prescribed to adults diagnosed with cancer. The definition of the most suitable therapy for an effective sedation in terminal cancer patients still represents one of the most challenging goals in medical practice. Due to their poor health, the correct dosing of drugs used for deep palliative sedation in terminal cancer patients, often already on polypharmacological therapy, can be extremely complicated, also considering possible drug-to-drug interactions that could lead to an increased risk of overdose and/or incongruous administration with fatal outcomes. The case of a terminal cancer patient is presented, focusing on the “adequacy” of administered therapy. Materials and Methods: A young male, affected by Ewing sarcoma, attending a palliative care at his own home, died soon after midazolam administration. Toxicological and histological analyses were performed on body fluids and organ fragments. Results and Discussion: Morphological reliefs evidenced a neoplastic mass, composed of lobulated tissue with a lardy, pinkish-gray consistency, extending from the pleural surface to the lung parenchyma, also present at the sacrum region (S1–S5), at the anterior mediastinum level, occupying the entire left pleural cavity, and infiltrating the ipsilateral lung. Metastatic lesions diffused to rachis and lumbar structures. The brain presented edema and congestion. Toxicological analyses evidenced blood midazolam concentrations in the range of 0.931–1.690 µg/mL, while morphine was between 0.266 and 0.909 µg/mL. Death was attributed to cardiorespiratory depression because of a synergic action between morphine and midazolam. The pharmacological interaction between midazolam and morphine is discussed considering the clinical situation of the patient. The opportunity to proceed with midazolam administration is discussed starting from guidelines recommendation. Finally, professional liability outlines are highlighted.

Illicit drugs seizures in 2013-2018 and characteristics of the illicit market within the Neapolitan area

The study presents results of toxicological analysis performed on seized material in Neapolitan area in the period from 2013 to 2018. A constancy in THC and heroin percentages is evidenced (%THC ~10% and ~11.5% for marijuana and hashish; heroine: 20-24%), with mean values exceeding the European data. Data on cocaine revealed a constant increment of active principle percentage over the studied period (from 40% in 2013 to ~65% in 2018), with peak of 70% in 2017; also, number of samples exceeding the mean value increased over years. Active principles contents resulted higher than the ones reported in other Italian area ever the same period; marijuana was prevalent on hashish, confirming an Italian trend different from other European countries. A map of the Campania region evidenced two main "storage" districts, one corresponding to the city center and the second located in the northern part. If compared with literature data on the presence of local mafia, these areas are perfectly superimposable to those with the highest risk of homicides, thus confirming the degree of radicalization of local organizations and the relative weight of proceeds from drugs sale. Moreover, such radicalization within the territory seems to be the main reason of the absence of new psychoactive substances among the seized material.

Application of a chemiluminescence immunoassay system and GC/MS for toxicological investigations on skeletonized human remains

Hair, larvae and cardiac muscle, the only biological samples present on a skeletonized human body found in a rural area, were used for forensic toxicological analyses in order to determine possible causes of death. Since no information about the victim or the circumstances of death was available (except for the place where the corpse was found, known to be a gathering place for drug addicts), the first approach for the analysis of non-conventional matrices involved the screening of different classes of active principles, using a chemiluminescence-based screening assay designed for whole blood. The immunoassay test results showed positivity to amphetamines, cocaine and opiates on water/methanol extract from cardiac tissue, larvae and hair samples. Gas chromatography-mass spectrometry (GC/MS) analyses confirmed the immunoassay results, except for amphetamines. The minimal sample preparation (hydration and extraction in an ultrasonic bath), the reduced sample volume required for the analyses, together with the correctness of results as confirmed by GC/MS, showed the suitability of the screening test for forensic applications on non-conventional matrices. Quantitative analyses in GC/MS allowed the cause of death to be ascertained on the basis of the ratio between parent drugs and metabolites.

Environmental and occupational exposure to bisphenol A and endometriosis: urinary and peritoneal fluid concentration levels

OBJECTIVES

The study aimed to give a first data set of bisphenol A (BPA) levels in the peritoneal fluid of patients suffering from endometriosis and to investigate the relationship between BPA exposure and endometriosis.

METHODS

A questionnaire investigating the occupational context, life environment, and habits was administered to 68 patients suffering from endometriosis and 60 endometriosis-free subjects (control group). Urine and peritoneal fluids samples were collected and analysed by GC/MSMS for BPA dosage.

RESULTS

Some of the investigated environmental/lifestyle risk factors (closeness to industries/activities at risk) were associated with an increase in endometriosis; smoking resulted as protective factor; others (use of food plastic boxes) did not seem to influence the onset of pathology. The association between the occupational exposure summarising all examined risk factors (working activity, personal protective equipment, seniority) and endometriosis was statistically significant (χ ² = 5.252, p = 0.02). Contrasting results were obtained when specific activities were examined. Detectable urinary BPA levels were found in all analysed samples (patients: 1.17-12.68 pg/µl; mean ± SD, 5.31 ± 3.36 pg/µl; control group: 1.28-2.35 pg/µl; mean ± SD, 1.64 ± 0.49 pg/µl; median; 1.46 pg/µl), with a statistically significant difference between patients and controls, showing an association between BPA exposure and endometriosis. Only a few subjects from the control group supplied peritoneal fluid; hence, no comparison test with patients (range 0.39-1.46 pg/µl; mean ± SD, 0.67 ± 0.30 pg/µl; median, 0.58 pg/µl) was carried out.

CONCLUSIONS

Results highlight the potential association between BPA exposure and endometriosis, as well as the current lack of knowledge regarding occupational exposure to BPA and the need of epidemiological studies focused on single activities/occupations, such as housewives, cleaners, students.

Evaluation by Environmental Monitoring of Pesticide Absorption in Farm Workers of 18 Italian Tomato Cultivations

Tomato cultivation farms of Southern Italy were investigated in order to evaluate the general working conditions and the levels of exposure of farm workers to pesticides, during the mixing/loading and the application of pesticides on fields. Information on working modalities, personal protective equipment, etc. was collected using a questionnaire. Inhaling and cutaneous exposure levels were measured, and the estimated pesticide total absorbed dose was compared with Admissible Daily Intakes (ADIs). Field treatments were mainly carried out by using sprayers with open cab tractors, and, in 57.9% of cases, the pesticide mixture was manually prepared by mixing pesticides in a pail, often without using gloves (59.5%). The estimated pesticides absorbed doses varied in the range 0.56–2630.31 mg (mean value, 46.9 mg), and 20% of the measured absorbed doses exceeded ADIs. The findings obtained in the 18 examined farms show a worrying situation, suggesting the investigation of many more farms, so that a statistically significant picture of tomato cultivations in Southern Italy could be formed. Besides, the planning of training courses aimed to increase workers consciousness about health risks and how they can be prevented is advisable.

[Production cycles and risk agents]

Agricultural working contexts are characterized by numerous and heterogeneous working activities, leading to a noteworthy variety of risks for workers' healthcare. Safety and health risks vary according to each specific working activity, following seasonal cycles and productive process's phases. In particular, here the attention has been focused on the main risks factors present in large farms for fruit crops production, greenhouses and silos. Preventive measures for risks management are indicated in relation to each working activity step. Together with injury risks, essentially due to work equipment and machinery, unfavourable microclimatic conditions and hazards related to the manual handling of loads are often present, as well as chemical and biological risk agents adopted during the sterilization, disinfection and fertilization of grounds, plants and storage places. The reported findings highlight the necessity of increasing the risk consciousness of agricultural operators in order to facilitate the adoption of indispensable preventive and protective measures.

[Algorithm validation for pesticide exposure risk evaluation by environmental monitoring data]

The risk evaluation related to the occupational exposure to hazardous substances can be performed either by analytical data coming from environmental and/or biological monitoring or by using models and mathematical algorithms. Models are often considered economically more advantageous, nevertheless, in order to assure their reliability, they need to be validated by objective monitoring data. A predictive model for the evaluation of risks due to the exposure to pesticides in agriculture was elaborated, and, for model validations, 20 tomato farms were examined. For each farm, information necessary to the risk evaluation by using the elaborated algorithm were collected and, simultaneously, an environmental monitoring for the evaluation of inhaling and cutaneous exposure was carried out. The potential risk was estimated by comparing analytical data from environmental monitoring with respect to ADI (Admissible Daily Intake) values, for each investigated pesticide. Then, the accordance between the potential risk and the risk given by the elaborated model was evaluated and an agreement of 85.6% was found, showing a substantial reliability of the proposed model.

[Risk evaluation of contact with pesticides in Naples municipality gardeners]

Pesticide use still now is a remarkable risk for all cultivation operators, including farmers and flower-growing workers. Recently, pesticides use on ornamental plant has been demonstrated to be able to determine a risk extension to general population. Aim of the project was to elaborate and to apply a method for pesticides risk evaluation in ornamental plant cultivations, as to define workers exposure and its possible diffusion to not occupationally exposed populations. Main features of method will be sampling and analysis approach. The first will estimate air dispersion of pesticides in garden centre, skin and garment smarminess in nurserymen and leaf adhered amounts, in concomitance with treatment and periodically to estimate natural decay. The latter will characterize pesticides by means of different methods (liquid and gaseous chromatography, spectrophotometry and spectrometry). Final aim will also be to identify the most reliable analytic method, as concerns accuracy, sensitivity and specificity.

Application of the standard addition approach for the quantification of urinary benzene

Urinary benzene is used as biomarker of exposure to evaluate the uptake of this solvent both in non-occupationally exposed population and in benzene-exposed workers. The quantitative determination of benzene in urine is carried out in a three steps procedure: urine collection, sample analysis by head space/solid phase microextraction/gas chromatography/mass spectrometry and analyte quantification. The adopted quantification method influences the initial step, hence the whole procedure. Two quantification approaches were compared as regards precision and accuracy: the calibration curves and the standard addition method. Even if calibration curves obtained by using urine samples from different subjects were always linear, their slopes and intercepts showed noteworthy variations, attributable to the influence of the biological matrix on benzene recovery. The standard addition method showed to be more suitable for compensating matrix effects, and a three-point standard addition protocol was used to quantify benzene in urine samples of 11 benzene-exposed workers (smokers and non-smokers). Urine from occupationally exposed workers was collected before and after work-shift. Besides urinary benzene, the applicability of the method was verified by measuring the urinary concentration of the S-phenylmercapturic acid, a specific benzene metabolite, generally adopted as biomarker in biological monitoring procedures. A similar trend of concentration levels of both analytes measured in urine samples collected before work-shift with respect to the after work-shift ones was found, showing the actual applicability of the standard addition method for biological monitoring purposes.

Mono- and diiodocyclophosphamide as possible internal standards for cyclophosphamide quantification: characterization by ion trap multi-stage mass spectrometry and effects of iodine-chlorine substitution on the fragmentation pattern

Hospital personnel involved in antineoplastic drug preparation and administration to patients are exposed to large amounts of these drugs. Labour legislation indicates the necessity of planning monitoring strategies aimed at prevention and/or reduction of drug exposure. Monitoring strategies consist of quantitative determinations of indicators, present in environmental and biological matrices. Among the antineoplastic drugs widely used, cyclophosphamide (CP) has been identified as a suitable indicator of potential exposure to mixtures of antineoplastic drugs. Many literature methods for quantitative analysis of CP involve either liquid (LC) or gas chromatography (GC) with mass spectrometry (MS), both of which require use of a suitable internal standard. The present work focuses on the synthesis of mono- and diiodocyclophosphamide (CPI and CPI(2)) to be used as internal standard. These compounds were analyzed by GC/EI-MS/MS and LC/ESI-MS(n) using ion trap mass spectrometry. The product ion mass spectra are interpreted in terms of proposed structures of fragment ions. Iodine-chlorine substitution resulted in a weakening of the carbon-halogen bond with a noteworthy influence on the ion fragmentation processes. The proposed suitability of CPI and CPI(2) as internal standards was based on similarities to CP as regards ionization and fragmentation processes. The results obtained suggest that CPI could be used as internal standard for CP quantification by LC/ESI-MS/MS, and CPI(2) for GC/EI-MS/MS analyses.

Determination of rapamycin: quantification of the sodiated species by an ion trap mass spectrometer as an alternative to the ammoniated complex analysis by triple quadrupole

Rapamycin is a potent immunosuppressive drug capable of significantly reducing acute graft rejection in kidney, liver and heart transplant patients. Its immunosuppressive activity and adverse effects have been related to rapamycin concentration, and therapeutic drug monitoring of the drug is deemed appropriate. This work was aimed at developing a new quantification method based on the isolation of the [M+Na]+ ion as precursor and its further fragmentation through an ion trap mass spectrometer equipped with an electrospray ionization source. A limit of detection (LOD) of 0.7 ng/mL was obtained, while the lower limit of quantification (LLOQ) was 2.4 ng/mL. The accuracy and reproducibility of the responses were evaluated and compared with results obtained when the [M+NH4]+ ion was chosen as the precursor in a triple quadrupole mass spectrometer. In this case the LOD was 0.5 ng/mL and the LLOQ 1.7 ng/mL. Data showed that it would be possible to use the quantification of the sodiated species for the routine determination of rapamycin, as an alternative to the commonly adopted method based on the ammoniated complex.