UPLC-MS/MS Method for Detection of Etomidate and Its Metabolite Etomidate Acid Quantity in Blood

OBJECTIVES

To establish a method for the simultaneous quantitative analysis of etomidate and its metabolite etomidate acid in blood, and to discuss its application value in actual cases.

METHODS

Acetonitrile precipitate protein method was used, and C18 column was selected. Gradient elution was performed with acetonitrile and 5 mmol/L ammonium acetate within 6 min. Electrospray ionization source in positive ion mode was used. The internal standard etomidate acid-d5 was obtained by etomidate-d5 alkaline hydrolysis reaction. Ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) was used for quantitative analysis. The methodological verification was conducted.

RESULTS

Etomidate and etomidate acid in blood showed good linear relationship in the quantitative linear range (r>0.999), with the lower limit of quantification was 2.5 ng/mL and 7.5 ng/mL, respectively. The accuracy, precision, recovery rate, and matrix effect of the method met the professional verification standards. The practical application results showed that etomidate and etomidate acid could be detected in the blood of the abusers, and their mass concentrations ranged from 17.24 to 379.93 ng/mL.

CONCLUSIONS

The method established in this study can simultaneously quantify etomidate and etomidate acid in blood, which is simple and convenient to operate with accuracy. It can meet the detection needs of actual cases and provide technical support for law enforcement to crack down on etomidate abuse.

Determination of Prostaglandins (Carboprost, Cloprostenol, Dinoprost, Dinoprostone, Misoprostol, Sulprostone) by UHPLC-MS/MS in Toxicological Investigations

Prostaglandins have stimulative influence on the human uterus and therefore were introduced to medical treatment in reproductive healthcare as labor inductors or abortifacients. The UHPLC-ESI-QqQ-MS/MS method was developed for six prostaglandins: carboprost, cloprostenol, dinoprost (PGF2α), dinoprostone (PGE2), misoprostol and sulprostone (substances for pregnancy termination) in pharmaceutical samples and was applied for the toxicological examination of pills containing misoprostol (collected during gynecological examination). There were used two internal standards: misoprostol-d5 and PGF2α-d4. The quantification of analytes was performed in the MRM mode. The linearity of method was in the range from 0.1 to 10 µg/mL, with a coefficient of determination above 0.997 (R2) for each compound. The precision and accuracy values did not exceed ±5.0%. Analysis of the pills revealed the presence of two substances: misoprostol and diclofenac. Misoprostol and diclofenac dose per sample were as follows: 608.8 ng (sample 1), 708.4 ng (sample 2), 618.8 ng (sample 3) and 67.7 mg (sample 1), 65.3 mg (sample 2) 67.3 mg (sample 3), respectively. A simple, precise and reliable method can be applied for routine examinations in terms of clinical and forensic toxicology examinations as well as in quality control of drugs for pharmaceutical purposes (original drugs and counterfeit medications).

Rapid Determination of Bucinnazine in Blood by UPLC-MS/MS

OBJECTIVES

To establish a rapid method for the analysis of bucinnazine in blood by UPLC-MS/MS and to apply the method to the practical case.

METHODS

After the internal standard was added to blood, the protein was precipitated with 900 μL mixed solution (Vacetonitrile∶Vwater=8∶2). After vortex and centrifugation, the protein was measured through 0.22 μm filter membrane. The separation was performed on C18 chromatography column, with acetonitrile and 5 mmol/L ammonium acetate containing 0.1% formic acid aqueous as mobile phase gradient elution at the flow rate of 0.4 mL/min. Multiple reaction monitoring scan was performed in electrospray positive ion mode, quantitative measurement was performed by internal standard method, and methodological verification was carried out.

RESULTS

The linear relationship of bucinnazine in blood was good in the range of 0.5-200 μg/L, the correlation coefficient (r) was 0.999 7, the limit of detection was 0.1 μg/L, the limit of quantitation was 0.5 μg/L, and the recovery was 78.3%-83.8% at 1, 10 and 100 μg/L mass concentration levels. The matrix effect was 69.4%-73.8%, the intra-day precision was 1.9%-2.8%, and the inter-day precision was 2.8%-3.2%, the accuracy was 3.1%-3.5%. The stability test results of 1 and 100 μg/L mass concentrations at -25 ℃ showed that the accuracy (bias) of 10 d was less than 4.5%.

CONCLUSIONS

This method has the advantages of simple pre-treatment process, fast sample processing speed, high sensitivity of instrument analysis, good stability of content determination and reliable identification results, and can meet the needs of case identification.

Research Progress on Machine Learning Assisted Non-Targeted Screening Strategy for Identification of Fentanyl Analogs

In recent years, the types and quantities of fentanyl analogs have increased rapidly. It has become a hotspot in the illicit drug control field of how to quickly identify novel fentanyl analogs and to shorten the blank regulatory period. At present, the identification methods of fentanyl analogs that have been developed mostly rely on reference materials to target fentanyl analogs or their metabolites with known chemical structures, but these methods face challenges when analyzing new compounds with unknown structures. In recent years, emerging machine learning technology can quickly and automatically extract valuable features from massive data, which provides inspiration for the non-targeted screening of fentanyl analogs. For example, the wide application of instruments like Raman spectroscopy, nuclear magnetic resonance spectroscopy, high resolution mass spectrometry, and other instruments can maximize the mining of the characteristic data related to fentanyl analogs in samples. Combining this data with an appropriate machine learning model, researchers may create a variety of high-performance non-targeted fentanyl identification methods. This paper reviews the recent research on the application of machine learning assisted non-targeted screening strategy for the identification of fentanyl analogs, and looks forward to the future development trend in this field.

Structural Analysis and Characterization of 4-F-α-PVP Analog 4-F-3-Methyl-α- PVP Hydrochloride

OBJECTIVES

To identify 1-(4-fluorophenyl)-2-(1-pyrrolidinyl) pentan-1-one (4-F-α-PVP) analog 1-(4-fluoro-3-methyl phenyl)-2-(1-pyrrolidinyl) pentan-1-one (4-F-3-Methyl-α-PVP) hydrochloride without reference substance.

METHODS

The direct-injection electron ionization-mass spectrometry (EI-MS), GC-MS, electrospray ionization-high resolution mass spectrometry (ESI-HRMS), ultra-high performance liquid chromatography-high resolution tandem mass spectrometry (UPLC-HRMS/MS), nuclear magnetic resonance (NMR), ion chromatography and Fourier transform infrared spectroscopy (FTIR) were integrated utilized to achieve the structural analysis and characterization of the unknown compound in the sample, and the cleavage mechanism of the fragment ions was deduced by EI-MS and UPLC-HRMS/MS.

RESULTS

By analyzing the direct-injection EI-MS, GC-MS, ESI-HRMS and UPLC-HRMS/MS of the compound in the samples, it was concluded that the unknown compound was a structural analog of 4-F-α-PVP, possibly with one more methyl group in the benzene ring. According to the analysis results of ¹H-NMR and ¹³C-NMR, it was further proved that the methyl group is located at the 3-position of the benzene ring. Since the actual number of hydrogen in ¹H-NMR analysis was one more than 4-F-3-Methyl-α-PVP neutral molecule, it was inferred that the compound existed in the form of salt. Ion chromatography analysis results showed that the compound contained chlorine anion (content 11.14%-11.16%), with the structural analysis of main functional group information by FTIR, the unknown compound was finally determined to be 4-F-3-Methyl-α-PVP hydrochloride.

CONCLUSIONS

A comprehensive method using EI-MS, GC-MS, ESI-HRMS, UPLC-HRMS/MS, NMR, ion chromatography and FTIR to identify 4-F-3-Methyl-α-PVP hydrochloride in samples is established, which will be helpful for the forensic science laboratory to identify this compound or other analog compounds.

Research Progress on Biological Matrix Reference Materials in Forensic Toxicology

Biological matrix reference material is a reference material that combines the target material with the biological matrix. The biological matrix reference material has higher consistency with the authentic specimens in forensic toxicology, and its application has a positive effect on improving the accuracy of test results. This paper reviews the research on the matrix reference materials corresponding to three common biological test materials (blood, urine and hair). In order to provide reference for the development and application of biological matrix reference materials in forensic toxicology, this paper mainly introduces the research progress of preparation technology of biological matrix reference materials and some existing products and their parameters evaluation.

Analysis of Forty-Two Psychoactive Substances in a Single Hair by Micro-Segmental Technique

OBJECTIVES

To establish an LC-MS/MS method based on single hair micro-segmental technique, and verify the detection of 42 psychoactive substances in 0.4 mm hair segments.

METHODS

Each piece of single hair was cut into 0.4 mm segments and extracted by sonication and the segments were immersed in dithiothreitol-containing extraction medium. Mobile phase A was the aqueous solution containing 20 mmol/L ammonium acetate, 0.1% formic acid, and 5% acetonitrile. Mobile phase B was acetonitrile. An electrospray ionization source in positive ion mode was used for data acquisition in multiple reaction monitoring (MRM) mode.

RESULTS

The 42 psychoactive substances in hair had a good linear relationship within their respective linear ranges (r>0.99), the limits of detection were 0.2-10 pg/mm, the limits of quantification were 0.5-20 pg/mm, the intra-day and inter-day precisions were 1.5%-12.7%, the intra-day and inter-day accuracies were 86.5%-109.2%, the recovery rates were 68.1%-98.2%, and the matrix effects were 71.3%-111.7%. The method was applied to hair samples collected from one volunteer at 28 d after a single dose of zolpidem, with zolpidem detected in 5 hairs was 1.08-1.60 cm near the root tip, and the concentration range was 0.62-20.5 pg/mm.

CONCLUSIONS

The micro-segmental technique of single hair analysis can be applied to the investigation of drug-facilitated sexual assault cases.

Progress in the Application of Magnetic Nanoparticles in Forensic Trace Analysis

Given the complexity of biological samples and the trace nature of target materials in forensic trace analysis, a simple and effective method is needed to obtain sufficient target materials from complex substrates. Magnetic nanoparticles (MNPs) have shown a wide range of application value in many research fields, such as biomedicine, drug delivery and separation, due to their unique superparamagnetic properties, stable physical and chemical properties, biocompatibility, small size, high specific surface area and other characteristics. To apply MNPs in the pretreatment of forensic materials, maximize the extraction rate of the target materials, and minimize interference factors to meet the requirements of trace analysis of the target materials, this paper reviews the application of MNPs in the fields of forensic toxicological analysis, environmental forensic science, trace evidence analysis and criminal investigation in recent years, and provides research ideas for the application of MNPs in forensic trace analysis.

Remediation of Surfactants Used by VUV/O3 Techniques: Degradation Efficiency, Pathway and Toxicological Analysis

Surfactants are increasingly used in systems that come into contact with the human body, such as food, pharmaceuticals, cosmetics and personal hygiene products. Increasing attention is being devoted to the toxic effects of surfactants in various human contact formulations, as well as the removal of residual surfactants. In the presence of ozone (O₃), anion surfactants-a characteristic micro-pollutant-such as sodium dodecylbenzene sulfonate (SDBS) in greywater, can be removed using radical advanced oxidation. Herein, we report a systematic study of the SDBS degradation effect of O₃ activated by vacuum ultraviolet (VUV) irradiation and the influence of water composition on VUV/O₃, and determined the contribution of radical species. We show a synergistic effect of VUV and O₃, while VUV/O₃ reached a higher mineralization (50.37%) than that of VUV (10.63%) and O₃ (29.60%) alone. The main reactive radicals of VUV/O₃ were HO•. VUV/O₃ had an optimal pH of 9. The addition of SO₄^2- had almost no effect on the degradation of SDBS by VUV/O₃, Cl^- and HCO₃^- slightly reduced the reaction rate, and NO₃^- had a significant inhibition on the degradation. In total, SDBS had three isomers, with which the three degradation pathways were very comparable. Compared with SDBS, the toxicity and harmfulness of the degradation by-products of the VUV/O₃ process decreased. Additionally, VUV/O₃ could degrade synthetic anion surfactants from laundry greywater effectively. Overall, the results show the potential of VUV/O₃ in safeguarding humans from residual surfactant hazards.

Structure Analysis of the Interfering Substance N-methyl-2-phenylpropan-1-amine of Methamphetamine in Wastewater

OBJECTIVES

To analyze the chemical structure of the interfering substance that affects the result of methamphetamine analysis in wastewater.

METHODS

A combination of GC-MS and liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) was used to analyze the mass spectrum characteristics of the interfering substance that affects the result of methamphetamine analysis and to infer its possible structure. Liquid chromatography-triple quadrupole-mass spectrometry (LC-TQ-MS) was used to confirm the control material.

RESULTS

Using LC-QTOF-MS in positive electrospray ionization (ESI⁺) mode, the mass-to-charge ratio (m/z) of quasi-molecular ion in the MS¹ mass spectrometry of interfering substance was identical to that of methamphetamine, indicating that the interfering substance was probably an isomer of methamphetamine. The MS² mass spectra obtained at three collision energies of 15 V, 30 V and 45 V were highly similar to methamphetamine, suggesting that the interfering substance contained methylamino and benzyl groups. Further analysis using GC-MS in electron impact (EI) ionization mode showed that the base peak in the mass spectrum of the interfering substance was at m/z 44. The interfering substance was confirmed to be N-methyl-2-phenylpropan-1-amine by compared with the standard reference.

CONCLUSIONS

The chemical structure of N-methyl-2-phenylpropan-1-amine is highly similar to methamphetamine, which is easy to cause interference for the detection of trace amounts of methamphetamine in wastewater using LC-TQ-MS. Therefore, in the actual analysis, the chromatographic retention time can be used to distinguish between N-methyl-2-phenylpropan-1-amine and methamphetamine.

Advances in mass spectrometry imaging for toxicological analysis and safety evaluation of pharmaceuticals

Safety issues caused by pharmaceuticals have frequently occurred worldwide, posing a tremendous threat to human health. As an essential part of drug development, the toxicological analysis and safety evaluation is of great significance. In addition, the risk of pharmaceuticals accumulation in the environment and the monitoring of the toxicity from natural medicines have also received ongoing concerns. Due to a lack of spatial distribution information provided by common analytical methods, analyses that provide spatial dimensions could serve as complementary safety evaluation methods for better prediction and evaluation of drug toxicity. With advances in technical solutions and software algorithms, mass spectrometry imaging (MSI) has received increasing attention as a popular analytical tool that enables the simultaneous implementation of qualitative, quantitative, and localization without complex sample pretreatment and labeling steps. In recent years, MSI has become more attractive, powerful, and sensitive and has been applied in several scientific fields that can meet the safety assessment requirements. This review aims to cover a detailed summary of the various MSI technologies utilized in the biomedical and pharmaceutical area, including technical principles, advantages, current status, and future trends. Representative applications and developments in the safety-related issues of different pharmaceuticals and natural medicines are also described to provide a reference for pharmaceutical research, improve rational clinical medicine use, and ensure public safety.

New psychoactive substances and low-income countries: a burgeoning (and neglected) crisis

New psychoactive substances (NPS) are compounds intended to replicate the effects of legal and illegal drugs. The continuous detec-tion of new NPS via several forensic toxicology techniques attests to the considerable NPS popularity all over the world, although such determinations rely on still indecisive findings, given the elusiveness inherent in NPS and the the lack of standardized and uniformly applied detection and screening techniques. A worrisome and neglected issue is the proliferation of NPS and other drugs of abuse in developing countries. Demographics may partly explain such an emerging threat, which in a globalized world is likely to have an impact that goes well beyond national borders, especially in light of the criminal organiza-tions' ability to function and operate in the cyberspace, harnessing the potential of the "dark web" to overstep the boundaries and oversight mechanisms put in place by nations and international institutions.

Assessment of Physicochemical, Microbiological and Toxicological Hazards at an Illegal Landfill in Central Poland

This study aimed to assess the physicochemical, microbiological and toxicological hazards at an illegal landfill in central Poland. The research included the analysis of airborne dust (laser photometer), the number of microorganisms in the air, soil and leachate (culture method) and the microbial diversity in the landfill environment (high-throughput sequencing on the Illumina Miseq); the cytotoxicity (PrestoBlue) and genotoxicity (alkaline comet assay) of soil and leachate were tested. Moreover, an analysis of UHPLC-Q-ToF-UHRMS (ultra-high-performance liquid chromatography-quadrupole-time-of-flight ultrahigh-resolution mass spectrometry) was performed to determine the toxic compounds and microbial metabolites. The PM₁ dust fraction constituted 99.89% and 99.99% of total dust and exceeded the threshold of 0.025 mg m⁻³ at the tested locations. In the air, the total number of bacteria was 9.33 × 10¹–1.11 × 10³ CFU m⁻³, while fungi ranged from 1.17 × 10² to 4.73 × 10² CFU m⁻³. Psychrophilic bacteria were detected in the largest number in leachates (3.3 × 10⁴ to 2.69 × 10⁶ CFU mL⁻¹) and in soil samples (8.53 × 10⁵ to 1.28 × 10⁶ CFU g⁻¹). Bacteria belonging to Proteobacteria (42–64.7%), Bacteroidetes (4.2–23.7%), Actinobacteria (3.4–19.8%) and Firmicutes (0.7–6.3%) dominated. In the case of fungi, Basidiomycota (23.3–27.7%), Ascomycota (5.6–46.3%) and Mortierellomycota (3.1%) have the highest abundance. Bacteria (Bacillus, Clostridium, Cellulosimicrobium, Escherichia, Pseudomonas) and fungi (Microascus, Chrysosporium, Candida, Malassezia, Aspergillus, Alternaria, Fusarium, Stachybotrys, Cladosporium, Didymella) that are potentially hazardous to human health were detected in samples collected from the landfill. Tested leachates and soils were characterised by varied cyto/genotoxins. Common pesticides (carbamazepine, prometryn, terbutryn, permethrin, carbanilide, pyrethrin, carbaryl and prallethrin), quaternary ammonium compounds (benzalkonium chlorides), chemicals and/or polymer degradation products (melamine, triphenylphosphate, diphenylphtalate, insect repellent diethyltoluamide, and drugs (ketoprofen)) were found in soil and leachate samples. It has been proven that the tested landfill is the source of the emission of particulate matter; microorganisms (including potential pathogens) and cyto/genotoxic compounds.

Adulterants in drugs of abuse: a recent focus of a changing phenomenon

The adulteration of drugs of abuse is a well-known practice with alarming public health implications. In fact, the presence of other substances than those declared by the drug dealers may expose the consumers to unexpected adverse effects, even potentially fatal ones depending on the adulterant. Various adulterants are often added during the manufacturing process as cutting agent for deliberate underdosing, such as in case of levamisole for cocaine, or to strengthen the drug ef-fect, as in case of fentanyl for heroin. The authors aimed to elaborate on such unfolding dynamics and concluded that continuous development of effective analytical tools, along with a closely focused evaluation of each case by the medical doctor is essential to clarify the origin of the intoxications, so as to undertake the best therapeutic pathway.

Are Patients with Schizophrenia Reliably Reporting their Cannabis Use? An African Cross-sectional Study

BACKGROUND

Most studies of the prevalence of cannabis use among patients with schizophrenia used a self-report as declared by the patient himself. We hypothesize that patients with schizophrenia did not tell the truth and might underreport their use for many reasons to be discussed later. Indeed, the under-report of cannabis use among these patients can affect the effectiveness of their treatment.

AIMS

To assess the degree of agreement between the prevalence values obtained from patients' reports and the results of the toxicological tests.

METHODS

A cross-sectional study was carried out on 403 patients with schizophrenia. A sociodemographic, psychiatric history and illicit drug use profile was performed for each patient. We assessed the patients with the Positive and Negative Syndrome Scale (PANSS), Calgary Depression score (CDSS), Barratt Impulsiveness Score (BIS-10) and Medication Adherence Rating Scale (MARS). The consumption of cannabis used was confirmed with MINI International Neuropsychiatric Interview (MINI-DSM IV) and using toxicological analysis.

RESULTS

Among the 403 patients who consented to give their urine samples, 49.1% (198/403) tested positive for cannabis, and 41.41% (82/198) underreported their use. The sensitivity and specificity of the questionnaire were 0.58 and 0.74. Based on the comparison between sociodemographic and psychiatric history data of patients who self-report and underreport their cannabis use, no significant difference was observed except for the duration of cannabis use and the score on the medication adherence scale. Moreover, it was found that impulsivity, PANSS score, CDSS score, and the type of schizophrenia are not involved in predicting the underreporting of cannabis use.

CONCLUSION

The rate of patients who under-report cannabis use is important. Therefore, toxicological analysis is becoming relevant for identifying drug use among schizophrenic patients and in the addictive comorbidity research field.

Testing for Trenbolone, an Anabolic Steroid, in Biological Fluids and Head Hair in a Post-Mortem Case

A 60-year-old man was found dead at home by his wife. The man was known to be a regular trainer in a fitness center and was described as a long-term user of anabolic steroids. The autopsy revealed heart failure with a cardiomegaly, a visceral congestion and a pulmonary edema. The local prosecutor ordered toxicological analyses but no anatomic pathology test. Initial analyses by UPLC-q-TOF-MS system indicated the presence in femoral blood of trenbolone, an anabolic steroid. Trenbolone was quantified with a liquid chromatography system coupled with a tandem mass spectrometer in various autopsy specimens, including hair. Concentrations of trenbolone were 3.9, 3.2, 231 and lower than 0.5 ng/mL in femoral blood, cardiac blood, bile and vitreous humor, respectively. Moreover, in head hair the concentration was 9 pg/mg. The presence of trenbolone in hair can be interpreted as repetitive exposures when compared to the limited literature data. Repetitive misuse of trenbolone can explain the advanced heart failure. This paper highlights the importance to test biological specimens for anabolic steroids in case of heart failure.

The key role of mass spectrometry in comprehensive research on new psychoactive substances

New psychoactive substances (NPS) are a wide group of compounds that try to mimic the effects produced by the 'classical' illicit drugs, including cannabis (synthetic cannabinoids), cocaine and amphetamines (synthetic cathinones) or heroin (synthetic opioids), and which health effects are still unknown for most of them. Nowadays, more than 700 compounds are being monitored by official organisms, some of which have been recently identified in seizures and/or intoxication cases. Toxicological analysis plays a pivotal role in NPS research. A comprehensive investigation on NPS, from the first identification of a novel substance until its detection in drug users to help in diagnostics and medical treatment, requires the use of a wide variety of instruments and analytical strategies. This paper illustrates the key role of mass spectrometry (MS) along a comprehensive investigation on NPS. The synthetic cannabinoid XLR-11 and the synthetic cathinone 5-PPDi have been chosen as representative substances of the most consumed NPS families. Moreover, both compounds have been investigated at our laboratory in different stages of the three-step strategy considered in this article. The initial identification and characterisation of the compound in consumption products, the first reported metabolic pathway and the development of analytical methodologies for its determination (and/or their metabolites) in different toxicological samples are described. The analytical strategies and MS instruments are briefly discussed to show the reader the possibilities that MS instrumentation offer to analytical scientists. This publication aims to be a starting point for those interested on the NPS research field from an analytical chemistry point of view.

Can the Intake of a Synthetic Tryptamine be Detected Only by Blood Plasma Analysis? A Clinical Toxicology Case Involving 4-HO-MET

Tryptamines represent a group of hallucinogenic new psychoactive substances with increasing prevalence. Unfortunately, only limited data concerning their toxicology and bioanalysis is available as tryptamines are not included in routine screening procedures in many laboratories. In order to expand the current knowledge, we report a non-fatal clinical toxicology case involving the synthetic tryptamine 4-HO-MET (4-hydroxy-N-methyl-N-ethyl-tryptamine, 3-{2-[ethyl(methyl)amino]ethyl}-1H-indol-4-ol, metocin, or methylcybin). Only blood was available and our systematic blood plasma screening approaches based on gas chromatography-mass spectrometry (GC-MS) and liquid chromatography (LC) coupled to low-resolution linear ion trap mass spectrometry (ITMSn) or high-resolution tandem mass spectrometry (HRMS/MS) were conducted. The ingestion of the synthetic tryptamine 4-HO-MET could be revealed by blood plasma analysis using both LC-based systematic screening approaches, but not using GC-MS. Furthermore, the detection of metabolites, which may be used to confirm an intake of the parent compound 4-HO-MET, was only successful using LC-HRMS/MS most probably due to its increased sensitivity compared to LC-ITMSn. A total of four metabolites were detected in blood including N-demethyl-, oxo-, and hydroxy-4-HO-MET, as well as the N-oxide. Finally, LC-HRMS/MS analysis revealed a plasma concentration of 193 ng/mL for 4-HO-MET using the standard addition method. The presented data may help clinical and forensic toxicologists with the interpretation of future cases involving synthetic tryptamines, especially if only blood samples are available.

Prevalence of positive toxicology analysis from the French national registry for sudden unexpected infant death (Tox-MIN)

BACKGROUND

Sudden unexpected infant death (SUID) remains the leading cause of postnatal mortality in many countries. French and international guidelines recommend a thorough examination with toxicology studies.

OBJECTIVES

The main objective was to determine the prevalence of toxic detection and positive analyses. The secondary objectives were to describe the different toxics and compare children with positive (Tox+) and negative results (Tox-) with other SUID risk factors.

DESIGN AND METHODS

We used the data registered from May 2015 to December 2018 by the French national SUID registry (OMIN). It collects data for all SUID cases admitted to any of the 35 participating French SUID referral centers.

RESULTS

Of the 624 SUID cases registered in the OMIN, a post-mortem toxicological analysis was performed in 398 infants. Thirty-six patients (9%) were positives for expected (Etox+ (n = 19 [53%], e.g., resuscitation drugs, regular treatments) and unexpected (UTox+) (n = 17 [47%]) toxics. The unexpected toxics were opioids (n = 8), cannabis (n = 4), cocaine (n = 3), cotinine (n = 2), carbon monoxide (n = 2), caffeine (n = 2), alcohol (n = 1) and GHB (n = 1). UTox + infants had a different seasonal distribution (p = .03), a higher incidence of inappropriate sleeping position and bedding at the time of death (respectively OR 3.8, p = .037 - OR 5.4, p = .026); inadequate body hygiene (OR 10.6, p = .0005), a younger maternal age (p = .045) and a higher rate of maternal drug abuse (OR 21.9, p = .0008).

CONCLUSION

The high rate of positive results warrants routine toxicology testing. The imputability of identified molecules is complicated by the presence of other known risk factors for SUID.

The Interest of a Systematic Toxicological Analysis Combined with Forensic Advice to Improve the Judicial Investigation and Final Judgment in Drug Facilitated Sexual Assault Cases

The conviction rate in drug facilitated sexual assault (DFSA) cases is known to be very low. In addition, the potential impact of toxicological results on the case is often not well understood by the judicial authorities. The aims of this study were (1) to obtain more knowledge concerning the prevalence of incapacitating substances in DFSA cases, (2) to create a more efficient DFSA analysis strategy taking background information into account, and (3) to evaluate the potential impact of systematic toxicological analysis (STA) on the final judicial outcome. This small-scale epidemiological study (n = 79) demonstrates that ‘commonly-used’ illicit drugs, psychoactive medicines and ethanol are more prevalent in DFSA cases in contrast to the highly mediatized date rape drugs. Additionally, via case examples, the interest of performing STA—to prove incapacitation of the victim—in judicial procedures with mutual-consent discussions has been demonstrated as it led to increased convictions. However, more attention has to be paid to ensure a short sampling delay and to get more accurate information from the medical treatment of the alleged victim. This will improve the interpretation of the toxicological analysis and thus its applicability in a DFSA case. The future is multi-disciplinary and will certainly lead to an efficient and more cost-effective DFSA approach in which STA can impact the final judgment.

Prevalence of Stimulant, Hallucinogen, and Dissociative Substances Detected in Biological Samples of NPS-Intoxicated Patients in Italy

A number of new psychoactive substances (NPS) have been released in the last decade, and the list of NPS continues to grow. This paper reports a retrospective evaluation of the toxicological analyses in 1,445 suspected intoxication cases by psychostimulant, hallucinogen, and dissociative NPS occurring in hospitals across Italy from 2011 to 2019. The objectives of the study were to contribute to the monitoring of the NPS diffusion based on analytically confirmed intoxications, and to evaluate the importance of the clinical toxicological laboratory in the diagnosis of NPS intoxication. For at least one NPS of the considered classes, 246 patients (17.0%) tested positive. Forty-four different NPS were detected and a consistent turnover was observed during the nine-year period, especially regarding cathinones. Among the positive cases, 47.2% tested positive for dissociative NPS, with particular regard to ketamine. Hallucinogens (30.9%) was the second most frequent NPS involved. Stimulants were found in 20% of the positive cases with a considerable presence of cathinones. Findings confirm the dynamism of the NPS phenomenon, underline the importance of awareness of this new public health threat among health care professionals, and highlight the need for analytical confirmation for the identification of the drugs in forensic contexts.

Understanding the pharmacokinetics of synthetic cathinones: Evaluation of the blood-brain barrier permeability of 13 related compounds in rats

Synthetic cathinones are the second most commonly seized new psychoactive substance family in Europe. These compounds have been related to several intoxication cases, including fatalities. Although the pharmacological effects, metabolism, and pharmacokinetics of cathinones have been studied, there is little information about the permeability of these compounds through the blood-brain barrier (BBB). This is an important parameter to understand the behavior and potency of cathinones. In this work, 13 selected cathinones have been analyzed in telencephalon tissue from Sprague-Dawley rats intraperitoneally dosed at 3 mg/kg. Our results revealed a direct relationship between compound polarity and BBB permeability, with higher permeability for the more polar cathinones. The chemical moieties present in the cathinone had an important impact on the BBB permeability, with lengthening of the α-alkyl chain or functionalization of the aromatic ring with alkyl moieties resulting in lower concentration in telencephalon tissue. Our data suggest that transport of cathinones is a carrier-mediated process, similar to cocaine transport across the BBB.

Evaluation of the Use of a Coffee Industry By-Product in a Cereal-Based Extruded Food Product

The evaluation of by-products to be added to food products is complex, as the residues must be analyzed to demonstrate their potential use as safe foods, as well as to propose the appropriate process and product for recycling. Since coffee is a very popular beverage worldwide, the coffee industry is responsible for generating large amounts of by-products, which include the coffee silverskin (CS), the only by-product of the roasting process. In this work, its characterization and food safety were evaluated by chemical composition assays, microbiological determinations, aflatoxin measurements and acute toxicity tests. The results showed that CS is safe for use in food, in addition to providing dietary fiber, protein and bioactive compounds. An extruded cereal-based ready-to-eat food product was developed through an extreme vertices mixture design, producing an extruded food product being a source of protein and with a high fiber content. Up to 15% of CS was incorporated in the extruded product. This work contributes to the establishment of routes for the valorization of CS; nevertheless, further research is necessary to demonstrate the sustainability of this food industry by-product.

Toxicological Analysis Unveiling the Low Rate of Self-Reporting of Addictive/Recreative Substances in Acute Severe Drug Overdose Cases

OBJECTIVE

Toxicological analysis (TA) is advised when assessing the prognosis and the treatment of drug overdose patients. Apart from this use, the value of TA has remained unclear. This study aimed at defining the value of TA regarding the toxicological diagnosis in severe overdose cases that involved addictive or recreational drugs (ARDs) that were used either alone or in combination with medicinal drugs.

METHODS

The patients who were enrolled in the study had been admitted to our intensive care unit for the treatment of poisoning. TA was performed using advanced technologies such as mass spectrometry of blood/urine on admission. An occurrence indicated the supposed ingestion of a defined substance. Patients were included in a group depending on the combination of the occurrences of supposed ingested drugs (SID) and the results of the 1) TA: SID+, TA+; 2) SID+, not searched by TA; 3) SID-, TA+.

RESULTS

There were 224 occurrences of 90 substances in 70 patients. ARDs were present in 30 patients (43%). ARD accounted for 24 occurrences in the SID+, TA+ group, 10 occurrences in the SID+, not searched group and 196 occurrences in the SID-, TA+ group. In the SID+, TA+ group, 9 occurrences (69%) of ethanol were confirmed by TA. Ingestion of ethanol was invalidated in 4 occurrences (31%). In the patients who denied ethanol ingestion, TA confirmed the non-ingestion of ethanol using 30 blood measures (81%). Ethanol was involved in 57% of the patients, being the lone substance in only 1 case.

CONCLUSION

In drug overdose instances that result in organ failure(s) and involve ARDs, self-reporting is of limited value in assessing the patients' exposure to ARD. Multiple consumptions expose patients to unexpected drug interactions.

Adherence to antihypertensive drug treatment in patients with apparently treatment-resistant hypertension in the INSPiRED pilot study

PURPOSE

Drug adherence may be a major problem in the therapy of hypertension and in the diagnosis of therapy resistance. Adherence can be assessed by indirect methods or by direct methods like drug detection in urine with liquid chromatography-mass spectrometric methods.

MATERIALS AND METHODS

The current analysis included patients with apparently treatment- resistant hypertension (TRH) referred for renal denervation (RDN) and included in the the INSPiRED pilot trial (NCT01505010). Adherence was repeatedly assessed by toxicological urine analysis over a time range of up to 17 months in a total of 18 patients.

RESULTS

In the first urine samples of 18 patients the adherence rate (percentage of number of detected vs. prescribed medical drugs) ranged from 0 to 100% with a median of 73.2%. In further urine samples collected during the following up to 17 months every individual patient exhibited considerable changes in the adherence rate, neither a constancy nor a tendency could be deduced.

CONCLUSIONS

Urine analysis results exhibit variation over time and an assessment at a certain time point cannot be regarded as representative or predictor for future behavior. Therefore, it appears necessary to perform drug adherence testing repeatedly over time.

Comparative study of fatal consequences of illicit and prescription drugs use/abuse in Bratislava and its vicinity

Using/abusing of illicit drugs as well as prescription drugs represents a serious health and social problem. The aim of the work is to present results of retrospective - prospective analysis of cases of illicit and prescription drugs related deaths in the period of years 2001 - 2017 in autopsy material of Bratislava forensic medicine workplaces. The criteria matched 302 cases - 1.9 % of all autopsies. There were 62 % of illicit drugs related deaths and 38 % of prescription drugs related deaths.

Metabolic Profile of Flunitrazepam: Clinical and Forensic Toxicological Aspects

BACKGROUND

Flunitrazepam (FNZ) is a potent hypnotic, sedative, and amnestic drug used to treat insomnia and as a pre-anesthetic agent. The illicit practice in drug-facilitated sexual assault led to important clinical and forensic concerns.

OBJECTIVE

In this work the metabolism of FNZ, and pharmacological- and toxicological-related effects, were fully reviewed.

METHODS

FNZ and related known metabolizing enzymes and metabolites were searched in books and in PubMed (U.S. National Library of Medicine) without a limiting period.

RESULTS

Major metabolic pathways include N-demethylation, 3-hydroxylation, nitro-reduction, and further N-acetylation of the amino group, yielding N-desmethylflunitrazepam, 3-hydroxy-flunitrazepam, 7-aminoflunitrazepam, and 7-acetamidoflunitrazepam, respectively. A combination of these reactions may lead to the formation of 7-amino-N-desmethylflunitrazepam, 7-acetamido-N-desmethylflunitrazepam, 3- hydroxy-7-aminoflunitrazepam, 3-hydroxy-7-acetamidoflunitrazepam, 3-hydroxy-N-desmethylflunitrazepam and glucuronide conjugates. Genotypic variations in enzymes, interactions with other drugs or stability of FNZ during storage can result in large interindividual variability in the toxicological results.

CONCLUSION

It is aimed that knowing the metabolism of FNZ may lead to the development of new analytical strategies for early detection, since this drug is typically present in very low concentrations in blood and urine when used to facilitate sexual assault.

[The coroner's autopsies in the Great Britain: the problems related to the quality of the studies, standardization, auditing, financial support and the approaches to their solution]

This article continues the series of previous publications of the authors based on the analysis of the detailed report of the experts of the National Confidential Enquiry into Patient Outcome and Death program (NCEPOD) designed to evaluate the quality of autopsies carried out by the coroners in the Great Britain. It was shown that only in 13 to 55% of the 1,691 case the operators had an opportunity to refer the necropsy materials for the pathological study. The problems encountered in association with histological and toxicological analysis arose from the misunderstanding between the coroners and the pathologists as regard the organizational aspects of autopsy studies as swell as the financial and economic considerations. The Coroner Rules that had been adopted in 1984 and remained in force in the country until 2005 needed to be radically revised, corrected, and amended to facilitate the solution of a number of problems and eliminate the formal organizational and technical contradictions that hampered the further improvement of the quality of autopsies that must be performed by the corners at the national rather than the local level. The maximum number of the unacceptable results were revealed in the protocols of autopsires carried out by the forensic medical experts. All pathologists in the Great Britain are recommended to pay special attention to all cases of sudden death of the adult subjects and the deceased epileptic patients. The detailed investigations are mandatory in all cases of death following medical manipulations, such as surgical interventions, and complications.

Metabolic profile of oxazepam and related benzodiazepines: clinical and forensic aspects

Anxiolytic drugs, namely benzodiazepines, are the most commonly used psychoactive substances since anxiety disorders are prevalent mental disorders particularly in the Western world. Oxazepam is a short-acting benzodiazepine and one of the most frequently prescribed anxiolytic drugs. It is also the active metabolite of a wide range of other benzodiazepines, such as diazepam, ketazolam, temazepam, chlordiazepoxide, demoxazepam, halazepam, medazepam, prazepam, pinazepam, and chlorazepate. Therefore, relevant clinical and forensic outocomes may arise, namely those related to interference in driving performance. It is clinically available as a racemic formulation, with S-enantiomer being more active than R-enantiomer. In humans, it is mainly polimorphically metabolized by glucuronide conjugation at the 3-carbon hydroxyl group, yielding stable diastereomeric glucuronides (R- and S-oxazepam glucuronide). Relevant metabolic and stereoselective interspecies differences have been reported. In this work, the pharmacokinetics of oxazepam with particular focus on metabolic pathways is fully reviewed. Moreover, the metabolic profile of other prescribed benzodiazepines that produce oxazepam as a metabolite is also discussed. It is aimed that knowing the metabolism of oxazepam and related benzodiazepines may lead to the development of new analytical strategies for its early detection and help in further toxicological and clinical interpretations.

Fatal Folic Acid Toxicity in Humans

Folic acid is B-9 vitamin. Folic acid is prescribed commonly for pregnant women to prevent neural tube defects in the fetus, patients under chemotherapy, pernicious anemia and to reduce the risk of stroke and cardiovascular disease. Acute or chronic ingestion of a large dose of folic acid generally manifests as neurological complications, which are reversible. In this present case, a 23-year-old pregnant woman committed suicide by consuming folic acid tablets and succumbed to death within 36 h. Postmortem toxicological analysis detected folic acid in viscera. Death following acute consumption of folic acid is rare and has been not reported in the literature, to the best of our knowledge.

Metabolism and toxicological analysis of synthetic cannabinoids in biological fluids and tissues

Synthetic cannabinoids, which began proliferating in the United States in 2009, have gone through numerous iterations of modification to their chemical structures. More recent generations of compounds have been associated with significant adverse outcomes following use, including cognitive and psychomotor impairment, seizures, psychosis, tissue injury and death. These effects increase the urgency for forensic and public health laboratories to develop methods for the detection and identification of novel substances, and apply these to the determination of their metabolism and disposition in biological samples. This comprehensive review describes the history of the appearance of the drugs in the United States, discusses the naming conventions emerging to designate new structures, and describes the most prominent new compounds linked to the adverse effects now associated with their use. We review in depth the metabolic pathways that have been elucidated for the major members of each of the prevalent synthetic cannabinoid drug subclasses, the enzyme systems responsible for their metabolism, and the use of in silico approaches to assist in predicting and identifying the metabolites of novel compounds and drug subclasses that will continue to appear. Finally, we review and critique analytical methods applied to the detection of the drugs and their metabolites, including immunoassay screening, and liquid chromatography mass spectrometry confirmatory techniques applied to urine, serum, whole blood, oral fluid, hair, and tissues.

Coronary thrombosis and marijuana smoking: a case report and narrative review of the literature

We encountered evidence of myocardial infarction due to coronary thrombosis in an autopsy of an occasional marijuana smoker. These findings prompted us to perform a narrative review of the literature to determine when post-mortem toxicological tests may support a temporal relationship between marijuana smoking and cardiovascular disease. Toxicological examination showed the presence of Δ-9-tetrahydrocannabinol, its main metabolite and cannabinol in blood and urine. Quali-quantitative analysis revealed that Δ-9-tetrahydrocannabinol was taken within 2 h of the onset of cardiovascular symptoms, according to circumstantial data. Post-mortem toxicological results must take into account the degradation and post-mortem redistribution of analytes. However, for any inference about the specific cardiovascular triggering effect of Δ-9-tetrahydrocannabinol intake, we maintain that cannabinoid analysis in blood samples must be considered an essential requirement to estimate the time of last intake and avoid incomplete documentation. The literature, combined with the present case report, highlights an association between marijuana use and negative cardiovascular events, although few authors have supported their conclusions with toxicological results. Thus, additional research is needed.

The application of capillary electrophoresis techniques in toxicological analysis

Capillary electrophoresis (CE) comprises a group of techniques used to separate chemical mixtures. Analytical separation is based on different electrophoretic mobilities, thereby allowing qualitative and quantitative evaluations to be made. The application of CE in medical science, especially in toxicological studies, is developing rapidly because of the short time required for analysis and its high sensitivity, selectivity and ability to determine substances of an acidic, alkaline and neutral character. This review focuses on the possibility of applying CE in toxicological analysis. Advances in different CE analyses and detection techniques connected with this method are described.

A Historical and Comparative Review of the Reception of Forensic Medical and Scientific Evidence under Different Systems of Law

The purpose of this paper is to review the historical basis for the substantial differences which exist between the two main systems of law (common law and civil law) in the reception of forensic medical and scientific evidence by courts of law, and in the medico-legal investigation of sudden deaths in the community. The historical reasons for these differences are explained, and the relevant merits of procedures for presenting expert evidence in the courts of common law and civil law countries are discussed. The early appearance of forensic medical and scientific evidence in continental European (civil law) courts is contrasted with its long delayed introduction into common law countries. Special attention is given to the role of such evidence in the routine investigation of sudden death, which now serves an important public health function. The paper concludes by pointing to the paradox that the civil law countries have succeeded in ensuring that their courts of law receive the best forensic medical and scientific evidence, whilst at the same time failing to ensure that sudden deaths of unexplained cause are adequately investigated.