Internet suicide guidelines: report of a life-threatening poisoning using tobacco extract.

BACKGROUND: Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site. OBJECTIVES: To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract. CASE REPORT: A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 microg/L) and cotinine peak levels (9092 microg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae. CONCLUSION: Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.

Mushroom Poisoning.

BACKGROUND: Poisonous mushrooms are eaten by mushroom hunters out of ignorance, after misidentification as edible mushrooms, or as a psychoactive drug. Mushroom poisoning commonly leads to consultation with a poison information center and to hospitalization. METHODS: This review is based on pertinent publications about the syndromes, toxins, and diagnostic modalities that are presented here, which were retrieved by a selective search in PubMed. It is additionally based on the authors' longstanding experience in the diagnosis and treatment of mushroom intoxication, expert consultation in suspected cases, macroscopic identification of wild mushrooms, and analytic techniques. RESULTS: A distinction is usually drawn between mushroom poisoning with a short latency of less than six hours, presenting with a gastrointestinal syndrome whose course is usually relatively harmless, and cases with a longer latency of six to 24 hours or more, whose course can be life-threatening (e.g., phalloides, gyromitra, orellanus, and rhabdomyolysis syndrome). The DRG diagnosis data for Germany over the period 2000-2018 include a total of 4412 hospitalizations and 22 deaths due to the toxic effects of mushroom consumption. 90% of the fatalities were due to the death cap mushroom (amatoxins). Gastrointestinal syndromes due to mushroom consumption can be caused not only by poisonous mushrooms, but also by the eating of microbially spoiled, raw, or inadequately cooked mushrooms, or by excessively copious or frequent mushroom consumption. CONCLUSION: There are few analytic techniques available other than the qualitative demonstration of amatoxins. Thus, the diagnosis is generally made on the basis of the clinical manifestations and their latency, along with meticulous history-taking, assisted by a mushroom expert, about the type(s) of mushroom that were consumed and the manner of their preparation.

Ethyl glucuronide determination: head hair versus non-head hair.

INTRODUCTION: In previous studies, hair analysis of ethyl glucuronide (EtG), a non-volatile, water-soluble, direct metabolite of ethanol, was shown to be adequate for the detection of social and chronic excessive alcohol consumption. As in some cases scalp hair is not available, the analysis of hair from alternative anatomical sites becomes of interest. AIMS: In this study, hair samples from head, beard, chest, armpit, stomach, pubis, arms and legs from 32 subjects were analyzed when available, in order to compare the EtG concentrations and to study if the cut-offs used for head hair could be used for non-head hair. METHODS: EtG was determined by GC/MS in negative chemical ionization mode using EtG-d5 as internal standard, after extraction by solid phase extraction using Oasis MAX columns and pentafluoropropionic anhydride (PFPA) derivatization. RESULTS: The results showed that in the cases of negative findings in head hair (EtG < 7 pg/mg), in 7 out of 12 cases negative results could also be found in non-head hair. The five others were positive, due to a positive EtG finding in pubic hair. In 20 cases of positive EtG results for head hair, in all cases positive results could also be found in non-head hair. CONCLUSIONS: In conclusion, although preliminary results indicate a clear trend regarding the accordance between EtG results in head hair and non-head hair, interpretation of non-head hair results remains to be carefully done for pubic hair, for which often higher concentrations have been found.

Simultaneous enantioselective quantification of methadone and of 2-ethylidene-1,5-dimethyl-3,3-diphenyl-pyrrolidine in oral fluid using capillary electrophoresis.

A capillary electrophoresis method was developed for the enantioselective quantification of methadone (MTD) and its main metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenyl-pyrrolidine (EDDP). The enantiomers of MTD and EDDP were resolved by CE in 5min using 0.2% highly sulphated gamma-cyclodextrins as chiral selectors and a 50mM phosphate solution at pH 4.5 as background electrolyte. The optimized method was applied and validated for oral fluid testing. Linear relationships were obtained for MTD enantiomers in the range of 8.1-625ng/mL and in the range of 7.6-500ng/mL for EDDP enantiomers. The detection limits ranged from 2.3 to 2.4ng/mL, whereas the limits of quantification ranged from 7.6 to 8.1ng/mL. Intra- and inter-assay precision and accuracy were acceptable, respectively. The method was applied to the analyses of 60 oral fluid specimens obtained from patients enrolled in a MTD maintenance programme. Our data pointed out that higher concentrations of (R)-MTD and the enantioselective excess of (S)-EDDP in OF may reflect the free fraction of MTD and EDDP enantiomers in plasma.

Determination of fentanyl in sweat and hair of a patient using transdermal patches.

Fentanyl is a synthetic opioid used to treat intense chronic pain. In this study, the authors report detection and quantification of fentanyl in sweat and hair of a patient receiving fentanyl (25 microg/h) via a transdermal therapeutic system (TTS) for 22 days. Sweat was collected using sweat patches every night on days 13-21 of the therapy, and hair was collected 12 weeks after the end of the treatment. Detection and quantification was performed with liquid chromatography-tandem mass spectrometry using electron spray ionization in selected reaction monitoring mode. Alfentanyl was used as internal standard for quantification in hair and in sweat. Sodium ions have been used as endogenous internal reference for determination of volume of sweat excreted on each patch. Results show presence of fentanyl in both matrices. Fentanyl concentrations in sweat varied from 0.17 to 1.02 ng/microL, and time-resolved segmented hair analysis showed a maximum fentanyl concentration of 0.48 ng/mg of hair during the period of the therapy.

Determination of the volume of sweat accumulated in a sweat-patch using sodium and potassium as internal reference.

In the present work, we assessed the suitability of sodium and potassium physiologically present in sweat, as internal reference allowing to re-calculate the corresponding volume of sweat collected on a PharmChek Patch. A method using capillary electrophoresis with indirect ultra-violet detection was developed for the determination of sodium and potassium in sweat. The concentrations determined in specimens collected from 12 females and 10 males, using a home-made system composed of polypropylene copolymer bag, were 1039+/-89 mg/L and 711+/-45 mg/L for sodium, and 489+/-293 mg/L and 474+/-196 mg/L for potassium, respectively. In parallel, for seven females and eight males, the comparison of the volume of sweat collected in the same way to the re-calculated volume of sweat accumulated in a patch using sodium as internal standard, gave an average agreement of 98.4+/-15.0%. Results demonstrated the usefulness of sodium as internal standard to determine the volume of sweat accumulated in a patch, and confirm the suitability of PharmChek patch for the collection and determination of cations in sweat.

Formation of scopolamine from N-butyl-scopolammonium bromide in cigarettes.

Scopolamine (hyoscine) is a naturally occurring alkaloid found in solonacea, the so-called "night shade" plants. Therapeutic applications of scopolamine are in ophthalmology to cause mydriasis and for the prevention of motion sickness, among others. It is known to induce hallucinogenic effects at a high dose. The N-butyl bromide derivative of scopolamine, available commercially as Buscopan, is commonly used as an antispasmotic. The possibility of forming scopolamine from N-butyl-scopolammonium bromide when burning cigarettes fortified with Buscopan was investigated based on a record of a prison inmate who claimed to experience hallucinations after smoking Buscopan. Liquid chromatography-tandem mass spectrometry in electrospray ionization mode was used to monitor the formation of scopolamine. Various series of eight cigarettes spiked with 10 mg of N-butyl-scopolammonium bromide with and without filters and in different smoking modes were investigated. The smoke of the burning cigarettes, the ashes, and the filter were analyzed for the presence of scopolamine. Scopolamine was detected in all cases.

Quantification of lorazepam and lormetazepam in human breast milk using GC-MS in the negative chemical ionization mode.

Lormetazepam (Loramet is a benzodiazepine mainly used as an hypnotic to treat insomnia. Lorazepam (Temesta) is used as an anxiolytic, tranquilizer, sedative, and anticonvulsant, and it is the major metabolite of lormetazepam. In this study, we designed a method to simultaneously detect and quantify these substances in human breast milk. Solid-phase extraction of 2 mL of milk was followed by derivatization with a trimethylsilyl reagent. Separation and detection was performed using gas chromatography coupled to mass spectrometry in the negative chemical ionization mode. Calibration curves were linear in the ranges of 10-200 and 1-20 ng/mL for lorazepam and lormetazepam, respectively. Limits of detection were estimated at 0.016 ng/mL for lormetazepam and 0.100 ng/mL for lorazepam. Our method was applied to real case samples from a woman receiving both benzodiazepines. Lorazepam concentrations varied from 55.3 to 123.1 ng/mL, and lormetazepam concentrations varied from 1.7 to 7.3 ng/mL.

Sensitive, rapid and validated gas chromatography/negative ion chemical ionization-mass spectrometry assay including derivatisation with a novel chiral agent for the enantioselective quantification of amphetamine-type stimulants in hair.

A novel chiral derivatisation agent, (2S,4R)-N-heptafluorobutyryl-4-heptafluorobutoyloxy-prolyl chloride, was used for the indirect resolution of amphetamine (AM), methamphetamine (MA), 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyethylamphetamine (MDEA) enantiomers using gas chromatography coupled to mass spectrometry operating in the negative-ion chemical ionization mode (GC/MS-NICI). This new chiral derivatisation reagent was readily obtained in optically pure form after a simple two-step synthesis. Optimal derivatisation was accomplished in 15 min at room temperature in a carbonate buffer and the resulting diastereoisomers were base line separated by GC in 12 min only. No racemization was observed during the derivatisation. The method was applied and fully validated for the enantiomeric quantification of amphetamines and methylenedioxylated amphetamines in hair. The analyses of 24 hair specimens from suspected ATS abusers showed that 24 cases were positive for MA and/or AM enantiomers and that in most cases the concentrations of (S)-MA and (S)-AM exceeded those of the corresponding (R)-enantiomers. One hair specimen was tested positive for both enantiomers of MDMA and MDA.

Relationship between blood alcohol concentration and carbohydrate-deficient transferrin among drivers.

Carbohydrate-deficient transferrin (CDT) was quantified in 408 blood specimens, randomly selected from 1260 drivers apprehended and submitted to blood alcohol concentration (BAC) determination. The first step of the study was to observe whether a BAC based pre-evaluation was relevant for deciding to test drivers for chronic alcohol abuse. For this purpose, the diagnosis of chronic alcohol abuse was verified by CDT quantification, with a voluntary high positive cut-off fixed at 3% for high specificity. The results display a significant increase in the part of chronic alcohol abusers with respect to increasing BAC: a few alcohol abusers were present in the BAC category below 0.5 g/L, and their frequency increased to 47 and 67% when BAC was between 3 and 3.5 g/L and above 3.5 g/L, respectively. Secondly, the usefulness of the biomarker CDT in the traffic safety context was investigated by observing whether drivers with abnormally increased CDT value had also higher BAC. The average BAC was 1.32 g/L in drivers with CDT below 1%, and increased to 2.28 g/L in drivers with CDT above 3%. Statistical analysis showed evidence of a monotone increasing link between BAC and CDT (P<0.0001). We confirmed here the relevance of BAC-based pre-evaluation before testing chronic alcohol abuse among drivers, and demonstrated that CDT is a biomarker suitable for traffic safety context, as drivers with increased CDT had significantly higher BAC.

Simultaneous enantioselective determination of amphetamine and congeners in hair specimens by negative chemical ionization gas chromatography-mass spectrometry.

Enantioselective quantification of amphetamine (AM), methamphetamine (MA), 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyethylamphetamine (MDEA) enantiomers in hair using gas chromatography-mass spectrometry (GC-MS) is described. Hair specimens were digested with 1M sodium hydroxide at 100 degrees C for 30 min and extracted by a solid phase procedure using Cleanscreen ZSDAU020. Extracted analytes were derivatised with (S)-heptafluorobutyrylprolyl chloride and the resulting diastereoisomers were quantified by GC-MS operating in the negative chemical ionization mode. Extraction yields were between 73.0 and 97.9%. Limits of detection varied in the range of 2.1-45.9 pg/mg hair, whereas the lowest limits of quantification varied between 4.3 and 91.8 pg/mg hair. Intra- and inter-assay precision and respective accuracy were acceptable. The enantiomeric ratios (R versus S) of AM, MA, MDA, MDMA and MDEA were determined in hair from suspected amphetamine abusers. Only MA and AM enantiomers were detectable in this collective and the quantification data showed in most cases higher concentrations of (R)-MA and (R)-AM than those of the corresponding (S)-enantiomers.

Drugs and chronic alcohol abuse in drivers.

Blood specimens from 210 drivers (179 male and 31 female) apprehended in Luxembourg from autumn 2001 to spring 2002 and requested for the determination of their blood alcohol concentration (BAC) were tested for medicinal drugs, illicit drugs, and chronic alcohol abuse (by quantification of the carbohydrate-deficient transferrin: CDT). These additional analyses were performed anonymously and with permission of state prosecutor. The 22.8% had consumed medicinal drugs, with benzodiazepines and antidepressants (10.9 and 7.6%, respectively) as main psychoactive classes. Cannabis was the most detected illicit drug (9.5%) but only one in three had THC detectable in their blood. Association of two or more psychoactive substances (poly-drug use) was observed in 27.6% of drivers (90.6% of drug consumers). On the basis of CDT values, 29.5% of drivers investigated were assumed to be chronic alcohol abusers. Statistical analysis revealed that chronic alcohol abuse and medicinal psychoactive drugs were associated with significantly higher BAC. Medicinal psychoactive drugs were clearly associated with poly-drug use, and were furthermore detected at supra-therapeutic levels in 34.9%.

HPLC analysis of generic antiretroviral drugs purchased in Rwanda.

A reversed phase HPLC method using photo diode array detection for the simultaneous quantification of lamivudine, stavudine, nevirapine, zidovudine, methyl paraben and propyl paraben in solid and liquid drug formulations was developed and validated. The separation was achieved using a Waters Symmetry C8 column, using a mobile phase gradient comprising 50 mM NaH2PO4 (pH 3.8) and acetonitrile (95:5 to 45:55, v/v) and a flow gradient (0.5 to 1.0 ml/min). The limits of detection and quantification were below 19 ng/ml and 55 ng/ml respectively. The intra- and inter-day assay precisions were within 4.4% relative standard deviations. The developed method was applied to 12 different generic antiretroviral medications, consisting of tablets, capsules and solutions, produced by two Indian manufacturers and purchased by the Central Agency of Essential Drug Procurement of Rwanda for the ESTHER project in Rwanda. The average content of the antiretroviral agent(s) compared to the labeled amount(s) was 101.4%. Methyl paraben and propyl paraben, added to solutions as preservatives, were within the FDA recommended limits.

[Alcohol, pharmaceuticals, illicit drugs and driving]. / Alcool, médicaments, stupéfiants au volant.

A great number of clinical, epidemiological, pharmacological and toxicological data on the influence of psychotropics on driving are available. These psychotropics include psycholeptics like ethanol, opioids, psychoanaleptics like cocaine, amphetamines and congeners, psychodysleptics like cannabis, LSD and magic mushrooms. General epidemiology and specific epidemiology for Luxembourg will be outlined. Practical aspects of roadside testing, forensic aspects as well as the place of hair testing in drugs and road safety issues will be discussed.

[25 years of toxicology in Luxembourg, contributions by the National Health Laboratory]. / Un quart de siècle de toxicologie au Luxembourg contributions du Laboratoire National de Santé.

A historical overview of the Institution and a retrospective of the most interesting works undertaken in the toxicology department as well as the methodology used in analytical clinical and forensic toxicology will be outlined. The main activities of the department are toxicological investigations of biological specimens of intoxicated patients as well as material involved in intoxication cases asked by sanitary and governmental authorities. Scientific research activities in the department as well as development and validation of analytical methodology will be reported.

GC/MS based identification of skunk spray maliciously deployed as "biological weapon" to harm civilians.

Our laboratory has been asked to elucidate the origin of a strong "toxic smell" present in a prominent politician's office, private house and motorcar. This stinky and pungent atmosphere has caused serious nausea and vomiting to several individuals. Urine samples were collected from the persons presenting symptoms of nausea for toxicological analysis. Drops, paper and cotton swabs of an oily liquid found at the implicated places were submitted by police to our laboratory for investigation. Methanol extracts of the drops were acetylated for gas chromatography/mass spectrometry (GC/MS) analysis in the electron impact mode; the cotton and paper swabs were analysed using headspace-gas chromatography/mass spectrometry (HS-GC/MS). The GC/MS analysis of the acetylated methanol extracts revealed that the major peaks of the chromatogram could be attributed to 2-methylquinoline, to 2-quinolinemethanethiol, to S-2-quinolinemethyl thioacetate, to 2-phenylethanethiol, to bis(E)-2-butenyl disulphide and to bis(3-methylbutyl) disulphide. Several volatile sulphur-containing compounds have been identified with the HS-GC/MS system. Detailed examination of the spectra as well as GC/MS analysis of commercially available skunk secret allowed us to relate the identified compounds to those present in the defence spray of skunks. No health sequels were observed for any of the persons implicated in this case.

Temporal variations of concentrations of currently used pesticides in the atmosphere of Strasbourg, France.

Atmospheric samples have been collected in Strasbourg between April 18 and May 29, 2007 and were analyzed for 71 current-use pesticides, of which 38 were detected. Average concentrations ranged from 0.09 ng m(-3) for Fenarimol to 110.42 ng m(-3) for Dimethachlor, which was slightly higher than the concentrations reported from other, comparable agricultural regions. Significant temporal variations were observed for 30 pesticides, and for most of them it could be shown that these were linked to time, temperature or atmospheric pressure. In several cases this helped to identify pesticide application just before or at the beginning of the sampling period, or ongoing treatment. Humidity, in contrast to previous reports, could not be linked to these variations. For the other 8 pesticides, only very little temporal variations were observed. Generally, these concentrations were low (less than 1 ng m(-3)), and it was assumed that they are not in use in Alsace at present.

Back to the roots of modern analytical toxicology: Jean Servais Stas and the Bocarmé murder case.

In 1850 the Belgian Count Hypolyte Visart de Bocarmé was accused of having killed his brother-in-law Gustave Fougnies by poisoning with nicotine. Bocarmé had isolated nicotine from tobacco leaves (Nicotiana tabacum). J. S. Stas (1813-1891) was committed expert and managed to convince the poisoner. He was the first scientist to deproteinize organ tissues by alcohol and could successfully identify nicotine after diethyl ether extraction from the victim's organs. During court trial this identification was challenged by his mentor M. J. B. Orfila from Paris, who had stated 3 years before, that it would never be possible to isolate and identify organic poisons from organ tissues.

Comparison of MTBSTFA and BSTFA in derivatization reactions of polar compounds prior to GC/MS analysis.

In this study, MTBSTFA and BSTFA, which are among the preferred derivatization reagents for silylation were both tested on derivatization of six different groups of polar chemicals to get information about usefulness in terms of sensitivity and specificity of both reagents. Tested compound groups were nitrophenols and methoxyphenols, sterols and sugars, dicarboxylic acids and hydroxylated polycyclic aromatic hydrocarbons. It was found that MTBSTFA-derivates produce characteristic fragmentation patterns presenting mainly the fragments [M](+), [M-57](+) and [M-131](+), of which [M-57](+) is generally dominant on the mass spectrogram. BSTFA-derivates mainly show the fragments [M](+), [M-15](+) and [M-89](+) whereof the molecular ion [M](+) is generally dominant. It was also found that steric hindrance and molecular mass play a very important role in the choice of the best suited derivatization reagent: compounds with sterically hindered sites derivatized with MTBSTFA produce very small analytical responses or no signal at all, and compounds with high molecular mass produce no characteristic fragmentation pattern when derivatization is performed with BSTFA. It was also found that MTBSTFA-derivatization facilitates separation of isomer analytes, suggesting its choice in combination to semi-polar columns, whilst BSTFA seems better for sterically hindered compounds. Findings were confirmed with applications of both reagents to biological and environmental matrices (urine and atmospheric aerosols).