Thermal desorption ambient ionization mass spectrometry for emergency toxicology.

In the emergency department, it is important to rapidly identify the toxic substances that have led to acute poisoning because different toxicants or toxins cause poisoning through different mechanisms, requiring disparate therapeutic strategies and precautions against contraindicating actions, and diverse directions of clinical course monitoring and prediction of prognosis. Ambient ionization mass spectrometry, a state-of-the-art technology, has been proved to be a fast, accurate, and user-friendly tool for rapidly identifying toxicants like residual pesticides on fruits and vegetables. In view of this, developing an analytical platform that explores the application of such a cutting-edge technology in a novel direction has been initiated a research program, namely, the rapid identification of toxic substances which might have caused acute poisoning in patients who visit the emergency department and requires an accurate diagnosis for correct clinical decision-making to bring about corresponding data-guided management. This review includes (i) a narrative account of the breakthrough in emergency toxicology brought about by the advent of ambient ionization mass spectrometry and (ii) a thorough discussion about the clinical implications and technical limitations of such a promising innovation for promoting toxicological tests from tier two-level to tier one level.

Generational synaptic functions of GABAA receptor ß3 subunit deteriorations in an animal model of social deficit.

BACKGROUND: Disruption of normal brain development is implicated in numerous psychiatric disorders with neurodevelopmental origins, including autism spectrum disorder (ASD). Widespread abnormalities in brain structure and functions caused by dysregulations of neurodevelopmental processes has been recently shown to exert adverse effects across generations. An imbalance between excitatory/inhibitory (E/I) transmission is the putative hypothesis of ASD pathogenesis, supporting by the specific implications of inhibitory γ-aminobutyric acid (GABA)ergic system in autistic individuals and animal models of ASD. However, the contribution of GABAergic system in the neuropathophysiology across generations of ASD is still unknown. Here, we uncover profound alterations in the expression and function of GABAA receptors (GABAARs) in the amygdala across generations of the VPA-induced animal model of ASD. METHODS: The F2 generation was produced by mating an F1 VPA-induced male offspring with naïve females after a single injection of VPA on embryonic day (E12.5) in F0. Autism-like behaviors were assessed by animal behavior tests. Expression and functional properties of GABAARs and related proteins were examined by using western blotting and electrophysiological techniques. RESULTS: Social deficit, repetitive behavior, and emotional comorbidities were demonstrated across two generations of the VPA-induced offspring. Decreased synaptic GABAAR and gephyrin levels, and inhibitory transmission were found in the amygdala from two generations of the VPA-induced offspring with greater reductions in the F2 generation. Weaker association of gephyrin with GABAAR was shown in the F2 generation than the F1 generation. Moreover, dysregulated NMDA-induced enhancements of gephyrin and GABAAR at the synapse in the VPA-induced offspring was worsened in the F2 generation than the F1 generation. Elevated glutamatergic modifications were additionally shown across generations of the VPA-induced offspring without generation difference. CONCLUSIONS: Taken together, these findings revealed the E/I synaptic abnormalities in the amygdala from two generations of the VPA-induced offspring with GABAergic deteriorations in the F2 generation, suggesting a potential therapeutic role of the GABAergic system to generational pathophysiology of ASD.

Mechanism of Intermittent Theta-Burst Stimulation in Synaptic Pathology in the Prefrontal Cortex in an Antidepressant-Resistant Depression Rat Model.

Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, is considered a potential therapy for treatment-resistant depression. The synaptic mechanism of iTBS has long been known to be an effective method to induce long-term potentiation (LTP)-like plasticity in humans. However, there is limited evidence as to whether the antidepressant effect of iTBS is associated with change in synaptic function in the prefrontal cortex (PFC) in preclinical study. Hence, we applied an antidepressant (i.e., fluoxetine)-resistant depression rat model induced by severe foot-shocks to investigate the antidepressant efficacy of iTBS in the synaptic pathology. The results showed that iTBS treatment improved not only the impaired LTP, but also the aberrant long-term depression in the PFC of antidepressant-resistant depression model rats. Moreover, the mechanism of LTP improvement by iTBS involved downstream molecules of brain-derived neurotrophic factor, while the mechanism of long-term depression improvement by iTBS involved downstream molecules of proBDNF. The aberrant spine morphology was also improved by iTBS treatment. This study demonstrated that the mechanism of the iTBS paradigm is complex and may regulate not only excitatory but also inhibitory synaptic effects in the PFC.

Differential mechanisms of synaptic plasticity for susceptibility and resilience to chronic social defeat stress in male mice.

Mood dysregulation refers to the inability of a person to control their negative emotions, and it is linked to various stressful experiences. Dysregulated neural synaptic plasticity and actin-filament dynamics are important regulators of stress response in animal models. However, until now, there is no evidence to differential the mechanisms of synaptic plasticity and actin-filament dynamics in stress susceptibility and stress-resistant. Here we found that depression-like behaviour was observed in the susceptible group following chronic social defeat stress (CSDS) exposure, but not in stress-resistant mice. High-frequency stimulation-induced long-term potentiation (LTP) was impaired in the CSDS-induced depression-susceptible group. Further, the levels of pro-brain derived neurotrophic factor (BDNF), mature BDNF, PSD-95, phosphorylated CaMKII, and phosphorylated Cofilin, an actin-filament dynamics regulator, were reduced in CSDS-induced depression-susceptible mice unlike in stress-resistant mice. These results demonstrate that synaptic plasticity-related molecules, such as BDNF and phosphorylated Cofilin, are important for maintaining synaptic functions and structure in mice that experience more stress.

Increased GABAergic inhibitory function against ischemic long-term potentiation in the CA1 region of the hippocampus.

Potentiation of N-methyl-D-aspartate receptor (NMDAR)-mediated excitatory synaptic plasticity around 1 h after brief exposure to anoxia/aglycemia is called ischemic long-term potentiation (iLTP), which is considered a pathological form of synaptic response during the early phase of ischemic stroke. It is known that GABAergic inhibitory transmission is also an important molecular process involved in synaptic plasticity and learning memory. However, whether GABAergic transmission is involved in iLTP and early-phase plasticity in ischemic stroke remains unknown. In this study, iLTP was found to be induced in the hippocampal Schaffer-collateral pathway by exposure to oxygen glucose deprivation (OGD). Western blot analysis was conducted to analyze excitatory synaptic receptors and inhibitory synaptic receptors following OGD. The ß3 subunit of the GABAA receptor (GABAAR) was markedly reduced, whereas the GluN2B subunit of the NMDAR was increased in the hippocampal area in the OGD group. Using extracellular recording, we demonstrated that application of GABAAR agonist midazolam could abolish the hippocampal iLTP. Moreover, midazolam had no significant effect on the increase in NMDAR subunit GluN2B, but ameliorated the reduction in the ß3 subunit of GABAAR after OGD. In summary, our results indicated that hippocampal GABAAR reduction promoted synaptic potentiation after OGD. Activation of GABAergic inhibitory transmission function could inhibit iLTP; thus, modulation of GABAergic function is a protective treatment method in the acute phase of synaptic plasticity in ischemic stroke.

Rapid identification of organophosphorus pesticides on contaminated skin and confirmation of adequate decontamination by ambient mass spectrometry in emergency settings.

RATIONALE: Dermal exposure to pesticides may cause severe intoxication and even result in a fatal outcome. To expedite rescue in the emergency department, it is mandatory to develop a point-of-care analytical method for immediate identification of pesticides on the skin of exposed personnel, and to perform immediate dermal decontamination to prevent further harm and optimize the chance for full clinical recovery. METHODS: Four of the most commonly used highly toxic pesticides that contaminate the skin were rapidly characterized by thermal desorption electrospray ionization mass spectrometry. The technique was also applied to confirm the completeness of pesticide decontamination from the skin. Pesticide sampling, desorption, ionization, and detection altogether took less than 30 s. In addition, different fabrics of protective garments worn by farmers were assessed with this efficient ambient mass spectrometric technique for their protective capabilities against dermal exposure to pesticides, and scanning electron microscopy was used to observe their different microstructures. The decontaminating efficacies of different cleansing agents for these skin contaminants were also evaluated by this technical platform. RESULTS: The repeatability of this method had a low relative standard deviation (<22%) for the detection of pesticides on the surface of swine skin. The detection limits of the pesticides in solution were found to be in the range of 3-20 ng/mL. Linearity was observed between the signal intensities and the concentrations of the four pesticides in solution within the range of 50 ng/mL to 50 µg/mL (R2 between 0.9921 and 0.9966). In addition, it was found that PVC fabric is optimal in preventing skin contamination by fenthion and detergent had the best efficiency for fenthion decontamination. CONCLUSIONS: Since the whole analytical process is extremely fast, this technique allows early point-of-care identification of contaminating pesticides on the skin of exposed patients in the emergency room, as well as rapid assessment of the adequacy of decontamination.

Rapid quantification of acetaminophen in plasma using solid-phase microextraction coupled with thermal desorption electrospray ionization mass spectrometry.

RATIONALE: Solid-phase microextraction coupled with thermal desorption electrospray ionization tandem mass spectrometry (SPME-TD-ESI-MS/MS) is proposed as a novel method for the rapid quantification of acetaminophen in plasma samples from a pharmacokinetics (PK) study. METHODS: Traces of acetaminophen were concentrated on commercial fused-silica fibers coated with a polar polyacrylate (PA) polymer using direct immersion SPME. No agitation, heating, addition of salt, or adjustment of the pH of the sample solution was applied during the extraction. Any acetaminophen absorbed on the SPME fibers was subsequently desorbed and detected by TD-ESI-MS/MS. RESULTS: Parameters of the absorption, sensitivity, reproducibility, and linearity for the SPME-TD-ESI-MS/MS method were evaluated. The time required to complete a TD-ESI-MS/MS analysis was less than 30 seconds. Matrix-matching calibration was performed to calculate the concentration of acetaminophen in the sample. A linear calibration curve with a concentration range of 100-10,000 ng/mL was constructed to calculate the quantity of acetaminophen. The SPME-TD-ESI-MS quantification results for acetaminophen in plasma were in good agreement with those obtained by the conventional LC/MS/MS method. CONCLUSIONS: With the proposed method, a 10-min SPME time was enough to achieve the lower limit of quantitation (i.e. 100 ng/mL) and for a complete PK profiling of acetaminophen. A shorter extraction time could be achieved by applying agitation, heating, adding salt, or adjusting the pH of the sample solution to enhance analyte absorption efficiency. The time required to detect acetaminophen on the SPME fiber was less than 30 s, allowing the rapid quantification of acetaminophen in plasma with good accuracy.

Ambient mass spectrometry for rapid diagnosis of psychoactive drugs overdose in an unstable patient.

A 25-year-old man suffered from consciousness change was sent to our emergency department by friends who reported that they were not sure what had happened to him. Physical examination revealed bilateral pupils dilatation, lethargy, slurred speech, and ataxia. Computer-aided tomographic scan of the brain revealed no definite evidence of intracranial lesions. Routine laboratory tests revealed total physiological turmoil. Despite immediate commencement of aggressive treatment, the patient's condition deteriorated long before the traditional drug screen provided an answer for the identities of the multiple drugs overdose. It ended up with the need for cardiopulmonary resuscitation, but in vain. At the end of the tragic event, under the suggestion of a colleague, a portion of the patient's urine specimen was sent to our university esoteric laboratory for rapid analysis by means of a newly-developed thermal desorption-electrospray ionization-mass spectrometry. Ketamine, 3,4-methylenedioxymethamphetamine, and 3,4-methylenedioxyamphetamine were identified in the urine sample within 30s. Conventional toxicological testing techniques like gas chromatography-mass spectrometry or liquid chromatography-mass spectrometry are currently used for identifying abused drugs. One concern is their time-consuming sample pretreatment which leads to relatively low efficiency in terms of turnaround time for revealing the identity of the consumed drugs particularly when the patients are severely overdosed. We learned a lesson from this case that a more efficient toxicological identification technique is essential to expedite the process of emergency care when the patients are so heavily overdosed that they are under critical life-threatening conditions.

Soluble Epoxide Hydrolase Inhibitor and 14,15-Epoxyeicosatrienoic Acid-Facilitated Long-Term Potentiation through cAMP and CaMKII in the Hippocampus.

Epoxyeicosatrienoic acids (EETs) are derived from arachidonic acid and metabolized by soluble epoxide hydrolase (sEH). The role of EETs in synaptic function in the central nervous system is still largely unknown. We found that pharmacological inhibition of sEH to stabilize endogenous EETs and exogenous 14,15-EET significantly increased the field excitatory postsynaptic potential (fEPSP) response in the CA1 area of the hippocampus, while additionally enhancing high-frequency stimulation- (HFS-) induced long-term potentiation (LTP) and forskolin- (FSK-) induced LTP. sEH inhibitor (sEHI) N-[1-(oxopropyl)-4-piperidinyl]-N'-[4-(trifluoromethoxy) phenyl)-urea (TPPU) and exogenous 14,15-EET increased HFS-LTP, which could be blocked by an N-methyl-D-aspartate (NMDA) receptor subunit NR2B antagonist. TPPU- or 14,15-EET-facilitated FSK-mediated LTP can be potentiated by an A1 adenosine receptor antagonist and a phosphodiesterase inhibitor, but is prevented by a cAMP-dependent protein kinase (PKA) inhibitor. sEHI and 14,15-EET upregulated the activation of extracellular signal-regulated kinases (ERKs) and Ca2+/calmodulin- (CaM-) dependent protein kinase II (CaMKII). Phosphorylation of synaptic receptors NR2B and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor subunit GluR1 was increased by TPPU and 14,15-EET administration. These results indicated that EETs increased NMDAR- and FSK-mediated synaptic potentiation via the AC-cAMP-PKA signaling cascade and upregulated the ERKs and CaMKII, resulting in increased phosphorylation of NR2B and GluR1 in the hippocampus.

Rapid point-of-care identification of oral medications in gastric lavage content by ambient mass spectrometry in the emergency room.

RATIONALE: Acute poisoning should be handled with high efficiency in order to minimize morbidity and mortality in the emergency room. Unfortunately, history-taking and physical examination are not always reliable. Mis-swallowing of oral medications is common in the pediatric group. This study aimed at developing a rapid point-of-care ambient mass spectrometric method for the early identification of ingested oral medications in gastric lavage content. METHODS: Four different types of oral medications that are most commonly mis-swallowed by children were diluted to different concentrations. Each of these chemical solutions was mixed with human gastric lavage content. A direct metallic sampling probe was dipped into the solution. It was then inserted promptly into the thermal desorption electrospray ionization source to carry out ionization and subsequent mass spectrometric analysis of the medications. The corresponding compounds were identified through matching of the obtained mass spectrometric data with those provided by well-established databases. RESULTS: Since no pretreatment of the specimen was required, the sampling step, and the subsequent thermal desorption electrospray ionization and mass spectrometric detection of the medications were completed within 30 s. Mass spectra were obtained for four different kinds of oral medication. The limit-of-detection of the four tested oral medications in gastric lavage content is at sub-ppm level, which is sensitive enough for emergency medicine applications since the quantities of medications ingested by pediatric patients are usually much higher. CONCLUSIONS: Thermal desorption electrospray ionization mass spectrometry, with informational support provided by an online mass spectral database, allows for early point-of-care identification of mis-swallowed oral medications in the evacuated gastric lavage contents obtained from gastric lavage of patients in the emergency room, and it is promising in providing important toxicological information to ensure the appropriateness of the subsequent medical management. Copyright © 2016 John Wiley & Sons, Ltd.

Different effectiveness of subthalamic deep brain stimulation in Parkinson's disease: A comparative cohort study at 1 year and 5 years.

BACKGROUND/PURPOSE: Subthalamic nucleus deep brain stimulation (STN-DBS) has been shown to produce long-term symptom improvement in Parkinson's disease. The aim of this study was to identify the target symptoms that show the most improvement at 1 year and at 5 years after STN-DBS. METHODS: This was a 5-year cohort study of 41 consecutive patients treated with bilateral STN-DBS. Clinical evaluations were performed 1 month prior to surgery and 1 year and 5 years after surgery. The outcome measurements at 1 year and 5 years were the changes compared with the baseline in Unified Parkinson's Disease Rating Scale (UPDRS) parts I, II, III, and IV scores, the Hoehn and Yahr stage, and Schwab and England Activities of Daily Living (SEADL) scores in the conditions of off-medication/on-stimulation and off-medication/off-stimulation. Further analysis included changes in the levodopa equivalent daily dose. RESULTS: When compared to the preoperative baseline off-medication condition, significant improvements were observed in the UPDRS parts I, II, III, and IV and SEADL (p < 0.001) scores in the off-medication/on-stimulation condition 1 year after STN-DBS. Five years after STN-DBS, improvements in UPDRS scores were observed only for parts II, III, and IV (p < 0.001). In the off-medication/off-stimulation condition, no significant improvement was observed. At 5 years, significant deteriorations were observed in scores for the UPDRS part III axial subitem (p = 0.005), UPDRS part I (p = 0.005), UPDRS part II (p < 0.001), and SEADL (p = 0.001). CONCLUSION: The long-term effect of STN-DBS on motor function is promising, although the magnitude of its effectiveness varied over the 5-year period.

Rapid Characterization of Undeclared Pharmaceuticals in Herbal Preparations by Ambient Ionization Mass Spectrometry for Emergency Care.

In Asia, some herbal preparations have been found to be adulterated with undeclared synthetic medicines to increase their therapeutic efficiency. Many of these adulterants were found to be toxic when overdosed and have been documented to bring about severe, even life-threatening acute poisoning events. The objective of this study is to develop a rapid and sensitive ambient ionization mass spectrometric platform to characterize the undeclared toxic adulterated ingredients in herbal preparations. Several common adulterants were spiked into different herbal preparations and human sera to simulate the clinical conditions of acute poisoning. They were then sampled with a metallic probe and analyzed by the thermal desorption-electrospray ionization mass spectrometry. The experimental parameters including sensitivity, specificity, accuracy, and turnaround time were prudently optimized in this study. Since tedious and time-consuming pretreatment of the sample is unnecessary, the toxic adulterants could be characterized within 60 s. The results can help emergency physicians to make clinical judgments and prescribe appropriate antidotes or supportive treatment in a time-sensitive manner.

Rapid identification of mushroom toxins by direct electrospray probe mass spectrometry for emergency care.

Mushroom poisoning occurs frequently after the ingestion of toxic wild mushrooms misidentified as edible species. The goal of this study is to develop a mass spectrometric platform to bypass the need for morphological recognition of poisonous mushrooms by experts and rapidly identify the toxins in the mushrooms for emergency care. Trace mushroom toxins were collected by penetrating and removing the mushrooms surface for 3 mm with a direct electrospray probe (DEP). The analytes on the DEP were then dissolved in the solution (70% isopropanol containing 0.1% acetic acid) flowing out of a solvent reservoir on the DEP. Electrospray ionization was induced from the sample solution as a high electric field was generated between the DEP and MS inlet. The obtaining mass spectrometric results were further analyzed with principal component analysis (PCA) to classify mushroom toxins. The mass spectrometric platform for detecting mushroom toxins was assessed for its sensitivity, precision, and efficiency by determining its limit-of-detection (LOD), repeatability, and turnaround time, respectively. As a result, the LODs of the mushroom toxins in pure methanol and spiked in human vomitus by DEP/MS were within 0.001-0.5 ng/µL and 0.01-1 ng/µL, respectively. Linear responses of the mushroom toxins in pure methanol with concentrations between 0.01 and 5 ng/µL (R2 between 0.9922 and 0.998) were obtained. The repeatability of the approach (n = 10) was shown in the low relative standard deviation value (<15%) from ten repeat analysis of mushroom toxins standard solution. The corresponding toxic compounds were identified through matching of the obtained mass spectrometric data with those provided by its companion database library of mushroom toxins. Since no time-consuming pretreatment of the samples is required, identification of mushroom toxins with DEP/MS was complete within 1 min. This will be helpful for the emergency physicians to make correct clinical judgment and prescribe appropriate medical treatment in a timely manner.

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician.

OBJECTIVES: The aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention. METHODS: A before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a "team norm" imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011-September 30, 2011) and after (October 1, 2011-January 30, 2012) intervention were compared. RESULTS: Patients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention. CONCLUSIONS: The intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.

The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge.

OBJECTIVES: The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. METHODS: This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. RESULTS: Of the 72188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001). CONCLUSIONS: Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.