[Alcohol and work. Consensus Document of the La.R.A. (Workers representing a risk for others) group]. / Alcol e Lavoro. Documento di consenso del gruppo La.R.A.

AIM: Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers. METHOD: A written document expressing agreement was produced following discussions between doctors, lawyers, bioethicists and social partners. RESULTS: There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consumption alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be violating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspectors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved. CONCLUSIONS: The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.

Targeted screening and quantification of synthetic cathinones and metabolites in hair by UHPLC-HRMS.

OBJECTIVE: Synthetic cathinones (SCs) are new psychoactive substances with sympathomimetic effects, which emerged into the illegal drug market to replace controlled stimulants. Since every year more powerful and toxic substances enter the illicit market, there is the need for analytical methodologies able to detect these new compounds in conventional and non-conventional biological matrices. We sought to develop and validate a targeted screening and quantification method for thirty-two parent SCs and two metabolites in hair samples by ultra-high-performance liquid chromatography coupled to high resolution mass spectrometry (UHPLC-HRMS). MATERIALS AND METHODS: 20 mg hair samples were soaked in 250 µL of 2 mM ammonium formate, methanol and acetonitrile mixture (50/25/25, v/v/v) and incubated overnight at 40°C. After incubation, the samples were evaporated to dryness under nitrogen stream and reconstituted with 100 µL of mobile phase mix (A:B, 80:20) and 10 µL were injected into UHPLC-HRMS. A Q ExactiveTM Focus Orbitrap Mass spectrometer with full scan and targeted data-dependent MS/MS scan acquisition was used for the screening and quantitation analysis. RESULTS: The assay was linear from 5 to 500 pg/mg hair for all the analytes under investigation. Intra-day and inter-day precision were always < 15% and matrix effect and analytical recovery were always within acceptable criteria (±25% and >50%, respectively). The developed method was applied to authentic hair samples from SCs consumers. The most prevalent found SCs were 3,4-Methylenedioxy-α-Pyrrolidinohexanophenone with a concentration range of 6.0-1,000.0 pg/mg along with α-Pyrrolidinohexiophenone (54.0 and 554.0 pg/mg, respectively), 3-Methylmetcathinone (556.0 and 5,000.0 pg/mg) and 4-Methylethcathinone (11.5 and 448.0 pg/mg) CONCLUSIONS: The developed method showed good selectivity, specificity, an easy and low-cost sample preparation and an analysis time compatible with a high throughput laboratory.

A survey of Italian and Spanish neonatologists and paediatricians regarding awareness of the diagnosis of FAS and FASD and maternal ethanol use during pregnancy.

BACKGROUND: Ethanol is the most widely used drug in the world and a human teratogen whose consumption among women of childbearing age has been steadily increasing. There are no Italian or Spanish statistics on ethanol consumption during pregnancy nor any information regarding prevalence of fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD). There is also a reasonable suspicion that these two diseases are underdiagnosed by professionals from the above-reported countries. The objectives of this study were: 1) to evaluate the experience, knowledge and confidence of Italian and Spanish neonatologists and paediatricians with respect to the diagnosis of FAS and FASD, and 2) to evaluate professionals awareness of maternal drinking patterns during pregnancy. METHODS: A multiple-choice anonymous questionnaire was e-mailed to Italian neonatologists registered in the mailing list of the corresponding Society and administered to Italian and Spanish paediatricians during their National Congress. RESULTS: The response rate was 16% (63/400) for the Italian neonatologists of the National Society while a total of 152 Spanish and 41 Italian paediatricians agreed to complete the questionnaire during National Congress. Over 90% of the surveyed physicians declared that FAS is an identifiable syndrome and over 60% of them identified at least one of the most important features of FAS. Although over 60% Italian responders and around 80% Spanish responders were aware that ethanol use in pregnancy is dangerous, approximately 50% Italian responders and 40% Spanish ones allowed women to drink sometimes a glass of wine or beer during pregnancy.Neonatologists and paediatricians rated confidence in the ability to diagnosis FAS and FASD as low, with over 50% responders feeling they needed more information regarding FAS and FASD identification in newborn and child. CONCLUSIONS: Italian and Spanish neonatologists and paediatricians do not feel confident about diagnosing FAS and FASD. More training is needed in order to accurately diagnose ethanol use during pregnancy and correctly inform pregnant women on the consequences on the newborn.

Commentary - Heroin purity and adulteration: an updated snapshot from the Italian Early Warning System.

Not Available.

[Prenatal exposure to drugs of abuse using meconium analysis in a low socioeconomic population in Barcelona]. / Exposición prenatal a drogas de abuso a través del análisis de meconio en una población de bajo nivel socioeconómico en Barcelona.

INTRODUCTION: For the first time in Europe, the <> aimed to estimate the prevalence of drug use by pregnant women and the subsequent foetal exposure to illicit drugs. PATIENTS AND METHOD: Between October 2002 and February 2004, 1209 mother-infant dyads from the Hospital del Mar, Barcelona, Spain met eligibility criteria and agreed to participate in the study. Data on socio-economic and demographic characteristics and on drug habits during pregnancy were collected using a structured questionnaire. Neonatal meconium was collected within 24h after birth and analyzed by standardized chromatographic techniques for the presence of opiates, cocaine, cannabinoids and amphetamines. RESULTS: Meconium analysis showed an overall 10.9% positivity for drugs of abuse, with a specific prevalence of heroin, cocaine and cannabis with foetal exposure of 4.7, 2.6 and 5.3%, respectively. Structured interviews also revealed that 0.3, 1.2 and 1.5% of mothers used heroin, cocaine and cannabis, respectively, while only one mother declared ecstasy consumption, confirmed by meconium analysis. Parental ethnicity and working class was not associated with drug use. Drug consuming mothers were shown to have a higher number of previous abortions when compared to non-consumer mothers, which was probably due to a lack of family planning. Significantly lower birth weight and length was found in newborns from mothers exposed to cocaine alone or in combination with other drugs. CONCLUSIONS: This study, although developed in a low socio-economic-status cohort, may serve as an eye opener for any hidden non-negligible drug consumption during pregnancy. In this sense, meconium analysis can be important to identify neonates with a high suspicion of exposure to drugs of abuse in utero, and provides the basis for appropriate treatment and adequate medical and social follow-up.

On-site screening and GC-MS analysis of cocaine and heroin metabolites in body-packers urine.

The illicit transportation of cocaine and heroin either swallowed or inserted into the rectum and/or vagina of individuals, defined as "body-packers", is becoming increasingly common. Assessment of smuggling by urinalysis from body-packers has been sparsely reported and on-site rapid screening methods are essentially lacking. We screened the presence of cocaine and heroin metabolites in urine from suspected body-packers by an on-site immunochromatographic test and confirmed the obtained results by gas chromatography-mass spectrometry and X-ray examination. Samples were collected from 64 individuals (45 men, 19 women) stopped at Fiumicino and Ciampino airports of Rome (Italy) for suspicion of internal concealment of cocaine and heroin between October 2006 and July 2007. Urine was immediately screened on-site by Cozart rapid urine test. Irrespective of test results, individuals underwent X-ray examination and urine samples were analyzed by gas chromatography-mass spectrometry (GC-MS). In 48 out of 64 cases (24 positives and 24 negatives) screening results were confirmed by GC-MS assay and X-ray examination. In 5 cases, positive to the on-site test and GC-MS analysis, abdominal radiography was negative and individuals resulted to be drug users. In 11 cases, negative to the on-site test and radiological investigation, GC-MS analysis found benzoylecgonine in 10 cases and morphine in one case. Concentration of both substances was in all cases lower than 50ng/ml and compatible with personal drug use. From obtained results, on-site detection of cocaine and heroin metabolites in the urine of suspected body-packers appears to be a reliable screening test to disclose internally concealed drugs and justify subsequent radiological investigations.

Synthetic cathinones related fatalities: an update.

OBJECTIVE: Synthetic cathinones, more commonly known as "bath salts", are synthetic drugs chemically related to cathinone, a psychostimulant found in the khat plant. They are the first most consumed products among new psychoactive substances, which cause psychostimulant and hallucinogenic effects determining a number of fatalities worldwide.  In this paper, we have systematically reviewed cases of synthetic cathinones-related fatalities analytically confirmed, which have occurred in the last few years. MATERIALS AND METHODS: Relevant scientific articles were identified in Medline, Cochrane Central, Scopus, Web of Science and Institutional/government websites up to November 2017 using the following keywords: synthetic cathinones, mephedrone, methylenedioxypyrovalerone, MDPV, methylone, ethylone, buthylone, fatal intoxication, fatalities and death. RESULTS: In total, 20 citations met the criteria for inclusion, representing several fatal cases with analytically confirmed synthetic cathinones in biological sample/s of the deceased. The death was attributed to hyperthermia, hypertension, cardiac arrest and more in general to the classic serotonin syndrome. Only rarely did the concentration of the parent drug causing fatality overcome the value of 1 mg/L in post-mortem biological fluids. CONCLUSIONS: Abuse of synthetic cathinones still represents a serious public health issue. Systematic clinical studies on both the animal and human model are lacking; therefore, the only available data are from the users who experience the possible hazardous consequences. Analytical methodologies for the identification of parent compounds and eventual metabolites both in ante-mortem and post-mortem cases need to be developed and validated. Analytical data should be shared through different communication platforms with the aim of stopping this serious health threat for drug users.

Hepatotoxicity associated with illicit use of anabolic androgenic steroids in doping.

Anabolic Androgenic Steroids (AAS) abuse and misuse is nowadays a harmful habit involving both professional or recreational athletes, as well as general population. AAS are also frequently present in over-the-counter dietary supplements without being declared in the list of ingredients, leaving consumers unaware of the risks of adverse effects. Indeed, health risks of AAS consumption in pharmaceutical preparations or dietary complements seem still underestimated and under-reported. The variety of complications due to AAS misuse involves cardiovascular, central nervous, musculoskeletal and genitourinary systems of both males and females; psychiatric and behavioral effects, damages to metabolic system, skin and mainly liver. For instance, relevant concern has been raised by the AAS hepatotoxicity including adenoma, hepatocellular carcinoma, cholestasis, and peliosis hepatis. The present review reports the information available on the hepatotoxic effects of AAS use in professional and amateur athletes.

"Vehicular homicide", a new Italian offence: law provisions and comparison with some other European countries.

According to the most recent World Health Organization report, road accidents represent a very serious public health issue, claiming each year more than 1.2 million lives worldwide and being the leading cause of death among young people aged between 15 and 29 years. Up to now, the policies to reduce this issue are different, unbalanced and often inadequate not only in Italy, but also in the other European Countries. Specifically, the Italian Parliament has recently introduced a new law (n. 41 of March 23rd, 2016), making vehicular homicide together with road traffic injuries a criminal offense, both to be punished as a result of negligence. The measure came into force on March 25th, 2016. In this paper, the provisions of the above-reported law have been assessed, taking into account the modifications introduced in the Penal Code by this law and the impact it is having and will have on drivers on a day-to-day basis. Similarities and differences with legislative framework of some other European countries were also examined. Finally, some open questions to be solved are named as an open eye for future considerations.

Application of a validated high-performance liquid chromatography-mass spectrometry assay to the analysis of m- and p-hydroxybenzoylecgonine in meconium.

A high-performance liquid chromatography (HPLC)-mass spectrometry (MS) assay, already validated for opiates and cocaine in meconium, has been re-applied for determination of m- and p-hydroxybenzoylecgonine, using nalorphine as the internal standard. Methodology included an initial extraction from the matrix by methanol and then a solid-phase extraction (SPE). A reversed-phase chromatography was used with a gradient of 1% acetic acid-acetonitrile coupled to atmospheric pressure ionization electrospray-mass spectrometry single ion monitoring mode. This method, validated in the range 0.005-1.00 microg analytes/g meconium, proved useful to identify and quantify these two metabolites in meconium samples, already tested for the presence of cocaine, benzoylecgonine and cocaethylene. A positivity of range of concentrations varied between 0.007 and 0.338 microg/g, confirming the importance of these two hydroxylated derivatives to monitor fetal exposure to cocaine.

Prenatal exposure to arecoline (areca nut alkaloid) and birth outcomes.

The betel nut is commonly used as a drug by Asian populations. A high prevalence of adverse pregnancy outcomes has been reported in women who chewed betel quid during gestation. The hypothesis that chronic exposure of the fetus to arecoline (the principal alkaloid of the areca nut) is the cause was investigated in a clinical observational study on six newborns from Asian mothers who chewed betel nut during pregnancy.

How the steady-state cotinine concentration in cigarette smokers is directly related to nicotine intake.

The relationship between nicotine intake and steady-state cotinine concentration was studied in a sample of 125 subjects who smoked their usual brands of cigarettes. Nicotine and tar yield of cigarettes was determined with a smoking machine, under standardized conditions. Blood was drawn about 8 hours after the last cigarette was smoked and serum cotinine was measured by high performance liquid chromatography. Cotinine levels ranged from 11 to 400 ng/ml, and nicotine daily intake ranged from 1 to 33 mg/day. Regression analysis and the correlation coefficient, r = 0.919, significant at p less than 0.0001, showed that steady-state cotinine level was linearly and directly related to daily available nicotine, with an increase in correlation coefficient directly related to the increase in tar and nicotine yield. From the findings we also conclude that smokers of low-tar cigarettes do not tend to compensate for lower yields of nicotine.

Modified procedure for labelling target cells in a europium release assay of natural killer cell activity.

Lanthanide europium chelated to diethylenetriaminopentaacetate (EuDTPA) can be used to label target cells such as tumor cells and lymphocytes (Blomberg et al., 1986a,b; Granberg et al., 1988). This procedure has permitted the development of new non-radioactive methods for the detection of target cell cytolysis by natural killer (NK) cells (Blomberg et al., 1986a,b), cytotoxic T lymphocytes (CTL) (Granberg et al., 1988) or complement-mediated cytolysis (Cui et al., 1992). However, we had no success with this method because of a lack of comparability between human NK cell activity simultaneously measured by a classical 51Cr release assay (Seaman et al., 1981) and EuDTPA release assay (Blomberg et al., 1986a). Furthermore, cell division and cell viability were significantly impaired by the suggested concentrations of EuCl3. In this paper, we present a modified non-cytotoxic method for target cell labelling with EuDTPA while cells are growing in culture medium.

Evaluation of immunoassays for the measurement of soluble transferrin receptor as an indirect biomarker of recombinant human erythropoietin misuse in sport.

Soluble transferrin receptor (sTfR) has been proposed as an indirect biomarker of the misuse of recombinant human erythropoietin in sport. An extended validation of four commercially available immunoassays for its measurement in serum is presented. Two ELISA techniques (ELISA1: Orion Diagnostica; ELISA2: R&D Systems), an immunoturbidimetric technique (Turbid: Roche Diagnostics), and a nephelometric technique (Nephel: Dade Behring) were investigated. Intra-laboratory precision better than 3% and correct accuracies were obtained for the Turbid and Nephel techniques using autoanalysers. Slightly worse precision (but always better than 11%) and correct accuracies were also obtained in almost all cases for the two ELISA techniques. Inter-laboratory results showed higher concordances for the ELISA procedures (intraclass correlation coefficients of 0.848 for ELISA1 and 0.973 for ELISA2 which was clearly better). Inter-technique correlations were good for the four techniques with lower dispersions found for the techniques using autoanalysers, i.e. Turbid and Nephel. While Turbid and ELISA1 results (expressed in mg/l) were comparable, results obtained with Nephel were approximately 2.7 times lower. The relationship between those three techniques was maintained when compared with ELISA2, which uses different units (nmol/l). We conclude that ELISA2 and Nephel in our hands were the most suitable techniques in terms of sensitivity, precision and accuracy, and adequacy of the calibration curve for the measurement of sTfR in real serum samples. Discrepancies observed in the results obtained with the different sTfR techniques showed that different reference standards were used and harmonization is recommended in order to obtain comparable results.

Drugs in semen.

Over the past 50 years, a decline in the quality of semen has been observed, possibly resulting in a reduction in male fertility. Among the factors affecting semen quality, exposure to drugs is of particular importance. It is known that drugs can be transported to the seminal plasma, which is made up of secretions from the various accessory genital glands. There is evidence that many drugs enter the male genitourinary tract by an ion-trapping process. Lipid solubility and the degree of ionisation of the drug, which depend on the pH of plasma and seminal fluid, are important factors in this process. To date, few studies have been conducted on this topic. Pharmacokinetic evaluation of the fluids of the male accessory gland have been performed in the case of chloroquine and caffeine only, while the effects of mesalazine (5-aminosalicylic acid), sulfasalazine, salicylate, propranolol, diltiazem, flunarizine, verapamil, caffeine and nicotine on sperm physiology and morphology have been examined. Although data from the literature are scarce and incomplete, it is evident that many drugs can be excreted into semen. These drugs may interfere with the most common semen characteristics, potentially resulting in a male-mediated teratogenic effect, or local and systemic responses in female recipients. Therefore, it may be advisable to include, in the processes of drug development, pharmacokinetic evaluation of a drug in the semen and analysis of standard microscopic parameters of the semen. This is particularly important for drugs known to concentrate in the semen.

Drug monitoring in nonconventional biological fluids and matrices.

Determination of the concentration of drugs and metabolites in biological fluids or matrices other than blood or urine (most commonly used in laboratory testing) may be of interest in certain areas of drug concentration monitoring. Saliva is the only fluid which can be used successfully as a substitute for blood in therapeutic drug monitoring, while an individual's past history of medication, compliance and drug abuse, can be obtained from drug analysis of the hair or nails. Drug concentrations in the bile and faeces can account for excretion of drugs and metabolites other than by the renal route. Furthermore, it is important that certain matrices (tears, nails, cerebrospinal fluid, bronchial secretions, peritoneal fluid and interstitial fluid) are analysed, as these may reveal the presence of a drug at the site of action; others (fetal blood, amniotic fluid and breast milk) are useful for determining fetal and perinatal exposure to drugs. Finally, drug monitoring in fluids such as cervical mucus and seminal fluid can be associated with morpho-physiological modifications and genotoxic effects. Drug concentration measurement in nonconventional matrices and fluids, although sometimes expensive and difficult to carry out, should therefore be considered for inclusion in studies of the pharmacokinetics and pharmacodynamics of new drugs.

Drugs in nails: physiology, pharmacokinetics and forensic toxicology.

In recent years, drug analysis in keratinised matrices, such as hair and nails, has received considerable attention because of several advantages over drug testing methodologies employing body fluids, such as urine or serum. For example, keratinic matrices, such as finger- and toenails, can accumulate drugs during long term exposure. Drugs are incorporated into nails by a double mechanism: (i) deposition into the root of the growing nail via the blood flow in the nail matrix; and (ii) incorporation via the nail bed during growth from the lunula to the beginning of the free margin. Together, these account for a wide retrospective window of drug detection. Nails can provide a good forensic matrix for the detection of drugs of abuse. Indeed, the international literature has reported the use of nail analysis in postmortem detection of drugs of abuse, drug testing in the workplace and drug screening to detect prenatal exposure, even though further studies are needed for correct interpretation of the data obtained. Another application of drug analysis in nails consists of the possibility of detecting the presence of an antimycotic at the site of action during antifungal therapy for patients with onychomycosis. When available, this evidence has permitted drug treatment of a shorter duration and reduced toxicity. However, so far the potential of drug monitoring in nails still lacks harmonisation and validation of analytical methodologies and a better comprehension of the possible correlation between drug concentrations in the matrix and period of exposure.

Cord serum cotinine as a biomarker of fetal exposure to cigarette smoke at the end of pregnancy.

This study investigated the association between biomarkers of fetal exposure to cigarette smoke at the end of pregnancy, cotinine in cord serum and in maternal and newborn urine samples, and quantitative measurement of smoking intake and exposure evaluated by maternal self-reported questionnaire. Study subjects were 429 mothers and their newborns from a hospital in Barcelona, Spain. A questionnaire including smoking habits was completed in the third trimester of pregnancy and on the day of delivery. Cotinine concentration in cord serum was associated with daily exposure to nicotine in nonsmokers and with daily nicotine intake in smokers. The geometric mean of cotinine concentration in cord serum statistically discriminated between newborns from nonexposed and exposed nonsmoking mothers, and between these two classes and smokers, and furthermore was able to differentiate levels of exposure to tobacco smoke and levels of intake stratified in tertiles. Urinary cotinine levels in newborns from nonsmoking mothers exposed to more than 4 mg nicotine daily were statistically different from levels in two other categories of exposure. Cotinine concentration in urine from newborns and from mothers did not differentiate between exposure and nonexposure to environmental tobacco smoke (ETS) in nonsmoking mothers. Cord serum cotinine appeared to be the most adequate biomarker of fetal exposure to smoking at the end of pregnancy, distinguishing not only active smoking from passive smoking, but also exposure to ETS from nonexposure.

Immunomodulating activity of MDMA.

MDMA (3,4-methylenedioxymethamphetamine) use can cause neurochemical, behavioral and endocrine alterations, similar to those produced by exposure to acute stress, suggesting its potential as a "chemical stressor." It is known that stressful stimuli can produce a depression of immune function and an alteration in immune cells distribution. In vitro exposure to MDMA resulted in a modulation of several immune functional parameters such as T-cell regulatory function, cytotoxic T-lymphocyte activity, natural killer cell activity and macrophage function. Administration of MDMA in rats produced a rapid and sustained suppression of induced lymphocytes proliferation and a significant decrease in circulating lymphocytes. These alterations in rat immune function were accompanied by a significant rapid increase in plasma corticosterone concentrations. It was postulated that the result of altered induced proliferation response of lymphocytes could have been due to a combined effect of direct action of MDMA on lymphocytes and to the activation of the hypothalamic pituitary adrenal axis (HPA axis) and/or the sympathetic nervous system (SNS) via central mechanisms. In humans, acute MDMA treatment produced a time-dependent immune dysfunction associated with MDMA plasma concentrations. Although total leukocyte count remained unchanged, there was a decrease in CD4+ T-cells and functional responsiveness of lymphocytes to mitogenic stimulation, while percentage of natural killer cells significantly increased. A rise of cortisol plasma concentrations similar to that observed in the rat model supported the hypothesis of MDMA-induced release of corticotrophin-releasing factor from the median eminence of the hypothalamus and subsequent HPA axis and SNS activation. The present findings indicate that MDMA ingestion may represent a potential health hazard for an increased risk of immune system-related diseases.