A Case Study Involving U-47700, Diclazepam and Flubromazepam-Application of Retrospective Analysis of HRMS Data.

The number of new psychoactive substances (NPS) available is constantly increasing, making it difficult for toxicology laboratories to keep screening methods up to date. Full scan high-resolution mass spectrometry (HRMS) is a versatile technique which allows for progressive updating of spectral databases to increase the scope of screening. It also allows for retrospective screening of data-specifically, reprocessing of data files using an updated spectral database without the need for re-extraction or reanalysis.The coronial case reported here illustrates the application of retrospective processing of HRMS data in the detection of emerging NPS. A 28-year-old male with a history of illicit drug use was found deceased at home. Initial routine screening of the post-mortem peripheral blood identified only methylamphetamine, amphetamine and trace amounts of lorazepam. A compound with an accurate mass and isotope ratio consistent with the opioid AH-7921 was also detected in the liquid chromatography (LC)-HRMS screen; however; the retention time and mass spectrum did not match the library. Further investigation confirmed the compound to be U-47700, another opioid and structural isomer of AH-7921. Several months later, after additional NPS had been added to the in-house HRMS database, retrospective screening of the HRMS data was performed, revealing the presence of designer benzodiazepines, diclazepam and flubromazepam as well as the psychedelic drug 2,5-dimethoxy-4-chloroamphetamine (DOC). Quantitative analysis gave the following results in peripheral post-mortem blood: U-47700 (330 µg/L), diclazepam (70 µg/L), flubromazepam (10 µg/L), methylamphetamine (290 µg/L) and amphetamine (150 µg/L) (DOC not quantitated). These substances, along with lorazepam and etizolam, were also confirmed in the post-mortem urine and an investigation into blood and urinary metabolites was carried out. All analyses were performed using the same LC-quadrupole-time of flight method. The cause of death was aspiration (of gastric content into airways and lungs) due to mixed drug toxicity.

The Increasing Use and Abuse of Tapentadol and Its Incorporation Into a Validated Quantitative Method.

Tapentadol is a centrally acting synthetic analgesic which is prescribed for the treatment of a range of chronic pain conditions. Its use in treating various pain conditions is increasing and, as with other opioids, it has the potential to be abused. We describe a three-stage incorporation of tapentadol into validated screening and quantitative methods through: (i) addition of retention time/mass spectral data to a database, (ii) qualitative validation and (iii) quantitative validation. This represents an efficient and flexible approach to the incorporation of new compounds of interest to existing screening methods. Tapentadol was analyzed in blood and serum samples using alkaline liquid-liquid extraction with identification and quantitation by liquid chromatography/time-of-flight mass spectrometry. In a series of six post-mortem cases where tapentadol was detected but was not a primary causative factor in death, blood concentrations ranged from 0.01 to 1.0 mg/L. In two cases where tapentadol was a significant contributor to death, post-mortem blood concentrations were 1.7 and 3.9 mg/L. In one of these fatal cases, ante-mortem blood and serum were also analyzed. The tapentadol concentration in the post-mortem blood was 30% higher than in the ante-mortem blood after a post-mortem interval of 13 days, indicating some potential for post-mortem redistribution. The measured ante-mortem blood:serum ratio was 1.7, and is the first such ratio to be reported. Other drugs were detected in almost all cases, with the majority being prescription analgesics, sedatives and antidepressants. The number of cases in which tapentadol has been detected has increased in recent years, highlighting the importance of screening for this drug in forensic toxicological laboratories.

Commemorative tattoos as markers for anniversary reactions and suicide.

Anniversary reactions include physical and/or psychiatric responses to the anniversary of the death of a person who was significant to the decedent. In the most extreme cases this may result in suicide. Two cases of suicide are reported to demonstrate the association with specific commemorative tattoos. Case 1: A 19-year-old man was found hanging by the neck by an electric flex in a shed. A commemorative tattoo had the name of his brother who had committed suicide by hanging in the same shed 9 years and 2 days previously. Case 2: A 47-year-old woman was found hanging by the neck by a rope attached to a metal beam in a shed at her home address. A commemorative tattoo had the name of her daughter who had committed suicide by hanging in the same shed 1 year and 5 days previously. Tattooing may record significant life events and so may be useful in a forensic context in helping to identify an unknown decedent. In cases of apparent suicide, correlating the details of a tattoo at autopsy with the available history or the date of death may also provide useful information that helps to clarify reasons for the event, as well as providing data on the incidence of significant anniversary reactions involving lethal self harm.

Heat-related deaths in Adelaide, South Australia: review of the literature and case findings - an Australian perspective.

Heat waves are not uncommon in Australia, but the event of 2009 was particularly severe and ranks third of the 21 recorded heat wave events in south-eastern Australia in terms of the resulting mortality and morbidity. This is a review of Coronial autopsy findings in South Australia (which has an area of nearly 1 million square kilometres with a population of 1.6 million that predominantly resides within the region of the capital: Adelaide) during the period of the 2009 heat wave. Fifty-four post-mortem examinations were performed on cases in which exposure to high ambient temperature was regarded as having caused or significantly contributed to the death. The findings (including results of toxicological and biochemical analyses, where available) are reviewed and compared with the post-mortem examination findings in 22 deaths over the same period not attributed to the effects of heat. There were no specific autopsy findings that distinguished heat-related from non heat-related deaths. The lack of specific post-mortem findings increases the reliance on scene investigation in order to be able to categorise a death as being heat-related. A checklist for scene investigators is proposed in order to assist with collection of relevant data to assist the Coronial investigation process.

Potential dangers of hay bailing.

Individuals engaged in farming have higher risks of injury and death from trauma than many other workers. Fatalities most often involve tractor-related incident such as roll-overs. Although it is also recognized that farm machinery may result in serious injuries and death, little has been reported on problems associated with hay baling, transport and storage. Case 1: A 43-year-old man trying to dislodge jammed hay in a hay baler had either been pulled, or had fallen, into the baler, where he had been crushed, rotated and then cocooned within a hay bale. The body showed extensive blunt trauma to the head, neck, chest, abdomen, pelvis and limbs, with burning from a fire that subsequently started within the overheated machine. Case 2: A 58-year-old man was crushed between the moving arms of a hay shuttle and a safety fence. Death was attributed to blunt chest and abdominal trauma with crush asphyxia. Case 3: A 56-year-old man fell some distance from the top of stacked hay bales fracturing his neck and causing virtual transection of his cervical spinal cord. These cases demonstrate rare forms of farm deaths that may be associated with the creation (baling), moving (shuttling) and storage of hay bales. All forms of farm machinery should be treated circumspectly, given the possibility that serious injury or death may result from inattention or inappropriate handling. Temporary stacking of hay bales may create high work platforms that risk falls with lethal consequences.

An audit of the contribution to post-mortem examination diagnosis of individual analyte results obtained from biochemical analysis of the vitreous.

Biochemical analysis of the vitreous humor from the eye is an accepted accessory test for post-mortem investigation of cause of death. Modern biochemical analyzers allow testing of a range of analytes from a sample. However, it is not clear which analytes should be requested in order to prevent unnecessary testing (and expense). The means and standard deviation of the values obtained from analysis of the vitreous humor for sodium, potassium, chloride, osmolality, glucose, ketones (ß-hydroxybutyrate), creatinine, urea, calcium, lactate, and ammonia were calculated from which the contribution of each analyte was reviewed in the context of post-mortem findings and final cause of death. For sodium 32 cases were regarded as high (more than one standard deviation above the mean), from which 9 contributed to post-mortem diagnosis [drowning (4), heat related death (2), diabetic hyperglycemia (2), and dehydration (1)], but 25 low values (greater than one standard deviation below the mean) made no contribution. For chloride 29 high values contributed to 4 cases--3 drowning and 1 heat-related, but these were all previously identified by a high sodium level. There were 29 high and 35 low potassium values, none of which contributed to determining the final cause of death. Of 22 high values of creatinine, 12 contributed to a diagnosis of renal failure. From 32 high values of urea, 18 contributed to 16 cases of renal failure (2 associated with diabetic hyperglycemia), 1 heat-related death, and one case with dehydration. Osmolarity contributed to 12 cases (5 heat-related, 4 diabetes, 2 renal failure, and 1 dehydration) from 36 high values. There was no contribution from 32 high values and 19 low values of calcium and there was no contribution from 4 high and 2 low values of ammonia. There were 11 high values of glucose, which contributed to the diagnosis of 6 cases of diabetic hyperglycemia and 21 high ketone levels contributed to 8 cases: 4 diabetic ketosis, 3 hypothermia, 3 ketosis of unknown cause, and 2 alcohol related deaths. A high lactate was identified in 25 cases, which contributed to 1 case with a diagnosis of metformin toxicity (1), but none of the 22 low lactate values contributed. The results of this audit have been used to reduce vitreous biochemistry test requests for sodium, osmolality, glucose, ketones, urea, and creatinine in most cases. Critical appraisal of each part of the post-mortem process should be undertaken to provide evidence to justify any investigative methods used in an autopsy.

Lethal head entrapment--a problem characteristic of early childhood.

Accidental deaths in infancy and early childhood often result from young childrens' lack of understanding of the dangers of certain situations and their physical inability to extricate themselves from potentially lethal circumstances. Two cases are reported to demonstrate an age-related susceptibility in the young to lethal head entrapment. Case 1: a 5-month-old girl smothered when she slipped down in her stroller, trapping her head beneath the frame and forcing her face into the soft material of the base. Case 2: a 14-month-old boy was hanged while exploring a filing cabinet when his head became caught between two lower drawers. Additional mental and physical characteristics that predispose young children and infants to lethal head entrapment include an inability to effectively problem solve once confronted with a hazardous situation, and relatively large heads and weak neck musculature. Because of these features lethal head entrapment represents a particular circumstance that may predispose to accidental asphyxial deaths in the very young. A combination of careful death scene and autopsy evaluations will be required to confirm the alleged circumstances of death in these cases, including mortuary re-enactments and assessment of the deceased infant's level of physical maturity and mobility.

Shopping cart injuries, entrapment, and childhood fatality.

Shopping carts may be associated with a variety of injuries, particularly in toddlers and young children. These usually relate to falls from carts or to tip-overs. Injuries that are sustained include hematomas/contusions, abrasions, lacerations, fractures, and fingertip amputations. Fatal episodes are uncommon and are usually due to blunt craniocerebral trauma from falls. A case involving a 19-month-old girl is reported who became entrapped when she inserted her head through the side frame of a cart that had been removed from a supermarket and left at her home address. Death was caused by neck compression. Although rare, the potential for lethal entrapment during unsupervised play means that the presence of stray shopping carts at private residences and in public places, including playgrounds and parks, is of concern. Strategies, such as coin deposits, should be encouraged to assist in the return of such carts to supermarkets.