Quantitation of Synthetic Cannabinoid Receptor Agonists in Postmortem Blood Using a Single Point Calibration.

Synthetic cannabinoid receptor agonists (SCRA) share minimal structural similarities to tetrahydrocannabinol or themselves. Due to their heterogeneous structures and the rapid appearance and disappearance of new SCRA on the drug scene, the quantitation of SCRA has not been attempted extensively. We present a wide series of SCRA concentrations based on a single-point calibration using peak height ratios for the extracted ion chromatogram of the protonated precursor ion against that of the internal standard. These concentrations are viewed as indicative only given the use of a single concentration "calibrator" based on the response of a deuterated analogue of a structurally related compound. What is of note, is that, despite the potential differences in potency the majority of SCRA seem to have relatively similar concentrations in postmortem cases.

Femoral blood concentrations of the designer benzodiazepine etizolam in post-mortem cases.

Etizolam is a thienodiazepine that although licensed for clinical usage in Japan, India and South Korea is commonly abused and detected in post-mortem cases around the world. To date, there are limited data in the literature to allow for the interpretation of blood concentrations of etizolam in post-mortem cases. A liquid chromatography with tandem mass spectrometry method was used to quantitate etizolam concentrations in 28 post-mortem cases where etizolam was detected. The median concentration of etizolam in femoral blood was 8.5 ng/mL (range 1.0-172.0 ng/mL; n = 24); in antemortem plasma, the etizolam concentration range was 4-44 ng/mL (n = 4). The mean age of the individuals abusing etizolam was 38.5 ± 8.4 years (median 39 years), with the majority being male (86%). In all of the cases, multiple drugs were detected, with the most common being pregabalin (61%) followed by morphine/heroin (54%), diazepam (54%) and benzoylecgonine (21%), illustrating the increasing problem of poly-substance use in drug abusers. The cause of death in the cases in which etizolam was detected was multi-drug toxicity in 87.5% of the cases, with 12.5% unrelated to drug use (hangings and blunt-force trauma). These data will further help forensic practitioners with the interpretation of post-mortem etizolam concentrations.

Flubromazolam: Detection in five post-mortem cases.

Flubromazolam is a potent triazole benzodiazepine with moderately long-lasting central nervous system-depressant effects relative to other benzodiazepines such as commonly prescribed diazepam. Flubromazolam has been studied in the living. However, there are no published reports including measured drug concentrations in post-mortem cases. We report five cases in which flubromazolam was detected in a systematic screen using high-resolution mass spectrometry and then quantified in femoral blood. In none of the five cases was the cause of death directly attributed to flubromazolam toxicity, as there was a variety of both sedative and stimulant drugs also present. However, it is important that the drug concentrations that were measured are made available for future post-mortem forensic interpretation.

Post-mortem diagnosis of kidney impairment: An experimental study.

The determination of the role that drugs may have played in a death is an important part of the investigation into unexplained deaths. Renal impairment may lead to a reduction in drug excretion rate and therefore an accumulation of drugs or metabolites, leading to possible toxic or lethal effects. Creatinine levels are known to be stable in the post mortem period and in life can give an indication of kidney function. There are however widely reported limitations when using creatinine in isolation and so we investigated the usefulness of using estimated glomerular filtration rate (eGFR) for scoring an individual as having renal impairment using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. We analysed unpreserved vitreous for creatinine in 812 individuals using an isotope dilution mass spectrometry (ID-MS) traceable enzymatic. We found that the biochemical analysis of post mortem vitreous creatinine and subsequent calculation of eGFR is a useful adjunct to the standard testing that takes place during a post-mortem examination and can assist in death investigation. Using an eGFR of <60 mL/min/1.73 m2 gave a sensitivity of 94.3% and specificity of 97.3% when scoring an individual as having renal impairment. We therefore recommend the calculation of eGFR for the determination of possible renal impairment in post mortem investigations. It is, of course, always pertinent to interpret any results using a wealth of case information. Extreme caution should be exercised in cases where insufficient clinical information/history is available, particularly in cases in which there is suspected diabetic ketoacidosis, dehydration or hospitalisation prior to death.

The relationship between antemortem and postmortem morphine concentrations.

Context of the Article: An important forensic problem is whether the presence of a drug such as morphine caused or contributed to a death or was merely incidental. The reliance that can be based on postmortem drug concentrations remains controversial. To investigate this further we obtained antemortem and postmortem samples of individuals admitted to hospital who were receiving morphine and who died in hospital.Methods: Eleven subjects were recruited. Samples were sent for analysis for free and total morphine concentrations.Results: The median difference (postmortem - antemortem) free morphine concentration was 25.5 (range 0 to +126) µg/L, p < .01; the mean difference between postmortem and antemortem total morphine concentration was 34.5 (range -225 to 342) µg/L (not significant).Discussion: Our study supports previous investigators who note that there is an inconstant and sometimes tenuous relationship between ante- and postmortem morphine concentrations.

Multiple fatalities in the North of England associated with synthetic fentanyl analogue exposure: Detection and quantitation a case series from early 2017.

BACKGROUND: Synthetic fentanyl analogues are highly potent opioid drugs which have no pharmaceutical use in humans. We detected the synthetic fentanyl analogues; carfentanil, butyryl fentanyl, fluorobutyrylfentanyl, furanylfentanyl, and alfentanil as well as fentanyl itself in 25 cases in early 2017. There have been no previous reports of synthetic fentanyl deaths in the United Kingdom (UK). METHODS: Cases in which the history clearly stated drug use but where a post mortem blood morphine concentration was lower than would be expected to explain the sudden death, were referred for further analysis by high resolution accurate mass (HRAM) mass spectrometry. RESULTS: 25 post mortem cases in which synthetic fentanyl analogues were implicated in the cause of death were reported from January to May 2017. No cases were seen in June 2017. The age range was 21-54 years and 22 were male. There was a history of heroin use, or markers of heroin use on toxicology screening in 21/25 cases. Carfentanil and fentanyl were detected in 7 cases. Multiple synthetic fentanyl analogues were present in 13 cases, with the remaining 5 cases having only carfentanil present. Synthetic fentanyl analogues were detected in combination with other drugs in all cases. Significant concentrations of ethanol were detected in only 2 cases. The concentration range of carfentanil in blood was 90-4004pg/mL. Of note, the 3 cases in which ante mortem carfentanil was quantified ranged from 21 to 98pg/mL. In all cases, death was attributed to combined central nervous system depression. CONCLUSIONS: This paper highlights a new and rapid emergence of these drugs into the UK illicit drug arena. Synthetic fentanyl analogues represent a significant challenge both analytically and clinically within the groups who misuse drugs. It is worthwhile considering the possibility of the presence of these drugs in cases in which a toxicological cause of death is not apparent analytically but there is a history of drug use and circumstantial evidence exists to support a drug-related death as the most likely cause. It may be that synthetic fentanyl analogues should be screened for routinely to avoid reporting any false negative results, but the cost implications and viability of this have not been fully evaluated.

Estimation of postmortem interval using vitreous potassium levels in cases of fatal road traffic collision

AIM OF THE STUDY: To produce a formula that can accurately predict postmortem interval (PMI) based on vitreous potassium levels using road traffic collision fatalities. MATERIAL AND METHODS: Vitreous humour samples were taken from 78 individuals who had died following road traffic collisions between 2010 and 2015. Samples were obtained from both eyes and were sent for on-site analysis. Measurement of potassium was by an indirect ion-specific electrode Siemens diagnostics ADVIA 2400 chemistry system. Exact time of death was known from police reports, the time of postmortem was recorded and the postmortem interval was calculated. Linear regression was then used to analyse the relationship between the two. The impact of age was also assessed. RESULTS: PMI was between 6 and 162 hours. As vitreous potassium increases, the PMI also increases; exhibiting a linear relationship. This is illustrated by a regression equation of PMI = 6.42[K+] - 40.94, R = 0.67 (p < 0.001). This produced a formula closely comparable with three other studies proposed in previous literature and produces estimates that may exceed one calendar day. When both age and medical intervention are accounted for there is an insignificant improvement in prediction. CONCLUSIONS: Validated methods have been used to produce a formula for prediction of PMI using vitreous potassium. Although this is specific to road traffic collisions, the methods are transferable and can be seen to be comparable with other recently published methods. Nonetheless, if greater levels of accuracy are required it is suggested that biomarkers delivering a higher level of precision should still be sought.

Maternal use of methadone and risk of sudden neonatal death.

AIM: To identify and describe infant deaths presenting suddenly and unexpectedly in whom there was a history of maternal methadone consumption or misuse of drugs during pregnancy. METHODS: Retrospective review of neonatal postmortem examinations between 2004 and 2011. RESULTS: A total of 138 autopsies were performed in infants up to 28 days. Thirty-two cases (23%) presented suddenly and unexpectedly. In 12 of 32 (37.5%), in whom the cause of death remained unexplained after a thorough postmortem, there was a history of methadone use and/or other drugs of abuse during pregnancy. Their mean age at death was 11 days (range 1-28 days). Multiple risk factors for sudden infant death syndrome were present in these 12 cases: smoking (10), prematurity (7), and inappropriate sleeping place (8). Five mothers were positive for hepatitis C. The history was inconsistent with the findings in only one case. CONCLUSION: An unexpectedly high proportion of infants dying suddenly and unexpectedly in the first month had a history of maternal substance misuse. All had multiple risk factors, for sudden infant death syndrome many avoidable. We would stress the need to emphasise the 'Safe Sleep' message with these families at every contact with health professionals.

Variation in postmortem liver sampling: implications for postmortem toxicology interpretation.

AIMS: To investigate the sites for postmortem liver sampling when toxicological analysis is required and to compare these to published guidelines which recommend sampling from deep within the right lobe of the liver. METHODS: A questionnaire was sent to all pathologists who had supplied liver samples to the Sheffield toxicology laboratory in 2011. Practices were audited against published standards. RESULTS: 79 liver samples had been provided from 39 pathologists. 30 pathologists replied. 15/30 pathologists had sampled from deep within the liver, but only 7/30 pathologists sampled from the deep within the right lobe. CONCLUSIONS: The published guidelines for liver sampling were either not known or not being followed by pathologists. Although this did not directly affect any of the cases audited, such a lack of knowledge of the recommended site of liver sampling may lead to incorrect interpretation if the site of liver sample is unknown by the receiving laboratory.

Drug- and alcohol-related deaths at a pediatric institution in the United kingdom.

AIM: The study aimed to identify the incidence, clinical presentation, and demographic features of drug- and alcohol-related deaths diagnosed at a pediatric pathology department between 2004 and 2010. MATERIAL AND METHODS: Databases of the histopathology and toxicology departments were searched. Three groups were defined as follows: (1) cause of death is toxicologically related; (2) drugs present are consistent with therapeutic range use; and (3) a drug was detected, but the contribution of this drug to the mechanism of death was not clear. RESULTS: Fifty-five cases (36 males, 19 females; mean, 4.8 years; range, 2 hours to 17 years) were identified. This corresponded to 3.3% (55/1669) of all postmortems. Ten cases were group 1, 42 cases were group 2, and 3 cases were group 3. The results in group 1 were methadone (n = 2); methadone, alcohol, and dothiepin (n = 1); diazepam (n = 1); dothiepin (n = 1); carbon monoxide (n = 2); tramadol (n = 1); codeine and paracetamol (n = 1); and dihydrocodeine, citalopram, amitriptyline, and paracetamol (n = 1). The types of death were considered accidental (n = 2), suicide (n = 2), and undetermined (n = 6). CONCLUSIONS: The presence of a toxin in lethal concentration was found in 10 (0.6%) of 1669 of any kind of postmortem examinations. This increased to 2.2% when the analysis was restricted to "sudden deaths." These results demonstrate the need to conduct toxicological screening in all postmortems of this sort.

Albumin level and patient age predict outcomes in patients referred for gastrostomy insertion: internal and external validation of a gastrostomy score and comparison with artificial neural networks.

BACKGROUND: Significant mortality after gastrostomy insertion remains and some risk factors have been identified, but no predictive scoring system exists. OBJECTIVE: To identify risk factors for mortality, formulate a predictive scoring system, and validate the score. Comparison to an artificial neural network (ANN). DESIGN: Endoscopic database analysis. SETTING: Six hospitals (2 teaching hospitals) in the South Yorkshire region, United Kingdom. PATIENTS: This study involved all patients referred for gastrostomy insertion. INTERVENTION: Generation of clinical scores to predict 30-day mortality in patients undergoing gastrostomy insertion. MAIN OUTCOME MEASUREMENTS: Risk factors for 30-day mortality. Internal and external validation of the score. Comparison with an ANN. RESULTS: Univariate analysis showed that 30-day mortality was associated with age, albumin levels, and cardiac and neurological comorbidities. Multivariate analysis showed that only age and albumin levels were independent. Modeling provided scores of 0, 1, 2, and 3 corresponding to 30-day mortalities of 0% (0-2.1), 7% (2.9-13.9), 21.3% (13.5-30.9), and 37.3% (24.1-51.9), respectively. Application of the scoring system at the other teaching hospital and the 4 district general hospitals gave 30-day mortality rates that were not significantly different from those predicted. Receiver operating characteristic curves for the score and the ANN were comparable. LIMITATIONS: Nonrandomized study. Score not used as a decision-making tool. CONCLUSION: The gastrostomy score provides an estimate of 30-day mortality for patients (and their relatives) when gastrostomy insertion is being discussed. This score requires evaluation as a decision-making tool in clinical practice. ANN analysis results were similar to the outcomes from the clinical score.

Undisclosed use of nonsteroidal anti-inflammatory drugs may underlie small-bowel injury observed by capsule endoscopy.

BACKGROUND & AIMS: Findings from capsule endoscopies (CEs) of patients with enteropathy from nonsteroidal anti-inflammatory drugs (NSAIDs) may be indistinguishable from those with Crohn's disease, making medication history crucial to image interpretation. Undeclared NSAID use has been proposed to cause unexplained peptic ulcers; we investigated whether it is also an issue among patients referred for small-bowel CE. METHODS: We collected demographic data, indications for CE, and medication history prospectively. A salicylate spot test and gas chromatography-mass spectrometry were performed for NSAID metabolites in urine samples of patients undergoing routine CE. Videos were analyzed by a gastroenterologist who was blinded to the urinalysis results. RESULTS: Seventy-six patients (52 women; mean age, 50 y) underwent CE for suspected small-bowel pathology. Urinalysis was positive in 13.6% of patients (salicylates, n = 3; ibuprofen, n = 6; and ibuprofen and diclofenac, n = 1) although only 1 of these patients declared use of an NSAID (aspirin). Although 2 patients had normal CE results, 80% had positive results, including the presence of erosions (n = 5), ulceration (n = 2), and ulcers with early stricturing (n = 1, diagnosed with Crohn's disease). A patient with small-bowel ulceration underwent surgery and was found to have NSAID-associated enteropathy, based on histologic analysis. CONCLUSIONS: Of patients who undergo CE, 13.6% took NSAIDs or aspirin, but most did not declare using these medications. Small-bowel inflammation was common in this cohort and could be mistaken for Crohn's disease. Patients should be questioned about use of over-the-counter medications, and routine urinalysis for NSAID metabolites may be helpful before interpretation of CE findings.

Validation of meconin as a marker for illicit opiate use.

The detection of markers for illicit opiate misuse is important both in the management of substance misuse and in the postmortem identification of illicit opiate use. In addition to 6-monoacetylmorphine and acetyl codeine, other markers, such as papaverine, noscapine, and their metabolites, have been proposed as markers of illicit opiate use. Urine samples (362) from individuals attending substance misuse services and 26 postmortem cases were analyzed for meconin, a noscapine metabolite by gas chromatography-mass spectrometry. Three hundred of the substance misuse service samples and 14 of the postmortem samples had morphine present as the major opiate. Meconin was detected in 284 (94.7%) of these substance misuse samples and 11 (78%) of the postmortem samples. There was a specificity of 100% in both groups. In the 62 substance misuse cases where morphine was not the major opiate detected and four separate cases in which medicinal diamorphine was known to have been administered, meconin was not detected. The use of meconin as a useful adjunct in detecting illicit opiate use is recommended.