Methadone-related death in detention.

Oral methadone may be prescribed to detainees with the aim of minimising the risk of fatal opioid poisoning on release. To study the circumstances under which methadone-related deaths can occur in detention, we audited reports of 17 [14 male, 3 female; median (range) age 34 (22-52) years] such deaths, July 2010-December 2011. The median (range) methadone dose was 40 (10-110) mg/d (N = 16). The median (range) post-mortem blood methadone concentration was 0.42 (0.16-1.40) mg/L. Those who died within 7 days of the commencement of methadone treatment were significantly younger (Mann-Whitney U 102.5, p < 0.05), were prescribed a significantly lower dose (U = 80.0, p < 0.05) and had significantly lower blood methadone concentrations at death (U = 106.5, p < 0.02) than in those given methadone long-term. In 8 reports the prisoner had been recorded as either 'sleepy' (N = 7), or 'unwell' in the hours before death. In 13 deaths, the prisoner was either found dead first thing in the morning, or in one instance could not be roused ('snoring heavily'). Pneumonia, tracheobronchitis, end-stage cirrhosis, and ischaemic heart disease/coronary artery atherosclerosis were cited as associated factors in four patients, all of whom were on long term stable methadone treatment. Attention to warning signs of likely methadone toxicity (daytime or excessive drowsiness, snoring, nausea/vomiting) and associated risk factors (use of drugs such as benzodiazepines and gabapentinoids, the presence of respiratory infection, liver or renal disease) could help minimise the risk of unexpected death in patients given methadone.

Clozapine-induced gastrointestinal hypomotility: presenting features and outcomes, UK pharmacovigilance reports, 1992-2017.

BACKGROUND: Clozapine-induced gastrointestinal hypomotility (CIGH) affects some 75% of patients treated with clozapine. AIMS: To document the incidence of potentially harmful CIGH in the UK. METHOD: We studied spontaneous UK pharmacovigilance reports recorded as clozapine-related gastrointestinal adverse drug reactions, 1992-2017. RESULTS: There were 527 patients reported with potentially harmful CIGH; 33% (n = 172) died. Deaths averaged 1 per year 1992-1999, 5 per year 2000-2009 and 15 per year 2010-2017. Those who died were older (median 52 years v. 49 years) and had been prescribed clozapine for longer than those who recovered (median 11.3 years v. 4.8 years), but there was no difference in prescribed dose. Within the first 4 years of clozapine treatment, there were 169 reports of CIGH, of which 3% (n = 5) were fatal. At 10-14 years there were 63 reports of CIGH, of which 25% (n = 16) were fatal. Among the deaths, males were younger (median 51, range 22-89 v. median 57, range 24-89 years) with higher clozapine doses (median 450, range 100-900 v. median 300, range 12.5-800 mg/d) than females. In non-fatal CIGH, surgery was the most frequent outcome (n = 92). The procedures included appendectomy, ileostomy, total/partial colectomy, colostomy/stoma and proctosigmoidectomy. Clozapine dosage was reduced in 6 patients, stopped and restarted in 23, 'continued' in 6 and discontinued permanently in at least 76 patients. CONCLUSIONS: The risk of serious morbidity/mortality from CIGH is substantial. The need to actively monitor bowel function and give laxatives to patients treated with clozapine is clear.

Clozapine in the treatment of refractory schizophrenia: a practical guide for healthcare professionals.

BACKGROUND: Clozapine remains the only medication licensed for treating refractory schizophrenia. However, it remains underutilized in part due to concerns regarding adverse events. SOURCES OF DATA: Published literature. AREAS OF AGREEMENT: Common adverse events during clozapine treatment include sedation, hypersalivation, postural hypotension, dysphagia, gastrointestinal hypomotility, weight gain, diabetes mellitus and dyslipidaemia. Rare but serious events include agranulocytosis, cardiomyopathy, myocarditis, pneumonia, paralytic ileus and seizure. AREAS OF CONTROVERSY: It remains unclear how best to minimize clozapine-induced morbidity/mortality (i) during dose titration, (ii) from hypersalivation and (iii) from gastrointestinal hypomotility. It is also unclear how clozapine pharmacokinetics are affected by (i) gastrointestinal hypomotility, (ii) systemic infection and (iii) passive exposure to cigarette smoke. Whether monthly haematological monitoring needs to continue after 12 months of uninterrupted therapy is also a subject of debate. GROWING POINTS: There is a need for better management of serious clozapine-related adverse events in addition to agranulocytosis. There is also a need for better education of patients and carers, general practitioners, A&E and ITU staff and others of the problems posed in using clozapine safely. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need for more research on assessing clozapine dosage (i) as patients get older, (ii) with respect to exposure to cigarette smoke and (iii) optimizing response if adverse events or other factors limit dosage.

Plasma and Urine Levamisole in Clinical Samples Containing Benzoylecgonine: Absence of Aminorex.

Aminorex has been reported as a metabolite of levamisole in man, but data on the aminorex concentrations in clinical samples are scant. We thus measured levamisole, aminorex and benzoylecgonine in urine, and levamisole and aminorex in plasma using achiral liquid chromatography-high resolution mass spectrometry. Centrifuged urine (50 µL) was diluted with LC eluent containing internal standard (benzoylecgonine-D3, 25 µg/L) (450 µL). For plasma, sample (200 µL) and Tris solution (2 mol/L, pH 10.6, 100 µL) were added to a 60.5 × 7.5 mm i.d. glass test tube. Internal standard solution (ketamine-D4, 200 µg/L) (10 µL) was added and the tube contents vortex-mixed (5 s). Butyl acetate:butanol (9 + 1, v/v; 200 µL) was added and after vortex-mixing (30 s) and centrifugation (13,680 × g, 4 min), the extract was evaporated to dryness and reconstituted in 10 mmol/L aqueous ammonium formate containing 0.1% (v/v) formic acid (150 µL). Prepared samples and extracts (100 µL) were analyzed using an AccucoreTM Phenyl-Hexyl column (2.6 mm a.p.s., 100 × 2.1 mm i.d.) maintained at 40°C. MS detection was in positive mode using heated electrospray ionization (ThermoFisher Q-ExactiveTM). Intra- and inter-assay accuracy and precision were ±20%, and ≤11%, respectively, for all analytes in both matrices. Lower limits of quantitation were 0.1 and 1 µg/L (all analytes) in plasma and urine, respectively. Of 100 consecutive urine samples submitted for drugs of abuse screening containing benzoylecgonine, levamisole was detected in 72 (median 565, range 4-72,970 µg/L). Levamisole was also measured in eight plasma samples (median 10.6, range 0.9-64.1 µg/L). A number of metabolites of levamisole (4-hydroxylevamisole, levamisole sulfoxide, levamisole glucuronide, and hydroxylevamisole glucuronide) were tentatively identified in urine. Neither aminorex, nor any of its reported metabolites were detected in any sample.

Cut Costs at All Costs!

The UK Government decision to close its Forensic Science Service (FSS) in 2010 left the criminal justice system in England and Wales bereft of impartial, high-level scientific support. The private sector was entrusted to fill the gap and to ensure that all results were accurate, timely, fit for purpose, easy to interpret, and above all gave value for money. In the event, however, a major provider has collapsed necessitating a rescue deal to minimise the impact of the fiasco. Moreover, there have been allegations of data manipulation in another private sector laboratory and possible falsification of evidence in a laboratory set up by a police force in an attempt to fill the gap left by the FSS. As to the future, appropriate laboratory regulation and inspection clearly has a part to play, but ironically 'quality management' adds an unnecessary and ever-increasing cost burden that may detract from quality. What is really needed are systems that combine public service and professional integrity with research and development. Involving investigators, coroners/medical examiners/judges, and prosecution and defence lawyers in educational fora would help build cross-professional co-operation and understanding.

Postmortem biochemistry: Current applications.

The results of biochemical analyses in specimens obtained postmortem may aid death investigation when diabetic and alcoholic ketoacidosis is suspected, when death may have been the result of drowning, anaphylaxis, or involved a prolonged stress response such as hypothermia, and in the diagnosis of disease processes such as inflammation, early myocardial infarction, or sepsis. There is often cross-over with different disciplines, in particular with clinical and forensic toxicology, since some endogenous substances such as sodium chloride, potassium chloride, and insulin can be used as poisons. The interpretation of results is often complicated because of the likelihood of postmortem change in analyte concentration or activity, and proper interpretation must take into account all the available evidence. The unpredictability of postmortem changes means that use of biochemical measurements in time of death estimation has little value. The use of vitreous humour is beneficial for many analytes as the eye is in a physically protected environment, this medium may be less affected by autolysis or microbial metabolism than blood, and the assays can be performed with due precaution using standard clinical chemistry analysers. However, interpretation of results may not be straightforward because (i) defined reference ranges in life are often lacking, (ii) there is a dearth of knowledge regarding, for example, the speed of equilibration of many analytes between blood, vitreous humour, and other fluids that may be sampled, and (iii) the effects of post-mortem change are difficult to quantify because of the lack of control data. A major limitation is that postmortem vitreous glucose measurements are of no help in diagnosing antemortem hypoglycaemia.

Antipsychotic-related fatal poisoning, England and Wales, 1993-2013: impact of the withdrawal of thioridazine.

CONTEXT: Use of second generation antipsychotics in England and Wales has increased in recent years whilst prescription of first generation antipsychotics has decreased. METHODS: To evaluate the impact of this change and of the withdrawal of thioridazine in 2000 on antipsychotic-related fatal poisoning, we reviewed all such deaths in England and Wales 1993-2013 recorded on the Office for National Statistics drug poisoning deaths database. We also reviewed antipsychotic prescribing in the community, England and Wales, 2001-2013. Use of routine mortality data: When an antipsychotic was recorded with other drug(s), the death certificate does not normally say if the antipsychotic caused the death rather than the other substance(s). A second consideration concerns intent. A record of "undetermined intent" is likely to have been intentional self-poisoning, the evidence being insufficient to be certain that the individual intended to kill. A record of drug abuse/dependence, on the other hand, is likely to have been associated with an unintentional death. Accuracy of the diagnosis of poisoning: When investigating a death in someone prescribed antipsychotics, toxicological analysis of biological samples collected post-mortem is usually performed. However, prolonged attempts at resuscitation, or diffusion from tissues into blood as autolysis proceeds, may serve to alter the composition of blood sampled after death from that circulating at death. With chlorpromazine and with olanzapine a further factor is that these compounds are notoriously unstable in post-mortem blood. Deaths from antipsychotics: There were 1544 antipsychotic-related poisoning deaths. Deaths in males (N = 948) were almost twice those in females. For most antipsychotics, the proportion of deaths in which a specific antipsychotic featured either alone, or only with alcohol was 30-40%, but for clozapine (193 deaths) such mentions totalled 66%. For clozapine, the proportion of deaths attributed to either intentional self-harm, or undetermined intent was 44%, but for all other drugs except haloperidol (20 deaths) the proportion was 56% or more. The annual number of antipsychotic-related deaths increased from some 55 per year (1.0 per million population) between 1993 and 1998 to 74 (1.5 per million population) in 2000, and then after falling slightly in 2002 increased steadily to reach 109 (1.9 per million population) in 2013. Intent: The annual number of intentional and unascertained intent poisoning deaths remained relatively constant throughout the study period (1993: 35 deaths, 2013: 38 deaths) hence the increase in antipsychotic-related deaths since 2002 was almost entirely in unintentional poisoning involving second generation antipsychotics. Clozapine, olanzapine, and quetiapine were the second generation antipsychotics mentioned most frequently in unintentional poisonings (99, 136, and 99 deaths, respectively). Mentions of diamorphine/morphine and methadone (67 and 99 deaths, respectively) together with an antipsychotic were mainly (84 and 90%, respectively) in either unintentional or drug abuse-related deaths. Deaths and community prescriptions: Deaths involving antipsychotics (10 or more deaths) were in the range 11.3-17.1 deaths per million community prescriptions in England and Wales, 2001-2013. Almost all (96%) such deaths now involve second generation antipsychotics. This is keeping with the increase in annual numbers of prescriptions of these drugs overall (<1 million in 2000, 7 million in 2013), largely driven by increases in prescriptions for olanzapine and quetiapine. In contrast, deaths involving thioridazine declined markedly (from 40 in 2000 to 10 in 2003-2013) in line with the fall in prescriptions for thioridazine from 2001. CONCLUSIONS: The removal of thioridazine has had no apparent effect on the incidence of antipsychotic-related fatal poisoning in England and Wales. That such deaths have increased steadily since 2001 is in large part attributable to an increase in unintentional deaths related to (i) clozapine, and (ii) co-exposure to opioids, principally diamorphine and methadone.

Fatal unintentional non-fire-related carbon monoxide poisoning: England and Wales, 1979-2012.

CONTEXT: Unintentional carbon monoxide poisoning remains a significant cause of morbidity and mortality in England and Wales. METHODS. STUDY DESIGN: observational case series. Data on fatal carbon monoxide poisoning in England and Wales from 1979 to 2012 were obtained from coroner reports. Data on unintentional non-fire-related carbon monoxide poisoning were extracted and were analysed by year of registration of death, sex, age group, and whether death occurred at a private house, flat, associated garage, or residential caravan ('home'), or elsewhere. RESULTS AND DISCUSSION: There were 28,944 carbon monoxide-related deaths, of which 82% were male. Deaths increased from 965 (1979) to 1700 (1987), and then fell to 182 (2012). Of these 2208 (64% male) were recorded as unintentional non-fire-related deaths. Annual numbers of these latter deaths fell from 166 in 1979 to 25 in 2012 (i.e. from 3.37 to 0.44 per million population). Some 81 and 92% of such deaths in males and in females, respectively, occurred at 'home'. A clear preponderance of male versus female deaths was seen in the 10-19, 20-39 and 40-64 years age groups, with similar numbers of deaths in males and in females in the younger (< 1 and 1-9 year) and higher (65-79 and 80 + years) age groups. A higher proportion of these excess deaths in males occurred outside the deceased's 'home' in those aged 10-19, 20-39 and 40-64 years. CONCLUSION: Deaths from unintentional non-fire-related carbon monoxide poisoning are now much less common in England and Wales than in earlier years, but remain a cause for concern. Installation and proper maintenance of carbon monoxide alarms in dwellings and outhouses, for example, and education not only of the public, but also of health and other professionals as to the danger posed by carbon monoxide could help prevent such deaths.

Drugs and other chemicals involved in fatal poisoning in England and Wales during 2000 ­ 2011.

CONTEXT: Fatal poisoning data can reveal trends in the poisons encountered, which can help guide prescribing practices and product safety and other legislation, and more recently has helped to monitor the use of emerging drugs of abuse ( ' legal highs ' ). METHODS: We searched Mortality Statistics ­ Injury and poisoning, Series DH4 (2000 ­ 2005), Mortality Statistics ­ Deaths registered in England and Wales, Series DR (2006 ­ 2011), and the Office for National Statistics drug poisoning database for information on fatal poisoning during 2000 ­ 2011. We also searched the Pubmed database for ' fatal ' and ' poisoning ' and ' England ' and ' Wales ' : this search yielded seven papers that gave relevant information on deaths reported during 2000 ­ 2011 that were not superseded by later publications. DEATHS FROM POISONING: The annual number of deaths from poisoning fell from 2000 (3092) to 2010 (2749), before increasing to 3341 in 2011. This increase was due in part to a change in the ICD coding relating to alcohol poisoning, suggesting that such deaths had been under-recorded previously. Although fatalities from dextropropoxyphene declined (287 in 2004 and 18 in 2011) following the withdrawal of co-proxamol (paracetamol [acetaminophen] and dextropropoxyphene [propoxyphene] mixture) during 2005 ­ 2007, deaths involving codeine and most notably tramadol (836 deaths during 2000 ­ 2011) increased. Deaths from paracetamol poisoning either alone, or with alcohol reached 89 in 2011, the lowest annual figure since 1974. However, in reality there has been no marked downward trend since 1999 despite reductions in pack size, continued publicity as to the dangers of paracetamol overdose, and improved liver failure treatment, including transplantation. The annual number of deaths from antidepressants remained relatively stable (median: 397, range: 335 ­ 469). Although the number of deaths from dosulepin [dothiepin] decreased (186 in 2000 and 49 in 2011), the number of deaths involving selective serotonin reuptake inhibitors increased (50 in 2000 and 127 in 2011). Although annual numbers of deaths involving diamorphine/morphine (88% unintentional) declined, deaths involving methadone (89% unintentional) increased and the total annual number of deaths from these drugs showed little change (2000: 1061, 2011: 995). Deaths involving amfetamine/metamfetamine remained relatively constant at about 50 annually, and whilst cocaine-related deaths fell by 48% during 2008 ­ 2011, and deaths involving MDMA and related compounds fell by 69% over this same period, deaths involving ' legal highs ' , notably γ -hydroxybutrate/ γ -butyrolactone and ketamine, increased. CONCLUSIONS: Alterations in the availability of paracetamol and of prescription drugs such as dextropropoxyphene and dosulepin have not been accompanied by decreases in the number of deaths from poisoning. Despite intense media and other interest, the annual number of deaths (250 ­ 300) involving ' recreational ' drugs remains small in relation to the 1000 or so deaths a year from diamorphine and/or methadone.

False-positive buprenorphine by CEDIA in patients prescribed amisulpride or sulpiride.

Buprenorphine is a potent partial opioid agonist that is analyzed in urine to (i) monitor adherence to maintenance or detoxification therapy and (ii) detect illicit use. Buprenorphine analysis is commonly conducted on urine by immunoassay, but is subject to cross-reactivity from other drugs/drug metabolites, including morphine, codeine and dihydrocodeine. This study reports false-positive buprenorphine analysis [Thermo Fisher Scientific cloned enzyme donor immunoassay (CEDIA)] in patients who denied unauthorized buprenorphine use prior to sampling, but who had been prescribed amisulpride. In two cases, confirmatory analysis by liquid chromatography-tandem mass spectrometry was negative (<0.5 µg/L) for buprenorphine and metabolites and positive for amisulpride. Although the cross-reactivity of amisulpride and sulpiride in the CEDIA buprenorphine assay is low (estimated at 0.003 and 0.002%, respectively), it remains a significant consideration given the likely high concentrations of these compounds in urine relative to the low cutoff of the buprenorphine assay. Neither amisulpride nor sulpiride was listed as potential sources of interference on the CEDIA data sheet when this work was performed. These findings highlight the importance of confirming immunoassay-positive buprenorphine results using a more selective analytical technique.

Simple methodology for the therapeutic drug monitoring of the tyrosine kinase inhibitors dasatinib and imatinib.

A simple HPLC method has been developed to measure imatinib and N-desmethylimatinib (norimatinib) in plasma or serum at concentrations attained during therapy. Adaptation of this method to LC-MS/MS also allows dasatinib assay. A small sample volume (100 µL HPLC-UV, 50 µL LC-MS/MS) is required and analysis time is <5 min in each case. Detection was by UV (270 nm) or selective reaction monitoring (two transitions per analyte) tandem mass spectrometry. Assay calibration was linear (0.05-10 mg/L imatinib, 0.01-2.0 mg/L norimatinib and 1-200 µg/L dasatinib), with acceptable accuracy (86-114%) and precision (<14% RSD) for both methods. A comparison between whole blood and plasma confirmed that plasma is the preferred sample for imatinib and norimatinib assay. For dasatinib, although whole blood concentrations were slightly higher, plasma is still the preferred sample. Despite considerable variation in the (median, range) plasma imatinib and norimatinib concentrations in patient samples [1.66 (0.02-4.96) and 0.32 (0.01-0.99) mg/L, respectively, N = 104], plasma imatinib was >1 mg/L (suggested target for response) in all but one sample from patients achieving complete molecular response. As to dasatinib, the median (range) plasma dasatinib concentration was 13 (2-143) µg/L (N = 33). More observations are needed to properly assess the potential role of therapeutic drug monitoring in guiding treatment with dasatinib.

An automated method for the simultaneous measurement of azole antifungal drugs in human plasma or serum using turbulent flow liquid chromatography-tandem mass spectrometry.

Azole antifungal drugs are important in the prophylaxis and treatment of invasive aspergillosis. Therapeutic drug monitoring may be indicated to (1) monitor adherence, (2) guide dosage and (3) minimise the risk of drug-drug interactions and dose-related toxicity. TurboFlow(TM) technology offers online, automated sample preparation. An Aria Transcend(TM) TLX-II coupled with a TSQ Vantage(TM) MS was used. Centrifuged samples (25 µL) were mixed with internal standard solution (975 µL) and 30 µL injected directly onto a C18-P-XL TurboFlow column. Analytes were focussed onto a Phenomenex Gemini Phenyl analytical column and eluted using a methanol/water gradient (flow-rate, 0.8 mL/min). Analytes were monitored in selected reaction monitoring mode (two transitions per analyte, positive mode APCI). Calibration ranges were as follows: itraconazole, hydroxyitraconazole, and posaconazole 0.05-5.0 mg/L; voriconazole and fluconazole 0.1-10 mg/L. Total analysis time was 12 min. TurboFlow column recovery was >77% for all analytes. Calibration was linear (R (2) > 0.99) for all analytes. Inter- and intra-assay imprecision (% RSD) was <8% and accuracy (nominal internal quality control values) 90-105% for all analytes. The limit of detection was 0.01 mg/L for all analytes. No matrix effects were observed. This method is simple, robust and suitable for measuring these compounds at concentrations attained during therapy.

An automated method for the measurement of a range of tyrosine kinase inhibitors in human plasma or serum using turbulent flow liquid chromatography-tandem mass spectrometry.

Tyrosine kinase inhibitors (TKIs) are used to treat a number of cancers, including chronic myeloid leukaemia and hepatocellular carcinoma. Therapeutic drug monitoring (TDM) may be indicated to (1) monitor adherence, (2) guide dosage, and (3) minimise the risk of drug-drug interactions and dose-related toxicity. On-line, automated sample preparation provided by TurboFlow technology (ThermoFisher Scientific) in conjunction with the sensitivity and selectivity of tandem mass spectrometry (MS/MS) detection may be applied to the analysis of single drugs and metabolites. We report the use of TurboFlow LC-MS/MS for the analysis of nine TKIs and metabolites (imatinib, N-desmethylimatinib, dasatinib, nilotinib, erlotinib, gefitinib, lapatinib, sorafenib, sunitinib) in human plasma or serum for TDM purposes. An Aria Transcend TLX-II system coupled with a TSQ Vantage was used. Samples (50 µL) were vortex mixed with internal standard solution (150 µL imatinib-D(8), gefitinib-D(8), sunitinib-D(10), and nilotinib-(13)C (2) (15) N(2) in acetonitrile) and, after centrifugation 100 µL supernatant were injected directly onto a 50 × 0.5-mm Cyclone TurboFlow column. Analytes were focussed onto a 50 × 2.1-mm (3 µm) Hypersil GOLD analytical column and eluted with an acetonitrile/water gradient. Analytes were monitored in selected reaction monitoring mode (positive APCI). Total analysis time was 7 min without multiplexing. Calibration was linear (R(2) > 0.99) for all analytes. Inter- and intra-assay precision (in percent relative standard deviation, RSD) was <11 % and accuracy 89-117 % for all analytes. No matrix effects were observed. This method is suitable for high-throughput TDM in patients undergoing chronic therapy with TKIs and has been utilised in the analysis of clinical samples.

Clozapine--a dangerous drug in a clozapine-naïve subject.

Clozapine is a uniquely effective antipsychotic, but is very toxic in clozapine-naïve subjects. A 34-year-old male patient in a mental health facility, who was not prescribed clozapine, took 350 mg clozapine obtained from another patient at night. He was found dead the next morning. The presence of cardiomegaly related to obesity may have increased the risk of suffering an acute cardiac event after ingestion of clozapine. The medication prescribed to the patient was not thought to have contributed to the fatal outcome. Post mortem femoral blood clozapine and norclozapine concentrations were 0.48 and 0.20mg/L, respectively. By way of comparison, audit of 104,127 plasma samples (26,796 patients) assayed for therapeutic drug monitoring purposes 1993-2007, showed plasma clozapine 0.35 mg/L or more in 57.5% samples (8.4% 1mg/L or more). Those involved in the investigation of clozapine-associated deaths need to be aware that that death in an adult may occur after a single 'therapeutic' dose. A diagnosis of fatal clozapine poisoning cannot be made solely on the basis of a post mortem blood clozapine measurement.

Was it poisoning?

The aim of post-mortem toxicology is to help establish the role that drugs or other poisons played in a death, or in events immediately before death. If self-poisoning is suspected then the diagnosis may be straightforward and all that may be required is confirmation of the agents involved. If the cause of death is not immediately obvious, however, then suspicion of possible poisoning is of course crucial. Blood sampling (needle aspiration, peripheral vein, e.g. femoral, ideally after proximal ligation) before opening the body, minimises the risk of sample contamination with, for example, gut contents or urine. The site of blood sampling should always be recorded. Other specimens (stomach contents, urine, liver, vitreous humor) may also be valuable and may be needed to corroborate unexpected or unusual findings in the absence of other evidence. The availability of ante-mortem specimens should not preclude post-mortem sampling. Appropriate sample preservation, transport, and storage are mandatory. Interpretation of post-mortem toxicology must take into account what is known of the clinical pharmacology, including pharmacokinetics, and toxicology of the agent(s) in question, the circumstances under which death occurred including the possible mechanism(s) of exposure, and other factors such as the sample(s) analysed and the analytical methods used. It was thought that concentrations of poisons measured in blood obtained at autopsy reflected the situation peri-mortem. However, we now know that changes may occur in the composition of body fluids, even peripheral blood, after death. Such changes are likely to be greater with centrally-acting drugs such as clozapine with large volumes of distribution, and may perhaps be minimised by prompt refrigeration of the body and performing the autopsy quickly. Better training in analytical toxicology is needed for pathologists and others who may be called upon to interpret toxicological data for the Courts. Undue reliance on quantitative results is likely to confuse sooner rather than later, especially in the case of centrally-acting drugs such as opioids and clozapine. Remember that the question is normally "was it poisoning?" or "was it an overdose?"--and not--"is it a fatal level"?

Measurement of serum lanthanum in patients treated with lanthanum carbonate by inductively coupled plasma-mass spectrometry.

BACKGROUND: Lanthanum carbonate is used as a phosphate binder in patients with stage V chronic kidney disease (CKD). While well tolerated in clinical trials, with no toxicity reported as regards bone and liver metabolism, and cognitive function, concerns remain over possible toxicity. Published methods for the measurement of lanthanum ion in biological samples include aggressive and complicated sample preparation steps that are unsuitable for routine use. A simple method has been developed and validated for the measurement of serum lanthanum. METHOD: A ThermoFisher Scientific XSERIES-II inductively coupled plasma-mass spectrometer was used to monitor ¹³9La. Validation was undertaken using internal quality control solutions containing lanthanum ion (0.20, 0.70 and 4.00 µg/L). Lanthanum was measured in patients (number = 20) with CKD prescribed lanthanum carbonate (500-1500 mg/d) and patients undergoing haemodialysis not prescribed lanthanum carbonate (number = 20). RESULTS: Accuracy and imprecision were >95% and <5%, respectively. Calibration was linear (range 0.1-5 µg/L, R² = 0.99). The lower limit of quantification (LLoQ) was 0.1 µg/L lanthanum ion. In patients with CKD not prescribed lanthanum carbonate, serum lanthanum was below the LLoQ. Out of 20 CKD patients prescribed lanthanum carbonate, serum lanthanum was measurable in only 12 (range 0.11-0.60 µg/L lanthanum ion). There was no apparent relationship between dose and serum lanthanum in these patients. CONCLUSIONS: A lack of relationship between the dose of lanthanum carbonate and the serum lanthanum concentration may have been due to poor adherence to the treatment regimen. However the concentrations measured were close to the LLoQ.

Basic drug analysis by strong cation-exchange liquid chromatography-tandem mass spectrometry: simultaneous analysis of amisulpride, and of metamfetamine and amfetamine in serum/plasma.

In the HPLC of basic drugs and metabolites, good efficiency and peak shape can often be attained using strong cation-exchange packings with isocratic 100% methanol eluents containing an ionic modifier at an appropriate pH* and ionic strength. Solvent extracts can be analysed directly, and use of ammonium acetate as modifier facilitates the use of atmospheric pressure chemical ionization (APCI)-tandem mass spectrometry, selected reaction monitoring mode. For the analysis of amisulpride and of metamfetamine/amfetamine in plasma (200 µL) after single oral doses in man, a column packed with Waters Spherisorb S5SCX (5 µm average particle size, 100 × 2.1 mm i.d.) was used with methanolic ammonium acetate (40 mmol/L, pH* 6.0, flow rate 0.5 mL/min) as eluent (35°C). Deuterated internal standards were used for each analyte. Detection was by positive-mode APCI. Responses for all analytes were linear over the calibration ranges. Intra-assay precision (RSD) was 2-18%, and inter-assay precision was 2-12%. The limit of detection was 0.5 µg/L for all analytes. No significant matrix effects or isobaric interferences were noted. The total analysis time was 7 min. Similar methodology can be applied to a wide range of basic analytes using MS/MS detection.

Gastrointestinal hypomotility: an under-recognised life-threatening adverse effect of clozapine.

AIM: To highlight some problems that may occur when investigating clozapine-associated deaths including (i) that death may be related to gastrointestinal hypomotility and (ii) that post-mortem blood clozapine and norclozapine concentrations may not reflect ante-mortem concentrations. CASE REPORTS: A 41-year-old male died 40 min after admission to hospital as a result of aspiration complicating severe, clozapine-induced constipation. At post-mortem the small bowel was dilated and contained bloodstained mucus, particularly within the jejunum. The large bowel was considerably dilated and contained large quantities of foul-smelling, bloodstained fluid and a small amount of stool. Its lining was focally congested, but there was no other obvious abnormality. Analysis of serum obtained on admission revealed clozapine and norclozapine concentrations of 0.56 and 0.43 mg/L, respectively, whereas post-mortem femoral whole blood obtained <34 h after death showed clozapine and norclozapine concentrations of 3.73 and 1.75 mg/L, respectively. In 6 out of a further 12 clozapine-associated deaths investigated 2002-9 there were reports of gastrointestinal tract problems of varying severity. CONCLUSIONS: Severe constipation or paralytic ileus in clozapine-treated patients may lead to intestinal necrosis and/or perforation, or pulmonary aspiration. In some such cases the immediate cause of death may be obvious, but in others only careful assessment of the clinical course of the terminal illness may reveal gastrointestinal hypomotility as a likely underlying cause of death.

A chloroform-related death: analytical and forensic aspects.

Chloroform is still encountered occasionally in clinical and forensic toxicology, hence knowledge of the special problems presented in the detection and measurement of this compound in biological specimens may be required. The aim of this paper is to review the available documentation on this topic in the context of a chloroform-related death. Early one morning in February 1999 a 34-year-old female was found dead fully clothed on a path near to a neighbour's garden. Amfetamine intoxication combined with hypothermia was accepted as the cause of the death in the absence of any other identifiable cause. Further investigation 17 months later revealed a blood chloroform concentration of 31 mg/L and the cause of death was revised to chloroform poisoning. A murder trial ensued, the indictment specifying forced inhalation as the route of exposure. The liver chloroform concentration measured 38 months after collection was reported as 1064 mg/kg and opinions were offered at trial that the autopsy findings, which included a gastritis, but no evidence of injury to the inside of the mouth and oesophagus, excluded the possibility of ingestion of a toxic dose of chloroform. It was asserted that the explanation for the high liver concentration was that the liver had concentrated chloroform from blood after death against a concentration gradient. At appeal against conviction 7 years later the conviction was quashed. It was found that the liver concentration should have been reported at trial as 1 mg/kg. Moreover, chloroform found in the stomach contents (162 mg/kg) 86 months after collection was irrefutable evidence that some, if not all, of the chloroform had been ingested. Screening for volatile poisons should always be considered if a cause of death is not immediately obvious, especially in young people and in known substance abusers. If the presence of an unstable or volatile analyte is suspected then sample collection, transport, and storage must be performed with the analysis in mind. Quantitative analysis of all available specimens should proceed forthwith once the presence of an unstable analyte is established if the cause of death is in doubt or if prosecution may follow. In the case of chloroform especial precautions are needed: (i) headspace analysis should be performed at 35 degrees C to preclude the possibility of artefactual formation from trichloroacetic acid, (ii) precautions to prevent cross-contamination of biological samples in the laboratory must be taken, and (iii) interpretation of analytical results must take account of the widespread presence of chloroform in the environment on the one hand, and that the toxicity of chloroform varies greatly depending on the circumstances and intensity of exposure on the other.

A petition to Mr Peel: Gideon Mantell and the trial of Hannah Russell.

In the summer of 1826, Hannah Russell was tried for petty treason, viz. the murder of her husband, Benjamin Russell, by poisoning. Their lodger, Daniel Leney, was indicted as her accomplice. The exact circumstances surrounding the death were unclear but Hannah was known to have purchased white arsenic (arsenious oxide). A local surgeon, Thomas Evans, supported at the post-mortem examination by two further surgeons, not only reported severe corrosion of the gastrointestinal tract, but also the recovery of nearly an eighth of an ounce of arsenic from the victim's stomach. Both accused were convicted and sentenced to death. Leney was executed, but Hannah Russell was respited because the trial judge, Sir Robert Graham, had doubts as to a direction he had given to the jury. The surgeon and paleontologist Gideon Mantell took up her case, stressing that death from arsenic could not have taken place as quickly as was alleged and maintaining that the chemical evidence of arsenic poisoning was inconclusive. He gained the support of some eminent chemists and physicians. Subsequently, forensic toxicologists [Sir] Robert Christison and Alfred Swaine Taylor pointed out that Mantell's arguments as to the possible time to death in arsenic poisoning were quite wrong. Moreover, Evans gave details of the analyses he and his colleagues had undertaken to Christison, who pronounced the findings sound, as indeed did Mantell after Evans and his colleagues published details of their investigations in the Sussex Advertiser. Papers in The National Archives show that Hannah was pardoned for the offence for which she was indicted, leaving it open to prefer a lesser charge. That this was never done may have been due to Mantell's campaign, at least in part, but the pardon she did receive was due to the concern of the trial judge as to the implications of the evidence presented at trial.