Postmortem examination and toxicological analysis for acute metonitazene intoxication in Japan: A case report.

Benzoimidazole analgesics (Nitazenes, NZs) are opioid receptor agonists that exhibit very strong pharmacological effects at minute doses, and their abuse has recently become a concern worldwide. Although no deaths involving NZs had been reported in Japan to date, we recently experienced an autopsy case of a middle-aged man who was determined to have died from poisoning by metonitazene (MNZ), a type of NZs. There were traces of suspected illegal drug use around the body. Autopsy findings were consistent with acute drug intoxication as the cause of death, but it was difficult to identify the causative drugs by simple qualitative drug screening. Analysis of compounds recovered from the scene where the body was found identified MNZ, and its abuse was suspected. Quantitative toxicological analysis of urine and blood was performed using a liquid chromatography high-resolution tandem mass spectrometer (LC-HR-MS/MS). Results showed that MNZ concentrations in blood and urine were 6.0 and 5.2 ng/mL, respectively. Other drugs detected in blood were within therapeutic ranges. Quantitated blood MNZ concentration in the present case was in the similar range as those reported in overseas NZs-related deaths. There were no other findings that could have contributed to the cause of death, and the decedent was judged to have died of acute MNZ intoxication. Emergence of NZs distribution has been recognized in Japan similarly to overseas; early investigation of their pharmacological effects as well as crackdown on their distribution is strongly desired.

Novel Matrix Normalization Technique for Accurate LC-ESI-MS/MS Detection and Quantification of Drugs and Their Metabolites in Toxicology Research and Practice.

Accurate identification and quantification of drugs and their metabolites (analytes) in biological matrices is an analytical foundation of clinical and forensic toxicology. For decades, liquid chromatography interfaced by electrospray ionization with tandem mass spectrometry (LC-ESI-MS/MS) has been a widely used technology for analysis in the field of toxicology, as well as in many other fields of bioscience. It is also known that ion response in LC-ESI-MS/MS analysis is influenced by coeluting biological compounds and that preanalytical sample clean-up is often insufficient in removing these interferences. As a result, a normalization technique is commonly used for assessment and compensation of matrix effects encountered in routine analysis. Internal standardization with a stable isotope analog of the analyte is the predominant normalization technique used in LC-ESI-MS/MS analysis. The technique, however, requires commercial availability or costly custom synthesis of an isotopic analog specific for each analyte. Here we describe an alternative technique for matrix normalization for use in high-volume, multianalyte testing without the need for isotope analogs. The technique involves analysis of the original sample (neat analysis) followed by analysis of a second sample aliquot (spike analysis) that has been fortified with a controlled amount of reference analyte. A calibration procedure similar to internal standardization is employed, using an ion response ratio of neat to fortified analyte. As a demonstration of the technique in multianalyte testing, we provide a detailed protocol for simultaneous detection and quantification of 102 drugs and drug metabolites in human urine. We also provide a support protocol for addition of new analytes to the multianalyte panel, allowing convenient collection of the validation data during routine testing. The matrix normalization technique and testing principles may be applicable to a wide range of analytes and biological matrices, not only those encountered in toxicology but also in other fields of bioscience. © 2023 Wiley Periodicals LLC. Basic Protocol: Detection and quantification of 102 toxicology analytes in urine by LC-ESI-MS/MS analysis using the threshold accurate calibration technique Support Protocol: Method for addition and validation of new analytes to expand the Basic Protocol.

Micro-segmental hair analysis: detailed procedures and applications in forensic toxicology.

PURPOSE: Since the 1980s, the detection sensitivity of mass spectrometers has increased by improving the analysis of drugs in hair. Accordingly, the number of hair strands required for the analysis has decreased. The length of the hair segment used in the analysis has also shortened. In 2016, micro-segmental hair analysis (MSA), which cuts a single hair strand at a 0.4-mm interval corresponding to a hair growth length of approximately one day, was developed. The advantage of MSA is that the analytical results provide powerful evidence of drug use in the investigation of drug-related crimes and detailed information about the mechanism of drug uptake into hair. This review article focuses on the MSA technique and its applications in forensic toxicology. METHODS: Multiple databases, such as SciFinder, PubMed, and Google, were utilized to collect relevant reports referring to MSA and drug analysis in hair. The experiences of our research group on the MSA were also included in this review. RESULTS: The analytical results provide a detailed drug distribution profile in a hair strand, which is useful for examining the mechanism of drug uptake into hair in detail. Additionally, the analytical method has been used for various scenarios in forensic toxicology, such as the estimation of days of drug consumption and death. CONCLUSIONS: The detailed procedures are summarized so that beginners can use the analytical method in their laboratories. Moreover, some application examples are presented, and the limitations of the current analytical method and future perspectives are described.

Ethyl glucuronide and ethyl sulfate: a review of their roles in forensic toxicology analysis of alcohol postmortem.

PURPOSE: This review presents the current methods used for determining ethyl glucuronide (EtG) and ethyl sulfate (EtS) concentrations in postmortem specimens, including sample preparation, analysis and the role of EtG and EtS in the postmortem assessment of the extent of alcohol abuse. METHODS: Papers pertaining to postmortem investigation were collected from scientific databases and reviewed. The papers were published between January 2006 and October 2020. RESULTS: Most of the analyses involved postmortem blood and urine samples, with a few reports using other bodily specimens and tissues. The method validation was not conducted for all applications. These reports were mostly intended to present data rather than interpret them, and the lack of effort in relating these ethanol biomarkers with the cause of death and/or determination of the time of deaths due to ethanol intoxication might decrease the applicability of these makers after a promising start between 2006 and 2010. Nevertheless, by the beginning of 2020, papers investigating ethanol biomarkers were still increasing. A considerable number of methods used liquid chromatography coupled with mass spectrometry (LC-MS) techniques that require less sample preparation (e.g., protein precipitation extraction, dilution, filtration, and centrifugation). Although solid-phase extraction can be applied, only three applications were reported. CONCLUSIONS: Matrix effects can be a substantial challenge in analytical methods based on LC-MS because they directly affect the ionization of analytes. However, these problems can be avoided due to the high cutoff values used to identify positive results for these ethanol biomarkers, which are often above 0.1-1 mg/L, and using internal standards. Research on using tissue specimens is recommended as most of the reported results on this type of specimen were promising.

Alternative matrices in forensic toxicology: a critical review.

PURPOSE: The use of alternative matrices in toxicological analyses has been on the rise in clinical and forensic settings. Specimens alternative to blood and urine are useful in providing additional information regarding drug exposure and analytical benefits. The goal of this paper is to present a critical review on the most recent literature regarding the application of six common alternative matrices, i.e., oral fluid, hair, sweat, meconium, breast milk and vitreous humor in forensic toxicology. METHODS: The recent literature have been searched and reviewed for the characteristics, advantages and limitations of oral fluid, hair, sweat, meconium, breast milk and vitreous humor and its applications in the analysis of traditional drugs of abuse and novel psychoactive substances (NPS). RESULTS: This paper outlines the properties of six biological matrices that have been used in forensic analyses, as alternatives to whole blood and urine specimens. Each of this matrix has benefits in regards to sampling, extraction, detection window, typical drug levels and other aspects. However, theses matrices have also limitations such as limited incorporation of drugs (according to physical-chemical properties), impossibility to correlate the concentrations for effects, low levels of xenobiotics and ultimately the need for more sensitive analysis. For more traditional drugs of abuse (e.g., cocaine and amphetamines), there are already data available on the detection in alternative matrices. However, data on the determination of emerging drugs such as the NPS in alternative biological matrices are more limited. CONCLUSIONS: Alternative biological fluids are important specimens in forensic toxicology. These matrices have been increasingly reported over the years, and this dynamic will probably continue in the future, especially considering their inherent advantages and the possibility to be used when blood or urine are unavailable. However, one should be aware that these matrices have limitations and particular properties, and the findings obtained from the analysis of these specimens may vary according to the type of matrix. As a potential perspective in forensic toxicology, the topic of alternative matrices will be continuously explored, especially emphasizing NPS.

Identification and characterization of novel synthetic cannabinoid ethyl-2-(1-(5-fluoropentyl)-1H-indole-3-carboxamido)-3,3-dimethylbutanoate (5F-EDMB-PICA).

PURPOSE: The purpose of the current study was to evaluate an analytical characterization of a novel synthetic cannabinoid ethyl-2-(1-(5-fluoropentyl)-1H-indole-3-carboxamido)-3,3-dimethylbutanoate (5F-EDMB-PICA), which has a similar chemical structure to the controlled synthetic cannabinoid 5F-MDMB-PICA. METHODS: The compound was analyzed by gas chromatography-mass spectrometry (GC-MS), supercritical fluid chromatography-quadrupole time-of-flight-mass spectrometry (SFC-QTOF-MS) and spectroscopic methods, such as attenuated total reflection (ATR)-Fourier transform infrared (FTIR), ultraviolet-visible (UV-VIS) and nuclear magnetic resonance (NMR) spectroscopies. RESULTS: In this study, we reported a comprehensive analytical data of 5F-EDMB-PICA. The data of analytical characterization for the 5F-EDMB-PICA were obtained by GC-MS, SFC-QTOF-MS, ATR-FTIR spectroscopy, UV-VIS spectroscopy, and 1H and 13C NMR spectroscopy. CONCLUSIONS: In this study, we presented a comprehensive analytical characterization of 5F-EDMB-PICA obtained by 1H NMR, 13C NMR, GC-MS, SFC-QTOF-MS, ATR-FTIR spectroscopy and UV-VIS spectroscopy. The analytical data of 5F-EDMB-PICA are very useful for forensic, toxicological, and clinical diagnosis.

Forensic toxicological and analytical aspects of carbamate poisoning - A review.

Pesticides play a pivotal role in modern agricultural practices and effective domestic pest control. Despite their advantages, pesticides pose a great danger to humans and animals due to their toxicity. Pesticides, particularly carbamates, are extensively used all over the world in crop protection and domestic pest control, however, also causing morbidity and mortality on a larger scale, which is of great significance in both clinical and criminal justice management.Carbamates are derived from a carbamic acid (NH2COOH) that are commonly used as insecticides. Ethienocarb, Sevin, Carbaryl, Fenoxycarb, Furadan, Carbofuran, Aldicarb, and 2-(1-Methylpropyl) phenyl N-methylcarbamate are examples of insecticides that include the carbamate functional group. By reversibly inactivating the enzyme acetylcholinesterase, these insecticides can induce cholinesterase inhibition poisoning.Chromatographic methods, notably gas and liquid chromatography have traditionally been employed to analyse carbamate pesticides and their metabolites in various matrices. These approaches are employed due to their ability to separate the chemicals contained in a sample; as well as identify and quantify these compounds utilizing advanced detection systems. Aside from these GC and LC conventional methods, other detection and/or hyphenated techniques such as single-quadrupole, ion-trap, triple-quadrupole, or tandem mass spectrometry, have been used in carbamate analysis to provide quick results with excellent sensitivity, precision, and accuracy.The objective of this review is to describe various analytical techniques used to detect and determine carbamate pesticides in various matrices which include urine, blood, and tissues that are commonly encountered in emergency hospital laboratories and forensic science laboratories.

Estimation of blood and urine levels of eight metals and essential trace elements collected from living Subjects compared to urine, cardiac and femoral postmortem blood, and other postmortem samples: A forensic toxicology study.

Along with the regular toxicology testing, different samples collected during the autopsy might be subjected to metal level estimation to investigate the cause of death in some cases. Utilizing a scientific procedure on postmortem specimens is crucial for interpreting forensic toxicological analytical results. Even modest procedural errors made by incompetent forensic toxicologists and chemists who lack proper specialized training and knowledge can alter the scientific conclusions and hence the legal verdict. The current work studies an overview of eight metals and element levels in living and deceased human bodies. It could be a substantial contribution to establishing normal or so-called "reference" metal levels under antemortem and postmortem situations, hence aiding in identifying reliable future interpretations of results produced by numerous researchers in the same field. AIM OF THE WORK: The current work aimed to study the concentration of eight metals in the blood samples (cardiac and femoral), urine, and other samples (Spleen, liver, and renal tissues) collected from human cadavers at different postmortem intervals in addition to blood and urine samples collected from the living population as a contribution to establishing normal or so-called "reference" metal levels under antemortem and postmortem situations. SUBJECTS AND METHODS: Postmortem autopsy blood samples (cardiac and femoral), urine, and other samples (Spleen, liver, and renal tissues) were collected from 400 deceased subjects. These samples were analyzed for the estimation of the eight metals under research, namely, Arsenic (As), Selenium (Se), Silver (Ag), Cadmium (Cd), Antimony (Sb), Mercury (Hg), Zinc (Zn) and Lead (Pb). In addition, blood and urine samples from 400 living volunteer subjects were analyzed for the same eight elements under study. RESULTS: In the postmortem group, the mean metal levels in cases with absent, early, and advanced putrefaction simultaneously in µg/L were 2.45 ± 3.30, 3.25 ± 5.18, and 3.81 ± 1.95 for As. For Se, the results were 10.74 ± 4.21, 10.54 ± 5.28, and 9.96 ± 4.14. 4.04 ± 1.74, 3.48 ± 1.32, and 3.74 ± 0.91 were the results for Ag. For Cd, they were 8.35 ± 3.91, 12.15 ± 3.05, and 24.51 ± 31.25 with P < 0.0001**. 1.48 ± 1.85, 1.61 ± 1.85, and 1.62 ± 1.74 were the same results for Sb; 6.07 ± 2.44, 5.22 ± 2.17, and 5.39 ± 1.82 for Hg. 395 ± 79.8, 553 ± 51.7, and 704 ± 97.2 for Zn with a P-value <0.005*. As for lead, the results were 15.61 ± 24.19, 14.76 ± 23.05, and 24.61 ± 52.72. As the postmortem interval increased, Cd and Zn levels increased (p < 0.0001, <0.005* simultaneously).

[Propofol: use, toxicology and assay features]. / Propofol: primenenie, toksikologicheskaya kharakteristika i osobennosti opredeleniya.

The study objective is to review the literature on the use, pharmacological properties, toxicology, and assay methods for intravenous anesthetic propofol. The scope and forms of propofol use, its pharmacokinetics, biotransformation features, which occurs more than 90% in the liver, and side effects associated with propofol use for anesthesia, are addressed. Propofol infusion syndrome (also known as PrIS) and deaths from propofol overdose due to medical errors, abuse, suicide attempts, and homicide are reported. Propofol identification and assay methods based on high-performance liquid chromatography (HPLC), gas chromatography with mass spectrometry (GC-MS), and liquid chromatography (LC) are described. The features of the methods performance are outlined; biological materials (the study objects) are listed: mainly blood and plasma, as well as urine, bile, hair, etc. The relevance of a comprehensive forensic chemical study of propofol is indicated, though there are few forensic studies of propofol.

Determination of Traditional and Designer Benzodiazepines in Urine through LC-MS/MS.

BACKGROUND: The detection of new designer benzodiazepines in biological fluids and tissues, together with the traditional ones, could represent an important analytical update for laboratories performing clinical and forensic toxicological analysis. OBJECTIVE: A liquid chromatography tandem mass spectrometry method (LC-MS/MS) has been developed, fully validated, and applied to a cohort of real urine samples collected from patients under withdrawal treatment and from intoxication cases. METHODS: 100 µL urines were added to a buffer solution containing deuterated internal standards; the samples were then extracted through a liquid/liquid procedure, dried under a nitrogen stream, and reconstituted in mobile phase. The chromatographic separation was performed in reverse phase through a C18 column with gradient elution. Mass spectrometry operated in positive polarization and multiple reaction monitoring mode. RESULTS: 25 molecules were optimized for instrumental analysis: 9 designer benzodiazepines and 16 traditional compounds (parent drugs and main metabolites). Sensitivity, specificity, linearity, accuracy, imprecision, recovery, matrix effects, and carry-over have been evaluated for all molecules. Only cinazepam did not satisfy all acceptance criteria for validation. 10 among the 50 analyzed samples tested positive for at least one of the monitored molecules. In particular, two different samples collected from the same case provided positive results for flubromazepam, a designer benzodiazepine. CONCLUSION: The method was proven to be useful in detecting not only traditional benzodiazepines but also new designer ones. The identification of a New Psychoactive Substance in real samples confirmed that analytical procedures should be updated to include as many substances as possible.

The importance of updatable analytical screening methods for new psychoactive substances in clinical and forensic toxicology.

Abstract: The continuous emergence of New Psychoactive Substances enter-ing the illegal markets poses always new challenges to forensic and clinical toxicology laboratories facing the lack of analytical methods capable of determining the newer parent compounds and eventual metabolites. More than 50 new molecules have been reported by the European Monitoring Centre for Drugs and Drug Addiction only in 2021, further expanding the panel of target analytes. However, the implementation of new detection methodologies may not be viable due to time constraints and inadequate resources. To this concern, the updatable analytical screening methods constitute a powerful tool for pharmacotoxicological laboratories investigating both non biological seizure materials and conventional and non conventional matrices coming from intoxications and fatalities of drugs consumers.

Analysis of conventional and nonconventional forensic specimens in drug-facilitated sexual assault by liquid chromatography and tandem mass spectrometry.

The incidence of drug-facilitated sexual assault (DFSA) has dramatically increased in the last decades. Forensic analytical scientists continuously seek new methods and specimens to prove the incidence of intoxication for the judiciary system. Factors influencing sample selection include the ease of obtaining the samples and the window of detection of the drugs, among others. Both conventional (blood, urine) and non-conventional specimens (hair, nails, fluids) have been proposed as suitable in DFSA cases. Reported sample treatments include a variety of liquid-liquid and solid-phase extraction as well as dilute-and-shoot procedures and microextraction techniques. Regarding analysis, liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) has emerged as the preferred confirmatory technique, due to its sensitivity, selectivity, and wide-scope applicability. In this review, we critically discuss the most common specimens and sample treatments/analysis procedures (related to LC-MS/MS) that have been reported during the last ten years. As a final goal, we intend to provide a critical overview and suggest analytical recommendations for the establishment of suitable analytical strategies in DFSA cases.

Determination of fentanyl and norfentanyl in cerumen in the setting of postmortem investigation.

Cerumen is an emerging alternative biological matrix in the field of forensic toxicology. An ultra-high-pressure liquid chromatography-mass spectrometry/mass spectrometry [UHPLC-MS/MS] method for the determination of fentanyl and norfentanyl in cerumen was developed and applied in a mixed drug toxicity fatal case. The method was found to be selective and sensitive (LOQ: 0.05 ng/mg for fentanyl and 0.02 ng/mg for norfentanyl), while validation included recovery, carryover, short-term stability, matrix effect, accuracy, and precision (RSD%). Accuracy ranged from 83.1% to 103.5%, while intra- and inter-day precision ranged from 8.6% to 13.1% and from 8.3% to 15.8%, respectively. Matrix effect experiments showed that matrix did not significantly affect signal intensity (82.3%-96.8%). Short-term stability concerning sample extracts was found satisfactory. Fentanyl and norfentanyl were detected in cerumen at a concentration of 1.17 and 0.36 ng/mg respectively. The findings in cerumen corroborate the cause of death and suggest that cerumen is a potential specimen for detecting drugs of abuse in forensic cases.

Retrospective analysis of laboratory data from 19,275 hair samples submitted for drug abuse/misuse analysis from February 2019 to June 2021.

Drug abuse/misuse is now a major global problem affecting public health as well as economic and social stability. This study presents a retrospective view of the prevalence of drugs in hair. Reasons for hair testing include the need for law enforcement to test suspicious individuals and the need for employers in specific industries to test their employees. Toxicology analysis results were reviewed for a total of 19,275 hair samples requested for drug abuse/misuse analysis at the Academy of Forensic Science over 29 months from February 2019 to June 2021. Drugs and their metabolites in hair samples were analyzed by liquid chromatography - tandem mass spectrometry. In the study, the 19,275 hair samples were screened for a total of 62 illegal drugs, which were divided into three categories: illegal-drugs (I), medication (II), and new psychoactive substances (III). These three categories contain 11, 29 and 22 drugs respectively. In these hair samples, 4852 (25.2 %) tested positive for one or more drugs. Among them, the positive rate of category I was the highest (48.7 %), followed by category II (28.5 %), and category III (22.7 %). Over all, the positive rate of male users (26.2 %) was higher than that of female users (23.7 %), and most of them were young people (25-44 years old). Illegal-drugs (morphine, etc.) had the highest positive rate. Under the influence of some certain factors, the drug abuse situation will also undergo corresponding changes. The results can provide a scientific knowledge database which can help in the prevention of drug abuse.

Xylazine: Pharmacology Review and Prevalence and Drug Combinations in Forensic Toxicology Casework.

Xylazine, an alpha-2 receptor agonist used in veterinary medicine for its sedative and muscle-relaxant effects, has been reported in forensic toxicology casework since the 1980s. It is not approved for human use, but it is used as an adulterant in heroin and illicit fentanyl. The prevalence and concentrations of xylazine in 2.5 years (January 2019-June 2021) of driving under the influence of drugs (DUID) and medico-legal death investigation (MDI) cases was investigated, including other drugs detected in combination with xylazine. Of over 170,000 cases screened for xylazine, 97% were classified as MDI. Over the course of the study period, the prevalence and geographical spread of xylazine increased. Overall, 2.8% of DUID and 2.1% of MDI cases screened positive for xylazine with concentrations of 5.1-450 ng/mL (mean = 36 ng/mL) and 5.0-11,000 ng/mL (mean = 41 ng/mL), respectively. Two MDI cases which had xylazine concentrations of 9,100 and 11,000 ng/mL were drug overdose suicides that did not involve any opioids. Opioids, primarily fentanyl and/or a fentanyl byproduct/metabolite were detected in 100% of DUID and all but two MDI cases. After opioids, stimulants, phyto-cannabinoids and benzodiazepines were the most common drug classes detected in conjunction with xylazine in both DUID and MDI casework. In summary, xylazine exposure continues to increase, mostly through the adulteration of illicit opioids. There is an extensive overlap in the concentrations between living and deceased individuals, making it difficult to interpret the role of the drug in MDI or DUID cases without other case information.

Liquid Chromatography High-Resolution Mass Spectrometry in Forensic Toxicology: What are the Specifics of Method Development, Validation and Quality Assurance for Comprehensive Screening Approaches?

The use of high-resolution mass spectrometry (HRMS) has increased over the past decade in clinical and forensic toxicology, especially for comprehensive screening approaches. Despite this, few guidelines in this field have specifically addressed HRMS issues concerning compound identification, validation, measurement uncertainty and quality assurance. To fully implement this technique, certainly in an era in which the quality demands for laboratories are ever-increasing due to various norms (e.g. the International Organization for Standardization's ISO 17025), these specific issues need to be addressed. This manuscript reviews 26 HRMSbased methods for qualitative systematic toxicological analysis (STA) published between 2011 and 2021. Key analytical data such as samples matrices, analytical platforms, numbers of analytes and employed mass spectral reference databases/libraries as well as the studied validation parameters are summarized and discussed. The article further includes a critical review of targeted and untargeted data acquisition approaches, available HRMS reference databases and libraries as well as current guidelines for HRMS data interpretation with a particular focus on identification criteria. Moreover, it provides an overview on current recommendations for the validation and determination of measurement uncertainty of qualitative methods. Finally, the article aims to put forward suggestions for method development, compound identification, validation experiments to be performed, and adequate determination of measurement uncertainty for this type of wide-range qualitative HRMSbased methods.

A retrospective analysis of data from illicit drug abuse cases in Beijing between 2018 and 2020.

The overall number of drug abuse cases has been on the rise around the world, causing it a disaster in many countries. In this retrospective study, we analyzed the characteristics of 11,903 drug abuse cases in Beijing, the capital of China, in the perspective of age, gender, nationality, region, season, type of specimens and various drugs, respectively. The case information was collected by the national-level forensic toxicology laboratory, which belongs to the China University of Political Science and Law. It was shown that the overall number of drug abuse cases had increased sharply from 2018 to 2019 and had a decrease of 25% in 2020. The incidence of drug abuse cases involving men was much higher than that of the cases involving women. The adolescents and young adults accounted for the largest share of drug abusers in our study. Haidian, as a national center of scientific and technological innovation with global influence, had the largest percentage of toxic substance-related cases, and the change was more pronounced than other districts during the 3-year-period. Chaoyang was second to Haidian in the number toxic substance-related cases. As a key window of economic, Chaoyang had the highest number of foreigner drug cases. June to August had the highest number of drug abuse cases, while amphetamines, opioids, cannabis and cocaine were the most common toxic substances involved in the cases we detected. To our knowledge, this is the first study to provide an overall analysis of drug abuse cases in Beijing, China. The study indicated the presence of a wide number of drug abuse cases in the capital city and confirmed the threat for the public safety and health. Such forensic information can assist the government to devise intelligence-based preventive and repressive measures and policies.

Heart rupture as an acute complication of cocaine abuse: A case report.

The purpose of this study is to show a very rare complication of acute cocaine poisoning, namely heart rupture. In the present case report, acute cocaine intoxication caused massive myocardial infarction, resulting in heart rupture and cardiac tamponade. A crime scene investigation found a dead body on the street in a drug dealing district. Examination of the body showed no external injuries. A thorough autopsy was performed showing massive cardiac tamponade with 510 ml of blood within the pericardium and full-thickness tissue lesion at the posterior wall of the left ventricle of 3.5 × 3 cm. Histological examination in hematoxylin and eosin was performed and confirmed the interruption of the posterior wall of the left ventricle with the presence of blood. In fact, although the correlation between cocaine and myocardial damage is well established, the relationship between heart rupture and acute cocaine intoxication is an extremely rare event. Moreover, since there are, to date, few reports of similar deaths, our report provides useful information regarding sudden death in a cocaine abuser. It is, therefore, of crucial importance to report this case to the scientific community.

A Two-Year Review of Fentanyl in Driving under the Influence and Postmortem Cases in Orange County, CA, USA.

In recent years, fentanyl is increasingly detected in overdose cases as well as human performance cases due to the current opioid epidemic. The comparison of fentanyl concentrations in deaths to recreational fentanyl use found in driving under the influence of drugs (DUID) cases is important to show how increased availability affects the historical knowledge of fentanyl. A 2-year review of fentanyl cases from Orange County, CA, USA, is presented to highlight fentanyl concentrations in these two case types. Any non-urine sample with fentanyl detected above the limit of detection of 0.5 ng/mL was reviewed in DUID and postmortem (PM) cases. The mean and median fentanyl concentrations in 199 antemortem (AM) blood samples from DUID cases were 14.2 ng/mL and 5.3 ng/mL, respectively, with a range of 0.5-303 ng/mL. In 285 central blood samples from PM cases, the mean was 29.1 ng/mL, the median was 16.9 ng/mL and the range was 0.6-636 ng/mL. In a total of 58 PM peripheral blood samples, the mean, median and range were 14.0 ng/mL, 10.0 ng/mL and 0.9-78.0 ng/mL, respectively. Of the 55 brain samples analyzed, the fentanyl mean, fentanyl median and range of fentanyl concentrations were 50.0 ng/g, 31.4 ng/g and 1.9-441 ng/g, respectively. Fentanyl concentrations in 16 liver samples had a mean of 82.0 ng/g, a median of 69.4 ng/g and a range of 11.6-226 ng/g. The overlap of fentanyl concentrations from the AM and PM samples highlights the importance of evaluating case circumstances when providing an interpretation in PM cases. Additional information such as age, gender, polydrug use and PM redistribution is presented for the cases included in the study.