Theoretical limits of the evaluation of drug concentrations in hair due to irregular hair growth

When examining concentration relationships of doses it must be taken into account that hair growth is irregular. Hair growing from the shaved skin after a single dose of a certain drug cannot possibly contain the same concentration as hair after the same dose that has not been cut over a long period. Concentrations can even change during the hair growth in cases where the hair had been cut a couple of months before the hair sample was taken. The variations in the expected concentrations can exceed 20%. On the other hand, the evaluation of a hair tuft which has grown after the last drug consumption may be important in forensic cases where the hair which has grown earlier is not available. This may lead to misinterpretations at low concentrations. Expected concentrations are calculated assuming a telogen part of 10%.     

Sulfide concentrations in postmortem mammalian tissues

Postmortem changes in sulfide concentrations in body tissues were examined in autopsied rats exposed to hydrogen sulfide concentrations of 550 to 650 ppm, and in nonexposed rats and humans. Analyses were made by gas chromatography, following an extractive alkylation. Sulfide concentrations in the blood, liver, and kidneys of rats increased in both the exposed and nonexposed groups, depending on the lapse of time after death. On the other hand, the lung, brain, and muscle showed little or no change in sulfide concentration with elapse of time after death. The data obtained from human tissues were almost the same as those for rats, except data for blood, in which no or little increase of sulfide was observed.     

Postmortem hydroxychloroquine concentrations in nontoxic cases

Hydroxychloroquine (HCQ) is a 4-aminoquinoline compound used to treat malaria and chronic autoimmune disorders and is not uncommonly found in the medical examiner setting. Studies have shown HCQ to have a long half-life (32-56 days in blood), high volume of distribution (580-815 L/kg), and therapeutic concentrations ranging from 0.03 to 15 mg/L, depending on the chronicity of treatment. Previous reports have shown that the toxic concentration of HCQ ranges from 3 to 26 mg/L, whereas the lethal concentration ranges from 20 to 104 mg/L. A report addressing nontoxic postmortem concentrations of HCQ in individuals known to be taking the medication, and in whom there is no evidence of toxicity, has not been previously undertaken. This study found that postmortem concentrations in nontoxic cases can range from 0.3 to 39 mg/L, which is well within the reported range of both lethal and toxic concentrations. It is recommended that all investigative and autopsy data be considered and that the cause of death not be certified based purely on blood HCQ concentrations.     

Postmortem atropine concentrations in resuscitation cases

The medications used during resuscitation are often in and of themselves toxic. Several reports have been published regarding toxicities of these drugs, including lidocaine, procainamide, and atropine. But how does a forensic pathologist or toxicologist differentiate a possible intoxication from therapeutic or resuscitory use especially given that the concentrations of such drugs, when used in the setting of resuscitation, have not been studied? Concentrations of a well-known resuscitation medication, atropine, were assessed in cases where it was administered before death during attempted resuscitation in an effort to address this deficiency. A review of deaths occurring in 2009 was undertaken to identify cases where drugs known to be used during resuscitation were present on toxicological analysis. Autopsy reports and medical records were examined to determine how much atropine was administered, the timing and route of administration, the time the sample was drawn (antemortem and postmortem), the source of the sample, and the ultimate cause of death. Eighty-nine cases were identified in which atropine was given before death during attempted resuscitation and was detected in the blood on postmortem toxicological screening; 11 cases were identified in which atropine was administered before death yet was not detected on the postmortem toxicological screening. Mean age was 41 years, and there were 65 males and 35 females. The overall median dose of atropine given was 3 mg, the median difference between the time of last administration of the atropine to the time of death (or draw for antemortem samples) was 15 minutes, and the median atropine concentration was 0.1 mg/L. Analysis failed to reveal significant differences in the atropine concentration based on the route of administration (intravenous or intraosseus), the cause of death, or the time since administration (within the first 2 hours). Analysis did reveal a difference between the atropine concentrations in peripheral versus central blood sources and with prolonged postmortem interval (>24 hours) suggesting postmortem redistribution.     

Hepatitis in drug poisonings

In the period between 1983 and 1987 autopsies were carried out on 120 drug victims at the Institute for Forensic Medicine in Hamburg, and 93 cases were serologically tested for hepatitis B. It was found that 50 cases (54%) were positive for anti-HBc, 39 (42%) for anti-HBs, and 5 cases (5%) for HBsAg. The prevalence of hepatitis-B-virus markers was dependent upon the age of the victims. In 81% inflammatory alterations of the liver (including unspecific reactive hepatitis) were diagnosed histologically. The pathogenesis of these serological and pathomorphological findings is discussed. Drug addicts are a group at risk for hepatitis B, and it can spread on account of the epidemiological connection with other risk groups, e.g., prostitutes and homosexuals. Postmortem serological investigations for hepatitis markers proved to be a well-established and reproducible means of differentiating histopathological liver alterations.     

Blood carbofuran concentrations in suicidal ingestion cases

We describe four fatal cases due to ingestion of carbofuran, a carbamate insecticide. Carbofuran was detected in the gastric contents using thin layer chromatography (TLC) and gas chromatography/mass spectrophotometry (GC/MS), and quantified in the blood using a gas chromatograph equipped with nitrogen-phosphorus detector (NPD). Fatal concentrations of carbofuran in blood ranged from 0.32 to 11.6 microg/ml.     

唾液中滥用药物分析及其与血液中药物浓度的相关性

唾液是一种成分简单、易于采集的体液,某些药物在唾液中的浓度可以反映其血药浓度。本文分析了滥用药物进入唾液的机制和影响因素,综述了唾液中滥用药物分析时样品的采集、前处理和检测方法以及唾液与血液中药物浓度的相关性。认为唾液是临床和法医学方面很有价值的分析样品,用唾液中滥用药物浓度来推测血药浓度具有一定的法医学意义。     

Clocapramine-related fatality. Postmortem drug levels in multiple psychoactive drug poisoning

A suicide caused by ingestion of multiple psychoactive drugs is reported. A 42-year-old man with a history of psychosis was found dead in a blood pool in his room. The forensic autopsy revealed two stab wounds on his chest. However, these wounds could not explain the cause of death. Eighty-six tablets were found in his stomach. Four psychoactive drugs; clocapramine (CC), chlorpromazine (CP), promethazine (PM) and clotiazepam (CT) were detected in blood and tissues. The concentrations of CC, CP, PM and CT in the femoral vein (FV) blood were 0.39, 0.61, 1.23 and 0.09 microg/ml, respectively. The cause and manner of death were attributed to suicidal multiple psychoactive drug poisoning.Postmortem drug redistribution showed great site-dependent variations with the lowest level in the FV blood. Remarkable variations were observed in CC, CP and PM, but not in CT compared to other three drugs. The variations were dependent on the volume of distribution (Vd) of the drugs. Our human case has demonstrated drugs with higher Vd values showed higher degree of postmortem redistribution of the drug and vice versa.     

Variation in nuclear DNA concentrations during urination

This study examined the cellular origin and concentration of nuclear DNA in human urine. Ten subjects provided two entire, first-morning voids: one as a single specimen and one as a consecutive series of samples. The serial samples were centrifuged, organically extracted, and quantified by slot-blot analysis. Total DNA concentrations ranged from 0.02 to 21.3 ng/mL for the males and 25.0 to 96.9 ng/mL for the females. The female samples were found to contain numerous vaginal epithelial cells. DNA was detected in all of the serial samples of nine subjects; however, the DNA concentrations varied considerably. With six subjects, the DNA concentration of the first serial sample was at least three times greater than that of the entire void. DNA was only detected in the first 21% of the void from one male subject. The results of this study have implications for the collection of urine samples.     

High haloperidol concentrations in a traffic suicide

High concentrations of haloperidol are seen in a psychiatric patient who ran from a health care facility into traffic. Haloperidol concentrations were found to be 1.2 mg/L in heart blood, 2.7 mg/L in brain, and 10.8 mg/L in liver. No other drugs were detected.     

Site-dependent postmortem changes in blood cocaine concentrations

When a forensic toxicologist interprets postmortem blood cocaine findings he usually must make assumptions regarding perimortem drug concentrations. In-vitro studies have shown that cocaine rapidly hydrolyzes in unpreserved blood, particularly at elevated temperatures. However, other studies have demonstrated site-dependent postmortem release of some drugs from tissue stores accompanied by increases in drug concentrations in the blood. This study was undertaken to investigate whether blood cocaine concentrations change in the body during the postmortem interval and, if so, to measure the direction and magnitude of the changes. In medical examiner cases in which scene investigation suggested that the decreased was a cocaine user, blood samples were collected as soon after death as possible. At autopsy, a second set of samples was collected. Analysis of paired samples by gas chromatography/mass spectrometry (GC/MS) revealed dramatic differences in the cocaine concentration. The magnitude and direction of the change appears to be site dependent. Usually, but not invariably, cocaine concentration in subclavian vein blood decreases while that in heart, aorta, and femoral vein blood increases during the interval between death and autopsy. The findings emphasize the danger inherent in attempting to estimate the concentration of cocaine in blood at the time of death from postmortem data.     

Postmortem concentrations of citalopram

The postmortem concentrations of citalopram in blood, bile, liver, and vitreous humour were investigated in 14 cases using a specially developed high performance liquid chromatography assay. Concentrations from drug and non-drug related deaths were categorized to determine a postmortem therapeutic and toxic range. Therapeutic citalopram concentrations for blood, bile, liver, and vitreous humour ranged to 0.4 mg/L, 2.1 mg/l, 6.6 mg/kg, and 0.2 mg/L, respectively. In one potentially fatal response to citalopram, concentrations were 0.8 mg/L, 6.0 mg/L, 0.3 mg/L for blood, bile and vitreous humour, respectively.     

Workplace drug testing in Europe

Not much information is available on workplace drug testing (WDT) in Europe. There is no specific legislation and there are no generally accepted guidelines. Many companies establish a drug policy with little or no provisions for drug testing. Often, testing is performed on-site by occupational physicians, with little or no quality control, no systematic confirmation of positives, no chain of custody and no adulteration testing. In some parts of Europe, e.g. in the United Kingdom and some Scandinavian countries, WDT is increasing in importance, but it is not as widespread as in USA. The most frequently performed tests are amphetamines, cannabinoids, cocaine, opiates and alcohol. The percentage of positives is variable, but seems to decrease with the years following the introduction of WDT. Cannabis is the drug that is most frequently found.Recently, the European Workplace Drug Testing Society (EWDTS) was founded, with the aims to ensure that WDT in Europe is performed to a defined quality standard and in a legally secured way and to provide an independent forum for all aspects of WDT.A working group in the United Kingdom has recently finalised the United Kingdom laboratory guidelines for legally defensible WDT and discussions are under way with the EWDTS to establish common guidelines.Many efforts will be needed to establish WDT as an accepted part of a company policy on drugs: establishing and maintaining the confidence in the results of the laboratory, establishing the legal status of WDT, preserving the privacy and rights of the employees, proving the cost-effectiveness of WDT in a European context, finding a balance between strict guidelines and enough flexibility to tailor testing to the changing needs. It is hoped that the exchange of experience between different countries will contribute to reaching these goals.     

Infectious endocarditis in drug addicts

Clinicomorphological features of infectious endocarditis (IE) were studied on autopsy material from chronic drug addicts. Of special interest were morphological changes in the lymphoid organs. The experience of the author and literature data suggest that IE in drug addicts is a manifestation of secondary immunodeficiency syndrome on the background of chronic narcotic intoxication.     

Systemic violence in drug markets

Even without the protection of the state and courts, illegal drug markets are generally peaceable. However occasionally specific markets exhibit high levels of violence. This essay examines the sources that might generate such violence, some internal to organizations (successional and disciplinary), some between organizations (territorial or transactional) and others between drug dealers and the state or its representatives. Particular attention is given to the extremely high rates of killing in the high level Mexican drug markets in 2007–2008 and what motivates the variety of targeted victims, including innocent parties and corrupt officials. The other episode examined in detail is the US crack market in the 1980s. The emphasis here is on the youth of the participants, the value of the drug itself and the intensity of law enforcement. Peter Andreas and Joel Wallman made helpful suggestions. The discussion of US markets is adapted from MacCoun et al. [16].

---

Blood versus bone marrow isopropanol concentrations in rabbits

The use of bone marrow to determine the blood isopropanol concentrations becomes important when a blood specimen is contaminated or unavailable. The blood/marrow isopropanol ratios were determined in rabbits autopsied 0, 4, and 24 h after sacrifice. The lipid content of the individual marrow specimens was shown to have a significant influence on the range of ratios. When the determined marrow isopropanol concentrations were corrected for lipid content, a better correlation between blood and marrow concentrations was obtained. The ratio (1.45 ± 0.17) was not altered significantly by postmortem time or temperature.Although acetone was not exogenously administered to the rabbits, but rather was endogenously produced from isopropanol metabolism, the relationship between blood and marrow acetone concentrations was somewhat linear. However, the range of observed and corrected blood/marrow acetone ratios was altered significantly by storage temperature, and delays between death and analysis. Thus, under the experimental conditions of this study, marrow isopropanol concentrations may be used to predict blood isopropanol concentrations, whereas marrow acetone concentrations can not.     

Blood versus bone marrow methanol concentrations in rabbits

Postmortem methanol levels in bone marrow and heart blood were determined in rabbits. The average ratio of heart blood concentration to observed bone marrow concentration in 36 rabbits was 2.6 ± 0.6 with a range of 1.5 to 4.2. Correcting for the lipid content of the bone marrow decreased the average ratio, reduced the ratio range and improved the correlation. The heart blood to corrected bone marrow ratio was 1.6 ± 0.3 with a range of 1.2 to 2.9. Direct injection gas chromatographic techniques were employed to quantitate methanol concentrations.     

Methamphetamine and amphetamine concentrations in postmortem rabbit tissues

The feasibility of detecting methamphetamine and its major metabolite, amphetamine, in postmortem tissues over a 2-year period was examined. It is important to determine if the abuse and toxic effects of drugs can be proved from evidence found in decayed, submerged, or stained tissue materials. The blood, urine, liver, skeletal muscle, skin and extremity bones from rabbits given methamphetamine intravenously were kept at room temperature, under 4 different conditions: sealed in a test tube, dried in the open air, submerged in tap water and stained on gauze. Methamphetamine was present in all the samples, with slight change in concentration in case of sealed and air dried tissues. Changes varied in bones kept in water. There were considerable decreases in methamphetamine in blood and urine stains. Despite long term storage, drug abuse and/or toxicity could be determined, in all tissues examined.