Tramadol (Ultram) concentrations in death investigation and impaired driving cases and their significance

We reviewed a series of 66 deaths in Washington State between 1995-2000 in which tramadol (Ultram and Ultracet, Ortho-McNeil) was detected in the decedent's blood, in order to assess the role tramadol was determined to have played. Additionally, we reviewed a series of 83 impaired driving cases in which tramadol was detected in order to establish a non-lethal blood tramadol concentration reference range. In both populations, tramadol was consistently found together with other analgesic, muscle relaxant, and CNS depressant drugs. Death was rarely attributable to tramadol alone. However, tramadol may be a significant contributor to lethal intoxication when taken in excess with other drugs, via the potential interaction with serotonergic antidepressant medications, as well as the potential for increased CNS depression. Although the incidence of tramadol detection has increased consistently over the last eight years, there is no evidence of a corresponding increase in the number of cases in which death was attributed solely to tramadol. Blood drug concentrations in many deaths exceeded the therapeutic serum range of 0.28-0.61 mg/L; however, the concentrations overlapped almost completely with the range identified in living subjects arrested for impaired driving. These findings suggest caution in the interpretation of blood tramadol concentrations outside of the recognized therapeutic range. It also suggests that the drug, even when used in moderate excess, is not a principle cause of death in suicidal or accidental deaths.     

Trace analysis of peroxide explosives by high performance liquid chromatography-atmospheric pressure chemical ionization-tandem mass spectrometry (HPLC-APCI-MS/MS) for forensic applications

An HPLC-APCI-MS(/MS) method for the (trace) analysis of the most commonly encountered peroxide explosives, hexamethylenetriperoxidediamine (HMTD) and triacetonetriperoxide (TATP), has been developed. With this method, HMTD and TATP have been analyzed in the same run. (Pseudo-)molecular ions of these peroxides have been obtained as base peak under the same condition. A series of product ions was produced from these pseudo-molecular ions ([HMTD - 1]+ and [TATP + NH4]+) in the MS/MS analysis. We also pioneered in showing that a TATP molecular ion [TATP + H]+ can be observed with HPLC-MS/MS. The limit of detection for HMTD and TATP was 0.26 and 3.3 ng, respectively, on column by HPLC-MS in the Full Scan mode and 0.08 and 0.8, respectively, by HPLC-APCI-MS/MS in Selected Reaction Monitoring (single mass unit) mode. The method presented has been applied successfully for the identification of peroxides in the bulk solid state (powder sample), as well as in post-blast extracts originating from a forensic case. For the post-blast extracts, the use of tandem MS has been shown clearly to be of crucial importance for the identification and detection of the peroxide explosives.     

The significance of pulmonary interstitial emphysema in live birth determination

The utility of pulmonary interstitial emphysema (PIE) in live birth determination is not well established. Because the distinction between live birth and stillbirth may be important in criminal proceedings, we undertook this study to investigate the relationship between the histologic finding of PIE and live birth. Sixty-six cases of infant death were retrieved and compared with 21 stillborn infants. Histologic sections of the lungs were characterized as "florid PIE," "equivocal PIE," or "absent PIE." Sixteen cases of florid PIE were identified, all in live born infants. Forty-seven cases of equivocal PIE were found in 36 live born and 11 stillborn infants. In 24 cases (14 live born infants and 10 stillborns), no PIE was identified. We examined the relationship between florid PIE in infants with sudden infant death syndrome (SIDS) or "sudden unexpected death in infancy, manner undetermined" (SUDI), and also its relationship to other variables. No association was found. The presence of equivocal PIE may be an artifact of tissue processing. Florid PIE is found only in live born infants. No correlation between the presence of florid PIE and cause of death could be determined.     

Lineup Identification by Children: Effects of Clothing Bias

This study examined effects of clothing cues on children's identification accuracy from lineups. Four- to 14-year-olds (n = 228) saw 12 video clips of individuals, each wearing a distinctly colored shirt. After watching each clip children were presented with a target-present or target-absent photo lineup. Three clothing conditions were included. In 2 conditions all lineup members wore the same colored shirt; in the third, biased condition, the shirt color of only one individual matched that seen in the preceding clip (the target in target-present trials and the replacement in target-absent trials). Correct identifications of the target in target-present trials were most frequent in the biased condition, whereas in target-absent trials the biased condition led to more false identifications of the target replacement. Older children were more accurate than younger children, both in choosing the target from target-present lineups and rejecting target-absent lineups. These findings suggest that a simple clothing cue such as shirt color can have a significant impact on children's lineup identification accuracy.     

Weight force during prone restraint and respiratory function

Prone maximal restraint position (PMRP, also known as hogtie or hobble) is often used by law enforcement and prehospital personnel on violent combative individuals in the field setting. Weight force is often applied to the restrained individual's back and torso during the restraint process. We sought to determine the effect of 25 and 50 lbs weight force on respiratory function in human subject volunteers placed in the PMRP. We performed a randomized, cross-over, controlled trial on 10 subjects placed in 4 positions for 5 minutes each: sitting, PRMP, PRMP with 25 lbs weight force (PMRP+25), and PRMP with 50 lbs weight force placed on the back (PMRP+50). We measure pulse oximetry, end-tidal CO2 levels, and forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). FVC and FEV1 were significantly lower in all restraint positions compared with sitting but not significantly different between restraint positions with and without weight force. Moreover, mean oxygen saturation levels were above 95% and mean end-tidal CO2 levels were below 45 mm Hg for all positions. We conclude that PMRP with and without 25 and 50 lbs of weight force resulted in a restrictive pulmonary function pattern but no evidence of hypoxia or hypoventilation.     

The designer drug situation in Ibiza

A total of 137 urine samples and 46 serum samples, corresponding to 154 self-confessed designer drugs consumers in Ibiza island, were analyzed for the presence of designer drugs: amphetamine and amphetamine derivatives (methamphetamine, methylenedioxymethamphetamine (MDMA), methylenedioxyethylamphetamine (MDEA), methylenedioxyamphetamine (MDA), p-methoxymethylamphetamine (PMMA), p-methoxyamphetamine (PMA), etc.), ketamine and gamma-hydroxybutyric acid. Among this population, coming both from the forensic clinic and from the emergency room of a hospital, a total of 99 cases were found positive for some designer drug. This study shows the prevalence of methylenedioxymethamphetamine (MDMA) among designer drug users, sole or in association with other drugs. Also, the mixture of MDMA with other designer drugs, ethanol and/or cocaine is shown to be more likely to produce toxic symptoms requiring clinical attendance in a hospital emergency room. These findings along with the consumption history, the concentrations of drugs and metabolites in urine and serum and the toxicological significance for the interpretation of some MDMA metabolites such as 4-hydroxy-3-methoxymethamphetamine (HMMA) are discussed in this study.     

Value of fetal autopsy after medical termination of pregnancy

We carried out a retrospective study of 352 medical terminations of pregnancy (MTP) carried out in a large French administrative region over two consecutive years. We analysed the indications for MTP and then compared the prenatal ultrasound diagnosis with fetal autopsy findings in order to demonstrate the value of pathological examination of the fetus in prenatal diagnosis and genetic counselling as well as the need to check by autopsy the quality of ultrasound screening. Preliminary analysis of the indication for these MTP showed that in 69.9% ultrasound screening had been carried out, revealing mainly brain abnormalities (22.2%) and heart defects generally associated with chromosomal abnormalities (32.1%). Prenatal findings were in agreement with autopsy results, showing no false-positive prenatal diagnoses. However, in 7.9% of cases in which brain abnormalities were detected, confirmation was not possible at autopsy because of tissue autolysis, showing the need for optimal conditions of expulsion. In 35.8% of cases, confirmation of the diagnosis by autopsy was not useful for management but still added to medical knowledge and demonstrated to the mother the reality of the defects. In 50.9%, the autopsy findings were decisive for genetic counselling.