Postmortem Blood Concentrations Research Articles

Postmortem diphenhydramine blood concentrations in children.

Diphenhydramine has been available for decades in non-prescription formulations for the treatment of allergic reactions, insomnia and symptomology associated with colds. In addition, dimenhydrinate, a precursor to diphenhydramine, is available in preparations for the treatment of nausea and vomiting. Diphenhydramine and other first-generation antihistamines are being replaced by second- and third-generation antihistamines which are associated with fewer side effects, notably the lack of drowsiness; however, there are still a variety of therapeutic uses that have persisted in both adults and children. In this study, postmortem blood concentrations of diphenhydramine were determined, by liquid chromatography tandem mass spectrometry, in seven children with concentrations ranging from 0.051 to 2.6 mg/L. The cause of death in two cases was attributed, at least in part, to diphenhydramine toxicity while diphenhydramine detection in five cases was considered incidental to the cause of death.

The Rise of Bromazolam in Postmortem Cases from Travis County, Texas and Surrounding Areas: 2021-2023.

As novel psychoactive substances (NPS) have continued to emerge over the last decade, NPS benzodiazepines have likewise increased in prevalence. They pose an evolving threat to public health and safety with regard to postmortem cases, particularly when used in combination with opioids. Bromazolam was first detected in Travis County, Texas (TX) in April 2021. Given the recent onset of the fentanyl epidemic in this region, the international rise of bromazolam, and increased reports of "benzo-dope", a retrospective study was conducted to characterize bromazolam-positive deaths in Travis County and surrounding counties from 2021-2023. Bromazolam was identified in 112 deaths from 2021-2023, accounting for 1.57% of cases submitted for toxicology testing (n=7,129). During that interval, a 7.5-fold increase was observed in postmortem bromazolam-related drug toxicities from 2021 (n=7) to 2023 (n=53). Fatalities primarily occurred in males in their early-30's. Postmortem concentrations ranged from 21-220 ng/mL, with mean (median) concentrations of 69.4 ± 48.4 (53.5) ng/mL. Polydrug use was present in 99% of bromazolam-positive deaths with co-occurrence with other drugs and drug classes widely varying over time. Bromazolam was attributed as the sole cause of death in one case with a postmortem blood concentration of 23 ng/mL. Polydrug use in bromazolam-related drug toxicities commonly involved fentanyl (82%), methamphetamine (41%), and cocaine (28%). Similarly, cases where bromazolam was an incidental finding and non-contributory to the cause of death often involved methamphetamine (38%), alprazolam (33%), and cocaine (33%). In light of the significant increase in fentanyl-related deaths in Travis County, the increasing prevalence of bromazolam accompanying fentanyl was particularly alarming due to the heightened risk of toxicity when used in combination. Identifying and evaluating bromazolam-related deaths clarifies the impact of bromazolam on this population, promotes awareness, and aids in identifying meaningful harm reduction strategies to decrease bromazolam-related morbidity and mortality.

Protonitazene detection in two cases of opioid toxicity following the use of tetrahydrocannabinol vape products in Australia

Introduction Protonitazene is an opioid belonging to the 2-benzylbenzimidazole structural class. We describe two cases of opioid toxicity involving the reported inhalation of a delta-9-tetrahydrocannabinol vape product in which protonitazene was detected. Case reports Case 1 was a young male found unconscious after the reported use of a delta-9-tetrahydrocannabinol vape. He suffered two subsequent apnoeic episodes requiring bag-valve-mask ventilation before eventual recovery. Only protonitazene was detected in blood at a concentration of 0.74 µg/L. Case 2 was a young male who died shortly after being found unresponsive. The postmortem femoral blood concentrations of protonitazene and delta-9-tetrahydrocannabinol were 0.33 µg/L and 2 µg/L, respectively. Analysis of a pod vaping device found in the decedent’s hand and a separate e-liquid bottle labelled as delta-9-tetrahydrocannabinol showed a mixture of protonitazene and delta-9-tetrahydrocannabinol. Discussion The opioid effects of protonitazene are mediated through β-arrestin2 and mu opioid receptor signalling pathways. Benzimidazole opioids are lipophilic and, when mixed with a suitable solvent, can be used in a vape device. It is anticipated that naloxone would have provided effective reversal of toxicity in our cases. Conclusions Novel routes of opioid administration, like vaping, may appear relatively innocuous in comparison to intravenous administration, but opioids may still be absorbed at high concentrations, resulting in severe opioid toxicity or death.

The undetected murder? Evaluation and validation of a practicable and rapid inductively coupled plasma-mass spectrometry method for the detection of arsenic, lead, and thallium intoxications in postmortem blood.

Homicide, suicide, or accident - elemental intoxication may be a cause in each of these types of deaths. Inductively coupled plasma mass spectrometry (ICP-MS) has emerged as the gold standard analytical method for toxic metal analysis in both clinical and forensic settings. An ICP-MS method was developed using a modified acidic workup for the quantitative determination of arsenic, lead, and thallium. Method validation focused on the assessment of linearity, between- and within-day precisions, limits of detection (LoD) and lower limits of quantification (LLoQ), and carryover. The method was applied to analysis of postmortem peripheral blood samples from 279 forensic cases for which orders for chemical-toxicological examination had been received from the public prosecutor's office. Using six-point and one-point calibrations (latter for rapid screening purposes), precisions and accuracies ranged from -4.8 to 5.8% and -6.4 to 7.5%. Analytical sensitivities for As, Pb, and Tl were 0.08, 0.18, and 0.01 μg/l (LoD) and 0.23, 0.66, and 0.03 μg/l (LLoQ), respectively. Observed postmortem peripheral blood concentrations were As, 1.31 ± 3.42 μg/L; Pb, 17.4 ± 13.1 μg/L; and Tl, 0.11 ± 0.07 μg/L (mean ± standard deviation [SD]). Elemental concentrations, determined in additional quality control samples, were in good agreement to those obtained with an external ICP-MS method based on alkaline sample processing. The current method is practicable and compatible with an ICP-MS system used for trace element analysis in an accredited medical laboratory. It allows for implementation of low-threshold investigations when metal intoxications are suspected in forensic routine.

A Series of 8 Illicit Fentanyl Intoxication Deaths in Infants and Toddlers.

We report 8 children younger than 2 years who died from acute illicit fentanyl intoxications in Connecticut between 2020 and 2022.The Connecticut Office of the Chief Medical Examiner (CT OCME) investigates all unexpected, violent, and suspicious deaths in Connecticut. The CT OCME's electronic database was searched for fentanyl deaths by age. All underwent autopsies and toxicology testing.The ages ranged from 28 days to 2 years (mean age, 12 months). The causes of death involved acute fentanyl intoxications with 1 having xylazine, 1 having para-fluorofentanyl, and 1 having cocaine and morphine. All the manners of death were certified as homicide. The postmortem fentanyl blood concentrations ranged from 0.40 to 46 ng/mL. Most of the children were found unresponsive after being put to sleep. Three were co-sleeping with adults (2 in bed; 1 on a recliner). There was a known history of parental/caregiver drug abuse in 7 of 8 of the fatalities.We summarize the key investigative, autopsy, and toxicological findings. As illicit fentanyl use increases, there is a potential for infant exposure and death. The investigation and certification of these deaths and the role of intentional administration versus inadvertent exposure due to caregiver neglect in the context of the certification of the manner of death are described.

Qualitative and quantitative characteristics of xylazine-associated deaths detected using a post-mortem toxicology testing program

Introduction The United States drug overdose crisis continues to evolve. Xylazine has been increasingly identified as an adulterant in illicit opioid supplies. The incorporation of novel adulterants, like xylazine, into the illicit drug supply adds complexity to post-mortem toxicology testing, public health messaging, substance use mitigation, and the treatment of people who use drugs. Methods We assessed trends, decedent characteristics, drug co-detection, and blood concentrations of xylazine-positive post-mortem cases in Michigan. We utilized a toxicology testing program capable of detecting several opioids and non-opioids in post-mortem blood samples within 72 hours. Results A total of 279 deaths were xylazine-positive between October 2019 and June 2023, with 100 percent positive for fentanyl. Only 30 percent of xylazine-involved samples were positive for naloxone, while 21.2 percent of xylazine-negative and opioid-positive samples were positive for naloxone. The percentage of xylazine-positive deaths increased from 3.2 percent in 2021 to 4.7 percent in January–June 2023. A median of five total drug groups were present among xylazine-positive deaths. Post-mortem xylazine concentrations for 55 decedent blood samples ranged from 5.2 to 200 µg/L. Discussion Our study demonstrated increases in xylazine detection among post-mortem cases. Our findings are consistent with national trends of increasing xylazine presence among drug-involved deaths. Our range of detected post-mortem xylazine blood concentrations was consistent with what has been reported in previous literature. Fentanyl was detected in 100 percent of xylazine-positive overdose deaths. Naloxone detection was relatively low, highlighting the continued importance of increasing naloxone access and distribution. Deaths associated with xylazine often involved multiple other drugs. Limited human clinical xylazine research precludes accurate interpretation and attribution of causality from these data. Conclusions Overdose-related deaths with xylazine detection are increasing in Michigan and across the United States. Further clinical and toxicological research can help contextualize the clinical significance of xylazine in opioid overdose, clarify epidemiologic and clinical research, and inform appropriate public health messaging.

Distribution of donepezil in postmortem casework

Donepezil is one of the primary treatments options for patients suffering from Alzheimer's Disease. In a review of more than 2200 postmortem donepezil positive blood specimens, 76% of concentrations were higher than the proposed therapeutic range. Means and medians were similar between central blood specimens and peripheral specimens, indicating minimal postmortem redistribution.Postmortem concentrations may not reflect those circulating antemortem. Mean and median postmortem blood concentrations were approximately 3-fold higher than those in antemortem blood specimens. Additionally, in cases where antemortem blood was available for testing, large increases in donepezil concentrations were reported between antemortem and postmortem specimens without documented administration by medical personnel. Elevated blood donepezil concentrations have been reported in multiple postmortem cases where cause of death was unrelated. The blood concentrations reported in cases where donepezil did not contribute to death overlapped with those in suspected drug overdose cases where other drugs may have been present. In 4 out of 5 suspected donepezil overdose cases, blood concentrations greater than 1000 ng/mL were reported, whereas less than 1% of all postmortem blood samples reviewed achieved these concentrations. Blood concentrations greater than 1000 ng/mL should be considered contributory when a drug overdose is suspected. Postmortem donepezil concentrations should be interpreted with caution in the context of a comprehensive case history.

Retrospective Analysis of Death Cases of Oral Diphenidol Hydrochloride Poisoning.

To explore the characteristics of postmortem examination, chemical examination and scene investigation of deaths caused by oral diphenidol hydrochloride poisoning, and so as to provide a reference for proper settlement and prevention of such deaths. The data of 22 deaths caused by oral diphenidol hydrochloride poisoning in a city from January 2018 to August 2020 were collected, including case details, scene investigations, autopsies, chemical examinations and digital evidence. Thirty-one cases of deaths caused by oral diphenidol hydrochloride poisoning reported in previous literature were also collected. In the 53 oral diphenidol hydrochloride poisoning death cases, 50 cases were suicide, 2 cases were accidental, while 1 case was undetermined. Fifty-two cases were found in the medical records or crime scene investigation reports with doses ranging from 775 mg to 12 500 mg, and 23 deceased were detected with postmortem blood concentrations ranging from 2.71 mg/L to 83.1 mg/L. Clinical symptoms were recorded in 6 patients, including conscious disturbance and convulsion. Among the 45 cases which were performed with external examination, 23 cases autopsied. Most of the deceased of oral diphenidol hydrochloride poisoning were suicide. No significant correlation was found between dose and blood concentration through the retrospective analysis of cases.

Acute sodium oxybate intoxication: a case report and review of the literature.

Despite a better safety profile than illicit γ-hydroxybutyric acid (GHB) and other GHB-analogs, sodium oxybate continues to raise serious concerns regarding clinical safety. In this study, the authors report the case of near-fatal intoxication involving sodium oxybate-alcohol combination in a 40-year-old woman. In addition, a review of the literature on published cases of intoxication involving this pharmaceutical form of GHB was conducted. A 40-year-old woman was admitted to the intensive care unit in a coma following voluntary ingestion of 18 g of sodium oxybate and alcohol. The GHB plasma concentration was quantified to be 146 mg/L using liquid chromatography coupled with tandem mass spectrometry. An English literature search was performed using PubMed without any limiting period to identify all available scientific publications involving cases of sodium oxybate intoxication; six cases were identified. Five cases involved fatal intoxication, with GHB post-mortem blood concentrations ranging from 11.5 to 3500 mg/L. One involved a non-fatal intoxication case with a GHB serum concentration of 569 mg/L 7 h post-ingestion. In the present case, the estimated elimination half-life was 154 min. The risk of acute poisoning appears to be high considering the pharmacokinetic properties of sodium oxybate. Physicians and toxicologists must take such properties into account.

Identification, measurement, and evaluation of blood concentrations of insulin glargine and insulin lispro by UPLC–MS–MS in a dead body suspected of insulin overdose

Insulin preparations, which are drug treatments for diabetes, cause fatal hypoglycemia when an overdose is administered. Cases of homicide and suicide using these preparations have been reported and are of great forensic interest. However, there are few reports assessing the postmortem concentration of insulin preparations, and it is often difficult to determine the cause of death. In the present study, we report a case of a suspected insulin glargine and insulin lispro overdose for suicide. A woman in her 30s had a history of mental illness and diabetes. The day before her death, she reported to her boyfriend that she had taken large doses of insulin preparations and prescription drugs. An autopsy revealed no fatal injuries or lesions. Drug screening tests revealed several prescription drugs, none of which showed toxic concentrations. Analysis using LC-MS/MS detected insulin glargine in the peripheral and cardiac blood at 429 μU/mL and 1362 μU/mL, respectively, whereas insulin lispro was detected in both the peripheral and cardiac blood at levels below the lower limit of quantification (LLOQ; <50 μU/mL). The cause of death was considered likely to be hypoglycemia caused by an overdose of insulin glargine. Insulin glargine is rapidly metabolized after subcutaneous administration and is rarely detected in the blood when used at therapeutic doses. There are no other reports on the quantification of insulin glargine parent compounds in postmortem samples, and this case provides important data on postmortem blood concentrations of insulin glargine intoxication.

Post-mortem oxycodone blood concentrations of hospitalized cancer and surgery patients compared with fatal poisonings

Oxycodone is a strong opioid drug commonly used to treat acute, cancer, and chronic non-malignant pain. In this study, all oxycodone-related medico-legal cases where death had occurred in a hospital or nursing home in Finland were investigated to determine the range of post-mortem (PM) oxycodone blood concentrations in a therapeutic setting. All toxicology cases in which oxycodone was detected in PM femoral blood during the 4-year period of 2016–2019 in Finland were retrieved from the national PM toxicology database. In this material, the 365 deceased hospital patient cases that met the study inclusion criteria were divided into four groups according to the cause and manner of death. The reference group of 121 fatal oxycodone poisoning cases comprised two groups: those with verified associated drug abuse and those without drug abuse. The median oxycodone concentration in PM blood was significantly higher in cancer patients (0.10 mg/L) than in patients with recent surgery (0.07 mg/L) or other disease (0.06 mg/L) (p < 0.05). In addition, the median oxycodone concentration was significantly lower in all hospital patient groups than in the poisoning groups, the latter displaying 0.38 mg/L (abuse) and 0.64 mg/L (no abuse) (p < 0.001). This study shows that half of the subjects in the cancer patient group had PM blood oxycodone concentrations above the typical clinical therapeutic plasma concentration range (0.005–0.10 mg/L). Appropriate medication of hospitalized surgery and cancer patients can result in concentrations of up to 0.2 and 0.6 mg/L, respectively, while higher concentrations are exceptional.

Fatal Intoxications from a Combination of 4-Fluoroamphetamine and 25C-NBOMe.

Six fatalities have occurred from the ingestion of a combination of new psychoactive substances (NPSs), 4-fluoroamphetamine (4FA) and 2-(4-chloro-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine (25C-NBOMe) over a 9-month period. Four of these fatalities (one older female and three young males) were from direct adverse effects of drugs, and one each from a fall while being intoxicated and during restraint. All cases were subject to full postmortem examinations that included collection of femoral blood. The four drug-caused fatalities had postmortem blood concentrations for 4FA and 25C-NBOMe of 330-682 ng/L (median 417) and 1.4-12 ng/mL (median 4.3), respectively. The other two cases (both young males) where death was considered to have been caused indirectly by drug intoxication had 4FA and 25C-NBOMe postmortem concentrations of 21 and 123 ng/mL, and 1.8 and 4.5 ng/mL, respectively. None of these cases showed concentrations of drugs that suggested use of high recreational doses. In one drug-caused death, capsules and a brown powder obtained from the scene were found to contain a mixture of these two NPSs. With the exception of one drug-caused death, other drugs were detected; however, the effects of the two NPSs together were regarded as the primary triggers for the deaths. There were no consistent symptoms or pathology in these cases; however, agitation/aggression was observed in two cases prior to their collapse, with seizures in possibly three cases. Pulmonary and/or cerebral edema was noted in three cases. Potentially significant natural disease (a mildly enlarged heart) was only observed in one drug-caused case. These cases illustrate a possible increased risk of sudden death with this combination of drugs, both of which can elevate serotonin concentrations as well as act as strong stimulants. These cases also illustrate the difficulty in detecting NPS in cases where no prior information is available that might suggest their use.

Difficulties in interpreting a therapeutic blood concentration of insulin lispro in postmortem blood: A case report

Illustrate the complexity of interpreting a postmortem therapeutic blood concentration of insulin in a probable case of suicide using insulin lispro. The identification and quantification of insulin and its analogues continues to be a challenge in the field of forensic toxicology. Its use is not always limited to the treatment of diabetes but is often used illicitly. Numerous cases of suicides and suicide attempts have been described in the literature and nevertheless, this number still seems to be underestimated due to both the inability of laboratories to identify and discriminate between synthetic analogues of human insulin and due to the chemical instability of insulin especially in postmortem samples. Our case concerns a 63-year-old man who was found dead by his brother at home. Three empty Humalog® insulin pens and a letter mentioning his suicide intention were found next to his bed. At the request of the prosecutor, an external examination of the corpse was performed and revealed only an asphyxial syndrome not specific to a cause of death. The presence of a blood glucose monitoring device on the right arm was also observed, suggesting that the subject was diabetic. External examination was unable to determine the exact cause of death. For this reason, the pathologist was oriented on a toxic death. In order to proceed to further toxicological investigations, peripheral blood, urine and hair samples were collected. It is important to underline that, due to the long period elapsed between the external examination and the pathologist's conclusion (enabling the initiation of the toxicological analysis) and due to administrative delays, insulin testing was performed only 9 months after the samples collection. Blood and urine samples were stored at +4 °C until analysis. The identification and quantification of insulin lispro was performed in the postmortem blood after precipitation in the presence of bovine insulin (internal standard), by a mixture of acetonitrile/methanol (ratio 1:1) followed by a step of ultrafiltration using Amicon® centrifugal filters (3 kDa) and a step of immunopurification using Iso-Insulin ELISA coated wells. The analysis was performed with a UHPLC- Q-TOF (XEVO G2-XS). Detection of insulin lispro was performed using the precursor molecular ion m/z 1162.543 (charge state 5 +). Since human insulin and insulin lispro share the exact same molecular mass (5807 Da), discrimination cannot be made using the multi-charged molecular ion. The distinction is based on fragment m/z 217 which is present only in insulin lispro spectrum. Toxicological tests performed on the blood sample did not reveal any xenobiotic of toxic nature. Insulin lispro was detected in the femoral blood sample at 1,1 ng/mL, whereas human insulin was not detected. Following the administration of a therapeutic dose of 0.2 U/kg of insulin Humalog ®, a maximum concentration of 1.66 ± 0.42 ng/mL is achieved. Consequently, the concentration found in our case was therapeutic. Nevertheless, given the unstable nature of insulin, especially in postmortem blood, it is not possible to exclude that death was caused by an insulin overdose. The long period between collection and analysis (9 months), the hemolyzed state of the blood, the storage of the sample in unsuitable tubes and the fact that we were able to detect even small concentrations of insulin lispro suggest that the concentration at the time of death was much higher. The pathologist concluded that the cause of death was probably an overdose of insulin lispro. This case highlights that the interpretation of a postmortem insulin concentration requires a complex approach involving the assessment of many factors such as the subject's medical history and the time, mode and state of preservation of the sample.

New insights into buprenorphine and methadone related fatalities at therapeutic concentration: 11-year results from French national DRAMES study

To present 11-year results from DRAMES (“Décès en Relation avec l’Abus de Médicaments Et de Substances” or Deaths in Relation with the Abuse of Drugs and Substances) study and provide new insights into deaths at therapeutic concentration for two opioid substitution treatments (OSTs): methadone (MTD) and buprenorphine (BUP). DRAMES study is an ANSM nationwide study initiated in 2005 in France. It is based on spontaneous declarations by forensic toxicologists and medical examiners of drugs of abuse related deaths in order to identify dangerous substances, assess their toxicity and monitor trends in fatalities. This database may be useful to better understand toxicity of MTD and BUP and therefore help forensic toxicologists in interpreting postmortem blood concentrations. The study included data from 2010 to 2020, from 27 laboratories in France. Drug imputability was determined cross-blinded by a forensic toxicologist and an addicto-vigilant pharmacist. A causality score from level 1 (high) to 4 (low) is assigned to each substance in connection with the occurrence of death according to the blood concentration and also making it possible to prioritize the molecules between them among those who are involved and those who are only identified. For level 1, depending on the number of molecules involved, the score breaks down into 1.0 (1 single substance), 1.1 (1 predominant substance), 1.2 (2 co-dominant substances) or 1.3 (at least 3 co-dominant substances). Monointoxication groups included 1.0 and 1.1 fatalities and polyintoxication group included 1.2 and 1.3 fatalities. Therapeutic concentrations were inferior to 200 ng/mL and inferior to 10 ng/mL for MTD and BUP, respectively. Non-parametric Mann-Whitney U tests were used to compare median concentrations between the different groups. The study included 1519 MTD-related deaths and 423 BUP-related deaths. Among those, 334 and 319 deaths were within the therapeutic range for MTD and BUP, respectively. For MTD at therapeutic concentrations, higher concentrations were observed in the monointoxication group than in the polyintoxication group (149 vs. 119 ng/mL; P < .001). But there was no difference between the naive and treated with OST groups (143 vs. 142 ng/mL; P = 0.461). Nor age, gender, association with cocaine or QTc-interval prolongation inducing drugs had a statistically significant effect on MTD concentrations. For BUP, at therapeutic concentrations, higher concentrations were observed in the monointoxication group than in the polyintoxication group (2.8 vs. 2.2 ng/mL; P = 0.048). BUP concentrations were also higher in treated with OST group than in naive ones (2.4 vs. 1.1 ng/mL; P = 0.005). This study identified different pattern for MTD and BUP fatalities at therapeutic concentration. Interestingly and contrary to BUP, at therapeutic concentrations, MTD concentrations did not differ in people under treatment and the naive ones. It has been showed that MTD induces more QTc-interval prolongation than BUP. Interindividual differences in susceptibility to cardiac toxicity could be an explanation for the deaths that could not be explained by therapeutic concentration or drug combination alone. This study identified a different pattern for BUP and MTD fatalities at therapeutic concentration, suggesting a different toxicity mechanistic for the two OSTs at these concentrations.

Analysis of human insulin and its therapeutic analogs by LC-HRMS: 4 years feedback and perspectives

To prove the involvement of insulins in intoxication is challenging in postmortem cases. Two insulins assays were developed and validated, quantitatively in blood and qualitatively in tissues. The aim is to share feedback from 4 years of these methods’ application, in clinical and forensic contexts. This retrospective study focused on cases for which insulins analysis was requested in these last 4 years. The studied parameters were: context of the request, samples transfer and analysis intervals, type and concentration results. For postmortem cases, samples were collected during autopsy according to a homemade protocol consisting in cardiac and peripheral blood, liver, kidney, muscle, injection site (IS). For clinical cases, samples were serum collected during hospitalization. Assay allows detection of human insulin and analogs: aspart, glulisine, lispro, detemir, degludec, glargine and M1. Blood samples assay consisted in 3 steps: protein precipitation, filtration and immunopurification before analysis on LC-HRMS (Bottinelli. Talanta 2021:225). Steps of cutting and ultrasonication in acidic ethanol were added for tissue samples (Bottinelli. Int J Legal Med 2021;135:1813–22). Sixty-six cases were analyzed between January 2018 and March 2022: 59 were postmortem cases for which insulin use was suspected (history of diabetes, insulin material found at corpse discovery place…) and 7 were clinical cases for which insulins analysis was requested for a diagnosis of severe hypoglycemia. Treatment by insulins was known in 23 cases and 13 cases were not diabetic. A total of 10 clinical sera, 94 postmortem bloods ( n = 53 peripheral; n = 41 cardiac), 16 IS, 20 muscles, 33 livers and 33 kidneys were analyzed. At least one insulin was identified in 29 cases (43%) corresponding to 8 positive sera (80%), 10 IS (62%), 7 muscles (35%), 12 cardiac bloods (29%), 11 peripheral bloods (21%), 7 kidneys (21%), and 4 livers (12%). In 7 cases, insulin administration was characterized by analysis of tissues as blood analysis was negative. In most postmortem cases, insulins were detected when postmortem interval was less than 72 h. Moreover, 50% of samples were positive when blood is centrifuged and freeze less than 24 h after sampling. All insulins were identified at least one time, but aspart (27%) and glargine/M1 (11%) were the most represented. For aspart, postmortem blood concentrations ranged from < 1.0 ng/mL (LOQ) to 432 ng/mL (mean: 50.1 ng/mL), with the highest measured for two non-diabetic people. Insulins intoxications are underestimated as underlined by numerous authors. Since the application of the new LC-HRMS methods, numerous cases of insulins use and intoxication were revealed. Preparation of postmortem samples is the crucial point requiring several steps with specific material. The expensive and time-consuming methods lead to a non-systematic perform, but only when data from autopsy or enquiries suggest possible insulin administration. Initially not dedicated to clinical cases, methods allowed to elucidate origins of severe hypoglycemia in various situations: Münchausen, degludec spontaneous release, suicide attempt, self-medication. The major detection of aspart and glargine is consistent with the prescription trends in France. More degludec detection was expected but was limited either because it was less implicated in intoxications or due to matrix effects. Autopsy realization within 72 h after death, centrifugation/freezing of blood samples within 24 h after sampling and analyses of several matrices including blood and tissues, seem to be crucial conditions to maximize chances for highlighting presence of insulins in postmortem cases. Even if the “simple” detection of an insulin is informative in numerous cases, interpretation of concentration would be relevant. However, insulins displayed a large range concentrations as numerous parameters could have an influence such as diabetes status, type of analog, metabolism, hemolysis… Define a therapeutic or toxic range seems complex and further studies are required. This could be possible with the increase of interest for this problematic in medico-legal research teams.

Designer benzodiazepines and their metabolites in post- and antemortem specimens: Quantitation by UHPLC-MS/MS and findings in Taiwan

Develop a method for the analysis of phenazepam, etizolam, and their metabolites in blood and urine; provide epidemiology findings for samples from autopsy and urine-drug-testing cases in Taiwan during the 2019–2021 period. Now widely abused designer benzodiazepines (DBZDs), phenazepam and etizolam are structural analogues of legal BZDs that are used for the treatment of insomnia, anxiety, muscle spasm, and epilepsy. Illegal uses of phenazepam (a long-acting 1,4-benzodiazepine derivative) and etizolam (a short-acting thienodiazepine derivative) were first reported in 2007 and 2011. An effective UHPLC-MS/MS based methodology was developed for the quantitation of the parent drugs (etizolam, phenazepam)—commonly occurred in low dose (0.5–3 mg)—and their metabolites (α-hydroxyetizolam, 3-hydroxyphenazepam) in blood and urine samples at low concentration levels. Epidemiological data of specimens from 6 autopsy and 197 urine-drug-testing cases in Taiwan (during the 2019–2021 period) are reported. Blood or urine (1 mL) samples were extracted under alkaline condition. Extracts were evaporated and reconstituted for injection onto the UHPLC-MS/MS system. Case urine specimens were first hydrolyzed by an enzymatic method prior to the extraction step. With the inclusion of 5- and 50-ng/mL quality controls in all analytical batches, deuterated analogues of the analytes were used as internal standards (ISTD) for the quantitations of phenazepam and etizolam, while α-hydroxytriazolam-d4/lorazepam-d4 were for α-hydroxyetizolam/3-hydroxyphenazepam. The mobile phase included 0.1% formic acid (v/v) in water (A) and methanol (B). Mass spectrometric analysis was performed in positive-ion multiple reaction monitoring (MRM) mode. Drug-free blood and urine samples (fortified with 10–200 ng/mL of the analytes) were used for method validation to achieve the following analytical parameters: (a) average extraction recovery (n = 5) was higher than 90%; (b) no matrix effect was observed—was apparently compensated for by respective deuterated ISTDs, if any; (c) intra-/inter-day precision (%CV) and accuracy ranges for blood were 0.56–9.27%/0.94–16.2% and 94–110%/92–109%, while the corresponding ranges for urine were 0.86–6.53%/0.87–13.8% and 86–107%/91–105%; and (d) limits of detection/lower limits of quantitation for the parent drugs and their metabolites were 0.25–5.0/5.0–10 ng/mL for urine and 0.25–0.50/1.0–5.0 ng/mL for blood. Among the 6 autopsy cases (4 male and 2 female; all under 40-year old) examined during this period, etizolam (together with methyl-α-pyrrolidinohexiophenone) were identified in only 1 death. For the remaining 5 cases, the range, mean ± std, and median of postmortem blood concentrations of phenazepam were 0.020–0.43 μg/mL, 0.13 ± 0.17 μg/mL, and 0.065 μg/mL, respectively. Multiple drugs (such as ketamine, p-methoxymethamphetamine, p-methoxyamphetamine, amphetamines, synthetic cathinones, and nimetazepam) were found in these case specimens, often with levels well over their respective lethal doses. Thus, phenazepam and etizolam were probably not the cause of death. The following statistics were found for the 197 urine-drug-testing cases: (a) etizolam/phenazepam were identified in 141/56 specimens; and (b) the range, mean ± std, and median of etizolam/phenazepam found in positive specimens were: 0.014–0.54/0.0050–0.056 μg/mL, 0.084 ± 0.14/0.014 ± 0.011 μg/mL, and 0.046/0.012 μg/mL, respectively. Drugs that are popular in Taiwan (such as ketamine, mephedrone, and metabolites of nimetazepam) were commonly found in these specimens. This relatively simple protocol was found effective and reliable for routine quantitations of etizolam, phenazepam and their metabolites in blood and urine and successfully applied to the analysis of postmortem and antemortem specimens from forensic cases. Epidemiological data indicated: (a) high positive rates for etizolam/phenazepam in drug-testing specimens (141/56 out of 197); and (b) these drugs were unlikely the cause of death for the 6 autopsy cases hereby reported.

Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020).

Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death. This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations. Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed. From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L). Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

Rapid infusion of excessive phenytoin: A newborn autopsy case.

The patient was a two-day-old female infant. The patient's mother was a primigravid in her 20s who developed premature abruption of the normal placenta on the first day of the 33rd week of gestation. The infant was born by emergency cesarean section with severe neonatal asphyxia with a birth weight of 1928g. Spontaneous circulation was returned 11min after birth. The infant was treated under mechanical ventilation in the neonatal intensive care unit, and phenobarbital was administered for repeated seizures. On day 2, spontaneous respiration was observed; however, the patient developed seizures repeatedly. The dose of phenobarbital reached the maximum and was switched to midazolam. In the early morning of day 3, while midazolam was administered up to the maximum dose, the infant developed status epilepticus, and the anticonvulsant drug was changed to phenytoin. Due to a calculation error, the intravenous administration of phenytoin was started at 400mg/30min, which is 10-fold of the normal dose. Six minutes later, after 80mg was administered, the administration was stopped due to a drop in blood pressure; however, the infant died of cardiac arrest. An autopsy, which was performed approximately 25h after death, revealed the blood phenytoin concentration in the heart was 63.85μg/mL. The cause of death was determined to be acute phenytoin toxicity. This is the first fatal case reported of the blood concentration of phenytoin caused by rapid intravenous administration.

Buprenorphine-Related Deaths in North Carolina from 2010 to 2018.

Buprenorphine (BUP) is a commonly prescribed medication for the treatment of opioid use disorder (OUD). As prescriptions increase in North Carolina, BUP is more frequently encountered statewide in routine postmortem casework. Between 2010 and 2018, there were 131 select cases investigated by the Office of the Chief Medical Examiner where BUP was detected in peripheral blood and considered a primary cause of death (COD), with no other opioids present and no other non-opioid substances found in the lethal range. The decedents ranged in age from 14 to 64 years, with 67% male. The mean/median peripheral blood concentrations were 4.1/2.1 ng/mL for BUP and 7.8/3.4 ng/mL for its metabolite, norbuprenorphine. These postmortem blood concentrations overlap antemortem therapeutic concentrations in plasma reported in the literature for opioid-dependent subjects receiving sublingual maintenance therapy. The pathologist considered scene findings, prescription history, autopsy findings, toxicological analysis and decedent behavior prior to death to conclude a drug-related COD. Many of the deaths were complicated by the presence of other central nervous system depressants along with contributory underlying cardiovascular and respiratory disease. The three most prevalent additive substances were alprazolam, ethanol and gabapentin, found in 67, 36 and 32 cases out of 131, respectively. Interpreting BUP involvement in a death is complex, and instances may be underestimated in epidemiological data because of the lack of a defined toxic or lethal range in postmortem blood along with its good safety profile. As expansion of access to OUD treatment becomes a priority, awareness of the challenges of postmortem interpretation is needed as increased use and diversion of BUP are inevitable.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis.

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.