Postmortem Redistribution Research Articles

A fatal mono-intoxication with 4-fluoroisobutyrylfentanyl: Case report with postmortem concentrations.

We report on a case of a 35-year-old man who died suddenly and unexpectedly due to a 4-fluoroisobutyrylfentanyl (4-FIBF) mono-intoxication. Pathological, toxicological and chemical investigations were conducted at the Netherlands Forensic Institute. A full three-cavity forensic pathological examination was performed according to international guidelines. Biological samples obtained during autopsy were comprehensively investigated for the presence of toxic substances using headspace gas chromatography (GC) with flame ionization detection, liquid chromatography-time-of-flight mass spectrometry (LC-TOF-MS), GC-MS, high-performance LC with diode array detection and LC-tandem MS (LC-MS-MS). The seized crystalline substance found next to the body was investigated using a presumptive color test, GC-MS, Fourier-transform infrared spectroscopy and nuclear magnetic resonance. Pathological investigation identified minor lymphocytic infiltrates in the heart, considered irrelevant for the cause of death. Toxicological analysis of the victims' blood indicated the presence of a fluorobutyrylfentanyl (FBF) isomer, with no other compounds detected. The FBF isomer was identified in the seized crystalline substance as 4-FIBF. 4-FIBF concentrations were quantified in femoral blood (0.030 mg/L), heart blood (0.12 mg/L), vitreous humor (0.067 mg/L), brain tissue (>0.081 mg/kg), liver tissue (0.44 mg/kg) and urine (approximately 0.01 mg/L). Based on the outcomes of the pathological, toxicological and chemical investigations, the cause of death of the deceased was attributed to a fatal 4-FIBF mono-intoxication. The presented case underlines the added value of a combined bioanalytical and chemical investigative approach to identify and subsequently quantify fentanyl isomers in postmortem cases. Furthermore, it demonstrates the importance of investigating the postmortem redistribution of novel fentanyl analogs to establish reference values and to subsequently allow for correct interpretation of cause of death analysis in future casework.

Postmortem redistribution of cocaine and its metabolites, benzoylecgonine and ecgonine methyl ester in humans: Important variables that might be influencing the central blood / peripheral blood ratio

IntroductionA big challenge in forensic toxicology is the correct interpretation of the results of quantitative analyses in postmortem cases. Postmortem drug concentrations not necessarily reflect the drug concentrations at the time of death, due to postmortem changes in drug concentrations caused by postmortem redistribution (PMR). Cardiac blood is more prone to PMR related concentration changes than peripheral blood. Because of this difference in susceptibility to PMR related concentration changes, the ratio of cardiac blood concentration/peripheral blood concentration (C/P) of a drug is an often-used marker of PMR. In this study, we investigated the relationship between different potentially significant variables and the C/P ratios of cocaine, benzoylecgonine (BE) and ecgonine methyl ester (EME) in humans. The aim was to elucidate the mechanisms involved in PMR of these substances and potentially provide guidelines aiding forensic toxicologists in the interpretation of postmortem quantitative results of cocaine and its metabolites. To differentiate between postmortem concentration changes due to redistribution versus degradation of cocaine, the relationships between these variables and metabolite/cocaine ratios were investigated as well. MethodToxicological results of all postmortem cases that were positive for cocaine, BE and/or EME investigated by the Netherlands Forensic Institute between January 1st 2010 and July 31st 2020 were reviewed. The C/P ratios, BE/cocaine ratios and EME/cocaine ratios were determined for all selected cases. Cocaine, BE and/or EME were quantified in both femoral blood and cardiac blood in a total of 148 cases. Ratios were compared between subgroups by performing either a Mann-Whitney U test or a Kruskal-Wallis test followed by post-hoc Mann-Whitney U test. ResultsA statistically significant difference in C/P ratio of EME was observed between trauma and non-trauma cases with median C/P ratios of 2.03 and 1.57, respectively (p value=0.001). A statistically significant difference in EME/cocaine ratio was observed between the BMI subgroups 18.5 – 25.0 kg/m2 and> 25 kg/m2 with median EME/cocaine ratios of 3.79 and 1.58, respectively (p-value<0.001). ConclusionPostmortem cocaine concentrations should be interpreted with caution, considering the occurrence of both PMR and postmortem degradation. When interpreting postmortem toxicological results in cocaine-related fatalities, it might prove useful to take the above-mentioned variables into account.

HPLC-MS/MS determination and the postmortem distribution or postmortem redistribution of paraquat and its metabolites in four fatal intoxication cases

HPLC-MS/MS analysis and postmortem distribution or postmortem redistribution of paraquat and its two metabolites in poisoning death cases were reported. Paraquat, monoquat, and paraquat monopyridone were extracted from the sample with acetonitrile or methanol, respectively, detected by ZORBAX HILIC Plus (4.6 × 100 mm, 3.5 μm) chromatographic column, with 0.1 % formic acid aqueous solution - 0.1 % formic acid acetonitrile solution (v/v) as mobile phase. Paraquat, monoquat, and paraquat monopyridone had a good linear relationship within the range of 10–1000, 1–400, and 1–1000 ng/mL (or g), the correlation coefficient (r) were all ≥ 0.9996. Their detection limits were lower than 1 ng/mL (or g). The detection accuracy was 91.25∼113.44 %. The intra-day and inter-day precision were 1.51–3.99 % and 1.92–4.93 %, respectively. This method was used to detect and analyze four rare paraquat poisoning cases. The distribution of paraquat, monoquat, and paraquat monopyridone is uneven, which is relatively high in the heart, blood, lung, and kidney. Heart blood/Peripheral blood ratio of paraquat, monoquat, paraquat monopyridone concentration in two poisoned cases were 1.4, 2.0, 1.5 and 1.9, 1.3, 1.2, which showed a location dependent postmortem redistribution. This is the first time that HPLC-MS/MS and the postmortem distribution or postmortem redistribution of paraquat metabolites in poisoned death cases have been reported. This research provides scientific basis for forensic identification of paraquat poisoning cases and extraction of biological specimen.

Entomotoxicology as a tool for forensic investigations

Entomotoxicology is a rapidly developing field in forensic investigations that combines the disciplines of forensic entomology and toxicology. This paper reviews the application of entomotoxicology as a tool for forensic investigations and highlights its potential in providing valuable information on the presence and effects of drugs or toxins in insects found at a crime scene. The analysis of insect evidence in forensic investigations has long been used to estimate the time of death and other important factors. However, the incorporation of toxicology into this analysis can provide critical information on the presence and effects of drugs or toxins in the body. Entomotoxicology has the potential to be a valuable tool in forensic investigations, particularly in cases involving drug-related deaths or poisonings. By studying the presence and distribution of drugs or toxins in insect tissue, entomotoxicology can provide information on the timing and pattern of drug use. The use of entomotoxicology in forensic investigations is not without challenges. Factors such as post-mortem redistribution and contamination of the crime scene can impact the reliability of the results. There is also a need for standardized protocols and validation studies to ensure the accuracy and reliability of the results.

Postmortem Redistribution of Lidocaine after Illegal Use

Lidocaine is the most common local anesthetics used for para cervical block to reduce pain associated with surgical abortion. Topical form of lidocaine and its contents have been used for illicit purposes and suicidal intentions. We present two case reports of lidocaine-related death. All samples were extracted using solid phase extraction and lidocaine was identified and quantified by gas chromatography with mass spectrometry. Lidocaine concentrations were detected all analyzed samples with lethal levels. Toxicological findings and factors affecting lidocaine postmortem redistribution and results interpretation are discussed.

Characteristics of structural morphological changes of the liver depending on the prescription of death coming

The purpose of the work is to analyze the literature data devoted to the study of postmortem morphological changes in liver tissue and their use to determine the prescription of death. Postmortem changes are based on the processes of postmortem redistribution of blood and autolysis, the speed and severity of development of which depends primarily on the lifetime pathology, as well as external temperature and humidity during storage of the corpse. The onset of biological death naturally entails the development of postmortem changes in the liver, manifested by a decrease in temperature, violations of the structure of organelles, cells and organ tissue as a whole. The determination and evaluation of developing postmortem morphological changes is necessary both for differential diagnosis with lifetime-developed pathological processes, and for determining the prescription of death coming. This necessitates research to study the features of the development of postmortem changes and to develop ways to assess them to determine the prescription of death coming.

Postmortem Distribution and Postmortem Redistribution of Carbofuran-7-Phenyl Glucuronic Acid in Rabbits.

To establish a carbofuran intragastric administration death model in rabbits, and to observe the postmortem distribution and postmortem redistribution of carbofuran-7-phenyl glucuronic acid (Glu-7PH) in rabbits. The postmortem distribution: Rabbits were given an administration of 1/2LD50, LD50, 2LD50 carbofuran. Dead rabbits were dissected immediately. Rabbits that had remained alive 2 hours were sacrificed by carbon dioxide (CO2) inhalation and dissected immediately. The myocardium, cardiac blood, liver, spleen, lung, kidney, brain and right hindlimb muscle were collected. The postmortem redistribution: After giving an administration of 4LD50 carbofuran, the myocardium, cardiac blood, liver, spleen, lung, kidney, brain, and right hindlimb muscle were collected at 0, 12, 24, 48, and 72 h postmortem in supine position at 15 ℃ room temperature. The quantity of Glu-7PH was determined by LC-MS/MS. The postmortem distribution: Among the three dose groups, there were significant differences in the quantities of Glu-7PH in different tissues. The postmortem redistribution: There was no significant difference in the Glu-7PH quantities in cardiac blood, mycardium, spleen, kidney, brain and right hindlimb muscle, but there was a significant difference in the Glu-7PH quantities in the liver and lung. The mycardium, cardiac blood, liver, lung, kidney, brain and hindlimb muscle of rabbits can be used as appropriate samples for Glu-7PH detection. However, it should be noted that Glu-7PH was redistributed postmortem in rabbit liver and lung.

Are the (New) Synthetic Opioids U-47700, Tramadol and Their Main Metabolites Prone to Time-Dependent Postmortem Redistribution?-A Systematic Study Using an In Vivo Pig Model.

The interpretation of analytical results in forensic postmortem (PM) cases often poses a great challenge, in particular, due to possible PM redistribution (PMR) phenomena. In terms of new synthetic opioids, such data are usually not available and, if so, they are from case reports without the exact knowledge of dose, user habits, time of consumption or PM interval (PMI). Hence, a controlled toxicokinetic pig study was performed allowing the examination of PM tissue distribution and possible PMR of U-47700, tramadol and the main metabolites N-desmethyl-U-47700 and O-desmethyltramadol (ODT). For this purpose, 12 domestic pigs received an intravenous dose of 100 µg/kg body weight (BW) U-47700 or 1,000 µg/kg BW tramadol, respectively. The animals were put to death with T61 8 h after administration, and relevant organs, tissues and body fluids were sampled. Subsequently, the animals were stored at room temperature (RT), and the samples were taken again after 24, 48, and 72 h PM. Following homogenization and solid-phase extraction, quantification was performed applying a standard addition approach and liquid chromatography-tandem mass spectrometry. Only low-to-moderate concentration changes of U-47700, tramadol and their main metabolites were found in the analyzed tissue specimens and body fluids during storage at RT depending on the chosen PMI. On the contrary, a remarkable concentration increase of tramadol was observed in the liver tissue. These findings indicate that both synthetic opioids and their main metabolites are only slightly prone to PMR and central blood might be the matrix of choice for quantification of these substances.

THE STABILITY OF HEROIN METABOLITES AND ADULTERANTS IN BLOOD TO EVALUATE ROLE OF THE STABILITY ON POSTMORTEM REDISTRIBUTION

The present study aimed to investigate the stability of morphine, morphine-3-β-glucuronide (M3G), morphine-6-β-glucuronide (M6G), 6-acetylmorphine (6-AM) from heroin metabolites, and codeine, codeine-6-glucuronide, nor-codeine, fentanyl, norfentanyl, paracetamol, caffeine from its adulterants at room temperature for 24 hours in order to understand the effect of instability in postmortem redistribution (PMR). The heroin metabolites and adulterants were spiked into the control blood sample with the standard addition method. Then they were kept at room temperature for 4 hours and 24 hours and the blood samples were prepared by liquid-liquid extraction method. The prepared samples were analyzed using the validated analytical method with a liquid-chromatography-tandem mass spectrometry. According to the results of this study, no significant changes were observed in the analyte concentrations in the 4- and 24-hour postmortem blood, and it is thought that the other mechanisms may be more responsible than the instability of analytes for the significant concentration changes in PMR.

Measurement of trace elements concentrations in human adipose tissue and links with phenotypic characteristics

Obesity is an international public health concern and it is related to various metabolic disorders such as type 2 diabetes mellitus and cardiovascular diseases [WHO, Obesity and overweight, 2021, online]. Some trace elements (i.e. Zn, Cd, Hg and Pb) have showed obesogen-like abilities [W. Shao, Environ Sci Pollut Res, 2017, 24, 11573–11581] but studies on chronic organs accumulation are limited. White adipose tissue (WAT), recognized as an endocrine and paracrine organ, stores energy and fat but its expansion causes obesity. Two main classes of WAT have been identified according to their location: subcutaneous adipose tissue (SAT) – including abdominal and gluteofemoral adipose tissues, which are highly sensitive to insulin- and visceral adipose tissue (VAT), sensitive to lipolysis and inflammation. A specific depot of VAT is the epicardial one, which exerts a direct vasocrine and paracrine influence on the heart. Although each of these adipose tissue depots shows functional specificities, very few epidemiological studies investigated the concentrations of trace elements in adipose tissues. Here we monitored trace element levels in four different adipose tissue deposits and explored their relation with different phenotypic data. Quantification of 16 trace elements (V, Cr, Mn, Co, Cu, Zn, As, Se, Mo, Ag, Cd, Sn, Sb, Pt, Hg, Pb) was performed by inductively coupled plasma - mass spectrometry (7700 Series, Agilent) in four deposits of human adipose tissue: visceral (VAT), epicardial (EAT), subcutaneous (SAT) and gluteofemoral (GAT). Samples of 103 persons, collected during autopsies in our center, were analyzed. Phenotypic data (age, sex, BMI), diabetes status and post-mortem interval were known. Multiple linear regression was used to look for association between phenotypic variables and trace elements concentrations. Cu, Zn, Se, Mn and Cd were detected in all adipose tissues samples; other trace elements were found only in some of the deposits. For most individuals, visceral adipose tissue samples showed higher trace element concentrations than subcutaneous ones. Interestingly, different trace elements presented a specific patterns of accumulation in the deposits. Adipose tissue did not appear to be strongly impacted by post-mortem redistribution. Only EAT showed significant difference ( P < 0.01) in Cd concentrations, depending on post-mortem interval (PMI): higher concentrations were measured when PMI > 48 h compared to PMI < 12 h. Most trace elements concentrations in adipose tissues showed a significant and negative association with BMI (for Co, Cu, Zn, Se, Mo in the four deposits and for V, Cr, Mn, Cd, Hg, Pb only in some of them). Association with age was significant and positive for As, Cd and Sn in some deposits and association with sex was significant only in few cases. Men presented significant higher arsenic levels than women in the four deposits and women showed significant higher concentrations of Cr (in EAT), Mn (in VAT), Se (in VAT), Mo (in VAT), Ag (in EAT), Cd (in VAT, EAT, and SAT) than men. Hypothesis of long-term accumulation of trace elements in adipose tissue is conceivable, yet it appeared to be element- and location-specific. Although the limited number of subjects included in this cohort was not enough to conclude on the significance of some outcomes, the tendencies observed raise new questions on the possible impact of trace elements on adipose tissue function. Therefore, further research is needed on this topic to corroborate the hypotheses raised in this study.

The systematic investigation of the role of adulterants into the postmortem redistribution of heroin

We aimed to investigate systematically the impact of adulterants on postmortem in vivo pharmacokinetic of heroin and its metabolites by determining the postmortem redistribution (PMR) of heroin in this study. Heroin (1 mg/kg) was administered intravenously to the rats. The rats were euthanized 1 hour after drug administrations, followed by placed in the supine position at room temperature. Femoral (right and left), subclavian, cardiac blood samples and liver, lung, kidney, myocardium and brain samples were collected at the time of death, postmortem 1st, 4th and 24th hour. Heroin (1 mg/kg) containing adulterants (1 mg/kg paracetamol, dextromethorphan and caffeine) was administered intravenously to the same number of rat groups, and the same procedures were repeated. All blood and organ tissue samples were analysed with validated liquid-liquid extraction methods using a liquid chromatography tandem-mass spectrometer. The changes in the levels of heroin metabolites during the postmortem interval were determined in different blood and tissue samples included in our study. Accordingly, apart from the minimal statistical differences in morphine concentrations in the left femoral blood, significant differences in each matrix throughout the postmortem interval, especially in heart blood, lung and kidney tissue were observed. In contrast to morphine, there are minimal differences in morphine-3-glucurinide concentrations in heart tissue and other matrices. Graphical differences were observed between morphine concentrations in heart blood, liver, myocardium and lung of animal groups in the presence of adulterants and animal groups in which heroin was administered alone. The findings obtained in this study may play an important role in elucidating heroin-related death cases by forensic toxicologists or pathologists.

Fatal intoxication involving 2,5-dimethoxy-4-chloroamphetamine (DOC): A case report

2,5-dimethoxy-4-chloroamphetamine (DOC) is a substituted alpha-methylated phenethylamine, which was identified for the 1st time in 2009 in France, but is not classified as an illegal narcotic. This report presents a fatal intoxication involving consumption of DOC with analysis of multiple matrices. A 26-year-old man was found dead in his friend's apartment after a party. At place, numerous bottles of alcohol were discovered. The man was known as a cannabis smoker. Except the observation of a multi-visceral congestion and oedematous lungs, no obvious cause of death was identified at autopsy. Peripheral blood (PB), cardiac blood (CB), urine and bile were collected. Immunological screening for amphetamine, methamphetamine, opiates, cannabinoids, cocaine, buprenorphine, methadone and MDMA was performed on urine. Quantification of cannabinoids was performed on PB by GC-MS/MS. Analysis of ethanol and other volatile compounds was performed on PB and urine using HS-GC-MS. Ethylglucuronide (EtG) was quantified in PB and urine by GC-MS/MS. General unknown screening (GUS) was performed on PB by GC-MS and LC-PDA/MS. DOC was quantified in bloods, urine and bile by UHPLC-MS/MS after liquid-liquid extraction, using MBDB-d5 as internal standard. The assay was validated on whole blood for linearity (range: 2.0 to 500 ng/mL), selectivity, precision and accuracy at limit of quantification (LOQ: 2.0 ng/mL) and at high-level concentration (High QC: 400 ng/mL). The dilution process was validated in urine (dilution factor 1/10). Immunological screening was positive for cannabinoids. Confirmation in PB quantified THC, 11-OH-THC and THC-COOH at 3.40, 2.10 and 36.0 ng/mL, respectively. Ethanol analyses were negative but EtG was quantified at 0.48 μg/mL and 161 μg/mL in PB and urine, respectively. Mirtazapine was quantified at therapeutic concentration (20 ng/mL) in PB. DOC was detected on GUS by GC-MS and LC-PDA/MS. The method of DOC quantification was validated by measurement of accuracy and precision at the LOQ (104% and 12.6%) and at the High QC (97.4% and 8.5%). The 10-fold dilution process in urine was validated in term of accuracy (100%) and precision (4.1%). Selectivity was validated by analyzing 6 blank samples and no interference was observed at DOC retention time. In the present case, DOC was quantified at 104 ng/mL, 322 ng/mL, 648 ng/mL and 371 ng/mL in PB, CB, urine and bile respectively. Presence of cannabinoids and EtG in blood and urine suggest alcohol and cannabis consumption several hours preceding the death. Reports of use of DOC have mainly described non-fatal intoxications, with reported blood concentrations from < 10 to 18 ng/mL (Abbara. TOXAC 2017;29:82–89). At our best knowledge, only one fatal case has been reported in the literature (Barnett. JAT 2014;38:589–591), in which DOC blood and urine concentrations were 377 and 3193 ng/mL. Difference between PB and CB concentrations in the present case could be explain by postmortem redistribution. In the present case, the circumstances of death, autopsy findings and toxicological results were consistent with a toxic cause of death by DOC overdose in association with cannabis consumption.

An autopsy case of fatal insulin preparation overdose

Insulin preparations, a group of drugs used to treat diabetes, are of great forensic interest because they are difficult to detect in blood while they are sometimes intentionally administered in large doses for suicide or murder. In this study, we validated a quantification method for insulin glargine and insulin lispro using liquid chromatography-tandem mass spectrometry (LC-MS/MS) in the blood sample from a case of suicidal overdose with insulin. Case: A woman in her 30s had a history of mental illness and diabetes. A day before her death, she informed her partner that she had self-administered large doses of insulin preparations and prescription drugs. Bovine insulin was used as the internal standard (IS). The blood sample (250 μL) was added to the diluent and IS solution, followed by 250 μL each of hexane and N,N-dimethylformamide, and the mixture was centrifuged (10000 g × 10 min). The supernatant was collected and 900 μL of 5% ammonium solution was added. The extract was analyzed using Nexera 30A, LCMS8060 (Shimadzu), L-column3 ODS C18 metal-free column (150 × 2.1 mm, 3 μm), ionization method: electrospray ionization+, multiple reaction monitoring conditions: insulin glargine [M + 6H]6+ 1011.5 > 1179.4, insulin lispro[M + 6H]6+ 968.9 > 217.0, bovine insulin (IS) [M + 6H]6+ 956.3 > 1120.9. The autopsy revealed no evidence of fatal injuries. Coronary artery stenosis was observed as a finding of endogenous disease, but there were no significant histopathological changes in the myocardium. Biochemical tests revealed the following: blood glucose level, 6 mg/dL; glucose in the vitreous region, 6 mg/dL; glycated hemoglobin (HbA1c), 11.2%; blood insulin level estimated using the chemiluminescent enzyme immunoassay method, 1.03 μU/mL (6.27 pmol/mL); and C-peptide concentration, 0.6 ng/mL (16.8 pmol/L). A drug screening test and simple quantification using LC-MS/MS detected many prescription drugs, but none of them were at intoxicating concentrations. The insulin analysis showed insulin glargine concentrations of 429 μU/mL in femoral blood and 1362 μU/mL in cardiac blood, and insulin lispro was detected in femoral and cardiac blood below the lower limit of quantification (<50 μU/mL). The cardiac/peripheral blood ratio, a measure of postmortem redistribution, was 3.2. Although the therapeutic ranges of insulin glargine and insulin lispro have not been defined, the femoral and cardiac blood concentrations of insulin lispro in this case was lower than the serum concentration (155 μU/mL) listed in the package insert. However, while the femoral and cardiac blood insulin glargine concentrations were considerably higher than the serum concentration (15 μU/mL) listed in the package insert. Considering that insulin is easily degraded in whole blood due to hemolysis, it is possible that insulin concentrations were even higher at the time of administration and death than those observed in autopsy specimens on the third postmortem day. However, since insulin lispro is a fast-acting analog of insulin (1–3 hours), it may have contributed to hypoglycemia but was not the direct cause of death, and hypoglycemia due to insulin glargine overdose was the most likely cause of death in this case. We quantified insulin lispro and insulin glargine in a case of suicide to determine insulin glargine's involvement in causing death. In future, it is necessary to examine postmortem degradation and redistribution of insulin and consider the appropriate concentration in postmortem samples of insulin poisoning.

Postmortem reference concentrations of elements in blood and urine

To establish postmortem reference concentrations of elements. Fatal intoxications, both accidental and intentional, are a global issue. In the western world intoxications with pharmaceuticals dominate, but in other parts of the world other substances are more common. Intoxication with elemental compounds is generally considered to be uncommon. In a forensic setting, elemental intoxications are of great importance when investigating both accidental, suicidal, and homicidal deaths. Arsenic, for example, is a classical poison which also has relevance in the modern era. Unlike for pharmaceuticals, postmortem reference concentrations for elements are scarce. For many elements it is therefore unknown if, and to what extent, they are affected by postmortem redistribution. The current study presents normal postmortem reference concentrations of 68 elements in femoral blood and urine. In addition, possible sources of error such as contamination from collection tubes, preservative potassium fluoride solution and storage time are evaluated. Paired blood and urine samples from 120 cases of death by suicidal hanging in Sweden were collected. 20 cases from each of the six local units of forensic medicine were used to account for possible regional differences. Additionally, the included cases reflected both short and long storage times. To account for possible elemental contamination from collection tubes and the added potassium fluoride solution, multiple batches of tubes and multiple samples of potassium fluoride solution were also analysed. Concentrations of elements were determined by double focusing sector field ICP-MS. Key descriptive statistics for all 68 elements are provided (including mean, median and percentiles) in blood and urine. Forensic highlights include blood concentrations of total arsenic (mean: 4.25 μg/g), thallium (mean: 0.14 μg/g) and antimony (mean: 14.82 μg/g). For several elements in blood and urine ( n = 24 and n = 25, respectively) a majority of elemental concentrations were below the limit of detection. The contribution of contamination from collection tubes were minor compared to the overall mean elemental concentrations in both blood and urine. Though the added solution of potassium fluoride contained a large assortment of elements, given the small amounts of this solution added to samples, the overall contribution is minor for most elements relative to the overall mean. However, there was a significant difference between samples with short and long storage time for 22 elements in blood and 17 elements in urine. These differences reflected both increases and decreases in concentration. Relative to antemortem elemental concentrations the postmortem concentrations show both increases and decreases. Of special note are markedly higher concentrations for several elements in blood (such as cadmium, chromium, manganese and antimony) compared to several antemortem populations. In general, it can be assumed the phenomenon of postmortem redistribution is as large for elements as it is for drugs and other substances. When evaluating individual concentrations, it is important to be aware of potential sources of contamination and the potential influence of storage time. Concentrations indicating overexposure must be evaluated together with autopsy findings and case circumstances to form a holistic view of the case as a whole. The present study provides an important tool when evaluating postmortem elemental concentrations. It fills a needed gap between large antemortem population studies and postmortem case reports or small case series of elemental intoxications. Together with the forensic autopsy and circumstantial information the present references will aid in diagnosing cases of potential elemental overexposure.

Overview on advantages & disadvantages of alternative matrices

To describe the advantages and disadvantages of alternative matrices in the field of clinical and forensic toxicology. A review of the characteristics and limitations of the most relevant alternative matrices have been conducted. Moreover, the main applications of the analysis of alternative matrices have been detail focusing on its usefulness in the resolution of real forensic and clinical cases. The advance in more sensible testing methodologies have been permitted the analysis of other biological specimens, traditionally inaccessible. Different alternative biological matrices can be used in clinical and forensic toxicological cases to obtain additional information to those obtain by the analysis of traditional matrices. Moreover, these matrices can be used to resolve problems or impediments of traditional matrices, such as invasive sample collection, detection of long-term exposure, contamination or postmortem redistribution… Some of the most used alternative matrices nowadays are hair, oral fluid, meconium or vitreous humor. The main advantage of hair analysis is the possibility to extend the window of detection to months or even years and perform a chronological profile of drug consumption. Hair analysis is applied to cases of driving license regranting, drug-facilitated crimes, determination of gestational drug exposure or verification of drug-use history, among others. Its main limitation is the lack of dose/concentration correlation and the issue of external contamination. Oral fluid has a comparable window of detection with blood, but with an easier and non-invasive sample collection. However, oral fluid has a limited dose/concentration correlation and there is the possibility of buccal and passive exposure contamination. The use of oral fluid for investigating impaired driving at the roadside and for testing drug-use at workplace has exponentially increased recently, showing the potential of this matrix as an alternative to blood in detecting recent consumption. Meconium can provide information of in utero drug exposure from the second and mainly third trimester of pregnancy, with an easy and non-invasive collection. However, in some cases this matrix cannot be available, is a non-homogenous sample and require sensitive and complex methodologies. Finally, vitreous humor is a very interesting postmortem sample for determining ethanol, but also other drugs of abuse, due to it is anatomically isolated (minimizing postmortem redistribution) and protected from putrefaction. Vitreous humor volume is low and data about drug concentrations in this matrix is limited and the interpretation is complex. The analysis of alternative matrices in isolation or in combination with traditional matrices can improve the resolution of clinical and forensic toxicological cases. The main advantages of alternative samples are an easy and non-invasive collection, while the main disadvantages are the necessity of sensitive methodologies and the lack of dose/concentration correlation. Moreover, the interpretation of the information provided by alternative matrices should be performed taking into account the characteristics of those samples. The use of alternative matrices in clinical and forensic toxicology complements the information provide by traditional matrices, specially when traditional matrices are not available, their collection is invasive, or drugs are no longer detect in them.

Deadly mono-intoxication after ingestion of 4F-MDMB-BICA

The synthetic cannabinoid (SC) 4F-MDMB-BICA was detected in the recent past in connection with numerous poisonings and fatalities. SC with a methyl-3,3-dimethylbutanoate structure are often afflicted with a high instability and usually rapidly degraded to the dimethylbutanoic acid metabolite (DBA), frequently resulting in small amounts of parent compound in samples. Here, we report on a fatality of a 41-year-old man who was found unconscious and declared dead after unsuccessful reanimation. At the scene, a few herbal incenses were found near to the deceased. The autopsy did not reveal any macro morphological cause of death. Among other things, a cerebral and pulmonary edema as well as an incipient pneumonia were found. The seized herbal mixtures were grinded and dispersed in ethanol. Aliquots of the supernatants were tested using GC/MS. Urine, heart blood (HB) and stomach contents were screened using GC/MS following liquid-liquid extraction. Additionally, urine and HB were screened following protein precipitation with acetonitrile using LC-QTOF-MS/MS in SWATH mode (column: Macherey-Nagel (MN) Nucleoshell RP 18 100 × 2 mm, 2.7 μm; MS: SCIEX QTOF 6600+, ESI+). Brain, lung, liver and kidney tissues were homogenized 1 + 4, bile fluid 1 + 9 with water. 4F-MDMB-BICA and DBA were quantified using AB-FUBINACA-D4 as internal standard in tissues as well as bile fluid, HB and peripheral blood (PB) after standard addition, enzymatic cleavage and solid phase extraction using LC-MS/MS (column: MN Nucleodur C18 Gravity 150 × 2 mm, 5 μm; MS: Thermo Fisher TSQ, ESI+). 4F-MDMB-BICA could be detected in every seized herbal mixture, one sample additionally contained ADB-BUTINACA. Besides ibuprofen, 4F-MDMB-BICA and several metabolites were detected in urine, HB and stomach contents. Quantification of the parent substance revealed concentrations of 18 ng/mL in HB, 11 ng/mL in PB, 12 ng/mL in bile fluid as well as low concentrations in other tissues. DBA was detected at concentrations of 100 ng/mL in HB, 31 ng/mL in PB, 96 ng/g in lung, 57 ng/g in kidney, 2 ng/g in brain and 9500 ng/mL in bile fluid. ADB-BUTINACA could not be found in any specimen. The relatively high concentrations of DBA in lung could indicate an acute pulmonary intake closely related to death. The concentrations in HB could have been elevated because of postmortem redistribution. The extremely high concentrations of DBA in bile fluid might be the result of a repeated consumption as well as an enterohepatic circulation. The results of the analyses indicate death due to an acute intoxication of 4F-MDMB-BICA. In contrast to most reported fatalities, the presented case could be attributed to a mono-intoxication after SC consumption.

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 50.0ng/g, 31.4ng/g and 1.9-441ng/g, respectively. Fentanyl concentrations in 16 liver samples had a mean of 82.0ng/g, a median of 69.4ng/g and a range of 11.6-226ng/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.

Abstract #28 Descriptive Report on Safety When Performing Intraoperative Neurophysiological Monitorization During Indirect Lumbar Canal Decompression

It is important for forensic toxicologists to remember that even if drug and metabolite results are accurately determined, the interpretation of these results may be problematic because of numerous non-analytical factors. Included among these factors that may influence the interpretation of analyte concentration are tolerance and addiction, post-mortem redistribution, age, hysteresis, adulterants, contaminants, and diluents. This Chapter provides an overview of these factors, and the effects they may have on interpretation.

Monte Carlo optimization method based QSAR modeling of postmortem redistribution of structurally diverse drugs

The Monte Carlo optimization method was employed for the development of the QSAR model for the prediction for postmortem redistribution of structurally diverse drugs.

Postmortem redistribution of morphine in humans: Important variables that might be influencing the central blood/peripheral blood ratio

IntroductionIn the field of forensic toxicology, many unexpected deaths are investigated as to whether toxicological substances may have caused or contributed to someone’s death. One of the factors that makes interpretation of the results of quantitative analysis in postmortem toxicology challenging, is that measured postmortem drugs levels may vary according to the sampling site and the interval between death and specimen collection. These site- and time-dependent variations are caused by ‘postmortem redistribution’ (PMR). Literature shows that there are several factors that determine the degree of PMR, such as cell and tissue changes after death, decomposition and the physicochemical characteristics of drugs. Blood from peripheral sites seems to be less affected by PMR than cardiac blood. Therefore, the ratio of cardiac blood concentration/peripheral blood concentration (C/P) of a drug is often used as a marker of the extent of postmortem redistribution. In this study, we investigated the relationship between different potentially important variables and the C/P ratio of morphine in humans in order to provide new insights that might assist in the interpretation of quantitative results in forensic casework. MethodToxicological results of all morphine positive postmortem cases investigated by the Netherlands Forensic Institute between January 1, 2010 and July 31, 2020 were reviewed. Morphine was quantified in both femoral and cardiac blood in a total of 103 cases. The C/P ratios were determined for all selected cases. To collect data for this study, all corresponding files were reviewed. C/P ratios were compared between subgroups by performing either a Mann-Whitney U test or a Kruskal-Wallis test, followed by a post-hoc Mann-Whitney U test. Bonferroni correction was performed to correct for the likelihood of a significant result by chance due to multiple testing. After Bonferroni correction, a p-value< 0.004 was considered statistically significant. ResultsThe data suggests a relationship between grade of decomposition at autopsy, position of the corpse at discovery, route of administration, attempted resuscitation and the C/P ratio of morphine with p-values of 0.010, 0.026, 0.035 and 0.046, respectively. ConclusionGrade of decomposition at autopsy, position of the corpse at discovery, route of administration and attempted resuscitation seem to be influencing the C/P ratio of morphine. Of these four variables, the route of administration seems to have the greatest impact.