A Forensic Diagnostic Algorithm for Drug-Related Deaths: A Case Series

The best evidence provided in the literature worldwide suggests the importance of harmonizing the investigation in drug-related fatalities. In this study, the application of a multidisciplinary approach in eight cases of drug-related deaths is presented. Although death scene findings could be highly suggestive of drug intoxication, external examination and toxicological screening test alone are insufficient. There are several variables, and it is not always easy to give the proper interpretation of the drug detection. A complete autopsy is necessary to correctly complete organ and tissues sampling for further histological and toxicological studies and obtain body fluids. The use of peripheral blood is recommended to avoid artifacts. The collection of many specimens is warranted to get more responses. The sampling aims to provide a picture of the distribution of the substance in the body. The sample and the selection of the drugs and the matrices to investigate are case-dependent. The presented diagnostic algorithm provides the coroner with all the elements to investigate drug-related deaths and cooperate with toxicologists. Toxicological forensic diagnosis is still extremely heterogeneous in regional and national contexts. Funding for method development, research, networking, facilities, and technologies improvement is mandatory to standardize the toxicological investigation

Slučaj trovanja sintetskim kanabinoidima u Hrvatskoj

The number of new psychoactive substances (NPS), synthetic cannabinoids (SCs) in particular, is growing constantly. Because of the insufficiently explored effects on consumer health, they have become a major problem in the emergency departments. They are difficult to identify, and there are no antidotes that could reverse their detrimental effects. We report a case of poisoning of a young man who used SCs. The patient was admitted to the emergency department of the Clinical Hospital Merkur, Zagreb (Croatia) after sniffing and smoking a herbal product bought on the street. He presented with severe cognitive difficulties and visible eye redness. Other symptoms included somnolence, disorientation, loss of coordination, unsteady gait, hyporeflexia, stiffness, cramps and cold limbs, blurred vision, teeth grinding, dry mouth, tinnitus, fear, suicidal thoughts, impaired focus, memory, and speech, sedation, fatigue, depression, thought blocking, and autistic behaviour. His skin was dry, and his mucosa dry and irritated. Herbal products “Rainbow Special” and “Luminated Aroma” used by the patient were qualitatively analysed with gas chromatography / mass spectrometry (GC/MS) after direct extraction with an organic solvent. Solid-phase extraction method was used to analyse serum and urine samples. Despite the negative findings of biological samples, mostly due to the limitations of GC/MS, the clinical picture infallibly pointed to the poisoning with SCs. This was confirmed by the findings of 5-fluoro AMB (methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3-methylbutanoate) in the herbal products.Broj novih psihoaktivnih tvari (engl. new psychoactive substances, krat. NPS), osobito sintetskih kanabinoida (engl. synthetic cannabinoids, krat. SC), stalno se povećava. Zbog nedovoljno istraženih učinaka na zdravlje korisnika, te tvari stvaraju velike probleme odjelima hitne medicine. Teško je dokazati njihovu prisutnost, a protuotrovi koji bi mogli poništiti njihovo štetno djelovanje nisu poznati. Prikazujemo slučaj trovanja mladog muškarca koji je konzumirao sintetske kanabinoide. Pacijent je zaprimljen na odjel hitne službe Kliničke bolnice Merkur u Zagrebu nakon šmrkanja i pušenja biljnog proizvoda kupljenoga na ulici. Prilikom dolaska u hitnu službu kliničkom slikom dominiraju kognitivne poteškoće (izrazito usporenih kretnji, polaganog izgovora), a objektivno je bilo uočljivo izrazito crvenilo očiju. Klinička slika bolesnika uključivala je niz različitih simptoma: stanje svijesti – somnolencija; neurološki simptomi – dezorijentiranost, gubitak koordinacije, nesiguran hod, hiporefleksija; oftalmološki simptomi – zamagljen vid; ORL simptomi – škripanje zubima, suha usta, šumovi u ušima; simptomi srca, krvožilja i dišnog sustava – nije imao; simptomi probavnog sustava – gubitak apetita; simptomi mišićno-koštanog sustava – ukočenost, grčevi i hladnoća udova; psihološki simptomi – konfuzija, strah, suicidalne misli, poremećaj pažnje, pamćenja i govora, sedacija, umor, depresija, blok misli, autistično ponašanje. Koža je bila suha, a sluznice suhe i iritirane. Heteroanamnestičkim podacima od majke, koja je donijela prazne vrećice marketinškog imena Rainbow Special i Luminated Aroma doznali smo da slične vrećice nalazi već godinu dana u sinovoj sobi, a istom zamjećuje da sin sve teže uči, ne može se koncentrirati i pratiti nastavu. Sin je odbijao prestati s konzumacijom. Biljni proizvodi Rainbow Special i Luminated Aroma, koje je pacijent konzumirao nakon izravne ekstrakcije s organskim otapalom, kvalitativno su analizirani plinskom kromatografijom / masenom spektrometrijom (GC / MS). Metodom ekstrakcije na čvrstoj fazi analizirani su uzorci seruma i mokraće. Unatoč negativnim nalazima bioloških uzoraka, uglavnom zbog ograničenja GC / MS metode, klinička je slika nedvojbeno upućivala na trovanje sintetskim kanabinoidima. To je potvrđeno i nalazima 5-fluor AMB (metil 2- (1- (5-fluoropentil) -lH-indazol-3-karboksamido)-3-metilbutanoata) u biljnim proizvodima

EtG Quantification in Hair and Different Reference Cut-Offs in Relation to Various Pathologies: A Scoping Review

CC BY 4.0Ethyl glucuronide (EtG) is a non-volatile, non-oxidative, hydrophilic, and stable ethanol phase II metabolite. EtG is produced through ethanol glucuronidation by UDP-glucuronosyltransferase (UGT), a phase II enzyme. EtG can be extracted from different biological matrices, including keratin ones, such as hair or nails. The purpose of this scoping review is to describe the relationship between EtG levels in hair and some of the most common and frequent pathological conditions and verify whether different reference cut-offs in relation to various pathologies have been identified in the scientific literature. In fact, in-depth knowledge of the influence of pathologies, such as diabetes mellitus, hepatic and renal dysfunction, on EtG production and its storage in keratin matrices would allow a more appropriate interpretation of obtained data and rule out false positives or false negatives. This scoping review is based on bibliographic research carried out on PubMed regarding the quantification of EtG in hair of subjects affected by different pathological conditions. According to the scientific literature, the main and most common pathologies that can affect the concentration of EtG in hair are liver and kidney diseases and diabetes. The EtG quantification analytical data should be interpreted carefully as they may have a great impact in both forensic and clinical contexts

Poisoning Caused by Medicines and Drugs of Abuse

We believe it is necessary to state a premise on the framing of poison and poisoning in the context of Forensic Toxicology as an important contribution to this Special Issue, which is composed of articles about this discipline—the discipline of “poison” [...

The mysterious death of Francesco I de' Medici and Bianca Cappello: an arsenic murder?

Modern analytical techniques have allowed re-evaluation of the cause of death of Francesco I de' Medici and his wife, Bianca Cappello. It now seems that the grand-ducal couple died of acute arsenic poisoning and not malaria as previously believe

Application of HRAM screening and LC–MS/MS confirmation of active pharmaceutical ingredient in “natural” herbal supplements

The growing market of herbal remedies worldwide could pose severe problems to consumers’ health due to the possible presence of potentially harmful, undeclared synthetic substances or analogues of prescription drugs. The present work shows a simple but effective approach to unequivocally identify synthetic anorectic compounds in allegedly ‘natural’ herbal extracts, by exploiting liquid chromatography/time of flight (Q-TOF LC/MS) technology coupled to liquid chromatography/triple quadrupole (LC–MS/MS) confirmation and quantitation. The procedure was applied to five tea herbal extracts and pills sold as coadjutant for weigh loss. The method exploited liquid–liquid sample extraction (LLE) and separation in a C18 (2.1 mm × 150 mm, 1.8 μm) column. QTOF acquisitions were carried out both in scan mode and all ion MS/MS mode and results were obtained after search against ad hoc prepared library. Sibutramine, 4-hydroxyamphetamine, caffeine and theophylline were preliminary identified samples. Confirmation and quantitation of the preliminary identified compounds were obtained in LC–MS/MS after preparation of appropriated standards. Sibutramine, caffeine and theophylline were finally confirmed and quantitate