Systematic toxicological analysis procedures for acidic drugs and/or metabolites relevant to clinical and forensic toxicology and/or doping control

Dilute and shoot approach for toxicology testing

Toxicology testing is performed in clinical settings, forensic settings, and for controlling doping. Drug screening is a toxicology test to determine if drugs are present in biological samples. The most common specimen type for drug testing is urine, as drugs and/or their metabolites are often more concentrated in the urine, extending the detection window of drugs. The dilute-and-shoot method is a simple procedure used in toxicology testing, where a sample is diluted before being directly injected into the liquid chromatography-mass spectrometry (LC-MS) system. This method is easy, quick, and cost-saving, and can be used for protein-poor liquid specimens such as urine. Thus, it is reasonable and attractive for busy toxicology laboratories to combine the dilute-and-shoot method with high-resolution hyphenated-MS for urine drug screening. This method has several disadvantages, including a suboptimal detection capability for certain analytes, as well as interference from co-eluting matrix components called matrix effects, in which co-eluting matrix molecules alter the ionization efficiency of the analyte molecules at the ionization source in LC-MS, altering (mostly reducing) the analyte detection capability. The matrix effect testing is essential for the validation of LC-MS-based assays. A reasonable approach to addressing these undesirable effects would be to minimize these components. The most straightforward approach is to reduce the amounts of matrix components by using a higher dilution of the specimen and a lower volume for specimen injection. Optimization of the chromatographic separation is another reasonable approach for reducing co-eluting matrix components with the analyte.

Current state-of-the-art approaches for mass spectrometry in clinical toxicology: an overview

INTRODUCTION

Hyphenated mass spectrometry (MS) has evolved into a very powerful analytical technique of high sensitivity and specificity. It is used to analyze a very wide spectrum of analytes in classical and alternative matrices. The presented paper will provide an overview of the current state-of-the-art of hyphenated MS applications in clinical toxicology primarily based on review articles indexed in PubMed (1990 to April 2023).

AREAS COVERED

A general overview of matrices, sample preparation, analytical systems, detection modes, and validation and quality control is given. Moreover, selected applications are discussed.

EXPERT OPINION

A more widespread use of hyphenated MS techniques, especially in systematic toxicological analysis and drugs of abuse testing, would help overcome limitations of immunoassay-based screening strategies. This is currently hampered by high instrument cost, qualification requirements for personnel, and less favorable turnaround times, which could be overcome by more user-friendly, ideally fully automated MS instruments. This would help making hyphenated MS-based analysis available in more laboratories and expanding analysis to a large number of organic drugs, poisons, and/or metabolites. Even the most recent novel psychoactive substances (NPS) could be presumptively identified by high-resolution MS methods, their likely presence be communicated to treating physicians, and be confirmed later on.

Summary statistics for drugs and alcohol concentration recovered in post-mortem femoral blood in Western Switzerland

In post-mortem investigations of fatal intoxication, it is challenging to determine which drug(s) were responsible for the death, and which drugs did not. This study aims to provide post-mortem femoral blood drug levels in lethal intoxication and in post-mortem control cases, where the cause of death was other than intoxication. The reference values could assist in the interpretation of toxicological results in the routine casework. To this end, all post-mortem toxicological results in femoral blood from 2011 to 2017 in Western Switzerland were considered. A full autopsy with systematic toxicological analysis (STA) was conducted in all cases. Results take into account the cause of death classified into one of four categories (as published by Druid and colleagues): I) certified intoxication by one substance alone, IIa) certified intoxication by more than one substance, IIb) certified other causes of death with incapacitation due to drugs, and III) certified other causes of death without incapacitation due to drugs. This study includes 1 990 post-mortem cases where femoral blood was analysed. The material comprised 619 women (31%) and 1 371 men (69%) with a median age of 50 years. The concentrations of the 32 most frequently recorded substances as well as alcohol are discussed. These include 6 opioids and opiates, 3 antidepressants, 6 neuroleptics and hypnotics, 1 barbiturate, 11 benzodiazepines (and related drugs), 2 amphetamine-type stimulants, cocaine, paracetamol, and tetrahydrocannabinol (THC). The most common substances that caused intoxication alone were morphine, methadone, ethanol, tramadol, and cocaine. The post-mortem concentration ranges for all substance are categorized as I, IIa, IIb, or III. Statistical post-mortem reference concentrations for drugs are discussed and compared with previously published concentrations. This study shows that recording and classifying cases is time-consuming, but it is rewarding in a long-term perspective to achieve a more reliable information about fatal and non-fatal blood concentrations.

A simple, cost-effective and rapid method for simultaneous determination of Strychnos nux-vomica alkaloids in blood and Ayurvedic medicines based on ultrasound-assisted dispersive liquid-liquid microextraction-thin-layer chromatography-image analysis

A simple, rapid, cost-effective and green analytical method is developed based on ultrasound-assisted dispersive liquid-liquid microextraction (US-DLLME) coupled to thin-layer chromatography (TLC)-image analysis for the simultaneous determination of two major alkaloids of Strychnos nux-vomica L i.e., strychnine and brucine. The method is composed of three steps, namely (i) US-DLLME by injecting a mixture of 100-μL chloroform (extraction solvent) and 1-mL methanol (disperser solvent) in 5 mL of aqueous sample, followed by ultrasonication and centrifugation, (ii) TLC of 20 μL of sedimented phase with methanol: ammonia (100:1.5, v/v) as the mobile phase and visualization under ultraviolet radiation (254 nm) and (iii) photography of TLC plate and quantification of spots by image analysis using freely available imageJ software (National Institute of Health, Bethesda, MD, USA). The limit of detection and limit of quantification for both alkaloids were found to be in the range of 0.12-0.15 and 0.36-0.48 μg/spot, respectively. The method was found to be linear in the range of 0.5-5 μg/spot with correlation coefficient (R2) of 0.995 and 0.997 for strychnine and brucine, respectively. The developed method was successfully applied for the determination of strychnine and brucine in Ayurvedic formulations and blood samples. The method does not require any sophisticated instrument and handling skills and can be adopted for rapid analysis of strychnine and brucine in forensic toxicological laboratories.

Analysis of loxoprofen in tablets, patches, and equine urine as tert-butyldimethylsilyl derivative by gas chromatography-mass spectrometry

Loxoprofen is a non-steroidal anti-inflammatory drug of the 2-arylpropionic acid type, which has used to treat musculoskeletal disorders in the horse racing industry. However, it has also used illicitly to mask clinical signs of inflammation and pain in racehorses. Thus, its accurate analysis has become an important issue in horse doping laboratories. In this study, an analytical method of loxoprofen was developed as tert-butyldimethylsilyl (TBDMS) derivative by gas chromatography-mass spectrometry (GC-MS). Characteristic fragment ions of [M-15], [M-57], and [M-139] permitted the accurate and selective detection of loxoprofen. Under optimal conditions, this method showed good linearity (r ≥ 0.999) in the range of 10-500 ng/mL, repeatability (% relative standard deviation = 5.6-8.5), and accuracy (% relative error = - 0.3-0.9) with a detection limit of 1.0 ng. When applied to the analysis of loxoprofen in tablet and patch products, loxoprofen was positively identified as TBDMS derivative by GC-MS. The present method provided rapid and accurate determination of loxoprofen in patch and tablet products. Levels of loxoprofen were highest in equine urine at 0.5 and 1 h after oral administration with single dose (3 mg/kg) to three horses, and then rapidly reduced to below the lower limit of quantification at 24 h. Therefore, the present method will be useful for the pharmacokinetic study and doping tests for loxoprofen and other similar acidic drugs in horses.

Liquid Chromatography-Tandem Mass Spectrometry: An Emerging Technology in the Toxicology Laboratory

In the last decade, liquid chromatography-tandem mass spectrometry (LC-MS/MS) has seen enormous growth in routine toxicology laboratories. LC-MS/MS offers significant advantages over other traditional testing, such as immunoassay and gas chromatography-mass spectrometry methodologies. Major strengths of LC-MS/MS include improvement in specificity, flexibility, and sample throughput when compared with other technologies. Here, the basic principles of LC-MS/MS technology are reviewed, followed by advantages and disadvantages of this technology compared with other traditional techniques. In addition, toxicology applications of LC-MS/MS for simultaneous detection of large panels of analytes are presented.

Assessment of carboxyhemoglobin, hydrogen cyanide and methemoglobin in fire victims: a novel approach

To establish the cause of death, carboxyhemoglobin (COHb), total hemoglobin (tHb), methemoglobin (MetHb), and hydrogen cyanide (HCN) were quantified in the blood of fire victims. We analyzed 32 out of 33 blood samples from forensic autopsy cases in a disastrous polyurethane mattress fire, which caused the deaths of 33 inmates at a prison in Argentina in 2006. The cadaveric blood samples were collected by femoral vein puncture. These samples were analyzed using the IL80 CO-oximeter system for tHb, MetHb, and COHb levels and by microdiffusion for HCN and COHb levels. Blood alcohol (ethanol) and drugs were examined by headspace gas chromatography-flame ionization detection (HS-GC-FID) and GC-mass spectrometry (MS), respectively. Polyurethane mattress samples were analyzed according to the California 117 protocol. The saturation of COHb ranged from 10% to 43%, tHb from 2% to 19.7%, MetHb from 0.10% to 35.7%, and HCN from 0.24 to 15mg/L. These HCN values are higher than the lethal levels reported in the literature. Other toxic components routinely measured (ethanol, methanol, aldehydes, and other volatile compounds) gave negative results in the 32 cases. Neither drugs of abuse nor psychotropic drugs were detected. The results indicate that death in the 32 fire victims was probably caused in part by HCN, generated during the extensive polyurethane decomposition stimulated by a rapid increase in temperature. We also considered the influence of oxygen depletion and the formation of other volatile compounds such as NOx in this disaster, as well as pathological evidence demonstrating that heat was not the cause of death in all victims. Furthermore, statistical analysis showed that the percentage values of COHb and MetHb in the blood were not independent variables, with χ(2)=11.12 (theoretical χ(2)=4.09, degrees of freedom=12, and α=0.05). However, no correlation was found between HCN and MetHb in the blood of the victims. This is the first report to assess the relationship between COHb and MetHb in forensic blood samples. We further discuss other factors that could lead to a lethal atmosphere generated by the fire and compare the data from this disaster with that of other published fire episodes.

Drug confirmation by mass spectrometry: Identification criteria and complicating factors

Drug confirmation by mass spectrometry coupled with chromatography is essential to toxicology, doping control, pain management, and workplace drug testing. High confidence in this technology is due to its superior specificity and sensitivity. However, there are challenges associated with drug confirmation, and proper setup and validation of these assays are important in assuring high-quality results. In this article, assay parameters required for drug confirmation are summarized based on recent scientific publications, various established guidelines, and our own practical experience. Factors affecting the result quality and correct results interpretation are critically reviewed. Several emerging technologies and their potential applications are briefly explored.

Resistant hypertension? Assessment of adherence by toxicological urine analysis

OBJECTIVE

Uncontrolled hypertension under antihypertensive multidrug regimen is not necessarily always true resistance. Incomplete adherence is one of several possible causes of uncontrolled hypertension. Nonadherence remains largely unrecognized and is falsely interpreted as treatment resistance, as it is difficult to confirm or exclude objectively. This is the first study assessing adherence in patients with apparent resistant hypertension systematically via toxicological urine screening.

METHODS

All patients referred from primary care physicians because of uncontrolled hypertension between 2004 and 2011 were analysed. Adherence was assessed in all patients with uncontrolled hypertension despite the concurrent use of at least four antihypertensive agents by using liquid chromatography-mass spectrometry analysis for antihypertensive drugs or their corresponding metabolites in urine.

RESULTS

A total of 375 patients with uncontrolled hypertension were referred. After optimization of drug therapy and exclusion of white coat hypertension, 108 patients met criteria for resistant hypertension. Of those, 15 patients had secondary causes of hypertension and 17 achieved goal blood pressure with quadruple antihypertensive therapy. Of the remaining 76 patients, 40 patients (53%) were found to be nonadherent. Among nonadherent patients, 30% had complete and 70% had incomplete adherence; 85% of the latter had taken less than 50% of drugs prescribed. Lack of adherence was almost evenly distributed between different classes of antihypertensive drugs.

CONCLUSION

Low adherence was the most common cause of poor blood pressure control in patients with apparent resistant hypertension, being twice as frequent as secondary causes of hypertension. Incomplete adherence was far more common than complete nonadherence; thus, assessment of adherence in patients on multiple drug regime is only reliable when all drugs are included in assessment. Assessing adherence by toxicological urine screening is a useful tool in detecting low adherence, especially in the setting of multidrug regimen as a cause of apparently resistant hypertension.

Rapid sample pre-treatment prior to GC-MS and GC-MS/MS urinary toxicological screening

Drug screening is an important issue in clinical and forensic toxicology. Gas chromatography coupled to mass spectrometry (GC-MS) remains the gold standard technique for the screening of unknown compounds in urine samples. However, this technique requires substantial sample preparation, which is time consuming. Moreover, some common drugs such as cannabis cannot be easily detected in urine using general procedures. In this work, a sample preparation protocol for treating 200 μL of urine in less than 30 min is described. The enzymatic hydrolysis of glucuro-conjugates was performed in 5 min thanks to the use of microwaves. The use of a deconvolution software allowed reducing the GC-MS run to 10 min, without impairing the quality of the compound identifications. Comparing the results from 139 authentic urine samples to those obtained using the current routine analysis indicated this method performed well. Moreover, additional 5-min GC-MS/MS programs are described, enabling a very sensitive target screening of 54 drugs, including THC-COOH or buprenorphine, without further sample preparation. These methods appeared as an interesting alternative to immuno-assays based screening. The analytical strategy presented in this article proved to be a promising approach for systematic toxicological analysis (STA) of drugs in urine.

A new strategy for basic drug extraction in aqueous medium using electrochemically enhanced solid-phase microextraction

This work describes an electrochemically enhanced solid-phase microextraction (EE-SPME) method using a mild negative potential (-0.6 V) for the enhanced extraction of the selected basic drugs in a pure aqueous matrix and urine samples. The EE-SPME method gave a more effective extraction of drugs (primarily via electrophoresis and complementary charge interaction) compared to that obtained with SPME (without applying a potential, and which is based on passive partitioning). The EE-SPME method eliminated the need for alkalizing, derivatizing the drugs, or modifying the fiber coating before extraction. The analysis of methamphetamine (MA) and amphetamine (AM) was selected as a typical example to demonstrate in detail the advantages of EE-SPME over SPME. Based on the results obtained, 3-min extraction efficiency for both the amphetamines using EE-SPME was better than that of 30-min using SPME. The developed EE-SPME-GC method exhibited wide linear ranges (2-1000 ng mL(-1)) for both the amphetamines with R(2) larger than 0.99, and the method detection limits (MDLs) for AM and MA were 0.26 and 0.12 ng mL(-1), respectively. In addition, the EE-SPME method developed was also successfully applied to enhance the extraction of several other basic drugs (ephedrine, 3,4-methylenedioxyamphetamine (MDA), atropine, methadone, cocaine, codeine, acetylcodeine and papaverine) with preconcentration factors from 157 to 2199, indicating the potential applicability of this method in the field of forensic, clinical and pharmaceutical analysis.

Evaluation of the identification power of RPLC analyses in the screening for drug compounds

The identification of drugs of abuse is an important issue in forensic science. The main goal is to trace and identify as many drugs as possible in the shortest possible time preferably with a simple analysis method. One possibility is to screen samples using a Liquid Chromatography-Diode Array Detection (LC-DAD) system. However, when simultaneously performing another analysis on a chromatographic column exhibiting selectivity differences from the first one, that is, orthogonal or dissimilar columns, a greater number of drugs can be possibly identified without investing a lot of extra time or money. The primary difficulty is then selecting the most appropriate columns. In this paper, it is demonstrated that selecting the most dissimilar columns based on measures such as correlation or Snyder's F(s) value is not optimal, because these measures do not take into account the identification power of the individual systems. This implies that a large number of drugs may not necessarily be identified on the systems selected using these criteria. Therefore, three other measures are tested to evaluate the identification power obtained by parallel screening on two columns or by comprehensive two-dimensional LC (LC x LC). The simplest approach is counting the number of compounds separable with a difference in retention time greater than a predefined critical value. However, this measure does not reflect the coelution pattern of the unidentified drugs nor the separation degree of all compounds. The second tested measure, information, enables differentiation between systems identifying the same number of compounds but resulting in a different coelution pattern. Multivariate selectivity, the third tested parameter, takes into account the degree of separation of all compounds and has the advantage that it reflects the gain in identification power achieved by introducing DAD data. All three proposed measures also enable evaluation of whether the corresponding LC x LC method will result in a greater identification power.

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Forensic toxicology

Forensic toxicology has developed as a forensic science in recent years and is now widely used to assist in death investigations, in civil and criminal matters involving drug use, in drugs of abuse testing in correctional settings and custodial medicine, in road and workplace safety, in matters involving environmental pollution, as well as in sports doping. Drugs most commonly targeted include amphetamines, benzodiazepines, cannabis, cocaine and the opiates, but can be any other illicit substance or almost any over-the-counter or prescribed drug, as well as poisons available to the community. The discipline requires high level skills in analytical techniques with a solid knowledge of pharmacology and pharmacokinetics. Modern techniques rely heavily on immunoassay screening analyses and mass spectrometry (MS) for confirmatory analyses using either high-performance liquid chromatography or gas chromatography as the separation technique. Tandem MS has become more and more popular compared to single-stage MS. It is essential that analytical systems are fully validated and fit for the purpose and the assay batches are monitored with quality controls. External proficiency programs monitor both the assay and the personnel performing the work. For a laboratory to perform optimally, it is vital that the circumstances and context of the case are known and the laboratory understands the limitations of the analytical systems used, including drug stability. Drugs and poisons can change concentration postmortem due to poor or unequal quality of blood and other specimens, anaerobic metabolism and redistribution. The latter provides the largest handicap in the interpretation of postmortem results.

Automated Mass Spectral Deconvolution and Identification System for GC-MS Screening for Drugs, Poisons, and Metabolites in Urine

Background: The challenge in systematic toxicological analysis using gas chromatography and/or liquid chromatography coupled to mass spectrometry is to identify compounds of interest from background noise. The large amount of spectral information collected in one full-scan MS run demands the use of automated evaluation of recorded data files. We evaluated the applicability of the freeware deconvolution software AMDIS (Automated Mass Spectral Deconvolution and Identification System) for GC-MS–based systematic toxicological analysis in urine for increasing the speed of evaluation and automating the daily routine workload.

Methods: We prepared a set of 111 urine samples for GC-MS analysis by acidic hydrolysis, liquid-liquid extraction, and acetylation. After analysis, the resulting data files were evaluated manually by an experienced toxicologist and automatically using AMDIS with deconvolution and identification settings previously optimized for this type of analysis. The results by manual and AMDIS evaluation were then compared.

Results: The deconvolution settings for the AMDIS evaluation were successfully optimized to obtain the highest possible number of components. Identification settings were evaluated and chosen for a compromise between most identified targets and general number of hits. With the use of these optimized settings, AMDIS-based data analysis was comparable or even superior to manual evaluation and reduced by half the overall analysis time.

Conclusions: AMDIS proved to be a reliable and powerful tool for daily routine and emergency toxicology. Nevertheless, AMDIS can identify only targets present in the user-defined target library and may therefore not indicate unknown compounds that might be relevant in clinical and forensic toxicology.

Two-step silylation procedure for the unified analysis of 190 doping control substances in human urine samples by GC–MS

Background: While a number of different derivatization procedures for screening GC–MS analysis of prohibited substances are followed by doping control laboratories, a unified derivatization procedure for the GC–MS analysis of 190 different doping agents was developed. Results: Following preliminary experiments, a two-step derivatization procedure was selected. The evaluation of various silylation parameters, such as reagent composition, reaction time, reaction temperature, catalysts and microwave oven reaction time, for this procedure was carried out. Conclusion: The suitability of the developed procedure was demonstrated through application on urine samples at concentration levels of the minimum required performance limit for all tested substances. This new derivatization procedure, which significantly decreases time and cost, is suitable for a routine basis application.

Fast quantitative determination of diuretic drugs in tablets and human urine by microchip electrophoresis with native fluorescence detection

Microchip electrophoresis (MCE) with native fluorescence detection has been applied for the fast quantitative analysis of pharmaceutical formulations. For this purpose, methods for fast separation and sensitive detection of the unlabeled diuretic drugs, amiloride, triamterene, bendroflumethiazide (BFMTZ), and bumetanide were developed. An epifluorescence setup was used enabling the coupling of different lasers into a commercial fluorescence microscope. The detection sensitivity of different excitation light sources was compared utilizing either a HeCd laser (lambda(exc) = 325 nm), a frequency quadrupled Nd:YAG laser (lambda(exc) = 266 nm), or a mercury lamp (lambda(exc) = 330-380 nm). At optimal conditions using the HeCd laser, the drugs were separated within 15 s with LODs less than 1 mug/mL for the four compounds. A linear relationship between concentration and peak area was obtained in the concentration range of 0.05-20 microg/mL with a mean correlation coefficient of around 0.996 for all analytes. The method was successfully applied to the analysis of the respective drugs in commercial formulations and in human urine without interference from other constituents. These data show that MCE has a great potential for reliable drug analysis.

Requirements for bioanalytical procedures in postmortem toxicology

The application of analytical techniques in postmortem toxicology is often more difficult than in other forms of forensic toxicology owing to the variable and often degraded nature of the specimens and the diverse range of specimens available for analysis. Consequently, analysts must ensure that all methods are fully validated for the particular postmortem specimen(s) used. Collection of specimens must be standardized to minimize site-to-site variability and should if available include a peripheral blood sample and at least one other specimen. Urine and vitreous humor are good specimens to complement blood. In some circumstances solid tissues such as liver are recommended as well as gastric contents. Substance-screening techniques are the most important element since they will determine the range of substances that were targeted in the investigation and provide initial indication of the possible role of substances in the death. While immunoassay techniques are still commonly used for the most common drugs-of-abuse, chromatographic screening methods are required for general unknown testing. These are still predominately gas chromatography (GC) based using nitrogen/phosphorous detection and/or mass spectrometry (MS) detection, although some laboratories are now using time-of-flight MS or liquid chromatography (LC)-MS(MS) to cover a sometimes more limited range of substances. It is recommended that laboratories include a second chromatographic method to provide coverage of acidic and other substances not readily covered by a GC-based screen when extracts do not include all physiochemical types. This may include a gradient high-performance liquid chromatography (HPLC) photodiode array method, or better LC-MS(MS). Substance-specific techniques (e.g., benzodiazepines, opiates) providing a second form of identification (confirmation) are now divided between GC-MS(MS) and LC-MS(MS) procedures. LC-MS(MS) has taken over from many methods for the more polar compounds previously used in HPLC or in GC methods requiring derivatization. Analysts using LC-MS will need to obtain clean extracts to avoid poor and variable sensitivity caused by background suppression of the signal. Isolation techniques in postmortem toxicology tend to favor liquid extraction; however solid-phase extraction and solid-phase microextraction methods are available for many analytes.

Comparison of Urinary On-Site Immunoassay Screening and Gas Chromatography-Mass Spectrometry Results of 111 Patients With Suspected Poisoning Presenting at an Emergency Department

On-site tests based on immunoassay techniques are widely used for toxicologic screening analysis in patients with suspected poisoning. However, such assays usually have been validated using urine samples with known concentrations of the investigated substances. In the present investigation, on-site screening results were evaluated in a clinical setting. This was a retrospective study of patients with suspected poisoning from January to December 2003 in the emergency department of a tertiary urban hospital. Urine samples were analyzed using the Triage 8 panel and gas chromatography-mass spectrometry (GC-MS). A total of 111 patients were included (54 female, 57 male; average age 37.8 +/- 19.7 years). A total of 3.8% of the patients showed no symptoms, 45.2% minor, 24.0% moderate, and 26.9% serious symptoms. In 50 patients (45.0%), Triage 8 results corresponded well with GC-MS results. In 17 patients (15.3%), the Triage 8 results were confirmed by GC-MS, but additional substances were determined that could not be detected by the Triage 8 panel. A completely negative Triage 8 screening result was obtained in 23 patients (20.7%) who showed toxicologically relevant findings in GC-MS. In 21 patients (18.9%), Triage 8 results could not be confirmed by GC-MS. The analysis of the results in view of the patients' medical histories revealed that in 20 patients (18.0%), no relevant toxic substance could be detected. Additionally, 8 patients (7.2%) showed intoxication with alcohol, which could not be detected by the presently applied toxicologic screening investigations. On-site screening results in suspected poisoning were not very helpful in the present study because practically every second patient ingested substances that were not detectable by the Triage 8 device. In addition, every fifth result was not in line with GC-MS findings. On-site test findings should be interpreted very carefully, and in critical cases, a GC-MS screening should be performed.

Capillary electrophoresis and the clinical laboratory

Over the past 15 years, CE as an analytical tool has shown great promise in replacing many conventional clinical laboratory methods, such as electrophoresis and HPLC. CE's appeal was that it was fast, used very small amounts of sample and reagents, was extremely versatile, and was able to separate large and small analytes, whether neutral or charged. Because of this versatility, numerous methods have been developed for analytes that are of clinical interest. Other than molecular diagnostic and forensic laboratories CE has not been able to make a major impact in the United States. In contrast, in Europe and Japan an increasing number of clinical laboratories are using CE. Now that automated multicapillary instruments are commercially available along with cost-effective test kits, CE may yet be accepted as an instrument that will be routinely used in the clinical laboratories. This review will focus on areas where CE has the potential to have the greatest impact on the clinical laboratory. These include analyses of proteins found in serum and urine, hemoglobin (A1c and variants), carbohydrate-deficient transferrin, forensic and therapeutic drug screening, and molecular diagnostics.

Post-mortem toxicology

Studies examining post-mortem processes are difficult to conduct since changes will have already occurred when the body arrives at the mortuary. While control of collection site for blood can minimize changes in concentration it is very difficult to conduct experiments in humans aimed at understanding the mechanisms and determining the extent of such changes. The use of appropriate animal models can be useful in this regard providing the species and conditions are carefully chosen. Pharmacokinetic studies in humans are also very useful for understanding the changes in drug concentration with time in blood (and other fluids) and also for improving our understanding of drug effects. Unfortunately, doses of illicit drugs that can be given are relatively low to guarantee safety hence extrapolations are made to real life situations. Individual case studies can be useful to describe an unusual or particularly interesting circumstances but little useful information can be obtained when trying to ascertain the role of competing factors, e.g. role of individual drugs when multiple drugs are present, varying toxicity between route of administration, and the role of age or natural disease when drugs are also present. Epidemiological approaches by reviewing large numbers of related cases are the most powerful tool to obtain this information. All of these studies need to operate under the ethical and legal framework appropriate for a jurisdiction. This paper discusses the relative merits of scientific approaches to research in post-mortem toxicology and provides guidance on the most appropriate techniques for future studies.

Indirect laser-induced fluorescence detection of diuretics separated by capillary electrophoresis

Indirect LIF detection was applied to the detection of four acidic diuretics separated by CZE. Semiconductor laser was employed to provide the stable excitation of 473 nm. With an optimized electrophoretic buffer system which contained 5 mM of triethylamine, 0.1 microM of fluorescein, and 5% of n-butanol, fast separation of four diuretics (ethacrynic acid, chlorthalidone, bendroflumethiazide, and bumetanide) can be performed within 3 min with the detection limits of 0.2-2 microg/mL. The impacts of buffer components including the concentrations of the electrolytes, fluorescence probe, and the organic additives were demonstrated. The method was applied for the detection of diuretics in urine. As an alternative way for the fast analysis of diuretics, this indirect detection method provided the technical support for future microchip performances, in which diuretics may be detected in the microchip by the common LIF detector without derivatization.

Information-Dependent Acquisition-Mediated LC−MS/MS Screening Procedure with Semiquantitative Potential

The development of a LC-MS/MS general unknown screening procedure for toxicologically relevant substances in blood samples by means of information-dependent acquisition on a Q-TOF is reported. IDA is an artificial intelligence-based product ion scan mode providing automatic "on-the-fly" MS to MS/MS switching. By performing information-dependent scanning at two different fragmentation energies, two collision-induced dissociation product ion spectra for each of the detected compounds are generated. As such, information-rich MS/MS spectra are obtained from precursor ions not known beforehand. In addition, limitation of the MS/MS acquisition time to an acceptable minimum resulted in an almost instantaneous switch back to the MS mode. As such, this approach provided MS chromatograms that still could be of use for semiquantitative purposes. Since the switching intensity threshold, unequivocally related to the background noise, proved a critical parameter, the solid-phase extraction procedure, the liquid chromatographic conditions, and the mass spectrometric parameters all were optimized to the advantage of information-dependent acquisition. Finally, the screening procedure we developed was benchmarked, on one hand, qualitatively against the results obtained from traditional GUS approaches in a number of routine toxicological laboratories (20 samples) and, on the other hand, quantitatively with respect to its potential against established LC-MS/MS methods (7 samples). The procedure performed very well from a qualitative point of view; almost all of the drugs detected by the conventional techniques were identified, as well as additional drugs that were not previously reported. The procedure proved well-suited for an initial semiquantitative assessment, as is customary in, for example, forensic toxicology before accurate intoxication levels are determined using targeted analytical analyses.

Preanalytic aspects in postmortem toxicology

The preanalytic phase has been recognized to have a substantial role for the quality and reliability of analytical results, which very much depend on the type and quality of specimens provided. There are several unique challenges to select and collect specimens for postmortem toxicology investigation. Postmortem specimens may be numerous, and sample quality may be quite variable. An overview is given on specimens routinely collected as well as on alternative specimens that may provide additional information on the route of administration, a long term or a recent use/exposure to a drug or poison. Autolytic and putrefactive changes limit the selection and utility of specimens. Some data from case reports as well as experimental investigations on drug degradation and/or formation during putrefaction are discussed. Diffusion processes as well as postmortem degradation or formation may influence ethanol concentration in autopsy specimens. Formalin fixation of specimens or embalmment of the corpse may cause considerable changes of initial drug levels. These changes are due to alterations of the biological matrix as well as to dilution of a sample, release or degradation of the drug or poison. Most important seems a conversion of desmethyl metabolites to the parent drug. Some general requirements for postmortem sampling are given based on references about specimen collection issues, for a harmonized protocol for sampling in suspected poisonings or drug-related deaths does not exist. The advantages and disadvantages of specimen preservation are shortly discussed. Storage stability is another important issue to be considered. Instability can either derive from physical, chemical or metabolic processes. The knowledge on degradation mechanisms may enable the forensic toxicologist to target the right substance, which may be a major break down product in the investigation of highly labile compounds. Although it is impossible to eliminate all interfering factors or influences occurring during the preanalytic phase, their consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample.

A rapid screening procedure for drugs and poisons in gastric contents by direct injection-HPLC analysis

A high performance liquid chromatographic method for toxicological drug screening of gastric content has been developed. The samples were diluted (1:3-1:30) in 0.01 N hydrochloric acid and injected into a reverse phase column for separation by gradient elution. Mobile phase consisted of solvent A (acetonitrile/water 90:10, 0.01 M sodium dodecylsulphate, 0.5% v/v glacial acetic acid) and solvent B (water/acetonitrile 90:10, 0.01 M sodium dodecylsulphate, 0.5% v/v glacial acetic acid); the gradient was programmed from 20 to 80% A in 30 min. The flow was kept constant at 1.5 ml/min. Two home-made internal standards, butyrylsalicylic acid and diacetyltubocurarine with retention times of 5.6 and 21.4 min, respectively, were used. Drugs are identified by matching their relative retention times and UV spectra (200-400 nm) with those contained in a home made library of more than 340 reference compounds (9 analgesics, 22 antidepressants, 30 antihistamines, 14 antihypertensives, 21 antirheumatics, 15 beta-blockers, 9 bronchodilators, 10 Ca antagonists, 14 diuretics, 26 neuroleptics, 25 tranquilizers, and other significant xenobiotic compounds). The fluorometric (FLD) emission spectrum (280-700 nm; excitation wavelength, 230 nm) was used as a further identification. At 50mg/l analyte concentrations, the injection of gastric content after dilution (1:3) produced S/N ratios in the range 8-140. The method is simple, rapid, rather inexpensive and proved to be a useful means of investigation if used in combination with GC-MS screening in blood. On the other hand, the system suffers from a relatively limited sensitivity for compounds with a low UV absorption and from interferences due to the presence in the matrix of some highly UV- and FL-responsive compounds (e.g. tryptophan).

Developing an Analytical Toxicology Service

Many acutely poisoned patients are treated with no laboratory help other than general clinical chemistry and haematology. Emergency toxicological analyses (24-hour availability) that could influence immediate patient management such as iron, lithium and paracetamol (acetaminophen), are relatively few in number and are remarkably similar worldwide. These assays should be provided at hospitals with large accident and emergency departments. More complex, less frequently needed clinical toxicological assays that can often be offered on a less urgent basis are usually provided from regional or national centres because of the need to make best use of resources. Recommendations as to the assays that should be provided locally and at regional centres are available for the UK and US, and are generally applicable. Regional centres normally diversify into specialised therapeutic drug monitoring, urine screening for drugs of abuse, metals analysis and sometimes forensic work in order to widen the repertoire of tests available and to increase funding. Whatever the type and quantity of work undertaken and the instrumentation used, guidelines are now available delineating staff training, method validation, assay operation, quality control/quality assurance, and indeed virtually all other aspects of laboratory operation. These considerations notwithstanding, clinical interpretation of analytical results remains a difficult area and is the responsibility of the reporting laboratory, at least in the first instance.

New designer drug 1-(3-trifluoromethylphenyl) piperazine (TFMPP): gas chromatography/mass spectrometry and liquid chromatography/mass spectrometry studies on its phase I and II metabolism and on its toxicological detection in rat urine

Studies are described on the phase I and II metabolism and the toxicological analysis of the piperazine-derived designer drug 1-(3-trifluoromethylphenyl)piperazine (TFMPP) in rat urine using gas chromatography/mass spectrometry (GC/MS) and liquid chromatography/mass spectrometry (LC/MS). The identified metabolites indicated that TFMPP was extensively metabolized, mainly by hydroxylation of the aromatic ring and by degradation of the piperazine moiety to N-(3-trifluoromethylphenyl)ethylenediamine, N-(hydroxy-3-trifluoromethylphenyl)ethylenediamine, 3-trifluoromethylaniline, and hydroxy-3-trifluoromethylaniline. Phase II reactions included glucuronidation, sulfatation and acetylation of phase I metabolites. The authors' systematic toxicological analysis (STA) procedure using full-scan GC/MS after acid hydrolysis, liquid-liquid extraction and microwave-assisted acetylation allowed the detection of TFMPP and its above-mentioned metabolites in rat urine after single administration of a dose calculated from the doses commonly taken by drug users. Assuming similar metabolism, the described STA procedure should be suitable for proof of an intake of TFMPP in human urine.

Effect of the location of hydrogen abstraction on the fragmentation of diuretics in negative electrospray ionization mass spectrometry

The diuretic agents bumetanide, xipamide, indapamide, and related compounds were investigated in order to determine the effect of different ionization sites on their collisionally activated dissociation and the corresponding fragmentation pathways. Therefore, analytes were selectively alkylated, and structural analogues as well as deuterium labeled compounds synthesized, which contain a reduced number of ionizable hydrogen atoms. Thus, specific hydrogen abstractions and their correlated dissociation routes of the negatively charged molecules were eliminated, providing evidence for the influence of the location of ionization on product ion spectra. Fragment ions such as m/z 78 indicate ionization at the commonly present sulfamoyl residue of diuretics but does not exclude additional ionization sites. Product ion spectra of the investigated diuretic agents proved to be composed by fragmentations initiated from different hydrogen abstractions. Moreover, the generation of radical anions by collision-activated dissociation of even-electron precursor ions was observed, the generation of which is discussed by proposed fragmentation pathways.

Capillary electrophoresis and its application in the clinical laboratory

Over the past 10 years, capillary electrophoresis (CE) is an analytical tool that has shown great promise in replacing many conventional clinical laboratory methods, especially electrophoresis and high performance liquid chromatography (HPLC). The main attraction of CE was that it was fast, used small amounts of sample and reagents, and was extremely versatile, being able to separate large and small analytes, both neutral and charged. Because of this versatility, numerous methods for clinically relevant analytes have been developed. However, with the exception of the molecular diagnostic and forensic laboratories CE has not had a major impact. A possible reason is that CE is still perceived as requiring above-average technical expertise, precluding its use in a laboratory workforce that is less technically adept. With the introduction of multicapillary instruments that are more automated, less technique-dependent, in addition to the availability of commercial and cost effective test kit methods, CE may yet be accepted as a instrument routinely used in the clinical laboratories. Thus, this review will focus on the areas where CE shows the most potential to have the greatest impact on the clinical laboratory. These include analysis of proteins found in serum, urine, CSF and body fluids, immunosubstraction electrophoresis, hemoglobin variants, lipoproteins, carbohydrate-deficient transferrin (CDT), forensic and therapeutic drug screening, and molecular diagnostics.

Mass spectrometric behavior of thiazide-based diuretics after electrospray ionization and collision-induced dissociation

The mass spectrometric behavior of 21 thiazide-based compounds after electrospray ionization in the negative ion mode and collision-induced dissociation was investigated on a triple-stage quadrupole mass spectrometer. The mass spectra show individual and common fragmentation patterns, the generations of which are discussed based on comparable molecular structures of commercially available substances and the synthesis of unlabeled, deuterated, and 15N-labeled analogues. The synthesis of deuterated thiazides is perfomed by condensation of 4-amino-6-chloro-1,3-benzenedisulfonamide with appropriately labeled aldehydes, while the introduction of 15N into the sulfonamide groups of thiazides was achieved by the synthesis of 4-amino-6-chloro-1,3-benzenedisulfonamide(15N2) from 3-chloroaniline via 4-amino-6-chloro-1,3-benzenedisulfonyl chloride. The most common fragments determined are m/z 269, 205, and 126 for 6-chloro-7-sulfamoyl-3-alkyl-3,4-dihydro-1,2,4-benzothiadiazine-1,1-dioxides and m/z 303, 239, and 160 for 6-trifluoromethyl-7-sulfamoyl-3-alkyl-3,4-dihydro-1,2,4-benzothiadiazine-1,1-dioxides. Individual fragmentation behaviors were found that mainly depended on the C-3-linked side chain.

Studies on the metabolism and toxicological detection of the new designer drug N-benzylpiperazine in urine using gas chromatography-mass spectrometry

Studies are described on the metabolism and on the toxicological analysis of the piperazine-like designer drug N-benzylpiperazine (BZP, scene name "A2") in rat and human urine using gas chromatography-mass spectrometry (GC-MS). The identified metabolites indicated that BZP was hydroxylated at the aromatic ring and that the piperazine moiety is metabolically degraded. Our systematic toxicological analysis (STA) procedure using full-scan GC-MS after acid hydrolysis, liquid-liquid extraction and microwave-assisted acetylation allowed the detection of the parent compound as well as of the above mentioned metabolites in rat urine after single administration of a dose calculated from the doses commonly taken by drug users. It has also proved to be applicable in authentic clinical or forensic cases. However, it should be considered that BZP is also a metabolite of the medicament piberaline.