Automated determination of carboxyhemoglobin contents in autopsy materials using head-space gas chromatography/mass spectrometry

Comparative Evaluation of Carboxyhemoglobin Quantification in Postmortem Whole Blood by CO-Oximetry and Headspace Gas Chromatography with Flame Ionization Detection and Atom Absorption Spectrophotometry

A comparative evaluation of two methods used for carboxyhemoglobin (COHb) determination in postmortem whole blood was performed: carbon monoxide (CO)-oximetry measuring at 128 wavelengths and headspace gas chromatography with flame ionization detection (HS-GC--FID) where CO was determined after catalytic reduction of CO to CH4 and Fe was determined by atom absorption spectrophotometry (AAS, 248.3 nm). An aliquot of 100 µL whole blood was loaded into the CO-oximetry module. In the HS-GC--FID analysis, to 1.0 mL of whole blood, 3.0 mL of saponin solution was added, mixed and centrifuged. To 20 mL HS vials, 400 µL of the supernatant was added and the vials were immediately sealed. One milliliter of potassium hexacyanoferrat (III) solution was added through the HS septum and mixed. The samples were incubated at 70°C for 5 min. CO was separated using He as carrier gas and a CP-Molsieve 5 Å PLOT capillary column. Fe was determined using 400 µL of the saponin supernatant diluted to 10 mL by water. During a period of ∼3 years, 124 postmortem whole blood samples were analyzed. Bland-Altman method comparison showed satisfactory agreement and no significant bias between the methods for the whole saturation range (5 to 85% COHb). Five samples, all with %COHb >40, showed deviations of more than 10% COHb in absolute terms. One sample, in the lower COHb range <10%, was false negative on the CO-oximetry method. The between-assay accuracy, reported as bias, at 60% COHb was -0.8% and -9.0%, and precision, reported as relative standard deviation, was 1.6% and 7.7%, for the CO-oximetry and HS-GC--FID-AAS methods, respectively. Both methods obtained satisfactory results in proficiency testing rounds, with z-scores <±2 (n = 11). This study showed that the CO-oximetry method based on the 128-wavelength principle and the HS-GC--FID-AAS method are comparable and satisfactory for %COHb determination in postmortem whole blood.

New strategy for carbon monoxide poisoning diagnosis: Carboxyhemoglobin (COHb) vs Total Blood Carbon Monoxide (TBCO)

Diagnosis of carbon monoxide (CO) poisonings has always been a challenging task due to the susceptibility to alterations of the optical state and degradation of blood samples during sampling, transport and storage, which highly affects the analysis with spectrophotometric methods. Methodological improvements are then required urgently because of increased reports of cases with discrepancies between results of the measured biomarker carboxyhemoglobin (COHb) and reported symptoms. Total blood CO (TBCO) measured chromatographically was thus proposed in a previous study as alternative biomarker to COHb. This approach was investigated in this study by comparing the two biomarkers and assessing the effects of various storage parameters (temperature, preservative, time, tube headspace (HS) volume, initial saturation level, freeze- and thaw- and reopening-cycles) over a period of one month. Results show that while for TBCO, concentrations are relatively stable over the observation period regardless of parameters such as temperature, time and HS volume, for COHb, concentrations are altered significantly during storage. Therefore, the use of TBCO as alternative biomarker for CO poisonings has been proposed, since it provides more valid results and is more stable even under non-optimal storage conditions. Additionally, it can be used to predict COHb in cases where sample degradation hinders optical measurement. Furthermore, a correction formula for COHb and TBCO is provided to be used in laboratories or circumstances where optimal storage or analysis is not possible, to obtain more accurate results.

Evaluation of screening for drug use using postmortem prolactin levels in serum and cerebrospinal fluid

Prolactin (PRL) levels can usually be controlled by PRL-inhibiting psychiatric drugs that include anti-dopamine agents. However, the use of dopamine (DA) antagonists may lead to hyperprolactinemia under certain clinical conditions. The aim of this study was to investigate postmortem PRL levels as potential markers of drug abuse, especially that of DA antagonists, in autopsy cases. We examined 121 autopsy cases, excluding cases involving acute hypoxia/ischemia, such as asphyxia, because PRL concentrations are reportedly increased under acute hypoxic conditions. Detected drugs were classified as either DA antagonists, stimulants, psychotropic drugs other than DA antagonists, or other non-psychotropic drugs, and many cases had no detected drugs. Samples comprised blood collected from the right heart chamber and cerebrospinal fluid (CSF). PRL protein level was measured by chemiluminescent immunoassay, and PRL gene expression in the anterior pituitary of autopsy cases was analyzed by reverse transcription-polymerase chain reaction. The PRL-positive cell ratio in the anterior pituitary gland was also measured by immunohistochemical analysis. The results indicated that PRL levels in the serum and CSF were higher in DA antagonist cases than in other cases. PRL levels in the serum and CSF also correlated with the PRL gene expression in cases with abuse of DA antagonists. However, no significant difference in the PRL-positive cell ratio in the anterior pituitary gland was evident between any of the classes of drug-detected and drug-undetected cases. These results suggest that postmortem measurements of PRL transcription levels may be useful for diagnosing cases of DA antagonist use.

Carbon monoxide analysis method in human blood by Airtight Gas Syringe - Gas Chromatography - Mass Spectrometry (AGS-GC-MS): Relevance for postmortem poisoning diagnosis

Carbon monoxide is one of the most abundant toxic air pollutants. Symptoms of a CO intoxication are non-specific, leading to a high number of misdiagnosed CO poisoning cases that are missing in the disease statistics. The chemical nature of the molecule makes it difficult to detect for long periods and at low levels, thus requiring a very accurate and sensitive method. Current methods capable of accurate and sensitive analyses are available, however an inconsistency between results and symptoms are frequently reported. Therefore, an improved method for the analysis of carbon monoxide in blood and in the headspace (HS) of the sampling tube with the use of Airtight Gas Syringe - Gas Chromatography - Mass Spectrometry (AGS-GC-MS) is hereby presented and validated, for CO concentrations in a range of 10-200 nmol/mL HS (2-40 μmol/mL blood). Analytical LOQ is found at 0.9 nmol/mL HS (0.18 μmol/mL blood) and LOD at 0.1 nmol/mL gas. Application to intoxicated samples from autopsies and comparison to previously published methods show that this method is more appropriate, since performed under fully controlled conditions. Results show higher CO concentrations compared to previous approaches, indicating that results might have been underestimating the true blood CO burden. Therefore, this approach has the potential to help reduce the misdiagnosed cases and the gap between measurement and diagnosis of CO poisonings.

Astrocytic clasmatodendrosis in the cerebral cortex of methamphetamine abusers

Postmortem investigation of methamphetamine (MA) abuse is an important task in forensic pathology. The present study investigated morphological changes in the astrocytes in the parietal cerebral cortex of MA abusers. Glial fibrillary acidic protein immunoreactivity in the cerebral cortex was examined in forensic autopsy cases for MA-detected group and control group. Clasmatodendrotic astrocytes (including those with swollen cell bodies and disintegrating distal processes) were frequently observed in the cerebral cortex of MA abusers. Quantitative analysis using a colour image processor showed a concomitant increase in the astrocyte area and astrocyte-to-vessel area ratio (size and number of astrocytes) in the grey matter in acute MA fatality and other MA-involved cases, although the astrocyte area (size) was also increased in cases of asphyxiation. The total astrocyte area (size) in the white matter was significantly higher in MA fatalities and asphyxia than in the other groups involving MA abusers. Those indices were independent of blood MA level, age, sex, survival or postmortem time. These observations suggest the increasing number and hypertrophic changes of astrocytes in the grey matter in MA abusers can be the outcome of long-term abuse, while disintegrating distal processes may exist only in acute fatal MA intoxication.

Comprehensive investigation of postmortem glucose levels in blood and body fluids with regard to the cause of death in forensic autopsy cases

The serum glucose level is regulated within a narrow range by multiple factors under physiological conditions, but is greatly modified in the death process and after death. The present study comprehensively investigated glucose levels in blood and body fluids, including pericardial fluid (PCF), cerebrospinal fluid (CSF) and vitreous humor, reviewing forensic autopsy cases (n=672). Right heart blood glucose level was often higher than at other sites, and the CSF glucose level was the lowest, showing greater dissociation in acute/subacute death cases. The glucose level was higher in the diabetic (high HbA1c) than in the non-diabetic (low HbA1c) group at each site (p<0.01-0.0001). Fatal diabetic ketoacidosis cases had evidently high glucose levels at each site; whereas in the non-diabetic group, blood glucose level was higher in fatal alcohol abuse, saltwater drowning, electrocution, cerebrovascular disease and sudden cardiac death due to ischemic heart disease. Fatal methamphetamine (MA) abuse, sepsis, malnutrition (starvation) and hypoglycemia due to antidiabetics showed markedly lower blood glucose levels. Ketones in bilateral cardiac blood and PCF were increased in diabetic ketoacidosis and fatal alcohol abuse as well as in most cases of hyperthermia (heatstroke), hypothermia (cold exposure) and malnutrition. These findings suggest that combined analysis of glucose, HbA1c and ketones in blood and body fluids is useful to investigate not only fatal diabetic metabolic disorders but also death processes due to other causes, including alcohol and MA abuse, as well as thermal disorders, sepsis and malnutrition.

An accurate method for microanalysis of carbon monoxide in putrid postmortem blood by head-space gas chromatography-mass spectrometry (HS/GC/MS)

Carbon monoxide (CO) may be the cause of more than half the fatal poisonings reported in many countries, with some of these cases under-reported or misdiagnosed by medical professionals. Therefore, an accurate and reliable analytical method to measure blood carboxyhemoglobin level (COHb%), in the 1% to lethal range, is essential for correct diagnosis. Herein a method was established, i.e. head-space gas chromatography-mass spectrometry (HS/GC/MS) that has numerous advantages over other techniques, such as UV spectrometry, for determination of COHb%. There was a linear relationship (R(2)=0. 9995) between the peak area for CO and the COHb% in blood. Using a molecular sieve-packed column, CO levels in the air down to 0.01% and COHb% levels in small blood samples down to 0.2% could be quantitated rapidly and accurately. Furthermore, this method showed good reproducibility with a relative standard deviation for COHb% of <1%. Therefore, this technique provides an accurate and reliable method for determining CO and COHb% levels and may prove useful for investigation of deaths potentially related to CO exposure.

Accuracy profile validation of a new method for carbon monoxide measurement in the human blood using headspace-gas chromatography-mass spectrometry (HS-GC-MS)

The aim of our study was to provide an innovative headspace-gas chromatography-mass spectrometry (HS-GC-MS) method applicable for the routine determination of blood CO concentration in forensic toxicology laboratories. The main drawback of the GC/MS methods discussed in literature for CO measurement is the absence of a specific CO internal standard necessary for performing quantification. Even if stable isotope of CO is commercially available in the gaseous state, it is essential to develop a safer method to limit the manipulation of gaseous CO and to precisely control the injected amount of CO for spiking and calibration. To avoid the manipulation of a stable isotope-labeled gas, we have chosen to generate in a vial in situ, an internal labeled standard gas ((13)CO) formed by the reaction of labeled formic acid formic acid (H(13)COOH) with sulfuric acid. As sulfuric acid can also be employed to liberate the CO reagent from whole blood, the procedure allows for the liberation of CO simultaneously with the generation of (13)CO. This method allows for precise measurement of blood CO concentrations from a small amount of blood (10 μL). Finally, this method was applied to measure the CO concentration of intoxicated human blood samples from autopsies.

High throughput headspace GC-MS quantitative method to measure the amount of carbon monoxide in treated tuna fish

A robust and dependable headspace HS-GC-MS method has been developed for the determination of carbon monoxide (CO) treated tuna fish. The performance of the method has been evaluated by analyzing spiked and blank samples. The proposed method uses a programmed temperature vaporizing (PTV) injector to implement the HS injection and overcome the negative effects on the column of water contained in the sample. The level of CO could be easily detected in the treated samples, its amount differing markedly from that detected in the untreated samples. Proper oven temperature programming prevented any deterioration of chromatographic performance caused by the accumulation of water, carbon dioxide and other low molecular weight hydrocarbons in the column during serial analyses. The introduction of PTV injection and the restoring of GC column, by oven temperature programming, were crucial for obtaining the required robustness. This procedure assures the run-to-run repeatability necessary for high throughput applications. The method affords linear calibration curves ranging from 50 to 2500 ng/g of CO content in tuna sample.

Evaluation of the methods used for carboxyhemoglobin analysis in postmortem blood

Numerous methods have been described in the literature for the determination of carboxyhemoglobin (COHb) in whole blood. The most popular and widely used have been (1) the spectrophotometric methods, which could be performed either by using a conventional spectrophotometer or by using specialized automated instruments known as CO-oximeters; (2) the gas chromatographic methods, with variable detection systems, which have been considered as the reference methods for every carbon monoxide analysis. The authors have critically reviewed previously reported comparative studies on these methods, considering statistical and analytical matters, in order to propose the best method for the determination of COHb in postmortem blood, that could be utilized in forensic toxicology laboratories where such analyses are limited in number (less than 20 per year). Criteria for evaluation have been accuracy, reliability, simplicity, time, and cost. The authors' concluding statement has been that the manual spectrophotometric method could be the method of choice for COHb determination in postmortem blood samples. It is simple, rapid, and reliable and fulfills the forensically acceptable accuracy. It is performed by the use of a conventional spectrophotometer, which is considered a basic instrument in every analytical laboratory.

Analysis of carbon monoxide in commercially treated tuna (Thunnus spp.) and mahi-mahi (Coryphaena hippurus) by gas chromatography/mass spectrometry

A simple and confirmative method for quantitative determination of carbon monoxide in tuna and mahi-mahi tissues using GC/MS, following chemical liberation of CO into headspace, is described. Carbon monoxide in recent years has been employed by the fishery industry to preserve fresh appearance in selected species of finfish during frozen storage, particularly in vacuum-packaged products. Indigenous CO contents of fresh Ahi tuna and mahi-mahi were examined using the method described in this study and found to be close to or less than 150 and 100 ng/g, respectively. Commercially CO-treated, vacuum-packaged tuna from multiple sources consistently showed CO level near or greater than 1 mug/g, while CO level in the only CO-treated frozen mahi-mahi sample was in the 500 ng/g range. The difference between untreated and treated specimens was in the range of 1 order of magnitude and thus suggested an easy quantitative and confirmative method of CO using widely available instrumentation that may be potentially useful for regulatory purpose in determining whether a commercially available product has been exposed to CO even if not labeled as such.

Ubiquitin immunoreactivity in the midbrain as a marker of stress to motor nervous systems in fatal injury

Previous studies showed an increase in the ubiquitin (Ub)-immunoreactive structures in the midbrain in acute deaths from asphyxiation and in fires in adult subjects. The present study examined the Ub-immunoreactivity in the midbrain as a marker of stress to motor nervous systems in fatal injury cases (over 35 years of age, n=140: blunt injuries, n=82; sharp injuries, n=58), compared with that in control groups (n=61) including death by strangulation, acute cardiac and cerebrovascular diseases. The intranuclear Ub-immunopositive inclusion of the pigmented dopaminergic neurons of the substantia nigra (inclusion Ub-index) and the granular 'dot-like' Ub-immunoreactivity area ('dot-like' Ub-area) in the crus cerebri were analyzed. In blunt injuries, those markers were high in abdomen and back injuries and low in head and chest injuries. The inclusion Ub-index was higher in the crush/pressure injury group than in those with injuries due to impact traffic accidents and falls. 'Dot-like' Ub-area was also low in falls. In sharp injury cases, cardiac injury with hemopericardium showed a higher inclusion Ub-index. These findings suggested that the stress to the motor nervous system may be very intense in crush/pressure injury and hemopericardium than in impact injury and fatal hemorrhages, respectively, and in abdomen and back injuries than in head and chest injuries.

Quantitative analysis of ubiquitin-immunoreactivity in the midbrain periaqueductal gray matter with regard to the causes of death in forensic autopsy

The aim of the present study was to examine Ub-immunoreactivity in the midbrain periaqueductal gray matter (PGM), which is involved in pain processing and modulation, in forensic autopsy cases (n=273) in relation to the causes of death: acute deaths from blunt injuries (n=75), sharp weapon injuries (n=36), fatal asphyxiation (n=22), drownings (n=16: freshwater, n=9; saltwater, n=7), fire fatalities (n=64), poisoning (n=12), hyperthermia (n=5), hypothermia (n=5), delayed deaths from blunt head injury (n=8), acute cardiac deaths (n=24), and acute cerebrovascular strokes (n=6). The Ub-immunoreactivity was clearly observed in the nuclei of the PGM neurons, showing no postmortem interference or age-dependency. A higher value was observed in blunt injuries, fire fatalities and also in saltwater drowning, hyperthermia and delayed head injury deaths. These findings suggest a complicated mechanism for the ubiquitination of PGM neurons, to which multiple factors including the intensity and duration of pains possibly under alert consciousness, traumatic and metabolic neurodegeneration may contribute.

Ubiquitin-immunoreactive structures in the midbrain of methamphetamine abusers

Ubiquitin (Ub) is involved in neurodegeneration and various stress responses in the brain. The present study investigated the Ub-immunoreactive structures in the midbrain of methamphetamine (MA) abusers as a marker of drug-induced neurodegeneration. Medico-legal autopsy cases were examined: fatal MA intoxication (n=14), other fatalities of MA abusers (n=23) including those due to injuries, asphyxiation, drowning, fire and natural diseases, and control groups (n=260). In the motor nervous systems, MA abusers showed a mild increase in the diffuse-type nuclear Ub-positivity in the pigmented neurons of the substantia nigra, depending on the blood MA level and irrespectively of the immediate causes of death. The intranuclear inclusion-type Ub-positivity of the nigral neurons and the granular 'dot-like' Ub-immunoreactivity area in the crus cerebri (cortico-spinal tracts) were usually low in MA abusers, and any increases were related to the immediate causes of death and the age of subjects. Acute MA fatality showed a higher neuronal Ub-positivity in the midbrain periaqueductal gray matter (PGM), which is involved in processing pain, fear and anxiety, and regulation of respiration and circulation. These findings suggest dysfunction of the nigral dopaminergic neurons and PGM neurons in the midbrain in MA abuse, which may account for the clinical symptoms.

Quantitative morphometry of granular ‘dot-like’ ubiquitin-immunoreactivity in the crus cerebri in asphyxiation and fire fatalities

In the central nervous system (CNS), a variety of ubiquitinated structures have been reported, usually as pathological alterations of the brain related to degenerative diseases or aging. However, previous studies showed an increase in the ubiquitin (Ub)-immunoreactive intranuclear inclusion of the pigmented neurons of the substantia nigra in the midbrain in asphyxiation and fire fatalities in the adult subjects. The aim of the present study was to examine granular 'dot-like' Ub-immunoreactivity in the crus cerebri (cortico-spinal tracts) in related fatalities (over 35 years of age, n=169), including fatal asphyxiation (n=27), drownings (n=14), fire fatalities (n=60), and control groups (n=68). Dot-like Ub-immunoreactivity was clearly observed in the descending tract of the crus cerebri. Morphometric analysis of the positive granular area (dot-like Ub-area) showed a higher value in strangulation and fire fatalities and a lower value in hemorrhagic and head injury deaths, as was observed for the inclusion-type neuronal Ub-positivity. However, there was a difference between those markers: a low value was seen for the inclusion-type neuronal Ub-positivity in hanging and drownings, and a difference in the dot-like Ub-area was detected between fire fatalities with lower and higher COHb levels. Our findings suggested the possible usefulness of these markers for examination of CNS stress responses in traumas, at least in middle-aged and elderly victims and a partial difference in stress reaction between the cortico-spinal tracts and dopaminergic neurons.

Validity of CO-oximetric determination of carboxyhaemoglobin in putrefying blood and body cavity fluid

Most commercial CO-oximeters pose warning flags in their measured carboxyhaemoglobin (COHb) levels when total haemoglobin (tHb) concentrations in the samples are below a certain threshold, typically about 3-4gdl. The warning flags acknowledge the fact that the haemoglobin levels are outside the ranges these instruments are designed (or validated) for. By using a parallel GC method and special sample treatment methods prior to CO-oximetric measurements, this study demonstrates that CO-oximeters could actually produce valid COHb results for samples with tHb as low as 1g/dl, and that the warning flags have no bearing to the accuracy and precision of the measurements. This study also indicates that warning flags due to high methaemoglobin (MetHb) and sulphaemoglobin (SHb), and often turbidity did not affect the validity of the CO-oximetric measurements.

Sample pre-treatment for CO-oximetric determination of carboxyhaemoglobin in putrefied blood and cavity fluid

Blood or blood-containing cavity fluid samples recovered from decomposed bodies in suspected carbon monoxide (CO) poisoning cases often have low total haemoglobin (tHb) levels or contain significant amounts of oily droplets, methaemoglobin (MetHb) and sulphaemoglobin (SHb), all conditions which render the validity of the measurements of carboxyhaemoglobin (HbCO) by commercially available CO-oximeters doubtful. Two sample pre-treatment methods, namely, centrifugal evaporation and addition of a commercially available standard haemoglobin solution containing a known level of HbCO, were developed to render such putrefied samples amenable to analysis by CO-oximeters. The methods developed were validated with samples of various degrees of putrefaction and various HbCO levels. The relative uncertainty of the determined HbCO levels as compared to their corresponding reference levels for the centrifugal evaporation method was approximately 5% and that for the standard addition method was <20%.

Immunohistochemical investigation of pulmonary surfactant-associated protein A in fire victims

To evaluate the forensic pathological significance of the immunohistochemical distribution of pulmonary surfactant-associated protein A (SP-A) in determining the cause of death in fires, 57 fire victims were examined by scoring the staining intensity. The highest SP-A score with dense granular deposits (aggregates) in the intra-alveolar space was frequently observed in cases with a lower blood carboxyhemoglobin (COHb) level (<60%). The SP-A score was relatively low in carbon monoxide intoxication due to causes other than fires. High SP-A scores showed a relation to the serum level and in part related to the bloody exudate in the lower airway. These observations suggested that the increase in SP-A in fire victims may be mainly related to pulmonary alveolar injury due to the inhalation of hot air and/or irritant gases rather than hypoxia.