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Fairman K, Choi MK, Gonnabathula P, Lumen A, Worth A, Paini A, Li M. An Overview of Physiologically-Based Pharmacokinetic Models for Forensic Science. TOXICS 2023; 11:126. [PMID: 36851001 PMCID: PMC9964742 DOI: 10.3390/toxics11020126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/16/2022] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
A physiologically-based pharmacokinetic (PBPK) model represents the structural components of the body with physiologically relevant compartments connected via blood flow rates described by mathematical equations to determine drug disposition. PBPK models are used in the pharmaceutical sector for drug development, precision medicine, and the chemical industry to predict safe levels of exposure during the registration of chemical substances. However, one area of application where PBPK models have been scarcely used is forensic science. In this review, we give an overview of PBPK models successfully developed for several illicit drugs and environmental chemicals that could be applied for forensic interpretation, highlighting the gaps, uncertainties, and limitations.
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Affiliation(s)
- Kiara Fairman
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Me-Kyoung Choi
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Pavani Gonnabathula
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Annie Lumen
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
| | - Andrew Worth
- European Commission, Joint Research Centre (JRC), 21027 Ispra, Italy
| | | | - Miao Li
- Division of Biochemical Toxicology, National Center for Toxicological Research, United States Food and Drug Administration, Jefferson, AR 72079, USA
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2
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Hansen SL, Nielsen MKK, Linnet K, Rasmussen BS. Suitability of cardiac blood, brain tissue, and muscle tissue as alternative matrices for toxicological evaluation in postmortem cases. Drug Test Anal 2023; 15:529-538. [PMID: 36611280 DOI: 10.1002/dta.3439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Drug concentrations in peripheral blood are often used to evaluate whether death was caused by drug intoxication. In some cases, peripheral blood is not available, and analytical results of alternative matrices should instead be used in the toxicological evaluation. However, reference concentrations of alternative matrices are few, which makes interpretation of results a challenge. In this study, concentrations of selected benzodiazepines, opioids, illicit drugs, and other commonly used drugs in postmortem femoral blood, cardiac blood, brain tissue, and muscle tissue are presented. Alternative matrix-to-femoral blood drug concentration ratios and correlations of blood and alternative matrix drug concentrations were calculated to examine which of the investigated alternative matrices were most suited to use for toxicological evaluation in cases where peripheral blood is not available. The results showed that concentrations in cardiac blood, brain tissue, and muscle tissue could be useful in the postmortem evaluation of most of the 19 selected analytes. In most cases, analytes were detected in all the alternative matrices. The median concentration ratios for the selected analytes in brain tissue, cardiac blood, and muscle tissue relative to femoral blood ranged from 0.57 to 3.42, 0.59 to 1.87, and 0.67 to 7.04, respectively. Overall, cardiac blood provided the concentrations most comparable with femoral blood concentrations, indicating that cardiac blood can be useful in cases where femoral blood is not available. However, the measured concentrations should be interpreted with caution.
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Affiliation(s)
- Stine Lund Hansen
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Katrine Klose Nielsen
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristian Linnet
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brian Schou Rasmussen
- Section of Forensic Chemistry, Department of Forensic Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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Havig SM, Vindenes V, Øiestad ÅML, Rogde S, Thaulow CH. Methadone, Buprenorphine, Oxycodone, Fentanyl, and Tramadol in Multiple Postmortem Matrices. J Anal Toxicol 2021; 46:600-610. [PMID: 34115841 PMCID: PMC9282245 DOI: 10.1093/jat/bkab071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022] Open
Abstract
Peripheral blood (PB) concentrations are generally preferred for postmortem toxicological interpretation, but some autopsy cases may lack blood for sampling due to decomposition or large traumas, etc. In such cases, other tissues or bodily fluids must be sampled; however, limited information exists on postmortem concentrations in matrices other than blood. Pericardial fluid (PF), muscle and vitreous humor (VH) have been suggested as alternatives to blood, but only a few studies have investigated the detection of opioids in these matrices. In this study, we aimed to investigate the detection of methadone, buprenorphine, oxycodone, fentanyl and tramadol in postmortem samples of PF, skeletal muscle and VH, in addition to PB and cardiac blood and if drug concentrations in these alternative matrices were comparable to those in PB and thereby useful for interpretation. In most of the 54 included cases, only one opioid was detected. Methadone, oxycodone, fentanyl and tramadol were detected in all of the alternative matrices in almost all cases, while buprenorphine was detected less often. For methadone, the concentrations in the alternative matrices, except in VH, were relatively similar to those in PB. Larger variations in concentrations were found for buprenorphine, oxycodone and tramadol. Quantitative analyses appeared useful for fentanyl, in all of the alternative matrices, but only four cases were included. Toxicological analyses of opioids in these alternative postmortem matrices can be useful for detection, but quantitative results must be interpreted with caution.
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Affiliation(s)
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo
| | | | - Sidsel Rogde
- Department of Forensic Sciences, Oslo University Hospital
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Ferreira E, Corte Real F, Pinho e Melo T, Margalho C. A Novel Bioanalytical Method for the Determination of Opioids in Blood and Pericardial Fluid. J Anal Toxicol 2020; 44:754-768. [DOI: 10.1093/jat/bkaa064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 05/23/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022] Open
Abstract
Abstract
Opioids are the drugs most commonly detected in overdose deaths and the second most consumed worldwide. An analytical methodology has been optimized and fully validated for the determination of codeine, morphine, 6-acetylmorphine, 6-acetylcodeine, oxycodone, oxymorphone and fentanyl in whole blood and pericardial fluid. The internal standards used were codeine-d3, morphine-d3, 6-acetylmorphine-d3 and fentanyl-d5. Before solid-phase extraction, volumes of 250 μL of blood and pericardial fluid were subjected to a protein precipitation (with 750 μL of ice-cold acetonitrile) and a microwave-induced oximation was performed using a solution of 1% aqueous hydroxylamine hydrochloride in phosphate-buffered saline (1:2, v/v). Finally, the dried extracts were further derivatized with a solution of n-methyl-n-(trimethylsilyl) trifluoroacetamide + 5% trimethylchlorosilane under microwave irradiation. The chromatographic analysis was carried out using gas chromatography–mass spectrometry operating in electron impact and selected ion monitoring mode. For all analytes, the method was linear between 5 and 1,000 ng/mL with determination coefficients (r2) >0.99. Depending on the analyte and matrix, the limit of detection varies between 3 and 4 ng/mL. Intra- and intermediate precision (<20%) and bias (±20%) were acceptable for all analytes in both matrices. The stability of the substances in the studied matrices was guaranteed, at least, 24 h in the autosampler, 4 h at room temperature and 30 days after three freeze/thaw cycles. This methodology was applied to real samples from the Laboratory of Chemistry and Forensic Toxicology, Centre Branch, of the National Institute of Legal Medicine and Forensic Sciences, Portugal.
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Affiliation(s)
- Elisa Ferreira
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P. (INMLCF, I.P.), Laboratório de Toxicologia Forense da Delegação do Centro, Azinhaga de Santa Comba - Polo das Ciências da Saúde, 3000-548 Coimbra, Portugal
- Departamento de Química da Faculdade de Ciências e Tecnologia da Universidade de Coimbra, R. Larga 2, 3004-535 Coimbra, Portugal
| | - Francisco Corte Real
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P. (INMLCF, I.P.), Laboratório de Toxicologia Forense da Delegação do Centro, Azinhaga de Santa Comba - Polo das Ciências da Saúde, 3000-548 Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Azinhaga de Santa Comba - Polo das Ciências da Saúde, 3000-548 Coimbra, Portugal
| | - Teresa Pinho e Melo
- Departamento de Química da Faculdade de Ciências e Tecnologia da Universidade de Coimbra, R. Larga 2, 3004-535 Coimbra, Portugal
| | - Cláudia Margalho
- Instituto Nacional de Medicina Legal e Ciências Forenses, I.P. (INMLCF, I.P.), Laboratório de Toxicologia Forense da Delegação do Centro, Azinhaga de Santa Comba - Polo das Ciências da Saúde, 3000-548 Coimbra, Portugal
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5
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Ketola RA, Kriikku P. Drug concentrations in post‐mortem specimens. Drug Test Anal 2019; 11:1338-1357. [DOI: 10.1002/dta.2662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Raimo A. Ketola
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
| | - Pirkko Kriikku
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
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6
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Ferner RE, Aronson JK. The toxicological significance of post-mortem drug concentrations in bile. Clin Toxicol (Phila) 2017; 56:7-14. [PMID: 28681613 DOI: 10.1080/15563650.2017.1339886] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Robin E. Ferner
- Institute of Clinical Science, University of Birmingham, and West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK
| | - Jeffrey K. Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe infirmary, Oxford, UK
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Bévalot F, Cartiser N, Bottinelli C, Fanton L, Guitton J. État de l’art de l’analyse de la bile en toxicologie médicolégale. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2016.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Sun D, Wen H, Externbrink A, Gao Z, Keire D, Krauss G, Jiang W. Ghost-Pill-Buster: A Case Study of Intact Levetiracetam Extended-Release Tablets after Dissolution Testing. CNS Drugs 2016; 30:455-60. [PMID: 27048352 DOI: 10.1007/s40263-016-0332-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Orally administered medications in extended-release (ER) dosage forms continue to play a pivotal role in the treatment of various central nervous system disorders. For certain ER dosage forms, pharmaceutical scientists have been familiar with the passage of intact tablet-like objects in patients' feces after administration of ER tablets or capsules based on water-insoluble or slowly dissolving excipients. Nevertheless, because of lack of awareness of the "ghost pill" phenomenon, anxiety has ensued among some patients and clinicians, who have less understanding of how drugs are released from these tablets once ingested. It has been brought to the attention of the US Food and Drug Administration (FDA) that epilepsy patients administered with Teva's levetiracetam ER tablets have noticed intact tablets in their stools and been concerned that they were not getting the needed dose of the drug. In response to neurologists' clinical reporting, the FDA has conducted investigations to confirm a minimal risk of incomplete drug release of Teva's drug product. OBJECTIVE The objective of this study was to evaluate the risks of incomplete drug release associated with the passing of intact levetiracetam ER tablets, by conducting in vitro dissolution testing. METHODS Dissolution testing of Teva's drug product was performed in accordance with the US Pharmacopeia monograph for levetiracetam ER tablets in phosphate buffer and bio-relevant buffers at different pH values. In addition, dissolution testing was conducted with split and crushed tablets. At the end of the dissolution testing, all samples were visually inspected for any undissolved pieces. RESULTS Approximately 90 % of levetiracetam had been released in all dissolution media after 8 h of dissolution. The levetiracetam ER tablets after dissolution testing remained fully intact in all dissolution media. The rates of drug release were significantly faster from split and crushed tablets than that from whole tablets. CONCLUSION On the basis of these findings, Teva's levetiracetam ER tablets may appear intact in the stools but have released the drug successfully. The FDA has requested Teva to revise its product labeling to include remarks regarding the potential passing of intact tablets. Since patients who notice ghost pills in their stools may impetuously crush or split the tablets of subsequent doses on their own, healthcare providers should instruct patients to swallow whole tablets throughout the treatment, in accordance with the drug label.
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Affiliation(s)
- Dajun Sun
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Generic Drugs, Office of Research and Standards, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Hong Wen
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Generic Drugs, Office of Research and Standards, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Anna Externbrink
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Pharmaceutical Quality, Office of Testing and Research, Silver Spring, MD, USA
| | - Zongming Gao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Pharmaceutical Quality, Office of Testing and Research, Silver Spring, MD, USA
| | - David Keire
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Pharmaceutical Quality, Office of Testing and Research, Silver Spring, MD, USA
| | - Gregory Krauss
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Wenlei Jiang
- US Food and Drug Administration, Center for Drug Evaluation and Research, Office of Generic Drugs, Office of Research and Standards, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA.
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9
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Bévalot F, Cartiser N, Bottinelli C, Guitton J, Fanton L. State of the art in bile analysis in forensic toxicology. Forensic Sci Int 2016; 259:133-54. [DOI: 10.1016/j.forsciint.2015.10.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/17/2015] [Accepted: 10/26/2015] [Indexed: 02/07/2023]
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10
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Bévalot F, Cartiser N, Bottinelli C, Fanton L, Guitton J. Vitreous humor analysis for the detection of xenobiotics in forensic toxicology: a review. Forensic Toxicol 2015; 34:12-40. [PMID: 26793276 PMCID: PMC4705140 DOI: 10.1007/s11419-015-0294-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/21/2015] [Indexed: 01/10/2023]
Abstract
Vitreous humor (VH) is a gelatinous substance contained in the posterior chamber of the eye, playing a mechanical role in the eyeball. It has been the subject of numerous studies in various forensic applications, primarily for the assessment of postmortem interval and for postmortem chemical analysis. Since most of the xenobiotics present in the bloodstream are detected in VH after crossing the selective blood-retinal barrier, VH is an alternative matrix useful for forensic toxicology. VH analysis offers particular advantages over other biological matrices: it is less prone to postmortem redistribution, is easy to collect, has relatively few interfering compounds for the analytical process, and shows sample stability over time after death. The present study is an overview of VH physiology, drug transport and elimination. Collection, storage, analytical techniques and interpretation of results from qualitative and quantitative points of view are dealt with. The distribution of xenobiotics in VH samples is thus discussed and illustrated by a table reporting the concentrations of 106 drugs from more than 300 case reports. For this purpose, a survey was conducted of publications found in the MEDLINE database from 1969 through April 30, 2015.
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Affiliation(s)
- Fabien Bévalot
- Laboratoire LAT LUMTOX, 71 Avenue Rockefeller, 69003 Lyon, France.,Institut de Médecine Légale, Université de Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France
| | - Nathalie Cartiser
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France
| | | | - Laurent Fanton
- Département de Médecine Légale, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Place D'Arsonval, 69437 Lyon Cedex 03, France.,CREATIS CNRS UMR 5220, INSERM U1044, Université de Lyon, Université Claude Bernard Lyon 1, INSA Lyon, 7 Avenue Jean Capelle, 69621 Villeurbanne Cedex, France
| | - Jérôme Guitton
- Laboratoire de Toxicologie, ISPB-Faculté de Pharmacie, Université de Lyon, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69373 Lyon Cedex 08, France.,Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, 165 Chemin Grand Revoyet, 69495 Pierre Bénite Cedex, France
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11
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Pages D, Delage M, Descoeur J, Mathieu O. Distribution post-mortem de l’oxycodone et de l’oxymorphone libres et conjuguées dans un cas d’intoxication létale chez un adulte. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2015. [DOI: 10.1016/j.toxac.2015.03.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Tylutki Z, Polak S. Plasma vs heart tissue concentration in humans - literature data analysis of drugs distribution. Biopharm Drug Dispos 2015; 36:337-351. [PMID: 25765563 DOI: 10.1002/bdd.1944] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/05/2015] [Accepted: 03/04/2015] [Indexed: 12/12/2022]
Abstract
Little is known about the uptake of drugs into the human heart, although it is of great importance nowadays, when science desires to predict tissue level behavior rather than to measure it. Although the drug concentration in cardiac tissue seems a better predictor for physiological and electrophysiological changes than its level in plasma, knowledge of this value is very limited. Tissue to plasma partition coefficients (Kp) come to rescue since they characterize the distribution of a drug among tissues as being one of the input parameters in physiologically based pharmacokinetic (PBPK) models. The article reviews cardiac surgery and forensic medical studies to provide a reference for drug concentrations in human cardiac tissue. Firstly, the focus is on whether a drug penetrates into heart tissue at a therapeutic level; the provided values refer to antibiotics, antifungals and anticancer drugs. Drugs that directly affect cardiomyocyte electrophysiology are another group of interest. Measured levels of amiodarone, digoxin, perhexiline and verapamil in different sites in human cardiac tissue where the compounds might meet ion channels, gives an insight into how these more lipophilic drugs penetrate the heart. Much data are derived from postmortem studies and they provide insight to the cardiac distribution of more than 200 drugs. The analysis depicts potential problems in defining the active concentration location, what may indirectly suggest multiple mechanisms involved in the drug distribution within the heart. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Zofia Tylutki
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str, , 30-688, Cracow, Poland
| | - Sebastian Polak
- Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Str, , 30-688, Cracow, Poland
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Tungaraza TE, Talapan-Manikoth P, Jenkins R. Curse of the ghost pills: the role of oral controlled-release formulations in the passage of empty intact shells in faeces. Two case reports and a literature review relevant to psychiatry. Ther Adv Drug Saf 2014; 4:63-71. [PMID: 25083252 DOI: 10.1177/2042098612474681] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Orally taken tablets in different formulations continue to have a central role in the treatment of various psychiatric and medical conditions. In order to improve compliance, reduce the frequency of taking medications and minimize the peaks and troughs associated with certain immediate-release formulations, pharmaceutical companies have developed a number of novel methods of delivering oral solid dosage medications in the form of controlled-release (CR) formulations. Some CR formulations have been associated with pharmacobezoars and false-positive findings on certain physical investigations. Though CR drugs are commonly used in psychiatry, clinicians appear to have a limited understanding of how they are released for absorption once ingested. Some have insoluble parts that are excreted in faeces as 'ghost pills'. Due to lack of awareness of this phenomenon to both patients and the physicians, anxiety has ensued in some patients. Some clinicians have been puzzled or have been dismissive when faced with curious patients wanting to know more after they had observed tablet-like looking structures in faeces. We present two cases from our clinical setting and a few drawn from the World Wide Web to highlight the role of CR medications and their association with the ghost pill phenomenon. The mechanisms involved in drug release relevant to psychiatry medications are also briefly reviewed. The ghost pill phenomenon occurs with certain CR medications. This is a normal and expected outcome related to drug-release mechanisms of some of these products. It is inevitable that some patients will see what looks like tablets or capsules in faeces. Raising awareness of this phenomenon among clinicians would facilitate discussions and information sharing at the initial process of medication prescribing. Awareness among patients and carers would also help to allay anxiety.
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Affiliation(s)
- Tongeji Elifazi Tungaraza
- Black Country Partnership Foundation Trust - Psychiatry, Penn Hospital, Penn Road, Wolverhampton WV4 5HN, UK
| | | | - Rosemary Jenkins
- Black Country Partnership Foundation Trust - Psychiatry, Penn Hospital, Wolverhampton, UK
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14
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Linares OA, Schiesser WE, Linares AD, Stefanovski D, Boston RC. A Transit Compartment Model Unmasks OxyContin's Reflective Pharmacokinetics From Urine Measurements in Humans. J Pain Palliat Care Pharmacother 2014; 28:96-108. [DOI: 10.3109/15360288.2014.908991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Organ-specific microcirculatory mass transport of oxycodone in humans: clinical implications for therapeutic use. Clin J Pain 2014; 31:206-13. [PMID: 24709626 DOI: 10.1097/ajp.0000000000000105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To begin to address the problem of heterogeneity of distribution of oxycodone (OC) in humans, we developed an organ-specific microcirculatory capillary-tissue exchange 2-compartment model for studying regional OC mass transport. MATERIALS AND METHODS The model was developed in silico. It quantifies OC's organ-specific mass transport rates, clearances and recycling, and it considers the effects of blood flow on OC's convective and diffusive transport. RESULTS What is new is the finding that OC undergoes local recycling at the level of organ-specific capillary-tissue exchange units in humans. Results indicate recycled OC occurs in sufficient amounts to function as a reusable source of circulating OC; which has important implications for OC dosing. Results show the brain, which is central to OC effects only receives about 8% of OC delivered to all organs via the microcirculation. This suggests that differential regulation of receptor binding, trafficking, internalization, or desensitization in the brain likely plays a dominant role in OC's central analgesic effects. DISCUSSION Organ-specific OC mass transport kinetics provide new information for OC dosing in pain management. The model promotes patient safety in opioid prescribing because it allows predictions to be made about the relative contribution that OC recycling makes to circulating OC levels. The model indicates that pharmacologic modulation of the microcirculation may give way to site-specific delivery of opioids in the future. Our study demonstrates that translation of bench in silico research data into clinical practice, although still challenging, is feasible and can assist in OC dose regimen design for patient safety.
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16
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Okic M, Cnossen L, Crifasi JA, Long C, Mitchell EK. Opioid overdose mortality in Kansas, 2001-2011: toxicologic evaluation of intent. J Anal Toxicol 2013; 37:629-35. [PMID: 24123621 DOI: 10.1093/jat/bkt085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Drug concentration is a factor in the determination of the manner of death, but considerable overlap exists between therapeutic and toxic concentrations. This study aims to quantify opioid mortality in Kansas from use of fentanyl, methadone and oxycodone and to evaluate utility of drug concentrations for the determination of the manner of death. Cases referred to a forensic pathology practice in Kansas for autopsy from 1 January 2001 to 31 December 2011 were considered. The criterion for inclusion was detection of fentanyl, methadone and/or oxycodone in postmortem toxicology. Of 9,789 cases, 3,315 had positive toxicology: 180 of fentanyl, 299 of methadone and 310 of oxycodone. There were 207 single opioid fatalities, 264 polydrug overdoses and 318 deaths where an opioid was present but not contributory to the mechanism of death. In line with published studies, incidence of opioid overdose deaths increased over the time of the study. Drug concentrations within each cause and manner of death covered broad ranges. Non-natural and natural manners had less overlap than existed within non-natural manners in limited comparisons. This study shows that drug concentration is independent of manner for non-natural deaths and although insufficient to identify intent, can provide a guideline in differentiating non-natural from natural deaths.
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Affiliation(s)
- Merisa Okic
- 1 Frontier Forensics Midwest, LLC, 40 S. 18th St., Kansas City, KS 66102, USA
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17
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McIntyre IM. Liver and peripheral blood concentration ratio (L/P) as a marker of postmortem drug redistribution: a literature review. Forensic Sci Med Pathol 2013; 10:91-6. [DOI: 10.1007/s12024-013-9503-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 11/24/2022]
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18
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KOKUBUN H, MATOBA M, YAMADA Y, YAGO K. Solutions for the Clinical Problems of Analgesics for Cancer Pain Treatment in Japan. YAKUGAKU ZASSHI 2011; 131:113-27. [DOI: 10.1248/yakushi.131.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | - Motohiro MATOBA
- Department of Palliative Medicine and Psycho-Oncology, National Cancer Center
| | - Yasuhiko YAMADA
- Department of Clinical Evaluation of Drug Efficacy, School of Pharmacy, Tokyo University of Phamacy and Life Science
| | - Kazuo YAGO
- Department of Pharmacy, Kitasato University Hospital
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19
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Dinis-Oliveira RJ, Carvalho F, Duarte JA, Remião F, Marques A, Santos A, Magalhães T. Collection of biological samples in forensic toxicology. Toxicol Mech Methods 2010; 20:363-414. [PMID: 20615091 DOI: 10.3109/15376516.2010.497976] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- R J Dinis-Oliveira
- Institute of Legal Medicine, Faculty of Medicine, University of Porto, Porto, Portugal.
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20
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Abstract
Our study showed that the perception of pain lessens with detoxification from chronic prescription opiate medications. Thus, removal of opiates resulted in less pain, and chronic administration of opiates actually increased pain perceptions. The underlying pathophysiology of increased pain sensitivity from chronic administration is not well understood. However, the enhanced pain from the development of tolerance and dependence is a common phenomenon. Clinicians are advised to limit their prescribing of opiate drugs to patients on a chronic basis. Further, unresolved pain complaints, and continued complaints of pain despite escalating doses of opiate medications suggest addiction and its adverse consequences. Identification of addiction and detoxification is the proper approach to pain management in chronic opiate administration.
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Miller DA, Dinunzio JC, Williams RO. Advanced formulation design: improving drug therapies for the management of severe and chronic pain. Drug Dev Ind Pharm 2008; 34:117-33. [PMID: 18302030 DOI: 10.1080/03639040701542200] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic pain is a condition affecting a vast patient population and resulting in billions of dollars in associated health care costs annually. Sufferers from severe chronic pain often require [correction of requite] twenty-four hour drug treatment through intrusive means and/or repeated oral dosing. Although the oral route of administration is most preferred, conventional immediate release oral dosage forms lead to inconvenient and suboptimal drug therapies for the treatment of chronic pain. Effective drug therapies for the management of chronic pain therefore require advanced formulation design to optimize the delivery of potent analgesic agents. Ideally, these advanced delivery systems provide efficacious pain therapy with minimal side effects via a simple and convenient dosing regime. In this article, currently commercialized and developing drug products for pain management are reviewed with respect to dosage form design as well as clinical efficacy. The drug delivery systems reviewed herein represent advanced formulation designs that are substantially improving analgesic drug therapies.
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Affiliation(s)
- Dave A Miller
- College of Pharmacy, University of Texas at Austin, Austin, Texas 78712, USA
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22
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Spiller HA, Bottei E, Kalin L. Fatal bupropion overdose with post mortem blood concentrations. Forensic Sci Med Pathol 2007; 4:47-50. [DOI: 10.1007/s12024-007-0030-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2007] [Indexed: 11/28/2022]
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23
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Miller NS. Failure of enforcement controlled substance laws in health policy for prescribing opiate medications: a painful assessment of morbidity and mortality. Am J Ther 2007; 13:527-33. [PMID: 17122534 DOI: 10.1097/01.mjt.0000212702.94495.25] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Controlled substances can be used for legitimate medical purposes to relieve pain and suffering, and allow management of medical and surgical conditions, whether acute or chronic in duration. However, because these are attractive, addicting drugs, diversion from sources such as physicians and pharmacists can lead to serious health problems. Of importance is that addiction to opiate medications can interfere with treatment of the original pain condition, and can lead to life threatening states because of poor judgment and depressed mood in the users. Consequently, the public has a vested interest in protecting the medical uses of these medications on the one hand, although reducing the morbidity and mortality from their diversion and addictive use. The controlled substance laws contain 3 sources of policy framework that governs the medical use and diversion of controlled substances: (1) international treaties, (2) federal laws and regulations, and (3) state laws and regulations. These laws are aimed at balancing the need to controlling use with adverse consequences against the therapeutic benefits opiate medications provide the public.
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Affiliation(s)
- Norman S Miller
- Department of Medicine, Michigan State University, East Lansing, Michigan 48823, USA.
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24
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Miller NS, Swiney T, Barkin RL. Effects of opioid prescription medication dependence and detoxification on pain perceptions and self-reports. Am J Ther 2006; 13:436-44. [PMID: 16988540 DOI: 10.1097/01.mjt.0000212894.35705.90] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this work is to document whether prescription opioid medications used for pain enhanced or worsened pain syndromes from medical conditions in patients who received a diagnosis of prescription opioid dependence as determined by a diagnosis by Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria. Further, whether detoxification improved or worsened pain perceptions and self-reports in patients who chronically administered prescription opioid medications. Our study consisted of a retrospective sample of patients taken from the Addiction Treatment Unit at St Lawrence Hospital in Lansing, MI. Patients were selected from those who voluntarily sought detoxification from opioid medications in an inpatient setting. Selection criteria for the study consisted of a DSM-IV diagnosis of opioid prescription medication dependence, willingness to undergo medical detoxification, cooperation with self-report scales, and abstinence from opioid medications. Study patients were randomly selected from discharges in patient census for the years 2001 to 2003. The significant findings were that self-reported pain scores improved during the detoxification from admission to discharge, from a mean of 5.5 at admission to mean of 3.4 at discharge (0 is no pain and 10 is the most pain). The detoxification period extended to an average of 5 days. Whereas oxycodone CR (OxyContin) produced higher levels of self-reported pain at admission than at discharge, and these patients experienced significant levels of pain reduction with decremental opioid doses as with other opioid medications. Patients with a DSM-IV diagnosis of prescription opioid dependence reported (self) less pain with detoxification and abstinence from the opioid medications.
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Affiliation(s)
- Norman S Miller
- Department of Medicine, Michigan State University, East Lansing, MI, USA.
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25
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Lewis RJ, Johnson RD, Hattrup RA. Simultaneous analysis of Thebaine, 6-MAM and six abused opiates in postmortem fluids and tissues using Zymark® automated solid-phase extraction and gas chromatography–mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2005; 822:137-45. [PMID: 15993661 DOI: 10.1016/j.jchromb.2005.05.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Revised: 05/02/2005] [Accepted: 05/13/2005] [Indexed: 11/17/2022]
Abstract
Opiates are some of the most widely prescribed drugs in America and are often abused. Demonstrating the presence or absence of opiate compounds in postmortem fluids and/or tissues derived from fatal civil aviation accidents can have serious legal consequences and may help determine the cause of impairment and/or death. However, the consumption of poppy seed products can result in a positive opiate drug test. We have developed a simple method for the simultaneous determination of eight opiate compounds from one extraction. These compounds are hydrocodone, dihydrocodeine, codeine, oxycodone, hydromorphone, 6-monoacetylmorphine, morphine, and thebaine. The inclusion of thebaine is notable as it is an indicator of poppy seed consumption and may help explain morphine/codeine positives in cases where no opiate use was indicated. This method incorporates a Zymark RapidTracetrade mark automated solid-phase extraction system, gas chromatography/mass spectrometry, and trimethyl silane (TMS) and oxime-TMS derivatives. The limits of detection ranged from 0.78 to 12.5 ng/mL. The linear dynamic range for most analytes was 6.25-1600 ng/mL. The extraction efficiencies ranged from 70 to 103%. We applied this method to eight separate aviation fatalities where opiate compounds had previously been detected.
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Affiliation(s)
- R J Lewis
- Civil Aerospace Medical Institute, Federal Aviation Administration, Forensic Toxicology Research Laboratory, AAM-610, P.O. Box 25082, Oklahoma City, OK 73125, USA
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Musshoff F, Padosch S, Steinborn S, Madea B. Fatal blood and tissue concentrations of more than 200 drugs. Forensic Sci Int 2004; 142:161-210. [PMID: 15172079 DOI: 10.1016/j.forsciint.2004.02.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.
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Affiliation(s)
- F Musshoff
- Institute of Legal Medicine, Rheinische Friedrich-Wilhelms-University, Stiftsplatz 12, Bonn 53111, Germany.
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Abstract
This review covers beta-phenylethylamines and isoquinoline alkaloids derived from them, including further products of oxidation. condensation with formaldehyde and rearrangement, some of which do not contain an isoquinoline system, together with naphthylisoquinoline alkaloids, which have a different biogenetic origin. The occurrence of the alkaloids, with the structures of new bases, together with their reactions, syntheses and biological activities are reported. The literature from July 2002 to June 2003 is reviewed, with 568 references cited.
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28
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Leikin JB, Watson WA. Post-mortem toxicology: what the dead can and cannot tell us. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2003; 41:47-56. [PMID: 12645967 DOI: 10.1081/clt-120018270] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The evaluation of postmortem laboratory assays of drugs needs to be performed in a systematic manner. The condition of the body, drug characteristics, matrix and site analysis are factors which need to be considered in the proper interpretation of an autopsy specimen result.
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Affiliation(s)
- Jerrold B Leikin
- Evanston Northwestern Healthcare OMEGA, Glenbrook Hospital, Glenview, Illinois, 60025, USA.
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