Recommendations on the measurement and use of the alcohol consumption biomarker CDT. A position paper from the IFCC Working Group on CDT standardisation.

BACKGROUND: Carbohydrate deficient transferrin (CDT) is a biomarker for excessive alcohol consumption utilized in clinical and forensic medicine and workplace testing. Previously, many different analytical methods for CDT were used and the measurand varied considerably, making direct comparison of test results difficult. To end this confusion, the IFCC established a working group on CDT standardisation (WG-CDT) which completed its tasks in 2017. METHODS: This IFCC position paper by the WG-CDT summarizes state of the art information about the measurand and the analytical methods and gives concise recommendations for its utilization. RESULTS: The results achieved by the CDT standardisation process led to accuracy improvements in national external quality assessment schemes over the years. A brief review of ROC based comparison studies with the traditional biomarkers (GGT, MCV, ALT and AST) discusses the bias resulting from inadequate study populations. In large groups of the general population the superior diagnostic performance of CDT is confirmed. CONCLUSION: The relationship between alcohol intake versus resulting CDT is discussed as well as the cutoff and measurement uncertainty. Concerning the application in practice, potential pitfalls are considered and recommendations handling both analytical and preanalytical caveats are given. Finally, some examples of serious misunderstandings in publications about CDT are addressed.

Toxicity and behavioural effects of ocfentanil and 2-furanylfentanyl in zebrafish larvae and mice.

The introduction of the so-called New Psychoactive Substances represents a problem of global concern due to several factors, including multiplicity of structures, poorly known activity, short half-life in the market, lack of pure standards etc. Among these problems, of the highest relevance is also the lack of information about metabolism and adverse effects, which must be faced using simple and low-cost animal models. On these grounds, the present work has been carried out on 5 days post fertilization zebrafish (Danio rerio) larvae in comparison with adult mice (Mus musculus). Ocfentanil and 2-furanylfentanyl were administered at different concentrations to zebrafish larvae (1, 10 µM) and mice (0.1, 1, 6, 15 mg/kg). The behavioural assay showed a decrease in basal locomotor activity in zebrafish, whereas in mice this effect was evident only after the mechanical stimulus. Larva extracts and mice urine were analysed by using liquid chromatography coupled to high resolution mass spectrometry to identify the metabolic pathways of the fentanyl analogs. For 2-furanylfentanyl, the most common biotransformations observed were hydroxylation, hydration and oxidation in zebrafish larvae, whereas mice produced mainly the dihydrodiol metabolite. Hydroxylation was the major route of metabolism for ocfentanil in zebrafish larvae, while in mice the O-demethylated derivative was the main metabolite. In addition, a study was conducted to evaluate morphological effects of the two drugs on zebrafish larvae. Malformations were noticeable only at the highest concentration of 2-furanylfentanyl, whereas no significant damage was observed with ocfentanil. In conclusion, the two animal models show similarities in behavioral response and in metabolism, considering the different biological investigated.

Sudden unexpected death in a 17-year-old boy due to unacknowledged adamantinoma-like Ewing sarcoma.

A 17-year-old male with no previous medical history was admitted 2 days before his death to a local hospital after mild dyspnea. Electrocardiography, chest radiography, and blood analysis revealed no abnormalities. Blood oxygen saturation was 99%, and SARS-CoV-2 nasopharyngeal swabs tested negative; thus, he was discharged without prescriptions. After 2 days, the subject died suddenly during a pool party. Forensic autopsy was performed analyzing all anatomical districts. Cardiac causes were fully excluded after deep macroscopic and microscopic evaluation; lung and brain analyses showed no macroscopic pathology. Finally, a large subglottic solid mass was detected. The whitish neoplasm showed an aggressive invasion pattern to the thyroid and adjacent deep soft tissues and occluded the trachea. High-power microscopy showed sheets of small, uniform cells with scant cytoplasm; round nuclei; and small, punctate nucleoli, with immunohistochemical expression of CK8-18, AE1/AE3, and CD99. Using FISH analysis, the break-apart molecular probes (EWSR1 (22q12) Break - XL, Leica Biosystem, Nussloch, Germany) showed distinct broken red and green fluorochromes, diagnostic of Ewing sarcoma. The neoplasm was characterized as adamantinoma-like Ewing sarcoma, and the mechanism of death was identified as airway obstruction. The rarity of the case resides in the circumstances of death, which pointed to the possibility of sudden unexpected death due to heart disease, but an oncological cause and the underlying mechanism were finally diagnosed. The best method to perform autopsies is still complete, extensive, and systematic macroscopic sampling of organs and districts followed by histopathological analysis, in addition to immunohistochemical and molecular investigations in those cases in which they are necessary. In fact, when neoplasms are detected, the application of advanced techniques such as immunohistochemistry and molecular diagnostics is fundamental to accurately certify death.

Zebrafish larvae: A new model to study behavioural effects and metabolism of fentanyl, in comparison to a traditional mice model.

In an effort to find alternatives to study in vivo the so-called New Psychoactive Substances (NPS), the present work was undertaken to investigate the use of zebrafish larvae as animal model in pharmaco-toxicology, providing behavioural and metabolism information. For this purpose, fentanyl, the progenitor of an extremely dangerous group of NPS, was administered at different doses to zebrafish larvae (1, 10, 50, 100 µM) in comparison to mice (0.1, 1, 6, 15 mg/kg), as a well-established animal model. A behavioural assay was performed at the time of the peak effect of fentanyl, showing that the results in larvae are consistent with those observed in mice. On the other hand, several morphological abnormalities (namely yolk sac edema, abnormal pericardial edema, jaw defect and spinal curvature) were found in larvae mostly at high fentanyl doses (50, 100 µM). Larva extract and mice urine were analyzed by using liquid chromatography coupled to high resolution mass spectrometry to identify the metabolic pathways of fentanyl. The main metabolites detected were norfentanyl and hydroxyfentanyl in both the tested models. In conclusion, the present study provides evidence that fentanyl effects on zebrafish larvae and metabolism are similar to rodents and consequently support the hypothesis of using zebrafish larvae as a suitable rapid screening tool to investigate new drugs, and particularly NPS.

Analytical and diagnostic aspects of carbohydrate deficient transferrin (CDT): A critical review over years 2007-2017.

The need for investigating alcohol abuse by means of objective tools is worldwide accepted. Among the currently available biomarkers of chronic alcohol abuse, carbohydrate-deficient transferrin (CDT) is one of the most used indicator, mainly because of its high specificity. However, some CDT analytical and interpretation aspects are still under discussion, as witnessed by numerous research papers and reviews. The present article presents a critical review of the literature on CDT appeared in the period from 2007 to 2017 (included). The article is organized in the following sections: (1) introduction, (2) pre-analytical aspects (3) analytical aspects (4) diagnostic aspects (5) concluding remarks. As many as 139 papers appeared in the international literature and retrieved by the search engines PubMed, Web of Science and Scopus are quoted.

Relationship between pharmacokinetics and pharmacodynamics of clopidogrel in patients undergoing percutaneous coronary intervention: comparison between vasodilator-stimulated phosphoprotein phosphorylation assay and multiple electrode aggregometry.

UNLABELLED: ESSENTIALS: The reliability of platelet tests as markers of the variable bioavailability of clopidogrel is not yet defined. Kinetics of clopidogrel active metabolite (CAM) and platelet response were studied in ischemic heart disease. CAM plasma maximum concentration (Cmax ) predicted vasodilator-stimulated phosphoprotein (VASP-P). Timely performed VASP-P, not an aggregation-based test, may be a surrogate for clopidogrel bioavailability. BACKGROUND: The high inter-individual variability in the inhibition of platelet function by clopidogrel is mostly explained by high variability in its transformation to an active metabolite (CAM). Objective We investigated the relations between pharmacokinetics and pharmacodynamics of CAM by comparing two methods of platelet function. METHODS: We enrolled 14 patients undergoing percutaneous coronary interventions for non-ST-segment elevation acute coronary syndrome or inducible myocardial ischemia. Plasma concentrations of clopidogrel and CAM, phosphorylation of vasodilator-stimulated phosphoprotein (VASP-P), expressed as a platelet reactivity index (PRI) and whole-blood platelet aggregation (multiple electrode aggregometer, MEA) were measured before and after a 600-mg clopidogrel loading dose (nine time-points) and before and after 75-mg maintenance doses on days 2, 7 and 30. RESULTS: Plasma concentrations of clopidogrel and CAM were highly variable. CAM reached maximal concentration (Cmax ) (median, 110.8 nm; range, 41.9-484.8) 0.5-2 h after the loading dose. A sigmoid dose-response curve defined the relations between CAMCmax and PRI after 3 to 24 h (IC50 , 459.6 nm; 95% confidence interval, 453.4-465.7; R(2) = 0.82). PRI was unchanged from baseline in patients with the lowest CAMCmax (< 83 nm, n = 7), indicating low sensitivity of VASP-P. PRI values were also predicted by CAMCmax at days 2, 7 and 30. Platelet aggregation measured by MEA did not show significant relations with either PRI or with CAM pharmacokinetics at any time-point. CONCLUSIONS: After 600 mg clopidogrel, VASP-P, but not whole-blood platelet aggregation measured by MEA, is almost entirely predicted by CAMCmax . VASP-P could be useful in studies aimed at investigating relations between CAM bioavailability and clinical events.

Toxicokinetics of cocaine and metabolites: the forensic toxicological approach.

Cocaine is one of the most used psychomotor stimulants all over the world. On this basis, the interest for the pharmacological activity and the pharmacodynamic and pharmacokinetic aspects of this drug is very prominent in both clinical and forensic toxicological environments. The review presents and discusses 65 scientific publications covering all the aspects of cocaine toxicokinetic, including absorption, distribution, metabolism and elimination of the drug. Particular attention has been dedicated to the studies on the disposition of the drug in alternative biological matrices, such as oral fluid, hair, fetus fluids and tissues, and sweat. In fact, in the last years the use of these matrices has been proposed in clinical and forensic drug analysis in order to obtain additional information to that which can be obtained by analyzing the traditional biological matrices, such as blood and urine.

Biomarkers for the Identification of Alcohol Use/Abuse: A Critical Review.

Alcohol abuse represents a highly relevant medical, social, and economic problem all over the world. The diagnosis of conditions of alcohol use or abuse is complex, requiring different and integrated methodologies; among them the use of biomarkers is a very helpful and objective tool. This review article discusses the currently available biomarkers of alcohol abuse, showing their positive and negative characteristics in terms of detection window, diagnostic sensitivity, diagnostic specificity, and analytical feasibility. Particular attention is dedicated to the most used biomarkers, represented by liver enzymes (AST, ALT, and GGT), MCV, CDT, EtG and EtS, FAEE, and PEth. A critical analysis of the different biomarkers showed wide variability in terms of detection window, sensitivity, and specificity. On this basis, the choice of any indicator should depend on the aim and context for which the diagnosis of alcohol abuse is required (e.g., clinical, fitness for driver's license, fitness to work, child custody). Moreover, this study showed that the diagnosis of alcohol abuse cannot be based only on the use of biomarkers, but it must also consider the integration of anamnestic, clinical, instrumental, and laboratory data.

Carbohydrate-deficient transferrin determined in blood microsamples from healthy newborns by using capillary zone electrophoresis.

OBJECTIVE: There is a paucity of studies on quantitative determination of carbohydrate-deficient transferrin (CDT) in newborns. The aim of our study was therefore to determine CDT concentrations in newborns by using capillary zone electrophoresis (CZE). MATERIAL AND METHODS: Capillary blood was collected from the heels of 28 at-term healthy newborns, simultaneously with the Guthrie card screening. Forty-seven adults were examined as controls. CZE separations were performed with a P/ACE MDQ capillary electropherograph in uncoated fused-silica capillaries using a commercial reagent kit. After iron saturation, the samples were loaded by application of 0.5 psi for 15 s, and separated under 28kV with UV detection. All relevant transferrin (Tf) glycoforms were separated within 7 min. CDT quantification (%CDT) was carried out by calculating the percentage ratio between the sum of the peak areas of CDT-related glycoforms and the sum of peak areas of all Tf glycoforms. RESULTS: In most cases, good separations of Tf glycoforms were obtained. In the newborns the %CDT was 0.51 versus 0.66 in adults (difference not statistically significant). Trisialo-Tf concentration was significantly lower in newborns (3.20) than in adults (4.11). Furthermore, pentasialo-Tf appeared to be lower in newborns (7.30) than in adults (14.00), but because complete separation of the peaks of tetrasialo- and pentasialo-Tf was not always possible, this finding could not be confirmed statistically. CONCLUSIONS: CZE showed definite advantages in terms of volume of blood to be collected, simplicity and standardization of analysis and, because of the direct detection of the separated zones, accuracy of quantification. The present study provides the basic information in the search for glycosylation defects in newborns.

Objective Diagnosis of Drowning by the "Diatom Test" - A Critical Review.

The identification of diatoms in the body tissues to prove a death by drowning (known as the diatom test) dates back to the end of the 19th century. However, in recent decades the reliability of this method was disproved because of an alleged inaccuracy and high false positive rate; nonetheless, the matter is still highly controversial. The purpose of the present work is to offer a critical review of the subject with a specific emphasis on the technical problems. In particular, contamination of samples during autopsy and of tissue extracts during processing was recognized as the main source of false positive results. However, the possibility of diatom passive penetration into the body (particularly into lungs) during submersion cannot be excluded, especially in highly transformed cadavers. Hence, tissues that are highly secluded from the drowning medium, such as bone marrow, are preferred as samples, according to the most recent literature. Additional information on the drowning site and circumstances can be drawn from the qualitative and quantitative comparison between the diatoms found in the body tissues and those present in the drowning water. From the analytical point of view, the majority of authors digest tissues by treatment with strong acids, often after oxidation; alternatively, proteolytic enzymes are widely used. Detection is generally carried out by light microscopy, but scanning electron microscopy (SEM) shows much better resolution, which is important for the identification of the smallest diatoms or diatom fragments. In the experimental part of the work, a recent evolution of SEM, known as environmental scanning electron microscopy (ESEM) has been tested on drowning victims. The main feature of ESEM is the possibility to work on standard microscopic preparations without the need of sample coating, which allows switching between light and electron microscopy, thus taking advantage of the wide optical field of the former technique and of the high resolution of the latter. On this basis, we propose an integrated approach to the diatom test including a screening with light microscopy (200-400×) and a confirmation with ESEM (5,000-20,000×). The review includes 92 references.

Determination of CDT, a marker of chronic alcohol abuse, for driving license issuing: immunoassay versus capillary electrophoresis.

The present work is aimed at a validation of the carbohydrate-deficient transferrin (CDT) determination in real cases by comparison between the a commercial immunometric method and a method based on capillary electrophoresis. Overall, 650 serum samples from subjects applying to re-obtain their driving license, previously withdrawn for "drunk driving", were investigated. A highly significant correlation (P < 0.001) was found between the results from immunoassay and capillary electrophoresis. However, particularly in the samples with CDT values around the cut-off or moderately elevated, a wide dispersion of the correlation data was found. This finding stresses the need to confirm by alternative techniques all the results from CDT immunoassays. For this purpose, capillary electrophoresis, because of its inherent characteristics of high selectivity, easy operation, high productivity and low operative costs looks well-suited for becoming the method of choice.

Capillary zone electrophoresis and artificial neural networks for estimation of the post-mortem interval (PMI) using electrolytes measurements in human vitreous humour.

Determination of electrolyte concentrations (mainly potassium) in vitreous humour has long been considered an important tool in human death investigations for the estimation of the post-mortem interval (PMI). On the basis of its well known potential in ion analysis, capillary zone electrophoresis (CZE) has recently been applied to achieve a rapid and simultaneous determination of inorganic ions in this extracellular fluid. In the present work, artificial neural networks (ANN) were applied for modelling of the relationship of multicomponent CZE analysis of K+, NH4+, Na+, and Ba2+ ions in vitreous humour with PMI. In a study based on 61 cases with different causes of death and a known PMI ranging from 3 to 144 h, the use of ANNs considering all inorganic ion data from the human vitreous humour, achieved a substantial improvement of post-mortem interval prediction. Good linear correlation was observed (r2 = 0.98) and in comparison to the traditional linear least squares (LLS) method applied only to K+ levels in the vitreous humour, the prediction of PMI with ANN was improved by a factor of 5 from approximately +/- 15 h to less than 3 h.

Potassium concentration differences in the vitreous humour from the two eyes revisited by microanalysis with capillary electrophoresis.

This paper presents a study of the variability of potassium concentrations in the vitreous humour of the two eyes of the same body at identical postmortem interval. The study was carried out by collecting microsample amounts (50 microl) of vitreous humour and by using an original method of capillary electrophoresis with indirect detection. The electrophoretic separations were carried out in a pH 4.5 running buffer composed of 5 mmol/l imidazole, 5 mmol/l 18-crown-6 ether and 6 mmol/l alpha-hydroxybutyric acid. Detection was by indirect UVabsorption at 214 nm. Vitreous humour samples were collected from 57 medico-legal autopsies or external examinations of cases of sudden natural or violent deaths. All samples prior to analysis were diluted 1:20 with a 40 microg/ml aqueous solution of barium, the used internal standard, and finally injected by nitrogen pressure. The mean concentrations of potassium measured in the two eyes of all the cases included in the present study ranged from 4.1 to 23.5 mmol/l with the postmortem interval values varying from 7 to 144 h. A highly significant (P<0.0001) linear correlation was found between these two parameters as described by the equation: y=0.1698x+2.3587, r=0.89. The intra-eye variability of potassium concentrations was low with an average RSD of 3.89% (+/- 1.83 SD) (48 eyes, five samples per eye). No statistically significant difference was found between the potassium concentrations in the two eyes of the same subject in a group of 24 cases, excepting a single case.

Use of beta-cyclodextrin in the capillary zone electrophoretic separation of the components of clandestine heroin preparations.

The present paper describes the methodological optimization and validation of a capillary zone electrophoresis method for the rapid determination of heroin, secondary products and additives present in clandestine heroin samples, by using 20 mM beta-cyclodextrins in phosphate buffer, pH 3.23. Applied potential was 15 kV and separation temperature was 24 degrees C; detection was by UV absorption at 200 nm wavelength. Heroin samples were first dissolved in CHCl3-MeOH (96:4, v/v) and injected by pressure (0.5 p.s.i., 3 s; 1 p.s.i.=6894.76 Pa) after evaporation of the organic mixture and reconstitution in aqueous buffer. Under the described conditions, phenylethylamine (internal standard), morphine, monoacetylmorphine, heroin, acetylcodeine, papaverine, codeine and narcotine were baseline resolved in less than 10 min. The limit of detection was better than 1 microg/ml for each analyte. The study of the intra-day and day-to-day precision showed, in terms of migration times, RSDs < or = 0.71% and, in terms of peak areas, RSDs < or = 3.2%. Also, the evaluation of linearity and analytical accuracy of the method provided good results for all the analytes investigated, thus allowing its application to real cases of seized controlled drug preparations.

Optimised determination of clobazam in human plasma with extraction and high-performance liquid chromatography analysis.

The analysis of clobazam by high-performance liquid chromatography and UV detection is described herein. After adding an internal standard, 600 microl of plasma were extracted under basic conditions onto disposable cartridges packed with celite. The organic extract was then evaporated to dryness and the residue reconstituted in 200 microl of mobile phase. A 20 microl aliquot was injected into chromatograph. The HPLC system was equipped with an Ultrasphere C8 analytical column coupled with an UV detector set at 235 nm. The mobile phase was an acetate buffer 20 mM, pH 5.5, containing acetonitrile and triethylamine 70:30:0.01 (v/v); the flow-rate was 1.8 ml/min. Using this method, clobazam can be detected with a sensitivity limit of 6 ng/ml and the RSD% intra- and inter-assay were lower than 5%. For its ruggedness and reliability, the proposed method is particularly suitable for therapeutic drug monitoring in epilepsy.

[Alcohol, drugs, pharmacologic agents, and street safety]. / Alcol, droga, farmaci e sicurezza stradale.

Deaths due to road accidents during weekends have become a worrying phenomenon in Italy. With the aim of highlighting the role of psychotropic substances (alcohol, drugs of abuse) in causing road accidents, a survey based on clinical and chemico-toxicological analyses has been carried out on car drivers in the Veneto region during night weekends since 1994. Rapid clinical screening was carried out on 7952 drivers. 1399 of these, suspected to be under the influence of psychotropic substances, were subjected to complete clinical and toxicological ascertainment involving the following procedures: a) anamnesis, aiming at evidence of possible current or past use of psychotropic substances; b) objective clinical examination, aiming at finding evidence of recent (signs of acute or chronic intoxication) or past use (signs of withdrawal or associated organic pathologies) of psychotropic substances; c) double sampling of blood and urine and chemico-toxicological analysis using immunochemical, GC-HS and GC/MS-SIM techniques. As well as many data of social and behavioural interest, processing of results demonstrated that: a) 56.7% of the drivers examined had consumed alcoholic beverages; b) 30.4% had BACs higher than the threshold permitted in Italy (80 mg/100 ml); c) 15.7% of drivers were found to be under the influence of drugs of abuse or psychoactive drugs; d) the most frequently found substances were (in order): cannabinoids, stimulants (cocaine, amphetamines), opiates.

Field-amplified sample stacking capillary zone electrophoresis applied to the analysis of opiate drugs in hair.

The present paper describes the methodological optimization and validation of capillary zone electrophoresis (CZE) for the determination of major opiates (morphine, codeine, 6-monoacetylmorphine, acetylcodeine, heroin) in hair samples by using a field-amplified sample stacking injection before the separation in a binary running buffer (0.1 M sodium phosphate, pH 2.5, with 40% ethylene glycol). The applied potential was 20 kV, at 25 degrees C. Detection was by UV absorption at the fixed wavelength of 214 nm or by recording the full spectrum between 190-400 nm, thus improving the analytical selectivity and identification power of CZE. Hair samples were liquid/liquid extracted; dried extracts, reconstituted with a low-conductivity solvent (0.1 mM phosphoric acid, with 80% 1-propanol), were injected by electromigration at 10 kV for 99 s, after a 0.5 mm plug of water. Under the described conditions, the limit of detection (with a signal-to-noise ratio of 3) in hair extracts was 100 pg/mL for codeine, 75 pg/mL for morphine and 6-monoacetylmorphine (6-MAM), 150 pg/mL for ethylmorphine, and 0.75 ng/mL for acetylcodeine and heroin. The precision of the method was validated for standards in pure solution by using internal standardization, providing for intraday and day-to-day assays, in terms of migration times, relative standard deviation (RSD) values < or = 0.2%, and in terms of peak areas, RSD values <5.71%.

Capillary electrophoretic separation of vitamins in sodium dodecyl sulfate containing buffers with lower aliphatic alcohols and n-hexane as organic modifiers.

The effect of lower organic alcohols as co-surfactants (methanol, ethanol, n-propanol, isopropanol, propanediol, n-butanol and isoamylalcohol) and n-hexane as an organic modifier in 12.5 mol/l phosphate buffer with varying SDS concentration was investigated using a set of vitamins and p-hydroxybenzoic acid as the test mixture. It was demonstrated that optimum separations can be achieved particularly at high concentrations of the surfactant; the selectivity can be changed by adding a co-surfactant; while propanol and isopropanol show the same properties as co-surfactants, the most efficient alcohols were isoamylalcohol and propanediol. n-Butanol was capable of selective separation of p-hydroxybenzoic acid in the test mixture. Addition of ethanol appears most effective at higher concentrations (while all the other alcohols are effective already at 5% concentration, the best results with ethanol were obtained when it constituted 20% of the background electrolyte). 5% Concentration of methanol resulted in poor separation of the test mixture, however if 300 microl/10 ml of hexane were added to 20 mmol/l SDS containing phosphate buffer, the resulting separation was practically the same as with 50 mmol/l SDS.

Analysis of morphine by RIA and HPLC in fingernail clippings obtained from heroin users.

Heroin is abused around the world and is frequently reported as the cause of death in overdose cases. Analysis of morphine in hair has been used in the past in forensic toxicology to study the addiction history of heroin addicts. The purpose of the present study was to evaluate the usefulness of the nail as an analytical specimen in the identification and quantification of morphine in fingernail clippings of known heroin users. Fingernail clippings were obtained from 26 consenting patients of the Glasgow Drug Problem Service. At the time of sampling, the participants provided answers to a questionnaire regarding their drug use patterns. Samples were decontaminated by sonication in SDS, deionized water and methanol, and the methanolic washes were screened for analyte presence. The washed nail clippings were then hydrolyzed and extracted. RIA was used for the screening and HPLC for the confirmation of morphine. Positive RIA results were obtained with nail clippings from 25 of the 26 heroin users. The levels ranged from 0.06 to 4.69 ng/mg with a mean morphine concentration of 1.67 ng/mg. HPLC results were positive for 22 of the 26 nail samples. The mean morphine level by HPLC was 2.11 ng/mg with a range from 0.14 to 6.90 ng/mg. Based on these results, we suggest that nails have the potential of becoming a powerful alternative to hair for the detection of past heroin use in forensic cases.