The effect of body posture during medication inhalation on exercise induced bronchoconstriction in asthmatic children.

RATIONALE: Inhaling medication in a standard body posture leads to impaction of particles in the sharp angle of the upper airway. Stretching the upper airway by extending the neck in a forward leaning body posture may improve pulmonary deposition. A single dose of inhaled corticosteroids (ICS) offers acute, but moderate protection against exercise induced bronchoconstriction (EIB). This study investigated whether inhaling a single dose of ICS in a forward leaning posture improves this protection against EIB. METHODS: 32 Asthmatic children, 5-16 years, with EIB (Median fall in FEV1 or FEV0.5 30.9%) performed two exercise challenge tests (ECT's) with spirometry in a single blinded cross-over trial design. Children inhaled a single dose of 200 µg beclomethasone dipropionate (BDP) 4 h before the ECT, once in the standard posture and once with the neck extended in a forward leaning posture. Spirometry was also performed before the inhalation of the single dose of BDP. RESULTS: Inhalation of BDP in both body postures provided similar protection against EIB (fall in FEV1 or FEV0.1 in standard posture 16.7%; in forward leaning posture 15.1%, p = 0.83). Inhaling ICS in a forward leaning posture significantly delayed EIB compared to inhaling in the standard posture (respectively 2.5 min ± 1.0 min vs. 1.6 min ± 0.8 min; difference 0.9 min (95CI 0.25; 1.44 min); p = 0.01). CONCLUSION: Inhalation of a single dose BDP in both the forward leaning posture and the standard posture provided effective and similar protection against EIB in asthmatic children, but the forward leaning posture resulted in a delay of EIB. REGISTER: NTR3432 (www.trialregister.nl).

Clotted blood as sign of alcohol intoxication: a retrospective study.

A total of 138 autopsies performed at the Institute of Legal Medicine of the University of Münster between 1994 and 2006 were subdivided into two groups: (1) 69 asphyxial deaths with a blood alcohol level (BAL) > 1 per thousand and (2) 69 asphyxial deaths with a BAL of 0.00 per thousand. The coagulation state in the central vessels was registered in all cases as fluid, compactly clotted or loosely clotted, and the post-mortem interval was recorded. Histology investigations were performed on the liver to analyze the incidence of hepatic fibrosis/cirrhosis. Fisher's exact test was performed to check for statistical significance. The blood was found to be clotted in 49.3% of the cases of group (1) and in 5.8% of group (2) (p < 0.01). The post-mortem interval did not have any influence on the coagulation state as observed in both groups. Liver fibrosis/cirrhosis was a rare finding detected in three cases in group 1 and in two cases in the control group 2 and, therefore, not relative to our observations. A distinctly positive BAL is often associated with heavy stages of blood coagulation as observed during autopsy. Distinctly positive alcohol concentrations have an influence on the fibrinolytic process and, hence, on the coagulation status.

Nicotine and cotinine in infants dying from sudden infant death syndrome.

The aim of this component of the German Study on Sudden Infant Death was to determine (1) nicotine concentrations in hair (NCH), as a marker of long standing exposure to tobacco, (2) cotinine concentrations in pericardial fluid (CCP) and (3) cotinine concentrations in liquor cerebrospinalis (CCL), the latter measures being markers of recent exposure to tobacco in the last few hours of life. The results obtained were compared with data on parental smoking revealed from interviews. In 100 cases of sudden infant death syndrome, material was taken at autopsy to determine NCH. In 41 cases, NCH and CCP, and in 70 cases, NCH and CCL were determined. Infants of mothers who stated having smoked during pregnancy had higher NCH than infants of non-smoking mothers (p = 0.008). Furthermore, there was a weak but statistically significant relationship between NCH's and the daily cigarette consumption of the mother during pregnancy (n = 64, r = 0.24, p = 0.05). In 43% of infants, nicotine could be detected in their hair, although the mothers had said at the interview that they did not smoke during pregnancy. On the other hand, in 33% of infants whose mother stated they had smoked during pregnancy nicotine was not detectable in the infant's hair. CCP's were strongly correlated with CCL's (r = 0.62, p = 0.0027). For this reason, both parameters were treated as equivalent for the detection of tobacco smoke exposure in the last hours before death. The influence of breast-feeding was evaluated by comparison of the nicotine concentrations in breast fed and non-breast-fed infants from smokers and non-smokers. Fivefold higher nicotine concentrations were determined in non-breast-fed infants of parents who smoked as compared to all other groups. It can be concluded that nicotine intake by passive smoking is much more important than by breast-feeding. We conclude that both interview data and biochemical measures should be sought to understand the true exposure to tobacco smoke.

LC-MS assay for quantitative determination of cardio glycoside in human blood samples.

A method is described for liquid chromatography-mass spectrometry analysis of the cardio glycosides digoxin and digitoxin in biological samples. The method was optimized for use in the forensic field and, therefore, comprises the determination from whole blood and tissue samples. Sample cleanup by solid phase extraction (SPE) on a functionalized polymeric phase was sufficient to limit matrix suppression to <10% for all analytes. Chromatographic separation was achieved using an RP-8 column. Detection of the cardio glycosides was performed with electrospray ionization in the positive mode. The system was run in single ion monitoring mode, measuring the sodium adducts (M + Na)+ of the analyte and of the internal standard, respectively. The method was fully validated for the analysis of blood samples and was also successfully applied in forensic cases. The method was accurate and precise over a linear concentration range up to 50 ng/g blood. Lower limit of quantitation was 0.2 ng/g for digoxin and 2 ng/g for digitoxin, respectively. As deuterated analyte was used as internal standard, we also present a new microwave-enhanced method for the fast preparation of the labelled analyte within 20 min.

Quantitative determination of taxine B in body fluids by LC-MS-MS.

A new specific and sensitive LC-MS-MS method for the detection of taxine B and isotaxine B, the main toxic pseudo-alkaloids from yew (Taxus sp.), in biological samples (blood, urine, gastric content) was developed. Biological samples were prepared for LC-MS-MS by means of solid-phase extraction (SPE) procedure and yielded a recovery of 86%. Chromatographic separation was achieved using an RP(18) column. Detection of taxine B and isotaxine B was performed using multiple reaction monitoring with m/z 584.2 as precursor ion, i.e. [M+H](+), of both isomers and m/z 194.3 and m/z 107.1 as product ions after collision-induced dissociation. Docetaxel was applied as internal standard. The method was fully validated for the analysis of blood samples. Linearity was proven in the range from 0.1-500 ng/g. The limit of detection and the limit of quantitation are 0.4 and 2 ng/g, respectively. The method was applied to the determination of taxine B and isotaxine B in four fatal cases (two humans, two horses) with suspected yew intoxication. Blood levels were 105, 168, 174 and 212 ng/g.

Sudden death after isobutane sniffing: a report of two forensic cases.

The intentional inhalation of a volatile substance ("sniffing") causing euphoria and hallucinations is an under-recognised form of substance abuse in children and adolescents with a high morbidity and mortality. Sudden death can be caused by cardiac arrhythmia, asphyxia or trauma. Two fatal cases of isobutane sniffing of cigarette lighter refill containing isobutane are reported. Toxicological investigations revealed the presence of isobutane in the heart blood and brain tissue of both cases (case 1: heart blood 0.1 microg/g, brain tissue 2.3 microg/g; case 2: heart blood 4.6 microg/g, brain tissue 17.4 microg/g) and the presence of its metabolite 2-methyl-2-propanol in the heart blood of both cases (0.5 and 1.8 microg/g, respectively). The histological investigations of the inner organs showed similar results in both victims. Autopsy findings, results of the histological and immunohistochemical investigations, toxicological findings and analytical procedures are discussed.

HPLC with laser-induced native fluorescence detection for morphine and morphine glucuronides from blood after immunoaffinity extraction.

A new immunoaffinity solid phase extraction of morphine and its phase II metabolites, morphine-3-beta-D-glucuronide and morphine-6-beta-D-glucuronide is described. An immunoadsorber was applied which was created for the first time by the immobilisation of specific antibodies (polyclonal, host: rabbit) by the sol-gel method. The extraction method in combination with high performance liquid chromatography-fluorescence determination has been validated and shown to be applicable to blood samples of heroin victims in a low concentration range. Blood extracts were essentially free of interfering matrix components when compared to C8-extracts. Additionally, a novel, sensitive and selective detection system for wavelength-resolved analysis of laser-induced fluorescence coupled to HPLC was developed. The analytes were excited with a frequency tripled Ti:Sa laser (lambda=244 nm quasi cw). The total emission spectrum was recorded with a detection system consisting of an imaging spectrograph and a back-illuminated CCD camera. This technique of detection, combined with an extended optical path (at least 6 mm could be illuminated by the laser), resulted in an optimal fluorescence intensity of the analytes. The method permitted the analysis of morphine, morphine-3-beta-D-glucuronide and morphine-6-beta-D-glucuronide in a low concentration range and could be applied to a complex matrix such as postmortem blood samples because analyte peaks could be discriminated from matrix peaks by their characteristic emission spectra.

Development of a psilocin immunoassay for serum and blood samples.

After the immunisation of rabbits with a psilocin-specific immunogen, polyclonal antisera were obtained. With these antisera a competitive, heterogeneous radioimmunoassay for the detection of psilocin was developed. As tracer a derivative of psilocin was synthesised, which contained a tritiated CH(3) group. The antisera showed a specific reaction with psilocin. The cross-reactivity of structurally related endogenous substances like serotonin, tryptophan and tyrosine was below 0.01%. Also common drugs of abuse (Delta(9)-tetrahydrocannabinol, cocaine, morphine, amphetamine) showed negligible cross-reactivity (0.01-2%). Only tricyclic neuroleptics with a (dimethylamino)ethyl side-chain showed some cross-reactivity (20%). Spiked serum and blood samples were analysed with this new immunoassay and the results obtained were compared with the values measured with a validated GC-MS method.

Determination of aconitine in body fluids by LC-MS-MS.

A very sensitive and specific method was developed for the determination of aconitine, the main toxic alkaloid from plants of the genus Aconitum L., in biological samples. The method comprised solid-phase extraction using mixed-mode Cs cation exchange columns followed by liquid chromatography-tandem mass spectrometry (LC-MS-MS). Chromatographic separation was achieved with a RP8 column. Detection of aconitine was achieved using electrospray in the positive ionisation mode and quantification was performed using multiple reaction monitoring with m/z 646.4 as precursor ion, i.e. [M+H]+ of aconitine and m/z 586.5, m/z 526.4 and m/z 368.4 as product ions after collision-induced dissociation. The method was fully validated for the analysis of blood samples: the limit of detection and the limit of quantitation were 0.1 ng/g and 0.5 ng/g, respectively. Within the linear calibration range of 0.5-25 ng/g, analytical recovery was 79.9%. In two fatal cases with suspected aconite intoxication, aconitine could be detected in blood samples at concentrations of 10.0 and 12.1 ng/g. In one case, aconitine could also be detected in the stomach content (3 ng/g) and in the other in the urine (180 ng/ml).

LC-MS determination of Taxus alkaloids in biological specimens.

A semi-quantitative LC-MS method was developed for the detection of the pseudo alkaloids of Taxus baccata (yew) from human body fluids and tissue samples. This method was used to examine the cause of death of a 43-year-old man who died several hours after he drank a decoction of taxus leaves. Autopsy and histology demonstrated early signs of myocardial hypoxia. Since investigation of the stomach content did not yield evidence of taxus ingestion, the taxus alkaloids were determined in blood, stomach content and tissue samples of the deceased by LC-MS. The samples were prepared by solid phase extraction on RP-18 columns. Chromatographic separation was achieved by HPLC on a RP-8 column, coupled to an ion trap mass spectrometer (Finnigan LCQ). An atmospheric pressure electrospray ionisation was performed. Spectra of the alkaloids were recorded in the single MS mode and in the MS-MS mode and compared with reference spectra obtained from an extract of yew leaves. In the stomach content, the kidneys, the liver and a heart blood sample of the deceased, alkaloids of Taxus baccata, predominantly taxine B and iso-taxine B, were identified. The semi-quantitative evaluation of the heart blood revealed a taxine concentration of 11 micro g taxine/g. As far as we know this is the first case in which a semi-quantitative analysis of taxine alkaloids has been performed.

LC-MS determination of oxydemeton-methyl and its main metabolite demeton-S-methylsulfon in biological specimens--application to a forensic case.

A sensitive method for the identification and quantitation of the organophosphate insecticide oxydemeton-methyl and its metabolite demeton-S-methylsulfon from human blood and various tissue samples has been established. After solid-phase extraction using C18 cartridges the extracts were analyzed by high-performance liquid chromatography with mass selective detection (Finnigan MAT LCQ). The method was completely validated. The limit of detection is 1 ng/g blood for the parent substance oxydemeton-methyl and 2 ng/g blood for the metabolite demeton-S-methylsulfon. This method was applied for the analysis of blood and tissue samples of a 58-year-old man who died after the intake of Metasystox R-Spezial, a product from Bayer containing oxydemeton-methyl. Because of a prolonged interval between the ingestion and death, the concentrations of oxydemeton-methyl and demeton-S-methylsulfon were very low. Although the body was already putrefied when the autopsy was performed, the chromatograms of blood and tissue samples were free of interfering peaks.

Dioxin in infants--an environmental hazard?

The concentrations of the most common dioxin and dibenzofuran congeners were measured in different tissues (e.g. liver, kidneys, subcutaneous fatty tissue and spleen) from 27 infants who died suddenly and unexpectedly. The cases could be subdivided into 2 groups consisting of 15 infants who died in 1991/1992 and in 12 infants who died in 1996/1997. The autopsies were carried out using a standardised protocol and additionally the parents were asked to supply details of the nutritional conditions. The age of the mother and the birth order of the infants were also recorded. From the results obtained by correlating these parameters with the dioxin concentrations three main factors could be established: 1) there was a significant decrease in the total dioxin concentration in infant tissues from 1991/1992 to 1996/1997 indicating a decrease in the environmental dioxin levels due to a decrease in dioxin emission, 2) the birth order was inversely and the duration of breast feeding directly proportional to the dioxin concentrations thus showing that the mothers can decontaminate themselves by breast feeding and 3) an accumulation of specific dioxin congeners was observed in the liver tissue but the pathophysiological significance of these observations is not yet fully understood. Because of the well-known beneficial effects of breast feeding and considering the results of the present study, this type of infant nutrition can be recommended without any restrictions.

Hallucinogenic mushrooms on the German market - simple instructions for examination and identification.

'Magic mushrooms' is the name most commonly given to psychoactive fungi containing the hallucinogenic components psilocybin and psilocin. Material confiscated by local authorities was examined using morphologic, microscopic, microchemical, and toxicological methods. Psilocybe cubensis was the most popular mushroom in the sample collective, followed by Psilocybe semilanceata, Panaeolus cyanescens and Psilocybe tampanensis. The alkaloid content was determined with <0.003-1.15% of psilocybin and 0.01-0.90% psilocin. Panaeolus cyanescens was the mushroom with highest levels of psilocybin and psilocin.

Immunoaffinity extraction of morphine, morphine-3-glucuronide and morphine-6-glucuronide from blood of heroin victims for simultaneous high-performance liquid chromatographic determination.

The development of an immunoaffinity-based extraction method for the determination of morphine and its glucuronides in human blood is described. For the preparation of an immunoadsorber, specific antisera (polyclonal, host: rabbit) against morphine, morphine-3-glucuronide and morphine-6-glucuronide were coupled to 1,1'-carbonyldiimidazole-activated tris-acrylgel and used for immunoaffinity extraction of morphine and its glucuronides from coronary blood. The resulting extracts were analysed by HPLC with native fluorescence detection. The mean recoveries from spiked blood samples were 71%, 76% and 88% for morphine, morphine-3-glucuronide and morphine-6-glucuronide, respectively. The limit of detection was 3 ng/g blood and the limit of quantitation was 10 ng/g blood for all three analytes. The results of the analysis of coronary blood samples from 23 fatalities due to heroin are presented.

A specific immunoassay for the determination of morphine and its glucuronides in human blood.

The development of specific antisera for immunochemical determination of morphine, morphine-3-glucuronide and morphine-6-glucuronide is described. Morphine was N-demethylated to normorphine and N-alkylated to give N-aminopropyl-normorphine as hapten for antisera against morphine. As haptens for antisera against morphine-3-glucuronide and morphine-6-glucuronide, N-aminopropyl-nor-morphine was glucuronidated in position 3 or 6 respectively. Each of these three haptens were coupled to BSA employing the glutaraldehyde method to obtain three different immunogens. Immunisation of rabbits with these conjugates gave anti-morphine, anti-morphine-3-glucuronide and anti-morphine-6-glucuronide antisera, which were tested in a competitive, heterogeneous radioimmunoassay. Tracers for this radioimmunoassay procedure were synthesised by substitution of morphine and morphine-6-glucuronide in position 2 with 125I and indirect iodination of the morphine-3-glucuronide hapten according to the method of Bolton and Hunter. The resulting antisera show very specific reactions with morphine, morphine-3-glucuronide and morphine-6-glucuronide. Cross reactivities of each antiserum with structurally related opiates and opioides are very low. The cross reactivities of the anti-morphine antiserum against morphine-3-glucuronide, morphine-6-glucuronide, codeine, codeine-6-glucuronide or dihydrocodeine were less than 0.3%, the anti-morphine-3-glucuronide antiserum against morphine, morphine-6-glucuronide, codeine, codeine-6-glucuronide or dihydrocodeine less than 0.1% and the anti-morphine-6-glucuronide antiserum against morphine, morphine-3-glucuronide, codeine or dihydrocodeine less than 0.1%, against codeine-6-glucuronide less than 2.3%. The determination of morphine, morphine-3-glucuronide and morphine-6-glucuronide in blood samples (limit of detection= 3, 1, 0.5 ng/g) of nine cases of fatal heroin overdose with this radioimmunoassay method and the comparison with a GC/MS method is described.

Antibody-mediated clean-up of blood for simultaneous HPLC determination of morphine and morphine glucuronides.

For the interpretation of the concentration of morphine in blood samples of heroin consumers information about the concentration of the analgesic active morphine metabolite morphine-6-glucuronide is very important. Thus a simple but specific clean-up procedure based on immuno-affinity chromatography is presented for the extraction of morphine, morphine-3-glucuronide and morphine-6-glucuronide from whole blood in cases of fatal heroin overdose. The preparation of the immunoabsorber by immobilization of antibodies against morphine-3-BSA and morphine-6-KLH with carbonyldiimidazole-activated trisacrylgel is described. The separation of the extracts is achieved by HPLC using native fluorescence detection. The limits of detection for this method are 10ng for morphine and morphine glucuronides/g blood. The results for the concentration of morphine and morphine glucuronides in blood from seven cases of heroin overdose are presented. By calculating the quotients for the concentrations of morphine-6-glucuronide/morphine the time elapsed since the last intake of heroin is estimated.