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Purpose: The aim of this study was to investigate the potential dose-dependent CYP2D6 inhibition by bupropion (BUP) in patients with depression., Methods: Patients combining BUP with venlafaxine were included from a therapeutic drug monitoring (TDM) database at the Diakonhjemmet Hospital (Oslo, Norway). The O/N-desmethylvenlafaxine metabolic ratio measured in TDM samples was used as a biomarker for CYP2D6 phenotype and was compared between patients treated with BUP 150 mg/d and 300 mg/d or greater. In addition, reference groups of venlafaxine-treated patients genotyped as CYP2D6 poor metabolizers (PMs, no CYP2D6 activity) and normal metabolizers (NMs, fully functional CYP2D6 activity) were included., Findings: A total of 221 patients were included in the study. The median O/N-desmethylvenlafaxine metabolic ratio was significantly higher in patients treated with BUP 150 mg/d (n = 59) versus 300 mg/d or greater (n = 34, 1.77 vs 0.96, P < 0.001). In CYP2D6 NMs (n = 62) and PMs (n = 66), the median metabolic ratios were 40.55 and 0.48, respectively. For patients treated with BUP 150 mg/d, 11 (19%) of the 59 patients were phenoconverted to PMs, whereas this was the case for 17 (50%) of the 34 patients treated with BUP 300 mg/d or greater., Conclusions: Bupropion exhibits a clear dose-dependent CYP2D6 inhibitory effect during treatment of patients with depression. This finding is of clinical relevance when adjusting dosing of CYP2D6 substrates during comedication with BUP. Half of the patients treated with high-dose BUP are converted to CYP2D6 PM phenotype. Because of the variability in CYP2D6 inhibition, TDM of CYP2D6 substrates should be considered to provide individualized dose adjustments during comedication with BUP., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Unexpected death caused by diabetic or alcoholic ketoacidosis is easily overlooked due to the non-specific symptoms. Although the acid betahydroxybutyrate (BHB) is the most abundant ketone body formed in conditions with ketoacidosis, routine analysis in postmortem investigations often only includes the neutral ketone body acetone. This study aims to evaluate the usefulness of implementing routine BHB analysis in postmortem cases, by investigating the relationship between BHB and acetone concentrations in postmortem blood and the main cause of death. From our database of forensic autopsy cases examined from 2012 to 2015, there were 376 cases with BHB and/or acetone detected in postmortem blood that could be paired with data from the Norwegian Cause of Death Registry. Cases were categorized into three groups based on cause of death: "Diabetes-related" (n = 38), "Alcohol-related" (n = 35) and "Other" (n = 303). Analysis of BHB in blood was performed using UHPLC-MS/MS (limit of quantification (LOQ) 52 mg/L) and of acetone using HS-GC-FID (LOQ 87 mg/L). For the purpose of the study, the acetone method was also validated for a LOQ of 23 mg/L. The median BHB concentration was significantly higher in the group of diabetes-related deaths (671 mg/L, range 68-1311 mg/L) compared to the group of alcohol-related (304 mg/L, range 65-1555 mg/L, p <0.001) and other causes of deaths (113 mg/L, range 0-1402 mg/L, p <0.001). In seven deaths (1.9%), the BHB blood concentration was above the suggested pathological threshold of 250 mg/L, without detection of acetone in blood above 23 mg/L. In 15% of deaths by other causes than diabetes or alcohol, a pathologically significant BHB blood concentration was detected. Our results indicate that BHB is a more reliable marker of pathologically significant ketoacidosis than acetone, and we suggest that BHB should be routinely analyzed in postmortem investigations., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The ratio between the concentrations of drugs in the oral fluid and blood (OF/B ratio) reflects the transfer of drugs from blood to oral fluid, which is influenced by several factors such as oral fluid contamination. OF/B drug concentration ratios for psychoactive drugs, including interindividual variation, were investigated in this study. For a portion of the material, oral fluid concentrations in both sides of the mouth were compared., Methods: Samples of whole blood and oral fluid collected using the Intercept device were obtained from 489 suspected drugged drivers. Concentrations of amphetamine, methamphetamine, THC, diazepam, N-desmethyldiazepam, clonazepam, alprazolam, oxazepam, nitrazepam, morphine, buprenorphine, and methadone were determined in blood and oral fluid samples using liquid chromatography-tandem mass spectrometry., Results: Median OF/B ratios were 18.6 for amphetamine, 13.8 for methamphetamine, 3.8 for morphine, 24.8 for buprenorphine, 3.7 for methadone, 0.026 for diazepam, 0.031 for N-desmethyldiazepam, 0.28 for alprazolam, 0.16 for clonazepam, 0.12 for oxazepam, 0.099 for nitrazepam, and 4.3 for THC. Large interindividual variations in OF/B ratios were observed. The median difference in concentrations in oral fluid from both sides of the mouth was less than 20% for all drugs, except THC and buprenorphine, which had median differences of 32%-34%., Conclusions: High OF/B ratios were found for amphetamines and opioids, reflecting a high degree of drug transfer from blood to oral fluid and a longer detection window in oral fluid than in blood. For benzodiazepines, low OF/B ratios were found. Results of the concentration measurements in oral fluid from both sides of the mouth could indicate that some remnants of THC and buprenorphine were present in the oral cavity. The large variations among individuals and between the 2 sides of the mouth suggest that drug concentrations in oral fluid do not accurately reflect drug concentrations in the blood.

Simultaneously collected samples of oral fluid and blood in a naturalistic setting could provide a qualitative impression of the relative detection times of drugs in oral fluid compared to blood. The aim of this study was to compare detections of different drugs in oral fluid and blood from a large material of paired samples. The study included results from 930 paired oral fluid and blood samples collected from drivers suspected for driving under the influence of drugs. Oral fluid was collected using the Intercept device. Blood samples were screened using an ultra high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS-MS) method and positive results were confirmed and quantified with a different analytical method. Oral fluid samples were analyzed using UHPLC-MS-MS. The drugs included in the study were: amphetamine, methamphetamine, tetrahydrocannabinol (THC), diazepam, N-desmethyldiazepam, clonazepam, alprazolam, nitrazepam, oxazepam, morphine, 6-monoacetylmorphine (6-MAM), methadone and buprenorphine. The drugs detected more frequently in oral fluid compared to blood were amphetamine (497 positive in oral fluid/408 positive in blood), methamphetamine (332/232), oxazepam (106/36), morphine (65/31) and 6-MAM (19/0). The drugs detected less frequently in oral fluid compared to blood were THC (224 positive in oral fluid/407 positive in blood), diazepam (137/160), N-desmethyldiazepam (183/188), clonazepam (148/307), alprazolam (47/68), nitrazepam (16/29) and buprenorphine (31/59). For methadone, the number of detections was the same in oral fluid and in blood (23/23). The results indicate that for amphetamine, methamphetamine, morphine and 6-MAM, relative detection time is longer in oral fluid than in blood, while for benzodiazepines, the results indicate that relative detection time is shorter in oral fluid than in blood. For oxazepam and buprenorphine, the results were dependent on the cut-off limits used. Regarding THC, the detection time in oral fluid depends on the sampling method. The relative detection time was shorter than in blood when using the Intercept device., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Peripheral blood (PB) is considered to be the golden standard for measuring postmortem drug concentrations. In several cases, PB is however not available, but information regarding drug findings might still be crucial in order to determine the cause of death. Antidepressants are frequently detected in postmortem samples from forensic toxicology cases, but the literature investigating concentrations in other matrices than peripheral and heart blood is limited.We here describe a study for comparison of concentrations for a large number of different drugs in six different matrices. A total of 173 postmortem cases were included in the study material. The results from 44 cases with findings of antidepressants (amitriptyline/nortriptyline, citalopram, mianserin, mirtazapine, paroxetine, sertraline, trimipramine and venlafaxine) are presented in this article. Concentrations in peripheral and cardiac blood (CB), pericardial fluid (PF), two muscle samples and vitreous humour (VH) are compared. Ratios between concentrations in different matrices have also been compiled from available literature.All the investigated antidepressants were detected in all different matrices, and comparable concentration levels were found in the different matrices with a few exceptions. Concentrations in VH were generally lower than in the other matrices, and in a few cases with low concentrations in blood the antidepressants were not detected in VH. For most of the cases, ratios of 0.5-2 were found between concentration in PB and that in the other matrices. Some deviant concentrations where however found.This study shows that CB, PF, muscle and VH can provide important indications of the corresponding concentrations in PB when PB is not available.

In some forensic autopsies blood is not available, and other matrices are sampled for toxicological analysis. The aims of the present study were to examine whether heroin metabolites can be detected in different post-mortem matrices, and investigate whether analyses in other matrices can give useful information about concentrations in peripheral blood. Effects of ethanol on the metabolism and distribution of heroin metabolites were also investigated. We included 45 forensic autopsies where morphine was detected in peripheral blood, concomitantly with 6-acetylmorphine (6-AM) detected in any matrix. Samples were collected from peripheral blood, cardiac blood, pericardial fluid, psoas muscle, lateral vastus muscle, vitreous humor and urine. Opioid analysis included 6-AM, morphine, codeine, and morphine glucuronides. The 6-AM was most often detected in urine (n = 39) and vitreous humor (n = 38). The median morphine concentration ratio relative to peripheral blood was 1.3 (range 0-3.6) for cardiac blood, 1.4 (range 0.07-5.3) for pericardial fluid, 1.2 (range 0-19.2) for psoas muscle, 1.1 (range 0-1.7) for lateral vastus muscle and 0.4 (range 0.2-3.2) for vitreous humor. The number of 6-AM positive cases was significantly higher (P = 0.03) in the ethanol positive group (n = 6; 86%) compared to the ethanol negative group (n = 14; 37%) in peripheral blood. The distribution of heroin metabolites to the different matrices was not significantly different between the ethanol positive and the ethanol negative group. This study shows that toxicological analyses of several matrices could be useful in heroin-related deaths. Urine and vitreous humor are superior for detection of 6-AM, while concentrations of morphine could be assessed from peripheral or cardiac blood, pericardial fluid, psoas muscle and lateral vastus muscle.

A sensitive and robust ultra-high-performance liquid chromatography-tandem mass spectrometry method has been developed and validated for the quantification of acetaminophen, dexchlorpheniramine, caffeine, cotinine and salicylic acid in postmortem blood samples from children younger than 4 years. The sample was prepared by a protein precipitation with ice-cold methanol/acetonitrile mixture (85:15, v/v). The organic phase was evaporated to dryness and the residue was dissolved in the mobile phase. Separation, with gradient elution and an acidic mobile phase, was achieved on an Acquity UPLC® HSS T3 column. The compounds were quantified using a multiple reaction-monitoring mode. Two transitions were monitored for each compound and one for the deuterated internal standards. The mass spectrometric detection in the positive ion mode was performed for all the compounds except salicylic acid which was detected in the negative ionization mode. The limits of quantification were as follows: acetaminophen 0.30 mg/L, dexchlorpheniramine 0.0050 mg/L, caffeine 0.099 mg/L, cotinine 0.00035 mg/L and salicylic acid 1.3 mg/L. Between-assay and within-assay precisions were ≤15% (biases: -10% to 26%) and ≤10%, respectively. Extraction recoveries varied from 93% to 137%. The matrix effects in blood, corrected with deuterated internal standards, were 100% ± 10% for all compounds except dexchlorpheniramine (111%) and caffeine (138%).

In postmortem cases, detection of drugs in blood is most relevant with regard to determining cause of death. However, it is sometimes also of interest to gain as much information as possible regarding the deceased's use of drugs in the period before death. The aim of this study was to compare results from analyses of a repertoire of psychoactive medicinal drugs in blood and hair samples from a larger material of postmortem cases. Hair samples in addition to blood were collected from 55 forensic autopsies and analyzed for a repertoire of 39 medicinal drugs (benzodiazepines, antidepressants and antipsychotics) using av fully validated liquid chromatography-tandem mass spectrometry method. In total, hair analyses gave information of the use of drugs not detected in blood in 47 of the 55 cases (85%). The most frequent single drugs detected in hair, but absent in blood, were benzodiazepines (64%), followed by antidepressants (35%). In each case, 1-10 (median two) single drugs were detected in hair, but absent in blood. In only two cases (4%), benzodiazepines were detected in blood and no benzodiazepines were detected in hair. In conclusion, hair analyses in addition to blood frequently indicate prior use of drugs that could yield important information about for instance unknown psychiatric diagnoses. In only a small number of cases lack of detections from the same drug class in hair might indicate reduced tolerance to drug effects.

Para-methoxymethamphetamine (PMMA) has caused numerous fatal poisonings worldwide and appears to be more toxic than other ring-substituted amphetamines. Systemic metabolism is suggested to be important for PMMA neurotoxicity, possibly through activation of minor catechol metabolites to neurotoxic conjugates. The aim of this study was to examine the metabolism of PMMA in humans; for this purpose, we used human liver microsomes (HLMs) and blood samples from three cases of fatal PMMA intoxication. We also examined the impact of CYP2D6 genetics on PMMA metabolism by using genotyped HLMs isolated from CYP2D6 poor, population-average, and ultrarapid metabolizers. In HLMs, PMMA was metabolized mainly to 4-hydroxymethamphetamine (OH-MA), whereas low concentrations of para-methoxyamphetamine (PMA), 4-hydroxyamphetamine (OH-A), dihydroxymethamphetamine (di-OH-MA), and oxilofrine were formed. The metabolite profile in the fatal PMMA intoxications were in accordance with the HLM study, with OH-MA and PMA being the major metabolites, whereas OH-A, oxilofrine, HM-MA and HM-A were detected in low concentrations. A significant influence of CYP2D6 genetics on PMMA metabolism in HLMs was found. The catechol metabolite di-OH-MA has previously been suggested to be involved in PMMA toxicity. Our studies show that the formation of di-OH-MA from PMMA was two to seven times lower than from an equimolar dose of the less toxic drug MDMA, and do not support the hypothesis of catechol metabolites as major determinants of fatal PMMA toxicity. The present study revealed the metabolite pattern of PMMA in humans and demonstrated a great impact of CYP2D6 genetics on human PMMA metabolism., (Copyright © 2017 by The American Society for Pharmacology and Experimental Therapeutics.)

Objective: The objective of this study was to look for dose- and concentration-effect relationships in experimental studies on single-dose administration of morphine on traffic-relevant behavioral tests by a systematic literature review and possibly to see whether a dose/concentration could be defined below which few or no tests would be affected., Methods: Searches for corresponding literature were conducted using MEDLINE, EMBASE, and PsycINFO, throughout March of 2016. The search strategy consisted of words colligated to cognitive and psychomotor functions of relevance to driving, in relation to morphine administration. The tests were arranged in main groups, and tests showing impairment were categorized by doses as well as calculated plasma concentrations., Results: Fifteen studies were included in the review. Impairment after the administration of a single intravenously dose of morphine was found in some of the tests on reaction time, attention, and visual functions. No impairment was observed in tests on psychomotor skills and en-/decoding. Tests on reaction time appeared to be less sensitive to the morphine administration, whereas tests on visual functions and attention appeared to be the most sensitive to the morphine administration. Single-dose administration of morphine with dosages up to 5 mg appeared to cause very few effects on traffic-relevant performance tasks. At higher dosages, impairment was found on various tasks but with no clear dose-effect relationship. Plasma morphine concentrations less than 50 nmol/L are most probably accompanied by few effects on traffic-relevant performance tasks., Conclusions: A plasma morphine concentration of 50 nmol/L (approximately 14.3 ng/mL) could represent an upper level, under which there is little accompanying road traffic risk. A single dose of 5 mg morphine IV and analgetic equivalence doses of fentanyl, hydromorphone, oxycodone, and oxymorphone are presented with the suggestion that few traffic-relevant effects will appear after such doses.

In previous experimental studies on heroin metabolites excretion in urine, the first sample was often collected a few hours after intake. In forensic cases, it is sometimes questioned if a positive urine result is expected e.g., 30 min after intake. The aim of this study was to investigate urinary excretion of heroin metabolites (morphine, 6-monoacetylmorphine (6-MAM) and morphine-3-glucuronide (M3G)) every 30 min until 330 min after injection of a 20 mg heroin dose in six pigs. Samples were analyzed using a previously published, fully validated liquid chromatography-tandem mass spectrometry method. All metabolites were detected after 30 min in all pigs. The time to maximum concentration (Tmax) median (range) for 6-MAM and morphine was 30 min (first sample) (30-120), and 90 min (30-330) for M3G. In four of the six pigs, the Tmax of 6-MAM and morphine was reached within 30 min. All analytes were still detectable at the end of study. This study showed that positive results in urine are expected to be seen shortly after use of heroin in pigs. Detection times were longer than previously indicated, especially for 6-MAM, but previous studies used lower doses. As the physiology of these animals resembles that of the humans, transferability to man is expected., (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

In 2010-2013, 29 fatal intoxications related to the designer drug paramethoxymethamphetamine (PMMA, 4-methoxymethamphetamine) occurred in Norway. The current knowledge about metabolism and toxicity of PMMA in humans is limited. Metabolism by the polymorphic cytochrome P450 (CYP) 2D6 enzyme to the psychoactive metabolite 4-hydroxymethamphetamine (OH-MA), and possibly by additional enzymes, is suggested to be involved in its toxicity. The aim of this work was to study the association between CYP genetics, PMMA metabolism and risk of fatal PMMA toxicity in humans. The frequency distribution of clinically relevant gene variants of CYP2D6, CYP2C9, CYP2C19 and CYP3A5, and the phenotypic blood CYP2D6 metabolic ratio (OH-MA/PMMA) in particular, were compared in fatal PMMA intoxications (n=17) and nonfatal PMMA abuse controls (n=30), using non-abusers (n=305) as references for the expected genotype frequencies in the Norwegian population. Our study demonstrated that the CYP2D6 enzyme and genotype are important in the metabolism of PMMA to OH-MA in humans, but that other enzymes are also involved in this biotransformation. In the fatal PMMA intoxications, the blood concentrations of PMMA were higher and the CYP2D6 metabolic ratios were lower, than in the nonfatal PMMA abuse controls (median (range) 2.1 (0.03-5.0) vs 0.3 (0.1-0.9) mg/L, and ratio 0.6 (0.0-4.6) vs 2.1 (0.2-7.4) p=0.021, respectively). Overall, our findings indicated that, in most cases, PMMA death occurred rapidly and at an early stage of PMMA metabolism, following the ingestion of large and toxic PMMA doses. We could not identify any genetic CYP2D6, CYP2C9, CYP2C19 or CYP3A5 predictive marker on fatal toxicity of PMMA in humans. The overrepresentation of the CYP2D6 poor metabolizer (PM) genotype found in the nonfatal PMMA abuse controls warrants further investigations., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Vitreous humor (VH) is an alternative matrix for drug analysis in forensic toxicology. However, little is known about the distribution of xenobiotics, such as opioids, into VH in living organisms. The aim of this study was to simultaneously measure heroin and metabolite concentrations in blood and VH after injection of heroin in a living pig model. Six pigs were under non-opioid anesthesia during the surgical operation and experiment. Ocular microdialysis was used to acquire dialysate from VH, and a venous catheter was used for blood sampling. Twenty milligrams of heroin was injected intravenously with subsequent sampling of blood and dialysate for 6 h. The samples were analyzed by ultra-performance liquid chromatography-tandem mass spectrometry. Heroin was not detected in VH; 6-monoacetylmorphine (6-MAM) and morphine were first detected in VH after 60 min. The morphine concentration in VH thereafter increased throughout the experimental period. For 6-MAM, C max was reached after 230 min in VH. In blood, 6-MAM reached C max after 0.5 min, with a subsequent biphasic elimination phase. The blood and VH 6-MAM concentrations reached equilibrium after 2 h. In blood, morphine reached C max after 4.3 min, with a subsequent slower elimination than 6-MAM. The blood and VH morphine concentrations were in equilibrium about 6 h after injection of heroin. In conclusion, both 6-MAM and morphine showed slow transport into VH; detection of 6-MAM in VH did not necessarily reflect a recent intake of heroin. Because postmortem changes are expected to be small in VH, these experimental results could assist the interpretation of heroin deaths., Competing Interests: There are no financial or other relations that could lead to a conflict of interest. Ethical approval All applicable international, national, and/or institutional guidelines were followed for the care and use of the animals. This study did not involve samples collected from human participants.

Cyclizine is an antihistamine with sedative effect used to treat motion sickness. A few studies have reported on cyclizine abuse among teenagers, and cyclizine abuse has been reported among opioid dependants receiving methadone, with the combination having been reported to produce strong psychoactive effects. Few reports exist on the possible toxic effects of cyclizine, and it is regarded as a safe drug most often sold as a non-prescription/over-the-counter drug. Very few cases of fatalities resulting from cyclizine overdose can be found in the literature. We present a case where a 22-year-old female was found unconscious and intoxication with drugs and alcohol was suspected. Whole blood from the femoral vein, urine and stomach content were collected during autopsy and screened for drugs of abuse and medicinal drugs. GC-MS screening of the stomach contents revealed presence of cyclizine and meclozine. Cyclizine and meclozine concentrations in blood were determined using a UPLC-MS-MS method. Quantification of femoral blood revealed a high concentration of cyclizine (16 mg/L), a low concentration of meclozine (0.2 mg/L) and ethanol 0.16 g/dL. No other medicinal drugs or drugs of abuse were detected. We report on a case of suicide where cyclizine was found to be the principal drug and question the safety of this drug.

Objective: To perform a systematic review of the present scientific literature on the treatment with methadone or buprenorphine related to (1) traffic accident risk in epidemiological studies and (2) their effects on cognitive and psychomotor functions of relevance to driving in experimental studies., Methods: Searches for corresponding literature were conducted in MEDLINE, EMBASE, and PsycINFO throughout March and June of 2010. The search strategy consisted of words colligated to accident risk and culpability, in addition to cognitive and psychomotor functions of relevance to driving, all in relation to methadone or buprenorphine administration. In total, 59 studies were included., Results: Early epidemiological studies found no substantial difference in motor vehicle accident risk between methadone maintenance therapy patients (MMPs) and control groups. However, more recent studies have found an increased risk of traffic accident involvement for both MMPs and buprenorphine maintenance therapy patients (BMPs). In experimental studies, impairments of cognitive and psychomotor functions have been observed among both MMPs and BMPs when compared to control groups. When comparing MMPs with BMPs, the latter appeared to be less impaired than MMPs, but this difference may be unrelated to the maintenance therapy. Further impairments have been observed among MMPs after single doses, after an additional versus regular daily dosing, in multiple versus single dosing, and after long-term treatment compared to baseline levels. All studies showed impairments among opioid-naïve subjects after the administration of a comparatively low and single dose of either methadone or buprenorphine., Conclusions: Both methadone and buprenorphine were confirmed as having impairing potentials in opioid-naïve subjects. At least some opioid maintenance therapy patients are observed having only slight impairments of relevance to driving. Knowing this when approaching the question of ability to drive, an individual evaluation of the driving performance, pertaining to the opioid maintained patient, may be the most useful and conclusive procedure.

During a 6 month period (July 2010-January 2011) we observed 12 fatal intoxications and 22 non-fatal cases related to the drug paramethoxymethamphetamine (PMMA) in Norway (4.8 mill inhabitants). This toxic designer drug, also known as "Death", is occasionally found in street drugs offered as "ecstasy" or "amphetamine". The present study aimed to evaluate the cause of death, and to compare the PMMA blood concentrations in fatal and non-fatal cases. Methods for identification and quantification of PMMA are presented. The median age of fatalities was 30 years (range 15-50) with 67% males; in non-fatal cases 27 years (20-47) with 86% males. In the 12 fatalities, the median PMMA blood concentration was 1.92 mg/L (range 0.17-3.30), which is in the reported lethal range of 0.6-3.1 mg/L in peripheral blood and 1.2-15.8 mg/L in heart blood. In the 22 non-fatal cases, the median PMMA concentration was 0.07 mg/L (range 0.01-0.65). Poly-drug use was frequent both in fatal and non-fatal cases. The PMA concentrations ranging from 0.00 to 0.26 mg/L in both groups likely represented a PMMA metabolite. Three fatalities were attributed to PMMA only, six to PMMA and other psychostimulant drugs, and three to PMMA and CNS depressant drugs, with median PMMA concentrations of 3.05 mg/L (range 1.58-3.30), 2.56 (1.52-3.23) and 0.52 mg/L (0.17-1.24), respectively. Eight victims were found dead, while death was witnessed in four cases, with symptoms of acute respiratory distress, hyperthermia, cardiac arrest, convulsions, sudden collapse and/or multiple organ failure. In summary, all fatalities attributed to PMMA had high PMMA blood concentrations compared to non-fatal cases. Our sample size was too small to evaluate a possible impact of poly-drug use. A public warning is warranted against use and overdose with illegal "ecstasy" or "speed" drugs., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A morphine to codeine ratio greater than unity (M/C>1) has been suggested as an indicator of heroin use in living individuals. The aim of this study was to examine the morphine to codeine ratio in a large population (N=2438) of forensically examined autopsy cases positive for 6-monoacetylmorphine (6-MAM) and/or morphine in blood and/or urine. Blood and urine concentrations of 6-MAM, morphine and codeine were examined using GC-MS and LC-MS/MS methods. In 6-MAM positive samples, the M/C ratio was greater than unity in 98% (N=917) of the blood samples and 96% (N=665) of the urine samples. Stratification of 6-MAM negative cases by M/C above or below unity revealed similarities in morphine and codeine concentrations in cases where M/C>1 and 6-MAM positive cases. Median blood and urine morphine concentrations were 8-10 times greater than codeine for both groups. Similarly to 6-MAM positive cases, 25-44 year-old men prevailed in the M/C>1 group. In comparison to cases where M/C ≤ 1, the M/C ratio was a hundred times higher in both 6-MAM positive and M/C>1 cases. The range of morphine concentration between the lowest and the highest quintile of codeine in M/C>1 cases was similar to that in 6-MAM positive cases. This range was much higher than for M/C ≤ 1 cases. Moreover, linear regression analyses, adjusted for age and gender, revealed a strong positive association between morphine and codeine in 6-MAM positive and M/C>1 cases. The M/C ratio appeared to be a good marker of heroin use in post-mortem cases. Both blood and urine M/C>1 can be used to separate heroin users from other cases positive for morphine and codeine., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Life-threatening arrhythmias have been suspected as one cause of the sudden infant death syndrome (SIDS), and this hypothesis is supported by the observation that mutations in arrhythmia susceptibility genes occur in 5-10% of cases. However, the functional consequences of cardiac potassium channel gene mutations associated with SIDS and how these alleles might mechanistically predispose to sudden death are unknown. To address these questions, we studied four missense KCNH2 (encoding HERG) variants, one compound KCNH2 genotype, and a missense KCNQ1 mutation all previously identified in Norwegian SIDS cases. Three of the six variants exhibited functional impairments while three were biophysically similar to wild-type channels (KCNH2 variants V279M, R885C, and S1040G). When co-expressed with WT-HERG, R273Q and K897T/R954C generated currents resembling the rapid component of the cardiac delayed rectifier current (I(Kr)) but with significantly diminished amplitude. Action potential modeling demonstrated that this level of functional impairment was sufficient to evoke increased action potential duration and pause-dependent early afterdepolarizations. By contrast, KCNQ1-I274V causes a gain-of-function in I(Ks) characterized by increased current density, faster activation, and slower deactivation leading to accumulation of instantaneous current upon repeated stimulation. Action potential simulations using a Markov model of heterozygous I274V-I(Ks) incorporated into the Luo-Rudy (LRd) ventricular cell model demonstrated marked rate-dependent shortening of action potential duration predicting a short QT phenotype. Our results indicate that certain potassium channel mutations associated with SIDS confer overt functional defects consistent with either LQTS or SQTS, and further emphasize the role of congenital arrhythmia susceptibility in this syndrome.

We present a case of a death of a diabetic man where the concentration of ethanol in post-mortem blood rose from 0.4 g/l 2 days after autopsy to 3.5 g/l 10 days after autopsy. The presence of fluoride ions in this blood sample was determined with ion chromatography and verified that fluoride ions were added to the vials. The concentrations of free fluoride, corresponding to 0.21 and 0.25% w/v potassium fluoride in blood and urine, respectively, were somewhat lower than the recommended 1% w/v. However, the amount of fluoride ions bound to calcium, proteins and other compounds in the samples is unknown. The blood sample was also subject to microbiological examination, which revealed growth of bacteria. In addition, a very high concentration of glucose was found in vitreous humour from the deceased. To determine whether the ethanol detected at the first analysis was of ante-mortem origin, ethyl glucuronide was analysed. Its absence, in the blood as well as the urine sample, strongly supported the theory that, in this case, all the ethanol detected was formed post-mortem. This case showed that ethanol may be formed in vitro at a very high concentration, despite the verified presence of fluoride ions. Possible reasons for this unusual formation of ethanol were the abundant presence of bacteria, a high level of glucose and, possibly, an insufficient amount of fluoride added to the vials.

Aim: Long QT syndrome (LQTS) has been shown to be the cause of death in some cases originally diagnosed as sudden infant death syndrome (SIDS). Such cardiac arrhythmias have also been noted in families with mitochondrial disease, and studies indicate that mitochondrial disease could be involved in SIDS. This makes the mtDNA polymorphism T3394C interesting, as a previous study has shown it to be associated with electrocardiographic (ECG) changes after exercise in a family with LQTS, where some members harboured a KCNH2 mutation., Subjects: A total of 245 SIDS cases and 176 control cases., Methods: DNA was prepared from blood/tissue samples. Polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) were performed to search for the mtDNA polymorphism and KCNH2 mutation. Differences were confirmed by sequencing., Results: The T3394C polymorphism was found in 3 pure SIDS cases (1.5%), 2 borderline SIDS cases (4.4%), 1 case of explained death (1.6%) and 2 living control cases (1.8%) (p = 0.62). The KCNH2 mutation was not found in cases or controls., Conclusion: The mtDNA polymorphism studied was found in a small number of SIDS cases and the frequency did not differ statistically from control subjects, making an association with increased SIDS risk unlikely.

Aim: Mitochondrial DNA (mtDNA) mutations have been proposed as a genetic risk factor for sudden infant death syndrome (SIDS). The aim of this study was to further investigate this issue, by sequencing the mitochondrial tRNA genes with flanking regions in SIDS cases and controls., Method: The selected genes were investigated in 24 cases of SIDS and 10 controls, the method used were direct sequencing. In addition, the A10398G mutation in the ND3 gene was investigated in 220 SIDS cases, 26 cases of infectious death and 93 controls, using allele-specific PCR., Results: Mutations, recorded as differences from the revised Cambridge sequence, were found in 32 different sites in the coding regions investigated. There was no difference in mutation frequency between SIDS cases and controls, and no single mutation was found associated with SIDS., Conclusion: The present study does not indicate an association between a specific mitochondrial tRNA gene mutation and SIDS, nor a higher mtDNA tRNA mutation frequency in SIDS cases than in controls.

Sudden infant death syndrome (SIDS) still accounts for considerable numbers of unexpected infant deaths in many countries. While numerous theories have been advanced to explain these events, it is increasingly clear that this group of infant deaths results from the complex interaction of a variety of heritable and idiosyncratic endogenous factors interacting with exogenous factors. This has been elegantly summarised in the "three hit" or "triple risk" model. Contradictions and lack of consistencies in the literature have arisen from diverse autopsy approaches, variable applications of diagnostic criteria and inconsistent use of definitions. An approach to sudden infant death is outlined with discussion of appropriate tissue sampling, ancillary investigations and the use of controls in research projects. Standardisation of infant death investigations with the application of uniform definitions and protocols will ensure optimal investigation of individual cases and enable international comparisons of trends.

Aim: To investigate the Gbeta3 subunit C825T polymorphism with regard to sudden unexpected infant death. The reported association between the Gbeta3s protein and increased immune cell function in humans makes this polymorphism highly interesting both with regard to sudden infant death syndrome (SIDS) and deleterious infectious disease., Methods: The cases investigated in the present study consist of 250 SIDS cases, 38 cases of sudden unexpected infant death due to infection and 99 living infant controls. Typing of the C825T polymorphism was performed by real-time PCR with allele-specific probes and melting curve analyses., Results: The cases of infectious death have a higher percentage of both the C allele (p=0.037 compared to the SIDS cases, p=0.022 compared to the controls) and the CC genotype (p=0.05 compared to the SIDS cases, p=0.016 compared to the controls). There were no differences between SIDS cases and controls., Conclusion: The observed association between the 825C allele and infectious death may indicate that the presence of the 825T allele exerts a protective effect towards serious infection, possibly through enhanced G protein signalling. The C allele, on the other hand, appears to represent a disadvantage in this regard.

Background: The aim of the study was to investigate bed sharing as a risk factor for sudden infant death syndrome (SIDS)., Material and Methods: Firstly, SIDS cases examined at our institute in two six-year periods before and after the back-to-sleep campaign (1984-89 and 1998-2003) were investigated. Secondly, a case-control study was performed, an investigation of variables such as bed sharing, parental smoking and breast-feeding in the SIDS group from the latter period versus 244 live control infants., Results: The age distribution of the SIDS victims in the two periods with high and low SIDS rates differed significantly (p = 0.004). In the latter period, fewer SIDS cases were seen in the classical distributional peak between the third and the fourth month of life, and a larger proportion of SIDS cases were seen within the first month of life. Furthermore, a smaller proportion of SIDS victims were found dead in the prone position (decrease from 89% to 49%, p < 0.001); and bed sharing at time of death occurred more frequently (increase from 7% to 35%, p < 0.001). In the case-control study, bed sharing was a significant risk factor for SIDS in infants aged 0-2 months (multivariate OR 5.3; 95 % CI 1.3-22, p = 0.02). Bed sharing with a smoking mother was associated with a 16-fold increased risk of SIDS (OR 16; 95% CI 2.1 - 118, p = 0.007). No relationship between bed sharing and SIDS was evident for age >2 months. Only 12% of the bed sharing SIDS victims aged <2 months where found in the prone position., Interpretation: Bed sharing is associated with an increased risk of SIDS for infants <2 months of age. Particularly hazardous is bed sharing with a smoking parent.

Background: Inherited arrhythmogenic disorders are a group of genetically determined diseases characterised by ventricular tachyarrhythmias sometimes leading to sudden death. The molecular bases of these disorders are mutations in genes coding for various cardiac ion channels. The most common cardiac ion channel disease is the long QT syndrome. This syndrome is rare, but probably more common in Norway than previously expected. We have recently started genetic testing for cardiac ion channel disorders at Rikshospitalet University Hospital in Oslo. This review describes the current understanding of the etiology, prognosis and management of cardiac ion channel disorders, based on literature and our own clinical experience., Interpretation: Cardiac ion channel disorders may lead to sudden cardiac death. Prophylactic and life-saving therapies are available for many of these disorders. Therapy and risk stratification depend on the clinical presentation, the ECG pattern, and which gene is mutated. Genetic testing offers the opportunity to exclude individual family members as mutation carriers.

Background: A large proportion of fatal car accidents cannot be explained by traffic environment, technical defects or risk-taking behaviour. Driver impairment from disease, alcohol, drugs or suicidal impulses may be involved., Material and Method: Autopsy protocols from 167 car drivers involved in traffic accidents in Southeast Norway 1994-99 were reviewed retrospectively., Results: In 89 of 135 deaths caused by trauma, there were no apparent explanations for the accident prior to autopsy. No differences were found with regard to signs of disease between drivers involved in unexplained and explained accidents. Drivers dead from trauma compared to drivers dead from natural causes had less often ischemic heart disease (p < 0.01). Blood alcohol level was above the statutory limit in 20% of drivers in both unexplained and explained accidents, and drugs were found in the blood in 27% of such cases. Only 13% of drivers in explained accidents collided with large motor vehicles, compared to 44% of the unexplained accidents., Interpretation: Drivers with fatal injuries sustained in unexplained accidents seldom show signs of cardiac disease that could have contributed to the accident. It seems that such unexplained accidents are more often due to driving under the influence of alcohol or drugs, or to possible suicidal impulses.

During the period between 1984 and 1999, 309 cases of sudden unexpected death in infancy and early childhood (0-3 years) were investigated at the Institute of Forensic Medicine in Oslo. In 73 cases, an explainable cause of death was found. In this non-sudden infant death syndrome (SIDS) group, 42 cases were due to disease, 14 to accidents, 7 to neglect/abuse and 10 cases were due to homicide. In 43 cases, there were pathological findings at the autopsy or suspect features in the history and/or circumstances, which were, however, insufficient to explain death ("borderline" SIDS). In the remaining 193 cases, nothing of significance was detected ("pure" SIDS). The purpose of the present study was to evaluate the importance of the different diagnostic tools used in diagnosing non-SIDS and borderline SIDS cases. The definition of SIDS requires a negative history as well as a negative autopsy result. Thus, the following variables were analysed: circumstances, medical history and autopsy, which included a gross pathological investigation, histology, neuropathology, microbiology, radiology and toxicology. In diagnosing deaths due to disease, histology, neuropathology and microbiology were the most important diagnostic tools. In contrast, information about the circumstances of death and the gross pathological findings at autopsy most often revealed the cause of death in accidents and cases of neglect/abuse and homicide. Following the drop in SIDS rate in Norway after 1989, the share of pure SIDS in proportion to the total population of sudden unexpected deaths in infancy and early childhood has decreased. The increasing proportion of non-SIDS and borderline SIDS cases presents a challenge to improve the quality of the investigation in cases of sudden death in infancy and early childhood.

The death of a 72-year-old woman with respiratory debilitation due to bronchogenic carcinoma is described. She overdosed herself with probably 200 to 350 mg of zopiclone. Zopiclone, quantitated by HPLC in femoral postmortem blood, was found to be 1.9 mg/L (4.8 micromol/L). This level is higher than many other zopiclone fatalities reported. We report a case where only zopiclone was detected.

Objective: The epidemiologic characteristics of unexplained stillbirths are largely unknown or unreliable. We define sudden intrauterine unexplained death as a death that occurs antepartum and results in a stillbirth for which there is no explanation despite postmortem examinations, and we present risk factors for this type of stillbirth in singleton gestations., Study Design: Singleton antepartum stillbirths (n = 291) and live births (n = 582) in Oslo were included and compared with national data (n = 2025 and n = 575,572, respectively). Explained stillbirths (n = 165) and live births in Oslo served as controls for the cases of sudden intrauterine unexplained death (n = 76) in multiple logistic regression analyses., Results: One fourth of stillbirths remain unexplained. The risk of sudden intrauterine unexplained death (1/1000) increased with gestational age, high maternal age, high cigarette use, low education, and overweight or obesity. Primiparity and previous stillbirths or spontaneous abortions were not associated with sudden intrauterine unexplained death., Conclusions: Risk factors for sudden intrauterine unexplained death are identifiable by basic antenatal care. Adding unexplored stillbirths to the unexplained ones conceals several risk factors and underlines the necessity of a definition that includes thorough postmortem examinations.

Cot death is the most important cause of death during the first year of life after the newborn period in Norway. A case control study was performed by sending questionnaires to 188 cot death parents and 475 control parents with infants matched for age, sex and time of birth. 76% of the cot death parents and 79% of the control parents completed the questionnaires. The male/female ratio of the babies in both groups was 64/36. The age distribution showed a peak between two and four months. 65% succumbed during the winter months. During the winter 32% died outdoors. This was true for only 16% of those who died during summer. A higher proportion of the cot death cases than the controls were premature (more than eight weeks). 78% of the cot death victims usually slept prone, whereas this was true for only 50% of the controls (p < 0.01). 91% of the cot death victims were found dead in a prone position. When comparing live babies during the first three months of life, significantly more cot death mothers than control mothers had stopped breastfeeding. A larger proportion of the cot death victims than the controls had had apparent life threatening events (p < 0.01). Foam mattresses were equally frequent in both groups.