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Insulin aspart (NovoRapid®, NovoMix®, Novolog® and Fiasp®) is a fast-acting analog of human insulin, indicated in the treatment of type I and II diabetes. It is administered before meals to mimic the physiological insulin secretion that follows a rise in blood glucose. Its misuse for the purposes of suicide and murder and in the context of factitious order has often been described. In forensic medicine, the identification of insulin in biological samples has always been complex. In this paper, we present a case of suicide of a 64-year-old man who died after the injection of insulin aspart. He was suffering from terminal lung cancer and left a letter explaining the reasons for his suicide. Four empty NovoRapid® pens were found near the body. Body examination was unremarkable, and the femoral blood was collected in two dry Vacutainer™ tubes (red cap) and two sodium fluoride (NaF) tubes (gray cap). A liquid chromatography coupled to high-resolution mass spectrometry method was used to identify and discriminate insulin aspart from human insulin after immunopurification in the blood samples and in the pens. Blood specimens tested positive for insulin aspart with the concentrations of 36 and 37 ng/mL in dry tubes and 58 and 71 ng/mL in tubes containing NaF when tested ∼3 weeks after the collection of the specimens. The contents of the pens also matched with insulin aspart. The stability of insulin in blood is a critical point in the interpretation of the concentrations due to their rapid decrease caused by the activity of proteases in blood. During a degradation study implemented to compare three preservatives and dry tubes, suitable insulin aspart stability was observed with disodium salt of ethylenediaminetetracetic acid and NaF. Given that NaF is standard in forensic toxicology for measuring blood alcohol concentrations, the authors suggest its use for blood collection when insulin intoxication is suspected.

A 29-year-old man with no previous medical history was found dead at home. Anabolic products (tablets and oily solutions) and syringes were found at the scene. The man was known to train regularly at a fitness club and to use anabolic drugs. Following an unremarkable autopsy with normal histology, toxicological analyses were requested by the local prosecutor to provide further information. Blood, head hair (5 cm, black), body hair (axillary and leg) and toe and finger nail clippings were submitted to liquid and gas chromatography coupled to tandem mass spectrometry (LC and GC–MS-MS) methods to test for anabolic steroids. Blood tested positive for testosterone (4 ng/mL), boldenone (26 ng/mL), stanozolol (3 ng/mL) and trenbolone (

Resume Si la conquete de l’espace a marque la fin du millenaire precedant, la decouverte du monde aquatique est l’activite en plein essor depuis le debut des annees 2000. Au-dela de l’aspect economique du fait d’une richesse encore peu exploitee tant pour l’alimentation que pour les minerais, les mers et oceans sont des lieux fascinants qui attirent de plus en plus, a la surface (navigation) et sous l’eau (apnee, plongee). Ainsi, la plongee est devenue en quelques annees le sport incontournable a pratiquer. La notion de plongee loisir, developpee par l’organisme americain PADI (Professional Association of Diving Instructors), inclut des exigences precises en matiere de limites, de formation et d’equipement. Pour l’homme, il n’est pas possible de respirer sous l’eau sans un materiel adapte, qui doit aussi tenir compte des conditions environnementales, en particulier du froid. Du fait d’un nombre croissant de plongeurs certifies dans tous les pays du monde, il n’est pas surprenant que certains d’entre eux souffrent de pathologies diverses pendant leur activite. Il existe donc, pour la plongee, un certain nombre de contre-indications definitives, comme l’insuffisance cardiaque ou respiratoire, l’epilepsie ou des contre-indications temporaires. Parmi cette derniere categorie, la consommation de nombreux medicaments est repertorie comme a risque, comme les s-bloquants, les anti-arythmiques, certains antidiabetiques ou encore les anxiolytiques, les neuroleptiques et les antidepresseurs. Les auteurs rapportent un accident fatal de plongee chez une pratiquante reguliere (niveau 3) ou l’expertise toxicologique a mis en evidence du citalopram, un antidepresseur de type inhibiteur de la recapture de la serotonine, dose a 66 ng/mL, soit une concentration therapeutique. Une revue de la litterature, basee sur les bibliotheques classiques (PubMed, Web of science, Scopus) les sites de federations de plongee et les assureurs specifiques (DAN, AquaMed) a mis en evidence une pauvrete de l’information disponible, alors meme que les antidepresseurs, surtout de nouvelle generation, sont tres largement prescrits a la population generale.

Summary Selective androgen receptor modulators (SARMs) are a class of drugs presenting identical anabolic properties to usual anabolic steroids (testosterone, stanozolol, nandrolone…) in addition to marked reduced androgenic effects. These drugs have emerged in the doping area within the early 2000s. Ligandrol, ostarine, RAD-140 and andarine are the most popular agents belonging to this class. According to the world anti-doping agency (WADA) prohibited list, SARMs are prohibited at all times (i.e. in and out-of-competition) and are listed under the section S1.2 (other anabolic agents), a section that also contains clenbuterol. The compilation of the WADA testing figures reports from 2015 to 2019 has indicated a regular increase of adverse analytical findings (AAF) due to SARMs, particularly with ostarine and ligandrol. The implementation of highly sensitive chromatographic anti-doping analyses has induced high-profile challenges of anti-doping rules violations as athletes have claimed in numerous occasions that contamination was the reason for their AAF. As a result, hair tests were presented in order to establish the circumstances of these AAF. In case of an adverse analytical finding, hair testing can be a complement to document the claim of the athlete but of course, the result should not be considered as an alternative to urinalysis. This is because a negative hair result cannot exclude the use of the detected drug and cannot overrule the urine result. A review of the scientific literature, using the key words “SARMs” and “hair” has indicated that only 7 papers were published on this topic, including 3 dealing with equine hair. Although literature seems very limited, there is an increasing request for hair tests, which as prompted our laboratory to develop screening methods. Drugs are extracted from hair after decontamination under mild alkaline condition and submitted to LC-MS/MS and LC-HRMS assays. In this review, several original cases are provided, and the challenges of interpreting these findings are highlighted in light of the lack of controlled studies in the literature.

Objectifs En 2019, Salomone et al. [1] publiaient que la 4-anilino N-phenethyl-piperidine (4-ANPP), precurseur et metabolite de nombreux derives du fentanyl pouvait servir de marqueur d’exposition dans les cheveux a cette classe de molecules ultra-actives. Dans le cadre d’une intoxication fatale au fentanyl, les auteurs ont voulu verifier que la 4-ANPP pouvait egalement etre retrouvee dans d’autres matrices biologiques d’interet medicojudiciaire. En France et plus generalement en Europe, le fentanyl est moins frequemment responsable de deces qu’aux Etats-Unis et est principalement utilise comme analgesique chez les patients cancereux. Son usage detourne est surtout limite au personnel hospitalier, mais peut s’observer par diversion de patchs (Durogesic). Pour echapper aux regulations legales, le fentanyl fait partie des molecules les plus copiees et l’on retrouve, dans la grande famille des nouvelles substances psychoactives (NPS), plus d’une cinquantaine d’analogues, dont le carfentanil, le furanylfentanil ou encore l’ocfentanil. Face a cette proliferation et a la quasi-impossibilite pour un laboratoire de disposer de tous les standards de reference, la recherche ciblee de 4-ANPP semble etre un excellent moyen de depistage pour cette classe d’opioides. Methode Un homme de 36 ans est retrouve decede a son domicile, malgre l’intervention des services de secours. D’apres les temoins, l’individu aurait pu utiliser un patch de fentanyl en l’appliquant sous la langue. Il etait connu comme consommateur de produits stupefiants. Aucune cause traumatique de mort n’a pu etre constatee lors de l’autopsie et le Procureur de la Republique a requis une expertise toxicologique de reference a partir des prelevements classiques (sang femoral, sang cardiaque, urine, bile, contenu gastrique, cheveux noirs, de 4–5 cm, en vrac). Une methode analytique par UHPLC-MS/MS (Xevo TQD) permettant de doser le fentanyl et son metabolite primaire, le norfentanyl et d’identifier la 4-ANPP a ete utilisee. Tous les echantillons ont ete analyses apres une extraction par un melange ether diethylique/dichloromethane/hexane/alcool isoamylique (50/30/20/0,5) a pH 9,5, en presence de fentanyl-D5 et de norfentanyl-D5. Chaque compose a ete identifie par 2 transitions ioniques, dont m/z 281 > 188 et 281 > 105 pour le 4-ANPP. Seul le fentanyl et le norfentanyl ont ete quantifies, la caracterisation de la 4-ANPP etant uniquement qualitative au laboratoire (usage pour criblage). Resultats Le fentanyl a ete dose a 44 ng/mL dans le sang cardiaque et a 30 ng/mL dans le sang femoral, ce qui tend a demontrer une possible redistribution post-mortem avec un ratio de 1,5, la litterature retenant 1,6. Le norfentanyl est a 2 ng/mL dans les 2 echantillons de sang. On retrouve egalement le fentanyl et le norfentanyl dans les autres echantillons : urine (20 et 2 ng/mL), bile (112 et 10 ng/mL), contenu gastrique (101 et 1 ng/mL) et enfin cheveux (652 et 92 pg/mg). La 4-ANPP a ete retrouvee dans toutes les matrices biologiques et se revele donc etre un marqueur essentiel pour mettre en evidence une consommation de derives du fentanyl. Conclusion Les concentrations de fentanyl sont tres superieures aux concentrations therapeutiques usuelles et sont potentiellement letales par depression respiratoire, chez un sujet consommateur regulier de cette molecule. A ce jour, la police n’a pas identifiee la source du stupefiant. Les faibles concentrations de norfentanyl sont en faveur d’un deces rapide apres la consommation. Retrouvee dans toutes les matrices biologiques, la 4-ANPP confirme son statut de marqueur d’exposition aux derives du fentanyl. Quelques observations complementaires du laboratoire sur d’autres derives du fentanyl ont confirme cette approche, le concept etant qu’un criblage positif de la 4-ANPP donne lieu a des investigations tres poussees pour identifier la source.

Fire death investigations attempt to determine whether a subject was alive or dead before the fire started. Therefore, it is essential to assess if the bone damage is traumatic or the result of exposure to heat. This observational study aims to expose the specific CT semiology of thermal bone lesions to allow the forensic radiologist to identify and distinguish them from traumatic lesions that would have preceded death. We retrospectively reviewed the CT findings of 25 bodies with thermal bone lesions for which a postmortem computed tomography (PMCT) was performed prior to an autopsy. Imaging findings were correlated to the autopsy data to identify the specific features of thermal bone lesions. Specific signs of thermal injuries to bone were identified on PMCT on all deceased cases. Thermal damages predominated in areas directly exposed to flames (rib cage, distal extremities) with less soft tissue coverage (“soft tissue shielding”). The mottled appearance of bone marrow was a constant sign of burned bones. Heat fractures such as trans-diploic fractures of flat bones and beveled (“flute-mouthpiece”) fractures of extremities seemed specifically related to thermal mechanism. In addition, we provided a better description of superficial cortical fissures of flat bones (“ancient Chinese porcelain”) and observed a “stair step” fracture of a long bone until now undescribed in radiological literature. Thermal bone lesions have specific CT findings, different on several points from traumatic injuries. Their knowledge is essential for radiologists and forensic physicians to provide an accurate report of injury and conclusions.

3-Methoxyphencyclidine (3-MeO-PCP) is a new psychoactive substance that belongs to the phencyclidines family, first identified in Europe in 2012. This drug presents a stronger binding to N-methyl-D-aspartate (NMDA) receptors when compared to phencyclidine, which results in more potent effects, even at low concentrations. Very few articles have been published regarding 3-MeO-PCP in forensic toxicology. In this paper, the authors present a fatal 3-MeO-PCP intoxication case. In addition to the detection of the parent drug, metabolites were investigated in urine and, for the first time in the scientific literature, in blood. 3-MeO-PCP and its metabolites were quantitated by liquid chromatography-tandem mass spectrometry system (LC-MS/MS). Identification was confirmed by liquid chromatography-high resolution mass spectrometry (LC-HRMS). 3-MeO-PCP tested positive in femoral blood (3 525 ng/mL) and urine (7 384 ng/mL). The femoral blood concentration was higher than the fatal concentrations range already reported in the literature (from 50 to 3 200 ng/mL). 3-MeO-PCP metabolites, including O-demethyl-3-MeO-PCP, piperidine-OH-3-MeO-PCP, O-demethyl-piperidine-di-OH-3-MeO-PCP and piperidine-di-OH-3-MeO-PCP, were detected in blood. In addition, two new metabolites, O-demethyl-piperidine-OH-3-MeO-PCP and O-demethyl-cyclohexyl-OH, were identified in both blood and urine. Unfortunately, due to the lack of reference material on the market, it was not possible to measure the concentration of these metabolites. However, the ratios between the metabolites and the parent drug were useful to estimate their analytical response and prevalence. At this time, considering the low ratios (

A 59-year-old male was found dead at home, with two empty vials of an oily preparation obtained from a manufacturer from East Europe. There was no label on the vial. The subject was a former weightlifter, also known as an anabolic steroids abuser. The local prosecutor ordered a body examination, which was unremarkable, and allowed collecting femoral blood, urine and scalp hair (6 cm, brown). He was treated for cardiac insufficiency with quinidine. Biological specimens were submitted not only to standard toxicological analyses including a screening with liquid chromatography (LC)–quadrupole time of flight, but also to a specific LC–tandem mass spectrometry method for anabolic steroids testing. Ethanol was not found in both blood and urine. Quinidine blood concentration (791 ng/mL) was therapeutic. No drug of abuse was identified. In blood, testosterone was less that 1 ng/mL and no other steroid was identified. In urine, testosterone/epitestosterone was 1.56 and boldenone was present at a concentration of 9 ng/mL. The hair test results, performed on the whole length, demonstrated repetitive steroids abuse, including not only testosterone (140 pg/mg), testosterone propionate (605 pg/mg) and testosterone decanoate (249 pg/mg), but also boldenone (160 pg/mg), trenbolone (143 pg/mg) and metandienone (60 pg/mg). Since forensic laboratories have limited access to steroid urinary metabolite reference material due to specific regulations (to avoid testing athletes before anti-doping verifications), hair analyses seem to be the best approach to document anabolic agents abuse. Indeed, in hair, the target drug is the parent compound; in addition, when compared to blood or urine, this matrix has a much larger window of detection. The pathologist concluded cardiac insufficiency in a context involving repetitive abuse of anabolic drugs. This case indicates that more attention should be paid to anabolic steroids, in a context of sudden cardiac death.

For 40 years, hair tests have been presented as the best approach to document long-term consumption of a drug. This unique property has found numerous applications in clinical, forensic, and occupational toxicology. However, since the beginning of its implementation in biology, external contamination, with an associated risk of false positive result, has been presented as the key in the final interpretation. Evidence of environmental contamination and subsequent health issues can be the task of any toxicologist. Because of recent progress of analytical equipment, it is now possible to quantify drugs in hair with high level of accuracy and specificity at the pg/mg range. Therefore, segmental hair tests can be used to document environmental contamination and are the objective of this publication. In a family law case, N,N-dimethyltryptamine (DMT), a powerful hallucinogen, has been found in the hair of the partner of a repetitive DMT smoker at 4 to 13 pg/mg in 6 × 1 cm segments, with a regular increase of concentrations from the proximal to the distal hair end. The low measured concentrations and the particular pattern of DMT distribution along the hair shaft seem to be typical of environmental contamination, the older hair (those of the distal part) being for a longer time in contact with the drug. Despite strong decontamination, drugs from the environment can remain bound to the hair matrix and therefore be able to be used to document environmental contamination.

For several years, the misuse of stimulant substances is increasingly observed both in the field of sport, to improve the functions of the body and therefore to be more performant, and also by non-athletes to make life more tolerable on a daily basis. Adrafinil, 2-((diphenylmethyl)sulfinyl)-N-hydroxyacetamide, is a drug designed for the treatment of narcolepsy by promoting an awakened state, and to treat alertness and neurological symptoms in the elderly. It is primarily metabolized in vivo to an active form, i.e. modafinil, 2-((diphenylmethyl)sulfinyl)acetamide. The World Anti-Doping Agency (WADA) banned these two drugs in sports in 2004. The authors report an authentic case involving adrafinil and modafinil. The laboratory was requested to test for adrafinil in a hair strand collected from a woman found in possession of vials of adrafinil and suspected of trafficking. A specific method was developed by liquid chromatography tandem mass spectrometry (LC-MS/MS). Unlike modafinil (varying from 6.8 to 13.9 ng/mg), adrafinil was not identified in the strand. The interpretation of the results was difficult because this is the first case describing human hair analysis. In order to be able to interpret the results, a self-administration study was conducted after an oral administration to a volunteer (200 mg) whose beard hair was collected 10 days after administration. The analysis of this specimen highlighted the presence of adrafinil at 0.8 ng/mg and modafinil at 0.5 ng/mg. These results demonstrate the dual identification of both compounds after a single consumption, even after administration of a low dose. According to these results, the analysis of the hair strand from the authentic case does not match with a consumption of adrafinil, in accordance with abuse of modafinil alone. Intelligence considered that this was a trafficking case of adrafinil, with no self-consumption.

Ostarine, also known as S22 or MK2866 and enobosarm, is a selective androgen receptor modulator (SARM). It has high anabolic potency, in addition to limited androgenic effects. At this time, ostarine has no therapeutic use, but can be abused for performance-enhancing purposes using the oral route, at dosages of 10-25 mg per day. As the drug can easily be obtained via the Internet or some fitness centers, athletes and more and more amateurs can use it without undergoing the deleterious physiological side effects that are generally associated with testosterone-related compounds. Since 2008, the World Anti-Doping Agency (WADA) has prohibited SARMs at-all-times in the category of "other anabolic agents" under section S1.2 of the WADA List. In a case of trafficking/abuse, ostarine was identified in nail (subject 1) and hair (subject 2) by LC/HRMS after incubation of 50 mg of matrix in a pH 9.5 buffer, followed by extraction with organic solvents. The drug was quantitated by LC-MS/MS. Ostarine tested positive at 61 pg/mg (toenails) and 111 pg/mg (fingernails) for subject 1. Ostarine was present at 146, 168, 93, and 101 pg/mg in the 4 × 3 cm hair sections of subject 2, clearly demonstrating long-term use.

Resume Les auteurs rapportent le cas d’une patiente de 29 ans traitee par rilpivirine pour une infection au VIH et presentant un syndrome de cushing iatrogene peu de temps apres l’instauration du budesonide. Devant l’hypothese d’une possible accumulation de budesonide dans l’organisme, les auteurs ont mis en avant une interaction entre un glucocorticoide de synthese et un inhibiteur non nucleosidique de la transcriptase inverse (NNRTI), le budesonide et la rilpivirine. Cette evaluation a ete realisee in vitro par des microsomes hepatiques humains. Les medicaments ont ete administres a des doses therapeutiques. Les cliniciens ont suppose que le syndrome de cushing iatrogene pouvait etre la consequence d’une accumulation de budesonide dans l’organisme. Dans un premier temps, afin de caracteriser sur le plan chromatographique (temps de retention, transitions) les deux metabolites principaux du budesonide (16α-OH-prednisolone et 6s-OH-budesonide), un volontaire sain a consomme 2,2 mg de budesonide, et ses urines sont prelevees durant 24 h. Une methode originale par UHPLC/MS-MS a ainsi ete mise en place. Dans un second temps, la possible interaction entre la rilpivirine et le budesonide est evaluee avec comme support des microsomes hepatiques humains (HLMs). Il est observe, lors de l’incubation simultanee, une diminution de la production des deux metabolites du budesonide et d’une accumulation de la molecule mere. Avec une concentration en rilpivirine a 10 mg/L, il est observe une augmentation de la reponse en budesonide de 41,4 % alors que celle des metabolites diminue, de 69,0 % pour le 16α-OH-prednisolone et de 59,2 % pour le 6s-OH-budesonide. Il a ete conclu que la rilpivirine est un inhibiteur probable du cytochrome CYP3A4, et agit ainsi sur la metabolisation du budesonide. Cette observation apparait comme la premiere etude existante permettant de prouver l’interaction in vitro entre ces deux molecules.

A 23-month-old boy was brought to a medical center by his mother, as she noticed that the father has gripped him around the neck and this had left marks. As a result of this, a child protection medical examination was requested. However, there was a significant chronology of mental health issues in the mother. Among the mother’s medications, quetiapine and propranolol were the more active. Given a consultant pediatrician was concerned that the boy was vulnerable and potentially has experienced neglect and physical harm, the local authority instructed a hair test to document possible poisoning. However, this occurred several months later, due to court delays (postponed hearings and decisions) when the child was 32-month old. The laboratory received a strand of hair of the child (12 cm in length, light brown in color) and a strand of hair of the mother (>20 cm in length, dark in color) with the request to test both specimens by segmentation (12 x 1 cm) for quetiapine, an anti-psychotic drug and propranolol, a β-blocker agent. After decontamination and segmentation, the specimens were incubated in borate buffer pH 9.5 and extracted by a mixture of ether/dichloromethane/hexane/isoamyl alcohol to test for the drugs, including norquetiapine by a specific LC–MS-MS method. The first 3 cm segments of the child’s hair were free of drug, roughly corresponding to the period he was no more in contact with the mother. Propranolol tested positive in the other segments at 15–72 pg/mg, with a linear increase from the proximal to the distal end. This was also observed for quetiapine, with concentrations in the range 10–18 pg/mg. Norquetiapine was never identified in the child’s hair. The following concentrations were observed in the mother’s hair: 6028–10,284, 910–4576 and 1116–6956 pg/mg for propranolol, quetiapine and norquetiapine, respectively. This confirmed that the donor was a long-term repetitive user of propranolol and quetiapine. The hair test results have indicated that the child was in contact with propranolol and quetiapine for a long period. It is not possible to put a temporal period for each segment, as the hair growth at the age of 32 months is not the same as for an adult (difference in the duration of the anagen period), nor to put any quantitative dosage or frequency of exposure(s) when interpreting the data. An increase of concentrations from root to tip was observed which is considered highly indicative of external contamination, with the older hair segments (those which are the more concentrated) being in contact for a longer time with contaminated items (hands of the mother, home items such as furniture, dishes, beddings, etc.). Overinterpreting drug findings in hair can have very serious legal implications in child protection cases, particularly when no other toxicological test and no clinical report exist to support voluntary administration of drugs. Whatever the findings, a proper interpretation of hair test results is critical and should be done ideally with other information available, such as medical history, witness statements and the available circumstances of the matter. A single hair test should not be used to determine long-term exposure to a drug.

An athlete challenged the result from an in-competition doping test which returned with an adverse analytical finding for stanozolol, claiming it was due to supplement contamination. Her lawyer asked the laboratory to analyze several hair specimens simultaneously collected from five different anatomical regions, head, arm, leg, pubis and armpit, to document the pattern of drug exposure. A specific UPLC–MS-MS method was developed. After decontamination with dichloromethane, stanozolol was extracted from hair in the presence of stanozolol-d3 used as internal standard, under alkaline conditions, with diethyl ether. Linearity was observed for concentrations ranging from 5 pg/mg to 10 ng/mg. The method has been validated according to linearity, precision and matrix effect. Concentrations of stanozolol in head hair, pubic hair, arm hair, leg hair and axillary hair were 73, 454, 238, 244 and 7,100 pg/mg, respectively. The concentration of stanozolol in head hair is in accordance with data published in the literature. When comparing the concentrations, body hair concentrations were higher than the concentration found in head hair. These results are consistent with a better incorporation rate of stanozolol in body hair when compared to head hair. The simultaneous positive concentrations in different hair types confirm the adverse analytical finding in urine of the top athlete, as the measured concentrations do not support the theory of contamination. For the first time, an anabolic agent was simultaneously tested in hair collected from five different anatomical regions from the same subject, with a large distribution of concentrations, due to anatomical variations, and these findings will help interpretation in further doping cases when documented with hair.

Insulin aspart (Novorapid ®, NovoMix®, Novolog® and Fiasp®) is a fast-acting analog of human insulin, indicated in the treatment of type I and II diabetes. It is administered before meals to mimic the physiological insulin secretion that follows a rise in blood glucose. Its misuse for the purposes of suicide, murder and in the context of factitious order has often been described. In forensic medicine, the identification of insulin in biological samples has always been complex. In this paper, we present a case of suicide of a 64-year-old man who died after the injection of insulin aspart. He was suffering from terminal lung cancer and left a letter explaining the reasons of his suicide. Four empty Novorapid® pens were found near the body. Body examination was unremarkable and femoral blood was collected in 2 dry Vacutainer tubes (red cap) and 2 sodium fluoride tubed (grey cap). A LC-HRMS method was used to identify and discriminate aspart insulin from human insulin after immunopurification in the blood samples and in the pens. Blood aspart insulin tested positive at 36 and 37 ng/mL in dry tubes, and at 58 and 71 ng/mL in tubes containing sodium fluoride when tested about 3 weeks after collection of the specimens. The contents of the pens also matched with insulin aspart.The stability of insulin in blood is a critical point in the interpretation of the concentrations due to their rapid decrease caused by the activity of proteases in blood. During a degradation study implemented to compare 3 preservatives and dry tubes, suitable insulin aspart stability was observed with EDTA and NaF. Given NaF is standard in forensic toxicology for measuring blood alcohol concentrations, the authors suggest its use for blood collection when insulin intoxication is suspected.

A 29-year-old man with no previous medical history was found dead at home. Anabolic products (tablets and oily solutions) and syringes were found at the scene. The man was known to train regularly at a fitness club and to use anabolic drugs. Following an unremarkable autopsy with normal histology, toxicological analyses were requested by the local prosecutor to provide further information. Blood, head hair (5 cm, black), body hair (axillary and leg), and toe and finger nail clippings were submitted to LC and GC-MS-MS methods to test for anabolic steroids. Blood tested positive for testosterone (4 ng/mL), boldenone (26 ng/mL), stanozolol (3 ng/mL) and trenbolone (1 ng/mL). Segmental head hair tests (2 x 2.5 cm) revealed a repeated consumption of testosterone (65-72 pg/mg), testosterone propionate (930-691 pg/mg), testosterone isocaproate (79 pg/mg-5 pg/mg), nandrolone decanoate (202-64 pg/mg), boldenone (16 pg/mg), stanozolol (575-670 pg/mg), trenbolone (4 pg/mg-not detected), drostanolone (112-30 pg/mg), drostanolone enanthate (26-5 pg/mg) and drostanolone propionate (15-4 pg/mg). In addition to the substances identified in head hair, testosterone decanoate, testosterone cypionate and nandrolone were identified in both body hair and nails. The experts concluded that the manner of death can be listed as toxic, due to massive repetitive use of anabolic steroids during the previous months. For anabolic agents, blood does not seem to be the best matrix to document a fatal intoxication. Indeed, these products are toxics when long term abused and are known to cause cardiac, hepatic and renal diseases. When compared to blood, hair and nails have a much larger window of detection. Therefore, keratinous matrices seems to be the best approach to test for anabolic steroids when a sudden death is observed in a context of possible abuse of steroids.

Fingerprints are invisible traces that result from a deposition of sweat and sebum present on the papillary ridges. As sweat and sebum contain drugs, fingerprints are promising since collection is rapid, non-invasive and difficult to falsify. Very limited data are available in the literature, and therefore, it seems opportune to study the transfer of xenobiotics onto the items taken in hand via the fingerprints. Two studies were implemented using the ballpoint pen as a model. The objective of the first study was to compare the nicotine concentrations found on the pens of three smokers and three non-smokers. Five pens, belonging to each subject and used regularly, were rubbed with a cotton swab dipped in methanol and analyzed by liquid chromatography coupled with tandem mass spectrometry (LC–MS-MS). The second study was to analyze the transfer via fingerprints of four volunteers, after administration of 30 mg of codeine. The objective was to determine the feasibility of this study and the time corresponding to the highest concentration of codeine. Over a 24-h period, new pens were handled for 5 min by the four volunteers, rubbed with a cotton swab dipped in methanol, and then analyzed by LC–MS-MS. The nicotine study showed a major difference between the nicotine concentrations obtained from smokers (between 6 and 276 ng/pen) and non-smokers (between 2 and 4 ng/pen). After administration of 30 mg of codeine, the analysis of the pens of the four volunteers allowed to demonstrate the presence of codeine up to 24 h between 9 and 544 pg/pen. Normal hygiene practices did not influence the final result. The highest concentration was observed after 2 h. Morphine was also detected (between 19 and 33 pg/pen). These preliminary results should be considered a demonstration of the interest of fingerprints testing to document drug exposure.

Oral antidiabetics are the drugs used to control blood sugar in diabetic subjects. The greatest risk of using these drugs is hypoglycaemia, which can be fatal if managed inappropriately. The diagnosis of hypoglycemia may be simple in diabetic subjects but can become a challenge in subjects with no history of exposure to these drugs. The major interest of testing for these compounds in hair is in the case of unexpected hypoglycaemias, as it enables discrimination between hypoglycaemias caused by antidiabetics and other reasons (e.g. insulinoma). Therefore it is important for a toxicology laboratory to screen for antidiabetics in hair due to the large window of detection this matrix allows associated to its long stability over time. In this study, a method has been developed and validated using liquid-chromatography coupled to tandem mass spectrometry for the analysis of 13 oral antidiabetics in hair. After addition of three different internal standards (hydroxy-tolbutamide-d9 for sulfonylureas, repaglinide-ethyl-d5 for glinides and vildagliptin-d3 for gliptins) and incubation in an ultrasonic bath in methanol, the hair was dissolved in NaOH and then subjected to liquid-liquid extraction. The validation procedure demonstrated an acceptable linearity for all compounds between 1 and 50,000 pg/mg. LOD and LOQ were between 0.5 and 5 pg/mg and 1-10 pg/mg respectively. Repeatability and reproducibility were below 20 % at two concentrations for all the analytes. The method was successfully applied to the hair of 18 diabetic patients under treatment of oral antidiabetics. The hair tested positive for gliclazide (3-21,400 pg/mg), sitagliptin (1.4-1.8 pg/mg), vildagliptin (3.3 - 1,740 pg/mg) and repaglinide (14.1 pg/mg).

Tizanidine, an imidazoline derivative close to clonidine, is a central alpha-2 adrenergic receptor agonist. Therapeutically, the drug is used as a muscle relaxant under the trade names Sirdalud™ or Zanaflex™. The drug is not prohibited by the World Anti-Doping Agency but, for therapeutic purposes, can only be obtained via a nominative temporary use authorization. The French public health police requested the laboratory to test for tizanidine in head hair specimens collected from international racing cyclists. Using Liquid chromatography-tandem mass spectrometry (LC/MS-MS) and confirmation by liquid chromatography-high-resolution mass spectrometry (LC/HRMS), after pH 9.5 borate buffer overnight incubation of 20 mg and subsequent solvents extraction, tizanidine was identified in the hair of three athletes at 1.1, 3.7, and 11.1 pg/mg. This is the first evidence that tizanidine is incorporated in human hair. However, it was not possible to interpret the data in terms of doses and frequency of use due to a lack of controlled study.

Although it has been published during the last 15 years that hallucinogens derived from new psychoactive substances are increasingly abused, the old psychedelic agents are still used. Among these vegetal compounds, magic mushrooms are frequently mentioned. The major ingredient of the Psilocybe species is psilocybin, which is rapidly converted into psilocin in the human body. Therefore, psilocin represents the key target to document magic mushrooms abuse. The aim of the present work was to develop a specific method to identify psilocin in human hair by LC-MS/MS and review potential pitfalls. The method involves incubation of 10 mg of cut hair in 1 mL of acid methanol in presence of psilocin-d10 for 2 h at 4 °C. The chromatographic separation was performed using a reverse phase column HSS C18 with a gradient elution of 8 min. Linearity was verified from 1 to 200 pg/mg (r2 = 0.9994), after spiking blank hair with the corresponding amounts of psilocin. The limit of detection was estimated at 0.4 pg/mg. The precision was lower than 20 % and there was no interference with any extractable material present in hair. Psilocin was identified in the hair of a repetitive magic mushrooms consumer at 2.5 pg/mg (segment 0–1 cm), 4.4 pg/mg (segment 1–2 cm) and 5.4 pg/mg (segment 2–3 cm). Cold conditions during hair preparation and protection from the light were found mandatory to avoid psilocin degradation.

A 43-year-old male, sport coach, presented him-self at the Emergency unit of a local hospital for epigastric pain, myalgia pain and severe headache. He claimed having used for some days a combination of GW1516 (cardarine), a peroxisome proliferator-activated receptor delta agonist (PPAR- δ) and MK2866 (ostarine), a selective androgen receptor modulator (SARM) to gain skeletal muscles. Cytolysis with marked increase of alanine aminotransferase or ALT (up to 922 UI/L) and aspartate aminotransferase or AST (up to 2558 UI/L) and massive rhabdomyolysis with elevated creatine phosphokinase or CPK (up to 86435 UI/L) were the main unusual biochemistry parameters. Using a specific liquid chromatography coupled to tandem mass spectrometry method, cardarine and ostarine tested positive in blood at 403 and 1 ng/mL, respectively. In urine, due to extensive metabolism, the parent GW1516 was not identified, while ostarine was at 88 ng/mL. Finally, both drugs were identified in hair (2 cm in length, brown in colour), at 146 and 1105 pg/mg for cardarine and ostarine, respectively. This clearly demonstrates repetitive abuse over the last 2 months. Asthenia was persistent for 2 weeks and 6 weeks after the admission, the subject fully recovered.

Promazine is one of the oldest phenothiazine derivatives that have been proposed for the treatment of various psychiatric disorders. The drug is available as tablets, as syrups and in injectable forms. Despite its prescription to millions of subjects, its detection in human hair has seldom been reported. The aim of the present work is to develop a specific method to identify promazine in human hair by liquid chromatography–tandem mass spectrometry and to apply it to a patient who was self-medicating. The method involves overnight incubation of 20 mg of cut hair in 1 mL of pH 9.5 borate buffer in the presence of amitriptyline-d3 at 40°C. The chromatographic separation was performed using a reverse phase column HSS C18 with a gradient elution for 15 min. Linearity was verified from 0.5 to 500 pg/mg (r2 = 0.9996), after spiking blank hair with the corresponding amounts of promazine. The limit of detection was estimated at 0.1 pg/mg. The precision was lower than 20%. Promazine was detected in the hair of a psychotic subject at 228–270 pg/mg in a 3 × 1 cm segment. Given this was a patient who was self-medicating, her physician requested an immediate drug discontinuation. In a fresh hair specimen collected 3 months later, the proximal segment (0–1 cm) tested positive at 0.9 pg/mg, clearly indicating that the time to obtain a negative result after promazine discontinuation is about 3–4 months.

Hair testing is a complementary approach to document doping agent(s) use All prohibited substances but hormones should be detectable in hair Interest and limitations of hair testing for doping agents are reviewed based on the authors' experience Although a lot of data are available for drugs of abuse, controlled studies are missing for anabolic steroids, diuretics and some unusual classes of substances.

Introduction: Chloramphenicol (2,2-dichloro-N-[1,3-dihydroxy-1-(4-nitrophenyl)porpan-2-yl]acetamide) is a bacteriostatic antibiotic of the phenicolated family, used in the past to treat meningitis, plague, cholera, or typhoid fever. Treatment with chloramphenicol can have life threatening side effects, the most serious of which is aplastic anemia, which may be fatal. For this reason, the antibiotic was removed from the French market in 2008.Case report: In this paper, the authors report the case of a woman consuming chloramphenicol possibly in the context of factitious disorder. After a capsule containing chloramphenicol was discovered in her hospital bed, a hair specimen (about 16 cm, brown, not oriented) was collected and sent to the toxicological laboratory in order to document exposure to chloramphenicol.Results: The drug was identified in the hair specimen of the subject at 13.7 ng/mg.Discussion: Identification of chloramphenicol in hair has not been reported in the literature. As consequence, the interpretation of the concentration, the dosage and the frequency of abuse are difficult to establish.Conclusion: Given the context, physicians considered the case as a possible factitious disorder, thus being a unique observation of using chloramphenicol in such a context.

Summary In recent years, the recreational use of new psychoactive substances (NPS) has increased all around the world. They are designed to cause similar effects to controlled drugs and are considered as alternative to illegal drugs. Among NPS, derivatives of cathinone, one of the psychoactive ingredients of the plant khat, have emerged in the recreational drug market. 3-methylmethcathinone or 3-MMC is a structural isomer of mephedrone (4-MMC) and a psychostimulant and hallucinogenic drug. Furthermore, to get intense recreational effect, 3-MMC can often be combined with other drugs, by chemsex practitioners. Users report a soft feeling of energy and increased concentration, as well as a feeling of well-being, euphoria and unbridled libido. There is a risk of significant psychological dependence after repetitive 3-MMC exposures. Very limited data about clinical, psychological and forensic aspects of 3-MMC abuse are available in the medical literature. The authors report 4 cases of subjects abusing 3-MMC and other drugs, involving two intoxications and two deaths. Biological samples were analysed by ultra-high performance liquid chromatography system coupled to a tandem mass spectrometry (UPLC-MS/MS™). 3-MMC was detected in concentrations ranging from 3 to 613 ng/mL in blood, and from 14 pg/mg to 17.1 ng/mg in hair. In view of these values, and those from the very limited literature, it is difficult to establish an impairment concentration or a lethal threshold of 3-MMC.

Summary Novel substances of performance have appeared since the 1960s. These substances are synthesized from anabolic androgenic steroids and are presented as designer steroids. They are used by top athletes for doping purposes as they increase lean body mass, strength, aggressiveness and lead to a shorter recovery time between workouts, but also by amateurs to improve their body aesthetic. Indeed, the use of designer steroids enables to improve performance and increase muscle mass. However, an overconsumption can cause health issues such as testicular cancer, hypogonadism or neuro-psychic disorders, including domestic violence. The designer steroids are available on the internet as dietary supplements. Their easy access and the difficulty of their detection is a big challenge for toxicological and forensic laboratories. The use of these drugs is problematic for doping, clinical and forensic aspects. As it is the case with other new psychoactive substances, obtaining reference material can be a challenge for toxicology laboratories. This short review of the literature aims to highlight some issues related to the abuse of designer steroids.