Population-based study of police-reported sexual assault in Baltimore, Maryland

OBJECTIVE: To document the population-based incidence of sexual assault in Baltimore, Md, victims' alcohol/drug use, and pre-event circumstances. METHODS: Between 1997 and 1999, the city's sexual assault treatment center treated 1,038 victims (age>or=13 years). Data were extracted from forensic narratives. Analysis was restricted to frequency tables and bar graphs. Incidence was calculated based on 1998 population figures. RESULTS: The incidence of sexual assault among females aged 13 years or older was 117 per 100,000. Seventy percent of patients were less than 30 years old. Fifty-three percent tested positive for alcohol/drugs. Two thirds sustained physical or genital injury; 30% sustained both. The most common pre-event circumstances were walking/being followed (27%) and visiting a friend's home (24%). CONCLUSION: This study revealed a high prevalence of physical/genital injury, supporting the call for an injury severity scale for sexual assault and for increased substance abuse counseling and educational/health resources to mitigate sexual assault and offer meaningful response when such crimes occur.     

Drug-facilitated sexual assault ('date rape')

In the past few years, drug-facilitated sexual assaults have received widespread media coverage. In addition to alcohol, the most frequently used date-rape drug, flunitrazepam (Rohypnol), a fast-acting benzodiazepine, and gamma-hydroxybutyrate (GHB) and its congeners are among the most popular drugs used for this purpose. The latter drug is easily procured at some gymnasiums, popular bars, discos, and rave clubs, as well as over the Internet. Perpetrators choose these drugs because they act rapidly, produce disinhibition and relaxation of voluntary muscles, and cause the victim to have lasting anterograde amnesia for events that occur under the influence of the drug. Alcoholic beverages potentiate the drug effects. We review several date-rape drugs, provide information on laboratory testing for them, and offer guidelines for preventing drug-facilitated sexual assault.     

Determination of the designer drugs 3, 4-methylenedioxymethamphetamine, 3,4-methylenedioxyethylamphetamine, and 3,4-methylenedioxyamphetamine with HPLC and fluorescence detection in whole blood, serum, vitreous humor, and urine

BACKGROUND: The popular designer drugs 3, 4-methylenedioxymethamphetamine (MDMA) and 3, 4-methylenedioxyethylamphetamine (MDEA) can be determined in serum, whole blood, and urine, but also in vitreous humor. The latter matrix is interesting when dealing with decomposed bodies in a toxicological setting. METHODS: After extraction, chromatographic separation was achieved on a narrow-bore C(18) column by gradient elution with fluorometric detection; results were confirmed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). RESULTS: The method was linear over the range of 2-1000 microg/L for whole blood, serum, and vitreous humor, and 0.1-5 mg/L for urine. Extraction recoveries were >70%, imprecision (CV) was 2.5-19%, and analytical recoveries were 95.5-104.4%. The limit of detection (LOD) and the limit of quantification (LOQ) were 0.8 and 2 microg/L, respectively, for whole blood, serum, and vitreous humor, and 2.5 microg/L and 0.1 mg/L, respectively, for urine. Excellent correlations between the quantitative LC-fluorescence and LC-MS/MS results were obtained. We found the following concentrations in a thanatochemical distribution study in rabbits: in serum, 5.3-685 microg/L for MDMA and from the LOQ to 14.5 microg/L for 3, 4-methylenedioxyamphetamine (MDA); in whole blood, 19.7-710 microg/L for MDMA and from the LOQ to 17.8 microg/L for MDA; in vitreous humor, 12.1-97.8 microg/L for MDMA and from the LOQ to 3.86 microg/L for MDA. In routine toxicological urine samples, concentrations ranged from LOQ to 14.62 mg/L for MDA, from LOQ to 157 mg/L for MDMA, and from LOQ to 32.54 mg/L for MDEA. CONCLUSIONS: The HPLC method described is sensitive, specific, and suitable for the determination of MDMA, MDEA, and MDA in whole blood, serum, vitreous humor, and urine.     

The involvement of drugs and alcohol in drug-facilitated sexual assault: a systematic review of the evidence

The rate of drug-facilitated sexual assault (DFSA; when an incapacitating drug is administered surreptitiously to facilitate sexual assault) is perceived to be increasing in the United Kingdom and elsewhere, causing international concern. This article examines evidence that quantifies the contribution of drugs in instances of alleged DFSA, identifies the substances involved, and discusses the implications of these findings. Of 389 studies examined, 11 were included in this review. The only study to consider covert drugging reported that 2% of alleged DFSA cases were attributable to surreptitious drug administration. Other studies failed to remove voluntary drug consumption from their cohort, biasing results. A study by the United Kingdom's National Forensic Services found no evidence to suggest that flunitrazepam (Rohypnol) had been used for DFSA during its 3-year investigation. In the United States, flunitrazepam is used recreationally, providing a likely explanation for its presence in samples of some alleged DFSA victims.     

Comparison of ELISAs for opiates, methamphetamine, cocaine metabolite, benzodiazepines, phencyclidine, and cannabinoids in whole blood and urine

BACKGROUND: ELISAs are widely utilized in forensic drug analysis. A comparative assessment of microtiter plate assays for the detection of six common classes of drug in blood and urine is described. METHODS: ELISAs for opiates, methamphetamine, benzodiazepines, cocaine metabolite, phencyclidine (PCP), and tetrahydrocannabinol (THC) metabolite were evaluated in a side-by-side study. The analytical performance of 12 commercially available ELISAs was determined in terms of binding characteristics, dose-response curves, limits of detection, sensitivity, intra- and interassay imprecision, and lot-to-lot reproducibility. Assay performance was also compared using 855 forensic casework samples. RESULTS: Detection limits in whole blood for morphine, D-methamphetamine, nordiazepam, benzoylecgonine, nordiazepam, PCP, and L-11-nor-9-carboxy-delta9-THC were 3, 2, <4, 5, 25, and 3 microg/L, respectively, for the STC ELISAs. Corresponding detection limits for Immunalysis ELISAs were <1, <2, <4, 5, <1, and 1 microg/L, respectively. Intraassay CVs (n = 8) at the immunoassay cutoff concentrations were 4.1-5.6% and 3.5-11% for STC and Immunalysis ELISAs, respectively. Corresponding interassay CVs were 3.1-10% and 6.5-20%. Of the 855 casework samples, there were a total of 92 discordant results (44 cannabinoid, 15 opiate, 15 methamphetamine, 11 benzodiazepine, and 7 cocaine metabolite). Gas chromatography-mass spectrometry analysis indicated a total of three unconfirmed positive results for Immunalysis assays and one unconfirmed positive for STC assays. CONCLUSIONS: A comparative assessment of drugs-of-abuse assays from two manufacturers indicated some key differences in analytical performance. Overall, Immunalysis assays offered superior binding characteristics and detection limits, whereas STC assays offered improved overall precision and lot-to-lot reproducibility.     

Sexual Assault Nurse Examiner/Forensic Nurse Hospital-based Staffing Solution: A Business Plan Development and Evaluation

Nationally and internationally, providing competent and sustainable sexual assault nurse examiner/forensic nurse coverage has been a shared challenge. This project, “Sexual Assault Nurse Examiner/Forensic Nurse Hospital-based Staffing Solution: A Business Plan Development and Evaluation,” provides an example for assessment, construction, implementation, and evaluation of a business plan for a sustainable sexual assault nurse examiner/forensic nurse staffing solution. By using preexisting float pool positions and converting them to sexual assault nurse examiner emergency nurses, coverage for sexual assault nurse examiner examinations in a 16-hospital health system was established, which decreased sexual assault nurse examiner turnover related to burnout while increasing the sustainability of sexual assault nurse examiner nurses who provided quality care to patients who had experienced a sexual assault, domestic or intimate partner violence, elder or child abuse or neglect, assault, strangulation, or human trafficking. Implementation of the business plan resulted in a 179% increase in completed sexual assault nurse examiner examinations and a 242% increase in all types of completed forensic examinations from 2015 to 2019 as 7 new community hospitals were added to the health system. A sum of more than $20 000 allocated for training new sexual assault nurse examiners/forensic nurses was saved per year by using a sexual assault nurse examiner emergency nurse. By creating a supportive structure that fosters and sustains sexual assault nurse examiners/forensic nurses, both medical and mental health concerns can be addressed through trauma-informed care techniques that will affect lifelong health and healing as well as engagement in the criminal justice process for patients who have experienced sexual assault, abuse, neglect, and violence.     

Pediatric sexual assault nurse examiner care: Trace forensic evidence, ano-genital injury, and judicial outcomes

Introduction: Although pediatric sexual assault nurse examiners (P-SANEs) have been providing care for over two decades there remain major gaps in the literature describing the quality of P-SANE care and legal outcomes associated with their cases. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P-SANE program described in terms of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault. Method: A retrospective review of medical and legal records of all patients presenting to the PED at Nationwide Children's Hospital with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 was conducted. Findings: Detection and documentation of ano-genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis was significantly improved since implementation of the P-SANE Program compared to the historical control. Discussion: The addition of a P-SANE to the emergency department (ED) provider team improved the quality of care to child/adolescent victims of acute sexual abuse/assault.     

Analysis of catecholamines in urine by positive-ion electrospray tandem mass spectrometry.

BACKGROUND: Determination of urinary catecholamines (CATs) is considered important for clinical diagnosis of pheochromocytoma, paraganglioma, and neuroblastoma. The major disadvantages of existing tests include relatively long instrumental analysis time and potential interference from drugs and drug metabolites that are structurally similar to CATs. METHODS: CATs were extracted from a 300-microL aliquot of urine by a two-step liquid-liquid extraction method specific for compounds containing a catechol group. Chromatographic separation did not require the use of ion-pairing reagents, which typically hinder MS detection but are frequently used in HPLC analysis of CATs. Instrumental analysis was performed by electrospray ionization tandem mass spectrometry (ESI-MS/MS) in the multiple-reaction monitoring mode. Stable-isotope-labeled CATs were used as internal standards. RESULTS: Epinephrine (E), norepinephrine (NE), and dopamine (D) were measured within 3.5 min instrumental run time. Quantification limits were 2.5 microg/L for E and D and 10 microg/L for NE. The total imprecision (CV) was < or =9.6%; extraction recoveries were 71% +/- 12%. CONCLUSIONS: HPLC with ESI-MS/MS in combination with sample preparation specific to catechol group-containing compounds allows rapid testing for disorders associated with increased CAT concentrations. The method is free of interferences from drugs and drug metabolites, which commonly interfere with HPLC methods.     

Simultaneous determination of betaine and N,N-dimethylglycine in urine

A method is described for the determination of betaine and its metabolite N,N-dimethylglycine in human urine. The method involves a deamination step and a solid-phase extraction to isolate both substances from urine followed by high performance liquid chromatography (HPLC) separation on a 5-μm SCX column with UV absorbance detection. Limit of detection is about 0.9 μg for both substances. Recoveries were > 85%. The method appears to be suitable for monitoring betaine and its metabolite in urine of patients undergoing therapy with betaine.     

Analysis of nicotine, 3-hydroxycotinine, cotinine, and caffeine in urine of passive smokers by HPLC-tandem mass spectrometry

BACKGROUND: A method is described for the simultaneous analysis of nicotine and two of its major metabolites, cotinine and 3-hydroxycotinine, as well as for caffeine from urine samples. The method was developed to assess exposure of restaurant and hotel workers to environmental tobacco smoke. METHODS: The method includes sample pretreatment and reversed-phase HPLC separation with tandem mass spectrometric identification and quantification using electrospray ionization on a quadrupole ion trap mass analyzer. Sample pretreatment followed standard protocols, including addition of base before liquid-liquid partitioning against dichloromethane on a solid matrix, evaporation of the organic solvent using gaseous nitrogen, and transferring to HPLC vials using HPLC buffer. HPLC separation was run on-line with the electrospray ionization-tandem mass spectrometric detection. RESULTS: The detection limits of the procedure were in the 1 microg/L range, except for nicotine (10 microg/L of urine). Still lower detection limits can be achieved with larger sample volumes. Recoveries of the sample treatment varied from 99% (cotinine) to 78% (3-hydroxycotinine). CONCLUSIONS: The method described is straightforward and not labor-intensive and, therefore, permits a high throughput of samples with excellent prospects for automation. The applicability of the method was demonstrated in a small-scale study on restaurant employees.     

The forensic exam: assessing health characteristics of adult female victims of recent sexual assault

Sexual assault of women is a major problem in the United States, and information about characteristics of adult female sexual assault victims who report and undergo a forensic exam is lacking. This study describes the health characteristics of recent adult female sexual assault victims who received a forensic exam and/or prophylactic treatment at a sexual assault center located in a southern urban area.     

Evaluation of a rapid gas-chromatographic method for the simultaneous quantitative determination of ethosuximide,phenyletheylmalonediamide, carbamazepine,phenobarbital, primidone and diphenylhydantoin in human serum

A simple and rapid gas Chromatographic method for the simultaneous estimation of the anticonvulsant drugs ethosuximide, carbamazepine, phenobarbital, primidone, diphenylhydantoin and the metabolite PEMA in serum is presented. The method is based on a simple ether extraction of 1 ml serum before and after precipitation of the proteins by ammonium sulfate and injection of the extract dissolved in methanol without derivative formation. Gas Chromatographic separation is performed on a highly polar acidic phase (SP 1000, a terephthalic acid modified Carbowax 20 M), for detection the instrument is equipped with a nitrogen selective detector, quantitation is performed by automatic electronic integration of peak areas in relation to the internal standard Mesantoin®. The optimal approach to the gas Chromatographic analysis of “problem drugs” like carbamazepine and phenobarbital is discussed, various stationary phases and support materials are compared for effectiveness with this method. In the analysis of over 800 routine serum samples as well as internal and external quality control samples this method was found to be reliable and the results reproducible.     

Validation of liquid chromatography-tandem mass spectrometry method for analysis of urinary conjugated metanephrine and normetanephrine for screening of pheochromocytoma

BACKGROUND: Metanephrines are biochemical markers for tumors of the adrenal medulla (e.g., pheochromocytoma) and other tumors derived from neural crest cells (e.g., paragangliomas and neuroblastomas). We describe a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the measurement of urinary conjugated metanephrines. METHODS: We added 250 ng of d3-metanephrine (d3-MN) and 500 ng of d3-normetanephrine (d3-NMN) to 1 mL of urine samples as stable isotope internal standards. The samples were then acidified, hydrolyzed for 20 min in a 100 degree C water bath, neutralized, and prepared by solid-phase extraction. The methanol eluates were analyzed by LC-MS/MS in the selected-reaction-monitoring mode after separation on a reversed-phase amide C16 column. RESULTS: Multiple calibration curves for the analysis of urine MN and NMN exhibited consistent linearity and reproducibility in the range of 10-5000 microg/L. Interassay CVs were 5.7-8.6% at mean concentrations of 90-4854 microg/L for MN and NMN. The detection limit was 10 microg/L. Recovery of MN and NMN (144-2300 microg/L) added to urine was 91-114%. The regression equation for the LC-MS/MS (x) and colorimetric (y) methods was: y = 0.81x - 0.006 (r = 0.822; n = 110). The equation for the HPLC (x) and LC-MS/MS (y) methods was: y = 1.09x + 0.05 (r = 0.998; n = 40). CONCLUSIONS: The sensitivity and specificity of the MS/MS method for urinary conjugated metanephrines offer advantages over colorimetric, immunoassay, HPLC, and gas chromatography-mass spectrometry methods because of elimination of drug interferences, high throughput, and short chromatographic run time.     

Examination of postmortem fluids and tissues for the presence of methylecgonidine, ecgonidine, cocaine, and benzoylecgonine using solid-phase extraction and gas chromatography-mass spectrometry

BACKGROUND: During the smoking of crack cocaine (COC), methyl ecgonidine (MED) is formed as one of the pyrolysis products. Once in the body, MED is converted to ecgonidine (ED) through several processes that include spontaneous hydrolysis and enzymatic hydrolysis. The presence of MED and/or ED could provide valuable information to help determine antemortem conditions in cases where COC is involved. Our goal was to examine postmortem tissues and fluids for the presence of MED, ED, COC, and benzoylecgonine (BZ). METHODS: Liver, brain, blood, and urine specimens obtained from 15 postmortem cases were extracted using solid-phase extraction, derivatized, and analyzed using gas chromatography-mass spectrometry with selective-ion monitoring. RESULTS: Median concentrations (range) of drugs observed in postmortem liver, brain, blood, and urine were 0 (0-10) ng/g, 7 (0-92) ng/g, 0 (0-42) microg/L, and 62 (0-2030) microg/L, respectively, for MED; 655 (90-3274) ng/g, 22 (0-52) ng/g, 119 (13-773) microg/L, and 456 (109-7452) microg/L, respectively, for ED; 57 (0-503) ng/g, 187 (0-1403) ng/g, 12 (0-88) microg/L, and 1208 (37-28 062) microg/L, respectively, for COC; and 821 (45-4980) ng/g, 524 (46-5153) ng/g, 458 (30-2071) microg/L, and 6768 (917-116 430) microg/L, respectively, for BZ. MED was detected in 12 of 15 postmortem cases. The concentrations were highest in urine compared with liver, brain, and blood. The hydrolysis product ED was detected in all postmortem cases, and the concentrations were substantially higher than MED in all liver, blood, and urine specimens. CONCLUSION: ED may be a more useful indicator of crack COC smoking.     

Sensitive gas chromatography-mass spectrometry method for simultaneous measurement of MDEA, MDMA, and metabolites HMA, MDA, and HMMA in human urine

BACKGROUND: A sensitive gas chromatography-mass spectrometry method was developed and validated for the simultaneous measurement of MDEA, MDMA, and its metabolites, 3,4-methylenedioxy-N-ethylamphetamine (MDEA), 3,4-methylenedioxymethamphetamine (MDMA or Ecstasy), and its metabolites, 4-hydroxy-3-methoxyamphetamine (HMA), 3,4-methylenedioxyamphetamine (MDA), and 4-hydroxy-3-methoxyamphetamine (HMMA) in human urine. METHODS: We hydrolyzed 1 mL urine, fortified with MDMA-d5, MDA-d5, and MDEA-d6, with 100 microL of concentrated hydrochloric acid at 120 degrees C for 40 min, then added 100 microL 10 N sodium hydroxide and 3 mL phosphate buffer 0.1 N (pH 6.0) were added to hydrolyzed urine specimens before solid-phase extraction. After elution and evaporation, we derivatized extracts with heptafluorobutyric acid anhydride and analyzed with gas chromatography-mass spectrometry operated in EI-selected ion-monitoring mode. RESULTS: Limits of quantification were 25 microg/L for MDEA, MDMA, and its metabolites. Calibration curves were linear to 5000 microg/L for MDEA, MDMA, HMA, MDA, and HMMA, with a minimum r2 > 0.99. At 3 concentrations spanning the linear dynamic range of the assay, mean overall extraction efficiencies from urine were >85.5% for all compounds of interest. Intra- and interassay imprecisions, produced as CV, were <15% for all drugs at 30, 300, and 3000 microg/L. CONCLUSIONS: This gas chromatography-mass spectrometry assay provides adequate sensitivity and performance characteristics for the simultaneous quantification of MDEA, MDMA, and its metabolites HMMA, MDA, and HMA in human urine. The method meets and exceeds the requirements of the proposed Substance Abuse and Mental Health Services Administration's guidelines for federal workplace drug testing of MDEA and MDMA in urine.     

Determination of coumarin-type anticoagulants in human plasma by HPLC-electrospray ionization tandem mass spectrometry with an ion trap detector.

BACKGROUND: Coumarin-type anticoagulants are used for the long-term treatment and prevention of thromboembolic disorders. The identification of these drugs is crucial in patients with an increased prothrombin time of unknown origin. The aim of this study was to develop a sensitive and specific method for the simultaneous determination of phenprocoumon, acenocoumarol, and warfarin in human plasma by HPLC-electrospray ionization tandem mass spectrometry. METHODS: After addition of the internal standard, p-chlorowarfarin, plasma samples were extracted using Oasis MCX solid-phase extraction cartridges. The compounds were separated on a Symmetry C18 column (Waters) with a mobile phase of acetonitrile-1 g/L formic acid (75:25 by volume) at a flow rate of 0.5 mL/min. RESULTS: Extraction and separation of the three drugs and the internal standard were accomplished in 9 min. The overall extraction efficiency was >89% for all three compounds. The limits of detection were 1 microg/L for phenprocoumon and warfarin and 10 microg/L for acenocoumarol. Regression analysis of the calibration data revealed good correlation (r(2) >or=0.995) for all compounds. Within-run accuracies for quality-control samples were +/- 1% to 7% of the target concentration, with CVs <9%. CONCLUSIONS: The proposed method enables the unambiguous identification and quantification of phenprocoumon, warfarin, and acenocoumarol in both clinical and forensic specimens. This method combines a new, rapid solid-phase extraction procedure with an extremely fast chromatographic analysis, which is especially advantageous for clinical laboratories.     

Unique sexual assault examiner program utilizing mid-level providers

Background: We implemented a unique sexual assault examiner (SAE) program utilizing Emergency Department (ED)-based mid-level providers. Sexual assault forensic evidence collection processes and training are not uniform in all EDs, with varying models in place. Methods: Our study evaluated the quality of SAE evidentiary collection in standardized evidence kits (Kits), compared to Kits from other EDs without the SAE program. We prospectively studied Kits from November 2004–October 2005. All Kits were evaluated for quantity (numbers of slides, envelopes, swabs), and quality (compliance with forensic standards) of evidence. Results: Although SAE Kits had similar total numbers of pieces of evidence, they had higher quality as measured by a greater number of compliant envelopes (5.44 vs. 1.44, p < 0.001) and a greater number of compliant slides (6.4 vs. 4.5, p < 0.001). SAE Kits had two measures with higher quality forensic evidence than non-SAE Kits. Conclusion: An integrated program of SAE-trained mid-level providers collect sexual assault Kits with a higher quality of forensic evidence than non-SAE providers.     

Alternate light sources in sexual assault examinations: an evidence-based practice project

The ability of sexual assault nurse examiners to correctly identify and collect DNA evidence improves patient outcomes and prosecution rates. The purpose of this paper is to present findings from a collaborative evidence-based practice (EBP) project between forensic nurses and baccalaureate nursing students. The goal of the project was to determine best practice using an alternate light source (ALS) to identify trace DNA evidence in sexual assault forensic examinations. Using the Johns Hopkins Nursing Evidence-based Practice model, the team searched several databases to summarize the limited amount of evidence available regarding this topic. Recommendations from the EBP project include: elimination of the Wood's lamp in sexual assault examinations; use of an ALS that provides appropriate wavelengths to detect DNA; education of forensic nurses about the advantages and limitations of an ALS; and additional research related to use of an ALS. By participating in similar collaborative efforts, practicing forensic nurses have the opportunity to collaborate with local colleges and universities to make complex projects more manageable while fulfilling the International Association of Forensic Nurses vision for ethical practice.