A new challenge in forensic toxicology exemplified by a case of murder under the influence of a synthetic cannabinoid – AM-2201

Among new psychoactive substances (NPS) available on the narcotic market, a significant number consists of synthetic cannabinoids commonly known as smokable herbal “spice” and “K2”, and which are legally treated as a legal alternative to marijuana. The dearth of information on the pharmacology of these intoxicants as they are introduced into the market has created the urgent need among healthcare providers for case studies on the substances belonging to this group, both in terms of the consequences of using such intoxicants, and in methods of detection. The subject of the present report is a multi-parameter analysis of a criminal case of an 18-year-old male who was charged with murder of his female relative and attempted murder of two other victims by stabbing. The defendant pleaded guilty, but he claimed that he had been acting without volition, because he was under the influence of the synthetic cannabinoid AM-2201, which had been purchased from a dealer as a 10 g package labelled “Mr Green – No bad trip”. Analytical methods including gas chromatography – electron ionization – quadrupole ion trap mass spectrometry (GC-EI-QIT/MS) and liquid chromatography, electrospray ionization, tandem mass spectrometry (LC-ESI-MS-MS) were developed to determine the presence of AM-2201 in the Mr Green – No Bad Trip, and in the blood of the perpetrator, respectively. Toxicological findings are discussed in the context of psychoactive and adverse physical effects resulting from the presence of AM-2201 in the human body; the observations were also analyzed in conjunction with data from the literature.     

散偏汤加减治疗偏头痛研究进展

偏头痛是一种常见的神经血管功能紊乱性疾病，多表现为反复发作的单侧或两侧剧烈头痛，偶伴恶心、呕吐、畏光、畏声等症状，具有反复发作、家族遗传的特点。中医认为偏头痛属于“头风”范畴，其发病多由外风引动导致，且与肝风内动有关。散偏汤出自清代医家陈士铎所创《辨证录·头痛门》，由川芎、白芷、郁李仁、香附、柴胡、白芥子、甘草组成，具有行气止痛，活血化瘀的作用，临床上常用于治疗偏头痛。目前应用散偏汤治疗偏头痛的临床研究多使用原方加减用药，或单独应用，或与西药/针刺联合应用。临床试验结果显示可以明显降低偏头痛积分、疼痛视觉模拟评分及内皮素水平等，减少止痛药使用频率，改善偏头痛症状显著且不良反应少。动物实验多从偏头痛发病不同解剖水平上探究散偏汤加减的起效机制，主要有降低一氧化氮（NO）、一氧化氮合酶（NOS）水平，减少神经递质的释放如5-羟色胺（5-HT）、神经肽（NPY），抑制神经元兴奋，阻断伤害性感受传导通路的传递，进而促进脑血液循环，调节神经递质而达到防治偏头痛的作用。该文结合偏头痛的发病机制，对散偏汤加减的临床应用、实验研究等方面的最新进展进行了系统综述，总结其防治偏头痛的作用机制，为临床治疗偏头痛提供新的思路。     

Orexin A decreases lipid peroxidation and apoptosis in a novel hypothalamic cell model

Current data support the idea that hypothalamic neuropeptide orexin A (OxA; hypocretin 1) mediates resistance to high fat diet-induced obesity. We previously demonstrated that OxA elevates spontaneous physical activity (SPA), that rodents with high SPA have higher endogenous orexin sensitivity, and that OxA-induced SPA contributes to obesity resistance in rodents. Recent reports show that OxA can confer neuroprotection against ischemic damage, and may decrease lipid peroxidation. This is noteworthy as independent lines of evidence indicate that diets high in saturated fats can decrease SPA, increase hypothalamic apoptosis, and lead to obesity. Together data suggest OxA may protect against obesity both by inducing SPA and by modulation of anti-apoptotic mechanisms. While OxA effects on SPA are well characterized, little is known about the short- and long-term effects of hypothalamic OxA signaling on intracellular neuronal metabolic status, or the physiological relevance of such signaling to SPA. To address this issue, we evaluated the neuroprotective effects of OxA in a novel immortalized primary embryonic rat hypothalamic cell line. We demonstrate for the first time that OxA increases cell viability during hydrogen peroxide challenge, decreases hydrogen peroxide-induced lipid peroxidative stress, and decreases caspase 3/7 induced apoptosis in an in vitro hypothalamic model. Our data support the hypothesis that OxA may promote obesity resistance both by increasing SPA, and by influencing survival of OxA-responsive hypothalamic neurons. Further identification of the individual mediators of the anti-apoptotic and peroxidative effects of OxA on target neurons could lead to therapies designed to maintain elevated SPA and increase obesity resistance.     

UPLC法测定奈韦拉平的含量及有关物质

目的：改进奈韦拉平的含量和有关物质测定方法 方法：采用 Acquity UPLC TSS T3 C18（2.1mm×50mm,1.8μm）,流动相为10mmol? L-1磷酸二氢铵溶液（pH5.0）-乙腈（80∶20）,流量为0.7ml?min-1,检测波长为220nm。结果：奈韦拉平在0.16～0.96mg? ml-1的范围内线性关系良好（r＝0.999,n＝6）, 平均回收率为99.6%,RSD＝2.0%（n＝9）。结论：本方法快速、简便、准确,专属性强。     

Evolution of the NBOMes: 25C- and 25B- Sold as 25I-NBOMe

Introduction

The NBOMes (N-benzyl-oxy-methyl derivatives of known 2C phenylethylamines) are a new and growing class of potent synthetic stimulants. Case reports provide the bulk of available safety and clinical data for clinicians. We report two cases of NBOMe intoxication with 25C-NBOMe (the first lab-confirmed US case) and 25B-NBOMe, respectively, both confirmed via triple quadrapole mass spectrometry.

Case Reports

Case 1: A 16-year-old girl had a generalized seizure after reported use of 25I-NBOMe. She presented with altered mental status, lower extremity rigidity, and elevated CPK (6042 U/L). Despite treatment with benzodiazepines, her lower extremity rigidity persisted and CPK peaked at 47,906 U/L. She was discharged on hospital day 8. Serum and urine specimens confirmed presence of 25C-NBOMe. Case 2: A 15-year-old boy developed bizarre behavior after reported use of 25I-NBOMe. In the ED, he had two generalized seizures and persistent muscle rigidity. CPK peaked at 429 U/L. Seizures were managed with benzodiazepines, and he was discharged within 24 h. Serum specimens revealed 25B-NBOMe.

Discussion

NBOMes are amphetamine derivatives and highly potent 5-HT_2A receptor agonists. Clinical manifestations are a product of enhanced central sympathetic and serotonergic tone. We report two cases of NBOMe intoxication in patients who believed they used 25I-NBOME, while lab confirmation proved otherwise. Whether unique clinical manifestations are specific to the NBOMe variant, dose, route of administration, or other factors is unknown. Laboratory confirmation may play a role in identifying unexpected NBOMe variants, while contributing to the epidemiologic data on these novel substances.     

Synthetic cannabinoid “Black Mamba” infidelity in patients presenting for emergency stabilization in Colorado: a P SCAN Cohort

Background: Use of new psychoactive substances (NPS) has increased over the last decade. During this period, variability of both clinical presentations and chemical compositions of these compounds has increased. Synthetic cannabinoids (SCs) are the most commonly used NPS and there are more than 100 documented unique molecules in this class. “Black Mamba”, often associated to ADB-FUBINACA, is the most commonly used SC in Colorado. It has been linked to kidney injury, myocardial toxicity, seizures, and death.

Objectives: We aim to identify the chemical constituents and quantification of eight cases of reported “Black Mamba” use in order to further understand the clinical variability in patients presenting for emergency stabilization.

Methods: We report data from eight cases of reported “Black Mamba” use prospectively captured through the Colorado site of the Psychoactive Surveilance Consortium and Analysis Network (P SCAN). P SCAN is a geographically representative group of academic hospitals that capture clinical presentation, outcome, and biologic samples from patients that present for emergency stabilization following NPS use. Serum and urine samples were analyzed and quantified by liquid chromatography-quadrupole time-of-flight mass spectrometry after a qualitative screen for over 600 unique NPS compounds.

Results: In the reported eight cases, the median age was 28 years old. There were four male and four females. Four patients had agitation/delirium and four patients had chest pain. Normal saline, benzodiazepines and ondansetron were the common treatment provided in the emergency department (ED). Two patients were discharged from the ED and six patients being admitted for emergency observation with a median length of stay (LOS) of six hours. No deaths were reported. Confirmatory testing revealed that only five patients (62.5%) had SCs found in blood or urine samples. Cocaine, NRG-3, 3-methoxyphencyclidine hydrochloride (MeO-PCP), and methamfetamine were identified in other presentations.

Conclusions: The wide range of clinical presentations from “Black Mamba” use may be explained by the wide variability of chemical constituents found by laboratory analysis.     

Synthesis and Characterization of Impurities in the Production Process of Lopinavir

Lopinavir is an antiretroviral drug used for the inhibition of HIV protease. Four related substances of lopinavir were observed during the manufacturing process of lopinavir in the laboratory and they were identified. The present work describes the origin, synthesis, characterization, and control of these related substances.