Fritz Pragst

Combined use of fatty acid ethyl esters and ethyl glucuronide in hair for diagnosis of alcohol abuse: Interpretation and advantages

In this study the combined use of fatty acid ethyl esters (FAEE) and ethyl glucuronide (EtG) for diagnoses of chronically excessive alcohol abuse is investigated at 174 hair samples from driving ability examination, workplace testing and child custody cases for family courts and evaluated with respect to the basics of interpretation. Using the cut-off values of 0.50 ng/mg for FAEE and 25 pg/mg for EtG, both markers were in agreement in 75% of the cases with 103 negative and 28 positive results and there were 30 cases with FAEE positive and EtG negative and 13 cases with FAEE negative and EtG positive. As the theoretical basis of interpretation, the pharmacokinetics of FAEE and EtG is reviewed for all steps between drinking of ethanol to incorporation in hair with particular attention to relationships between alcohol dose and concentrations in hair. It is shown that the concentrations of both markers are essentially determined by the area under the ethanol concentration in blood vs. time curve AUC(EtOH), despite large inter-individual variations. It is demonstrated by calculation of AUC(EtOH) on monthly basis for moderate, risky and heavy drinking that AUC(EtOH) increases very strongly in the range between 60 and 120 g ethanol per day. This specific feature which is caused by the zero-order elimination of ethanol is a favorable prerequisite for a high discrimination power of the hair testing for alcohol abuse. From the consideration of the different profiles of FAEE and EtG along the hair and in agreement with the literature survey, a standardized hair segment 0-3 cm is proposed with cut-off values of 0.5 ng/mg for FAEE and 30 pg/mg for EtG. This improves also the agreement between FAEE and EtG results in the cases of the present study. A scheme for combined interpretation of FAEE and EtG is proposed which uses the levels of abstinence and the double of the cut-off values as criteria in addition to the cut-offs. Considering the large variations in the relationship between ethanol dose and FAEE and EtG concentrations in hair, the combined use of both parameters strongly increases the accuracy of the diagnosis by mutual confirmation and identification of false positive or false negative results due to biological variations or analytical errors.

General unknown screening in hair by liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-QTOF-MS).

The retrospective investigation of the exposure to toxic substances by general unknown screening of hair is still a difficult task because of the large number of possible poisons, the low sample amount and the difficult sample matrix. In this study the use of liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) was tested as a promising technique for this purpose. In the optimized procedure, 20mg hair were decontaminated with water and acetone and two times extracted by 18h incubation with 0.5ml of a mixture of methanol/acetonitrile/H(2)O/ammonium formate at 37°C. A mixture of deuterated standards from different drug groups was added for quantification and method control. The united extracts were evaporated to a residue of 0.5ml and 5μl were injected without clean-up for LC-QTOF-MS measurement (instrument Agilent 6530) with positive electrospray ionization and in data dependent acquisition mode. For peak identification the accurate mass data base and spectral library of the authors was used which contains accurate mass CID spectra of more than 2500 and theoretically calculated accurate mass data of more than 7500 toxicologically relevant substances. Validation at the example of 24 illegal drugs, their metabolites and benzodiazepines resulted in limits of detection of 0.003-0.015ng/mg, and limits of quantification of 0.006-0.021ng/mg with good accuracy and intra- and interday reproducibility. The matrix effect by ion suppression/enhancement was 72-107% for basic drugs and 42-75% for benzodiazepines. Yields of the hair extraction above 90% were determined for 59 drugs or metabolites. The method was applied to hair samples from 30 drug fatalities and from 60 death cases with known therapeutic drug intake at life time. Altogether 212 substances were identified with a frequency per drug of 1-40 (mean 4.2) and per case of 2-33 (mean 10.2), between them 35 illegal drug related substances and 154 therapeutic drugs. Comparison with the data known from case histories and from the analysis of blood, urine and gastric content showed only a low agreement, with many unexpected drugs detected and many reported drugs not detected in hair. Basic drugs and metabolites such as opioides, cocaine, amphetamines, several groups of antidepressants, neuroleptics, beta-blockers or the metamizole metabolite noramidopyrine were found with high frequency whereas acidic and several neutral drugs such as cannabinoids, salicylic acid, furosemide, barbiturates, phenprocoumone or cardiac glycosides could not be detected with sufficient sensitivity, mainly because of the low ion yield of positive ESI for these compounds. The advantage of a comprehensive acquisition of all substances is paid by a lower sensitivity in comparison to targeted screening LC-MS/MS procedures. In conclusion, the procedure of sample preparation and LC-QTOF-MS analysis proved to be a robust and sensitive routine method in which the qualitative screening for a wide variety of toxic substances in hair is combined with the quantitative determination of selected illegal drugs.

Fatty acid ethyl ester concentrations in hair and self-reported alcohol consumption in 644 cases from different origin.

For diagnosis of chronic alcohol abuse, fatty acid ethyl esters (FAEE) were determined in hair samples from 644 individuals, mainly parents from child protection cases. The analysis for ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate was performed according to a validated procedure consisting of external degreasing by two times washing with n-heptane, extraction with a mixture of dimethylsulfoxide and n-heptane, separation and evaporation of the n-heptane layer, headspace solid phase microextraction of the residue after addition of phosphate buffer pH 7.6 and gas chromatography-mass spectrometry using deuterated internal standards. For interpretation, the sum of the concentrations of the four esters C(FAEE) was used with the cut-offs 0.5 ng/mg for the proximal scalp hair segment 0-3 cm or less and 1.0 ng/mg for scalp hair samples with a length between 3 and 6 cm and for body hair. C(FAEE) ranged from 0.11 to 31 ng/mg (mean 1.77 ng/mg, median 0.82 ng/mg). The mean concentration ratio between the 4 esters was 8:45:38:9. 298 cases had C(FAEE) above the cut-offs. Self-reported drinking data were obtained in 553 of the cases in the categories abstinent (156 cases), moderate drinking (252 cases) and excessive drinking (145 cases). Median and box-plot data clearly demonstrate differentiation of these ingestor sub-populations by C(FAEE). However, in the abstinent and moderate groups the consumption was frequently underreported (37 and 110 cases positive) whereas in the group self-reported excessive drinking 32 cases were negative. Comparison of C(FAEE) with carbohydrate-deficient transferrin (CDT) in 139 cases and gamma-glutamyltransferase (GGT) in 136 cases showed a good agreement in CDT- and GGT positive cases (27/28 and 32/41) but a large portion of the negative CDT- and GGT-results with positive hair test (44/100 and 48/95) which is explained mainly by the much shorter time window of CDT and GGT. No significant correlation was found between persons weight and C(FAEE) showing that the test is not biased against physical fitness or obesity. Furthermore, there was no statistically significant difference between scalp hair (541 samples) and hair from other body sites (84 samples). In conclusion, FAEE in hair appeared to be suitable markers for the detection of excessive drinking. However, as there is no proportionality between drinking amount and C(FAEE), the additional use of other markers can increase the reliability of the interpretation.

Combined use of liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) and high performance liquid chromatography with photodiode array detector (HPLC-DAD) in systematic toxicological analysis

Time of flight mass spectrometry provides new possibilities of substance identification by determination of the molecular formula from accurate molecular mass and isotope pattern. However, the huge number of possible isomers requires additional evidence. As a suitable way for routine performance of systematic toxicological analysis, a method for combined use of liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) and high performance liquid chromatography with diode array detector (HPLC-DAD) was developed and applied to blood samples from 77 death cases. The blood samples were prepared by extraction with CH(2)Cl(2) and by protein precipitation with acetonitrile (1:4 (v/v)). The evaporated extracts were reconstituted in 35% acetonitril/0.1% formic acid/H(2)O and aliquots were injected for analysis by LC-QTOF-MS (Agilent 6530) and HPLC-DAD (Agilent 1200). A valve switching system enabled simultaneous operation of both separated chromatographic lines under their respective optimal conditions using the same autosampler. The ESI-QTOF-MS instrument was run in data dependent acquisition mode with switching between MS and MS/MS (cycle time 1.1s) and measuring the full mass spectra and the collision induced dissociation (CID) fragment spectra of all essential [M+H](+) ions. Libraries of accurate mass CID spectra (~2500 substances) and of DAD-UV spectra (~3300 substances) of the authors were used for substance identification. The application of this procedure is demonstrated in detail at four examples with multiple drug intake or administration. In the 77 cases altogether 198 substances were identified (87 by DAD and 195 by QTOF-MS) with a frequency between 1 and 20. In practical application, the sample preparation proved to be suitable for both techniques and for a wide variety of substances with different polarity. The automatic performance of the measurements was efficient and robust. Mutual confirmation, decrease of false positive and false negative identifications, and the semi-quantitative estimation of the concentrations by HPLC-DAD for a first assessment of the toxicological relevance of the qualitative result were shown to be the main advantages of the method combination.

Interpretation problems in a forensic case of abstinence determination using alcohol markers in hair

In a child custody case a mother with a longstanding history of alcohol misuse had to show absolute abstinence for one year. She entered a residential rehabilitation for six months and was tested two months later by way of a hair test for ethyl glucuronide (EtG) with the result of 22 pg/mg in the proximal 0-1cm segment and the segments 1-2 cm and 2-3 cm being negative. This was interpreted as a minimum alcohol intake of 20-50 units per week in the month before sampling. Since the mother denied any alcohol intake a second hair sample was collected seven weeks after the first and analyzed for fatty acid ethyl esters (FAEEs) by a second laboratory. A low concentration of 0.03 ng/mg was measured within the 0-6 cm segment of recently bleached hair and was interpreted as showing no evidence of alcohol use during the last six months. Three further hair samples were analyzed during the next nine months with low EtG values (<2.4-3.3 pg/mg, 0-3 cm segment) and low FAEE values (0.27-0.53 ng/mg, 0-6 cm segment). These findings were summarized as indicating continued low alcohol consumption over the past one year period. As a consequence of the conflicting results, the case was dealt with in a hearing before the Family Division of the High Court of London. It was concluded in the judgment that the evidence did not indicate that the mother had consumed alcohol in the period tested by the hair samples. It was stated that the evidence in this case highlighted the need for the exercise of considerable caution when hair tests for alcohol are being interpreted and relied upon, both generally and particularly in isolation, and that this case is a proper reminder of the need for expert evidence to be given in a manner according to the Practice Direction.

11-Nor-Δ9-tetrahydrocannabinol-9-carboxylic acid ethyl ester (THC-COOEt): Unsuccessful search for a marker of combined cannabis and alcohol consumption

11-Nor-Delta(9)-tetrahydrocannabinol-9-carboxylic acid ethyl ester (THC-COOEt) can be presumed to be a mixed metabolite formed during combined consumption of cannabinoids and alcohol. In order to examine this hypothesis, THC-COOEt and its deuterated analogue D(3)-THC-COOEt were synthesized as reference substance and internal standard from the corresponding carboxylic acids and diazoethane and methods were developed for the sensitive detection of THC-COOEt in plasma and hair based on gas chromatography-electron impact mass spectrometry after silylation with N-methyl-N-tert-butyldimethylsilyl-trifluoroacetamide and gas chromatography-negative chemical ionization mass spectrometry (GC-NCI-MS) as well as tandem mass spectrometry (GC-NCI-MS-MS) after derivatization with pentafluoropropionyl anhydride. The methods were applied for THC-COOEt determination to plasma samples from 22 drunk driving cases which contained both ethanol (0.30-2.16 mg/g) and THC-COOH (15-252 ng/mL) as well as to 12 hair samples from drug fatalities which were both positive for THC (0.09-2.04 ng/mg) and fatty acid ethyl esters as markers of chronic alcohol abuse (0.70-6.3 ng/mg). In none of these samples THC-COOEt could be found with limits of detection of 0.3 ng/mL in plasma and 2 pg/mg in hair in 11 samples using GC-NCI-MS and 0.2 pg/mg in one sample using GC-NCI-MS. Therefore, the use of this compound as a marker for combined cannabis and alcohol consumption could not be achieved.

Isomerization of cannabidiol and Δ9-tetrahydrocannabinol during positive electrospray ionization. In-source hydrogen/deuterium exchange experiments by flow injection hybrid quadrupole-time-of-flight mass spectrometry

RATIONALE Liquid chromatography/tandem mass spectrometry (LC/MS/MS) is frequently used for analysis of cannabinoids in drug abuse control. Despite differences in structure, the isomers Δ(9) -tetrahydrocannabinol (THC) and cannabidiol (CBD) provide identical fragment spectra after positive electrospray ionization (ESI). For elucidation of the reason, hydrogen/deuterium (H/D) exchange experiments were performed. METHODS Solutions of THC and CBD in D(2) O/acetonitrile (50:50, v/v) were flow-injected into acetonitrile as the mobile phase and measured by hybrid quadrupole-time-of-flight mass spectrometry (FI-QTOF-MS) in targeted MS/MS mode. The MS and collision-induced dissociation (CID) spectra at 10, 20 and 40 eV were interpreted with respect to number and position of exchanged hydrogen atoms. For comparison the same measurements were preformed in H(2) O, after addition of 0.5% formic acid and with negative ESI. RESULTS Depending on injected volume and position in the response curve, up to 7 or 8 hydrogen atoms were exchanged by deuterium in THC or CBD. Positive ESI CID spectra were available for precursors with up to 4 exchanged D-atoms and showed that besides the OH groups also an H/D exchange at carbon atoms of the non-aromatic part of the molecules occurred for both THC and CBD. After negative ESI, no H/D exchange in addition to the OH groups and different CID spectra of both substances was found. CONCLUSIONS Injection of the investigated substances in D(2) O and measurement by FI-QTOF-MS proved to be an efficient way to perform H/D exchange experiments. The results were interpreted as an acid-catalyzed in-source equilibration between THC and CBD leading to the same precursor ions and to an H/D exchange in the methyl groups under the increased acidic conditions in the positive ESI droplets. Therefore, in positive LC/ESI-MS/MS, peak identification by CID spectra or by abundance ratio of multiple reaction monitoring (MRM) transitions is not sufficient for unambiguous discrimination between THC and CBD and must be supported by retention time or other experimental evidence.

Effect of the analyzed hair length on fatty acid ethyl ester (FAEE) concentrations in hair – Is there congruence of cut-offs for 0–3 and 0–6 cm hair segments?

BACKGROUND According to the current SoHT consensus for the use of alcohol markers in hair FAEEs can be analyzed in the proximal 0-3 or 0-6 cm segment with the cut-offs 0.2 and 0.4 ng/mg for abstinence assessment and 0.5 and 1.0 ng/mg for chronic excessive alcohol consumption. Both sets of cut-offs should be congruent for uniform interpretation. METHODS FAEEs were determined in parallel for the 0-3 and the 0-6 cm segment of 157 hair samples and the concentration ratio between both segments (0-3 cm)/(0-6 cm) was calculated. For comparison, EtG was measured in the 0-3 cm segment of 135 of these samples and the FAEE concentration ratio was calculated by re-evaluation of segmental concentrations from further 42 samples of a previous study. RESULTS The concentration ratio ranged from 0.3 to 1.5 (mean 0.83, median 0.82) and showed that the current cut-offs (ratio 0.50) are not congruent and that the cut-offs of the 0-3 cm are more restrictive against alcohol use or abuse. There was no correlation between the ratio and the concentration of FAEEs or EtG showing that the ratio does not depend on the drinking amount. Furthermore, no significant difference of the ratio was found between cosmetically untreated, bleached, dyed or spayed hair samples. Adaptation of the 0-3 cm cut-offs by increasing to 0.3 and 0.8 ng/mg respectively improved the congruence of both segment lengths but did not lead to a better agreement between FAEE and EtG interpretation. CONCLUSIONS It follows from the results and further literature data that the variable length of the proximal hair segment between 3 and 6 cm which is possible according to the present SoHT consensus additionally contributes to the uncertainty of interpretation caused by biological variability and hair cosmetics. Furthermore, it is improbable from the present state of knowledge that a proximal segment length above 3 cm unambiguously enables the detection of alcohol consumption or abuse occurring more than 3 months before sampling. Therefore, it should be considered in a future consensus to redefine the hair length for both markers on 0-3 cm.

Commentary on current changes of the SoHT 2016 consensus on alcohol markers in hair and further background information.

The consensus on alcohol markers in hair was revised for the fourth time by an expert group of the Society of Hair Testing based on current state of research. This revision was adopted by the members of the Society during the business meeting in Brisbane on August 29th 2016. For both markers, ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEEs), two cut-off values for discrimination between teetotalers or occasional low amount consumption and moderate alcohol drinking (low cut-off), and between non-excessive (abstinence up to moderate alcohol intake) and chronic excessive drinking (high cut-off value) were critically examined. For the current revision, the cut-off values for EtG (7pg/mg and 30pg/mg, respectively) remained unchanged despite different findings or discussions published in the meantime. This was mainly due to the lack of broader data collections from new studies with great numbers of volunteers following thorough study concepts. In contrast, an essential change of the consensus was accepted for the FAEEs, where the concentration of ethyl palmitate (E16:0) can be used autonomously for interpretation instead of the concentration sum (ΣFAEE) of the four esters ethyl myristate, ethyl palmitate, ethyl oleate and ethyl stearate, as previously applied. After evaluation of the data from seven laboratories, the E16:0 cut-off for abstinence assessment was defined at 0.12ng/mg for the 0-3cm segment and at 0.15ng/mg for the 0-6cm segment. The cut-off for chronic excessive drinking was fixed at 0.35ng/mg for the 0-3cm segment and at 0.45ng/mg for the 0-6cm segment. The use of E16:0 with these cut-offs in place of ΣFAEE for alcohol intake assessment produces only a minor loss in discrimination power, leads to no essential difference in the interpretation concerning chronic excessive alcohol consumption and is suitable to confirm EtG results in abstinence assessment if ethanol containing hair sprays or lotions are excluded.

High concentrations of lead and barium in hair of the rural population caused by water pollution in the Thar Jath oilfields in South Sudan

In the oil fields of Thar Jath, South Sudan, increasing salinity of drinking water was observed together with human incompatibilities and rise in livestock mortalities. Hair analysis was used to characterize the toxic exposure of the population. Hair samples of volunteers from four communities with different distance from the center of the oil field (Koch 23km, n=24; Leer 50km, n=26; Nyal 110km, n=21; and Rumbek 220km, n=25) were analyzed for altogether 39 elements by inductively coupled plasma-mass spectrometry. Very high concentrations and a toxic health endangerment were assessed for lead and barium. The concentration of lead increased steadily with decreasing distance from the oil field from Rumbek (mean 2.8μg/g) to Koch (mean 18.7μg/g) and was there in the same range as in highly contaminated mining regions in Kosovo, China or Bolivia. The weighting materials in drilling muds barite (BaSO4) and galena (PbS) were considered to be the sources of drinking water pollution and high hair values. The high concentrations of lead and barium in hair demonstrate clearly the health risk caused by harmful deposition of toxic industrial waste but cannot be used for diagnosis of a chronic intoxication of the individuals.