Acute myocardial infarction following off label retrobulbar injection of desmopressin for non-arteritic anterior ischemic optic neuropathy (NAION). Causal correlation or coincidence?

A 60-year-old man, apparently healthy with negative history for cardiovascular diseases, was hospitalized because of an unilateral sudden and painless severe visual loss. Diagnosis of NAION was made. Two separate and immediately consecutive injections of betamethasone (2 mg/0.5 mL) and desmopressin (2 mcg/0.5 mL) were performed in the retrobulbar space. Fifteen minutes later, the patient suddenly developed cold sweat, dyspnoea, thoracic pain and severe hypotension. Acute myocardial infarction was diagnosed by ECG. Desmopressin was the probable causative agent. Thrombotic events following intravenous or oral administration of desmopressin have been documented in the medical literature. To the best of our knowledge this is the first case in which a thrombotic event was associated with the retrobulbar route. Retrobulbar desmopressin administration in patients with NAION can be probably associated with AMI. Considering its invasiveness and the unproven benefit in the treatment of NAION, this therapeutic approach can not be currently recommende

Insects found on a human cadaver in central Italy including the blowfly Calliphora loewi (Diptera, Calliphoridae), a new species of forensic interest

In the case of unidentified bodies the estimation of the period since death or of the season of death plays an important role to focus the attention on a reduced number of people among the ones reported missing. Forensic entomology can be one of the most important methods for these estimations, as occurred in this case. Flies are typically the first insects to colonize a dead body. The case reported here concerns the colonisation by insects of a male body in advanced decay found during the winter in Central Italy. This case is of particular interest as few data are available on the entomological evidence in the cold season. In particular, in this case we recovered Calliphora loewi (Calliphoridae), a species never collected before on dead bodies in Southern Europe. Larvae of the black soldier fly Hermetia illucens (Stratiomyidae), pupae and larvae belonging to genus Hydrothea (Muscidae), and Necrobia rufipes (Cleridae) specimens were also collected. The estimated PMI enabled identification of the cadaver, confirmed by DNA analysis

HOW SHOULD LIVING ENTOMOLOGICAL SAMPLES BE STORED?

Sampling and storing insect evidence alive is an important task in forensic entomology as it can impact survival and growth rates. To investigate the effect of cooling and storing of insect evidence before its arrival in the laboratory, samples of all three larval stages of the blow fly species Lucilia sericata and Calliphora vicina were analysed. A first group was stored at room temperature and a second one in a refrigerator (~5°C) for 16h, all without air, supply of food and sawdust. Afterwards they were kept at 6-8°C in a Styrofoam box for 8h, simulating a transport situation. Mortality rate (MR) was calculated and 25% of the surviving larvae were killed and measured to check for interim growth. The remaining alive specimens were reared at 25 °C until adult’s eclosion for estimating a possible storage impact on survival during later development. The results were then compared with a control which was not temporary stored and chilled but left feeding in boxes with air-permeable lid on food substrate at 25°C. A 24h temporary storage stopped the larval growth in comparison with the control especially in early larval stages in both species. A high MR of up to100% for third instar (L3) larvae stored both at room temperature and in a cold environment without air supply was found. Oxygen supply can reduce significantly the MR at least for L3 larvae of L. sericata. Findings provide scientific evidence for the recommendation to store larval samples at cold temperatures with both oxygen and food supply. The high MR for samples of the last larval stage clearly shows the need for a fast delivery after sampling and a more sophisticated storage procedure like e.g. air supply. Storing live samples at room temperature without air access should be avoided

CLEIA of humor vitreous in a case of suicidal insulin overdose

Insulin overdoses have been mostly described in literature as accidental and suicidal deaths, especially in diabetic patients. The present case study deals with a 68 years old male found dead in his bedroom. The victim worked as health care professional in a rescue team, suffering from depression for several years. At the death scene, two ampoules of soluble insulin were recovered close to the body, one of which was empty. At autopsy, no signs of trauma and no injection marks were found at common sub-cutaneous or intravenous injection sites. No other remarkable findings, but hemorrhagic pulmonary edema along with astrogliosis and neuronal degeneration/necrosis in the subcortical regions and corpus callosum were observed. The blood specimen was inadequate due to hemolysis, since it was not centrifugated soon after sampling. Biochemical analysis was performed on bilateral samples of vitreous humor by using electro-chemiluminescence immunoassay (CLEIA). The insulin concentration was 61.11 mU/L in the right vitreous humor and 74.23 mU/L in the left one; the C-peptide concentration was 0.166 ng/mL in right vitreous and 0.157 ng/mL in the left one. The results are in agreement with levels of insulin and C-peptide detected in previous case studies. Based on these findings the cause of death was determined as suicidal insulin overdoses probably by sublingual administration. This way of self-administration was a diagnosis for exclusion as it has been demonstrated that sublingual human insulin has hypoglycemic effects similar to insulin injected. The case study emphasizes the potential role of vitreous humor as reliable alternative substrate for biochemical analysis compared to post-mortem serum or blood samples in cases of fatal insulin intoxication. Furthermore, the CLEIA is an encouraging analytical method to be considered in such cases, although still not validated to perform quantitative analysis of post-mortem fluids

Effects of different storage and measuring methods on larval length values for the blow flies (Diptera: calliphoridae) Lucilia sericata and Calliphora vicina

In forensic entomology, the methods of sampling, killing, and storing entomological samples can affect larval age estimation, and, hence, the estimation of the minimum post-mortem interval. In the existing manuals, there is a certain amount of heterogeneity regarding methods and the recommendations for best practice in forensic ento- mology are insufficiently validated. This study evaluated three different length-measurement methods for larval stages and examined the influence of different killing and storing methods on the larval length of two forensically important blow flies, Lucilia sericata and Calliphora vicina. The three different measuring methods were a) a ruler with a 0.1 mm scale, b) a geometrical micrometer, and c) a computer-aided stereomicroscope. They were used to measure the length of L1–L3 C. vicina larvae and detect no significant differences. This supports the view that a simple tool like a geometrical micrometer can produce reli- able results in forensic entomology. Newly hatched larvae of L. sericata and C. vicina were killed with hot water (HW) and divided into two equal sub- samples. Lengths of all larvae were measured immediately after killing, then every 24 h until day 4, and once more after 7 days of storage in ≥70%-ethanol. L. sericata larvae only showed significant changes in length in the HW group stored at room temperature. After 4 and 7 days of storage, these 24-h- and 72-h-old larvae showed a significant decrease in length compared with those in a fridge at 6 °C. This decrease can, however, be considered a negligible natural variation without foren- sically relevant consequences for larval age estimation of L. sericata samples. For C. vicina, an increase in length was observed over time. This was significant only for younger larvae (24-48 h old) stored in 70%-ethanol. This variance in length can lead to a wrong estimation of age; however, only for larvae stored in 70%-ethanol, not for those stored in 96%-ethanol. Novelty statement: We examined the influence of different killing and storing methods on two forensically impor- tant blow flies, Lucilia sericata and Calliphora vicina. For the latter species we additionally were evaluating three different length measurement methods. The results of both experiments suggest that it is possible to kill and store fly larvae directly in (not hot) ≥70%-ethanol. This simplifies the sampling and storing of fly evidence at the crime scene. We also compared the influence of three different measuring methods for estimating the length of L1–L3 C. vicina larvae by using a) a ruler with a 0,1 mm scaling, b) a geometrical micrometer and c) a comput- er-aided stereomicroscope. No significant differences were detected, supporting the view, that a simple tool like a geometrical micrometer can produce reliable results. This study helps to simplify the sampling and evaluation of entomological evidence and to backup or questioning existing guidelines and best practice recommendations

Biphasic bioresorbable scaffold (TruFit®) in knee osteochondral defects: 3-T MRI evaluation of osteointegration in patients with a 5-year minimum follow-up

PURPOSE: The aim of this study is to follow morphological imaging characteristics and osteointegration of TruFit® bone graft substitute (BGS) plugs in cases of chondral and osteochondral defects of the articular surface of the knee joint, using high-quality cartilage-sensitive 3-T magnetic resonance imaging (MRI), linked to clinical outcomes. METHODS: The MRI was used to assess osteointegration and biological evolution of the TruFit® BGS plugs in cases with minimum 5-year follow-up: The TruFit® plug was used in 46 patients for a total of 47 cases with mean age of 57.89 (range 32-80). In this study, we reviewed only the cases with minimum follow-up of 5 years: 5 patients with mean age 64.4 years (minimum 38, maximum 80). The mean follow-up was 71 months (range 63-77). Patients were evaluated clinically, with Lysholm Knee Scoring Scale and MOCART Scale. RESULTS: 3-T MRI, which is preferable to 1.5 T for the better signal-to-noise ratio, contrast and the ability to acquire morphological images at higher spatial resolution, shows a satisfactory integration of bone scaffolds in studied cases for more than 5 years and a satisfactory restoration of the articular cartilage, with the exception of a case of which we still have to consider the factors age, type of lesion and the relationship between the plugs implanted. CONCLUSION: Clinical and radiological results significantly improve in a longer follow-up time

Advances in Entomotoxicology. Weaknesses and Strengths.

Medical forensic entomotoxicology currently deals mainly with the potential use of carrion-feeding insects as indirect proxy samples for detecting toxicants (e.g., drugs, poisons and other xenobiotic chemicals) when poisoning is suspected. Insects can provide a reliable biological source of proxy samples of xenobiotics where no body fluids or tissues traditionally sampled for toxicological analysis are available, especially in badly decomposed bodies such as pre-skeletonized, mummified and/or burnt bodies. Insects feeding on human tissues can ingest all of the substances taken by living humans, including common pharmaceuticals, illicit drugs, poisons, and heavy metals. Environmental forensic entomotoxicology seeks similar sources of evidence of toxicants in the environment in general. The detection of toxicants in different types of entomological remnants (including puparial cases and fecal material) through various analytical techniques has been demonstrated in many experimental and case studies. Forensic entomotoxicology also investigates the effects of toxicants on arthropod development, survival, and morphology and their implications for estimating post-mortem intervals (PMIs). This is crucial for forensic entomologists because the estimation of the minimum time since death is their most frequently requested task. A PMI estimate based on the estimated age of immature insects, without considering the effects of common toxicants on the rate of development, could easily be in error by hours and even days, depending on the toxicant, the insect species, and how long development has already progressed. Like toxicology in general, entomotoxicology is still in the process of developing validated protocol standards, commonly requested by courts internationally and is addressing the shortage of reliable pharmacokinetic information about toxicants in arthropods. Limitations in the application of quantitative toxicological results are related to several entomological and toxicological phenomena that affect analytical findings, particularly the affinity of toxicants to certain tissues (tropism) because of their basic molecular structure; inter-stadial variability arising from the feeding stage of larvae, the tissues they ate, and site-to-site variability; post mortem re-distribution of toxicants from tissues; post mortem and bacterial degradation of toxicants. There is a strong need of further research in these matters. These phenomena mean that insects are very useful as qualitative toxicological proxy specimens and less useful as quantitative evidence. All experts involved in a death investigation should be aware of how useful a drug screen on entomological specimens can be, and of the caveats due in the interpretation of quantitative toxicant concentrations. When poisoning is suspected in bodies colonized by insects, it is recommended that investigators undertake all reasonable methods and techniques to support a reliable diagnosis of the cause and time of death, including a toxicological screen on insect specimens. The role and applicability of entomotoxicology in court trials is likely to increase when validated protocols and methods can be systematically applied to the toxicological analysis of entomological samples