Miran Čoklo

Retrospective analysis of free-fall fractures with regard to height and cause of fall

Free-fall fractures represent a specific form of blunt force trauma that can be hard to interpret because of the numerous factors that affect it. The aim of this study is to focus on skeletal injury patterns resulting from free-falls and to analyse the relationship between specific skeletal fractures, and the height and cause (accidental vs. suicidal) of the fall. A total of 179 autopsy reports of fatal free-falls from known heights were analysed at the Department of Forensic Medicine and Criminalistics, in Rijeka, Croatia. The location, type and frequency of fractures, as well as the number and distribution of fractured regions were analysed with regard to height and cause of fall. Height was found to be the major factor influencing fracture patterns in free-falls. In our sample, the frequencies of thoracic fractures, fractures to the extremities and those to the pelvis increased with height. Head fractures show no such relationship. However, types of fractures recorded in different anatomical regions, including the cranium, differ between height groups suggesting different injury mechanisms in each. Victims of falls generally sustained fractures in more than one body region, and the number of injured regions correlates significantly with height. Although no statistical difference was found in the number of fractured regions or frequency of fractures between accidental fallers and suicidal jumpers, jumpers showed a significantly higher number of bilateral extremity fractures when compared to victims of accidental falls. Logistic regression analyses also demonstrate a significant relationship between lower extremity fractures, and the cause of the fall. Our results highlight the need for further investigations of the influence that behaviour and height have in free-fall fractures.

Perforin expression is upregulated in the epidermis of psoriatic lesions.

Background  There are currently very few data regarding the role of cell‐mediated cytotoxicity in psoriasis. Both cytotoxic T lymphocytes and natural killer (NK) cells mediate cytotoxicity reactions, mainly by two distinct pathways, the perforin/granzyme and the Fas/Fas ligand pathway.

The first report of extraosseous Ewing's sarcoma in the rectovaginal septum.

Aims and Background To report an extremely rare case of Ewings sarcoma located in the rectovaginal septum. Ewings sarcoma is a highly malignant neoplasm of bone, which usually occurs during childhood. Common extraosseous localizations of Ewings sarcoma include the trunk, extremities, uterus, cervix and vagina. Methods A 45-year-old woman presented to us with a six-month history of pain in the lower abdomen during intercourse. Pelvic examination was performed and a palpable mass was found. The mass had a size of 9 × 6 cm, a soft tissue consistency, was partially movable and the patient felt the pain during palpation. Examination of the inguinal lymph nodes revealed no signs of inguinal adenopathy. The results of laboratory tests, rectoscopy, chest X-rays, barium enema and bone scan were normal. Computed tomography (CT) showed an inhomogeneous expansive mass in the rectovaginal septum measuring 8.7 × 6.1 cm, without any signs of rectum or bladder invasion. The vascular structures of the pelvis were normal. At laparotomy the process was judged inoperable and only biopsy of the tumor mass was carried out. Histology showed a neoplasm with small, round to oval cells with scarce cytoplasm. Immunohistology with the monoclonal antibody CD99 (MIC-2 gene product, Ewings sarcoma marker, clone 12E7, DAKO A/S, Glostrup, Denmark) revealed an extraosseous Ewings sarcoma. The patient was treated with chemotherapy followed by whole-pelvis external beam radiation and intracavitary brachytherapy. Results A residual mass measuring 3.5 × 2.5 cm was visible on a control CT scan 18 months after treatment; however, the patient was feeling well and refused surgery to remove the residual mass. Conclusions To our knowledge this is the first reported case of extraosseous Ewings sarcoma in the rectovaginal septum.

The role of perforin-mediated apoptosis in lichen planus lesions

Lichen planus is recognized as a T-cell-mediated disease. Histologically, it is characterized by the formation of colloid bodies representing apoptotic keratinocytes. The apoptotic process mediated by CD8+ cytotoxic T lymphocytes (CTLs) and NK cells mainly involves two distinct pathways: the perforin/granzyme pathway and the Fas/FasL pathway. So far, little is known regarding the role of perforin-mediated apoptosis in lichen planus. In the present study, the expression and distribution of perforin, T and NK cell subsets in the epidermis and dermis of lesional and nonlesional lichen planus skin were studied. Skin biopsy specimens from lesional and nonlesional skin of ten patients with lichen planus and eight healthy persons were analysed by immunohistochemistry. Significant accumulation of T cells, particularly of CD4+ and CD8+ subsets, was found in both epidermis and dermis of lichen planus lesions compared with nonlesional and healthy skin. There were no significant differences in the incidence of NK cells (CD16+ and CD56+) between lesional, nonlesional and healthy skin. Perforin expression was significantly upregulated in the epidermis of lichen planus lesions. In conclusion, accumulation of perforin+ cells in the epidermis of lichen planus lesions suggest a potential role of perforin in the apoptosis of basal keratinocytes.

Suicidal drowning in Southwestern Croatia: a 25-year review.

We designed a retrospective study to analyze suicidal drowning deaths occurring between 1981 and 2005. During the study period there were 134 cases of suicidal drowning accounting 10% of all suicides, and 31% of all drowning deaths. Of the 134 drowning suicides, 76 (57%) incidents occurred in the sea, 46 (34%) in water wells, 8 (6%) in rivers, and 4 (3%) in bathtubs. During the study period, cases of suicidal drowning were not identified in males and females under the age of 20. In females aged 65 years and older, drowning represents the most common type of suicide. Commonly, the victims were sober at the time of the incident. Cases of suicidal drowning committed in water wells are unexpectedly high, considering abundance of salt water.

Immunohistochemical surfactant protein-A expression: Fatal drowning vs. postmortem immersion

The postmortem diagnosis of drowning continues to be one of the most difficult in forensic pathology because of unspecific autopsy findings. It must be always remembered that disposal of a victim body in water is not unknown in homicide. The most important physiological consequence in fatal drowning is hypoxemia. The air-liquid interface of alveoli and distal airways of the mature lung are lined with a thin layer of lung surfactant, composed of phospholipids, proteins and neutral lipids. Surfactant components are synthesized and/or incorporated into lung surfactant in alveolar type II cells, and secreted to form an airspace lining film. The composition and function of lung surfactant is disturbed in cases od acute lung injury (ALI) including drowning. Surfactant protein-A (SP-A) is the most abundant surfactant protein. Surfactant protein-A (SP-A) is secreted by type II alveolar cells and cells. Its immunohistochemical distribution is observed in two different pathways: a linear membranous staining and a granular intra-alveolar staining. We hypothesize the significance of immunohistochemical detection of SP-A and its help in determination of the time of death, and possibly distinguishing of death by immersion vs. postmortem immersion using the morphological analysis applied on SP-A immunohistochemical stained lung tissue samples. We also argue in favor of routine use of SP-A staining in selected forensic cases where pathogenesis includes mechanical asphyxia and lung pathology. Although some studies reached conclusions to define the mechanisms involved in pathogenesis of mechanical asphyxia and aspiration necessity of additional studies arose. The mechanism of the production of massive aggregates remains to be determined. In the mean time the detection of SP-A (immunohistochemical) as well as biochemical is potentially useful tool in the forensic practice with possible application in daily practice.

Predicting sentinel lymph node metastases in infiltrating breast carcinoma with vascular invasion

Sentinel lymph node and clinically negative axillary node status was compared with well-known clinicopathological characteristics such as tumor size, histologic and nuclear grade, lymphovascular invasion, steroid receptor, and HER-2 status in patients with breast cancer (pT1 and pT2). Positive sentinel lymph nodes were found in 29 of 100 patients: 19 with metastases detected by hematoxylin and eosin staining and 10 with micrometastases confirmed by immunohistochemistry with cytokeratin. Positive sentinel lymph nodes were present in larger carcinomas (P < 0.03), more frequently in tumors with negative PR status (P < 0.037) and evident lymphovascular invasion (P < 0.002). Lymphovascular invasion was also associated with breast cancer of higher histologic (P = 0.011) and nuclear grade (P = 0.039). Tumor size and the presence of lymphovascular invasion were found to be significant predictors of pathologically positive sentinel lymph node in T1 and T2.

HPV 6-positive giant keratoacanthoma in an immunocompetent patient.

Keratoacanthoma (KA) is a clinically distinct, rapidly growing lesion that generally presents as a solitary crateriform nodule in sun-exposed areas in elderly, fair-skinned individuals. A KA larger than 20-30 mm is referred to as giant keratoacanthoma, a relatively rare lesion especially in young patients. Such lesions grow rapidly with possible destruction of underlying tissues. In addition to ultraviolet exposure, KAs have also been associated with chemical carcinogens, chemical peels, genetic factors, chronic skin conditions that produce scarring, trauma and thermal burns. Immunosuppressed patients, especially after transplantation, also develop KAs. A viral etiology has been suggested but not confirmed. We encountered a case of giant keratoacanthoma (greater than 50 mm in diameter) with induration of underlying structures on the upper lip of a 39-year-old male sailor. The patient reported sudden appearance and rapid enlargement of the lesion in only three weeks. Biopsy of the cutaneous lesion and the characteristic clinical history suggested the diagnosis of keratoacanthoma. Total excision with primary closure of the defect by a nasolabial advancement flap was performed. Histological examination of the tumor mass confirmed the diagnosis of KA with infiltrative growth and perineural invasion. Immunosuppression was excluded by blood analyses, as were HIV, syphilis and hepatitis infections. Only low-risk genital HPV type 6 was detected in the lesion, suggesting a possible cocarcinogenic effect of HPV and UV light in a chronically sun-exposed patient.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period

BACKGROUND The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA). PATIENTS AND METHODS The study was performed at the University Childrens Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed. RESULTS There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation. CONCLUSION IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Angioimmunoblastic lymphadenopathy with dysproteinemia following doxycycline administration

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) is a primary lymphoproliferative T-cell disorder, currently classified as a peripheral T-cell non-Hodgkins lymphoma. AILD is characterized by generalized lymphadenopathy, hepatosplenomegaly, immunological abnormalities, polyclonal hypergammaglobulinemia and anemia. We report a case of AILD in an 80-year-old male who presented with a generalized pruritic maculopapular eruption and fever following doxycycline administration. The maculopapular rash progressed to formation of confluent nodules, plaques and finally erythroderma with lymphadenopathy and hepatosplenomegaly. Blood analysis revealed an elevated erythrocyte sedimentation rate and polyclonal hypergammaglobulinemia. Lymph node biopsy showed almost complete effacement of the nodal architecture with diffuse proliferation of small vessels forming an arborizing network, surrounded by atypical lymphocytes, usually CD3+ CD4+ and occasionally CD3 + CD8+. There were also larger cells (immunoblastic shape) that displayed CD20 positively, some scattered plasma cells, and eosinophils. Histology of a cutaneous lesion showed spongiosis and infiltration of the epidermis by atypical lymphocytes with large hyperchromatic nuclei, perivascular dermal lymphocytic infiltrate (CD3+) mixed with plasma cells and occasional large immunoblasts (CD20+). During hospitalization the patient developed hemolytic anemia (Coombs positive) and lung metastases. The prognosis of AILD is generally poor, with a median survival of less than 20 months. Our patient died two and a half months after the diagnosis was made due to sepsis caused by Staphylococcus aureus isolated in hemoculture.