Determining the manner of death in victims in drug-induced psychosis: a case of an atypical head stab wound

This case report presents a rare case of an atypical head stab wound suffered by a drug addict and inflicted with a screwdriver during drug-induced psychosis. It describes the diagnostic and treatment procedures in the hospital and the findings of the subsequent autopsy. It also analyzes the review of the interpretation of the CT scans made upon admission and the subsequent treatment by an independent medical review panel, which revealed signs of medical mismanagement. Therefore, it also discusses the legal consequences that the case may have involved for the attending physicians in addition to the consequences for the suspected perpetrator. The report raises many issues encountered in the case in terms of the clinical treatment and forensic determination of the manner of death in cases of injuries caused by sharp instruments and highlights the importance of comprehensive evaluation of the circumstantial evidence together with the clinical or autopsy findings, since such evidence may sometimes be overlooked in clinical practice.

Transnasal Endoscopic Pituitary Surgery-The Role of a CT Scan in Individual Tailoring of Posterior Septum Size Resection

OBJECTIVE

This study was designed to evaluate the possibility of predicting the minimum size of septal resection for safe tumor extraction in transnasal paraseptal pituitary adenoma resection from preoperative computed tomography scans.

METHODS

A retrospective CT scan analysis was performed on 20 patients who underwent endoscopic pituitary surgery at the University Hospital in Ostrava. Virtual insertion of the straight instrument into the sphenoid cavity was simulated using a CT scan. The minimum septal resection size was predicted and compared to various diameters in the nasal cavity. The results were then compared with cadaveric dissections, in which septal resections were performed at 1 cm and 2 cm distances from the anterior sphenoid wall. The association between cadaver dissections and CT scan results was studied.

RESULTS

A total of 20 patients who underwent endoscopic transnasal surgery for pituitary adenoma between the years 2020 and 2021 were enrolled in the study. The mean virtual posterior septal size resection needed to reach the medial edge of the ICA with the straight instrument, without infracturing the nasal septum, was 13.2 mm. In cadavers with a 1 cm posterior septal resection, the medial edge of the ICA was reached with the straight instrument. In 2 cm resections, it was possible to reach beyond the lateral edge of the ICA.

CONCLUSION

There is no significant correlation between the minimum septal size resection and measured diameters in the nasal cavity. According to our study, a 1 cm resection is sufficient for a non-extended pituitary tumor extraction. More extensive septal resections allow for better maneuverability and overview in the surgical field.

Spontaneous Regression of a Symptomatic Cyst of the Cavum Septi Pellucidi and Vergae

Spontaneous regression of cysts of the cavum septi pellucidi (CSP) and cavum vergae (CV) is rare and little discussed. The authors present their case report of this phenomenon following a severe headache in a 23-year-old woman, in whom magnetic resonance imaging (MRI) had previously confirmed significant thinning of the left lateral cyst wall. We consider this finding to be a possible predisposing factor to rupture and the spontaneous regression of such cysts. In addition to the mechanism of cyst regression, the interrelated causes of their expansion and formation will be discussed.

Endoscopic two-port technique for orbital tumours: combined transnasal and sublabial approach

INTRODUCTION

The aim of this study was to present the indications for a combined endoscopic transnasal and sublabial transantral approach for the surgical treatment of orbital lesions.

MATERIAL AND METHODS

This case study enrolled 10 patients scheduled for endoscopic transnasal surgery for treating orbital lesions from 2009 to 2020. When the tumour was localised to the medial part of the orbit, patients underwent endoscopy with a transnasal mononostril approach. Alternatively, when the tumour was localised to the mediocaudal part of the orbit, and when instrument manoeuvreability was limited, the transnasal approach was combined with a sublabial transantral approach. Herein, we evaluate the indications, complications, and advantages of monoportal and combined two-portal approaches.

RESULTS

8/10 patients (80%) underwent surgery with the transnasal mononostril approach, and 2/10 (20%) underwent surgery with the combined transnasal mononostril and sublabial transantral approach. In the two latter cases, visualisation of the operation field was excellent, and there was adequate room for manipulating instruments.

CONCLUSIONS

The combined mononostril-transantral approach provided the space necessary to manoeuvre instruments and to visualise the surgical field in treating mediocaudal orbital lesions.

CLINICAL IMPLICATIONS

This two-portal approach enables extensive resections of intraconal lesions. It should be considered to be a suitable and safer alternative to the binostril approach.

Internal Carotid Injury during Skull Base Surgery-Case Report and a Review of the Literature

Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention.

Does Endoscopic Transnasal Optic Nerve Decompression Followed by Radiosurgery Improve Outcomes in the Treatment of Parasellar Meningiomas?

Introduction: The clinical management of parasellar meningiomas (PM) is challenging due to their intimate association with critical neurovascular structures. Consensus regarding the recommended treatment protocol is lacking. This study will evaluate patients’ visual outcomes following endoscopic transnasal optic nerve decompression (ETOND) and will investigate the possibility of reducing the rate of complications associated with stereotactic radiosurgery (SRS). Methods: Retrospective analysis was conducted on all patients who underwent ETOND for PM between 2013 and 2020. The study comprised 12 patients (7 women and 5 men aged 36–75 years; mean, 55.2 years; median, 57.6 years) in which 14 optic nerve decompression procedures were carried out. Patients were followed up for 6 to 86 months (mean, 29.3 months; median, 25 months). There were five cases of spheno-orbital meningioma, four cases of cavernous sinus meningioma, and one case each of petro-clival meningioma, optic nerve sheath meningioma, and planum sphenoidale/tuberculum sellae meningioma. Visual outcome was evaluated and any postoperative complications noted. Results: Improvements in visual acuity were noted in 10 of 14 eyes (71.4%) 3 to 6 months postoperation. Visual acuity remained stable in the remaining four eyes. No deterioration of visual acuity was noted during the follow-up period. In total, 9 of the 12 patients underwent SRS. No tumor growth was determined, while reduction in tumor volume was noted in five patients following SRS. No complications associated with SRS or the surgical procedure were noted. Conclusions: ETOND appears to be a promising technique for increasing rates of improved visual function, while reducing the risk of post SRS-related complications. In combination with subsequent SRS, it is an ideal treatment modality in the management of parasellar meningiomas. Confirmation of our findings would require a larger, prospective multicenter study.

Regeneration of Post-Agricultural Brownfield for Social Care Needs in Rural Community: Is There Any Transferable Experience?

In the 21st century, rural communities face many challenges, including implications of dynamic population aging, a lack of social care services, and the occurrence of abandoned post-agricultural brownfields. This paper is methodologically based on the findings derived from a set of qualitative in-depth interviews with the key rural stakeholders, explores the decisive factors and limits, accelerators, and barriers governing successful regeneration of the post-agricultural brownfield in the post-socialist environment. We are using the case of the regeneration project of a large-scale former communist agricultural cooperative, located in Vranovice, the Czech Republic, to illuminate how complex and challenging the redevelopment of a post-agricultural brownfield into a social care facility for elderly people is. A wide agreement among the experts in the field of community development exists that this regeneration project can serve as a model example for other rural municipalities that are sharing similar local development issues. Our findings illustrate how important and challenging at the same time are the matters of good governance, the active and long-term participation of stakeholders in the regeneration project, and the real-life introduction of the public–private partnership concept, particularly in immensely transforming the post-socialist countryside.

Mechanical Properties of Porous Structures for Dental Implants: Experimental Study and Computational Homogenization

A combined experimental and numerical study on titanium porous microstructures intended to interface the bone tissue and the solid homogeneous part of a modern dental implant is presented. A specific class of trabecular geometries is compared to a gyroid structure. Limitations associated with the application of the adopted selective laser melting technology to small microstructures with a pore size of 500 μm are first examined experimentally. The measured effective elastic properties of trabecular structures made of Ti6Al4V material support the computational framework based on homogenization with the difference between the measured and predicted Young’s moduli of the Dode Thick structure being less than 5%. In this regard, the extended finite element method is promoted, particularly in light of the complex sheet gyroid studied next. While for plastic material-based structures a close match between experiments and simulations was observed, an order of magnitude difference was encountered for titanium specimens. This calls for further study and we expect to reconcile this inconsistency with the help of computational microtomography.

Acute portal vein thrombosis in noncirrhotic patients - different prognoses based on presence of inflammatory markers: a long-term multicenter retrospective analysis

Background: Portal vein thrombosis (PVT) is a partial or complete thrombotic occlusion of the portal vein and is rare in noncirrhotic patients.Patients and methods: 78 adult patients with noncirrhotic acute PVT without known malignity were evaluated. Patients with initial CRP level 61-149 mg/l were excluded.Results: Patients were divided into two groups - the first one (33 patients) was characterized with signs of inflammation and CRP over 149 mg/l. The second group (45 patients) was without signs of inflammation and CRP level less than 61 mg/l. The frequency of prothrombotic hematologic factors was statistically significantly different in levels of factor VIII and MTHFR 677 C mutation. All patients from both groups underwent the same oncologic and hemato-oncologic screening which was positive in 23 patients (51.1%) in the group without signs of inflammation. In the group of patients with clinical and laboratory signs of inflammation oncologic and hemato-oncologic screening was positive only in 1 patient (3.0%). Complete portal vein recanalization was achieved in 19.2%, partial recanalization in 26.9%.Conclusions: Patients with clinical signs of inflammation and acute PVT have a low risk of malignancy in contrast to patients without signs of inflammation and acute PVT, which have a high risk of oncologic or hemato-oncologic disease. Patients with negative hemato-oncologic screening should be carefully observed over time because we expect they are at higher risk for the development of hemato-oncologic disease, independent from the presence and number of procoagulation risk factors.

Effect of antibiotic therapy on proton MR spectroscopy findings in human pyogenicbrain abscesses

BACKGROUND

This work aims to determine how antibiotic therapy influences MR spectroscopic findings in patients undergoing treatment for pyogenic brain abscess.

METHODS

This prospective, single center study included all patients who received treatment for brain abscesses at the Neurosurgery Department of University Hospital Ostrava between 2012-2017. Pre-operative MR imaging was carried out on all patients including diffusion-weighted imaging and in vivo single-voxel proton spectroscopy with intermediate echo time. The following factors were evaluated: duration of antibiotic therapy, characteristics of MR imaging and spectra findings and culture results.

RESULTS

MR spectroscopy findings characteristic of brain abscesses, i.e. the resonances of at least one of the metabolites concerned (amino acids, acetate, alanine and succinate), were observed in 23 patients who had undergone antibiotic therapy for less than 72 hours beforehand (median 7 hours; IQR 30 hours). The 20 patients who underwent antibiotic therapy for longer than this (the median time was 336 hours with an IQR of 284 hours) showed no abscess-specific metabolites, only nonspecific lactate and/or lipid resonance (p <0.0005). These results were further compared with culture findings of pus samples taken intra-operatively: a significantly higher rate of positive culture (78,2%) was determined in cases where antibiotics were administered less than 72 hours before MRS (p <0.0005).

CONCLUSIONS

Prolonged antibiotic therapy can influence MRS findings in pyogenic brain abscesses - a fact which is certainly necessary to take into account in its differential diagnosis. The disappearance of the characteristic metabolites can be indirectly interpreted as an indicator of successful antibiotic therapy in cases where surgical intervention is not possible. Further study in this field is required to confirm the results of this study.

Brain abscess and pyocephalus: our experience with treatment

INTRODUCTION

Pyocephalus always presents serious complications in the treatment of brain abscesses, and is associated with high rates of mortality and morbidity. This study aimed to comprehensively evaluate this understandably feared complication from a purely medical perspective by using an evidence-based approach and drawing comparisons from the available literature, which mostly comprises case reports.

METHODS

This was a prospective monocentric study of all patients treated for brain abscesses at the Neurosurgery Clinic of the University Hospital Ostrava between 2012 and 2017. The cohort was divided into two groups for statistical comparison; one group comprised those in which pyocephalus occurred before or during treatment, while the other group comprised patients without this complication. Particular consideration was given to the effect of pyocephalus on morbidity and mortality rates and C-reactive protein levels, as well as to the identification of risk factors, and to its possible therapeutic influence. Patients were followed up for six months.

RESULTS

A total of 43 patients were treated for a brain abscess. An unequivocal diagnosis of pyocephalus was established via CT and MRI brain scans in five cases (11.6%). In the cohort as a whole, mortality and morbidity rates were 23.3% and 48.8% respectively. Among patients with pyocephalus the incidence of mortality and morbidity was 40% and 66.6% respectively. The presence of pyocephalus is not a significant predictor of either morbidity (p 0.575) or mortality (p 0.664). In patients with pyocephalus, we determined elevated CRP levels on the day of surgery (p 0.038). The occurrence of epileptic seizures in the acute phase of the disease is associated with a poor outcome (p 0.039).

CONCLUSIONS

Pyocephalus will continue to be a serious complication in the treatment of brain abscesses, although we were unable to determine its utility as a prognostic factor. Patients with this complication have elevated CRP levels on the day of operation.

Comparing endoscopic and open decompression of the ulnar nerve in cubital tunnel syndrome: a prospective randomized study

BACKGROUND

Prospective randomized data is currently lacking which compares endoscopically assisted surgery with open surgical techniques in the treatment of cubital tunnel syndrome (CUTS). The aim of this study is to compare patient outcome in both techniques.

METHOD

This prospective study comprised of 45 patients who, between October 2014 and February 2017, were randomly assigned to undergo either endoscopic or open surgery (22 and 23 patients respectively) for decompression of the ulnar nerve. Patients were followed up at 3 and 12 months postoperation. McGowan classification was used to determine the severity of symptoms. Surgical outcome was evaluated by Bishop classification. Pain levels were monitored according to gender from 0 to 10 days postoperation. Other factors investigated were chronic scar pain, working status, operation duration, and patient satisfaction regarding postoperative scarring and the procedure itself.

RESULTS

Both methods are equally effective in the treatment of CUTS (Bishop score excellent or good 90% vs 96%). Postoperative pain is significant particularly in the first few days following surgery, but with no significant difference depending on procedure. In the open group, postoperative pain was significantly higher in women than in men; pain did not differ between the sexes in the endoscopic group. The tendency to lower levels of pain among endoscopically operated women in comparison with women in the open group was not statistically notable. Patients who underwent open decompression experienced notably higher levels of postoperative chronic scar pain. Although working status and satisfaction with the surgical outcome were the same in both groups, satisfaction with scarring was higher in the endoscopy group. Operation time was significantly longer by endoscopy.

CONCLUSIONS

Both studied methods produced equal satisfactory outcomes in the treatment of CUTS. Endoscopy has the potential to minimize chronic scar pain and improve scarring esthetics, at the expense of longer operating time.

CLINICAL TRIAL REGISTRATION NUMBER

Supported by Ministry of Health, Czech Republic-conceptual development of research organization (FNOs/2014, project number 20). Graphical abstract Median postoperative pain from 0 to 10 days by group.

Posttraumatic hydrocephalus

Posttraumatic hydrocephalus (PH) is a common complication of craniocerebral trauma. It is necessary to bear this entity in mind, especially when managing craniocerebral trauma patients, because if not detected in time, it can significantly affect morbidity and mortality. It needs to be distinguished from brain atrophy with axonal degeneration, a condition requiring an entirely different treatment approach. Key words: hydrocephalus - posttraumatic - VP shunt - brain CT - progression of neurological status.

Hunting with sticky tape: functional shift in silk glands of araneophagous ground spiders (Gnaphosidae)

Foraging is one of the main evolutionary driving forces shaping the phenotype of organisms. In predators, a significant, though understudied, cost of foraging is the risk of being injured by struggling prey. Hunting spiders that feed on dangerous prey like ants or other spiders are an extreme example of dangerous feeding, risking their own life over a meal. Here, we describe an intriguing example of the use of attachment silk (piriform silk) for prey immobilization that comes with the costs of reduced silk anchorage function, increased piriform silk production and additional modifications of the extrusion structures (spigots) to prevent their clogging. We show that the piriform silk of gnaphosids is very stretchy and tough, which is an outstanding feat for a functional glue. This is gained by the combination of an elastic central fibre and a bi-layered glue coat consisting of aligned nanofibrils. This represents the first tensile test data on the ubiquitous piriform gland silk, adding an important puzzle piece to the mechanical catalogue of silken products in spiders.

[Rupture of focal nodular hyperplasia in the 37th week of pregnanacy - case report]

OBJECTIVE

We describe a case of spontaneous hepatic rupture associated with undiagnosed focal nodular hyperplasia of a patient in the third trimester of pregnancy. Additionally, we provide a brief review of literature.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynaecology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague.

RESULTS

We report the case of a 29 year old patient with otherwise physiological pregnancy, who was hospitalized with pain in left hypochondrium. The patient experienced painful respiration, increasing in intensity in supine position. The possibility of lung embolism was considered and ruled out. Based on a suspected haemoperitoneum, caesarean section was performed. During the inspection of peritoneal cavity a ruptured tumor on the liver was identified. Histological examination showed focal nodular hyperplasia.

CONCLUSION

Focal nodular hyperplasia is a benign liver lesion. Complications involving rupture or bleeding are very rare. 17 cases of hepatic rupture associated with focal nodular hyperplasia were described in published reports with only one case related to pregnancy. Our case emphasizes the importance of a close cooperation between a gynaecologist, radiologist and surgeon.

[Current status regarding surgical treatment of pancreatic cancer in the Czech Republic]

INTRODUCTION

The aim is to map the current situation in the surgical treatment of pancreatic cancer in the Czech Republic. This information has been obtained from surgical treatment providers using a simple questionnaire and by identifying the so called high volume centres. The information has been collected in the interest of organizing and planning research projects in the field of pancreatic cancer treatment.

METHOD

We addressed centres known to provide surgical treatment of pancreatic cancer. A simple questionnaire formulated one question about the total number of pancreatic resections, also separately for the diagnoses PDAC - C25, in the last two years (2014 and 2015). Other questions focused on the use of diagnostic methods, neoadjuvant therapy, preoperative assessment of risks, the possibility of rapid intraoperative histopathology examination, Leeds protocol, monitoring of morbidity and mortality including long-term results, and the method of postoperative follow-up and treatment. ÚZIS (Institute of Health Information and Statistics of the Czech Republic) was addressed with a request to analyze the frequency of reported total numbers for DPE, LPE, TPE and to do the same with respect to diagnosis C 25 for the last two years, available for the entire Czech Republic (2013, 2014).

RESULTS

Altogether 19 institutions were identified by the preceding audit, which reported more than 10 pancreatic resections annually; these institutions were addressed with the questionnaire. Sixteen institutions responded to the questions, 13 of them completely.

CONCLUSION

The majority of potentially radical surgeries for PDAC in the Czech Republic are carried out at 6 institutions. All of the institutions that participated in the survey collect data about morbidity and mortality and monitor their results.

KEY WORDS

pancreas cancer outcomes surgery.

Abdominal closure reinforcement by using polypropylene mesh functionalized with poly-ε-caprolactone nanofibers and growth factors for prevention of incisional hernia formation

Incisional hernia affects up to 20% of patients after abdominal surgery. Unlike other types of hernia, its prognosis is poor, and patients suffer from recurrence within 10 years of the operation. Currently used hernia-repair meshes do not guarantee success, but only extend the recurrence-free period by about 5 years. Most of them are nonresorbable, and these implants can lead to many complications that are in some cases life-threatening. Electrospun nanofibers of various polymers have been used as tissue scaffolds and have been explored extensively in the last decade, due to their low cost and good biocompatibility. Their architecture mimics the natural extracellular matrix. We tested a biodegradable polyester poly-ε-caprolactone in the form of nanofibers as a scaffold for fascia healing in an abdominal closure-reinforcement model for prevention of incisional hernia formation. Both in vitro tests and an experiment on a rabbit model showed promising results.

[Transnasal endoscopic surgery approach in intraorbital tumors]

OBJECTIVES

To determine the role of transnasal endoscopic approach to orbital lesions.

METHODS

Retrospective case series.

RESULTS

Three patients underwent endoscopic diagnostic surgery for orbital lesions. In all three patients was successfully finded out the diagnosis, the orbita was decompressed. In two cases it resulted to visual recovery, in one case was determine a diagnosis of metastatic adenocarcinoma. In one case the tumor was removed totally.

CONCLUSION

Using endoscopic approach to the orbit allowed good approach to the biopsy of orbital lesions, allowed decompression an in limited count of cases this access allowed a complete tumour removal. On the other hand, generally endoscopic approach is useful only for limited lesions (extraconal), usually it allowed only debunking, not the complete resection of orbital pathology.

[Delayed gastric emptying after partial duodenopancreatectomy]

INTRODUCTION

Delayed gastric emptying (DGE) is a relatively common complication in patients after partial duodenopancreatectomy (PDPE) and significantly contributes to their postoperative morbidity. There has only been a small amount of interest attributed to DGE in Czech literature. The aim of this article is to present and analyze our own experience with the occurrence of DGE after PDPE.

MATERIALS AND METHODS

Retrospective analysis of prospectively collected data from 106 patients who underwent a PDPE at the Department of Surgery, University Hospital Motol and 2nd Medical Faculty, between 2001 and 2011. The data were statistically analyzed using the Chi-square test with statistical significance set at 5% of probability value (p < 0.05).

RESULTS

During the reporting period, PDPE was performed in 106 patients with a pathological process in the pancreatic head. 4 patients died in the postoperative period (30-day mortality 3.8%). Major postoperative complications occurred in 31 patients (morbidity 29%), with clinically significant DGE (grade B and C) in almost half of them (16 patients). Along with the DGE, 4 patients suffered from other major complications (2 pancreatic anastomotic insufficiency, 1 bile fistula and 1 external pancreatic fistula). We did not prove a statistically significant difference in the incidence of DGE depending either on the type of resection or pancreatic anastomosis type.

CONCLUSION

DGE contributes significantly to postoperative morbidity in patients after PDPE and is associated with other serious postoperative complications in a considerable number of cases.