A right atrial mass: thrombus, tumour or other?

A 71-year-old man was admitted with right lower lobe pneumonia, right-sided pleural effusion and congestive cardiac failure. He had been well until a left occipito-parietal embolic stroke (documented on computed tomography; CT) 2 years previously. Chronic atrial fibrillation and hypertension were noted and he was commenced on digoxin, warfarin and amlodipine. A transthoracic echocardiogram showed normal left ventricular contractility, mild mitral regurgitation and a severely dilated left atrium. He made a full neurological recovery.

Precursor T-lymphoblastic leukemia with a novel t(1;22)(p34;q13)

A 37-year-old woman that presented with cervical lymphadenopathy and leukocytosis was found to have precursor T-lymphoblastic leukemia (T-ALL). Cytogenetic study of the leukemic cells showed a 46,XX, t(1;22)(p34;q13) karyotype. The t(1;22)(p34;q13) is a novel chromosomal abnormality in human malignancies and is probably a variant form of the t(1;14)(p34;q11) found in precursor T-ALL.

Are maternal deaths on the ascent in Singapore? A review of maternal mortality as reflected by coronial casework from 1990 to 1999

INTRODUCTION

In Singapore, published maternal mortality rates (MMR) over the last decade (1990 to 1999) have been so low (0.0 to 1.0 per 1000 live births and still births) as to imply that maternal deaths are rare to the point of being non-existent in some years. This inference is counterintuitive, and earlier studies on maternal mortality, amniotic fluid embolism (AFE) and pulmonary thromboembolism (PTE) have also suggested otherwise. Accordingly, local trends in maternal mortality warrant further examination.

MATERIALS AND METHODS

A descriptive and comparative study, comprising a clinico-pathological review of maternal deaths, for which autopsies were conducted by the Centre for Forensic Medicine, during a 10-year period from 1990 to 1999. The annual necropsy-based, MMR (estimated MMR), as well as the prevalence of maternal deaths during this time, were estimated with the aid of the relevant, published demographic data on live births and still births. These were compared with the corresponding rates calculated (calculated MMR) from raw demographic data on maternal deaths classified as such in the published data.

RESULTS

Coronial autopsies were conducted on a total of 51 cases of maternal death, of which 33, 17 and 1 were direct, indirect and fortuitous deaths, respectively. The annual, estimated MMR ranged from 0.4 to 1.8 per 10,000 live births and still births. The estimated MMR was twice as high as the calculated MMR and a statistically significant upward linear trend was demonstrated for the former (P = 0.046). AFE (16/51) and PTE (10/51) were the two most common causes of maternal death; their corresponding cause-specific, 10-year prevalence being 0.33 and 0.21 per 10,000 live births and still births, respectively. There was apparent clustering of the cases of PTE during the earlier part of the last decade (1990 to 1995), corresponding to a statistically significant, upward trend in its overall necropsy incidence during that time (P = 0.019). Cardiovascular and pulmonary disorders constituted the bulk of indirect deaths (13/17), while antenatal suicides accounted for 3 of these deaths (0.06 per 10,000 live births and still births).

CONCLUSIONS

This was an upward trend in MMR, as reflected in coronial casework, over the last decade. It would appear that the local, estimated (direct and indirect) maternal mortality prevalence compares favourably with the MMR reported in developed countries. The apparent rate of AFE was no less than 4 times higher than that reported in the United Kingdom, while the maternal mortality rate from PTE was at least as high. Allowing for the possibility that such deaths were under-reported, the actual annual MMR and 10-year prevalence could be appreciably higher than the estimates presented here. There may well be a case for the establishment of a comprehensive database of maternal deaths, that is updated continually and contemporaneously, in Singapore.

The 3-week sulphasalazine syndrome strikes again

A 34-year-old lady developed a constellation of dermatitis, fever, lymphadenopathy and hepatitis, beginning on the 17th day of a course of oral sulphasalazine for sero-negative rheumatoid arthritis. Cervical and inguinal lymph node biopsies showed the features of severe necrotising lymphadenitis, associated with erythrophagocytosis and prominent eosinophilic infiltrates, without viral inclusion bodies, suggestive of an adverse drug reaction.A week later, fulminant drug-induced hepatitis, associated with the presence of anti-nuclear autoantibodies (but not with other markers of autoimmunity), and accompanied by multi-organ failure and sepsis, supervened. She subsequently died some 5 weeks after the commencement of her drug therapy.Post-mortem examination showed evidence of massive hepatocellular necrosis, acute hypersensitivity myocarditis, focal acute tubulo-interstitial nephritis and extensive bone marrow necrosis, with no evidence of malignancy. It is thought that the clinico-pathological features and chronology of this case bore the hallmarks of the so-called "3-week sulphasalazine syndrome", a rare, but often fatal, immunoallergic reaction to sulphasalazine.

Fatal retroperitoneal haemorrhage: an unusual complication of percutaneous endoscopic gastrostomy

A 93-year-old lady with dementia, neurological dysphagia and aspiration pneumonia, died from massive retroperitoneal haemorrhage which developed as a rare and, it is believed, hitherto unreported, complication of percutaneous endoscopic gastrostomy (PEG), which was performed for feeding purposes. It is postulated that the initial, unsuccessful attempt at needle puncture of the stomach, under endoscopic guidance, had resulted in iatrogenic perforation and laceration of the splenic and superior mesenteric veins close to their confluence with the portal vein. It would also appear that dense fibrous adhesions between the pyloro-antral region of the stomach and the posterior hepatic surface had altered the immediate anatomical relations of the stomach in such a manner as to have predisposed to these events.

A preoperative protocol for the prevention of infection in children with tunnelled right atrial catheters

The use of central venous lines has come to be widely accepted by children with cancer and their families. However, attendant infection is a cause of considerable morbidity. Coagulase-negative staphylococci, the predominant aerobic species on the skin, are now the commonest cause of catheter-related bacteremia. We introduced a protocol to reduce the colonization of the skin at the catheter insertion site. Antiseptic skin scrubs, with 4% chlorhexidine gluconate, were performed on the neck and anterior chest the night before and again on the morning of the surgical procedure. A single dose of cephalothin (or vancomycin for penicillin-allergic patients) was administered IV immediately before the operation. Compared to the 12 month period prior to initiation of this protocol, the rate of infections (occurring within 30 days of catheter placement) in the 3.5 year period of intervention dropped from 8 to 4.9 per 1,000 catheter days. The proportion of infections that were staphylococcal was reduced from 93 to 63% and the proportion of non-ports removed within 30 days of placement fell from 45 to 0%. Despite these changes, the major contribution to improved infection control appeared to be the use of an increased proportion of ports (a rise from <10 to almost 60%).

BCR/ABL inhibition by an escort/phosphatase fusion protein

Cellular transformation by the BCR/ABL oncogene depends on the ABL-encoded tyrosine kinase activity. To block BCR/ABL function, we created a unique tyrosine phosphatase by fusing the catalytic domain of SHP1 (SHP1c) to the ABL binding domain (ABD) of RIN1, an established binding partner and substrate for c-ABL and BCR/ABL. This fusion construct (ABD/SHP1c) binds to BCR/ABL in cells and functions as an active phosphatase. ABD/SHP1c effectively suppressed BCR/ABL function as judged by reductions in transformation of fibroblast cells, growth factor independence of hematopoietic cell lines, and proliferation of primary bone marrow cells. In addition, the leukemogenic properties of BCR/ABL in a murine model system were blocked by coexpression of ABD/SHP1c. Both the "escort" function provided by ABD and the inhibitor function provided by the phosphatase of SHP1c were necessary for effective BCR/ABL interference. Expression of ABD/SHP1c also reversed the transformed phenotype of K562, a human leukemia-derived cell line. These results have direct implications for leukemia therapeutics and suggest an approach to block aberrant signal transduction in other pathologies through the use of appropriately designed escort/inhibitors.

Perioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury

INTRODUCTION

In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures.

MATERIALS AND METHODS

A retrospective (descriptive and comparative) study, comprising a clinico-pathological review of a series of 270 perioperative deaths (defined as deaths occurring during or after invasive therapeutic or diagnostic procedures, up to a week after discharge, and excluding cases of major trauma from suicides, homicides, as well as road and industrial accidents) reported to the Coroner, for which autopsies were conducted at the Department of Forensic Medicine from 1995 to 1997.

RESULTS

The necropsy incidence of 4.4% (270/6074) represented a significant rise over the previous triennia (P < 0.01). As in previous years, there was a predominance of males (M:F = 1.65:1) and middle-aged to elderly patients (range 0 to 92 years, mean 55.8 years, median 63 years), most of whom had died after a variable, but usually brief, postoperative interval [0 to 97, 4.2, 1 day(s)] and a more variable period of hospitalisation (< 1 to 289, 12.6, 7 days). A total of 408 invasive procedures were performed, amounting to an average of 1.5 per patient; 101 patients (37.4%) underwent multiple (> 1) interventions, which were initially classified as elective procedures in 27 cases. There were 66 (24.4%) iatrogenic deaths, of which 2 (0.7%) were due to anaesthetic mishaps; 18/64 iatrogenic deaths, unrelated to anaesthesia, occurred after the first postoperative day. The proportions of such deaths amongst patients subjected to multiple interventions, or initial elective procedures, were more than twice as high as amongst those undergoing single procedures, and those initially classified as emergencies (35.6% versus 16.6% and 33.3% versus 13.2%, respectively; P < 0.01). Only 51/66 (77.3%) iatrogenic deaths received Coroner's verdicts of misadventure; no verdict of criminal negligence was recorded during the period in question.

CONCLUSIONS

There appears to have been a steady increase in the number of perioperative deaths reported to the Coroner over the previous triennia (1989 to 1997) for which autopsies were conducted. While this observation may not denote an increase in perioperative morality rates per se, it may be indicative of an increasingly "aggressive" or defensive approach to the clinical management of seriously ill patients, particularly over the past decade. Although the rate of iatrogenic deaths appears to have stabilised, it is too early to say whether this apparent trend will persist in the future. It is perhaps not surprising that the risk of iatrogenic injury appears to increase with the number of interventions performed; however, it is not clear why initial, supposedly elective, interventions should be associated with an apparently greater risk of iatrogenic injury than those classified as emergency procedures. The substantial divergence between the autopsy finding of an iatrogenic death and the corresponding Coroner's verdict of misadventure may be comforting to clinicians, but certainly warrants further examination.

Bronchioloalveolar carcinoma with metastasis to the pituitary gland: a case report

An unusual case of metastatic bronchioloalveolar carcinoma of the lung presented as a pituitary tumour in a young adult Chinese female, who subsequently died after having undergone trans-sphenoidal resection. Metastatic cancers of the pituitary are uncommon even in necropsy series and rarely give rise to clinical symptoms. This case draws attention to the fact that, although uncommon, pituitary metastases have been noted with increasing frequency and their distinction from primary pituitary tumours is often difficult. A metastatic pituitary tumour may be the initial presentation of an unknown primary malignancy, wherein the metastatic deposits may also be limited to the pituitary gland. Clinicians and pathologists alike should consider a metastatic lesion in the differential diagnosis of a non-functioning pituitary tumour.

A review of pedestrian fatalities in Singapore from 1990 to 1994

The authors reviewed 369 consecutive pedestrian fatalities, which occurred from 1990 to 1994. This represented 28.5% (range 23.3 to 37.2; 95% CI 26% to 31%) of all road accident autopsies during that time. The mean and median ages of this population were 51 (95% CI 48.63 to 53.37) and 54 years, respectively. There were 160 (43.3%) who were in the economically productive ages of 20 to 59 years. Of the 369 victims, 224 (60.7%) were males and 145 (39.3%) females, there being a preponderance of males across all age groups. Most of these accidents occurred during the hours of daylight and in conditions of good weather and visibility. It was estimated that pedestrian behaviour contributed, in part, to at least three-quarters of these fatalities. The majority of these pedestrians died from multiple injuries (181; 49.1%) and closed head injury (146; 39.6%). The vast majority of subjects (357; 96.7%) had injury severity scores (ISS) > or = 16. A total of 100 subjects (27.1%) died at the sites of the accidents. Of these, 99 had ISS > or = 16, with 31 having had ISS = 75 (maximum score). Similarly, all 55 deaths that occurred in the A & E departments were associated with ISS > or = 16, with 6 having ISS = 75. This would imply that most of the deaths that had occurred on site and at A & E departments were not unexpected. Interestingly, no pedestrian aged < or = 12 years had an ISS < or = 16, suggesting that they may be more vulnerable to serious or life-threatening injury than adults. There were 46 (12%) victims who had detectable levels of ethanol in their blood samples, of whom, 10 had ISS = 75. However, the difference between the latter proportion and that of the rest of the pedestrian population who had no alcohol detected in their blood samples (31/323), was only marginally significant (95% CI 0.002 to 0.245). There was a high prevalence of pre-existing and intercurrent diseases, such as ischaemic heart disease (58.8%), hypertensive heart disease (30.4%), chronic obstructive airways disease (47.4%), bronchopneumonia (18.2%) and evidence of systemic hypertension (40.7%). It is submitted that the existence of these underlying conditions should be anticipated, or suspected, in the management of injured pedestrians, particularly the elderly, as they may influence the outcome of their critical care.

Fatal falls from a height: the use of mathematical models to estimate the height of fall from the injuries sustained

The authors undertook a review of fatal falls from a height, that occurred in 1991-92 in Singapore, with the objective of constructing mathematical models relating the height of fall to the injuries sustained. The 603 cases studied showed a mean age of 41.4 years with a male to female ratio of approximately 2:1. A sub-sample of 416 (69%) of these subjects had fallen from known heights (mean, 26.9 m; range, 3-69.6 m) and were studied in further detail. Bivariate analysis of this group showed that their injury severity score (ISS) was significantly correlated with the height of fall (H) and age (P < 0.01; r = 0.412 and 0.187, respectively). As the ISS is not strictly a continuous variable and varied markedly with H, it was categorised into bands (ISSB) before being subjected to further analysis. Regression modelling to adjust for mutual confounding showed that both height of fall and age were significant independent determinants of the ISSB (P < 0.0001). A model with H as the dependent variable was then constructed to relate the height of fall to ISSB and other statistically significant indicators of the extent and the severity of the injuries sustained. A second model with bands of height (HB) as the dependent variable was similarly constructed to assess the effect of banding both height and ISS. Our findings suggested that the height of fall was significantly associated with age, ISS and the extent of injury (mostly AIS > or = 3), and confirmed the usefulness of these models for investigative purposes. Statistical models could be designed and used to assess any apparent discrepancy between injury severity as determined at autopsy and the suspected/alleged height of fall.

Who dies at A&E? The role of forensic pathology in the audit of mortality in an emergency medicine department

The authors reviewed a total of 481 deaths, which occurred in an accident and emergency (A&E) department of a major general hospital, over a 3-year-period, from 1 January, 1992 to 31 December, 1994. Of these, 428 (89.0%) were referred to the coroner, with full medico-legal autopsies being conducted in 236 (55.1%) of the latter. There was a marked preponderance of male subjects (male:female ratio = 1.86) and, not unexpectedly, the likelihood of an autopsy being performed decreased with the patient's age. Nevertheless, all patients who died from trauma (or unnatural causes) underwent autopsies, irrespective of age. In all, autopsies were conducted for 70 traumatic and 166 natural deaths, with the mean age (95% CI) of the former group being some 19 years less than that of the latter (33.2 (28.4-38.1) vs. 52.0 (48.6-55.4), (P < 0.001). A comparison of the provisional causes of death (as recorded by the attending physicians in their clinical notes) with the autopsy findings yielded a higher diagnostic accuracy for traumatic deaths than for natural fatalities (correct diagnoses: 44/70 vs. 36/166; discordant diagnoses: 2/70 vs. 24/166, P < 0.01). This difference was accentuated after the patients who were dead upon arrival were excluded (44/55 vs. 36/96; 2/55 vs. 24/96, P < 0.005). As the injury severity score (ISS) is closely correlated with mortality, the autopsy findings were also used to calculate these values for 59 of a total of 70 patients who died from trauma or from unnatural causes. This showed that 24 had scores of 75 (incompatible with life), while 33 had ISS values above 16 (poor prognosis). The remaining 11 cases were not amenable to evaluation by means of the ISS. It was estimated that in approximately a third (18/55) of the misdiagnosed and undiagnosed natural fatalities, a correct diagnosis might have substantially altered acute management. This, in turn, could have improved patient survival, at least at the A&E level. By comparison, the perceived clinical impact of wrong diagnoses (two) and failure to diagnose (four) on traumatic deaths would have been almost negligible, as these patients generally had ISS values ranging from 30-75, with only one notable exception where the score was 10. Generally, given the circumstances under which physicians are required to work in A&E departments, the time spent with each patient is necessarily short. Furthermore, as there is usually limited access, if at all, to patients' medical records, very little relevant clinical or thanatological information is available, when death occurs. Therefore, in this instance, the medico-legal autopsy assumes the role of being an important investigative tool for the emergency physician. It may also contribute, substantially, towards medical audit and the enhancement of physicians' clinical acumen.

Accidental intraventricular vincristine administration: an avoidable iatrogenic death

A patient with acute lymphoblastic leukaemia was mistakenly given vincristine intraventricularly, as part of an intensified course of chemotherapy. Despite a CNS washout and supportive treatment, the patient developed progressive ascending paralysis, gradually lapsed into coma and died some 10 days later. Autopsy and post-mortem histological examination showed evidence of brain death caused by florid encephalomyelitis, apparently induced by the intraventricular administration of vincristine.

Perioperative deaths: a comparative study of coroner's autopsies between the periods of 1989-1991 and 1992-1994

An earlier retrospective, clinicopathological review of 132 perioperative Coroner's autopsies (excluding cases of preoperative major trauma), conducted by the Department of Forensic Medicine during the period from January 1989 to December 1991, showed that such cases accounted for an average of 2% of all Coroner's autopsies performed during that time. Of these, 15.2% were iatrogenic deaths which were unrelated to anaesthetic complications. Over the subsequent 3-year period (January 1992 to December 1994), there were 170 similar cases, arising from a total of 6468 Coroner's autopsies, representing a composite necropsy incidence of 2.6% (annual incidence: 2.5% to 2.8%) and an absolute increase of 38 cases over the previous period (P < 0.05). Also, the proportion of non-anaesthetic, iatrogenic deaths almost doubled to 28.8% (P < 0.02). Although these observations do not, considered alone, denote a rise in perioperative mortality during the second period (1992 to 1994), as compared to the first, since both studies were limited to deaths reported to the Coroner, they do seem to emphasize the need for a comprehensive ongoing clinical and medico-legal audit of perioperative deaths locally. At present, the proportion of perioperative deaths which are not reported to the Coroner and, thereby, escape medico-legal review, remains undertermined. In addition, as at the end of June 1995, only 23 of 51 pathologically unnatural deaths received a Coroner's verdict of misadventure, with an additional 11 such cases pending inquiry. This rather wide divergence between medical opinion and legal judgement could be a subject of further research.

Natural disease and alcohol intoxication amongst drivers of motor vehicles in Singapore from 1989 to 1993: a study of 140 necropsies

A 5-year retrospective study of 140 necropsies conducted on drivers of vehicles (excluding motorcyclists) involved in fatal motoring events, drawn from 1285 traffic deaths, showed a marked preponderance of males (95%) and of Chinese subjects (87.1%), with over half (53.6%) aged between 20 and 39 years. Approximately a third was free of morphological evidence of natural disease, while the remainder showed evidence of various combinations of ischaemic heart disease (64.3%), hypertensive heart disease (38.6%), chronic obstructive airways disease (25.7%), benign hypertensive nephrosclerosis (15%), cerebral atheroma (15%) and other conditions. While the majority succumbed to the effects or complications of severe trauma, 35 subjects (25%) died from natural (that is, non-traumatic) causes, with 17 or almost half of these having occurred as sudden deaths "at the wheel", not associated with any form of collision. The mean age of the former (traumatic deaths) was 35.3 years while that of the latter (natural deaths) was 55.2 years (P < 0.001). Notably, ischaemic heart disease was the predominant natural cause, accounting for 31 of all such cases, none of which resulted in death or injury to any passenger, pedestrian or another motorist. It was also the cause of death in 12 vocational drivers, corresponding to 0.9% of all traffic deaths during this period. Although 34 drivers (24.3%) had detectable blood ethanol levels at autopsy, of which 28 (20%) exceeded the current legal limit of 80 mg/100 ml, all of the cases where death was attributed to natural causes were free of ethanol. However, 15 subjects (10.7%) who had died from trauma but had significant underlying pathology, comprising 13 cases of ischaemic heart disease, had blood ethanol concentrations well above the legal limit. It is possible that, in at least some of the latter, alcohol consumption might have acutely aggravated the underlying pathology and combined to contribute to the occurrence of these fatal accidents.

Sudden infant death in a tropical environment: Singapore's experience

A total of 206 cases of sudden infant deaths examined at the Institute of Science and Forensic Medicine, Singapore, over a 5 year period (1989-93) were identified to assess the pattern of sudden death in this age group, which was subdivided into the neonatal and post-neonatal periods. A total of 34% (70) of infant deaths occurred in neonatal life and the remaining 66% (136) in the post-neonatal period; 90% of the neonatal deaths were natural, of which over half were due to congenital heart disease and complications of prematurity. Unnatural deaths in this period were uncommon, there being only seven such deaths. In the post-neonatal period, unnatural deaths constituted 25% of the total with trauma and aspiration heading the list. Natural deaths in the post-neonatal period are predominantly due to infections (34%) and a group of sudden natural deaths with minimal findings (31%). The latter group may arguably represent cases of Sudden Infant Death Syndrome (SIDS). The yearly incidence of this group in our study varied between 0.08 to 0.2 per 1000 live births, which is considerably lower than the incidence quoted for Western populations. The criteria for the classification and the impact of sudden infant deaths in Asian countries are discussed.

Regulatory Genes Controlling MPG1 Expression and Pathogenicity in the Rice Blast Fungus Magnaporthe grisea

MPG1, a pathogenicity gene of the rice blast fungus Magnaporthe grisea, is expressed during pathogenesis and in axenic culture during nitrogen or glucose limitation. We initiated a search for regulatory mutations that would impair nitrogen metabolism, MPG1 gene expression, and pathogenicity. First, we developed a pair of laboratory strains that were highly fertile and pathogenic toward barley. Using a combinatorial genetic screen, we identified mutants that failed to utilize a wide range of nitrogen sources (e.g., nitrate or amino acids) and then tested the effect of these mutations on pathogenicity. We identified five mutants and designated them Nr- (for nitrogen regulation defective). We show that two of these mutations define two genes, designated NPR1 and NPR2 (for nitrogen pathogenicity regulation), that are essential for pathogenicity and the utilization of many nitrogen sources. These genes are nonallelic to the major nitrogen regulatory gene in M. grisea and are required for expression of the pathogenicity gene MPG1. We propose that NPR1 and NPR2 are major regulators of pathogenicity in M. grisea and may be novel regulators of nitrogen metabolism in fungi.

Button-pexy fixation for repair of ileostomy and colostomy prolapse

Intestinal stomas are used in the surgical management of a number of congenital and acquired gastrointestinal conditions. Minor stomal complications are relatively common and are often well managed with nonoperative measures. Stomal prolapse may not represent a serious problem, but occasionally it requires surgical correction because of severe skin excoriation, bleeding, or incarceration of the bowel. The authors describe the treatment of stomal prolapse with the technique of button-pexy fixation, as originally described by C.W. Mayo.

An unusual case of pneumatically-induced facial and cervical injuries

An army mechanic sustained a penetrating mandibular injury, associated with right atlantooccipital dislocation, when the inner tube of a military truck tyre burst. It is thought that he had used a sledgehammer, having wielded it lengthwise with the free end of its hollow cylindrical handle held uppermost, to reposition the locking ring of the fully inflated tyre. In all probability, the sudden release of highly pressurised air disloged the locking ring and forced the circular end of the handle into his right lower jaw, thereby fracturing the mandible and causing an acute hyperextension injury of the cervical spine, with resultant profound spinal shock and instantaneous death.

A fatal case of drug-induced multi-organ damage in a patient with Hansen's disease: dapsone syndrome or rifampicin toxicity?

An elderly patient with borderline tuberculoid Hansen's disease (leprosy) developed the diaminodiphenylsulphone syndrome after approximately 8 weeks of multi-drug therapy comprising dapsone and rifampicin. Postmortem histological examination, following autopsy, demonstrated features consistent with drug-induced hepatitis, tubulo-interstitial nephritis and myocarditis. Although these could have been engendered by dapsone toxicity, it was thought that a concommitant adverse reaction to rifampicin, which is known to be hepatotoxic, nephrotoxic and possibly capable of predisposing to the dapsone syndrome, could not be excluded.

Sudden death arising from a congenital coronary artery fistula

A medico-legal autopsy conducted on a young Chinese man, a victim of sudden unexpected death, with a vague and unconfirmed history of congenital cardiovascular disease, revealed the presence of a congenital right coronary artery (arteriosystemic) fistula communicating with the markedly hypertrophied left ventricle, which showed microscopic evidence of myocardial ischaemia. The pathology of this rare condition is described and briefly reviewed.

Iatrogenically-related, fatal haemorrhage occurring in end-stage renal failure: a series of three cases

Three patients with end-stage renal failure died from acute haemorrhage which, in the first two cases, was related to the use of internal jugular catheters for haemodialysis. In the third instance, severe haemorrhage was caused by the apparent self-insertion of a 16-gauge butterfly needle, connected to a siliconised cannula (also designed for haemodialysis) into the superficial median cubital vein of the left forearm. The hazards associated with the use of internal jugular catheters and the medicolegal implications of these cases are briefly discussed.

Pulmonary thromboembolism is not uncommon--results and implications of a five-year study of 116 necropsies

A retrospective study of 116 cases of fatal pulmonary thromboembolism, drawn from a total of 11,044 Coroner's autopsies, conducted over a 5-year period, yielded a necropsy prevalence of 1.05%, with an annual incidence varying between 0.78%-1.32%. There was a statistically significant peak monthly incidence of 1.89% in September (P < 0.03), as well as significantly higher rates between April to September as a whole, compared to the rest of the year (P < 0.03). There was a marked preponderance of females (male:female ratio = 0.59) and 48.3% of the subjects were > or = 60 years of age, with a distinct peak (23.3%) in the 8th decade. The prevalence of the common predisposing factors were as follows: surgery 41.4%, trauma 30.2%, sepsis 22.4%, obesity 18.1%, malignancy 10.3% and pregnancy 4.3%. The peak time of death following trauma and/or immobilization was one week. Apparently, a total of 54 subjects (46.6%) were ambulant prior to death, while 29 (25%) did not have any of the common risk factors studied. The prevalence of cigarette smoking and oral contraception could not be ascertained due to inadequate clinical documentation, even among medical inpatients. The majority of deaths (85.3%) occurred in hospitals, of which 44.8% were surgical patients. Pulmonary thromboembolism was apparently not suspected in 77.1% of the 105 patients who died whilst under the care of qualified medical practitioners, there being no significant difference between medical and surgical inpatients. In these cases, death was most often attributed to acute myocardial infarction or ischaemic heart disease. The study also showed a high prevalence of underlying chronic obstructive airways disease (37.1%) and of moderate to severe coronary atheroma (37.9%). The clinico-pathological and medico-legal implications of these findings are discussed.

Pulmonary cartilage embolism: fact or artefact?

Microscopic examination of the lungs of a victim of traumatic asphyxia showed the presence of isolated foci of pulmonary bone marrow and cartilage embolism, although no macroscopic fractures were found. This condition could have resulted from a microfracture at a costochondral junction caused by the severe chest compression that led to the victim's death, or it might have been a resuscitation artefact. The possible role of pulmonary cartilage embolism as a marker of antemortem injury is considered.

Sudden postoperative death from ruptured intracranial vascular malformations in a patient receiving total parenteral nutrition

A 30-year-old female patient underwent oesophagectomy and colonic transposition for multiple oesophageal strictures associated with epidermolysis bullosa dystrophica. On the 9th postoperative day, she had convulsions and died, whilst in a state of severe hyperglycaemia, which was presumably iatrogenically induced by total parenteral nutrition. Autopsy and subsequent histological examination revealed that the cause of death was acute subarachnoid haemorrhage from ruptured, intracranial cryptic arteriovenous malformations. Postmortem vitreous biochemistry confirmed that death had occurred in a state of hyperglycaemia. The pathology of intracranial vascular malformations and the medico-legal implications of this case are discussed.

Acute fulminant, fatal coxsackie B virus infection: a report of two cases

Within a space of four months, between March to June 1993, medico-legal autopsies on 9 sudden infant deaths from natural causes were conducted at the Department of Forensic Medicine. Of these, 6 were due to unspecified interstitial pneumonitis or myocarditis (consistent with viral aetiologies), while 1 was attributed to adenovirus infection. The remaining 2 were due to fulminant Coxsackie virus (type B1) infection, where the post-mortem findings included leptomeningitis, myocarditis, florid interstitial pneumonitis, pancreatitis and focal hepatic necrosis. Coxsackie B viruses are often implicated in perinatal disease and, together with other viral infections, should be considered in the investigation of all sudden infant deaths.

Ischaemic heart disease as a natural cause of death in motorists

A study of 2,709 fatalities among road users, arising from a total of 59,164 accidents resulting in injury or death, between 1983-1992 in Singapore, showed that 1,134 and 904 deaths involved drivers of motor vehicles and motorcyclists (excluding pillion riders) respectively. In 13 cases of the former and 2 of the latter, death was deemed to have occurred naturally as a consequence of ischaemic heart disease. Two taxi drivers and both motorcyclists had apparently either collapsed "at the wheel" or whilst mounted on their motorcycles without their vehicles having been involved in actual accidents. In the remaining 11 cases, the vehicles had collided with other vehicles, fixed roadside structures or had veered off the road. However, none of these resulted in injury or death to passengers, occupants or other vehicles or to passing pedestrians. Thus, the prevalence of fatal ischaemic heart disease, as a natural cause of death, among motorists during this time was 0.7% (SD +/- 0.5), corresponding to 0.25 per 1000 (SD +/- 0.18) accidents resulting in injury or death; with less than 0.5% (SD +/- 0.4), corresponding to 0.19 per 1,000 accidents (SD +/- 0.17) resulting in injury or death, being associated with actual collisions. Although significant and dramatic metabolic derangements may occur during driving, thereby predisposing motorists to ischaemic heart disease, or aggravating pre-existing disease, these results and those of earlier studies would appear to suggest that serious road accidents are rarely caused by, or contributed to, coronary atherosclerosis and its attendant complications.

Cecal volvulus in the Cornelia de Lange syndrome

Cornelia de Lange syndrome is a congenital malformation characterized by severe growth failure, mental retardation, and multiple physical anomalies. A variety of gastrointestinal anomalies have been described, including malrotation, colonic duplication, and nonfixation of the colon. Two patients with Cornelia de Lange syndrome presented to our institution with acute distal bowel obstruction. In both cases, emergency laparotomy showed cecal volvulus with necrosis of the terminal ileum, cecum, and ascending colon, secondary to nonfixation of the colon. Resection and an end-ileostomy were performed and later successfully reversed in both patients. Intestinal obstruction is a known cause of death in these children, and nonfixation of the colon has been identified during autopsy. Parents of children with Cornelia de Lange syndrome should be counseled as to the possibility of bowel obstruction resulting from cecal volvulus. This awareness may lead to earlier identification and treatment of this potentially lethal gastrointestinal tract anomaly.

Massive chylothorax associated with lymphangiomatosis of the bone

Chylothorax in the absence of tumor or trauma is uncommon. Lymphangiomatosis of the bone, although extremely rare, has been associated with chylothorax. The authors describe the case of a 12-year-old boy who presented with a symptomatic left chylothorax associated with lymphangiomatosis of the ribs, scapula, and clavicle. Despite tube thoracostomies and the initiation of total parenteral nutrition, massive losses of chyle persisted, resulting in hypoproteinemia and severe lymphopenia. Control of the chylothorax was achieved by a parietal pleurectomy and application of fibrin glue (Tisseel). In the literature there are 16 cases of chylothorax associated with lymphangiomatosis of the bone. Their presentation, treatment, and outcome are reviewed. Conservative treatments such as dietary manipulations or thoracenteses were rarely successful. Thoracotomy with parietal pleurectomy on the side of the effusion is usually effective in controlling the chylothorax. Lymphangiomatosis should be considered a diagnostic possibility for any child who presents with a chylothorax.

A case of sudden maternal death associated with resuscitative liver injury

A pregnant lady suffered massive pulmonary thromboembolism whilst undergoing pelvic ultrasonography at an obstetric unit. She was vigorously resuscitated for approximately 2 h and later transferred to a cardiovascular surgical department where an emergency pulmonary embolectomy was performed, at which time, some 21 of blood, emanating from lacerations of the right hepatic lobe, were found in the peritoneal cavity. Despite heroic measures, she died intraoperatively, having developed clinical features of disseminated intravascular coagulation. Autopsy demonstrated the presence of multiple liver lacerations which are believed to have been caused by protracted external cardiac massage and would have contributed to her death.

Amniotic fluid embolism as a cause of sudden maternal death

The aetiology of amniotic fluid embolism has remained very much an enigma, although recent evidence points towards a combination of a severe haemodynamic disturbance, consisting of transient pulmonary hypertension, profound hypoxia and left ventricular failure, followed by secondary coagulopathy in about 40 per cent of patients who survive the initial event. Leucotrienes, prostaglandins and other vasoactive substances contained in amniotic fluid are postulated to play a fundamental role in its pathogenesis. In addition, amniotic fluid is also thought to possess thromboplastin-like properties. In common with all other causes of maternal death, it warrants a thorough and careful medico-legal investigation.

Peri-operative deaths in Singapore: a forensic perspective in a study of 132 cases

A study of 132, largely non-traumatic, peri-operative deaths out of 6605 Coroner's autopsies, conducted over a three-year period from 1989 to 1991, showed a preponderance of males (M:F ratio = 1.36), with almost half (46.3%) being middle-aged subjects between 40 to 59 years, while infants (< one year old) made up about a tenth of the cases. A total of 51 cases (38.6%) were related to cardiothoracic surgery, which also accounted for the majority of deaths that had occurred intra-operatively (11/21 or 8.3% in all) and within the first postoperative day (16/36 or 12.1% in all). The vast majority of cases (81.8%) were pathologically natural deaths, with 15.2% attributable to complications or mishaps of surgery and invasive diagnostic or therapeutic procedures. There were three anaesthetic deaths which accounted for 2.3% of the cases. Out of 124 completed Coroner's inquiries as at the end of June 1993, verdicts of death from natural causes were recorded in 110 (83.3%) cases. General surgery accounted for the highest proportion of unnatural deaths (6.1%), which was twice that for cardiothoracic surgery (3.0%). While there was close agreement between a finding of a pathologically natural death and a similar Coroner's verdict (107/110 or 97.3%), only a total of ten out of 23 pathologically unnatural deaths received verdicts of misadventure at the time of writing. Although a verdict of misadventure usually pertained to an iatrogenic death, this was not invariably the case. Thus far, no findings of medical negligence was made in any of the Coroner's inquiries into these cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Amniotic fluid embolism: a review of 10 fatal cases

A study of 10 fatal cases of amniotic fluid embolism, confirmed by autopsy and post-mortem histological examination, that occurred in Singapore between 1983-1992, showed that the majority (9 cases) were multiparous, with between 2-4 previous normal pregnancies each. Seven had uneventful antenatal histories. In all cases, the clinical onset was sudden and unexpected, having occurred during the first stage of labour in 8 subjects and being associated with convulsions in 5. There were seven cases of coagulopathy, with 6 of disseminated intravascular coagulation. Overall, foetal survival was poor. Three cases were associated with induction of labour, while another 3 occurred after augmentation. Emergency caesarean sections were performed in 5 cases. Autopsy demonstrated moderate to severe pulmonary oedema in 9 cases, accompanied by pulmonary haemorrhage in 6. Mild coronary atheroma was present in 6 cases, with 3 showing subendocardial haemorrhage. Significant utero-cervical ruptures or lacerations were found in 3 cases. Microscopy demonstrated the presence of squamous epithelial emboli within the pulmonary vasculature in all cases. Other histological features included fibrin microthrombi (3 cases), alveolar and pulmonary interstitial inflammation, focal myocardial and hepatocellular necrosis, and myocardial interstitial inflammation. Although the precise pathogenesis of amniotic fluid embolism has remained somewhat enigmatic, recent evidence points towards a combination of a severe haemodynamic disturbance followed by secondary coagulopathy in about 40% of patients who survive the initial event. Leucotrienes, prostaglandins and other vasoactive substances contained in amniotic fluid are postulated to play a fundamental role in its pathogenesis. Amniotic fluid is also thought to possess thromboplastin-like properties.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatal haemorrhage following intra-aortic balloon counterpulsation: a case report and a brief review of its clinico-pathological and medico-legal aspects

Intra-aortic balloon counterpulsation may result in serious and possibly fatal vascular complications, such as arterial dissection, in as many as 20 per cent of cases. A significant proportion of these complications may go unrecognized clinically. The following is an account of such a case from Singapore in which an elderly patient with a history of severe ischaemic heart disease died within 25 hours of coronary bypass surgery (resulting from massive intraperitoneal haemorrhage), as a consequence of post-operative intra-aortic balloon counterpulsation. The clinico-pathological and medico-legal aspects of the case are also discussed, together with a brief mention of the role of post-mortem coronary angiography in assessing venous graft patency and integrity.

Isolated colonic hemangioma in a child

Hemangiomas of the large bowel are very rare and usually occur in the rectosigmoid. A large cavernous hemangioma of the colon was demonstrated in a 9-month-old child who presented with recurrent lower gastrointestinal tract bleeding. Barium examination demonstrated an annular lesion of the hepatic flexure. Computed tomography demonstrated the extent of the lesion, and contrast enhancement suggested the vascular nature of the tumour before a laparotomy was performed to remove the tumour.

Connection of electronic medical devices in ICU according to the standard 'MIB'

In the daily routine of an SICU, particularly in cardiac surgery, the nurses are to an increasing extent confronted with problems of connecting and using medical instruments as well as with documentation of the data of these instruments. An increasing number of user errors is to be expected. Use of advanced computer technology can help avoid such errors. In this paper the system 'ALODIN' is presented which is developed in our institutions according to the IEEE standard 'Medical Information Bus' (MIB). ALODIN-I will be part of a CCCS (computerized critical care system) which is installed in the clinic for cardiovascular surgery at Medical School Hannover.

Use of a computerized closed-loop sodium nitroprusside titration system for antihypertensive treatment after open heart surgery

This study evaluates the clinical applicability of administering sodium nitroprusside by a closed-loop titration system compared with a manually adjusted system. The mean arterial pressure (MAP) was registered every 10 and 30 sec during the first 150 min after open heart surgery in 20 patients (group 1: computer regulation) and in ten patients (group 2: manual regulation). The results (16,343 and 2,912 data points in groups 1 and 2, respectively), were then analyzed in four time frames and five pressure ranges to indicate clinical efficacy. Sixty percent of the measured MAP in both groups was within the desired +/- 10% during the first 10 min. Thereafter until the end of observation, the MAP was maintained within +/- 10% of the desired set-point 90% of the time in group 1 vs. 60% of the time in group 2. One percent and 11% of data points were +/- 20% from the set-point in groups 1 and 2, respectively (p less than .05, chi-square test). The computer-assisted therapy provided better control of MAP, was safe to use, and helped to reduce nursing demands.

Omental pedicle grafting in the treatment of postcardiotomy sternotomy infection

Postcardiotomy sternal infection occurred in 20 (2%) of 1007 patients undergoing cardiac surgery between September 1985 and December 1987, a 10-fold increase over the preceding 33 months (4 [0.24%] of 1627 patients). Cultures were sterile in 5 patients and yielded staphylococci in 12 and a variety of bowel organisms in 3. The cause for the increased occurrence of sternal wound infection is unclear after multivariate analysis, although infections have precipitously dropped subsequent to changing to cefuroxime sodium antibiotic prophylaxis. Treatment has evolved to appropriate antibiotics and early débridement of involved sternum and cartilage. Rewiring the sternum is not attempted. If gross purulence is not present, primary closure is accomplished using muscle flaps (2 patients) or omental pedicle grafts (17 patients). In the presence of gross purulence, the wound is packed open for 5 days and then closed in the above fashion. Two patients required skin grafts for primary closure. The omental pedicle flap is preferred due to simplicity and improved coverage of the sternal defect inferiorly. Nineteen patients healed primarily. A superficial wound infection was drained in 1 patient. Midline incisional hernias developed in 3 muscular patients. Omentum is now harvested through a left subcostal incision. Hospital stay was under 2 weeks in 13 patients. One death occurred due to multisystem failure prior to completion of wound closure. In our experience, early sternal débridement and omental pedicle grafting with primary closure is appropriate therapy for postcardiotomy sternotomy infections. The presence of gross purulence may require 5 days of open packing prior to omental grafting. No significant complications occurred, and mortality was low. A left subcostal incision for omental harvesting is utilized to avoid the occurrence of delayed incisional hernias.

Closure of bronchopleural fistulas by an omental pedicle flap

Bronchopleural cutaneous fistulas are a serious problem that are difficult to treat with any assurance of success. Thoracoplasty, muscle pedicle grafts, and attempts at reclosure have been used with limited success. We have used the omental flap technique in the management of five patients with bronchopleural cutaneous fistulas. In our patients and in four cases in the literature, the success rate has been 100 percent. The omental pedicle flap is a simple way to close bronchopleural fistulas. It avoids extensive chest wall dissection and destruction in patients who often have marked respiratory embarrassment and other underlying disease. The results have been excellent.

[Anorectal continence following manual and mechanical anastomosis suture. Results of a controlled study of rectal surgery]

In a controlled clinical trial-manual vs. stapler anastomosis in rectal surgery-it was found that both suture techniques per se made no difference in the function of anal continence. The anal pressures at rest and sphincter contraction remained unchanged. A linear reduction of functional reservoir of the "neorectum" could be shown, which depended on the level and healing of the anastomosis. An anastomosis level at 6 cm from anocutaneous line is important for functional reasons. Anastomoses above this level do not cause any consequences for anal continence. Anastomoses below this level result in a reduced functional reservoir for at least 6 months. Within this period a decrease in anal continence is possible, especially in cases of disturbed healing of the anastomosis.

Effects of public description on the detection and tolerance of laboratory pain

Experimental procedures designed to modify an hypothesized pain detection threshold were arranged to test the notion that to describe a painful experience publicly results in subsequent increased detection of similar pain. First, subjects were pre-tested on their ability to detect and tolerate cold pressor pain. While waiting for a second test, half of the subjects were engaged in conversation by a confederate to whom the subject described his/her impressions of the pre-test. The other half waited in silence for the second test. Results showed that, relative to those who did not describe pain, subjects who publicly described the pain experience had low pain thresholds on the post-test, tolerated the pain less long and reported engaging in a greater number of thoughts indicating that the pain started sooner and was more intense on the post-test. Possible mechanisms to explain this effect are discussed, clinical implications are presented and directions for future research on the same process are outlined.

Prevention of complications after liver trauma

Treatment of 681 cases of liver trauma during the past ten years at the San Francisco General Hospital was reviewed. The mortality was 14.7 per cent and the morbidity rate 18.9 per cent. The complications relating specifically to liver injury were bleeding subphrenic or subhepatic abscesses, intrahepatic abscess, biliary fistula, and liver failure. These complications and the recommended management of the liver injury are discussed.