Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases

AIM

An epidemic of hand, foot and mouth disease (HFMD) occurred in Singapore between September and November 2000. During the epidemic, there were four HFMD-related deaths and after the epidemic, another three HFMD-related deaths. This study sought to determine the risk factors predictive of death from HFMD disease.

METHODS

The risk factors for fatal HFMD were determined by comparing clinical and laboratory findings between fatal cases (n = 7) and non-fatal controls (n = 131) admitted between September 2000 and April 2001. Enterovirus 71 positive fatal cases (n = 4) and non-fatal controls (n = 63) were also compared.

RESULTS

In total, 138 HFMD cases with a mean age of 32 mo were studied. The majority of fatal cases died from interstitial pneumonitis, of whom three also had brainstem encephalitis. Of the 131 non-fatal cases, 3 had concomitant infections (respiratory syncytial virus bronchiolitis, right-sided pneumonia, Haemophilus influenzae type b meningitis), 2 had aseptic meningitis, and 1 each had transient drowsiness, intravenous immunoglobulin-related complications and transverse myelitis. By multivariate logistic regression analysis, atypical physical findings (p = 0.0006), raised total white cell count (p = 0.0128), vomiting (p = 0.0116) and absence of mouth ulcers (p = 0.043) were predictive of a fatal course. Although previous epidemics have described neurogenic pulmonary oedema as the main cause of death, the fatal cases in this study died mainly from interstitial pneumonitis alone or with myocarditis or encephalitis.

CONCLUSION

Although HFMD is generally a benign disease, risk factors such as vomiting, absence of mouth ulcers, atypical presentation and raised total white cell count should alert the physician of a fatal course of illness.

A case of sudden death from primary intracranial germinoma complicated by microvascular disease of the heart

A coroner's autopsy conducted on an 11.5-year-old girl, with a history of hypopituitarism, manifesting as growth hormone deficiency associated with short stature, demonstrated the presence of an undiagnosed hypothalamic intracranial germinoma, showing hypophyseal and mesencephalic invasion, together with histological evidence of microvascular (small coronary artery) disease of the heart. The substantive, or primary, cause of her sudden death was clearly the intracranial germinoma, which was acutely haemorrhagic and necrotic. However, it is postulated that there might be an, as yet, undescribed association between this malignancy and the pathogenesis of the coronary microvascular disease; the latter being deemed, in this instance, to be a contributory cause of death.

Fatal pulmonary thromboembolism in Singapore: has anything changed?

A previous study of fatal pulmonary thromboembolism (PE) during a five-year period (1989-1993) in Singapore found a low post-mortem prevalence of fatal PE (1.05%). The present study investigated cases of fatal PE among 10,097 coroner's post-mortems conducted between 1994 and 1998 at the Centre for Forensic Medicine, Health Sciences Authority, Singapore, and compared the results with the previous study. There were 130 cases of fatal PE, representing a post-mortem prevalence of 1.29%. This is comparable to the previous study but is lower than most other published series from other countries. There was a shift towards younger subjects, with the modal age group being 40 to 49 years, compared with 70 to 79 years previously. A large proportion of subjects had risk factors for PE, with 42.3%, 23.8% and 11.5% having had a history of surgery, trauma or malignancy respectively. After the onset of immobility or trauma, 50% of subjects developed PE in the first seven days and 76.8% in the first two weeks. PE was not suspected as the cause of death in 74.6% of cases under medical care. The incidence of fatal PE in Singapore remains low. However, a large proportion of cases continue to be unsuspected as the cause of death. It would appear that, on the whole, a correct clinical diagnosis of fatal pulmonary thromboembolism remains largely elusive.

Comparison of human and porcine aortic valves

We compared the anatomy of human and porcine aortic valves. Porcine hearts were collected from the abattoir. Human hearts from patients who had died of non-cardiac causes were examined in the mortuary; only undamaged and anatomically normal hearts were used. Silicon casts were prepared by injecting engineering silicon at 80 mm Hg into the aortic arch. Various features of the aortic valve were measured: circumference, length between the commissural end point and central point of coaptation, surface diameter, and surface area. In total, 12 porcine and 12 human aortic valves were studied. The average circumferences of the human and porcine aortic valves were 8.00 +/- 0.2 (SD) cm and 7.90 +/- 1.0 cm, respectively. The central point of coaptation in human valves was skewed toward the left coronary cusp, whereas in porcine valves it was skewed toward the non-coronary cusp. In human aortic valves, the non-coronary cusp had the largest surface diameter and surface area with mean measurements of 3.6 +/- 0.2 cm and 1.230 +/- 0.228 cm(2), respectively; the left coronary cusp was smallest for the same variables with measurements of 3.1 +/- 0.3 cm and 0.898 +/- 0.357 cm(2). In porcine valves, the right coronary cusp had the largest surface diameter and surface area with mean measurements of 3.9 +/- 0.7 cm and 1.716 +/- 0.81 cm(2), respectively; the non-coronary cusp was the smallest for the same variables with measurements of 2.9 +/- 0.5 cm and 1.023 +/- 0.659 cm(2). These differences suggest that when using porcine valves as transplant material (e.g., stentless valves), geometric considerations, such as commissural length, may be important.

Suicide trends in Singapore: two decades down the road

In this study, recent trends in the incidence and methods of suicide in Singapore, over the period 1991-2000, were compared with the results of a previous study covering the period 1975-1984 (Tan, 1986). The present study included a total of 3,834 suicidal deaths reported to the coroner and investigated by the Centre for Forensic Medicine of the Health Sciences Authority. The results showed that the crude suicide rate had stabilised over the last decade and that the rate was highest among elderly males. The three most common methods employed were falls from a height (69.3%), hanging (20.7%) and poisoning (5.5%). Comparison of the results of both studies showed that the crude suicide rate had stabilised over the last two decades. However, there was an increase in the suicide rates among males, as compared with the previous study, and a marginal decrease in suicide rates among females over this time. There was also an appreciable change in the methods of suicide employed, in that there was an increase in the proportion of deaths due to falls from a height and corresponding reductions in the proportions of deaths by hanging and poisoning.

Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore

Singapore experienced a large epidemic of hand, foot and mouth disease (HFMD) in 2000. After reviewing HFMD notifications from doctors and child-care centers, we found that the incidence of HFMD rose in September and declined at the end of October. During this period, 3,790 cases were reported. We performed enteroviral cultures on 311 and 157 specimens from 175 HFMD patients and 107 non-HFMD patients, respectively; human enterovirus 71 (HEV71) was the most frequently isolated virus from both groups. Most of the HFMD patients were <4 years of age. Three HFMD and two non-HFMD patients died. Specimens from two HFMD and both non-HFMD patients were culture positive for HEV71; a third patient was possibly associated with the virus. Autopsies performed on all three HFMD and one of the non-HFMD case-patients showed encephalitis, interstitial pneumonitis, and myocarditis. A preparedness plan for severe HFMD outbreaks provided for the prompt, coordinated actions needed to control the epidemic.

Epidemic hand, foot and mouth disease caused by human enterovirus 71, Singapore

Singapore experienced a large epidemic of hand, foot and mouth disease (HFMD) in 2000. After reviewing HFMD notifications from doctors and child-care centers, we found that the incidence of HFMD rose in September and declined at the end of October. During this period, 3,790 cases were reported. We performed enteroviral cultures on 311 and 157 specimens from 175 HFMD patients and 107 non-HFMD patients, respectively; human enterovirus 71 (HEV71) was the most frequently isolated virus from both groups. Most of the HFMD patients were </=4 years of age. Three HFMD and two non-HFMD patients died. Specimens from two HFMD and both non-HFMD patients were culture positive for HEV71; a third patient was possibly associated with the virus. Autopsies performed on all three HFMD and one of the non-HFMD case-patients showed encephalitis, interstitial pneumonitis, and myocarditis. A preparedness plan for severe HFMD outbreaks provided for the prompt, coordinated actions needed to control the epidemic.

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.

Massive hepatocellular [correction of hepatocullular] necrosis: was it caused by Orlistat?

Orlistat (tetrahydrolipostatin) is a lipase inhibitor which is used, in conjunction with appropriate dietary control, for the treatment of obesity. It is generally deemed to be a safe drug, which mainly exerts a topical action on the stomach and small bowel, with negligible systemic absorption and oral bioavailability. Consequently, its adverse effects have largely been limited to relatively mild gastrointestinal disorders. However, there have been recent, published reports of non-fatal acute hepatitis and systemic hypertension associated with its use. The present case concerns a 62-year-old male who died from massive hepatocellular necrosis, consistent with drug-induced, fulminant hepatitis, associated with the use of oral orlistat, presumably administered at the recommended daily dose of 360 mg. It is postulated that this may represent a rare idiosyncratic reaction to the drug.

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.

Fatal pulmonary haemorrhage from a perforated and possibly iatrogenic thoracic aortic aneurysm

A 56-year-old man, with Noonan's syndrome, underwent surgical correction of an aortic co-arctation almost two decades before his sudden and unexpected demise. The immediate cause of death was massive pulmonary haemorrhage, which was preceded by recurrent mild haemoptysis that was attributed to pneumonia, clinically. Autopsy revealed the presence of a saccular thoracic aortic aneurysm, arising from the apparently weakened anastomosis left by the previous operation. The aneurysm had eroded into the apical segment of the left lung, where it perforated with consequent severe, acute pulmonary haemorrhage. It was observed that the anastomotic line traversed the aneurysmal wall, with the resultant formation of a true aneurysm, rather than merely a pseudo-aneurysm. It is postulated that this finding of an iatrogenic true aneurysm represents a rare, delayed complication of aortic surgery.

Did he drown or was he murdered?

An unemployed, 60-year-old Singaporean gentleman died during a brief overseas trip to another South-East Asian country. He had, presumably, drowned in the bathtub of his hotel room, which he shared with his then 44-year-old companion, who was supposedly his nephew. The relevant public health and medico-legal authorities of the host country conducted an external examination of the body at the scene, whereupon they agreed with the police that his death was probably due to accidental drowning following an episode of syncope. It would appear that this verdict was based almost entirely on circumstantial and hearsay evidence. No autopsy was performed. In its place, considerable reliance was placed on the observation that abdominal compression resulted in the outflow of a small amount of water from the mouth, as being proof of drowning. A few days later, the body was cremated in the host country and the remains (ashes) were subsequently repatriated to Singapore. It later transpired that, shortly before they embarked on the ill-fated trip, the deceased's 'nephew' had purchased, on the former's behalf, travel insurance policies (covering accidental injury and death) amounting to a total of S$800,000 from five different insurance companies, as well as a separate life policy for a further S$100,000, most of which had been issued within the fortnight prior to their departure. Interestingly, the beneficiary (later the plaintiff in the ensuing civil trial some three years later) of all of these policies, was the ex-wife of the deceased's 'nephew', with whom he had, in fact, continued to live although they were officially divorced several years ago. Whilst the claim against the life policy had been settled, the first five insurers declined to issue payment on grounds of suspicion that the deceased had been the victim of a homicide, planned or executed by the 'nephew', wherein the beneficiary was a conspirator of sorts. The author was approached by defence counsel (representing the various insurers), for assistance in this matter. It was felt that a proper forensic review was seriously hampered by the lack of a full autopsy which would have been indispensable in ascertaining the actual cause of death and in eliminating other possibilities, apart from drowning, such as death from natural causes, other forms of injury, poisoning, or homicide. It was also emphasized that the mere presence of ingested water is not diagnostic of drowning. Eventually, after a protracted but unsuccessful attempt at mediation (in the course of which, the plaintiff rejected the offer of a reduced, although apparently sizable quantum), the matter came before the High Court, which found in favour of the defendants. It appeared that the judge was more than convinced that the deceased was indeed the victim of a homicide of which the plaintiff was a conspirator and her ex-husband, the perpetrator, as even a cursory perusal of the written judgement would indicate. Accordingly, the court ruled that the plaintiff (in her capacity as both the beneficiary of the insurance policies and executor of the estate) and her ex-husband had, effectively, deprived the insurers of their contractual right (as stipulated in the insurance policies) to have an autopsy conducted on the body of the deceased and they were, therefore, entitled to deny liability. This case illustrates the difficulties inherent in conducting an independent review of a putative instance of drowning, where convincing and reliable forensic evidence and documentation are largely wanting; this being compounded by its occurrence in a foreign jurisdiction whose medico-legal practices differ substantially from that to which one is accustomed. It may even be said that the corpus delecti was destroyed, in this instance, by cremation. It is also unusual in that a de-facto finding of murder was made in a civil court (whose standard of proof is that of a balance of probabilities) and that this had, subsequently, spurred the police to undertake a criminal investigation for conspiracy to murder. In the event, the civil appeal was dismissed by the Court of Appeal, but no charge was laid against any of the suspects for want of sufficient forensic or investigative evidence of a criminal offence having been committed.

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.