Medicolegal aspects of the Thai Airbus crash near Kathmandu, Nepal: findings of the investigating pathologists

A Thai Airbus, carrying 99 passengers and 14 crew members, traveling from Bangkok to Kathmandu, hit a mountain and crashed several minutes before landing. There were no survivors. Recovered human remains, none of which was easily identifiable, varied in size from a small piece of muscle to mutilated bodies. Of the 97 fragments, only 15 were sufficiently intact (albeit, only partially) to be designated as "bodies." Of the fragments and "bodies," only 11 were positively identified. Causes of death, although all traumatic, could not be stated accurately due to the degree of disintegration. Identification of human remains in these circumstances is a major problem for the pathologist.

Cytokine regulation of low-density lipoprotein receptor gene transcription in human mesangial cells

BACKGROUND

The intracellular transport of lipids through regulation of the LDL receptor (LDLr) may be important in the progression of renal dysfunction. The present study was undertaken to investigate whether cytokines have any major effects on LDLr regulation and lipid-mediated glomerular injury in human mesangial cells (HMC).

METHODS

We explored the effects of 50 ng/ml of tumour necrosis factor alpha (TNF alpha), 5 ng/ml of transforming growth factor beta (TGF beta), platelet-derived growth factor (PDGF), and interleukin-1beta (IL-1beta) on the regulation of LDLr gene transcription in a human mesangial cell line (HMCL) using cell proliferation, LDL binding, northern blot and LDLr promoter activity assays.

RESULTS

TNF alpha, TGF beta, PDGF or IL-1beta did not significantly stimulate HMCL proliferation at the concentrations given above, but maximally stimulated LDLr mRNA expression and increased LDLr promoter activity by 167.48+/-23.56%, 150.47+/-24.41%, 127.71+/-24.65% and 163.01+/-31.91% respectively, at 24 h. An increased LDL binding was observed in parallel with increased LDLr mRNA. The tyrosine kinase transduction pathway was involved in LDLr upregulation induced by all four cytokines. Additionally, TGF beta involved serine/threonine kinase and G-protein pathways, and IL-1beta involved calmodulin, serine/threonine kinase and PKC pathways in upregulating LDLr. A high concentration of LDL (250 microg/ml) inhibited promoter activity, but TNF alpha, TGF beta, PDGF and IL-1beta co-incubated with LDL could override transcriptional inhibition by LDL.

CONCLUSION

TNF alpha, TGF beta, PDGF and IL-1beta increased LDLr gene expression by increasing sterol-independent and mitogenesis-independent gene transcription. This process may contribute to lipid deposition and foam cell formation in HMC.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a rare disorder associated with less than 1% of colorectal carcinomas (CRCs). Since FAP is a potentially preventable cause of CRC clinicians should have an adequate knowledge of it to identify the disease and to manage the patient and family. FAP is an autosomal dominant inherited disorder characterised by the development of more than a hundred adenomatous polyps in the colon and rectum which can undergo malignant change. Children of an affected individual are at 50% risk of inheriting the predisposing gene. After the identification of an index patient, genetic testing in combination with the detection of extra-colonic manifestations allows more accurate identification of family members likely to have the faulty gene, enabling the targetting of screening and preventive surgery only to those at risk. FAP also provides insights into the development, progression and prevention of sporadic CRC.

Toluene diisocyanate exposure in a glove manufacturing plant

CASE REPORT

An accidental exposure due to reuse of containers of toluene diisocyanate to transport nontoxic substances and subsequent occupational toxic exposure caused illness among forty workers in a glove manufacturing plant. Examination and investigation of the patients and factory site inspection were carried out. Toluene diisocyanate-contaminated latex was examined by the infrared spectroscopy. Thirty-two of forty patients had muscle pain and seven had elevated creatine phosphokinase activity. These features have not been reported previously as components of toluene diisocyanate toxicity and their underlying causation remains speculative.

Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour

Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural (n = 30) or spinal blockade (n = 30) for labour analgesia and compared with spinal anaesthesia (n = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% (n = 4) had abnormal dorsal column function compared with 97% (n = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). All patients in the Caesarean section group developed lower limb motor weakness, compared with only 10% (n = 6) in the low-dose groups (p < 0.001). There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.

Childhood poisoning in Sri Lanka

Poisoning in children is a common accident and poison information services should be aware of the toxic agents responsible for poisoning in the community. A retrospective hospital based study was performed, before the establishment of the National Poisons Information Centre in Sri Lanka. There were 4,556 admissions of poisoning to the selected hospitals in the Western Province in 1986 and of this, 540 (11.4%) were below 15 years. Males accounted for 66%. Kerosene oil was responsible for 47% of the poisoning cases in less than 5 years age group, while kerosene oil, pesticides and plants/mushrooms were the commonest toxic agents in the 5 to 14 years age group. The case fatality rate was 3.2%.

Neonatal welfare and placental transfer of fentanyl and bupivacaine during ambulatory combined spinal epidural analgesia for labour

To investigate current concerns that potent opioid drugs, such as fentanyl, used for labour regional analgesia may affect neonatal status, maternal and umbilical plasma concentrations of fentanyl and bupivacaine at delivery were measured in 40 nulliparous patients receiving low-dose combined spinal epidural analgesia. Neonatal assessments included Apgar scores, umbilical blood gases and neurobehavioural tests. All maternal and umbilical venous plasma concentrations were low. Maternal and umbilical vein total fentanyl concentrations increased with increasing doses of epidural fentanyl (r = 0.46 and 0.30, respectively, p < 0.01). There were no significant differences between maternal and umbilical venous plasma total or free concentrations of fentanyl. Mean umbilical vein/maternal fentanyl ratios were 1.12 for total drug and 1.20 for free drug and values were unrelated to the last epidural bolus to delivery interval (r = 0.12, p = 0.49). There were no correlations between Apgar scores, umbilical blood gases or neurobehavioural scores and umbilical venous concentrations of either fentanyl or bupivacaine. The dose of fentanyl used for ambulatory combined spinal epidural analgesia would appear to have a negligible effect on neonatal condition.

Post partum magnetic resonance imaging: lumbar tissue changes are unrelated to epidural analgesia or mode of delivery

Thirty five women consented post partum to daily lumbar back pain assessments and magnetic resonance imaging (MRI) (0.15 Tesla) within 48 hours of delivery using a T(1) weighted spin echo and a fat suppression sequence (STIR) to identify tissue water. Nine women (26%) had lumbar disc abnormalities on MRI scan. Variable degrees of soft tissue changes in the lumbar region were observed using the STIR sequence in all patients after delivery. Eight women (23%) had mild, 15 (43%) moderate, and 12 (34%) severe changes with an average of 5 segments involved. These changes were reversible and related neither to the mode of delivery, nor to the trauma of epidural cannulation.

Accidental intrathecal insertion of an extradural catheter during combined spinal-extradural anaesthesia for caesarean section

The combined spinal-extradural technique is used to provide analgesia and anaesthesia in obstetric anaesthetic practice. The accidental insertion of an extradural catheter into the dural opening made previously by the spinal needle is thought to be a theoretical risk. We report a case during combined spinal-extradural anaesthesia for Caesarean section in which this complication occurred.

Pesticide poisoning in the Asia-Pacific Region and the role of a regional information network

Pesticide poisoning is an important cause of morbidity and mortality in many countries in the world. It has been estimated that 95% of fatal pesticide poisonings occur in developing countries, many of which are in the Asia-Pacific region. Agriculture based economies, easy availability of pesticides, poverty related socioeconomic problems, lack of adequate protective clothing, and limited treatment facilities are some of the factors contributing to the high morbidity and mortality. There is a lack of easily accessible information on pesticide related ill health in the countries of Asia-Pacific Region. Although Poison Centers are active in some countries, lack of resources is a major constraint on the provision of an efficient service. There are several intercountry projects and information networks in the region dealing with agriculture and environment but no such information facilities are available concerning pesticide poisoning. A Regional Pesticide Poisoning Information Network for the Asia-Pacific Region could disseminate information on pesticide related illness to any individual or institution via print and electronic media. Such a network could work towards close cooperation between all poisons centers and toxicologists in the region to reduce the rising morbidity and mortality from pesticide poisoning.

Gamma delta T cell receptor repertoire in brain lesions of patients with multiple sclerosis

The identification of activated T cells in the brains of patients with multiple sclerosis (MS) suggests that these cells are critical in the pathogenesis of this disease. Recently we have used the PCR method to analyse rearrangements of V alpha and V beta genes of the T cell receptor (TCR) in samples of MS and control brains. The results of these studies showed that TCR V gene usage in MS brains may be restricted and in particular that V beta genes may be preferentially rearranged in certain HLA haplotypes associated with susceptibility to MS. In view of the recent evidence that T lymphocytes bearing the gamma delta chains may have autoreactive potential, we have assessed whether or not such TCR-bearing lymphocytes were also present in chronic MS lesions. TCR V gamma and V delta were analysed by the PCR method using a panel of V gamma and V delta primers paired with C gamma or C delta primers in 12 MS brains, as well as in brain samples of ten normal post-mortem cases and three neurological controls. TCR V gamma-C gamma and V delta-C delta rearrangements were confirmed using Southern blotting and hybridisation of the PCR products with specific C gamma and C delta probes. Only one to four rearranged TCR V gamma and V delta transcripts were detected in each of the 23 brain samples obtained from 12 MS patients, with the majority of gamma delta T cells expressing the V gamma 2 and V delta 2 chains. In marked contrast, V gamma and V delta transcripts could only be found in one of the ten non-neurological control brains analysed. To assess the clonality of V gamma 2 and V delta 2 T cell receptor chains in the brain samples of MS patients, we have sequenced the junctional regions of the TCR V gamma-N-J gamma-C gamma and V delta-N-D delta-N-J delta-C delta segments amplified from brain tissues, CSF and spleens of two MS patients and from the spleen of two control subjects. The sequence analysis obtained so far shows no compelling evidence of an MS specific expansion of one or more clones expressing particular types of gamma delta T cell receptors. In contrast, a clonal expansion of a different population of TCR gamma delta-bearing T cells was found in the spleen of both an MS patient and one of the control individuals.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of plain and alkalinized local anaesthetic mixtures of lignocaine and bupivacaine for elective extradural caesarean section

We have examined a local anaesthetic mixture of 0.5% bupivacaine 10 ml and 2% lignocaine 10 ml with adrenaline 1 in 200,000, to which 8.4% sodium bicarbonate 2 ml was added, for extradural Caesarean section. The alkalinized mixture of local anaesthetics produced a block of more rapid onset and density than a mixture of bupivacaine and lignocaine alone (P less than 0.001).

Acute poisoning: a major health concern in Sri Lanka

The importance of acute poisoning as a cause of morbidity and mortality in many developing countries has been highlighted in recent times. This study discusses the utilization of routinely collected data from hospitals for background information required in planning and implementing preventive programs. The high prevalence of poisoning and its distribution countrywide were highlighted by the routinely collected data, while the retrospective study of hospital admissions identified the wide range of toxic agents and age and sex differentials in the pattern of poisoning. Even though the overall case fatality rate was 7.6%, there was wide variation among the different toxic agents.

Varying amounts of stretch stimulus regulate stretch-induced muscle hypertrophy in the chicken

1. The effects of different amounts of passive stretch per day and number of days of stretch on muscle hypertrophy in the chicken patagialis (PAT) muscle were determined. 2. Stretch for 24 hr per day (h/d) resulted in a more rapid hypertrophy both on a wet and dry tissue basis (P less than 0.001) than stretch for 4 h/d. 3. Stretch increased PAT weight 43% and 25% in 24 h/d and 4 h/d treatments, respectively, after 10 days of stretch, but by day 25 of stretch there was no difference between treatments. 4. In a second experiment, the PAT muscle was hypertrophied and then the effects of intermittent stretch (4 h/d) on regression of hypertrophy (muscle atrophy) were investigated. 5. Intermittent stretch (4 h/d) for 5 and 10 d significantly (P less than 0.001) inhibited regression of hypertrophied muscle. 6. The results of the present study indicate that stretch-induced hypertrophy can be modulated by varying the amount of stretch applied per day. 7. Intermittent stretch can be used to inhibit the regression which occurs when a continuous stretch stimulus is removed. 8. Intermittent stretch is a useful model for investigating mechanisms of muscle hypertrophy and inhibition of muscle atrophy.

Poisoning with plants and mushrooms in Sri Lanka: a retrospective hospital based study

A retrospective hospital-based study in Sri Lanka showed that out of 4556 cases of poisoning, 2.5% were caused by plants and mushrooms. Gloriosa superba (44%), and Ricinus communis (24%) were the commonest plants responsible for poisoning; 39% of the victims were less than 15 y old. Gastric lavage and iv fluids were the most common therapeutic measures used. There were 8 deaths, all due to G superba. There is a need for public education to prevent poisoning, which is a major health concern.

Sudden unexpected death due to familial hypertrophic obstructive cardiomyopathy

Hypertrophic cardiomyopathy is a familial condition with a very distinct risk of sudden death in males in certain families. The disease appears to be not uncommon in Sri Lanka. A sudden death in a 26-year-old healthy man is reported: At autopsy the heart was 500 g due mainly to left ventricular hypertrophy, and showed histological changes consistent with cardiomyopathy. Symptomless family members of the deceased were subsequently referred to a cardiologist. Cardiomyopathy was diagnosed in one of them.

Medical certification of cause of death in the General Hospital, Colombo

To determine the accuracy of death certification by hospital doctors, all certificates of deaths issued for one month in the General Hospital, Colombo were studied. Only 97 (38%) of the 253 certificates were correctly recorded according to the internationally accepted criteria. The immediate, antecedent and contributory causes of death were not written in the correct place in 75 (30%) certificates, while unacceptable causes of death were found in 49 (19%). Abbreviations had been written in 13 (5%) instances. Death certificates had been issued without informing the coroner in 14 (6%) cases, which was irregular. The need for accurate certification of death for disease surveillance, research and planning is stressed.

National Poisons Information Centre in a developing Asian country--the first year's experience

The National Poisons Information Centre (NPIC) in Sri Lanka was established in January 1988. It received 353 enquiries in the first year of which 37% concerned pesticide poisoning. More than half the instances were of self-poisoning; consistent with the high suicide rate in the island. Over a quarter of poisoning episodes were among 19-25 year olds. Follow-up of enquiries showed 31 (9%) deaths. Collaboration with developed countries helped in the formation of the NPIC, fulfilling a long felt need among doctors in the island.

An unusual case of fatal accidental paraquat poisoning

Paraquat, a useful contact herbicide is now used in over 130 countries of the world, including Sri Lanka. The number of cases of accidental poisoning reported with paraquat is small, relative to instances of suicide. When a clear history is not available, accidental paraquat poisoning is sometimes difficult to diagnose. A 9-year-old boy was admitted to a peripheral hospital with a history of diarrhoea and vomiting. He later developed abdominal pain, subcutaneous emphysema and difficulty in breathing. Following transfer to a district hospital and then to a teaching hospital, poisoning with paraquat was suspected only on day 11 of the illness. On persistent questioning, on day 13 of the illness the child remembered that the day prior to the onset of illness, on his way from a shop, he felt thirsty and having found an empty bottle of Gramoxone (paraquat) on the wayside he used it to drink water from a water tank. The child died on day 17 and the histology of the lung showed typical changes of paraquat poisoning. This tragic episode emphasises the need for proper disposal of empty containers of all poisonous substances.

Effects of low-density lipoproteins on mesangial cell growth and viability in vitro

Recent animal studies suggest that abnormal lipid metabolism may play a role in the pathogenesis of glomerulosclerosis. In order to define mechanisms whereby lipoproteins could contribute to glomerular injury, the effect of Low-density lipoprotein (LDL) concentration on the proliferation of rat mesangial cells was studied in vitro. Human LDL was added to culture medium that had been rendered otherwise lipid free and proliferation rate was estimated by measuring incorporation of 3H-thymidine. When compared to standard medium, LDL-enriched medium stimulated cell division when present in protein concentrations of between 10 and 100 micrograms/ml. At greater concentrations (more than 200 micrograms/ml), cell proliferation was inhibited and above 500 micrograms/ml cells sustained visible morphological injury when assessed under phase contrast microscopy. Estimation of 51Cr release from prelabelled cells confirmed that LDL was cytotoxic in these greater concentrations. A similar pattern of proliferation and toxicity has been observed in vascular smooth muscle cell cultures over a corresponding range of LDL concentrations. These results strengthen the analogy between glomerulosclerosis and atherosclerosis and provide further evidence that lipoproteins may contribute directly to glomerular scarring.

Preventable acute organophosphate poisoning deaths

Poisoning with cholinesterase inhibiting insecticides such as organophosphates (OP) is a major health problem in Sri Lanka, with over 10,000 hospital admissions and over 1,000 hospital deaths annually. Atropine and pralidoxime are the most useful antidotes in the treatment of OP poisoning. Three cases of fatal OP poisoning are described where although the initial diagnosis and therapy were correct, patients did not survive due to inadequate atropine therapy. The need for continuous monitoring and administering adequate doses of atropine in OP poisoning for several days is stressed.

Respiratory failure from severe organophosphate toxicity due to absorption through the skin

Organophosphates are the most common group of chemicals involved in poisoning in Sri Lanka. Usually, poisoning is by ingestion for suicidal purposes, although accidental poisoning is not uncommon. Poisoning due to absorption through intact or damaged skin is rare. A 32-year-old man was admitted to a peripheral hospital following assault with a 100-ml bottle of insecticide called Monocrotophos, an organophosphate. He had a 2-in. long laceration just above his left eyebrow and there was spilling of the liquid contained in the bottle over his head and face. The liquid was wiped off but the head or face was not washed. After about 3 h the patient developed symptoms and signs of early organophosphate poisoning which were treated with atropine and pralidoxime. On the 3rd day, while on therapy, the patient developed severe weakness of limbs and respiratory distress needing intubation and assisted ventilation. The patient was transferred to the neurology intensive care unit of the General Hospital, Colombo, on the eighth day. His serum potassium levels were low and an ECG showed prominent U waves in all leads. The plasma cholinesterase levels were within 37.5-50% of normal even on the 20th day indicating severe exposure.

Reliability of HbA1 assay in the mass survey for diabetes mellitus, with special reference to the preservation and transportation of blood samples

Studies on the reliability of the HbA1 assay in mass surveys for diabetes mellitus were carried out with special reference to the preservation and transportation of blood samples. It is essential to confirm that the preservation and transportation of samples have no effect on values for HbA1, since most of the mass surveys are carried out as field works. In our experience the levels of HbA1 remained unchanged for one week, both in samples kept at 4 degrees C, and in frozen samples kept at -40 degrees C or -80 degrees C and transported on solid CO2. The levels of HbA1 in the samples transported from Manila to Wakayama by the above-mentioned methods did not differ from those obtained in corresponding fresh samples. There was a good correlation between levels of HbA1 and levels of plasma glucose obtained 1 or 2 hr after breakfast (PPG). It was concluded that the use of both criteria (HbA1 of more than 8.00% and PPG of more than 120 mg/100 ml) in the diagnosis of diabetes mellitus is more reliable than use of either one alone.