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Gilbert Lau
Forensic Science Medicine and Pathology 06/2011; · 1.44 Impact Factor
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ABSTRACT: In almost any instance of suspected iatrogenic fatality, the attending forensic pathologist faces the challenging and often daunting task in ascertaining the cause of death, determining if an iatrogenic injury had indeed occurred and if so, its contribution to the causation of death. The Forensic Medicine Division of the Health Sciences Authority in Singapore embarked on a 6 year study of such deaths to identify pertinent factors that may facilitate the assessment of iatrogenic injuries and their contribution to mortality. A total of 106 iatrogenic deaths, arising from 613 coroner's peri-procedural autopsies conducted during the period of 2005-2010 were reviewed with particular reference to the following parameters: (1) clinico-pathological correlation; (2) the length of survival; (3) the number of interventional procedures. A comprehensive analysis of these cases indicated that they could be classified into the following 3 categories, in relation to the role of clinico-pathological correlation in the ascertainment of the causes of death: (A) advantageous but not essential; (B) essential; (C) critical. A large proportion of the cases (76.5%) were assigned categories B and C. Only the minority of cases (23.6%) were assigned category A. Also, as the number of days of survival between injury and death, and the number of interventional procedures after injury increases, the greater the need for detailed clinical documentation to ascertain the cause of death.
Forensic Science Medicine and Pathology 06/2011; 8(1):23-33. · 1.44 Impact Factor
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ABSTRACT: This retrospective study aims to assess the epidemiology of road traffic accident (RTA) fatalities in Singapore, other causes of death besides trauma in a RTA, and identify the groups at risk.
Data of 1038 RTA fatalities were reported between 2000 and 2004. Analyses using the Fisher's exact test for discrete variables and multivariate Cox regression analysis were performed to identify groups at risk. The risk of fatality was measured using the prevalence rate ratio (PRR).
The median age of victims in the sample was 36 years (interquartile range 24 to 55). Eight hundred and thirty six cases (78%) were in the economically productive age range of 15 to 65 years. Over the 5-year period, there was a preponderance of males. Majority of fatalities involved multiple injuries. There were also 64 (6.2%) and 25 (2.4%) cases of RTA fatalities from infective and cardiovascular (CVS) causes, respectively. Multivariate analyses showed that those > or = 60 years were 4 (95% CI of PRR, 3.04 to 5.43) times as likely to be pedestrian fatalities. Conversely, the risk of fatalities involving pedestrians and cyclists was reduced for males (PRR = 0.58; 95% CI, 0.46 to 0.73). However, males were at increased risk of fatalities involving motorcyclists, scooter and pillion riders (PRR = 1.96; 95% CI, 1.43 to 2.70), whereas such risk was reduced for those aged 30 to 59 (PRR = 0.70; 95% CI, 0.58 to 0.85) or > or = 60 years (PRR = 0.30; 95% CI, 0.21 to 0.42), respectively.
As such, it appears that the groups at-risk had varying demographic characteristics. Public education could be modified to target these different groups to reduce the number of fatalities.
Annals of the Academy of Medicine, Singapore 07/2009; 38(7):594-6. · 1.25 Impact Factor
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Gilbert Lau
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ABSTRACT: An eight-year-old female developed cerebral infarction, with eventual brain death, as a consequence of therapeutic embolisation of a large facial haemangioma. Post-mortem histological examination revealed the presence of identical foreign body emboli, consistent with at least one of the embolic agents used in the procedure, within the haemangioma and both cerebral hemispheres. It is possible that some of these particles might have entered the cerebral circulation through anastomoses between the right external and internal carotid arteries, and subsequently crossed over from the ipsilateral to the contralateral cerebral vasculature via the Arterial Circle of Willis.
Medicine, science, and the law 08/2008; 48(3):256-60. · 0.45 Impact Factor
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Marcus Eng Hock Ong,
Xiuyuan Yan, Gilbert Lau,
Eng Hoe Tan,
Anushia Panchalingham,
Benjamin Sieu-Hon Leong,
Victor Yeok Kein Ong,
Ling Tiah,
Susan Yap,
Swee Han Lim,
Anantharaman Venkataraman
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ABSTRACT: To study out-of-hospital cardiac arrests (OHCA) occurring in primary healthcare facilities (HCF) in Singapore and to compare these with arrests occurring in the community.
This prospective observational study was part of the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Included were all patients with OHCA occurring in HCF. Patient characteristics, cardiac arrest circumstances, EMS response and outcomes were recorded according to the Utstein style.
From 1 October 2001 to 14 October 2004, the data from 2428 subjects were received of which 138 patients were OHCA occurring in HCF. This is an incidence of 1.12/100,000 population per year and constituted 6.0% of all OHCA. Arrest occurring in HCF were more likely to be witnessed (p<0.01), or have bystander CPR (p<0.01). The HCF group was also more likely to receive CPR with both compression and ventilation (p<0.01) and have a non-trauma cause of arrest (p=0.03). HCF arrests also had a shorter collapse to call (EMS number) than the non-HCF group (HCF 1.54min versus non-HCF 5.36min, p=0.01). However, no HCF patient received defibrillation prior to EMS arrival. HCF patients were more likely to have return of spontaneous circulation at any time (p=0.05), survival to hospital admission (p<0.01) and survival to discharge (p<0.01) compared to non-HCF patients.
This study suggests that primary health care providers do have an important role locally in managing out-of-hospital cardiac arrest. We propose an initiative to encourage early defibrillation by primary health care providers.
Resuscitation 07/2007; 74(1):38-43. · 3.60 Impact Factor
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Gilbert Lau
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ABSTRACT: A 32-year-old female underwent laparoscopic salpingectomy of an ectopic (third) pregnancy under general anaesthesia, at approximately six weeks' amenorrhoea. She developed severe respiratory distress after extubation and died on the second postoperative day. It appears that she had a history of a mild, persistent productive cough for a period of about a month prior to the operation that was attributed to an upper respiratory tract infection. Autopsy demonstrated the presence of a large mediastinal tumour, whose existence was apparently unsuspected preoperatively, encasing the ascending thoracic aorta, aortic arch and the proximal segments of the brachiocephalic and subclavian arteries, and causing extrinsic airway compression. Subsequent microscopic examination showed histological and immunohistochemical features of a mediastinal large B-cell lymphoma. It is thought that the mechanical effects exerted by the advanced mediastinal tumour upon the airways and the thoracic cage, coupled with the pathophysiological effects of general anaesthesia on respiratory movement and airway patency, had led to the patient's unfortunate demise in early pregnancy.
Medicine, science, and the law 02/2007; 47(1):74-8. · 0.45 Impact Factor
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ABSTRACT: This study provides an analysis of 640 completed suicide cases in Singapore for the years 2001 and 2002, compared to previous years and in relation to demographic and socioeconomic factors, as well as to the characteristics of a subgroup of suicide victims with prior psychiatric illness. There was little change in the suicide pattern over the 2 years studied compared to previous years. The sex ratio was constant at 1.5. Population-adjusted ratios were 1 for Chinese, 0.5 for Malays, and >1 for both Indians and other ethnic groups. Falling from heights ranked first in terms of method adopted for both years. A disproportionately higher number of suicides were recorded for the 25-34 and the > or =75-year-old age groups. A total of 47 (17.2%) in 2001 and 74 (20.2%) in 2002 of the cases had a history of prior psychiatric illness, with psychotic disorders being the most common diagnostic category. There was also a statistically significant correlation between unemployment and incidence rates. Although the overall rate of elderly suicides had gone down since the 1990s, prevention strategy should focus on the elderly as this rate is still about 3-4 times the national average.
Crisis The Journal of Crisis Intervention and Suicide Prevention 01/2007; 28(3):148-55. · 1.09 Impact Factor
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ABSTRACT: Falls from a height are a common problem in Singapore. However, there has been no analysis of the injury patterns and outcomes of patients who survived initial resuscitation after falls from a height in Singapore. One hundred and thirty-nine patients admitted over a two-and-a-half year period after falls of greater than one storey were studied. The higher the fall, the greater the likelihood of hypotension and neurological injury. The length of stay in hospital, the number of operative procedures and mortality also correlated with the height of the fall. The overall mortality rate was 11% but rose to 47% among patients who were hypotensive on admission. About half of the deaths were due to head injury with haemorrhage being the second most common cause. The majority of patients who fell from five or more storeys did so intentionally, and had more severe torso and extremity injuries compared with those who fell accidentally. These findings suggest that efforts in injury prevention and aggressive evaluation and treatment of fall victims arriving alive at the hospital continue to be important.
Medicine, science, and the law 08/2004; 44(3):201-6. · 0.45 Impact Factor
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ABSTRACT: A 42-year-old female developed fulminant hepatic failure after having ingested an undetermined quantity of a herbal product over a period of approximately four months prior to the onset of her illness. Clinically, the cause of liver failure was assessed to be drug-induced and she eventually underwent total hepatectomy, with porto-caval shunting, in anticipation of a living-unrelated liver transplant. Unfortunately, her condition deteriorated and she died less than 48 hours post-operatively, approximately three weeks post-admission. An autopsy showed that the subject was deeply jaundiced and severely obese (BMI: 47.1 kg m(-2)), with evidence of diffuse haemorrhage, including the presence of 1.35 l of blood in the peritoneal cavity. The liver had been removed and was later recovered as a formalin-fixed specimen which was markedly contracted, comprising multiple micronodules interspersed with extensive areas of dense fibrotic tissue. Histologically, there was massive necrosis of the hepatic parenchyma, such that the residual hepatocytes were disposed as nodules displaying variable cellular regeneration and ballooning degeneration, attended by florid ductal proliferation and mixed inflammatory infiltrates. Infective, autoimmune, metabolic, vascular, neoplastic and most other natural causes of massive hepatocellular necrosis were effectively excluded. Analysis of the post-mortem blood samples yielded fluconazole, metronidazole, frusemide, lignocaine and tramadol, (therapeutic agents administered to the patient during her last illness). Subsequent analysis of the residual capsules revealed that they were adulterated by fenfluramine, N-nitrosofenfluramine (1.3-1.6 mg per capsule), nicotinamide (13.3-15.6 mg per capsule) and thyroid extract. None of the herbal ingredients is currently known to be hepatotoxic and much the same applies to fenfluramine, nicotinamide (except when taken in mega-doses) and thyroid extract. However, as nitrosamines are known to be variably hepatotoxic, it would be reasonable to surmise that, in the absence of a more plausible cause of liver damage, N-nitrosofenfluramine was the likely cause of massive hepatocellular necrosis in this instance.
Medicine, science, and the law 08/2004; 44(3):252-63. · 0.45 Impact Factor
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ABSTRACT: Suicide is a complex behaviour. Genetic and environmental factors are implicated in suicide. Both factors require genes to exert their effects. One gene hypothesized to be involved in the pathophysiology of suicide is cholecystokinin. Alterations in cholecystokinin receptor binding have been reported to be significant in young suicide victims as compared to matched controls in the frontal and cingulate cortex. In this study we report the Cholecystokinin-B gene expression using RT-PCR, between suicide completers [(N = 10); mean age 37.2+/-12 years] and control subjects [(N = 10); mean age 37.6+/-11.9 years]. Cholecystokinin-B gene expression was significantly higher in the cerebellum (P = 0.006), cingulate gyrus (P = 0.024) and pre-frontal cortex (P = 0.017) of suicide completers when compared to their age and sex-matched controls.
Neuroscience Letters 04/2004; 357(2):107-10. · 2.11 Impact Factor
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ABSTRACT: 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.
Forensic Science International 11/2003; 137(1):1-5. · 2.30 Impact Factor
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ABSTRACT: 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.
Medicine, science, and the law 11/2003; 43(4):307-14. · 0.45 Impact Factor
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ABSTRACT: 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.
Clinical Anatomy 06/2003; 16(3):193-6. · 1.29 Impact Factor
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ABSTRACT: 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.
Medicine, science, and the law 05/2003; 43(2):141-7. · 0.45 Impact Factor
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ABSTRACT: 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.
Emerging infectious diseases 01/2003; 9(1):78-85. · 6.17 Impact Factor
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ABSTRACT: 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.
Medicine, science, and the law 11/2002; 42(4):309-12. · 0.45 Impact Factor
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Gilbert Lau
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ABSTRACT: 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.
Forensic Science International 05/2002; 126(2):167-70. · 2.30 Impact Factor
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Gilbert Lau
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ABSTRACT: 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.
Medicine, science, and the law 05/2002; 42(2):172-80. · 0.45 Impact Factor
