Assessing the causes of under-five mortality in the Albert Schweitzer Hospital service area of rural Haiti

OBJECTIVES. Limited information is available regarding the causes of under-five mortality in nearly all countries in which mortality is the highest. The purpose of this study was to use a standard computerized protocol for defining the leading cause of death among children in a high-mortality rural population of Haiti and to highlight the need for similar studies elsewhere in Haiti and throughout the high-mortality areas of Latin America and the Caribbean. METHODS. In 2001 a standardized, closed-ended verbal autopsy questionnaire endorsed by the World Health Organization was administered to a representative, population-based sample of the mothers or other caregivers of 97 children who had died before reaching 5 years of age between 1995 and 1999 in the service area of the Albert Schweitzer Hospital, which is located in the rural Artibonite Valley of Haiti. With the data from the questionnaires we used a computerized algorithm to generate diagnoses of the cause of death; the algorithm made it possible to have more than one cause death. RESULTS. Acute lower respiratory infection (ALRI) was the leading diagnosis, present in 45 percent of all under-five deaths, followed by enteric diseases, present in 21 percent of deaths. Neonatal tetanus, preterm birth, and other early neonatal causes unassociated with ALRI or diarrhea were present in 41 percent of the neonatal deaths. Among children 1-59 months of age, ALRI was present in 51 percent of the deaths, and enteric diseases in 30 percent. Deaths were concentrated during the first few months of life, with 35 percent occuring during the first month. Among the neonatal deaths, 27 percent occurred on the first day of life and 80 percent occured during the first 10 days of life. CONCLUSIONS. In the Albert Schweitzer Hospital program area - and presumably in other areas of Haiti as well - priority needs to be given to the prevention of and early, effective treatment of ALRI, diarrhea, and early neonatal conditions. This study points to the need for more, similar standardized assessments to guide local, regional, and national programs (AU)

Psychological autopsy as a method of investigating suicide in Jamaica [Abstract]

OBJECTIVE: To assess the usefulness of the psychological autopsy in the Jamaican setting for investigating the characteristics of suicides in respect of psychiatric diagnoses and stressful life events. METHODS: The study was conducted in the parishes of Kingston, St.Andrew and St.Catherine, Jamaica. All suicide cases occuring between January 1 and December 31, 1998, were identified on the basis of police records. After obtaining informed consent the autopsy process initiated by interviewing key informants identified by relatives. Semi-structured interviews to assess mental state and stressful life events were conducted by a psychiatrist and supplemented by a review of case notes. A structured questionnaire was used to assess sociodemographic characteristics. An assessment of mental status prior to death was done and DSM IV criteria used to classify psychiatric disorders. Thiry-two suicides were studied using the psychological autopsy method. There was overwhelming willingness among key informants to be interviewed. RESULTS: The approach was fairly time consuming; interviews ranged from forty-five minutes to four hours (mean of 2 hours) having to be extended at times to allow for expression of emotions by informants. The method allowed for fairly easy retrospective formulation of psychiatric diagnosis (90 percent of victims) and for the elucidation of comorbidity. Substancial levels of stressful life events were also exposed. Many relatives expressed relief at being able to discuss these deaths with a neutral person. CONCLUSIONS: The psychological autopsy approach has provided valuable insights into the epidemiological and psychosocial context of suicide occurrence in these three Jamaican parishes. It has potential for ongoing surveillance and in the planning of prevention programmes. Its use among community mental health professionals should be evaluated. (AU)

Autopsy rates at the University Hospital of the West Indies, 1968-1997

Autopsy rates have not been reported at the University Hospital of the West Indies (UHWI) for more than three decades. Declining rates have been documented worldwide, and so we sought to define autopsy rates over the past three decades at UHWI. We conducted a retrospective analysis of the numbers and types of autopsies performed on deaths occuring in the institution, and calculated the relevant autopsy rates. The overall autopsy rate for the study period was 52.7 percent with a statistically significant decline from 65.3 percent in the first decade to 39.3 percent in the third. The non-coroner's autopsy rate showed a concomitant decline from 57.5 percent to 31.5 percent while the coroner's autopsy rate remained stable with a slight increase from 28.1 percent to 29.1 percent. The factors that might have led to the decline of the autopsy are discussed.(AU)

Correlation between clinical and autopsy diagnosis at the University of the West Indies

Autopsies help in the understanding of the disease process, check the accuracy of clinical diagnosis and provide reliable data for the epidemiologist. Although the number of comparative autopsy studies is very limited, the rate of discrepancy between clinical and autopsy ranges from 4 to 68 per cent. To determine the discrepancy between clinical and autopsy diagnoses, and to find out the major disease groups where the errors are most frequently made, a preliminary study was undertaken. One hundred and seventy-eight consecutive autopsies at the University Hospital of the West Indies over an eighteen month period were analysed and the results were compared with similar studies from other institutions. The overall rate of major discrepancy was 16 percent. The most frequently missed diagnoses were thromboembolism (40 percent), followed by malignancies (25 percent) and infection (22 percent). Sickle-cell disease made a special group. In the majority of the sicklers there was no anatomical cause of death, neither was there a clinical diagnosis as to the cause of death. The overall discrepancy rate and the rate of error in major groups in this study is lower than in other similar studies (AU)

Pathology of the lungs in childhood malnutrition in Jamaica: light and electron microscopy

The autopsy records of 115 children with severe protein-energy malnutrition were reviewed. Sections of the lung histology showed evidence of bacterial pneumonia in 49 percent of cases. An additional 18 percentshowed bronchitis, bronchiolitis or interstitial pneumonitis. Aspiration of gastric contents was evident in 10 percent of cases; 6 percent showed pulmonary oedema and congestion. In the remaining cases, no lung pathology was identified (17 percent). In 8 cases, rapid autopsy examination permitted fixation of lung tissue for electron microscopy. These included 4 cases of bronchopneumonia, one of which was associated with viral pneumonia. Another interstitial pneumonitis, probably of viral aetiology, was also studied. Both these virus-associated cases showed loss of type I pneumocytes and hyperplasia of type II pneumocytes. Another patient with herpes simplex hepatitis showed necrotic emboli in pulmonary capillaries with virions, as well as colonies of interstitial bacteria. One patient with acute pulmonary oedema displayed severe endothelial cell swelling on electron microscopy. In one case, there was no evidence of respiratory changes, apart from desquamation of type I pnuemocytes. Useful information can be obtained on the fine structure of the lung, using samples taken soon after death. (AU)

Perinatal mortality survey in Jamaica: aims and methodology

The Jamaican Perinatal Mortality survey was designed to identify the true perinatal mortality rate, and assess the factors which could contribute towards a reduction in perinatal mortality on the island. All births in a 2-month period (n=10527) were compared with all perinatal deaths occurring over a 12-month period (n=2069). Over half the deaths (n=1058) received a detailed post-mortem examination. Use of the Wigglesworth classification identifies the major component of perinatal death in this country to be associated with intrapartum asphyxia (44 percent of deaths). Deaths due to congenital malformations and miscellaneous causes contribute relatively little (<10 percent) to the overall mortality rate. Over a quarter of deaths apparently occur before the onset of labour, a a fifth are prematurely liveborn but die of causes related to immaturity (Summary)

Haemophagocytic syndrome

Two fatal cases of haemophagocytic syndrome diagnosed on the basis of autopsy findings at the Queen Elizabeth Hospital, Barbados, are presented. They were both young patients, a male 20 years of age and a female 28 years of age, with common clinical features of severe constitutional symptoms, pharyngeal haemorrhages, pancytopenia, and fever. The female patient had elevated titres to herpes simplex virus indicative of recent infection as well as postmortem evidence of overwhelming mixed bacteria sepsis. In both cases, histopathological studies showed lymphoid depletion and histiocytes displaying haemophagocytosis. (AU)

Perinatal mortality in Jamaica 1986-1987

A large population-based study of all stillbirths and neonatal deaths occurring on the island of Jamaica during a 12 month period is described. During this time, 2069 perinatal deaths were identified in an estimated total of 54,400 infants born giving a perinatal death rate of 38.0 per 1000 births. The death rate was 5 times higher among twins than singletons. An attempt was made to obtain detailed postmortem examination of as many cases as possible. In the event, 51 percent of the infants who died perinatally had such postmortem examination. Postmortem rate was affected by sex, multiplicity of the infant, time of death, month of death and area of delivery. Deaths were classified using the Wigglesworth scheme. The distribution of categories was similar in the months when the postmortem rate was 70 percent to the rest of the time period when the post-mortem rate was only 40 percent. The Wigglesworth classification of deaths identified those associated with intrapartum asphyxia as the most important group, accounting for over 40 percent of deaths overall and 59 percent of deaths of infants of more than 2500 g birthweight. Antepartum fetal deaths were the second largest group, comprising 20 percent of deaths. Sixty percent of the infants in this group weighted less than 2500 g at birth. Major malformations were responsible for few perinatal deaths in Jamaica. This simple classification is important as it focuses attention on details of labour and delivery that may require change and is useful in planning future delivery of obstetric and neonatal care. (AU)

Autopsy experience in Barbados

Although there is world-wide concern about the decrease in autopsy rates, to the authors' knowledge, the rates in Barbados have never been documented. The calculation of the non-coroner's autopsy rates and accordance score, and the possible value of these autopies performed at the Queen Elizabeth Hospital constitute this paper (AU)

Autopsy in Barbados - abstract

Since 1977, the status of the autopsy has been the subject of much debate. The following questions have been posed: (i) Has the autopsy outlived its usefulness? (ii) Is the autopsy worth the expended effort and cost? (iii) How can the contributions of this physician service achieve their maximum usefulness and receive appropriate recognition? The College of American Pathologists' Foundation Conference has made an appeal to revitalize the autopsy. There was concern about the falling rate of autopsies in teaching hospitals. The Queen Elizabeth Hospital has been one of the hospitals involved in the Eastern Caribbean Medical Scheme since 1965. There is undergraduate and postgraduate teaching. Medical students have been doing their Pathology and Microbiology clerkships at this hospital since 1981. The morbid anatomy sub-department of Pathology also services the whole island. Is the autopsy rate at this institution, a teaching hospital, acceptable? Is maximum benefit being gained from the autopsies performed? In order to answer the above questions, the autopsy reports from the Pathology Department were reviewed for the four-year period (1979-1982). The autopsy rates were 17 percent, 14 percent, 13 percent and 16 percent respectively. The concordance score of 303 of the 400 autopsies performed during this period was calculated. Ninety-seven cases had to be excluded because of insufficient data. In 149 cases, the primary disease as diagnosed at autopsy had been recognized clinically, but in 154 cases it had not. The predominant diseases missed included sepsis, pulmonary thrombo-embolism, pulmonary oedema and gastrointestinal haemorrhage. Though the autopsy rate is low, there is a high discordant rate. The autopsy in Barbados is therefore potentially capable of improving medical care, not only through the teaching of medical students, but through the interest and involvement of the clinicians in autopsies requested (AU)

Vitreous humor analytes in assessing the postmortem interval and the antemortem clinical status

Various body fluids have been used in the diagnosis of diseases. Rapid changes occur in the blood and cerebrospinal fluid after death. Vitreous humor, being well protected, shows a more gradual change. It has been found to be a useful adjunct in determining the time of death in an individual and in diagnosing certain antemortem clinical conditions (AU)

A fatal episode of accidental methomyl poisoning

Three fatalities from the accidental ingestion of methomyl, a carbamate pesticide, are reported. The methomyl had been stored in an unlabelled tin can and was accidentally used in preparing "roti," an Indian dish. The identification of the source of the poison through animal tests and further chemical identification is described. The lethal dose of methomyl was estimated to have been between 12 and 15 mg/kg body weight. (Summary)

Hepatic ultrastructure in congenital syphilis

The ultrastructural changes in the liver in a case of congenital syphillis were studied. Treponema organisms were easily demonstrated in 1-æm sections stained by toluidine blue, as well as in electron micrographs. Most organisms were extracellular, but some were identified within hepatocytes.(AU)

A 3-year review of medico-legal autopsies performed at the Kingston Public Hospital, Jamaica (1973-1975)

This report presents and discusses 946 medico-legal deaths which occured at the Kingston Public Hospital between January 1, 1973 and December 31, 1975. Sixteen per cent of the deaths were due to firearm injuries, 30 percent to motor vehicle accidents, 38 percent to sudden or unexpected natural causes, 12 percent to assault and 4 percent to either burns, abortions or poisoning. The desperate need for establishing a Department of Legal Medicine in Jamaica is emphasized. (AU)

Morphologic studies on the non-cancerous cervix in Jamaicans at different ages

A morphologic investigation on 100 cervices removed at autopsy from negro Jamaian women at different ages showed that columnar epithelium was frequently located on the portio vaginalis at all ages. The absence of this phenomenon in some fetal cervices supports the hpothesis of embryologic displacement rather than stimulation by maternal estrogens. Squamous metaplasia was common at all ages, even in the fetus; it showed little relationship to chronic inflammation, but the high frequency in post-pubertal cases (80 percent) could have some relationship to the high incidence of cervical cancer in Jamaica. Chronic inflammation was not observed in the fetal cervix but occurred in most infants in whom it was attributed to congenital "erosion". However, the cervices of children revealed a marked discrepancy between the presence of "erosion" and the degree and frequency of chronic inflamation (83 percent). This change is unexplained and requires further study (AU)

Variation in human aortic fatty streaks among geographic locations

Histological features of aortic fatty streaks were examined in male subjects aged 10-39 from Guatemala, Jamaica Negro, Durban Bantu, New Orleans Negro, New Orleans white, Lima and Santiago. These groups were selected from the 19 available in the IAP (International Atheroschlerosis Project) because they represented the greatest contrasts between the extent of fatty streaks in the young and raised lesions in the elders. Among these seven groups the extent of raised lesions in the older subjects was significantly but weakly correlated with the type of fatty streaks in the young as measured by lesion thickness, content of demonstrable lipid, numbers of foam and spindle cells. The severity of leukocytic infiltration and prevalence of foci of necrosis in fatty streaks however, correalted strongly with raised lesions (rank r=0.90). We interpret this to imply that the presence of leukocytes and of foci of necrosis in the fatty streak marks its propensity to progress into raised lesions. If this formulation is correct, then the presence of both features in the histology of fatty streaks could be used as a marker in future studies of factors bearing upon the emergence of raised lesions out of fatty streaks (AU)