Strong evidence for age as the single most dominant predictor of medically supervised driving test-mini mental status test outcomes provide only weak but significant moderate additional predictive value.

BACKGROUND: With age, medical conditions impairing safe driving accumulate. Consequently, the risk of accidents increases. To mitigate this risk, Swiss law requires biannual assessments of the fitness to drive of elderly drivers. Drivers may prove their cognitive and physical capacity for safe driving in a medically supervised driving test (MSDT) when borderline cases, as indicated by low performance in a set of four cognitive tests, including e.g. the mini mental status test (MMST). Any prognostic, rather than indicative, relations for MSDT outcomes have neither been confirmed nor falsified so far. In order to avoid use of unsubstantiated rules of thumb, we here evaluate the predictive value for MSDT outcomes of the outcomes of the standard set of four cognitive tests, used in Swiss traffic medicine examinations. METHODS: We present descriptive information on age, gender and cognitive pretesting results of all MSDTs recorded in our case database from 2017 to 2019. Based on these retrospective cohort data, we used logistic regression to predict the binary outcome MSDT. An exploratory analysis used all available data (model 1). Based on the Akaike Information Criterion (AIC), we then established a model including variables age and MMST (model 2). To evaluate the predictive value of the four cognitive assessments, model 3 included cognitive test outcomes only. Receiver operating characteristics (ROC) and area under the curve (AUC) allowed evaluating discriminative performance of the three different models using independent validation data. RESULTS: Using N = 188 complete data sets of a total of 225 included cases, AIC identified age (p < 0.0008) and MMST (p = 0.024) as dominating predictors for MSDT outcomes with a median AUC of 0.71 (95%-CI 0.57-0.85) across different training and validation splits, while using the four cognitive test results exclusively yielded a median AUC of 0.55 (95%-CI 0.40-0.71). CONCLUSIONS: Our analysis provided strong evidence for age as the single most dominant predictor of MSDT outcomes. Adding MMST provides only weak additional predictive value for MSDT outcomes. Combining the results of four cognitive test used as standard screen in Swiss traffic medicine alone, proved to be of poor predictive value. This highlights the importance of MSDTs for balancing between the mitigation of risks by and the right to drive for the elderly.

[Daytime Sleepiness in Patients with Restless Legs Syndrome: A Risk Factor for Traffic Accidents?] / Tagesschläfrigkeit bei Patienten mit Restless-Legs-Syndrom: Risikofaktor für Verkehrsunfälle?

Daytime Sleepiness in Patients with Restless Legs Syndrome: A Risk Factor for Traffic Accidents? Abstract. Restless legs syndrome (RLS) is a symptom complex of predominantly leg-focused paraesthesias and the associated increased urge to move. Since evening exacerbations are typical, many patients suffer from sleep disorders, which can lead to increased daytime fatigue in the long term. The present retrospective data analysis investigated a potentially relevant relationship between RLS and an increased incidence of traffic accidents due to daytime sleepiness in Swiss road traffic. A direct correlation between RLS and the occurrence of traffic accidents could not be found. Nevertheless, the question of increased daytime sleepiness should not be absent from any (traffic) medical discussion.

Inhalant deaths in South Australia: a 20-year retrospective autopsy study.

A 20-year retrospective study of inhalant deaths in South Australia, autopsied at Forensic Science SA, was undertaken from January 1983 to December 2002. Thirty-nine cases were identified from an autopsy pool of 18,880 cases, with a male to female ratio of 12:1. Sixty-four percent of the victims (N = 25) died during voluntary inhalation of volatile substances and 28% (N = 11) committed suicide utilizing a volatile substance or gas. The remaining 3 cases involved a workplace accident (N = 1) and 2 cases of autoerotic death where inhalants were being used to augment solitary sexual activity. The mean age of the 28 victims of accidental inhalant death of 21 years (range, 13-45 years) was considerably less than that of the 11 suicide victims of 31.5 years (range, 17-48 years). No homicides were found. Approximately one quarter of the victims were Aboriginal (N = 11), 10 of whom had died as a result of gasoline inhalation ("petrol sniffing"). Other common substances of abuse were aliphatic hydrocarbons such as butane. The study has shown that those most at risk for accidental or suicidal inhalant deaths were young males, with 92% of victims overall being male, and with 77% of victims being under 31 years of age. Gasoline inhalation remains a significant problem in Aboriginal communities in South Australia.

Mechanisms of unexpected and/or sudden death in Lafora disease.

A 23-year-old male was found dead wedged between two chairs at his home address. His past history included a diagnosis of Lafora disease (a type of heritable progressive myoclonic epilepsy) at the age of 16 years. This had been characterised by the development of epilepsy and progressive motor impairment and mental deterioration. Diagnosis had been confirmed by demonstration of mutation in the EPM2A gene on chromosome 6q24. At autopsy, petechial haemorrhages were noted of the face and conjunctivae bilaterally. There were no other significant findings apart from gastric contents within the airways. Death was attributed to positional asphyxia complicated by aspiration of gastric contents. Although death in Lafora disease is usually predictable and often protracted, sudden and/or unexpected death may occur and involve status epilepticus, sudden unexpected epileptic death, choking, aspiration of gastric contents, and cardiac arrhythmias. In addition, the possibility exists of unnatural causes of death, such as accidents, provoked by epilepsy or physical inability of the victims to extricate themselves from dangerous situations, or homicides, provoked by difficulties in caring for individuals with significant and progressive disabilities.

The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults--a 25-year study.

A 25-year retrospective study of cases of crush/traumatic asphyxia autopsied at Forensic Science SA, Adelaide, Australia from 1980 to 2004 was undertaken. A total of 79 cases of crush asphyxia was found consisting of 63 males (80%) and 16 females (20%). The age range of the males was 19-86 years (mean=41.8 years) and of the females was 19-75 years (mean=38.6 years). In 18 cases the exact circumstances of death were unclear, leaving 61 cases in which details of the fatal episode were available. Major categories included vehicle crashes (N=37), industrial accidents (N=9), farm accidents (N=6) and entrapment beneath vehicles (N=5). Forty of the 79 victims (51%) had only very minor bruises and abrasions; 28 (35%) had evidence of chest compression with rib and sternal fractures and large areas of soft tissue bruising of the chest; 7 cases (9%) had other significant injuries or findings that had contributed to death. All of these victims had signs of crush asphyxia in the form of intense purple congestion and swelling of the face and neck, and/or petechial hemorrhages of the skin of the face and/or conjunctivae. The pattern of pathological findings of crush asphyxia was not influenced by the presence or absence of concomitant serious or lethal injuries. In 4 cases (5%) where the circumstances of the lethal episode were those of crush asphyxia there were no characteristic pathological findings. This study has shown that a high percentage of crush asphyxias may be caused by vehicle accidents. It has also demonstrated that on occasion fatal crush asphyxia may have to be a diagnosis of exclusion, made only when there are characteristic death scene findings, and no evidence of lethal natural diseases or injuries at autopsy, with negative toxicological screening.

Fatal electrocution in adults--a 30-year study.

A retrospective study was undertaken of all cases of death in adults (>16 years) due to electrocution which were autopsied at Forensic Science SA, Adelaide, Australia, over a 30-year period from 1973 to 2002. A total of 96 cases were identified with 87 males (91%) (mean age=41.6 years; range 17 to 86 years) and nine females (9%) (mean age=49.2 years; range 20 to 76 years). Deaths were due to accidents in 66 cases (69%; M:F = 63:3), suicides in 28 cases (29%; M:F=24:4) and homicides in two cases (2%). Both homicide victims were females, with females accounting for only 5% of the accidents and 14% of suicides. The number of accidental deaths increased until the early 1990s and then declined, whereas suicidal electrocutions were only found in the last 20 years of the study. Most deaths (N = 80; 83%) were due to low voltage circuits (<1000 volts), with deaths due to high voltages occurring in 15 cases (16%). One death was due to lightning (1%). While suicides were evenly distributed throughout the year, most accidental deaths occurred in late spring and summer (N = 42; 64%) with the lowest number of accidental deaths occurring in winter and early spring. This report demonstrates a significantly higher rate of electrocution deaths among males, with a summer predominance of accidental deaths, most likely due to increased outdoor activities in better weather. The reduction in cases over the last decade of the study may be a reflection of the success of workplace and domestic safety campaigns. Female electrocution suicides and electrocution homicides were rare events.

Café coronary syndrome-fatal choking on food: an autopsy approach.

To examine the characteristic features of fatal food asphyxia and to develop an autopsy approach to such cases a retrospective study of autopsy files was undertaken at Forensic Science SA (Adelaide, Australia) over a 10 year period from 1993 to 2002 for all cases of food asphyxia/café coronary syndrome. Forty-four cases were identified (M;F=21:23), with one infant (11 mths) and 43 adults (30-96 yrs; mean 68.9 yrs), with a preponderance of victims (57%) aged between 71 and 90 yrs. Deaths occurred in nursing homes (N=22) cases, at home (N=11) and in restaurants (N=4). Twenty-seven of the victims (61%) had histories of neurological or psychiatric disorders such as dementia (N=8), schizophrenia (N=6), Alzheimer disease (N=4), atherosclerotic cerebrovascular disease (N=4), mental impairment (N=2), multiple sclerosis (N=1), Parkinson disease (N=1) and obsessive-compulsive disorder (N=1). Twenty-seven cases (61%) were described as either edentulous or having significant numbers of teeth missing. Toxicological evaluation of blood revealed alcohol and a variety of psychotropic prescription medications in 19 cases. Sudden collapse during or shortly after a meal should always raise the possibility of café coronary and the autopsy examination should not only attempt to demonstrate airway occlusion by a bolus of food, but also to identify or exclude underlying neurological disease. Such cases may raise issues concerning adequacy of care and appropriateness of medication. The diagnosis of café coronary syndrome can only be made with confidence after the clinical history and circumstances of death have been clearly established, impacted material has been demonstrated in the airway at autopsy (or recorded by those attempting resuscitation), risk factors have been identified and other possible causes of death have been excluded.

Congenital mesenteric defects and unexpected death-a rare finding at autopsy.

Gastrointestinal causes of sudden and/or unexpected death in the young are uncommon and only rarely involve congenital anomalies of the mesentery. Two cases are reported of unexpected deaths following herniation of intestine through congenital mesenteric defects to illustrate the forensic issues that may arise. Case 1 involves a 2.5-year-old girl who collapsed on arrival to hospital following 18 hours of fever and apparently mildly nonspecific symptoms. Resuscitation was unsuccessful, and at autopsy a segment of gangrenous small intestine was found that had herniated through a congenital mesenteric defect. Case 2 involves a 23-year-old woman with a past history of severe mental and physical disabilities who was found dead in her bed. She had a recent history of mild diarrhea and vomiting, but had not appeared particularly ill. At autopsy the peritoneal cavity was filled with a very dilated and obstructed colon as a result of herniation of a segment of sigmoid colon through a distal small intestinal mesenteric defect. These cases demonstrate that symptoms and signs of intestinal ischemia may not be clearly manifested in early childhood and that developmental delay may also result in older individuals presenting in a nonspecific manner. Although rare, congenital mesenteric abnormalities with compromise of the intestinal vasculature remain a possibility to be considered at autopsy in all cases of unexpected death, despite the lack of a clear history of significant gastrointestinal disturbance. Death may relate to ischemic compromise of either the herniated portion of intestine (as in case 1) or to the stretched intestine bordering the hernial orifice (as in case 2).

Conditions and circumstances predisposing to death from positional asphyxia in adults.

Positional asphyxia refers to a situation where there is compromise of respiration because of splinting of the chest and/or diaphragm preventing normal respiratory excursion, or occlusion of the upper airway due to abnormal positioning of the body. Examination of autopsy files at Forensic Science SA revealed instances where positional asphyxia resulted from inadvertent positioning that compromised respiration due to intoxication, multiple sclerosis, epilepsy, Parkinson disease, Steele-Richardson-Olszewski syndrome, Lafora disease and quadriplegia. While the manner of death was accidental in most cases, in one instance suicide could not be ruled out. We would not exclude the possibility of individuals with significant cardiac disease succumbing to positional asphyxia, as cardiac disease may be either unrelated to the terminal episode or, alternatively, may result in collapse predisposing to positional asphyxia. Victims of positional asphyxia do not extricate themselves from dangerous situations due to impairment of cognitive responses and coordination resulting from intoxication, sedation, neurological diseases, loss of consciousness, physical impairment or physical restraints.

Matricides in South Australia - a 20-year retrospective review.

A 20-year retrospective review of files at Forensic Science SA, Adelaide, Australia was undertaken for cases of matricide occurring between the years 1985 and 2004. A total of 11 cases were identified: 10 males and 1 female. The victims were aged between 42 and 83 years (mean=61 years) and the perpetrators were aged between 15 and 53 years (mean=28.7 years). In all 11 cases weapons such as blunt objects (N=5), knives (N=5), firearms (N=3), or ligatures (N=1) were involved in the assaults, with injuries inflicted by the weapons causing death in 10 cases. In five cases trauma was caused by more than one injurious agent/action; e.g. there was evidence of immersion and burning in two cases. In four cases there were multiple (>10) significant injuries inflicted by perpetrators suffering from schizophrenia (N=2), 'mental impairment' (N=1) and a 'combination of psychiatric disorders' (N=1). One perpetrator committed suicide after killing his mother. Six of the ten surviving perpetrators were found not guilty of murder on the grounds of mental illness or impairment, and one perpetrator had the charge reduced from murder to manslaughter due to underlying mental conditions that included previous brain injury. Matricides are uncommon forms of homicide that have similar features in most communities studied. Intra-familial tensions with underlying psychiatric illness in the perpetrator are common findings.

Histologic dating of bruises in moribund infants and young children.

It is generally held that leukocytes are found within bruised subcutaneous tissues within 4-12 h of injury as part of a standard cellular response to trauma. As a corollary, the absence of leukocytes is often cited as evidence of more recent injury. To investigate how long after injury it may be before a leukocyte response occurs selected bruises from three children aged 27, 11, and 3 months, respectively, were examined microscopically. All of the children had sustained lethal head trauma, with survival on life-support equipment for some time in hospital, and with bruises of at least 24-h duration confirmed by medical evaluation (at 30, 44, and 79 h from the time of initial medical evaluation to death). Histologic examination of selected lesions in all three cases revealed extravasation of red blood cells within subcutaneous tissues, but no leukocyte infiltration or other cellular reaction. Other bruises in these children exhibited a standard inflammatory response. This study has shown that selected bruises in three children were present for at least 30 h without a leukocyte infiltrate. Caution should, therefore, be exercised in assigning too rigid a time course to bruising in infants and young children based on a lack of a vital reaction, as the absence of leukocytes within soft tissues of bruised skin in these cases may not necessarily indicate that the injuries are recent. Variability in tissue response may also occur in different bruises in the same individual. Whether severe craniocerebral trauma played a role in delaying the cellular response in these particular injuries is unclear.

Is right coronary artery hypoplasia and sudden death an underdiagnosed association?

Determining whether hypoplasia of a coronary artery has caused or contributed to death is often complicated by an absence of histologic evidence of myocardial ischemia in the area of the heart supplied by the affected artery and also by the lack of data for assessing coronary artery size at autopsy. A 45-year-old woman is reported who collapsed and died and who was found at autopsy to have a dominant, small-caliber, right coronary artery, with acute and chronic ischemic changes in the posterior interventricular septum supplied by the diminutive vessel. This case provides evidence that small-caliber coronary arteries may be associated with a lethal outcome. Given the difficulties that may occur in determining whether there is a causal link between small coronary artery caliber and death, it is possible that this may be an underdiagnosed cause of sudden cardiac death, rather than a coincidental finding of minimal significance.

Mechanisms of unexpected death and autopsy findings in Leigh syndrome (subacute necrotising encephalomyelopathy).

A 21-year-old previously-well woman who was undergoing medical investigations for problems with balance and suspected multiple sclerosis, developed a headache and breathing difficulties, and died suddenly and unexpected at home. The autopsy was unremarkable except for pulmonary and cerebral oedema. However, subsequent microscopy of the brain revealed characteristic features of Leigh syndrome with multifocal areas of astrogliosis, capillary proliferation, and parenchymal vacuolation. While Leigh syndrome is more commonly diagnosed in infancy, manifestations may occur throughout early life into adulthood. Sudden and unexpected death is a rare presentation that may be associated with cerebral necrosis and oedema. An awareness of the variable manifestations of Leigh syndrome is necessary in forensic practice as not all cases will present in a typical manner and sudden death may occur before a diagnosis has been established. The heritable nature of this condition makes accuracy of diagnosis essential.

Ultrastructural changes in the cervical epithelium during the estrous cycle of the marsupial Monodelphis domestica (grey short-tailed opossum).

Ultrastructural changes in the cervical epithelium related to the estrous cycle have been studied in the South American marsupial Monodelphis domestica. The two cervices protrude with prominent papillae into the sinus vaginalis. At times of simple columnar at others of more pseudostratified character consists of two types of cells, ciliated and secretory cells. The mucosal epithelium is uniform in its entire length and shows no division into an endo- and ectocervix. The mucosa of the cervix differs from the uterine endometrium. There are no glandular structures, but the luminal epithelium shows deep invaginations underlined by dense connective tissue. The most conspicuous changes include the height and the differentiation of the cervical epithelium which attains its maximum development during estrus, where secretory cells are fully packed with large secretory granules and ciliated cells are well developed. After extruding their granules, secretory cells may transform into ciliated cells, while ciliated cells show the phenomenon of deciliation in which cilia packets are shed into the cervical lumen. This transformation process takes place mainly during post- and metestrus. The presence of solitary cilia is only noticeable during pro-estrus, being in contrast to the uterine epithelium where they appear during the whole estrous cycle.

Ultrastructural changes in the uterine luminal and glandular epithelium during the oestrous cycle of the marsupial Monodelphis domestica (grey short-tailed opossum).

Ultrastructural changes in the endometrium associated with the oestrous cycle were studied in the South American marsupial Monodelphis domestica. The most conspicuous changes include the height and the differentiation of the uterine luminal and glandular epithelium, which consists of ciliated and non-ciliated cells. The glandular epithelium attains its maximum development during oestrus, the luminal epithelium at postoestrus. A distinct increase in the number of ciliated cells can be observed during pro-oestrus, reaching a maximum number at oestrus; this is followed by a process of deciliation. The presence of solitary cilia on the apices of non-ciliated cells is very conspicuous during all oestrous stages and can best be seen on the luminal epithelium. These findings differ from the observations in eutherian mammals, where solitary cilia are only found in the immature uterus or after ovariectomy. The secretory activity of non-ciliated cells of the luminal epithelium is hardly noticeable along the apical membrane and stains only very faintly with Alcian blue. The glandular epithelium cells are filled apically with exocytotic vesicles at oestrus and early postoestrus. However, in contrast to the cervical gland cells, they hardly stain with Alcian blue, indicating that mucins of a different type must be present. Mechanisms for the remodelling of the luminal and glandular epithelium are especially conspicuous at metoestrus and early pro-oestrus and include the presence of autolysosomes, residual bodies and apoptotic bodies. In the endometrial stroma, around the uterine glands, macrophages accumulate and attain a typical oestrous stage-dependent appearance during their phagocytotic activities.