Sanjeev Lalwani

Fatal road traffic accidents and their relationship with head injuries: An epidemiological survey of five years

In depth studies of fatal vehicular accidents provide valuable data for implementing effective emergency services to reduce the trauma related mortality and strengthening legal measures in peak hours of fatal accidents. We aimed to study, pattern of injuries especially fatal traumatic brain injuries occurring in vehicular accidents. Postmortem reports and clinical records of victims of road traffic accident autopsied during the period of 2001–2005 at Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, were analyzed retrospectively. Out of total 7008 medico legal autopsies conducted during the study period, 2472 (35.27 %) were of vehicular accidents. The male/female ratio was 7.49:1. Commonest age group affected was between 21-40 years involving 1341 (54.24%) cases. Pre-hospital mortality was in 985 (39.84 %) cases. Fatal traumatic brain injuries were seen in 1699 (68.73%) cases. Skull fractures were found in 1183 (69.63%) cases of head injury; most common bone fractured was temporal bone (n=559, 47.25%). The commonest variety of intracranial hemorrhage was subdural hemorrhage (n=1514, 89.11%). The craniotomy was done in 297 (17.48%) cases; maximum mortality (41.07%) was seen within 4–ays. Most commonly injured abdominal organ was liver (n=532, 21.52%). No significant difference was evident in incidence of fatal vehicular accident on weekends and weekdays. However November month took maximum toll of deaths (n=273, 11.04%) of total vehicular accident fatalities in five year duration. 53.20% of fatal accident occurred between 6 PM and 6 AM. The results of study emphasize the need to improve the pre hospital care with provision of trauma services at site and to establish neurosurgical facilities with trauma registry.

Suicide among children and adolescents in south Delhi (1991–2000)

Objective : Suicide among youth is of great concern and a subject requires thorough study to formulate prevention strategy. In this paper the incidence and trends of suicide among children and adolescent of South Delhi have been reported.Methods : A retrospective analysis was carried out on 222 cases of suicidal deaths pertaining to age group of 10–18 years, the postmortem examination on the body of which were conducted in Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi during the period from 11st January 1991 to 311st December 2000. The particular of cases were analyzed according to age group, sex, method used and causes of committing suicide.Results : Out of 222 cases 123(55.4%) were of girls (Female : Male 1.24:1). Commonest age group involved was 15–18 years in both the sexes. Commonest method used for committing suicide was hanging (57% in girls, 49.5% in boys) followed by poisoning (37.4% in girls, 49.5% in boys).Conclusion : Methods used to commit suicide are widely available and are difficult to restrict. Therefore, suicide prevention strategy based on risk factors could be more effective rather than limiting the access to methods.

Study on arsenic level in public water supply of Delhi using hydride generator accessory coupled with atomic absorption spectrophotometer.

Surveillance of drinking water is essentially a health measure intended to protect the public from water borne diseases. Hydride generator accessory coupled with atomic absorption spectrophotometer was used to analyze arsenic level in 49 ground water samples collected from different areas of Delhi. Arsenic level in ground water samples was in the range of 0.0170 to 0.100 ppm (Mean-0.0431, Standard Deviation-0.0136, Std. error of Mean-0.00194) with minimum concentration at Raney Well No. 7 (0.0170 ppm) and maximum at Kotla Mubarak Pur (0.100 ppm). Arsenic containing sediments and percolation of chemicals into soil as the result of dumping of garbage rich in chemicals into open landfills could be the possible source of arsenic in ground water of Delhi. Extensive survey and continuous monitoring is required to be made to assess the magnitude of problem and earlier intervention.

Quantitative analysis of the Kawase versus the modified Dolenc-Kawase approach for middle cranial fossa lesions with variable anteroposterior extension.

OBJECT The surgical corridor to the upper third of the clivus and ventral brainstem is hindered by critical neurovascular structures, such as the cavernous sinus, petrous apex, and tentorium. The traditional Kawase approach provides a 10 × 5-mm fenestration at the petrous apex of the temporal bone between the 5th cranial nerve and internal auditory canal. Due to interindividual variability, sometimes this area proves to be insufficient as a corridor to the posterior cranial fossa. The authors describe a modification to the technique of the extradural anterior petrosectomy consisting of additional transcavernous exploration and medial mobilization of the cisternal component of the trigeminal nerve. This approach is termed the modified Dolenc-Kawase (MDK) approach. METHODS The authors describe a volumetric analysis of temporal bones with 3D laser scanning of dry and drilled bones for respective triangles and rhomboid areas, and they compare the difference of exposure with traditional versus modified approaches on cadaver dissection. Twelve dry temporal bones were laser scanned, and mesh-based volumetric analysis was done followed by drilling of the Kawase triangle and MDK rhomboid. Five cadaveric heads were drilled on alternate sides with both approaches for evaluation of the area exposed, surgical freedom, and angle of approach. RESULTS The MDK approach provides an approximately 1.5 times larger area and 2.0 times greater volume of bone at the anterior petrous apex compared with the Kawases approach. Cadaver dissection objectified the technical feasibility of the MDK approach, providing nearly 1.5-2 times larger fenestration with improved view and angulation to the posterior cranial fossa. Practical application in 6 patients with different lesions proves clinical applicability of the MDK approach. CONCLUSIONS The larger fenestration at the petrous apex achieved with the MDK approach provides greater surgical freedom at the Dorello canal, gasserian ganglion, and prepontine area and better anteroposterior angulation than the traditional Kawase approach. Additional anterior clinoidectomy and transcavernous exposure helps in dealing with basilar artery aneurysms.

Deaths of homeless unclaimed persons in South Delhi (2001-2005): a retrospective review.

Homeless people are at increased risk of death for several reasons. We reviewed 735 cases of homeless, unclaimed persons found dead in public places in South Delhi who were brought for autopsy at the Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, during the study period from 2001-2005. Most of the deceased were male (n=645, 87.75%) with a M: F ratio of 7.17:1. The commonest age group involved was 31-40 years (n=228, 31.02%). Most victims (n=451, 61.36%) died from natural causes, followed by accidental deaths (n=233, 31.70%) and homicides (n=26, 3.54%). The majority of deaths were reported in the rainy season (n=284, 38.64%). The deceased were mostly recovered from the road or road side (n=352, 47.89%). Few studies on this subject have been published in India. More research is needed to identify the health-related problems of such people and possible contributory factors to mortality.

Menstruation and suicide: an exploratory study.

Previous research has reported mixed findings on the effect of the menstrual cycle on suicidal behavior. The contribution of menstruation to completed suicide is also controversial, though the studies are very limited and have not been carefully designed. To explore the relationship, 217 autopsies on completed suicides were performed, matched to a control group at the All India Institute of Medical Sciences in New Delhi. The results show that 54.46% of people who died by suicide were menstruating (results excluded pregnancies), compared to 6.75% of the control group. Menstruation in those who completed suicide, compared to a control group, appeared to have an association with suicide. More research is warranted.

Quantitative analysis of variable extent of anterior clinoidectomy with intradural and extradural approaches: 3-dimensional analysis and cadaver dissection.

BACKGROUND: Drilling of the anterior clinoid process (ACP) is an integral component of surgical approaches for central and paracentral skull base lesions. The technique to drill ACP has evolved from pure intradural to extradural and combined techniques. OBJECTIVE: To describe the computerized morphometric evaluation of exposure of optic nerve and internal carotid artery with proposed tailored intradural (IDAC) and complete extradural (EDAC) anterior clinoidectomy. METHODS: We describe a morphometric subdivision of ACP into 4 quadrangles and 1 triangle on the basis of fixed bony landmarks. Computerized volumetric analysis with 3-dimensional laser scanning of dry-drilled bones for respective tailored IDAC and EDAC was performed. Both approaches were compared for the area and length of the optic nerve and internal carotid artery. Five cadaver heads were dissected on alternate sides with intradural and extradural techniques to evaluate exposure, surgical freedom, and angulation of approach. RESULTS: Complete anterior clinoidectomy provides a 2.5-times larger area and 2.7-times larger volume of ACP. Complete clinoidectomy deroofed the optic nerve to an equal extent as by proposed the partial tailored clinoidectomy approach. Tailored IDAC exposes only the distal dural ring, whereas complete EDAC exposes both the proximal and distal dural rings with complete exposure of the carotid cave. CONCLUSION: Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility. ABBREVIATIONS: ACP, anterior clinoid process EDAC, extradural anterior clinoidectomy ICA, internal carotid artery IDAC, intradural anterior clinoidectomy MOB, meningo-orbital band ON, optic nerve SOF, superior orbital fissure

Practical guidelines for setting up neurosurgery skills training cadaver laboratory in India

Though the necessity of cadaver dissection is felt by the medical fraternity, and described as early as 600 BC, in India, there are no practical guidelines available in the world literature for setting up a basic cadaver dissection laboratory for neurosurgery skills training. Hands-on dissection practice on microscopic and endoscopic procedures is essential in technologically demanding modern neurosurgery training where ethical issues, cost constraints, medico-legal pitfalls, and resident duty time restrictions have resulted in lesser opportunities to learn. Collaboration of anatomy, forensic medicine, and neurosurgery is essential for development of a workflow of cadaver procurement, preservation, storage, dissection, and disposal along with setting up the guidelines for ethical and legal concerns.

Development and validation of an ESI-LC-MS/MS method for simultaneous identification and quantification of 24 analytes of forensic relevance in vitreous humour, whole blood and plasma†

Detection and quantification of drugs from various biological matrices are of immense importance in forensic toxicological analysis. Despite the various reported methods, development of a new method for the detection and quantification of drugs is still an active area of research. However, every method and biological matrix has its own limitation, which further encourage forensic toxicologists to develop new methods and to explore new matrices for the analysis of drugs. In this study, an electrospray ionization-liquid chromatograph-tandem mass spectrometry (ESI-LC-MS/MS) method is developed and validated for simultaneous identification and quantification of 24 drugs of forensic relevance in various body fluids, namely, whole blood, plasma and vitreous humour. The newly developed method has been validated for intra-day and inter-day accuracy, precision, selectivity and sensitivity. Absolute recovery shows a mean of 84.5, 86.2, and 103% in the vitreous humour, whole blood and plasma respectively, which is suitable for the screening procedure. Further, the absolute matrix effect (AME) shows a mean of 105, 96.5, and 109% in the vitreous humour, whole blood and plasma, respectively. In addition, to examine the practical utility of this method, it has been applied for screening of drugs in post-mortem samples of the vitreous humour, whole blood and plasma collected at autopsy from ten cadavers. Experimental results show that the newly developed method is well applicable for screening of analytes in all the three matrices.

E-suicide note: A newer trend and its medico-legal implications in India

Rapid advancements of information and communication technology in the form of electronic mails, mobile phones, social networking sites, etc have an increasing impact on peoples day to day life. It has been observed that these readily available applications are used frequently to express suicidal intentions. There are many studies on conventional handwritten suicide notes but suicide note in electronic format is an emerging issue and an under-researched phenomena. The authors have termed it as “E-suicide note” and discuss its medico-legal implications in India with examples from their observations.