Reduction of systemic fungal infections in patients with hematological malignancies, neutropenia, and prolonged fever by early amphotericin B therapy

Clinico-pathological discrepancies in the diagnosis of causes of death in adults in Mozambique: A retrospective observational study

Background

Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact.

Aim

We assessed the accuracy of the clinical diagnoses in a tertiary referral hospital in sub-Saharan Africa by comparison with post-mortem findings. We also identified potential risk factors for misdiagnoses.

Methods

One hundred and twelve complete autopsy procedures were performed at the Maputo Central Hospital (Mozambique), from November 2013 to March 2015. We reviewed the clinical records. Major clinico-pathological discrepancies were assessed using a modified version of the Goldman and Battle classification.

Results

Major diagnostic discrepancies were detected in 65/112 cases (58%) and were particularly frequent in infection-related deaths (56/80 [70%] major discrepancies). The sensitivity of the clinical diagnosis for toxoplasmosis was 0% (95% CI: 0–37), 18% (95% CI: 2–52) for invasive fungal infections, 25% (95% CI: 5–57) for bacterial sepsis, 34% (95% CI: 16–57), for tuberculosis, and 46% (95% CI: 19–75) for bacterial pneumonia. Major discrepancies were more frequent in HIV-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p = 0.0236).

Conclusions

Major clinico-pathological discrepancies are still frequent in resource constrained settings. Increasing the level of suspicion for infectious diseases and expanding the availability of diagnostic tests could significantly improve the recognition of common life-threatening infections, and thereby reduce the mortality associated with these diseases. The high frequency of clinico-pathological discrepancies questions the validity of mortality reports based on clinical data or verbal autopsy.

Clinico-pathological discrepancies in the diagnosis of causes of maternal death in sub-Saharan Africa: retrospective analysis

BACKGROUND

Maternal mortality is a major public-health problem in developing countries. Extreme differences in maternal mortality rates between developed and developing countries indicate that most of these deaths are preventable. Most information on the causes of maternal death in these areas is based on clinical records and verbal autopsies. Clinical diagnostic errors may play a significant role in this problem and might also have major implications for the evaluation of current estimations of causes of maternal death.

METHODS AND FINDINGS

A retrospective analysis of clinico-pathologic correlation was carried out, using necropsy as the gold standard for diagnosis. All maternal autopsies (n = 139) during the period from October 2002 to December 2004 at the Maputo Central Hospital, Mozambique were included and major diagnostic discrepancies were analyzed (i.e., those involving the cause of death). Major diagnostic errors were detected in 56 (40.3%) maternal deaths. A high rate of false negative diagnoses was observed for infectious diseases, which showed sensitivities under 50%: HIV/AIDS-related conditions (33.3%), pyogenic bronchopneumonia (35.3%), pyogenic meningitis (40.0%), and puerperal septicemia (50.0%). Eclampsia, was the main source of false positive diagnoses, showing a low predictive positive value (42.9%).

CONCLUSIONS

Clinico-pathological discrepancies may have a significant impact on maternal mortality in sub-Saharan Africa and question the validity of reports based on clinical data or verbal autopsies. Increasing clinical awareness of the impact of obstetric and nonobstetric infections with their inclusion in the differential diagnosis, together with a thorough evaluation of cases clinically thought to be eclampsia, could have a significant impact on the reduction of maternal mortality.

Diagnostic errors in three medical eras: a necropsy study

BACKGROUND

Studies comparing the accuracy of clinical diagnosis in unselected patients who died in hospital in different medical eras have shown no decline of errors in the main diagnosis. We assessed changes in diagnostic accuracy over 20 years.

METHODS

We analysed retrospectively diagnostic errors, with use of necropsy as the gold standard for diagnosis. We randomly selected 300 patients who died at a tertiary-care teaching hospital in Switzerland--100 in each of 1972, 1982, and 1992. We classified discrepancies between clinical diagnosis and necropsy findings as major and minor errors.

FINDINGS

The overall necropsy rate at the hospital stayed at around 90% for the whole period. During the study, the frequency of major discrepancies declined significantly (1972, 30%; 1982, 18%; 1992, 14%; p=0.007). The rate of minor diagnostic errors increased significantly from 23% in 1972 to 46% in 1992 (p<0.001). The increase in overall diagnostic accuracy occurred mainly because of a significant improvement in specificity for cardiovascular diseases (1972, 85%; 1982, 82%; 1992, 97%; p=0.034) and non-significantly improved sensitivity (1972, 69%; 1982, 82%; 1992, 86%; p=0.061). Sensitivity also improved for infectious diseases (1972, 25%; 1982, 67%; 1992, 86%; p=0.036). Sensitivity and specificity for neoplastic diseases were high originally and did not change. The total number of diagnostic procedures per year increased from 191 in 1972 to 259 in 1992, mainly because of non-invasive techniques, such as ultrasonography, and endoscopies.

INTERPRETATION

The frequency of major diagnostic errors in unselected patients who died in hospital was halved over 20 years, probably because of improved clinical skills and new diagnostic procedures.

The effects of antifungal chemoprophylaxis and empiric therapy on invasive fungal infection in neutropenic children with malignant neoplasms

Since January 1987, chemoprophylaxis and empiric therapy with antifungal drugs have been used routinely in neutropenic children with neoplasms. The incidence of terminal invasive fungal infection (IFI) diagnosed by autopsy findings is compared in two groups: group A, consisting of 25 patients autopsied between January 1982 and December 1986, and group B, consisting of 14 patients autopsied between January 1987 and December 1991. There was no difference in the incidence of IFI between the two groups, but the characteristics of IFI appeared to differ. With the recent intensification of chemotherapy, the patients in group B had more risk factors for IFI. It might therefore have been anticipated that group B patients may have shown an increase in IFI. No such increase was observed, suggesting that the prophylaxis was effective. Autopsy findings also showed that the target organs of IFI were localized and that systemic candidiasis was decreased in group B. It is thus concluded that the present antifungal countermeasures are effective, although some problems still remain.