Clinical and autopsy correlation evaluated in a university hospital in Spain (1991-2000)

Discordance between clinical and post-mortem diagnoses at a tertiary hospital

Advances in modern medicine and more accurate and precise diagnostic procedures have been considered to be the main reason for the reduction in autopsy rates. However, there is still a discrepancy between clinical and autopsy diagnoses. This retrospective study, designed as a cross-sectional study, included a sample of 931 patients who died at the Clinical Hospital Centre ‘Zemun’. We analysed sex, age, length of hospitalisation and clinical and post-mortem diagnoses, including the discrepancies between them. In 314 (34%) cases, there was complete agreement between the clinical and autopsy diagnoses, complete disagreement in the same percentage and incomplete agreement in 303 (32%) cases. In people aged >60 years, the risk of misdiagnosis was 2.5-fold higher than in the those aged <60 years (odds ratio (OR)=2.522, p<0.001), while the influence of sex on the risk of misdiagnosis was not statistically significant (OR=0.981, p>0.05). An increase in the number of autopsies would be one of the best methods to make discrepancies between clinical and post-mortem diagnoses visible, and a good method for continuous evaluation of diagnostic tests, as well as for providing a wider perspective on presentations of different clinical conditions.

Communicating with the coroner: how religion, culture, and family concerns may influence autopsy decision making

Based on coronial data gathered in the state of Queensland in 2004, this article reviews how a change in legislation may have impacted autopsy decision making by coroners. More specifically, the authors evaluated whether the requirement that coronial autopsy orders specify the level of invasiveness of an autopsy to be performed by a pathologist was affected by the further requirement that coroners take into consideration a known religion, culture, and/or raised family concern before making such an order. Preliminary data reveal that the cultural status of the deceased did not affect coronial autopsy decision making. However, a known religion with a proscription against autopsy and a raised family concern appeared to be taken into account by coroners when making autopsy decisions and tended to decrease the invasiveness of the autopsy ordered from a full internal examination to either a partial internal examination or an external-only examination of the body. The impact of these findings is briefly discussed.

The autopsy imperative: medicine, law, and the coronial investigation

The central purpose of this paper is to address the tension between legal and medical discourses within the coronial system. Medical expertise, based largely upon internal autopsy, becomes positioned as providing the more important information, rather than the legal model which focuses on evidence gathering at the scene. This paper will examine the aspects of the history, philosophy and consequences of the processes by which the medical model gained its current dominance and will conclude that, while autopsies are necessary, they are also over-used in the coronial system.

Multimodality minimally invasive autopsy--a feasible and accurate approach to post-mortem examination

BACKGROUND

Autopsy examination has been the bedrock of western medicine. With the decline in the autopsy rate secondary to the negative psychological impact to the deceased's relatives, the benefits of autopsy have been undermined. Minimally invasive autopsy has been introduced but has not been widely adopted as an alternative to the 'traditional' open approach. This technique not only provides information on the cause of death abut also minimizes the disfigurement induced to the deceased. Our study aims to explore the feasibility and evaluate the accuracy of this technique.

METHODS

A series of coroner cases ordered for autopsy were examined by a group including an experienced forensic pathologist and two experienced laparoscopic surgeons using thoracoscopic, laparoscopic, endoluminal or endovascular approaches. The procedure was video-recorded and the provisional diagnoses and causes of death were made based on the findings. These findings were subsequently correlated with the full autopsy examination. A few limited clinical post-mortem examinations were also performed with consent from relatives.

RESULTS

A total of 22 cases of minimally invasive autopsies were performed from November 2007 to March 2008. The median duration of the procedures was 78.3+/-20.7 min. Thoracoscopies and laparoscopies were performed in 18 patients while additional arterioscopic examination with endoscope was performed in two patients with suspected aortic diseases. Four consented limited clinical autopsies were also performed: two of them involved thoracoscopic biopsies of lung tissues, one was a para-mortem upper endoscopy for the investigation of pathology of the stomach and the other one was laparoscopy for a patient, who died of unexplained acidosis. Comparison with full autopsies showed that the accuracy of the diagnosis was 94.4%, the sensitivity was 90%, the specificity was 100%, the positive predictive value was 100% and the negative predictive value was 88.9%.

CONCLUSION

Minimally invasive autopsy is a feasible approach, yielding accurate findings when compared with conventional autopsies. The former can be a valuable tool for obtaining more valuable information in situations when the next-of-kin of the deceased does not consent to a conventional 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.

Autopsia clínica: una herramienta más en el servicio de urgencias hospitalario

BACKGROUND AND OBJECTIVE

We aimed to know the usefulness of clinical autopsy at the medical room of an emergency department in a teaching hospital.

PATIENTS AND METHOD

Retrospective study of clinical autopsies performed in the emergency department of a teaching hospital between 1995 and 2000. We explored the correlation between clinical emergency and autopsy diagnosis.

RESULTS

The number of deaths was 1,484 (0.9%) among 165,662 patients attended in the emergency medical room in the study period. Of 281 autopsies (18.9%), 227 (15.3%) were judicial. Only 54 clinical autopsies (3.6%) were included. Dyspnea and chest pain, the two more frequent guide symptoms, were in concordance with the two more prevalent initial clinical diagnoses: respiratory and cardiovascular diseases. 38.9% (21 cases) of autopsies agreed with the clinical diagnosis and 14.8% (8 cases) did not agree with it. 25.9% (14 cases) of autopsies were diagnostic since the clinical diagnosis, both initial and final, was unknown. Moreover, 14.8% (8 cases) autopsies were explanatory. Furthermore, 5.6% (3 cases) of autopsies were undetermined. With regard to the main cause of death, there were 9 (16.7%) cases of previously unknown neoplasms.

CONCLUSIONS

The results of the present study confirm the need and usefulness of autopsy in patients dying in the medical room of emergency departments, as well as the crucial role of the clinico-pathological exercise in the definitive diagnosis of the postmortem examination.

Comorbidity in dementia: an autopsy study

CONTEXT

There is a paucity of accurate postmortem data pertinent to comorbid medical conditions in patients with dementia, including Alzheimer disease.

OBJECTIVES

The purposes of this study were (a) to examine general autopsy findings in patients with a dementia syndrome and (b) to establish patterns of central nervous system comorbidity in these patients.

DESIGN

Review of autopsy reports and selected case material from 202 demented patients who had "brain-only" autopsies during a 17-year period (1984-2000) and from 52 demented patients who had general autopsies during a 6-year period (1995-2000).

SETTING

Large academic medical center performing approximately 200 autopsies per year.

RESULTS

Among the 52 patients who underwent complete autopsy, the most common cause of death was bronchopneumonia, which was found in 24 cases (46.1%). Other respiratory problems included emphysema, found in 19 (36.5%) of 52 patients, and pulmonary thromboembolism, found in 9 (17.3%) of 52 patients. In 6 cases, pulmonary thromboembolism was the proximate cause of death. Twenty-one (40.3%) of the 52 patients had evidence of a myocardial infarct (varying ages) and 38 (73.1%) had atherosclerotic cardiovascular disease, 27 of a moderate to severe degree. Four clinically unsuspected malignancies were found: 1 each of glioblastoma multiforme, diffusely infiltrative central nervous system lymphoma, pancreatic adenocarcinoma, and adenocarcinoma of the lung. One patient with frontotemporal dementia and amyotrophic lateral sclerosis died of severe meningoencephalitis/ventriculitis, probably secondary to seeding of the central nervous system by an infected cardiac valve. Of the 202 demented patients who underwent brain-only autopsies, the following types of dementia were found: 129 (63.8%) cases showed changes of severe Alzheimer disease, 21 (10.4%) showed combined neuropathologic abnormalities (Alzheimer disease plus another type of lesion, such as significant ischemic infarcts or diffuse Lewy body disease), 12 (5.9%) cases of relatively pure ischemic vascular dementia, 13 (6.4%) cases of diffuse Lewy body disease, and 8 (4.0%) cases of frontotemporal dementia. The remaining 19 (9.4%) patients showed miscellaneous neuropathologic diagnoses, including normal pressure hydrocephalus and progressive supranuclear palsy. Among the demented patients, 92 (45.5%) had cerebral atherosclerosis, which was moderate to severe in 65 patients (32.2%).

CONCLUSIONS

Some of the conditions found at autopsy, had they been known antemortem, would likely have affected clinical management of the patients. Autopsy findings may be used as a quality-of-care measure in patients who have been hospitalized in chronic care facilities for a neurodegenerative disorder.