Comparison between clinical diagnoses and autopsy findings in a pediatric intensive care unit in São Paulo, Brazil

Neonatal autopsy-is it relevant in today's era?

Autopsy of infants can provide vital information about the cause of death and contributes to the detection of diagnostic errors, especially in a low- or middle-income country. To observe the clinicopathological agreement in neonatal deaths in neonatal intensive care units (NICU) and comment on the additional information retrieved by autopsy. A retrospective observational study was conducted in the NICU from January 2020 to December 2022. Neonatal deaths were analyzed, and clinical details and autopsy findings were collected. Both clinical and pathological diagnoses were classified according to the Goldman classification. Twenty-two newborn infants were enrolled. The mean gestational age was 33.5 (±4.38) weeks, and the median birth weight was 1510 (1005-2100) g. There was complete concordance between clinical and pathological diagnosis in 11 (50%) cases. Major diagnostic errors occurred in 41% of cases. Respiratory system disorders (lung infections, airway anomalies) accounted for six (54%) cases of missed diagnosis. Our study showed that the diagnosis was revised after autopsy in about one-third of cases, and newer findings were identified in one-fifth of cases.

Major discrepancy between clinical diagnosis of death and anatomopathological findings in adolescents with chronic diseases during 18-years

OBJECTIVES

To evaluate the inconsistency between clinical diagnosis of death and autopsy findings in adolescents with chronic diseases.

METHODS

A cross-sectional study including a sample of adolescents' autopsies who died in a pediatric and adolescent tertiary hospital over 18 consecutive years. During this period, there were n = 2912 deaths, and n = 581/2912(20%) occurred in adolescents. Of these, n = 85/581(15%) underwent autopsies and were analyzed. Further results were divided into two groups: Goldman classes I or II (high disagreement between main clinical diagnosis of death and anatomopathological findings, n = 26) and Goldman classes III, IV or V (low or no disagreement between these two parameters, n = 59).

RESULTS

Median age at death (13.5 [10‒19] vs. 13 [10‒19] years, p = 0.495) and disease duration (22 [0‒164] vs. 20 [0‒200] months, p = 0.931), and frequencies for males (58% vs. 44%, p = 0.247) were similar between class I/II vs. class III/IV/V. The frequency of pneumonia (73% vs. 48%, p = 0.029), pulmonary abscess (12% vs. 0%, p = 0.026), as well as isolation of yeast (27% vs. 5%, p = 0.008), and virus (15% vs. 2%, p = 0.029) identified in the autopsy, were significantly higher in adolescents with Goldman class I/II compared to those with Goldman class III/IV/V. In contrast, cerebral edema was significantly lower in adolescents of the first group (4% vs. 25%, p = 0.018).

CONCLUSION

This study showed that 30% of the adolescents with chronic diseases had major discrepancies between clinical diagnosis of death and autopsy findings. Pneumonia, pulmonary abscess, as well as isolation of yeast and virus were more frequently identified at autopsy findings in the groups with major discrepancies.

AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE

Objective:

Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU).

Methods:

This is a cross-sectional, retrospective study on 31 patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria.

Results:

Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. There was a 67% decrease in the number of autopsies over the last 10 years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). There was greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Seven patients were admitted in critical health conditions and died within the first 24 hours of hospitalization.

Conclusions:

Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

[Analysis of the major clinical-pathological discrepancies in autopsies of adults in a tertiary referral hospital between 2008-2017]

OBJECTIVE

To compare and contrast clinical diagnoses with autopsy findings in order to identify unexpected, relevant discrepancies.

MATERIAL AND METHOD

A retrospective observational study of the revision of autopsies of adults and their respective medical records in order to classify them according to referral department and Goldman's classification was carried out at the Central University Hospital of Asturias between 2008-2017.

RESULTS

694 (52.6%) of 1320 autopsies were included in the study. Discrepancies were observed in 57.6% of cases, although the majority (39.3%) were minor. Type I discrepancies were identified in 63 autopsies (9.1%); malignant neoplasms being the main pathology observed (57.1%), mainly of gastrointestinal origin (about 28%). The second most common discrepancy was found in cases of infectious diseases (23.8%) followed by pulmonary embolism (15.9%). 64 autopsies were classified as type II discrepancies (9.2%), with myocardial infarct the most common (37.5%), especially acute myocardial infarction (18 cases), followed by bronchoaspirations (18.7%), DIC (15.6%), massive haemorrhages (9.4%) and other conditions. It was considered that both the ICU and the Internal Medicine Service were responsible for the largest number of major discrepancies (type I and II), accounting for about 45% of type I and slightly more than 56% for type II.

CONCLUSION

Autopsies are an essential means of identifying ante-mortem clinical errors. The incidence of major discrepancies in the Central University Hospital of Asturias (18.3%) is comparable to that of leading hospitals worldwide.

Mortality in adolescents and young adults with chronic diseases during 16 years: a study in a Latin American tertiary hospital

OBJECTIVES

To evaluate mortality in adolescents and young adult patients with chronic diseases followed in a Latin American tertiary hospital.

METHODS

A cross-sectional retrospective study was performed in a tertiary/academic hospital in the state of São Paulo, Brazil. Death occurred in 529/2850 (18.5%) adolescents and young adult patients with chronic diseases, and 25/529 (4.7%) were excluded due to incomplete medical charts. Therefore, 504 deaths were evaluated.

RESULTS

Deaths occurred in 316/504 (63%) of early adolescent patients and in 188/504 (37%) of late adolescent/young adult patients. Further comparisons between early adolescents (n=316) and late adolescent/young adult patients (n=188) with pediatric chronic diseases at the last hospitalization showed that the median disease duration (22.0 [0-173] vs. 43.0 [0-227] months, p<0.001) was significantly lower in early adolescents vs. late adolescent/young adult patients. The median number of previous hospitalizations was significantly lower in the former group (4.0 [1-45] vs. 6.0 [1-52], p<0.001), whereas the last hospitalization in intensive care unit was significantly higher (60% vs. 47%, p=0.003). Regarding supportive measures, palliative care was significantly lower in the younger group compared to the older group (33% vs. 43%, p=0.02). The frequencies of renal replacement therapy (22% vs. 13%, p=0.02), vasoactive agents (65% vs. 54%, p=0.01), and transfusion of blood products (75% vs. 66%, p=0.03) were significantly higher in the younger group. The five most important etiologies of pediatric chronic diseases were: neoplasias (54.2%), hepatic diseases/transplantation (10%), human immunodeficiency virus (5.9%), and childhood-onset systemic lupus erythematosus and juvenile idiopathic arthritis (4.9%). Autopsy was performed in 58/504 (11%), and discordance between clinical and postmortem diagnoses was evidenced in 24/58 (41.3%).

CONCLUSIONS

Almost 20% of deaths occurred in adolescents and young adults with distinct supportive care and severe disease patterns. Discordance between clinical diagnosis and autopsy was frequently observed.

PICU Autopsies: Rates, Patient Characteristics, and the Role of the Medical Examiner

OBJECTIVES

Autopsy rates in North American Children's hospitals have not been recently evaluated. Our objectives were 1) to determine the autopsy rates from patients cared for in PICUs during a portion of their hospital stay, 2) to identify patient characteristics associated with autopsies, and 3) to understand the relative role of medical examiner cases.

DESIGN

Secondary analysis of data prospectively collected from a sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 2011 and April 2013.

SETTING

Eight quaternary care PICUs.

PATIENTS

Patients in the primary study were less than 18 years old, admitted to a PICU and not moribund on PICU admission. Patients included in this analysis were those who died during their hospital stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sociodemographic, clinical, hospital, and PICU data were compared between patients who had autopsies conducted and those who did not and between medical examiner and nonmedical examiner autopsies. Of 10,078 patients, 275 died of which 36% (n = 100) had an autopsy performed. Patients with cancer who died were less likely to receive autopsies (p = 0.005), whereas those who died after trauma or cardiac arrest had autopsies performed more often (p < 0.01). Autopsies were more common in patients with greater physiologic instability at admission (p < 0.001), and those who received more aggressive PICU care. Medical examiner cases comprised nearly half of all autopsies (n = 47; 47%) were conducted in patients presenting with greater physiologic instability (p < 0.001) and more commonly after catastrophic events such as cardiac arrest or trauma (p < 0.001).

CONCLUSIONS

In this first multicenter analysis of autopsy rates in children, 36% of deaths had autopsies conducted, of which nearly half were conducted by the medical examiner. Deaths with autopsy are more likely to be previously healthy children that had catastrophic events prior to admission.

Learning From Investigation After Death

OBJECTIVES

The acceptability of traditional postmortem examination to bereaved families, coupled with a misguided professional view about their limited utility, has led to decrease in this ultimate investigation. Research recurrently demonstrates that postmortem examination provides clinically relevant information despite ever-improving diagnostic techniques. This review examines postmortem examination for children who die in PICU-whether consented or nonconsented (legally mandated). It explores how such investigations might provide useful information and suggests that PICU and pathology teams work together to provide information for bereaved families to either enable them to consent to postmortem interventions or understand necessary forensic processes. Newer technologies such as postmortem imaging and laparoscope-assisted/ultrasound-guided tissue sampling are reviewed, with the hope that greater acceptability to families may lead to a welcome resurgence in postmortem information for clinicians, tempered by realization that widespread acceptance of their equivalence to standard techniques by most forensic services is awaited.

DATA SOURCES

Literature review.

STUDY SELECTION

Journal articles describing practices in pediatric and adult postmortem examination.

DATA EXTRACTION

Not available.

DATA SYNTHESIS

Not available.

CONCLUSIONS

The PICU team have a duty to help bereaved parents understand what postmortem investigations are available, or might be mandated, after the death of their child. A thoughtful, unhurried, and compassionate discussion should be arranged with expert pathology teams and any specialists who have cared for the child to explain how investigations can provide information about what is involved-including availability and suitability of newer techniques. This should include information about when a child's body, organs, or tissues will be available for the funeral, necessary legal procedures and how and when results will be explained to them.

The role of post-mortem MRI in the neonatal intensive care unit

OBJECTIVE

Post-mortem examination can provide important information about the cause of death and play a significant role in the bereavement process. Autopsies reveal previous unknown medical problems approximately 20 to 30% of the time. A non-invasive magnetic resonance imaging-based post-mortem examination (PM-MRI) may provide an alternative for families who do not consent to an autopsy.

STUDY DESIGN

This study was a prospective observational study of recently expired neonates and infants. Subjects underwent a full body MRI scan (brain, chest, abdomen and pelvis) followed by conventional autopsy if the family desired to have one. MRI results were compared with autopsy findings and the ante-mortem clinical diagnosis. A follow-up survey was conducted to investigate family perceptions of the PM-MRI process.

RESULTS

Thirty-one infants underwent full PM-MRI. Of 31 infants, 19 (61%) had complete agreement between the clinician's impression and PM-MRI. Twenty-four infants also had conventional autopsy, with 14/24 (58%) infants having PM-MRI results consistent with autopsy findings. PM-MRI was superior at detection of free intraperitoneal/intrathoracic air and hepatic iron overload. Whole-body PM-MRI did not have the resolution to detect focal/microscopic injury, vascular remodeling and some forms of brain injury. Of those families who remembered the PM-MRI findings, the majority felt that the information was useful.

CONCLUSIONS

PM-MRI studies may provide an important adjunct to conventional autopsy and a substitute when the latter is not possible for personal or religious reasons. Clinicians should be aware of, and communicate with the family, the resolution limits of the whole-body PM-MRI to detect certain types of injury.

Diagnostic errors in the pediatric and neonatal ICU: a systematic review

OBJECTIVE

Diagnostic errors lead to preventable hospital morbidity and mortality. ICU patients may be at particularly high risk for misdiagnosis. Little is known about misdiagnosis in pediatrics, including PICU and neonatal ICU. We sought to assess diagnostic errors in PICU and neonatal ICU settings by systematic review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, and Cochrane.

STUDY SELECTION

We identified observational studies reporting autopsy-confirmed diagnostic errors in PICU or neonatal ICU using standard Goldman criteria.

DATA EXTRACTION

We abstracted patient characteristics, diagnostic error description, rates and error classes using standard Goldman criteria for autopsy misdiagnoses and calculated descriptive statistics.

DATA SYNTHESIS

We screened 329 citations, examined 79 full-text articles, and included 13 studies (seven PICU; six neonatal ICU). The PICU studies examined a total of 1,063 deaths and 498 autopsies. Neonatal ICU studies examined a total of 2,124 neonatal deaths and 1,259 autopsies. Major diagnostic errors were found in 19.6% of autopsied PICU and neonatal ICU deaths (class I, 4.5%; class II, 15.1%). Class I (potentially lethal) misdiagnoses in the PICU (43% infections, 37% vascular) and neonatal ICU (62% infections, 21% congenital/metabolic) differed slightly. Although missed infections were most common in both settings, missed vascular events were more common in the PICU and missed congenital conditions in the neonatal ICU.

CONCLUSION

Diagnostic errors in PICU/neonatal ICU populations are most commonly due to infection. Further research is needed to better quantify pediatric intensive care-related misdiagnosis and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.

Post-mortem MRI as an alternative to non-forensic autopsy in foetuses and children: from research into clinical practice

Although post-mortem MRI (PMMR) was proposed as an alternative to conventional autopsy more than a decade ago, the lack of systematic validation has limited its clinical uptake. Minimally invasive autopsy (MIA) using PMMR together with ancillary investigations has now been shown to be as accurate as conventional autopsy in foetuses, newborns and infants and is particularly useful for cerebral, cardiac and genitourinary imaging. Unlike conventional autopsy, PMMR provides a permanent three-dimensional auditable record, with accurate estimation of internal organ volumes. MIA is becoming highly acceptable to parents and professionals, and there is widespread political support and public interest in its clinical implementation in the UK. In the short to medium term, it is desirable that a supraregional network of specialist centres should be established to provide this service within the current National Health Service framework.

Red blood cell transfusion practice in a Pediatric Intensive Care Unit

OBJECTIVES

To describe a population of children that received red blood cell transfusions.

METHODS

A retrospective observational study carried out at the Pediatric Intensive Care Unit of the Instituto da Criança of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo in 2004, with children that received red blood cell transfusions.

RESULTS

Transfusion of red blood cells was performed in 50% of the patients hospitalized. Median age was 18 months, and the primary motive for admission was respiratory insufficiency (35%). Underlying disease was present in 84% of the cases and multiple organ and system dysfunction in 46.2%. The median value of pretransfusion hemoglobin concentration was 7.8 g/dL. Transfused patients were undergoing some form of therapeutic procedure in 82% of the cases.

CONCLUSIONS

Red blood cell transfusions are performed at all ages. Hemoglobin concentration and hematocrit rate are the primary data used to indicate these transfusions. The values of arterial serum lactate and SvO2were seldom used. Most patients transfused were submitted to some form of therapeutic procedure, and in many cases, transfusions were carried out in patients with multiple organ and system dysfunctions.

A continuous heparin infusion does not prevent catheter-related thrombosis in infants after cardiac surgery

OBJECTIVE

To determine whether a continuous infusion of heparin reduces the rate of catheter-related thrombosis in neonates and infants post cardiac surgery. Central venous and intracardiac catheters are used routinely in postoperative pediatric cardiac patients. Catheter-related thrombosis occurs in 8% to 45% of pediatric patients with central venous catheters.

DESIGN

Single-center, randomized, placebo-controlled, double-blinded trial.

SETTING

Cardiovascular intensive care unit, university-affiliated children's hospital.

PATIENTS

Children <1 yr of age recovering from cardiac surgery.

INTERVENTIONS

Patients were randomized to receive either continuous heparin at 10 units/kg/hr or placebo. The primary end point was catheter-related thrombosis as assessed by serial ultrasonography.

RESULTS

Study enrollment was discontinued early based on results from an interim futility analysis. Ninety subjects were enrolled and received the study drug (heparin, 53; placebo, 37). The catheter-related thrombosis rate in the heparin group, compared with the placebo group, was 15% vs. 16% (p = .89). Subjects in the heparin group had a higher mean partial thromboplastin time (52 secs vs. 42 secs, p = .001), and this difference was greater for those aged <30 days (64 secs vs. 43 secs, p = .008). Catheters in place > or = 7 days had both a greater risk of thrombus formation (odds ratio, 4.3; p = .02) and catheter malfunction (odds ratio, 11.2; p = .008). We observed no significant differences in other outcome measures or in the frequency of adverse events.

CONCLUSIONS

A continuous infusion of heparin at 10 units/kg/hr was safe but did not reduce catheter-related thrombus formation. Heparin at this dose caused an increase in partial thromboplastin time values, which, unexpectedly, was more pronounced in neonates.

Invasive mold infections in iatrogenically immunocompromised children: an eight-yr review

IMI are emerging as an important cause of mortality and morbidity among the growing number of immunocompromised children. A retrospective chart review was performed in all patients with a proven diagnosis of IMI over an eight-yr period (1997-2004) at The Hospital for Sick Children, Toronto, Canada to document the incidence, clinical spectrum, microbiology, treatment, and outcome of pediatric IMI. Twenty-eight patients developed IMI over the study period (10 cancer, 12 HCT, and six SOT patients). IMI occurred in 0.51%, 2.2% and 3.2% after a median time of 118, 60 and 71 days, among cancer, HCT and SOT recipients, respectively. Aspergillus spp. infection was diagnosed most commonly (23 patients) and the most common site of infection was the lung (21 patients). Patients at increased risk included those with acute myelogenous leukemia, allogeneic unrelated HCT recipients, graft-versus-host disease, and lung transplant recipients. The mortality after one yr was 60% among cancer patients, 58% among HCT patients, and 16% among SOT patients.

Macroscopic postmortem findings in 235 surgical intensive care patients with sepsis

BACKGROUND

Although detailed analyses of the postmortem findings of various critically ill patient groups have been published, no such study has been performed in patients with sepsis. In this retrospective cohort study, we reviewed macroscopic postmortem examinations of surgical intensive care unit (ICU) patients who died from sepsis or septic shock.

METHODS

Between 1997 and 2006, the ICU database and autopsy register were reviewed for patients who were admitted to the ICU because of sepsis/septic shock, or who developed sepsis/septic shock at a later stage during their ICU stay and subsequently died from of sepsis/septic shock. Clinical data and postmortem findings were documented in all patients.

RESULTS

Postmortem results of 235 patients (84.8%) were available for statistical analysis. The main causes of death as reported in the patient history were refractory multiple organ dysfunction syndrome (51.5%) and uncontrollable cardiovascular failure (35.3%). Pathologies were detected in the lungs (89.8%), kidneys/urinary tract (60%), gastrointestinal tract (54%), cardiovascular system (53.6%), liver (47.7%), spleen (33.2%), central nervous system (18.7%), and pancreas (8.5%). In 180 patients (76.6%), the autopsy revealed a continuous septic focus. The most common continuous foci were pneumonia (41.3%), tracheobronchitis (28.9%), peritonitis (23.4%), uterine/ovarial necrosis (9.8% of female patients), intraabdominal abscesses (9.1%), and pyelonephritis (6%). A continuous septic focus was observed in 63 of the 71 patients (88.7%) who were admitted to the ICU because of sepsis/septic shock and treated for longer than 7 days.

CONCLUSIONS

Relevant postmortem findings explaining death in surgical ICU patients who died because of sepsis/septic shock were a continuous septic focus in approximately 80% and cardiac pathologies in 50%. The most frequently affected organs were the lungs, abdomen, and urogenital tract. More diagnostic, therapeutic and scientific efforts should be launched to identify and control the infectious focus in patients with sepsis and septic shock.

How is mechanical ventilation employed in a pediatric intensive care unit in Brazil?

OBJECTIVE

To investigate the relationship between mechanical ventilation and mortality and the practice of mechanical ventilation applied in children admitted to a high-complexity pediatric intensive care unit in the city of São Paulo, Brazil.

DESIGN

Prospective cohort study of all consecutive patients admitted to a Brazilian high-complexity PICU who were placed on mechanical ventilation for 24 hours or more, between October 1(st), 2005 and March 31(st), 2006.

RESULTS

Of the 241 patients admitted, 86 (35.7%) received mechanical ventilation for 24 hours or more. Of these, 49 met inclusion criteria and were thus eligible to participate in the study. Of the 49 patients studied, 45 had chronic functional status. The median age of participants was 32 months and the median length of mechanical ventilation use was 6.5 days. The major indication for mechanical ventilation was acute respiratory failure, usually associated with severe sepsis / septic shock. Pressure ventilation modes were the standard ones. An overall 10.37% incidence of Acute Respiratory Distress Syndrome was found, in addition to tidal volumes > 8 ml/kg, as well as normo- or hypocapnia. A total of 17 children died. Risk factors for mortality within 28 days of admission were initial inspiratory pressure, pH, PaO2/FiO2 ratio, oxygenation index and also oxygenation index at 48 hours of mechanical ventilation. Initial inspiratory pressure was also a predictor of mechanical ventilation for periods longer than 7 days.

CONCLUSION

Of the admitted children, 35.7% received mechanical ventilation for 24 h or more. Pressure ventilation modes were standard. Of the children studied, 91% had chronic functional status. There was a high incidence of Acute Respiratory Distress Syndrome, but a lung-protective strategy was not fully implemented. Inspiratory pressure at the beginning of mechanical ventilation was a predictor of mortality within 28 days and of a longer course of mechanical ventilation.

Clinico-pathological discrepancies in a general university hospital in São Paulo, Brazil

INTRODUCTION

The autopsy rate has continuously diminished over the past few decades, reducing the quality of medical care and the accuracy of statistical health data.

OBJECTIVE

To assess the accuracy of clinical diagnoses by comparing pre- and postmortem findings, and to identify potential risk factors for misdiagnoses.

METHODS

Retrospective evaluations performed between June 2001 and June 2003 in a 2,500-bed tertiary university hospital in São Paulo, Brazil, including 288 patients who died at that institution and had a postmortem examination.

RESULTS

Clinical and autopsy records were reviewed and compared for categorization using the adapted Goldman criteria. The overall major and minor discrepancy rates were 16.3% and 28.1%, respectively. The most common missed diagnoses were pulmonary embolism, pneumonia, and myocardial infarction, and the most prevalent underlying diseases were infectious diseases, cerebro-cardiovascular conditions, and malignancies. Patients age 60 or older had an increased risk of diagnostic disagreement, as did female patients. The period of hospitalization, last admission unit at the hospital and underlying disease were not significantly related to the pre-mortem diagnostic accuracy.

DISCUSSION

The discrepancy rate found in this study is similar to those reported globally. The factors influencing diagnostic accuracy as well as the most commonly missed diagnoses are also consistent with the literature.

CONCLUSION

Autopsy remains a crucial tool for improving medical care, and effort must be focused on increasing its practice worldwide.

The conventional autopsy in modern medicine

In many countries, including the UK, where relatives' consent is required, clinical autopsy rates (i.e. autopsies other than those required by law) have been declining since the 1950s. In the UK, even in teaching hospitals, the clinical autopsy rate has fallen to only 10% of deaths or less. At this rate of decline, clinical autopsies - and the pathologists who perform them - face extinction. The future practice of medicine will be blind to the many adverse consequences of clinical actions or omissions. The reasons for this decline are manifold and these have to be addressed if autopsy is to stand a chance of survival. The future of autopsy lies in promoting public support for autopsies, in some cases adapting the autopsy to address specific questions, thus making more effective use of information from autopsies. Only by ensuring that the next generation of doctors have experienced the powerful educational benefit of examining the body after death will the importance of autopsy to modern medicine be understood.