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Świderski P, Rzepczyk S, Bożek B, Żaba C. Minimally invasive autopsy - endoscopic approach to post-mortem diagnostics. Wideochir Inne Tech Maloinwazyjne 2024; 19:122-128. [PMID: 38974768 PMCID: PMC11223537 DOI: 10.5114/wiitm.2023.134122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/04/2023] [Indexed: 07/09/2024] Open
Abstract
The noticeable decline in the number of autopsies performed in recent years requires investigation into the causes of the phenomenon and attempts to prevent it. One potential cause of this trend is fear of disfiguring the body. Carrying out autopsies using a minimally invasive method may reduce the decrease in the number of autopsies performed. The first work on the development of the method and its continuation gave promising results. This allows us to start a discussion on attempts to introduce the method. The solution seems especially justified when the alternative is to completely abandon post-mortem examinations using the traditional method. Laparoscopy and thoracoscopy are tools that allow for accurate imaging and analysis of organ changes. Enriching them with additional tests using endoscopic techniques may have a positive impact on the accuracy of autopsy diagnoses. The development of a clear protocol for minimally invasive post-mortem diagnosis requires further research to determine the accuracy of the method.
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Affiliation(s)
- Paweł Świderski
- Department of Forensic Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Szymon Rzepczyk
- Department of Forensic Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Beata Bożek
- Department of Forensic Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Czesław Żaba
- Department of Forensic Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Bart NK, Robson D, Muthiah K, Jansz PC, Hayward CS. How do mechanical circulatory support patients die? Autopsy findings for left-ventricular assist device/total artificial heart nonsurvivors. J Heart Lung Transplant 2023; 42:1753-1763. [PMID: 37422144 DOI: 10.1016/j.healun.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/03/2023] [Accepted: 07/02/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Although life saving for end-stage heart failure patients, permanent mechanical circulatory support (MCS) is often the proximate cause of death in those that do not survive to transplant. Autopsy remains the gold standard for diagnosing causes of death and a vital tool for better understanding underlying pathology of nonsurvivors. The aim of this study was to determine the frequency and outcomes of autopsy investigations and compare these with premortem clinical assessment. METHODS The autopsy findings and medical records of all patients who underwent left ventricular assist device (LVAD) or total artificial heart (TAH) insertion between June 1994 and April 2022 as a bridge to transplant, but subsequently died pre-heart transplantation were reviewed. RESULTS A total of 203 patients had a LVAD or TAH implanted during the study period. Seventy-eight patients (M=59, F=19) died prior to transplantation (age 55 [14] years, INTERMACS=2). Autopsies were conducted in 26 of 78 patients (33%). Three were limited studies. The leading contributor to cause of death was respiratory (14/26), either nosocomial infection or associated with multiorgan failure. Intracranial hemorrhage was the second most common cause of death (8/26). There was a major discrepancy rate of 17% and a minor discrepancy rate of 43%. Autopsy study added a total of 14 additional contributors of death beyond clinical assessment alone (Graphical Abstract). CONCLUSIONS Over an observational period of 26years, the frequency of autopsy was low. To improve LVAD/TAH patient survival to transplant, better understanding as to cause of death is required. Patients with MCS have complex physiology and are at high risk of infection and bleeding complications.
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Affiliation(s)
- Nicole K Bart
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia; Notre Dame University, Sydney, New South Wales, Australia.
| | - Desire Robson
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Kavitha Muthiah
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Paul C Jansz
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher S Hayward
- St Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
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Tambuzzi S, Maciocco F, Gentile G, Boracchi M, Bailo P, Marchesi M, Zoja R. Applications of microbiology to different forensic scenarios - A narrative review. J Forensic Leg Med 2023; 98:102560. [PMID: 37451142 DOI: 10.1016/j.jflm.2023.102560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
In contrast to other forensic disciplines, forensic microbiology is still too often considered a "side activity" and is not able to make a real and concrete contribution to forensic investigations. Indeed, the various application aspects of this discipline still remain a niche activity and, as a result, microbiological investigations are often omitted or only approximated, in part due to poor report in the literature. However, in certain situations, forensic microbiology can prove to be extremely effective, if not crucial, when all other disciplines fail. Precisely because microorganisms can represent forensic evidence, in this narrative review all the major pathological forensic applications described in the literature have been presented. The goal of our review is to highlight the versatility and transversality of microbiology in forensic science and to provide a comprehensive source of literature to refer to when needed.
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Affiliation(s)
- Stefano Tambuzzi
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Via Luigi Mangiagalli, 37, 20133, Milano, Italy
| | - Francesca Maciocco
- Azienda Ospedaliera "San Carlo Borromeo", Servizio di Immunoematologia e Medicina Trasfusionale (SIMT), Via Pio II°, n. 3, Milano, Italy
| | - Guendalina Gentile
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Via Luigi Mangiagalli, 37, 20133, Milano, Italy.
| | - Michele Boracchi
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Via Luigi Mangiagalli, 37, 20133, Milano, Italy
| | | | - Matteo Marchesi
- ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Riccardo Zoja
- Dipartimento di Scienze Biomediche per la Salute, Sezione di Medicina Legale e delle Assicurazioni, Università degli Studi di Milano, Via Luigi Mangiagalli, 37, 20133, Milano, Italy
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Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13010141. [PMID: 36611433 PMCID: PMC9818351 DOI: 10.3390/diagnostics13010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/29/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.
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Giugni FR, Salvadori FA, Smeili LAA, Marcílio I, Perondi B, Mauad T, de Paiva EF, Duarte-Neto AN. Discrepancies Between Clinical and Autopsy Diagnoses in Rapid Response Team-Assisted Patients: What Are We Missing? J Patient Saf 2022; 18:653-658. [PMID: 35067620 DOI: 10.1097/pts.0000000000000962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The rapid response team (RRT) assists hospitalized patients with sudden clinical deterioration. There is scarce evidence of diagnostic accuracy in this scenario, but it is possible that a considerable rate of misdiagnosis exists. Autopsy remains a valuable tool for assessing such question. This study aimed to compare clinical (premortem) and autopsy (postmortem) diagnoses in patients assisted by the RRT and describe major discrepancies. METHODS We reviewed 104 clinical data and autopsies from patients assisted by the RRT during a cardiac arrest event in a tertiary care hospital in Brazil. Clinical and autopsy diagnostic discrepancies were classified using the Goldman criteria. Other clinical and pathological data were described, and the group with major diagnostic discrepancies was further analyzed. RESULTS We found 39 (37.5%) patients with major diagnostic discrepancies. Most frequent immediate causes of death in this group determined by autopsy were sepsis (36%), pulmonary embolism (23%) and hemorrhagic shock (21%). Pulmonary embolism was the cause of death significantly more frequent in the major discrepancy group than in the minor discrepancy group (23% versus 3%, P = 0.002). We individually described all major diagnostic discrepancies. CONCLUSIONS We found a high rate (37.5%) of major misdiagnosis in autopsies from patients assisted by the RRT in a tertiary teaching hospital. Pulmonary embolism was the most inaccurate fatal diagnosis detected by autopsy.
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Affiliation(s)
| | - Fernanda Aburesi Salvadori
- Time de Resposta Rápida, Diretoria Clínica, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - Luciana Andrea Avena Smeili
- Time de Resposta Rápida, Diretoria Clínica, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - Izabel Marcílio
- Núcleo de Vigilância Epidemiológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - Beatriz Perondi
- Time de Resposta Rápida, Diretoria Clínica, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - Thais Mauad
- Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo
| | - Edison Ferreira de Paiva
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Sharp AL, Baecker A, Nassery N, Park S, Hassoon A, Lee MS, Peterson S, Pitts S, Wang Z, Zhu Y, Newman-Toker DE. Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method. Diagnosis (Berl) 2021; 8:177-186. [PMID: 32701479 DOI: 10.1515/dx-2020-0049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 12/02/2023]
Abstract
OBJECTIVES Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method. METHODS Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events). RESULTS A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%). CONCLUSIONS The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health System Science, Kaiser Permanente School of Medicine, Pasadena, CA, United States
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Najlla Nassery
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ming-Sum Lee
- Kaiser Permanente Southern California, Los Angeles Medical Center, Division of Cardiology, Los Angeles, CA, United States
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samantha Pitts
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Yuxin Zhu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Karande S, Sanju S, Vaideeswar P. Infective Endocarditis: Clinical and Autopsy Diagnosis. Indian J Pediatr 2020; 87:1073-1074. [PMID: 32542484 DOI: 10.1007/s12098-020-03275-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/13/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Sunil Karande
- Department of Pediatrics, Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, 400012, India.
| | - Sidaraddi Sanju
- Department of Pediatrics, Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, 400012, India
| | - Pradeep Vaideeswar
- Department of Pathology (Cardiovascular & Thoracic Division), Seth G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, India
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Blease CR, Bell SK. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety. Diagnosis (Berl) 2019; 6:213-221. [DOI: 10.1515/dx-2018-0106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/08/2019] [Indexed: 12/21/2022]
Abstract
Abstract
Error resulting from missed, delayed, or wrong diagnoses is estimated to occur in 10–15% of ambulatory and inpatient encounters, leading to serious harm in around half of such cases. When it comes to conceptualizing diagnostic error, most research has focused on factors pertaining to: (a) physician cognition and (b) ergonomic or systems factors related to the physician’s working environment. A third factor – the role of patients in diagnostic processes – remains relatively under-investigated. Yet, as a growing number of researchers acknowledge, patients hold unique knowledge about themselves and their healthcare experience, and may be the most underutilized resource for mitigating diagnostic error. This opinion article examines recent findings from patient surveys about sharing visit notes with patients online. Drawing on these survey results, we suggest three ways in which sharing visit notes with patients might enhance diagnostic processes: (1) avoid delays and missed diagnoses by enhancing timely follow up of recommended tests, results, and referrals; (2) identify documentation errors that may undermine diagnostic accuracy; and (3) strengthen patient-clinician relationships thereby creating stronger bidirectional diagnostic partnerships. We also consider the potential pitfalls or unintended consequences of note transparency, and highlight areas in need of further research.
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Abstract
OBJECTIVES To determine characteristic features of myocardial infarction (MI) diagnosed at autopsy and establish the incidence of discrepancy. METHODS Autopsy cases at a tertiary hospital with a pathologic diagnosis of acute MI were evaluated for clinicopathologic features. Modified Goldman's classification was used to classify discrepant cases. RESULTS Of 529 autopsy cases, 19 (3.6%) demonstrated acute/subacute MI as a pathologic diagnosis. Thrombosis was identified in a minority of cases (3/19, 15.8%). Major clinicopathologic discrepancies were identified in four (21.1%) cases. CONCLUSIONS Although acute MI is an uncommon diagnosis rendered at hospital autopsy, a notable subset of cases demonstrates diagnostic discrepancy between the clinical impression and ultimate pathologic diagnosis. Interestingly, most MI cases in this series are not related to plaque disruption and thus best classified as a type 2 MI, which is associated with imbalance between oxygen demand and supply.
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Affiliation(s)
- Sakda Sathirareuangchai
- Department of Pathology, John A. Burns School of Medicine, University of Hawaii, Honolulu
- Department of Forensic Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - David Shimizu
- Department of Pathology, John A. Burns School of Medicine, University of Hawaii, Honolulu
- Department of Pathology, Queen’s Medical Center, Honolulu, HI
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Factors Influencing Acceptance of Post-Mortem Examination of Children at a Tertiary Care Hospital in Nairobi, Kenya. Ann Glob Health 2019; 85. [PMID: 31276331 PMCID: PMC6634467 DOI: 10.5334/aogh.2504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Clinical autopsies are not often part of routine care, despite their role in clarifying cause of death. In fact, autopsy rates across the world have declined and are especially low in sub-Saharan Africa. OBJECTIVES We set out to identify factors associated with acceptance of pediatric autopsies among parents of deceased children less than five years old, and examined local preferences for minimally invasive tissue sampling (MITS) procedures during post-mortem (PM) examinations. METHODS From December 2016 to September 2017, we contacted 113 parents/next of kin who had been previously approached to consent to a PM examination of their deceased child as part of a Kenyan study on cause of death. Interviews occurred up to three years after the death of their child. FINDINGS Seventy-three percent (83/113) of eligible study participants were enrolled, of whom 62/83 (75%) had previously consented to PM examination of their child. Those who previously consented to PM had higher levels of education, were more likely employed, and had more knowledge about certain aspects of autopsies than non-consenters. The majority (97%) of PM consenters did so because they wanted to know the cause of death of their child, and up to a third believed autopsy studies helped advance medical knowledge. Reasons for non-consent to PM examination included: parents felt there was no need for further examination (29%) or they were satisfied with the clinical diagnosis (24%). Overall, only 40% of study participants would have preferred MITS procedures to conventional autopsy. However, 81% of autopsy non-consenters would have accepted PM examination if it only involved MITS techniques. CONCLUSION There is potential to increase autopsy rates by strengthening reasons for acceptance and addressing modifiable reasons for refusals. Although MITS procedures have the potential to improve autopsy acceptance rates, they were not significantly preferred over conventional autopsies in our study population.
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Gao P, Li X, Zhao Z, Zhang N, Ma K, Li L. Diagnostic errors in fatal medical malpractice cases in Shanghai, China: 1990-2015. Diagn Pathol 2019; 14:8. [PMID: 30704492 PMCID: PMC6357365 DOI: 10.1186/s13000-019-0785-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background Medical disputes remain unabated in China. Previous studies have shown the changes of diagnostic discrepancy over time in developed countries, but diagnostic discrepancy remains understudied in China, especially in the setting of medical disputes. We sought to describe the year-based changes of diagnostic discrepancies in medical disputes, and to identify factors associated with classes of diagnostic discrepancy. Methods We conducted a retrospective cohort study of all medically disputed cases from 1990 through 2015 in Shanghai, China, with use of necropsy as the gold standard for diagnosis. Cases were grouped based on national legislative eras. Diagnostic discrepancy was classified as major errors (class I and II), minor errors (class III and IV), no discrepancy (class V) and undetermined (class VI) based on discrepancy severity. Results There were 482 medical disputes. Cases were predominantly males (male: female = 1.6:1) and concentrated in patients less than 10 years old or between 50 and 70 years. Major and minor discrepancy accounted for 51.7 and 34.8%, respectively. Fifty-five cases (11.2%) were non-discrepant (Class V). The dispute rate remained high before the first round of legislation (mean 0.31 per 1 million patients) but declined dramatically afterwards (R2 = − 0.82, p < 0.001 for time trends). Over the national legislative eras, the annual number of cases with diagnostic errors declined steadily. Incidence rates of discrepancy decreased significantly for class I (R2 = − 0.73, p = 0.024), II (R2 = − 0.48, p = 0.013), III (R2 = − 0.69, p < 0.0001), IV (R2 = − 0.69, p < 0.0001) and V discrepancy (R2 = − 0.58, p = 0.0018). Diseases from the respiratory system had significantly lower risks of any diagnostic errors (OR = 0.48, 95% 0.24–0.95, p = 0.036). A neoplasm carrier increased by 92% the risk of any diagnostic error (OR = 1.92; 95%CI 1.18–3.14; p = 0.009) and hypertension reduced by 78% the risk of minor errors (OR = 0.22, 95%CI 0.06–0.91, p = 0.036). Severity of discrepancy relieved over years and associated with ageing in patients with cardiovascular diseases (p = 0.01). Conclusions The rate of fatal medical disputes and diagnostic discrepancy declined after stepwise legislations in China. Respiratory diseases, neoplasm carrier and hypertension could be independent predictors for assessing diagnostic errors.
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Affiliation(s)
- Pan Gao
- Department of Pathology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People's Republic of China.,Shanghai Diabetes Institute, Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200032, People's Republic of China
| | - Xiaoqiang Li
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, People's Republic of China
| | - Ziqin Zhao
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, 138 Yixueyuan Road, Xuhui District, Shanghai, 200032, People's Republic of China
| | - Nong Zhang
- Department of Pathology, School of Basic Medical Sciences, Fudan University, Shanghai, 200032, People's Republic of China
| | - Kaijun Ma
- Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Public Security Bureau, 803 North Zhongshan Road, Hongkou District, Shanghai, 200083, People's Republic of China.
| | - Liliang Li
- Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, 138 Yixueyuan Road, Xuhui District, Shanghai, 200032, People's Republic of China. .,Shanghai Key Laboratory of Crime Scene Evidence, Shanghai Public Security Bureau, 803 North Zhongshan Road, Hongkou District, Shanghai, 200083, People's Republic of China.
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Nunes RAB, Ramirez HSM, Aiello VD. Case 6 - Woman with Ischemic Heart Disease Admitted due to Chest Pain and Shock. Arq Bras Cardiol 2018; 111:860-863. [PMID: 30517382 PMCID: PMC6263468 DOI: 10.5935/abc.20180231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rafael Amorim Belo Nunes
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HC-FMUSP), São Paulo, SP - Brazil
| | - Hilda Sara Montero Ramirez
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HC-FMUSP), São Paulo, SP - Brazil
| | - Vera Demarchi Aiello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HC-FMUSP), São Paulo, SP - Brazil
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de Macedo IS, Dinardi LFL, Pereira TV, de Almeida LKR, Barbosa TS, Benvenuti LA, Ayub-Ferreira SM, Bocchi EA, Issa VS. Thromboembolic findings in patients with heart failure at autopsy. Cardiovasc Pathol 2018; 35:23-28. [DOI: 10.1016/j.carpath.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/09/2018] [Indexed: 01/25/2023] Open
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Coffey S, Harper AR, Cairns BJ, Roberts IS, Prendergast BD. Clinical information has low sensitivity for postmortem diagnosis of heart valve disease. Heart 2017; 103:1031-1035. [PMID: 28183793 DOI: 10.1136/heartjnl-2016-310718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/26/2016] [Accepted: 12/27/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Accuracy of routinely collected information concerning cause of death is essential for public health and health systems planning. Since clinical examination has relatively low sensitivity for detection of valvular heart disease (VHD), mortality data based on clinical information alone might routinely underestimate the number of deaths due to VHD. METHODS We compared autopsy findings against premortem clinical information for 8198 consecutive adult postmortems (mean age 69.1 years, 61.3% men), performed in a single UK tertiary referral centre with on-site cardiac surgical facilities over a 10-year period (2004-2013) during which 21% of the adult population underwent postmortem examination. RESULTS Following postmortem, VHD was the principal cause of death in 165 individuals (2.0%), a principal or contributory cause ('any cause') of death in 326 (4.0%) and an incidental (ie, non-causal) finding in a further 346 (4.2%). Clinical documentation of VHD before death was highly specific but relatively insensitive for postmortem identification of VHD as the principal (specificity 96.8%; 95% CI 96.4% to 97.2%; sensitivity 69.7%, 95% CI 62.1% to 76.6%) or any (specificity 98.1%; 95% CI 97.8% to 98.4%; sensitivity 68.4%, 95% CI 63.1% to 73.4%) cause of death. VHD (principally aortic stenosis, endocarditis and rheumatic heart disease) was newly noted at postmortem and listed as a cause of death in 142 individuals (1.7%). CONCLUSIONS Clinical information recorded premortem is highly specific but relatively insensitive for the cause of death established at autopsy. Population-based mortality statistics that depend on premortem clinical information are likely to routinely underestimate the mortality burden of VHD.
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Affiliation(s)
- Sean Coffey
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, UK
- Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St Leonards, Australia
| | - Andrew R Harper
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Benjamin J Cairns
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
- British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Ian Sd Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS Trust, Oxford, UK
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15
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Schertenleib TI, Pospischil A, Hässig M, Kircher PR, Hilbe M. Comparison of Clinical and Pathological Diagnoses in Cats and Dogs. J Comp Pathol 2017; 156:217-234. [PMID: 28233522 DOI: 10.1016/j.jcpa.2017.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 12/19/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
The comparison of clinical ante-mortem and pathological post-mortem diagnoses is a prerequisite for quality control, but is rarely done in veterinary medicine. This study reports the occurrence and concurrence of clinical and pathological diagnoses linked to death in 1,000 cats and 1,000 dogs examined and subjected to necropsy examination at the University of Zurich, Switzerland. Potential factors influencing the correlation between diagnoses were examined retrospectively. In 5.8% of cats and 5.2% of dogs no diagnosis was made; in 2.6% and 3.8% of cases only a clinical, and in 17.8% and 11.2%, respectively, only a pathological diagnosis was available. Of the 73.8% of cats and 79.8% of dogs with both diagnoses present, 38.3% and 36.2% were in agreement, while there was disagreement in 17.9% and 16.0%, respectively. The remaining cases (43.8% and 47.8%) had different levels of further diagnostic procedures following necropsy examination. In both species, the manner of death, the clinical discipline submitting the animal for necropsy examination and the quality of the necropsy submission request, as well as the timespan between death and necropsy examination in dogs, proved to influence the concurrence between diagnoses. In contrast, the organ system affected and the type of disease entity were, for both species, the most influential factors in the concurrence of diagnoses. Therefore, in veterinary medicine, even in times of improving diagnostic abilities, necropsy examination still reveals important information for quality control and education.
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Affiliation(s)
- T I Schertenleib
- Institute of Veterinary Pathology, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, Zürich, Switzerland
| | - A Pospischil
- Institute of Veterinary Pathology, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, Zürich, Switzerland
| | - M Hässig
- Department of Farm Animals, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, Zürich, Switzerland
| | - P R Kircher
- Department of Small Animals, Division of Diagnostic Imaging, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, Zürich, Switzerland
| | - M Hilbe
- Institute of Veterinary Pathology, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, Zürich, Switzerland.
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Issa VS, Dinardi LFL, Pereira TV, de Almeida LKR, Barbosa TS, Benvenutti LA, Ayub-Ferreira SM, Bocchi EA. Diagnostic discrepancies in clinical practice: An autopsy study in patients with heart failure. Medicine (Baltimore) 2017; 96:e5978. [PMID: 28121951 PMCID: PMC5287975 DOI: 10.1097/md.0000000000005978] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Autopsies are the gold standard for diagnostic accuracy; however, no recent study has analyzed autopsies in heart failure (HF).We reviewed 1241 autopsies (January 2000-May 2005) and selected 232 patients with HF. Clinical and autopsy diagnoses were analyzed and discrepancies categorized according to their importance regarding therapy and prognosis.Mean age was 63.3 ± 15.9 years; 154 (66.4%) patients were male. The causes of death at autopsy were end-stage HF (40.9%), acute myocardial infarction (17.2%), infection (15.9), and pulmonary embolism 36 (15.5). Diagnostic discrepancies occurred in 191 (82.3%) cases; in 56 (24.1%), discrepancies were related to major diagnoses with potential influence on survival or treatment; pulmonary embolism was the cause of death for 24 (42.9%) of these patients. In 35 (15.1%), discrepancies were related to a major diagnosis with equivocal influence on survival or treatment; in 100 (43.1%), discrepancies did not influence survival or treatment. In multivariate analysis, age (OR: 1.03, 95% CI: 1.008-1.052, P = 0.007) and presence of diabetes mellitus (OR: 0.359, 95% CI: 0.168-0.767, P = 0.008) influenced the occurrence discrepancies.Diagnostic discrepancies with a potential impact on prognosis are frequent in HF. These findings warrant reconsideration in diagnostic and therapeutic practices with HF patients.
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Aiello VD. The autopsy as the cornerstone for education and research in cardiology. AUTOPSY AND CASE REPORTS 2016; 6:1-3. [PMID: 28210566 PMCID: PMC5304554 DOI: 10.4322/acr.2016.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Vera Demarchi Aiello
- Laboratory of Pathology - Heart Institute - School of Medicine - Universidade de São Paulo, São Paulo/SP - Brazil
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18
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Chao CT, Tsai HB, Chiang CK, Huang JW, Hung KY. Acute kidney injury as a risk factor for diagnostic discrepancy among geriatric patients: a pilot study. Sci Rep 2016; 6:38549. [PMID: 27982065 PMCID: PMC5159791 DOI: 10.1038/srep38549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/09/2016] [Indexed: 01/22/2023] Open
Abstract
Diagnostic discrepancy, defined as different admission and discharge diagnoses, could be a potential source of diagnostic error. We evaluated whether acute kidney injury (AKI) in the elderly affected their risk for diagnostic discrepancy. Patients aged ≥60 years from the general medical wards were prospectively enrolled and divided according to AKI status upon admission, using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. We compared their discharge and admission diagnoses and identified patients with a diagnostic discrepancy, using multiple logistic regression analysis to evaluate the relationship between initial AKI and the presence of a diagnostic discrepancy. A total of 188 participants (mean age, 77.9 years) were recruited. Regression analysis showed that initial AKI on admission was associated with a higher risk of diagnostic discrepancy upon discharge (odds ratio [OR] 3.3; p < 0.01). In contrast, higher AKI severity was also associated with an increased risk of diagnostic discrepancy (for KDIGO grade 1, 2, and 3; OR 2.92, 3.91, and 4.32; p = 0.04, 0.03, and 0.02, respectively), suggesting that initial AKI upon admission could be an important risk factor for diagnostic discrepancy. Consequently, reducing geriatric AKI might have the potential to reduce diagnostic discrepancy among these patients.
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Affiliation(s)
- Chia-Ter Chao
- Department of Medicine, National Taiwan University Hospital Jinshan branch, New Taipei City, Taiwan.,Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan.,Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Bin Tsai
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Kang Chiang
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Integrative Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan-Yu Hung
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu branch, Hsin-Chu County, Taiwan
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Mazeikiene S, Laima S, Chmieliauskas S, Fomin D, Andriuskeviciute G, Markeviciute M, Matuseviciute A, Jasulaitis A, Stasiuniene J. Deontological examination: Clinical and forensic medical diagnoses discrepancies. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2016. [DOI: 10.1016/j.ejfs.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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20
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Nichols L. Patient cueing, a type of diagnostic error. AUTOPSY AND CASE REPORTS 2016; 6:27-31. [PMID: 27284538 PMCID: PMC4880431 DOI: 10.4322/acr.2016.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 02/22/2016] [Indexed: 11/23/2022] Open
Abstract
Diagnostic failure can be due to a variety of psychological errors on the part of the diagnostician. An erroneous diagnosis rendered by previous clinicians can lead a diagnostician to the wrong diagnosis. This report is the case of a patient who misdiagnosed herself and then led an emergency room physician and subsequent treating physicians to the wrong diagnosis. This mechanism of diagnostic error can be called patient cueing.
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Affiliation(s)
- Larry Nichols
- Department of Pathology - Mercer University School of Medicine, Macon/GA - USA
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21
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Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med 2016; 9:137-46. [PMID: 27284262 PMCID: PMC4881921 DOI: 10.2147/ijgm.s96741] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Misdiagnosis, either over- or underdiagnosis, exposes older patients to increased risk of inappropriate or omitted investigations and treatments, psychological distress, and financial burden. Objective To evaluate the frequency and nature of diagnostic errors in 16 conditions prevalent in older patients by undertaking a systematic literature review. Data sources and study selection Cohort studies, cross-sectional studies, or systematic reviews of such studies published in Medline between September 1993 and May 2014 were searched using key search terms of “diagnostic error”, “misdiagnosis”, “accuracy”, “validity”, or “diagnosis” and terms relating to each disease. Data synthesis A total of 938 articles were retrieved. Diagnostic error rates of >10% for both over- and underdiagnosis were seen in chronic obstructive pulmonary disease, dementia, Parkinson’s disease, heart failure, stroke/transient ischemic attack, and acute myocardial infarction. Diabetes was overdiagnosed in <5% of cases. Conclusion Over- and underdiagnosis are common in older patients. Explanations for over-diagnosis include subjective diagnostic criteria and the use of criteria not validated in older patients. Underdiagnosis was associated with long preclinical phases of disease or lack of sensitive diagnostic criteria. Factors that predispose to misdiagnosis in older patients must be emphasized in education and clinical guidelines.
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Affiliation(s)
- Thomas R Skinner
- Department of Internal Medicine, Sunshine Coast Health Service District, Nambour Hospital, Nambour, QLD, Australia
| | - Ian A Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jennifer H Martin
- Southern School of Medicine, University of Queensland, Brisbane, QLD, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Affiliation(s)
| | - Luiz Otávio Savassi Rocha
- Internal Medicine Department - Faculty of Medicine - Federal University of Minas Gerais - Belo Horizonte/MG - Brazil
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23
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Berlot G, Calderan C, Fiorenza C, Cappelli D, Addesa S, Bussani R. Infective and non-infective endocarditis in critically ill patients: a clinical-pathological study. Intern Emerg Med 2014; 9:773-8. [PMID: 24519321 DOI: 10.1007/s11739-014-1054-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/23/2014] [Indexed: 11/24/2022]
Abstract
The aims of this study are to estimate the incidence, the outcome and the associated risk factors of infective and non-infective endocarditis (IE and NIE, respectively) in intensive care unit (ICU) patients. We studied the post-mortem findings and the clinical data of the patients who died in our ICU between 1996 and 2010. Of the 765 reviewed autopsies, 21 patients (2.7%) presented cardiac vegetations. These cases consisted of 12 IEs and 9 NIEs. Three patients with IE had a mechanical prosthetic valve, and in 11 cases invasive devices had been used. Multiple peripheral embolisms were discovered at autopsy. In particular, the brain appeared to be more affected in patients with IE, while pulmonary embolisms were commonly associated with NIE. Blood cultures were positive in nine patients with IE. The imaging diagnostics (transthoracic and transesophageal echocardiography) which were seldom performed in both groups, proved to be of little help. As a consequence, an IE was correctly diagnosed before death in three patients (25%) and suspected in two other cases (17%), while a NIE was diagnosed before death in one patient alone. In conclusions, critically ill patients admitted to general ICUs, multiple factors related both to the underlying conditions and to performed procedures can facilitate the occurrence of IE and NIE making, at the same time, their diagnosis challenging. Many cases, in fact, are diagnosed only at autopsy. Yet again, post-mortem examination proves to be an invaluable tool for the evaluation of diagnostic accuracy in critical care.
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Affiliation(s)
- Giorgio Berlot
- Department of Anaesthesia and Intensive Care, Cattinara Hospital, Strada di Fiume 447, 34149, Trieste, Italy,
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24
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Madaloso BA, Gutierrez PS. Case 3/2014--81-year-old patient hospitalized for decompensated heart failure. Arq Bras Cardiol 2014; 103:e1-e10. [PMID: 25120087 PMCID: PMC4126765 DOI: 10.5935/abc.20140102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Bruna Affonso Madaloso
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Sampaio Gutierrez
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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25
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Lack of progress in valvular heart disease in the pre-transcatheter aortic valve replacement era: increasing deaths and minimal change in mortality rate over the past three decades. Am Heart J 2014; 167:562-567.e2. [PMID: 24655706 DOI: 10.1016/j.ahj.2013.12.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 12/25/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Valvular heart disease (VHD) is an increasingly common problem in clinical practice. With the development of new but expensive therapeutic options, health care systems require timely epidemiological information on VHD. We sought to determine the mortality burden of VHD and how it has changed over time. METHODS Population level data from the United States (US) from 1979 to 2009 were used to examine trends in VHD mortality rates over time. Our outcome measure was death, where the primary cause of death was valvular heart disease. RESULTS The annual number of VHD deaths increased from 15,054 in 1979 to 26,663 in 2009, an increase of on average 2.8% in the US each year (R(2) = 0.97, P < .001). The total VHD mortality rate increased with older age and male sex. There was little overall change in age- and sex-adjusted total VHD mortality rate over time (mortality rate ratio per year 0.999, 95% confidence interval 0.999 to 0.999, P < .001). Non-rheumatic aortic valve disease accounted for 45.2% of all VHD deaths. Adjusted mortality rates for aortic valve disease, mitral valve disease and endocarditis increased (P < .001), while that for rheumatic heart disease decreased (P < .001). If VHD mortality rates remain stable, deaths due to VHD are projected to double over the next 25 years. CONCLUSIONS Despite improvements in mortality rates for other major conditions and in surgical outcomes for VHD, adjusted VHD mortality rates showed minimal change over the 31 years examined. The ageing population is driving a marked increase in the number of deaths due to VHD.
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26
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Politi TR, Gutierrez PS. Case 5: a 73 year-old man with heart failure, preserved systolic function and associated renal failure. Arq Bras Cardiol 2013; 101:e86-94. [PMID: 24343555 PMCID: PMC4081174 DOI: 10.5935/abc.20130220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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27
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Letter by Coffey et al Regarding Article, “Estimating Deaths From Cardiovascular Disease: A Review of Global Methodologies of Mortality Measurement”. Circulation 2013; 128:e84. [DOI: 10.1161/circulationaha.113.002123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Clinical and needle autopsy correlation evaluation in a tertiary care teaching hospital: a prospective study of 50 cases from the emergency department. Am J Forensic Med Pathol 2013; 33:194-6. [PMID: 22543521 DOI: 10.1097/paf.0b013e31823d295e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With gradual fall in autopsy all over the world in recent years, the present study aimed to assess the accuracy of clinical diagnosis and efficacy of needle autopsy from the emergency department. Fifty deceased patients, who died in the emergency department during a period of 1 year, were subjected to needle autopsy of the major viscera, using spring-loaded automated biopsy gun, and the findings were correlated with clinical diagnosis. The deceased patients were in the age range of 12 to 80 years (mean [SD], 50.48 [18.41] years). The tissues yielded from various organs were as follows: lungs, 90%; liver, 82%; kidney, 48%; heart, 28%; spleen, 22%; and pancreas, 18%. Before death, 86 clinical diagnoses were recorded, of which 21 (24%) (eg, metabolic encephalopathy, cardiac arrhythmia, diabetic ketoacidosis) were impossible to verify on needle autopsy. A total of 48 new diagnoses, missed by physicians, were revealed by needle autopsy. The most frequently missed diagnoses were liver fatty change (19 patients) and pneumonitis (11 patients). Other frequently missed diagnoses were chronic hepatitis (3 patients) and cancer (2 patients: 1 lung squamous cell carcinoma and 1 lung adenocarcinoma). Major diagnostic errors (Goldman classes I and II) were noted in 16 (32%) of 50 cases. Needle autopsy can be a better alternative in the absence of conventional autopsy.
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29
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Endocardites: nouveautés, pièges et controverses. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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30
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Fernández Guerrero ML, Álvarez B, Manzarbeitia F, Renedo G. Infective endocarditis at autopsy: a review of pathologic manifestations and clinical correlates. Medicine (Baltimore) 2012; 91:152-164. [PMID: 22543628 DOI: 10.1097/md.0b013e31825631ea] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The frequency of autopsies appears to be declining, and the usefulness has been challenged. We reviewed cases of autopsied active infective endocarditis (IE) during 2 periods based on the availability of high-tech 2-dimensional echocardiograms: Period 1 (P1) included 40 cases studied from 1970 to 1985, and Period 2 (P2) included 28 cases seen from 1986 to 2008--that is, before and after the introduction of echocardiograms in our institution. We conducted the study to reassess the pathology of IE and to determine how frequently diagnosis is not made during life.The age of patients increased 10 years on average between the 2 periods, and comorbidities were significantly more frequent in P2. While the frequency of rheumatic valve disease and prosthetic valve endocarditis (PVE) decreased, degenerative valve disease increased. Isolated mitral or aortic valve IE was most common. Right-sided IE was observed in patients with Staphylococcus aureus bacteremia from infected venous lines. In most cases IE involved only the cusps of cardiac valves. "Virulent" microorganisms caused ulcerations, rupture, and perforation of the cusps and necrosis of chordae tendiniae and perivalvular apparatus. In PVE the lesions were located behind the site of attachment, and vegetations were seen on the sewing ring in both metallic and biologic prostheses. Infection spread to adjacent structures and myocardium with ring abscess observed in 88% of cases. Prosthetic detachment causing valve regurgitation was associated with abscesses in 76% of cases; these patients developed persistent sepsis and severe cardiac failure. Obstruction occurred in patients with PVE of the mitral valve. Acute purulent pericarditis was observed in 22% of cases, mainly in patients with aortic valve IE and myocardial abscesses.Gross infarcts were seen in 63% of cases but were asymptomatic in most instances. The spleen, kidneys, and mesentery were the sites most frequently involved. Myocardial infarctions were found in less than 10% of cases. Abscesses were also frequently found and were a common source of persistent fever and bacteremia. Glomerulonephritis was more common in the first period. Brain pathology consisted of ischemic and hemorrhagic infarcts and abscesses. Cerebral bleeding was more frequent in patients with PVE on anticoagulant therapy. Neutrophilic meningitis was observed in S. aureus IE.Diagnosis of IE was not made during life in 14 (35%) cases during P1 and 12 (42.8%) cases in P2. Overall, diagnosis was missed until autopsy in 38.2% of cases. IE was hospital acquired in 28 instances. While a clinical diagnosis was made in all but 4 cases of early-onset PVE (23.5%), the diagnosis was not made during life in 22 of 51 patients with native-valve IE (43.1%). Of these 22 patients, IE was hospital acquired in 11 (50%). The absence of fever, cardiac murmurs, and many of the typical stigmata of endocarditis may have led to the diagnosis being overlooked clinically.Brain bleeding, cardiac failure and less frequently acute myocardial infarct were the most common causes of death.IE continues to be missed frequently until autopsy. Postmortem examination is an important tool for evaluating the quality of care, and for guiding teaching and research related to cardiovascular infections.
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Affiliation(s)
- Manuel L Fernández Guerrero
- From the Division of Infectious Diseases (Department of Medicine) and Surgical Pathology, Instituto de Investigaciones Sanitarias Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
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Soeiro ADM, Ruppert AD, Canzian M, Capelozzi VL, Serrano CV. Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure: demographics, etiologic and pulmonary histologic analysis. Clinics (Sao Paulo) 2012; 67:213-7. [PMID: 22473400 PMCID: PMC3297028 DOI: 10.6061/clinics/2012(03)02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 10/25/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life. METHODS This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression. RESULTS In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema. CONCLUSIONS For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported.
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Diagnostic validity of fatal cerebral strokes and coronary deaths in mortality statistics: an autopsy study. Eur J Epidemiol 2010; 26:221-8. [PMID: 21170572 PMCID: PMC3079075 DOI: 10.1007/s10654-010-9535-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 12/03/2010] [Indexed: 10/24/2022]
Abstract
Mortality statistics represent important endpoints in epidemiological studies. The diagnostic validity of cerebral stroke and ischemic heart disease recorded as the underlying cause of death in Norwegian mortality statistics was assessed by using mortality data of participants in the Bergen Clinical Blood Pressure Study in Norway and autopsy records from the Gade Institute in Bergen. In the 41 years of the study (1965-2005) 4,387 subjects had died and 1,140 (26%) had undergone a post mortem examination; 548 (12%) died from cerebral stroke and 1,120 (24%) from ischemic heart disease according to the mortality statistics, compared to 113 (10%) strokes and 323 (28%) coronary events registered in the autopsy records. The sensitivity and positive predictive value of fatal cerebral strokes in the mortality statistics were 0.75, 95% confidence interval (CI) [0.66, 0.83] and 0.86 [0.77, 0.92], respectively, whereas those of coronary deaths were 0.87 [0.84, 0.91] and 0.85 [0.81, 0.89] respectively. Cohen's Kappa coefficients were 0.78 [0.72, 0.84] for stroke and 0.80 [0.76, 0.84] for coronary deaths. In addition to female gender and increasing age at death, cerebral stroke was a negative predictor of an autopsy being carried out (odds ratio (OR) 0.69, 95% CI [0.54, 0.87]), whereas death from coronary heart disease was not (OR 1.14, 95% CI [0.97, 1,33]), both adjusted for gender and age at death. There was substantial agreement between mortality statistics and autopsy findings for both fatal strokes and coronary deaths. Selection for post mortem examinations was associated with age, gender and cause of death.
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Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates. Mod Pathol 2010; 23:1225-30. [PMID: 20526285 DOI: 10.1038/modpathol.2010.107] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Autopsy rates have been affected by a number of factors, including technological advances and clinician beliefs of the diminished value of the autopsy. Such factors have resulted in a cultural shift in medicine away from the autopsy. Despite this shift, a number of studies have shown significant differences between antemortem clinical diagnoses and postmortem findings. Surveys of clinician beliefs about the autopsy have pointed toward antemortem diagnostic advancements as an important factor in declining rates. No study to date has addressed the hypothesis that such perceptions in diagnostic certainty have been matched by an actual decay in the yield of valuable or new information obtained by the autopsy. To address this hypothesis, we retrospectively compared the class I and class II discrepancies identified in 284 patients who died in three clinical settings with differing intensities of antemortem diagnostic workup. Despite a significantly different intensity of antemortem workup for patients in each clinical setting, including patients on a medical intensive care unit, patients on a surgical service and patients in an affiliated nursing home, discrepancy rates were found to be similar. Overall discrepancy rates for the medical intensive care unit, surgery service and nursing home patients were 27.8, 32.7 and 31.3%, respectively (P=0.84). In addition, we found no statistical difference in the complexity of workup in discrepant and nondiscrepant cases in each clinical setting. Our study data refute the hypothesis that the intensity of antemortem diagnostic evaluation correlates with an actual decrease in the rate of major diagnostic discrepancies identified at autopsy.
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Westover AN, Nakonezny PA. Aortic dissection in young adults who abuse amphetamines. Am Heart J 2010; 160:315-21. [PMID: 20691838 PMCID: PMC2924822 DOI: 10.1016/j.ahj.2010.05.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 05/12/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND Case reports suggest a relationship between amphetamine abuse/dependence and aortic dissection, but no population-based epidemiologic studies have examined this link. Our objective was to test the hypothesis that young adults with a diagnosis of amphetamine abuse/dependence would be at higher risk for aortic dissection after accounting for known risk factors. METHODS In this population-based case-control study of 30,922,098 discharges from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1995 to 2007, among persons aged 18 to 49 years, we identified 3,116 thoracic and thoracoabdominal aortic dissections using International Classification of Disease, Ninth Edition, Clinical Modification codes 441.01 and 441.03. The SURVEYLOGISTIC procedure in SAS 9.2 (SAS Institute, Cary, NC) was used to account for the Nationwide Inpatient Sample sampling methodology. RESULTS In a multiple logistic regression analysis, while controlling for known risk factors, amphetamine abuse/dependence was significantly associated with aortic dissection (adjusted odds ratio = 3.33, 95% CI = 2.37-4.69, P < .0001). CONCLUSIONS This statistically significant association suggests that amphetamine abuse/dependence may play a role in aortic dissection in young adults in the United States.
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Affiliation(s)
- Arthur N Westover
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-8828, USA.
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Torgersen C, Moser P, Luckner G, Mayr V, Jochberger S, Hasibeder WR, Dünser MW. Macroscopic postmortem findings in 235 surgical intensive care patients with sepsis. Anesth Analg 2009; 108:1841-7. [PMID: 19448210 DOI: 10.1213/ane.0b013e318195e11d] [Citation(s) in RCA: 168] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Christian Torgersen
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Gutierrez PS, Brito TD, Lopes MBS, Alves VAF. The value of necropsy in quality control of medical diagnosis: the gold standard for years to come. Clinics (Sao Paulo) 2009; 64:161-2. [PMID: 19330238 PMCID: PMC2666451 DOI: 10.1590/s1807-59322009000300002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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