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Shikino K, Shimizu T, Otsuka Y, Tago M, Takahashi H, Watari T, Sasaki Y, Iizuka G, Tamura H, Nakashima K, Kunitomo K, Suzuki M, Aoyama S, Kosaka S, Kawahigashi T, Matsumoto T, Orihara F, Morikawa T, Nishizawa T, Hoshina Y, Yamamoto Y, Matsuo Y, Unoki Y, Kimura H, Tokushima M, Watanuki S, Saito T, Otsuka F, Tokuda Y. Evaluation of ChatGPT-Generated Differential Diagnosis for Common Diseases With Atypical Presentation: Descriptive Research. JMIR MEDICAL EDUCATION 2024; 10:e58758. [PMID: 38915174 PMCID: PMC11199925 DOI: 10.2196/58758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/03/2024] [Accepted: 05/19/2024] [Indexed: 06/26/2024]
Abstract
Background The persistence of diagnostic errors, despite advances in medical knowledge and diagnostics, highlights the importance of understanding atypical disease presentations and their contribution to mortality and morbidity. Artificial intelligence (AI), particularly generative pre-trained transformers like GPT-4, holds promise for improving diagnostic accuracy, but requires further exploration in handling atypical presentations. Objective This study aimed to assess the diagnostic accuracy of ChatGPT in generating differential diagnoses for atypical presentations of common diseases, with a focus on the model's reliance on patient history during the diagnostic process. Methods We used 25 clinical vignettes from the Journal of Generalist Medicine characterizing atypical manifestations of common diseases. Two general medicine physicians categorized the cases based on atypicality. ChatGPT was then used to generate differential diagnoses based on the clinical information provided. The concordance between AI-generated and final diagnoses was measured, with a focus on the top-ranked disease (top 1) and the top 5 differential diagnoses (top 5). Results ChatGPT's diagnostic accuracy decreased with an increase in atypical presentation. For category 1 (C1) cases, the concordance rates were 17% (n=1) for the top 1 and 67% (n=4) for the top 5. Categories 3 (C3) and 4 (C4) showed a 0% concordance for top 1 and markedly lower rates for the top 5, indicating difficulties in handling highly atypical cases. The χ2 test revealed no significant difference in the top 1 differential diagnosis accuracy between less atypical (C1+C2) and more atypical (C3+C4) groups (χ²1=2.07; n=25; P=.13). However, a significant difference was found in the top 5 analyses, with less atypical cases showing higher accuracy (χ²1=4.01; n=25; P=.048). Conclusions ChatGPT-4 demonstrates potential as an auxiliary tool for diagnosing typical and mildly atypical presentations of common diseases. However, its performance declines with greater atypicality. The study findings underscore the need for AI systems to encompass a broader range of linguistic capabilities, cultural understanding, and diverse clinical scenarios to improve diagnostic utility in real-world settings.
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Affiliation(s)
- Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
- Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Yuki Otsuka
- Department of General Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Masaki Tago
- Department of General Medicine, Saga University Hospital, Saga, Japan
| | - Hiromizu Takahashi
- Department of General Medicine, Juntendo University Hospital Faculty of Medicine, Tokyo, Japan
| | - Takashi Watari
- Integrated Clinical Education Center Hospital Integrated Clinical Education, Kyoto University Hospital, Kyoto, Japan
| | - Yosuke Sasaki
- Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan
| | - Gemmei Iizuka
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
- Tama Family Clinic, Kanagawa, Japan
| | - Hiroki Tamura
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Koichi Nakashima
- Department of General Medicine, Awa Regional Medical Center, Chiba, Japan
| | - Kotaro Kunitomo
- Department of General Medicine, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Morika Suzuki
- Department of General Medicine, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Sayaka Aoyama
- Department of Internal Medicine, Mito Kyodo General Hospital, Ibaraki, Japan
| | | | - Teiko Kawahigashi
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
| | | | - Fumina Orihara
- Division of General Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Toru Morikawa
- Department of General Medicine, Nara City Hospital, Nara, Japan
| | - Toshinori Nishizawa
- Department of General Internal Medicine, St. Luke’s International Hospital, Tokyo, Japan
| | - Yoji Hoshina
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Yuichiro Matsuo
- Department of Clinical Epidemiology and Health Economics, The Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuto Unoki
- Department of General Internal Medicine, Iizuka Hospital, Fukuoka, Japan
| | - Hirofumi Kimura
- Department of General Internal Medicine, Iizuka Hospital, Fukuoka, Japan
| | - Midori Tokushima
- Saga Medical Career Support Center, Saga University Hospital, Saga, Japan
| | - Satoshi Watanuki
- Department of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Takuma Saito
- Department of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Fumio Otsuka
- Department of General Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
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Fukuzawa F, Yanagita Y, Yokokawa D, Uchida S, Yamashita S, Li Y, Shikino K, Tsukamoto T, Noda K, Uehara T, Ikusaka M. Importance of Patient History in Artificial Intelligence-Assisted Medical Diagnosis: Comparison Study. JMIR MEDICAL EDUCATION 2024; 10:e52674. [PMID: 38602313 PMCID: PMC11024399 DOI: 10.2196/52674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/31/2024] [Accepted: 02/15/2024] [Indexed: 04/12/2024]
Abstract
Background Medical history contributes approximately 80% to a diagnosis, although physical examinations and laboratory investigations increase a physician's confidence in the medical diagnosis. The concept of artificial intelligence (AI) was first proposed more than 70 years ago. Recently, its role in various fields of medicine has grown remarkably. However, no studies have evaluated the importance of patient history in AI-assisted medical diagnosis. Objective This study explored the contribution of patient history to AI-assisted medical diagnoses and assessed the accuracy of ChatGPT in reaching a clinical diagnosis based on the medical history provided. Methods Using clinical vignettes of 30 cases identified in The BMJ, we evaluated the accuracy of diagnoses generated by ChatGPT. We compared the diagnoses made by ChatGPT based solely on medical history with the correct diagnoses. We also compared the diagnoses made by ChatGPT after incorporating additional physical examination findings and laboratory data alongside history with the correct diagnoses. Results ChatGPT accurately diagnosed 76.6% (23/30) of the cases with only the medical history, consistent with previous research targeting physicians. We also found that this rate was 93.3% (28/30) when additional information was included. Conclusions Although adding additional information improves diagnostic accuracy, patient history remains a significant factor in AI-assisted medical diagnosis. Thus, when using AI in medical diagnosis, it is crucial to include pertinent and correct patient histories for an accurate diagnosis. Our findings emphasize the continued significance of patient history in clinical diagnoses in this age and highlight the need for its integration into AI-assisted medical diagnosis systems.
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Affiliation(s)
- Fumitoshi Fukuzawa
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Yasutaka Yanagita
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Shun Uchida
- Uchida Internal Medicine Clinic, Saitama-shi, Japan
| | - Shiho Yamashita
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Yu Li
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Chiba-shi, Japan
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Mentink MG, Latten BGH, Bakers FCH, Mihl C, Benali F, Nelemans PJ, Rennenberg RJMW, Koopmans RP, Bergmans DCJJ, Kubat B, Hofman PAM. Efficacy of postmortem CT and tissue sampling in establishing the cause of death in clinical practice: a prospective observational study. J Clin Pathol 2024; 77:259-265. [PMID: 36581447 DOI: 10.1136/jcp-2021-207946] [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: 09/13/2021] [Accepted: 12/18/2022] [Indexed: 12/30/2022]
Abstract
AIMS The aim of this study is to evaluate whether agreement with autopsy-determined cause of death (COD) increases by use of postmortem CT (PMCT) or PMCT in combination with postmortem sampling (PMS), when compared with clinical assessment only. METHODS This prospective observational study included deceased patients from the intensive care unit and internal medicine wards between October 2013 and August 2017. The primary outcome was percentage agreement on COD between the reference standard (autopsy) and the alternative postmortem examinations (clinical assessment vs PMCT or PMCT+PMS). In addition, the COD of patient groups with and without conventional autopsy were compared with respect to involved organ systems and pathologies. RESULTS Of 730 eligible cases, 144 could be included for analysis: 63 underwent PCMT without autopsy and 81 underwent both PMCT and autopsy. Agreement with autopsy-determined COD was significantly higher for both PMCT with PMS (42/57, 74%), and PMCT alone (53/81, 65%) than for clinical assessment (40/81, 51%; p=0.007 and p=0.03, respectively). The difference in agreement between PMCT with PMS and PMCT alone was not significant (p=0.13). The group with autopsy had a significantly higher prevalence of circulatory system involvement and perfusion disorders, and a lower prevalence of pulmonary system involvement. CONCLUSION PMCT and PMS confer additional diagnostic value in establishing the COD. Shortcomings in detecting vascular occlusions and perfusion disorders and susceptibility to pulmonary postmortem changes could in future be improved by additional techniques. Both PMCT and PMS are feasible in clinical practice and an alternative when autopsy cannot be performed.
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Affiliation(s)
- Max Guillaume Mentink
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Bart G H Latten
- Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
- Pathology, Netherlands Forensic Institute, Den Haag, Netherlands
| | - Frans C H Bakers
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Casper Mihl
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
- CARIM school for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Faysal Benali
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | | | - Richard P Koopmans
- Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | - Bela Kubat
- Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Paul A M Hofman
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
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Latten BGH, Kubat B, van den Brandt PA, zur Hausen A, Schouten LJ. Cause of death and the autopsy rate in an elderly population. Virchows Arch 2023; 483:865-872. [PMID: 37269366 PMCID: PMC10238230 DOI: 10.1007/s00428-023-03571-0] [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: 02/16/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/05/2023]
Abstract
Autopsy rates are declining, while major discrepancies between autopsies and clinical diagnoses remain. Still, little is known about the impact of suspected underlying diseases, for example, a diagnosis of cancer, on the autopsy rate. The aim of this study was to investigate the relation between the clinical cause of death, a history of cancer, and the medical autopsy rate using data from the Netherlands Cohort Study on Diet and Cancer (NLCS), a large prospective cohort study with a long follow-up. The NLCS is a prospective study initiated in 1986 and includes 120,852 persons (58,279 males and 62,573 females), 55-69 years of age at the time of enrollment. The NLCS was linked with the Dutch Nationwide Pathology Databank (PALGA), the Dutch Population Register (GBA), the Netherlands Cancer Registry, and the causes of death registry (Statistics Netherlands). If applicable, the 95% confidence intervals were calculated. During the follow-up of the NLCS, 59,760 deaths were recorded by linkage with the GBA from 1991 until 2009. Of these, a medical autopsy was performed on 3736 deceased according to linkage with PALGA, resulting in an overall autopsy rate of 6.3%. Major variations in the autopsy rate were observed according to the cause of death. The autopsy rate increased according to the number of contributing causes of death. Lastly, a diagnosis of cancer affected the autopsy rate. The clinical cause of death and a history of cancer both influenced the medical autopsy rate in a large national cohort. The insight this study provides may help clinicians and pathologists counteracting the further downfall of the medical autopsy.
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Affiliation(s)
- Bartholomeus G. H. Latten
- Department of Pathology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Piet A. van den Brandt
- Department of Epidemiology, GROW–School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Axel zur Hausen
- Department of Pathology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Department of Pathology, GROW–School for Oncology and Reproduction, Maastricht University, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Leo J. Schouten
- Department of Epidemiology, GROW–School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Muacevic A, Adler JR, Phillips CL, Cummings OW, Saxena R. Concordance of Solid Organ Biopsy Diagnoses With Hospital Autopsy and the Contribution of Biopsies to Death. Cureus 2023; 15:e33889. [PMID: 36819431 PMCID: PMC9934933 DOI: 10.7759/cureus.33889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/18/2023] Open
Abstract
Biopsies of the liver, lung, and kidney are performed for many indications, including organ dysfunction, mass lesions, and allograft monitoring. The diagnosis depends on the sample, which may or may not be representative of the lesion or pathology in question. Further, biopsies are not without risk of complications. Autopsies are a resource for assessing the accuracy of biopsy diagnoses and evaluating possible complications. Herein, we aimed to compare liver, lung, and kidney biopsy diagnoses with those from autopsies conducted soon after the procedure and to assess the contribution of biopsy to mortality. A 28-year search of our database identified 147 patients who were autopsied after dying within 30 days of a liver, lung, or kidney biopsy. The concordance of the biopsy diagnosis with the autopsy findings was determined. Finally, medical records were reviewed to determine the likelihood that a biopsy contributed to the patient's death. The contribution of the biopsy to death was categorized as "unlikely," "possible," or "probable." Overall concordance between biopsy and autopsy diagnoses was 87% (128/147), including 95% (87/92), 71% (32/45), and 90% (9/10) for liver, lung, and kidney biopsies, respectively. Concordance was lower for biopsies of suspected neoplasms versus non-neoplastic diseases. Lung biopsy concordance was higher for wedge biopsy versus needle or forceps biopsy. A biopsy was determined to at least "possibly" contribute to death in 23 cases (16%). In conclusion, an autopsy is an important tool to validate liver, lung, or kidney biopsy diagnoses. Confirmation of biopsy diagnoses via post-mortem examination may be particularly valuable when patients die soon after the biopsy procedure. Furthermore, an autopsy is especially useful when patients die soon after a biopsy in order to determine what role, if any, the procedure played in their deaths. Though biopsy complications are uncommon, a biopsy may still contribute to or precipitate death in a small number of patients.
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Suwalowska H. The invisible body work of 'last responders' - ethical and social issues faced by the pathologists in the Global South. Glob Public Health 2022; 17:4183-4194. [PMID: 35587285 PMCID: PMC9901416 DOI: 10.1080/17441692.2022.2076896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This paper utilises empirical data to explore the value of 'body work' performed by last responders charged with the duty of dead body management, with a focus on the Global South. While frontline staff work to save lives, little is known about the experiences and roles of those who care for the dead in global health in times of crises and even during normal times. This paper discusses ethical and socio-cultural challenges pathologists face in 'working on the bodies of others' while conducting any form of post-mortem procedures - necessary for ascertaining and recording the causes of death. Identifying and reporting the cause of death have significant public health benefits and provide closure for bereaved families. Despite the foregoing, the pathology field does not attract funding from governments or donors, and it is overlooked compared to other disciplines. Autopsy procedure bears social stigma - as it is associated with body mutilation and therefore disrespecting the dead; certain cultural beliefs or taboos about impurity and death persist, further raising some social and ethical tensions. As a result, the dearth of autopsy procedures contributes to the cause of death uncertainty in global health.
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Affiliation(s)
- Halina Suwalowska
- Nuffield Department of Population Health, Ethox Centre, Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK, Halina Suwalowska Old Road Campus, Oxford OX3 7LF, UK
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When is a postmortem examination carried out? A retrospective analysis of all Swedish deaths 1999-2018. Virchows Arch 2022; 482:721-727. [PMID: 36445483 PMCID: PMC9707416 DOI: 10.1007/s00428-022-03462-w] [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: 04/22/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022]
Abstract
The objective of this study was to assess who is merited an autopsy in Sweden. Data from the Swedish cause of death (COD) registry over a period of 20 years was retrieved and analysed. A multinominal logistic regression analysis was performed to identify the variables that were most strongly associated with the performance of a clinical or forensic autopsy (CA/FA).A definite COD, i.e. a COD based on autopsy findings, was registered in 12.6% of all deceased during the investigated period. In the remaining cases, the COD was presumed by the clinicians. Being male, born in the Nordic region, dying in a private residence, and unnatural death were most strongly associated with the performance of CA/FA. In contrast, being female, dying from dementia, dying at a nursing home, being born outside of Europe, or living in a small city or rural area seldom led to the performance of CA/FA.The above is certainly surprising as an autopsy provides an opportunity to investigate the cause of death, validate clinical diagnoses, detect unexpected aberrations, audit health care, and provide feedback to clinicians to facilitate their continuing education.
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Mahapatra L, Lu HC, Mansour M, Byrnes K. Discrepancies Between Clinical and Anatomic Causes of Death in Acute Invasive Fungal Sinusitis. Arch Pathol Lab Med 2022; 146:1281-1285. [PMID: 35041753 DOI: 10.5858/arpa.2021-0148-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Acute invasive fungal sinusitis (AIFS) can be challenging to diagnose because of its varied clinical presentation. OBJECTIVES.— To evaluate the discrepancies between clinical and autopsy diagnoses in patients with histologic evidence of AIFS at a tertiary care center. DESIGN.— Autopsy cases with a pathologic autopsy diagnosis of AIFS from the past 20 years at a tertiary hospital were evaluated for clinicopathologic features. Modified Goldman classification was used to classify discrepant cases. Clinical history was also reviewed. RESULTS.— Of 7071 institutional autopsy cases during 20 years, 9 met inclusion criteria and demonstrated AIFS at autopsy. Angioinvasive fungal elements were histologically identified in all cases, with multiorgan involvement in most cases (6 of 9; 67%). Major clinicopathologic discrepancies were identified in 6 cases (67%). CONCLUSIONS.— AIFS is an uncommon diagnosis rendered at autopsy. There is a subset of cases that demonstrate discrepancy between the clinical impression and pathologic autopsy diagnosis. Antemortem diagnosis of AIFS can be challenging, especially in cases without prototypical clinical symptoms and positive fungal cultures. At autopsy, there was multiorgan involvement, supporting extensive tissue sampling to evaluate for AIFS, even in the setting of negative fungal cultures or lack of classic symptoms. These findings highlight the importance of the pathologist's role at autopsy in the definitive diagnosis of AIFS, especially in clinically equivocal cases.
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Affiliation(s)
- Lily Mahapatra
- From the Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Missouri. Lu is now with the University of California, San Francisco School of Medicine, Oakland
| | - Hsiang-Chih Lu
- From the Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Missouri. Lu is now with the University of California, San Francisco School of Medicine, Oakland
| | - Mena Mansour
- From the Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Missouri. Lu is now with the University of California, San Francisco School of Medicine, Oakland
| | - Kathleen Byrnes
- From the Department of Pathology and Immunology, Washington University in St Louis School of Medicine, St Louis, Missouri. Lu is now with the University of California, San Francisco School of Medicine, Oakland
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Magrupov BA, Sharipova VK, Ubaydullaeva VU, Vervekina TA, Alimov AK, Rashidov DZ, Karimov AA, Kochetov VE. [Comparison of the final clinical and autopsy detected diagnoses in sepsis]. Arkh Patol 2022; 84:38-44. [PMID: 35880598 DOI: 10.17116/patol20228404138] [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] [Indexed: 06/15/2023]
Abstract
UNLABELLED With sepsis, more than a third of patients die, while the immediate causes of death may remain unknown. Autopsy largely helps to establish them. OBJECTIVE Identification of discrepancies in the final clinical and autopsy detected diagnoses in patients with sepsis who died in the surgical intensive care unit. MATERIAL AND METHODS 107 cases of patients with sepsis who died in the Department of Surgical Resuscitation of the Republican Scientific Center for Emergency Medical Care in 2020-2021 were studied. Autopsy was performed in 60 (56%) of the deceased. The autopsy was performed within 24 hours after the death was pronounced. The final clinical and pathoanatomic diagnoses were compared in accordance with the International Goldman System and the Russian Classification of categories of diagnosis discrepancies. RESULTS As a result of autopsies, 3 (5%) of the deceased had a discrepancy in the diagnoses of class I and 14 (23%) - class II according to the International Goldman System. During his lifetime, diseases or their complications were not recognized in 17 (28%) cases, mainly acute myocardial infarction of type 2 (3 cases) and liver abscesses (3 cases). CONCLUSION A pathoanatomic autopsy is a modern and important diagnostic tool that can clarify the causes of death.
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Affiliation(s)
- B A Magrupov
- Center for the Development of Professional Qualifications of Medical Workers, Tashkent, Republic of Uzbekistan
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - V Kh Sharipova
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - V U Ubaydullaeva
- Center for the Development of Professional Qualifications of Medical Workers, Tashkent, Republic of Uzbekistan
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - T A Vervekina
- Center for the Development of Professional Qualifications of Medical Workers, Tashkent, Republic of Uzbekistan
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - A Kh Alimov
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - D Z Rashidov
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - A A Karimov
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
| | - V E Kochetov
- Republican Scientific Center for Emergency Medical Care, Tashkent, Republic of Uzbekistan
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Abstract
Epidemiologic studies of diagnostic error in the intensive care unit (ICU) consist mostly of descriptive autopsy series. In these studies, rates of diagnostic errors are approximately 5% to 10%. Recently validated methods for retrospectively measuring error have expanded our understanding of the scope of the problem. These alternative measurement strategies have yielded similar estimates for the frequency of diagnostic error in the ICU. Although there is a fair understanding of the frequency of errors, further research is needed to better define the risk factors for diagnostic error in the ICU.
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Affiliation(s)
- Paul A Bergl
- Department of Critical Care, Gundersen Lutheran Medical Center, 1900 South Avenue, Mail Stop LM3-001, La Crosse, WI 54601, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Yan Zhou
- Department of Critical Care Medicine, Geisinger Medical Center, 100 N Academy Avenue, Danville, PA 17822, USA; Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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Khare P, Gupta R, Agarwal S, Bhatnagar A, Anand R. Spectrum of Renal Lesions on Autopsy: Experience of a Tertiary Level Institute Based on Retrospective Histopathological Analysis. Cureus 2021; 13:e17064. [PMID: 34522542 PMCID: PMC8428196 DOI: 10.7759/cureus.17064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Last few decades have seen a remarkable increase in the elderly population. Aging is an established risk factor for chronic kidney diseases associated with increased mortality and morbidity. The frequency and spectrum of renal pathology on autopsy specimen is not well documented and is often overlooked by physicians as well as forensic pathologists. AIM The present study aims to find out the prevalence and pattern of various types of renal pathologies, based on the histopathological analysis of renal tissue where autopsies were performed whether related or unrelated to renal diseases. MATERIAL AND METHODS This retrospective study of six years consisted of 557 autopsies. The bits of 417 samples of kidney tissue/whole kidney, retrieved at the time of autopsy were received, processed, and examined. RESULTS The male to female ratio approximately was 2:1, and 83.69% of cases were in 11-50 years age groups. Among the 159 cases having definitive renal findings, the commonest pathologies were seen in tubules and interstitial tissues (58.49% cases), followed by 38.36% cases with involvement of all components of renal tissues. There were four cases of isolated vascular changes and one case having Hodgkin's lymphoma. The series had 12 cases of renal tuberculosis. CONCLUSIONS The study highlights the various lesions of kidney found in renal tissue obtained on autopsy. The physician as well as forensic pathologists must be aware of the high prevalence and wide spectrum of possible pathologies in the kidney. The focus should be to develop more efficacious diagnostic methods for timely intervention.
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Affiliation(s)
- Pratima Khare
- Pathology, Dr Baba Saheb Ambedkar (BSA) Medical College and Hospital, New Delhi, IND
| | - Renu Gupta
- Pathology, Dr Baba Saheb Ambedkar (BSA) Medical College and Hospital, New Delhi, IND
| | - Swapnil Agarwal
- Pathology, Dr Baba Saheb Ambedkar (BSA) Medical College and Hospital, New Delhi, IND
| | - Avni Bhatnagar
- Pathology, Dr Baba Saheb Ambedkar (BSA) Medical College and Hospital, New Delhi, IND
| | - Rajani Anand
- Pathology, Dr Baba Saheb Ambedkar (BSA) Medical College and Hospital, New Delhi, IND
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12
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Möbius D, Fitzek A, Hammer N, Heinemann A, Ron A, Schädler J, Zwirner J, Ondruschka B. Ultrasound in legal medicine-a missed opportunity or simply too late? A narrative review of ultrasonic applications in forensic contexts. Int J Legal Med 2021; 135:2363-2383. [PMID: 34292383 PMCID: PMC8295453 DOI: 10.1007/s00414-021-02661-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/02/2021] [Indexed: 01/15/2023]
Abstract
Objectives Conventional autopsies remain the gold standard of postmortem healthcare quality assurance and help gathering extended knowledge on diseases. In answer to constantly declining autopsy rates non- or minimally invasive autopsy methods were introduced. Ultrasound is a well-established tool for imaging commonly used in clinical practice. This narrative review aims to summarize the current literature regarding the feasibility and validity of ultrasound in a forensic context. Material and methods A PubMed database search was carried out. Abstracts were scanned for pre-defined ex- and inclusion criteria, followed by a snowball search procedure applied to the primarily included articles. Results Forty-five publications met our inclusion criteria. The selected articles concern the feasibility of ultrasound in pre- or postmortem settings, forensic age estimation, and minimally invasive approaches. For imaging, ultrasound was deemed a reliable tool for the examination of epiphyses und superficial wounds, with limitations regarding internal organs and image quality due to postmortem changes. Ultrasound-guided minimally invasive approaches yielded higher success rates for adequate tissue sampling. Many investigations were carried out in low- and middle-income countries focusing on infectious diseases. Conclusion Ultrasound seems a promising but underutilized imaging tool in legal medicine to date. Promising approaches on its feasibility have been conducted. Especially for minimally invasive methods, ultrasound offered significant improvements on qualified biopsy sampling and thus appropriate diagnostics. Moreover, ultrasonic evaluation of epiphyses for age estimation offered valuable results. Nevertheless, further assessment of ultrasonic feasibility in forensic contexts is needed.
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Affiliation(s)
- Dustin Möbius
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Antonia Fitzek
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Niels Hammer
- Institute of Macroscopic and Clinical Anatomy, University of Graz, Graz, Austria.,Department of Orthopedic and Trauma Surgery, University of Leipzig, Leipzig, Germany.,Fraunhofer IWU, Dresden, Germany
| | - Axel Heinemann
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Ron
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Schädler
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann Zwirner
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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13
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Matkowski AFI, Benbow EW. Histopathology at autopsy: why bother? Histopathology 2021; 79:77-85. [PMID: 33445222 DOI: 10.1111/his.14335] [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: 11/10/2020] [Accepted: 01/10/2021] [Indexed: 11/28/2022]
Abstract
AIMS The frequency of histopathological sampling at autopsy varies, even though inadequate sampling may limit the value of autopsy reports. This study aims to investigate the contribution of histopathology at autopsy in a major teaching hospital. METHODS AND RESULTS A total of 532 coronial autopsy reports from Manchester Royal Infirmary were analysed retrospectively. Gross and microscopic diagnoses were compared and classified as concordant, discordant, histology needed (i.e. indeterminate or unremarkable gross findings) or autolysed. Revisions made to the cause of death following histopathology were categorised as: altered direct cause of death, altered indirect cause of death, concordant with supportive information, irrelevant or inconclusive. The study was limited to brain, heart, kidney, liver, lung and spleen. Histopathology had been requested in 141 cases (27%), which were further analysed. The greatest discordance between gross and microscopic findings was observed in the lung (11.6%). The organs most frequently requiring histopathology to provide a diagnosis were the kidney and lung, at 52.8 and 28.2%, respectively. Alterations were made to the direct cause of death in 45% of cases where histopathology was taken; it provided additional or supportive information in a further 38%. Diagnoses of primary malignancy had a sensitivity of 74% [confidence interval (CI) = 0.59-0.86] and bronchopneumonia had a sensitivity of 45% (CI = 0.29-0.62). CONCLUSION Histopathology has a major impact on the interpretation of organ pathology and determining a cause of death at autopsy.
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Affiliation(s)
| | - Emyr W Benbow
- School of Medical Sciences, University of Manchester, Manchester, UK.,Department of Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust (MFT), Manchester, UK
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14
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Rusu S, Lavis P, Domingues Salgado V, Van Craynest MP, Creteur J, Salmon I, Brasseur A, Remmelink M. Comparison of antemortem clinical diagnosis and post-mortem findings in intensive care unit patients. Virchows Arch 2021; 479:385-392. [PMID: 33580806 PMCID: PMC8364530 DOI: 10.1007/s00428-020-03016-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022]
Abstract
Autopsy is an important quality assurance indicator and a tool to advance medical knowledge. This study aims to compare the premortem clinical and postmortem pathology findings in patients who died in the Intensive Care Unit (ICU), to analyze if there are any discrepancies between them, and to compare the results to two similar studies performed in our institution in 2004 and 2007. Between January 1, 2016, and December 31, 2018, 888 patients died in the ICU and 473 underwent post-mortem examination (PME) of whom 437 were included in the present study. Autopsies revealed discrepancies between clinical diagnosis and pathologic findings according to in 101 cases (23.1%) according to Goldman classification. Forty-eight major discrepancies (class I and class II) were identified in 44 cases and the most frequent identified discrepancies were pulmonary embolism (3/12) as class I and malignancies (13/35) as class II. They were more frequent in patients hospitalized for less than 10 days then in the group with more than 10 days of hospitalization (13.8% vs 4.5%; p = 0.002). No statistical difference has been noticed concerning age, gender, and ICU stay. We observed an increase of performed autopsies and a total discrepancy rate similar to the studies performed in the same institution in 2004 (22.5%) and 2007 (21%). In conclusion, discrepancies between clinical and PME diagnoses persist despite the medical progress. Secondly, the autopsy after a short hospital stay may reveal unexpected findings whose diagnosis is challenging even if it may be suspected by the intensivist.
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Affiliation(s)
- Stefan Rusu
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium
| | - Philomène Lavis
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Jacques Creteur
- Hôpital Erasme, Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Salmon
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium.,Centre Universitaire Inter Regional d'Expertise en Anatomie Pathologique Hospitalière (CurePath), Charleroi (Jumet), Belgium.,DIAPath - Center for Microscopy and Molecular Imaging, Université Libre de Bruxelles, Gosselies, Belgium
| | - Alexandre Brasseur
- Hôpital Erasme, Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Myriam Remmelink
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium. .,Centre Universitaire Inter Regional d'Expertise en Anatomie Pathologique Hospitalière (CurePath), Charleroi (Jumet), Belgium.
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15
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Priemer DS, Gravenmier C, Batouli A, Hooper JE. Overview of Pathologic Findings of Vaping in the Context of an Autopsy Patient With Chronic Injury. Arch Pathol Lab Med 2020; 144:1408-1413. [PMID: 32383974 DOI: 10.5858/arpa.2019-0637-ra] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Electronic cigarettes are handheld devices that heat an inner liquid containing chemicals to be aerosolized and inhaled, and have become a popular alternative to conventional cigarettes. Their use, termed vaping, has been linked to severe injury, with 2711 cases of associated lung injury and 60 deaths reported to the Centers for Disease Control and Prevention at the time of writing. Published case reports and series have emerged detailing clinical and imaging characteristics of vaping-induced lung injury. However, the pathologic characteristics of these induced injuries are still being established, particularly findings occurring over time. OBJECTIVE.— To illustrate the autopsy findings of an older patient who died of vaping-induced injury after prolonged symptomology and to provide a review of the most recent literature regarding the basic science, epidemiology, clinical presentation, imaging characteristics, and pathology of vaping-induced lung injury. DATA SOURCES.— Autopsy case and peer-reviewed literature. CONCLUSIONS.— Vaping-induced lung injury has emerged as a public health issue, and this case represents a rare opportunity to evaluate this issue at autopsy. Most commonly, the injury has been attributed to tetrahydrocannabinol product use as opposed to nicotine. This case demonstrates that as today's young and relatively healthy "vapers" grow older and develop the comorbidities that come with advanced age, there is serious risk of chronic lung damage from vaping that could result in death. Further observations and studies, particularly autopsy evidence, are clearly important to understand the possible outcomes.
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Affiliation(s)
- David S Priemer
- From the Department of Pathology (Priemer, Gravenmier, Hooper), Johns Hopkins University, Baltimore, Maryland
| | - Curtis Gravenmier
- From the Department of Pathology (Priemer, Gravenmier, Hooper), Johns Hopkins University, Baltimore, Maryland
| | - Amir Batouli
- the Department of Radiology (Batouli), Johns Hopkins University, Baltimore, Maryland
| | - Jody E Hooper
- From the Department of Pathology (Priemer, Gravenmier, Hooper), Johns Hopkins University, Baltimore, Maryland
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16
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Driessen RGH, Latten BGH, Bergmans DCJJ, Hulsewe RPMG, Holtkamp JWM, van der Horst ICC, Kubat B, Schnabel RM. Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study. Virchows Arch 2020; 478:1173-1178. [PMID: 33306143 PMCID: PMC8203528 DOI: 10.1007/s00428-020-02984-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Abstract
Early death in sepsis occurs frequently; however, specific causes are largely unknown. An autopsy can contribute to ascertain causes of death. The objective of the study was to determine discrepancies in clinical diagnosis and postmortem findings in septic intensive care unit (ICU) patients deceased within 48 h after ICU admission. All septic ICU patients who deceased within 48 h after ICU admission were identified and included. Four intensivists determined the clinical cause of death by medical record review. An autopsy was performed within 24 h of death. Clinical diagnosis and postmortem findings were compared and classified as autopsy-identified missed clinical diagnoses and autopsy-refuted diagnoses. Class I and II missed major diagnoses using the Goldman criteria were scored. Between 2012 and 2017, 1107 septic patients were admitted to ICU. Of these, 344 patients (31%) died, of which 97 patients (28%) deceased within 48 h. In 32 (33%) early deceased patients, an autopsy was agreed. There were 26 autopsy-identified missed clinical diagnoses found, mostly myocardial infarction (n = 4) and pneumonia (n = 4). In four patients (13%), a class I discrepancy was found. In fourteen patients (42%), a class II discrepancy was found. In conclusion, an autopsy is an important diagnostic tool that can identify definite causes of death. These diagnoses deviate from diagnoses established during admission in early deceased sepsis patients.
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Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | | | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Riquette P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Johanna W M Holtkamp
- Department of Intensive Care Medicine, St. Jans Gasthuis, Weert, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
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17
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Autopsy examination in sudden cardiac death: a current perspective on behalf of the Association for European Cardiovascular Pathology. Virchows Arch 2020; 478:687-693. [PMID: 33111163 PMCID: PMC7990811 DOI: 10.1007/s00428-020-02949-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 01/19/2023]
Abstract
In sudden cardiac death, an autopsy is an essential step in establishing a diagnosis of inherited cardiac disease and identifying families that require cardiac screening. To evaluate aspects of post-mortem practice in Europe, a questionnaire was designed and circulated to both clinical and forensic pathologists. There was a 48% response rate and information was obtained from 17 countries. The results showed a wide variety in the management of sudden cardiac death, with a general tendency towards a lack of thorough investigation. In up to 40% of cases, autopsies were not performed in subjects less than 50 years who may have died from cardiac disease. Reasons for this were lack of finance and lack of interest from police, legal authorities, and doctors. Only 50% of pathologists seem to follow a standard protocol for autopsy examination, apparently due to lack of expertise and/or training. When autopsies were performed, histology and toxicology were almost always taken, genetic studies were generally available and retention of the heart for specialist study was usually permitted. Our results suggest that although the standard of practice is appropriate in many centres, many more cases should have autopsies, especially in sudden deaths in subjects less than 50 years.
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18
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Clinical Relevance of Unexpected Findings of Post-Mortem Computed Tomography in Hospitalized Patients: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207572. [PMID: 33081003 PMCID: PMC7589901 DOI: 10.3390/ijerph17207572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 01/20/2023]
Abstract
Background and objective: The current literature describing the use of minimally invasive autopsy in clinical care is mainly focused on the cause of death. However, the identification of unexpected findings is equally important for the evaluation and improvement of daily clinical care. The purpose of this study was to analyze unexpected post-mortem computed tomography (PMCT) findings of hospitalized patients and assess their clinical relevance. Materials and methods: This observational study included patients admitted to the internal medicine ward. Consent for PMCT and autopsy was requested from the next of kin. Decedents were included when consent for at least PMCT was obtained. Consent for autopsy was not obtained for all decedents. All findings reported by PMCT were coded with an International Classification of Diseases (ICD) code. Unexpected findings were identified and subsequently categorized for their clinical relevance by the Goldman classification. Goldman class I and III were considered clinically relevant. Additionally, correlation with autopsy results and ante-mortem imaging was performed. Results: In total, 120 decedents were included and evaluated for unexpected findings on PMCT. Of them, 57 decedents also underwent an autopsy. A total of 1020 findings were identified; 111 correlated with the cause of death (10.9%), 508 were previously reported (49.8%), 99 were interpreted as post-mortem changes (9.7%), and 302 were classified as unexpected findings (29.6%). After correlation with autopsy (in 57 decedents), 24 clinically relevant unexpected findings remained. These findings were reported in 18 of 57 decedents (32%). Interestingly, 25% of all unexpected findings were not reported by autopsy. Conclusion: Many unexpected findings are reported by PMCT in hospitalized patients, a substantial portion of which is clinically relevant. Additionally, PMCT is able to identify pathology and injuries not reported by conventional autopsy. A combination of PMCT and autopsy can thus be considered a more comprehensive and complete post-mortem examination.
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19
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Needle placement accuracy in CT-guided robotic post mortem biopsy. CURRENT DIRECTIONS IN BIOMEDICAL ENGINEERING 2020. [DOI: 10.1515/cdbme-2020-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Forensic autopsies include a thorough examination of the corpse to detect the source or alleged manner of death as well as to estimate the time since death. However, a full autopsy may be not feasible due to limited time, cost or ethical objections by relatives. Hence, we propose an automated minimal invasive needle biopsy system with a robotic arm, which does not require any online calibrations during a procedure. The proposed system can be easily integrated into the workflow of a forensic biopsy since the robot can be flexibly positioned relative to the corpse. With our proposed system, we performed needle insertions into wax phantoms and livers of two corpses and achieved an accuracy of 4.34 ± 1.27 mm and 10.81 ± 4.44 mm respectively.
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20
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Menéndez C, Quintó L, Castillo P, Fernandes F, Carrilho C, Ismail MR, Lorenzoni C, Hurtado JC, Rakislova N, Munguambe K, Moraleda C, Maixenchs M, Macete E, Mandomando I, Martínez MJ, Alonso PL, Bassat Q, Ordi J. Quality of care and maternal mortality in a tertiary-level hospital in Mozambique: a retrospective study of clinicopathological discrepancies. LANCET GLOBAL HEALTH 2020; 8:e965-e972. [PMID: 32562652 PMCID: PMC7303952 DOI: 10.1016/s2214-109x(20)30236-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/05/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although an increasing number of pregnant women in resource-limited areas deliver in health-care facilities, maternal mortality remains high in these settings. Inadequate diagnosis and management of common life-threatening conditions is an important determinant of maternal mortality. We analysed the clinicopathological discrepancies in a series of maternal deaths from Mozambique and assessed changes over 10 years in the diagnostic process. We aimed to provide data on clinical diagnostic accuracy to be used for improving quality of care and reducing maternal mortality. METHODS We did a retrospective analysis of clinicopathological discrepancies in 91 maternal deaths occurring from Nov 1, 2013, to March 31, 2015 (17 month-long period), at a tertiary-level hospital in Mozambique, using complete diagnostic autopsies as the gold standard to ascertain cause of death. We estimated the performance of the clinical diagnosis and classified clinicopathological discrepancies as major and minor errors. We compared the findings of this analysis with those of a similar study done in the same setting 10 years earlier. FINDINGS We identified a clinicopathological discrepancy in 35 (38%) of 91 women. All diagnostic errors observed were classified as major discrepancies. The sensitivity of the clinical diagnosis for puerperal infections was 17% and the positive predictive value was 50%. The sensitivity for non-obstetric infections was 48%. The sensitivity for eclampsia was 100% but the positive predictive value was 33%. Over the 10-year period, the performance of clinical diagnosis did not improve, and worsened for some diagnoses, such as puerperal infection. INTERPRETATION Decreasing maternal mortality requires improvement of the pre-mortem diagnostic process and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of diagnostic tests. Comparison of post-mortem information with clinical diagnosis will help monitor the reduction of clinical errors and thus improve the quality of care. FUNDING Bill & Melinda Gates Foundation and Instituto de Salud Carlos III.
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Affiliation(s)
- Clara Menéndez
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| | - Llorenç Quintó
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Paola Castillo
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Department of Pathology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Mamudo R Ismail
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Cesaltina Lorenzoni
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Juan Carlos Hurtado
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Department of Microbiology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Natalia Rakislova
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Department of Pathology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Cinta Moraleda
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Maria Maixenchs
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Miguel J Martínez
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Department of Microbiology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Pedro L Alonso
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Quique Bassat
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Catalan Institution for Research and Advanced Studies, Barcelona, Spain; Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Jaume Ordi
- ISGlobal, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain; Department of Pathology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
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21
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Mentink MG, Bakers FCH, Mihl C, Lahaye MJ, Rennenberg RJMW, Latten BGH, Kubat B, Hofman PAM. Introduction of postmortem CT increases the postmortem examination rate without negatively impacting the rate of traditional autopsy in daily practice: an implementation study. J Clin Pathol 2020; 74:177-181. [PMID: 32675309 DOI: 10.1136/jclinpath-2020-206734] [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: 05/08/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 11/03/2022]
Abstract
AIM The aim of this implementation study was to assess the effect of postmortem CT (PMCT) and postmortem sampling (PMS) on (traditional) autopsy and postmortem examination rates. Additionally, the feasibility of PMCT and PMS in daily practice was assessed. METHODS For a period of 23 months, PMCT and PMS were used as additional modalities to the autopsy at the Department of Internal Medicine. The next of kin provided consent for 123 postmortem examinations. Autopsy rates were derived from the Dutch Pathology Registry, and postmortem examination rates were calculated for the period before, during and after the study period, and the exclusion rate, table time, time interval to informing the referring clinicians with results and the time interval to the Multidisciplinary Mortality Review Board (MMRB) meeting were objectified to assess the feasibility. RESULTS The postmortem examination rate increased (from 18.8% to 32.5%, p<0.001) without a decline in the autopsy rate. The autopsy rate did not change substantially after implementation (0.2% decrease). The exclusion rate was 2%, the table time was 23 min, and a median time interval of 4.1 hours between PMCT and discussing its results with the referring clinicians was observed. Additionally, more than 80% of the MMRB meetings were held within 8 weeks after the death of the patient. CONCLUSIONS Our study shows that the implementation of a multidisciplinary postmortem examination is feasible in daily practice and does not adversely affect the autopsy rate, while increasing the postmortem examination rate.
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Affiliation(s)
- Max G Mentink
- Department of Radiology and Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Frans C H Bakers
- Department of Radiology and Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands.,Department of Radiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Max J Lahaye
- Department of Radiology, Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Roger J M W Rennenberg
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Bart G H Latten
- Department of Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands.,Department of Pathology, Netherlands Forensic Institute, Den Haag, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands.,Department of Pathology, Netherlands Forensic Institute, Den Haag, The Netherlands
| | - Paul A M Hofman
- Department of Radiology and Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
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22
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Waidhauser J, Martin B, Trepel M, Märkl B. Can low autopsy rates be increased? Yes, we can! Should postmortem examinations in oncology be performed? Yes, we should! A postmortem analysis of oncological cases. Virchows Arch 2020; 478:301-308. [PMID: 32651729 PMCID: PMC7969536 DOI: 10.1007/s00428-020-02884-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/29/2020] [Accepted: 06/14/2020] [Indexed: 12/29/2022]
Abstract
Ever declining autopsy rates have been a concern of pathologists as well as clinicians for decades. Notably, in the field of oncology, data on autopsies and discrepancies between clinical and autoptic diagnoses are particularly scarce. In this retrospective study, we show the effect of a simple catalog of measures consisting of a different approach to obtain consent for autopsy, structured conferencing, and systematic teaching of residents, as well as a close collaboration between clinicians and pathologists on the numbers of autopsies, especially of oncological patients. Additionally, postmortem examination protocols from the years 2015 until 2019 were analyzed, regarding rates of discrepancies between clinical and autoptic causes of death in this category of patients. Autopsy numbers could be significantly increased from a minimum in 2014 (60 autopsies) to a maximum in 2018 (142 autopsies) (p < 0.0001). In the 67 autopsies of oncological cases, a high rate of 51% of major discrepancy between clinical and autoptic causes of death could be detected. In contrast to the general reported decline of autopsy rates, we present rising autopsy numbers over the past 5 years with an increasing number of oncological cases who underwent a postmortem examination. The high percentage of major discrepancies between clinical and autopsy diagnosis is in contrast to an expected decrease of major discrepancies in times of precise diagnostic methods and underlines the importance of autopsies to ensure high quality in diagnostics and therapy not only in the field of oncology.
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Affiliation(s)
- Johanna Waidhauser
- Institute of Pathology and Molecular Diagnostics, University Medical Center Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany. .,Department of Hematology and Medical Oncology, University Medical Center Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Benedikt Martin
- Institute of Pathology and Molecular Diagnostics, University Medical Center Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Martin Trepel
- Department of Hematology and Medical Oncology, University Medical Center Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Medical Center Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
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Horvat A, Filipovic J. Healthcare system quality indicators: the complexity perspective. TOTAL QUALITY MANAGEMENT & BUSINESS EXCELLENCE 2020. [DOI: 10.1080/14783363.2017.1421062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ana Horvat
- Department for Quality Management and Standardization, Faculty of Organizational Sciences, University of Belgrade, Belgrade, Serbia
| | - Jovan Filipovic
- Department for Quality Management and Standardization, Faculty of Organizational Sciences, University of Belgrade, Belgrade, Serbia
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Mazeikiene S, Stasiuniene J, Vasiljevaite D, Laima S, Chmieliauskas S, Fomin D, Simakauskas R, Jasulaitis A. Deontological examination as a criterion for the assessment of personal healthcare professional quality: A Strobe compliant retrospective study. Medicine (Baltimore) 2020; 99:e18770. [PMID: 32011467 PMCID: PMC7220242 DOI: 10.1097/md.0000000000018770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Discrepancies between clinical and autopsy diagnoses range from 30% to 37%. The significance of deontological examinations remains high. In the pursuit of proper evaluation of diagnostic discrepancies, the establishment of pathogenesis, the mechanism of death, and a correct diagnosis are of particular importance.A retrospective study of deontological examinations, aimed at the detection of medical errors and carried out by the State Forensic Medicine Service during the period 1989 to 2016, was performed. The clinical and autopsy data from 1007 cases were collected in compliance with the research protocol.The number of deontological examinations tends to increase. In 60% of cases, the deceased were men. Most cases were in the age group of 50 to 59 years. Most examinations were carried out in relation to improperly provided healthcare services and the patient's death in surgery, admission, intensive care and obstetrics-gynecology departments. In 13% of cases, the diagnosis did not coincide and, in 79% of cases, the diagnoses fully coincided. In 68% of cases, the medical error was disproved.The number of deontological examinations is increasing. In most cases, clinical and autopsy diagnoses fully matched. Incorrectly clinically diagnosed intracranial injuries were the most common diagnostic mistakes. The data are similar to the results of research in other countries and would be relevant to ensuring the prevention of medical mistakes and the improvement of healthcare quality.
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Added value of post-mortem computed tomography (PMCT) to clinical findings for cause of death determination in adult "natural deaths". Int J Legal Med 2019; 134:1457-1463. [PMID: 31853676 PMCID: PMC7295833 DOI: 10.1007/s00414-019-02219-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/27/2019] [Indexed: 11/30/2022]
Abstract
Purpose The aim of this study was to investigate whether post-mortem computed tomography (PMCT) provides additional information regarding the cause of death and underlying diseases in a general practitioners’ (GP), out-of-hospital population. Methods and materials Bodies donated to our anatomy department between January 2014 and January 2018, who consecutively underwent a total body PMCT and had given permission for retrieval of their medical records during life, were included. PMCT scans were assessed by a radiologist and compared with the cause of death as stated in the medical records. Discrepancies were analyzed with an adjusted Goldman classification. Results Ninety-three out of the 274 scanned donors during the inclusion period had given consent for the retrieval of their medical records, of which 79 GP’s responded to the request thereof (31 men, 48 women, average age 72.8 years, range 36–99). PMCT identified 49 (62%) cases of cancer, 10 (12.7%) cardiovascular diseases, 8 (10.1%) severe organ failures, 5 (6.3%) cases with signs of pneumonia, 2 (2.5%) other causes, and 7 (8.9%) cases without an (underlying) definitive cause of death. Eleven major discrepancies on the Goldman classification scale, with possible relevance to survival between PMCT and GP records, were identified. Conclusion PMCT can have added value for the detection of additional findings regarding the cause of death in an out-of-hospital, GP’s population, especially to identify or exclude major (previously non-diagnosed) underlying diseases.
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Friberg N, Ljungberg O, Berglund E, Berglund D, Ljungberg R, Alafuzoff I, Englund E. Cause of death and significant disease found at autopsy. Virchows Arch 2019; 475:781-788. [PMID: 31691009 PMCID: PMC6881421 DOI: 10.1007/s00428-019-02672-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 09/10/2019] [Accepted: 09/22/2019] [Indexed: 11/20/2022]
Abstract
The use of clinical autopsy has been in decline for many years throughout healthcare systems of developed countries despite studies showing substantial discrepancies between autopsy results and pre-mortal clinical diagnoses. We conducted a study to evaluate over time the use and results of clinical autopsies in Sweden. We reviewed the autopsy reports and autopsy referrals of 2410 adult (age > 17) deceased patients referred to two University hospitals in Sweden during two plus two years, a decade apart. There was a decline in the number of autopsies performed over time, however, mainly in one of the two hospitals. The proportion of autopsy referrals from the emergency department increased from 9 to 16%, while the proportion of referrals from regular hospital wards was almost halved. The autopsies revealed a high prevalence of cardiovascular disease, with myocardial infarction and cerebrovascular lesion found in 40% and 19% of all cases, respectively. In a large proportion of cases (> 30%), significant findings of disease were not anticipated before autopsy, as judged from the referral document and additional data obtained in some but not all cases. In accordance with previous research, our study confirms a declining rate of autopsy even at tertiary, academic hospitals and points out factors possibly involved in the decline.
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Affiliation(s)
- Niklas Friberg
- Department of Immunology, Genetics and Pathology, Uppsala University, Dag Hammarskjölds väg 20, 751 85, Uppsala, Sweden.
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Sölvegatan 25, 221 85, Lund, Sweden.
- Department of Pediatrics, Lund University, Lasarettsgatan 40, 221 85, Lund, Sweden.
| | - Oscar Ljungberg
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Sölvegatan 25, 221 85, Lund, Sweden
| | - Erik Berglund
- Division of Transplantation Surgery, CLINTEC, Karolinska Institute, Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - David Berglund
- Department of Immunology, Genetics and Pathology, Uppsala University, Dag Hammarskjölds väg 20, 751 85, Uppsala, Sweden
| | - Richard Ljungberg
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Sölvegatan 25, 221 85, Lund, Sweden
| | - Irina Alafuzoff
- Department of Immunology, Genetics and Pathology, Uppsala University, Dag Hammarskjölds väg 20, 751 85, Uppsala, Sweden
| | - Elisabet Englund
- Department of Clinical Sciences, Division of Oncology and Pathology, Lund University, Sölvegatan 25, 221 85, Lund, Sweden
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Latten BGH, Overbeek LIH, Kubat B, Zur Hausen A, Schouten LJ. A quarter century of decline of autopsies in the Netherlands. Eur J Epidemiol 2019; 34:1171-1174. [PMID: 31728879 DOI: 10.1007/s10654-019-00572-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Autopsy rates have been declining worldwide. The present study reports the outcome of a retrospective analysis of all non-forensic autopsies in the Netherlands over a course of 25 years, and compares these with the most recent Dutch study. METHOD Retrospectively, 25 years of data on clinical autopsies from the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands (PALGA) was paired with the mortality registry (Statistics Netherlands). RESULTS The crude prevalence of autopsies declined from 7.07% in 1991 to 2.73% in 2015. After adjusting for age at death, there was no difference in autopsy rate between males and females. An increasing age significantly decreased the autopsy rate. CONCLUSION In the Netherlands, clinical autopsies have been declining over the last quarter century. Age at death, but not sex, was associated with the autopsy rate. These different results stress the importance of correct collection and analysis methods of data.
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Affiliation(s)
- Bartholomeus G H Latten
- Department of Pathology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Lucy I H Overbeek
- Donders Center of Medical Neurosciences, Radboud University, Houtlaan 4, 6525 XZ, Nijmegen, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Axel Zur Hausen
- Department of Pathology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Leo J Schouten
- Department of Epidemiology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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Palhares AEM, Ferreira L, Freire M, Castillo P, Martínez MJ, Hurtado JC, Rakislova N, Varo R, Navarro M, Casas I, Vila J, Monteiro WM, Sanz A, Quintó L, Fernandes F, Carrilho C, Menéndez C, Ordi J, Bassat Q, Lacerda M. Performance of the minimally invasive autopsy tool for cause of death determination in adult deaths from the Brazilian Amazon: an observational study. Virchows Arch 2019; 475:649-658. [PMID: 31201504 PMCID: PMC6861203 DOI: 10.1007/s00428-019-02602-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 06/06/2019] [Indexed: 01/19/2023]
Abstract
The uncertainty about the real burden of causes of death (CoD) is increasingly recognized by the international health community as a critical limitation for prioritizing effective public health measures. The minimally invasive autopsy (MIA) has shown to be a satisfactory substitute of the complete diagnostic autopsy (CDA), the gold standard for CoD determination in low- and middle-income countries. However, more studies are needed to confirm its adequate performance in settings with different epidemiology. In this observational study, the CoD obtained with the MIA were compared with the clinical diagnosis and the results of the CDA in 61 deaths that occurred in an infectious diseases referral hospital in Manaus, Brazilian Amazon. Concordance between the categories of diseases obtained by the three methods was evaluated by the Kappa statistic. Additionally, we evaluated discrepancies between clinical and complete diagnostic autopsy diagnoses. The MIA showed a substantial concordance with the CDA (Kappa = 0.777, 95% CI 0.608-0.946), and a perfect or almost perfect coincidence in specific diagnosis (ICD-10 code) between MIA and CDA was observed in 85% of the cases. In contrast, the clinical diagnosis showed a fair concordance with the CDA (Kappa = 0.311, 95% CI 0.071-0.552). Major clinico-pathological discrepancies were identified in 49% of cases. In conclusion, the MIA showed a substantial performance for CoD identification. Clinico-pathological discrepancies remain high and justify the need for post-mortem studies, even in referral hospitals. The MIA is a robust substitute of the CDA for CoD surveillance and quality improvement of clinical practice in low- and middle-income settings.
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Affiliation(s)
| | - Luiz Ferreira
- Fundação de Medicina Tropical Dr. Heitor Viera Dourado, Manaus, 69040-000, Brazil
| | - Monique Freire
- Fundação de Medicina Tropical Dr. Heitor Viera Dourado, Manaus, 69040-000, Brazil
| | - Paola Castillo
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Department of Pathology, Hospital Clinic - Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Miguel J Martínez
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Department of Microbiology, Hospital Clinic - Universitat de Barcelona, 08036, Barcelona, Spain
| | - Juan Carlos Hurtado
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Department of Microbiology, Hospital Clinic - Universitat de Barcelona, 08036, Barcelona, Spain
| | - Natalia Rakislova
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Department of Pathology, Hospital Clinic - Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Rosauro Varo
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), 1929, Maputo, Mozambique
| | - Mireia Navarro
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Isaac Casas
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Jordi Vila
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Department of Microbiology, Hospital Clinic - Universitat de Barcelona, 08036, Barcelona, Spain
| | - Wuelton M Monteiro
- Fundação de Medicina Tropical Dr. Heitor Viera Dourado, Manaus, 69040-000, Brazil
- National Council for Scientific and Technological Development (CNPq, Brasilia, Brazil) fellow, Brasília, Brazil
| | - Ariadna Sanz
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Llorenç Quintó
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, 1653, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, 1653, Maputo, Mozambique
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, 1653, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, 1653, Maputo, Mozambique
| | - Clara Menéndez
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), 1929, Maputo, Mozambique
| | - Jaume Ordi
- ISGlobal-Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain.
- Department of Pathology, Hospital Clinic - Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain.
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça (CISM), 1929, Maputo, Mozambique
- ICREA, Catalan Institution for Research and Advanced Studies, Passeig de Lluís Companys 23, 08010, Barcelona, Spain
- Paediatric Infectious Diseases Unit, Paediatrics Department, Hospital Sant Joan de Déu - Universitat de Barcelona, 8950, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain
| | - Marcus Lacerda
- Fundação de Medicina Tropical Dr. Heitor Viera Dourado, Manaus, 69040-000, Brazil
- National Council for Scientific and Technological Development (CNPq, Brasilia, Brazil) fellow, Brasília, Brazil
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Wittekind C, Gradistanac T. Post-Mortem Examination as a Quality Improvement Instrument. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 115:653-658. [PMID: 30375329 DOI: 10.3238/arztebl.2018.0653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 11/06/2017] [Accepted: 06/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Autopsies are considered an important quality assurance instrument in medicine, yet autopsy rates in many countries have been declining for many years. The proper role of the post-mortem examination in modern medicine is a matter deserving of study. METHODS This review is based on a selective search of the literature for publications on the role of autopsies as a quality assurance instrument. RESULTS Multiple studies have revealed substantial rates of discrepancy between pre- and post-mortem diagnoses, with reported rates lying in the range of 10% to 40%. The frequen- cy of so-called Goldman I erroneous diagnoses, i.e., those that are determined at autopsy and might have influenced the patient's survival, ranges from 2.4% to 10.7%. It can be as- sumed that the rate of serious diagnostic errors revealed by autopsy would fall if autopsy rates were to rise. Independently of the above-mentioned studies, a large-scale study of data from the period 1988-2008 revealed a decline in the rate of Goldman I erroneous diagnoses by more than half. The qualitative effects of autopsies, however, are difficult to measure. At present, imaging studies and minimally invasive or endoscopic diagnostic procedures can be performed post mortem as well, but the available studies show that these methods do not yet suffice to enable a coherent pathogenetic classification of disease processes. CONCLUSION Autopsies should still be performed in the interest of quality assurance in medicine. Uniform standards in the performance and reporting of autopsies could lead to im- provement in the use of the data acquired through them.
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Miller CR, Boor PJ, Campbell GA. A Case of Previously Unsuspected Cardiac Sarcoidosis Diagnosed at Autopsy and 23-Year Review of One Institution's Sarcoidosis Deaths. Acad Forensic Pathol 2019; 9:97-106. [PMID: 34394795 DOI: 10.1177/1925362119851242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/27/2019] [Indexed: 12/18/2022]
Abstract
Sarcoidosis is a noncaseating granulomatous disease of unknown etiology. The incidence is 11 per 100 000 white individuals and 34 per 100 000 black individuals. Cardiac involvement is seen in 2% to 5% of patients with systemic sarcoidosis and is often clinically undetected. This may be due to relative rarity of cardiac involvement, variability in presentation, or that there are no good clinical criteria for the diagnosis of cardiac sarcoidosis. Patients may be totally asymptomatic or have heart block, myocardial infarctions, heart failure, or sudden cardiac death, which may be due to involvement of the conduction system by sarcoidosis. We present a case of a 54-year-old black male with hypertension and hyperlipidemia. Prior to his death, he was witnessed to suddenly stand up, grab his chest, and collapse. His clinical cause of death was hypertensive and atherosclerotic cardiovascular disease. A retrospective review of autopsy cases over the last 23 years (1995-2018) at our institution (n = 6900) was undertaken. This case illustrates a rare disease and highlights the importance of complete autopsy even in patients who might otherwise be signed out as an external exam or records review only.
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Ordi J, Castillo P, Garcia-Basteiro AL, Moraleda C, Fernandes F, Quintó L, Hurtado JC, Letang E, Lovane L, Jordao D, Navarro M, Bene R, Nhampossa T, Ismail MR, Lorenzoni C, Guisseve A, Rakislova N, Varo R, Marimon L, Sanz A, Cossa A, Mandomando I, Maixenchs M, Munguambe K, Vila J, Macete E, Alonso PL, Bassat Q, Martínez MJ, Carrilho C, Menéndez C. Clinico-pathological discrepancies in the diagnosis of causes of death in adults in Mozambique: A retrospective observational study. PLoS One 2019; 14:e0220657. [PMID: 31490955 PMCID: PMC6730941 DOI: 10.1371/journal.pone.0220657] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact. Aim We assessed the accuracy of the clinical diagnoses in a tertiary referral hospital in sub-Saharan Africa by comparison with post-mortem findings. We also identified potential risk factors for misdiagnoses. Methods One hundred and twelve complete autopsy procedures were performed at the Maputo Central Hospital (Mozambique), from November 2013 to March 2015. We reviewed the clinical records. Major clinico-pathological discrepancies were assessed using a modified version of the Goldman and Battle classification. Results Major diagnostic discrepancies were detected in 65/112 cases (58%) and were particularly frequent in infection-related deaths (56/80 [70%] major discrepancies). The sensitivity of the clinical diagnosis for toxoplasmosis was 0% (95% CI: 0–37), 18% (95% CI: 2–52) for invasive fungal infections, 25% (95% CI: 5–57) for bacterial sepsis, 34% (95% CI: 16–57), for tuberculosis, and 46% (95% CI: 19–75) for bacterial pneumonia. Major discrepancies were more frequent in HIV-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p = 0.0236). Conclusions Major clinico-pathological discrepancies are still frequent in resource constrained settings. Increasing the level of suspicion for infectious diseases and expanding the availability of diagnostic tests could significantly improve the recognition of common life-threatening infections, and thereby reduce the mortality associated with these diseases. The high frequency of clinico-pathological discrepancies questions the validity of mortality reports based on clinical data or verbal autopsy.
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Affiliation(s)
- Jaume Ordi
- Department of Pathology, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | - Paola Castillo
- Department of Pathology, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Alberto L. Garcia-Basteiro
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Amsterdam Institute for Global Health and Development (AIGHD), Academic Medical Center, Amsterdam, The Netherlands
| | - Cinta Moraleda
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Llorenç Quintó
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Juan Carlos Hurtado
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Emili Letang
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Service of Infectious Diseases, Hospital del Mar, Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Lucilia Lovane
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Dercio Jordao
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Mireia Navarro
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Rosa Bene
- Department of Medicine, Maputo Central Hospital, Maputo, Mozambique
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Mamudo R. Ismail
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Cesaltina Lorenzoni
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Assucena Guisseve
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Natalia Rakislova
- Department of Pathology, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Lorena Marimon
- Department of Pathology, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Ariadna Sanz
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Anelsio Cossa
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Inacio Mandomando
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Maria Maixenchs
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Jordi Vila
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Pedro L. Alonso
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ICREA, Catalan Institution for Research and Advanced Studies, Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Miguel J. Martínez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Clara Menéndez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud, Madrid, Spain
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Latten BG, Bakers FC, Hofman PA, zur Hausen A, Kubat B. The needle in the haystack: Histology of post-mortem computed tomography guided biopsies versus autopsy derived tissue. Forensic Sci Int 2019; 302:109882. [DOI: 10.1016/j.forsciint.2019.109882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 06/12/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
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O'Brien J, Jones N, Horrigan M, Al-Kaisey AM. Rare cause of pulmonary hypertension - pulmonary tumour thrombotic microangiopathy. BMJ Case Rep 2019; 12:12/8/e225756. [PMID: 31401584 DOI: 10.1136/bcr-2018-225756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary tumour thrombotic microangiopathy (PTTA) is a rare but lethal cause of pulmonary hypertension (PHT). Its underlying mechanism is believed to be fibrocellular intimal proliferation and microthrombosis. It has been reported in association with gastric adenocarcinoma and breast, pancreatic and lung cancers. The diagnosis is often made on postmortem examination due to the absence of diagnostic criteria and its rare occurrence. We describe the case of a middle-aged man who presented with rapidly progressive PHT. He deteriorated into multiorgan failure despite aggressive medical therapy and died 4 weeks after his initial presentation. A postmortem examination confirmed the diagnosis of PTTA in addition to the finding of signet cell gastric adenocarcinoma. This case highlights the lethal nature of this rare condition, the ongoing challenges in making an antemortem diagnosis, and the importance of postmortem examination in determining the cause of death to provide closure for both, the treating physician and the family.
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Affiliation(s)
- Joseph O'Brien
- Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Nicholas Jones
- Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Mark Horrigan
- Cardiology, Austin Health, Heidelberg, Victoria, Australia
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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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Quality of external post-mortem examination and death certificates at the University Hospital in Hamburg, Germany. Rechtsmedizin (Berl) 2019. [DOI: 10.1007/s00194-019-0323-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
A clinical as well as forensic autopsy is a uniform medical investigation of the deceased, which mainly serves to verify the plausibility of information on the cause, mode and mechanism of death provided by the police and/or medical personnel. Despite its importance in the context of a conclusive assessment of a person's medical history and in detecting any criminal correlation or malpractice, a significant decline in autopsies is evident in Iceland. This article gives an overview on autopsy rates in Iceland and compares the situation with European countries.
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Affiliation(s)
- S N Kunz
- Division of Forensic Pathology, Landspítali University Hospital Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Þ Bergsdóttir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Pathology, Landspítali University Hospital Reykjavik, Iceland
| | - J G Jónasson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Pathology, Landspítali University Hospital Reykjavik, Iceland
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Njuguna HN, Zaki SR, Roberts DJ, Fligner CL, Keating MK, Rogena E, Walong E, Gachii AK, Maleche-Obimbo E, Irimu G, Mathaiya J, Orata N, Lopokoiyit R, Maina J, Emukule GO, Onyango CO, Gikunju S, Owuor C, Kinuthia P, Bunei M, Fields B, Widdowson MA, Mott JA, Chaves SS. Determining the Cause of Death Among Children Hospitalized With Respiratory Illness in Kenya: Protocol for Pediatric Respiratory Etiology Surveillance Study (PRESS). JMIR Res Protoc 2019; 8:e10854. [PMID: 30632968 PMCID: PMC6705666 DOI: 10.2196/10854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/02/2018] [Accepted: 10/04/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, where the burden of respiratory disease-related deaths is the highest, information on the cause of death remains inadequate because of poor access to health care and limited availability of diagnostic tools. Postmortem examination can aid in the ascertainment of causes of death. This manuscript describes the study protocol for the Pediatric Respiratory Etiology Surveillance Study (PRESS). OBJECTIVE This study protocol aims to identify causes and etiologies associated with respiratory disease-related deaths among children (age 1-59 months) with respiratory illness admitted to the Kenyatta National Hospital (KNH), the largest public hospital in Kenya, through postmortem examination coupled with innovative approaches to laboratory investigation. METHODS We prospectively followed children hospitalized with respiratory illness until the end of clinical care or death. In case of death, parents or guardians were offered grief counseling, and postmortem examination was offered. Lung tissue specimens were collected using minimally invasive tissue sampling and conventional autopsy where other tissues were collected. Tissues were tested using histopathology, immunohistochemistry, and multipathogen molecular-based assays to identify pathogens. For each case, clinical and laboratory data were reviewed by a team of pathologists, clinicians, laboratorians, and epidemiologists to assign a cause of and etiology associated with death. RESULTS We have enrolled pediatric cases of respiratory illness hospitalized at the KNH at the time of this submission; of those, 14.8% (140/945) died while in the hospital. Both analysis and interpretation of laboratory results and writing up of findings are expected in 2019-2020. CONCLUSIONS Postmortem studies can help identify major pathogens contributing to respiratory-associated deaths in children. This information is needed to develop evidence-based prevention and treatment policies that target important causes of pediatric respiratory mortality and assist with the prioritization of local resources. Furthermore, PRESS can provide insights into the interpretation of results using multipathogen testing platforms in resource-limited settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/10854.
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Affiliation(s)
- Henry N Njuguna
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sherif R Zaki
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | | | - M Kelly Keating
- Infectious Disease Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | | | | | | | | | | | | | | | | | - Gideon O Emukule
- Influenza Program, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Clayton O Onyango
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Stella Gikunju
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Collins Owuor
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | | | - Barry Fields
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Joshua A Mott
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sandra S Chaves
- Influenza Program, Centers for Disease Control and Prevention, Nairobi, Kenya.,Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Zerbini T, Singer JM, Leyton V. Evaluation of the discrepancy between clinical diagnostic hypotheses and anatomopathological diagnoses resulting from autopsies. Clinics (Sao Paulo) 2019; 74:e1197. [PMID: 31531570 PMCID: PMC6735273 DOI: 10.6061/clinics/2019/e1197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/04/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES An objective of clinical autopsies is to determine the final cause of death and the pathological changes that may have triggered it. Despite advances in Medicine, the level of discrepancy between clinical and autopsy diagnoses remains significant. The aim of this study was to compare the data obtained from autopsies carried out at the São Bernardo do Campo/SP Death Verification Section with clinical diagnostic hypotheses proposed during medical care. METHOD This was a retrospective study involving the comparison of necroscopic reports issued by the São Bernardo do Campo/São Paulo Death Verification Section in 2014 and 2015 and the Cadaver Referral Guides completed by attending physicians prior to the necroscopic examination. RESULTS A total of 465 cases were analyzed. In general, discrepancies between the clinical diagnostic hypothesis and the autopsy diagnosis occurred in 28% of the cases. A logistic regression model, with diagnostic discrepancy as a response variable and sex, age, duration of care, type of institution providing medical care and organ system as explanatory variables, was fit to the data; the results indicated that all explanatory variables with the exception of organ system are not significant (p>0.132). CONCLUSIONS Discrepancies between clinical diagnostic hypotheses and autopsy diagnoses continue to occur, despite new developments in complementary examinations and therapies. The odds of a discrepancy when patients present with diseases of the cardiac system are greater than those when there are problems in the vascular, endocrine and neurological systems.
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Affiliation(s)
- Talita Zerbini
- Departamento de Medicina Legal, Etica Medica e Medicina Social e do Trabalho, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | - Julio M Singer
- Instituto de Matematica e Estatistica, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vilma Leyton
- Departamento de Medicina Legal, Etica Medica e Medicina Social e do Trabalho, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Olson AP, Graber ML. Learning from tragedy – improving diagnosis through case reviews. Diagnosis (Berl) 2018; 5:171-173. [DOI: 10.1515/dx-2018-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew P.J. Olson
- University of Minnesota Medical School , Departments of Medicine and Pediatrics , Minneapolis, MN , USA
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40
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Implementation of modern tools in autopsy practice-the way towards contemporary postmortal diagnostics. Virchows Arch 2018; 474:149-158. [PMID: 30426205 DOI: 10.1007/s00428-018-2482-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/11/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33 days to 15 days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1 year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.
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Priemer DS, Berry WA, Hawley DA, Cramer HM. Death within 30 days of fine needle aspiration: Post-mortem confirmation of FNA diagnoses and the contribution of FNA to patient mortality. Diagn Cytopathol 2018; 46:993-1003. [PMID: 30353701 DOI: 10.1002/dc.23985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/04/2018] [Accepted: 05/24/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fine needle aspiration (FNA) diagnoses are usually confirmed via surgical pathology or via evaluation of clinical outcomes. However, such confirmation may not occur for patients who die shortly after FNA, and autopsy may be a useful quality assessment tool in these cases. Also, there is little data investigating the relationship between FNA and mortality. We sought to demonstrate the autopsy as a quality assessment tool for the FNA and assess the contribution of FNA to mortality in patients who die soon after the procedure. METHODS A search of our database was performed from 1992 to 2016 for patients who were autopsied after dying within 30 d of an FNA. Concordance between findings from FNA, autopsy, and any intervening surgical pathology material was determined. Finally, a subjective determination of the likelihood that FNAs contributed to deaths was made by reviewing autopsy reports. The contribution was categorised as either "unlikely", "possible", or "probable". RESULTS Fifty-eight patients (average age = 58 y) met the search criteria. Thirty-six (62%) patients had malignancies. Surgical pathology material was obtained concurrently or following FNA in 20 cases (34%). There was 73% concordance between FNA and autopsy findings, which compares to 80% concordance between FNA and surgical pathology diagnoses. The FNA was determined to be at least possibly contributory to death in 7/58 cases (3 cases designated as "probable," and 4 as "possible"). CONCLUSION Autopsy can be used to validate FNA diagnoses and, like surgical pathology, confirms that FNA diagnoses are mostly accurate. However, in a small number of patients, FNA can precipitate death.
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Affiliation(s)
- David S Priemer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - William A Berry
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dean A Hawley
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Harvey M Cramer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Kim K, Lee YM. Understanding uncertainty in medicine: concepts and implications in medical education. KOREAN JOURNAL OF MEDICAL EDUCATION 2018; 30:181-188. [PMID: 30180505 PMCID: PMC6127608 DOI: 10.3946/kjme.2018.92] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/27/2018] [Accepted: 07/05/2018] [Indexed: 05/30/2023]
Abstract
In an era of high technology and low trust, acknowledging and coping with uncertainty is more crucial than ever. Medical uncertainty has been considered an innate feature of medicine and medical practice. An intolerance to uncertainty increases physicians' stress and the effects of burnout and may be a potential threat to patient safety. Understanding medical uncertainty and acquiring proper coping strategies has been regarded to be a core clinical competency for medical graduates and trainees. Integrating intuition and logic and creating a culture that acknowledges medical uncertainty could be suggested ways to teach medical uncertainty. In this article, the authors describe the concepts of medical uncertainty, its influences on physicians and on medical students toward medical decision making, the role of tolerance/intolerance to uncertainty, and proposed strategies to improve coping with medical uncertainty.
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Affiliation(s)
- Kangmoon Kim
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
| | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Wilson ML, Fleming KA, Kuti MA, Looi LM, Lago N, Ru K. Access to pathology and laboratory medicine services: a crucial gap. Lancet 2018; 391:1927-1938. [PMID: 29550029 DOI: 10.1016/s0140-6736(18)30458-6] [Citation(s) in RCA: 205] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/28/2017] [Accepted: 12/08/2017] [Indexed: 01/02/2023]
Abstract
As global efforts accelerate to implement the Sustainable Development Goals and, in particular, universal health coverage, access to high-quality and timely pathology and laboratory medicine (PALM) services will be needed to support health-care systems that are tasked with achieving these goals. This access will be most challenging to achieve in low-income and middle-income countries (LMICs), which have a disproportionately large share of the global burden of disease but a disproportionately low share of global health-care resources, particularly PALM services. In this first in a Series of three papers on PALM in LMICs, we describe the crucial and central roles of PALM services in the accurate diagnosis and detection of disease, informing prognosis and guiding treatment, contributing to disease screening, public health surveillance and disease registries, and supporting medical-legal systems. We also describe how, even though data are sparse, these services are of both insufficient scope and inadequate quality to play their key role in health-care systems in LMICs. Lastly, we identify four key barriers to the provision of optimal PALM services in resource-limited settings: insufficient human resources or workforce capacity, inadequate education and training, inadequate infrastructure, and insufficient quality, standards, and accreditation.
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Affiliation(s)
- Michael L Wilson
- Department of Pathology and Laboratory Services, Denver Health, Denver, CO, USA; Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Kenneth A Fleming
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA; Green Templeton College, University of Oxford, Oxford, UK
| | - Modupe A Kuti
- Department of Chemical Pathology, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Lai Meng Looi
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nestor Lago
- Department of Pathology, University of Buenos Aires, Buenos Aires, Argentina
| | - Kun Ru
- Department of Pathology and Laboratory Medicine, Institute of Hematology, Chinese Academy of Medical Sciences, Tianjin, China
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Dunwoodie Stirton F, Heslop P. Medical Certificates of Cause of Death for people with intellectual disabilities: A systematic literature review. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2018; 31:659-668. [DOI: 10.1111/jar.12448] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Fred Dunwoodie Stirton
- The Learning Disabilities Mortality Review (LeDeR) Programme; School for Policy Studies; University of Bristol; Bristol UK
| | - Pauline Heslop
- The Learning Disabilities Mortality Review (LeDeR) Programme; School for Policy Studies; University of Bristol; Bristol UK
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Sonnemans LJP, Kubat B, Prokop M, Klein WM. Can virtual autopsy with postmortem CT improve clinical diagnosis of cause of death? A retrospective observational cohort study in a Dutch tertiary referral centre. BMJ Open 2018; 8:e018834. [PMID: 29549202 PMCID: PMC5857682 DOI: 10.1136/bmjopen-2017-018834] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To investigate whether virtual autopsy with postmortem CT (PMCT) improves clinical diagnosis of the immediate cause of death. DESIGN Retrospective observational cohort study. INCLUSION CRITERIA inhospital and out-of-hospital deaths over the age of 1 year in whom virtual autopsy with PMCT and conventional autopsy were performed. EXCLUSION CRITERIA forensic cases, postmortal organ donors and cases with incomplete scanning procedures. Cadavers were examined by virtual autopsy with PMCT prior to conventional autopsy. The clinically determined cause of death was recorded before virtual autopsy and was then adjusted with the findings of virtual autopsy. Using conventional autopsy as reference standard, we investigated the increase in sensitivity for immediate cause of death, type of pathology and anatomical system involved before and after virtual autopsy. SETTING Tertiary referral centre. PARTICIPANTS 86 cadavers that underwent conventional and virtual autopsy between July 2012 and June 2016. INTERVENTION PMCT consisted of brain, cervical spine and chest-abdomen-pelvis imaging. Conventional autopsy consisted of thoracoabdominal examination with/without brain autopsy. PRIMARY AND SECONDARY OUTCOME MEASURES Increase in sensitivity for the immediate cause of death, type of pathology (infection, haemorrhage, perfusion disorder, other or not assigned) and anatomical system (pulmonary, cardiovascular, gastrointestinal, other or not assigned) involved, before and after virtual autopsy. RESULTS Using PMCT, the sensitivity for immediate cause of death increased with 12% (95% CI 2% to 22%) from 53% (41% to 64%) to 64% (53% to 75%), with 18% (9% to 27%) from 65% (54% to 76%) to 83% (73% to 91%) for type of pathology and with 19% (9% to 30%) from 65% (54% to 76%) to 85% (75% to 92%) for anatomical system. CONCLUSION While unenhanced PMCT is an insufficient substitute for conventional autopsy, it can improve diagnosis of cause of death over clinical diagnosis alone and should therefore be considered whenever autopsy is not performed.
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Affiliation(s)
- Lianne J P Sonnemans
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Bela Kubat
- Department of Pathology, Netherlands Forensic Institute, Hague, The Netherlands
- Department of Pathology, Maastricht UMC+, Maastricht, The Netherlands
| | - Mathias Prokop
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Willemijn M Klein
- Department of Radiology and Nuclear Medicine, Radboudumc, Nijmegen, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht UMC+, Maastricht, The Netherlands
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Abstract
Objective Although the autopsy still is a valuable tool in health statistics, health care quality control, medical education, and biomedical research, autopsy rates have been declining worldwide. The aim of this study was to examine trends of overall, clinical and forensic autopsy rates among adults in the Netherlands over the last four decades, and trends per sex, age (groups), and hospital type. Methods We performed a retrospective study covering 35 years of Dutch national death counts (1977–2011), the number of in-hospital deceased patients, the number of deaths due to external causes, and the proportion of autopsies performed in these populations. The effects of sex, age and hospital category were analysed by linear and logistic regression and differences were evaluated by chi-square tests. Results Overall autopsy rates declined by 0.3% per calendar year, clinical autopsy rates by 0.7% per calendar year (from 31.4% to 7.7%), and forensic autopsy rates did not decline. Per calendar year the fraction of in-hospital deceased patients decreased by 0.2%. Autopsy rates were highest among men and younger patients; clinical autopsy rates were highest for patients dying in academic hospitals. Conclusions In the Netherlands clinical autopsy rates have rapidly declined while at the same time the fraction of in-hospital deaths decreased, both contributing to the overall reduced absolute number of autopsies performed. It is important to improve awareness among both clinicians and general practitioners of the significance of the clinical autopsy.
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Khare P, Gupta R, Ahuja M, Khare N, Agarwal S, Bansal D. Prevalence of Lung Lesions at Autopsy: A Histopathological Study. J Clin Diagn Res 2017; 11:EC13-EC16. [PMID: 28658765 DOI: 10.7860/jcdr/2017/24747.9827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/05/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Autopsies are carried out to establish the identity, cause of death, time of death, and ante-mortem or post-mortem nature of death. These help in establishing the cause of death and ascertain the disease process which led to death. AIM To study the prevalence and pattern of lung diseases in medicolegal autopsies, confirmed by histopathological examination. MATERIALS AND METHODS This retrospective study was carried out in the Department of Pathology. Tissue bits from lungs, retrieved at the time of autopsy, were preserved in 10% formalin. These were processed and examined microscopically. A total of 86 cases were received during the period of study. RESULTS Among these 86 cases, in 4 cases (4.8%) the tissue was autolysed and in another 26 cases (30.1%) histopathology was unremarkable. Significant microscopic findings were found in 56 cases (65.1%). Wide spectrum of microscopic findings were seen, the commonest being oedema and congestion (28.5%) followed by changes in interstitium (11.9%). There were 9.5% cases of granulomatous inflammation and 5.9% cases each of acute pneumonia and emphysema. There were 1.2% cases each of Hyaline Membrane Disease (HMD), Meconium Aspiration Syndrome (MAS) and Acute Respiratory Distress Syndrome (ARDS) in the series. The series also had 1.2% cases of young adult having fungal colonies surrounded by necrosis and abscess formation. Possibility of mucormycosis was suggested in that case. CONCLUSION This study highlights various lesions in lungs confirmed by histopathology, which were either incidental or direct cause of death. The short coming in present study was non receipt of whole organ or representative sample at the time of autopsy, which if overcome will set much higher standard of autopsy reporting and would be a more useful tool in understanding cause of death.
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Affiliation(s)
- Pratima Khare
- Consultant and Head, Department of Pathology, Dr B.S.A. Hospital, New Delhi, India
| | - Renu Gupta
- Senior Specialist, Department of Pathology, Dr B.S.A. Hospital, New Delhi, India
| | - Mukta Ahuja
- Senior Resident, Department of Pathology, Dr B.S.A. Hospital, New Delhi, India
| | - Nupur Khare
- Intern, Dr B.S.A. Hospital, New Delhi, India
| | - Swapnil Agarwal
- Medical Officer, Department of Pathology, Dr B.S.A. Hospital, New Delhi, India
| | - Deepti Bansal
- Senior Resident, Department of Pathology, Dr B.S.A. Hospital, New Delhi, India
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Fleming KA, Naidoo M, Wilson M, Flanigan J, Horton S, Kuti M, Looi LM, Price C, Ru K, Ghafur A, Wang J, Lago N. An Essential Pathology Package for Low- and Middle-Income Countries. Am J Clin Pathol 2017; 147:15-32. [PMID: 28158414 DOI: 10.1093/ajcp/aqw143] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives We review the current status of pathology services in low- and middle-income countries and propose an “essential pathology package” along with estimated costs. The purpose is to provide guidance to policy makers as countries move toward universal health care systems. Methods Five key themes were reviewed using existing literature (role of leadership; education, training, and continuing professional development; technology; accreditation, management, and quality standards; and reimbursement systems). A tiered system is described, building on existing proposals. The economic analysis draws on the very limited published studies, combined with expert opinion. Results Countries have underinvested in pathology services, with detrimental effects on health care. The equipment needs for a tier 1 laboratory in a primary health facility are modest ($2-$5,000), compared with $150,000 to $200,000 in a district hospital, and higher in a referral hospital (depending on tests undertaken). Access to a national (or regional) specialized laboratory undertaking disease surveillance and registry is important. Recurrent costs of appropriate laboratories in district and referral hospitals are around 6% of the hospital budget in midsized hospitals and likely decline in the largest hospitals. Primary health facilities rely largely on single-use tests. Conclusions Pathology is an essential component of good universal health care.
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Affiliation(s)
- Kenneth A Fleming
- From the Centre for Global Health, National Cancer Institute, Washington, DC
- Green Templeton College
| | - Mahendra Naidoo
- From the Centre for Global Health, National Cancer Institute, Washington, DC
| | - Michael Wilson
- Department of Pathology, University of Colorado School of Medicine
- Department of Pathology & Laboratory Services, Denver Health, Denver, CO
| | - John Flanigan
- From the Centre for Global Health, National Cancer Institute, Washington, DC
| | - Susan Horton
- Global Health Economics, University of Waterloo, Waterloo, Canada
| | - Modupe Kuti
- Department of Chemical Pathology, College of Medicine, University of Ibadan & University College Hospital, Ibadan, Nigeria
| | - Lai Meng Looi
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chris Price
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kun Ru
- Department of Pathology and Lab Medicine
| | | | - Jianxiang Wang
- Institute of Hematology, Chinese Academy of Medical Sciences, Beijing, China
| | - Nestor Lago
- Department of Pathology, University of Buenos Aires, Buenos Aires, Argentina
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Diagnostic accuracy of postmortem imaging vs autopsy-A systematic review. Eur J Radiol 2016; 89:249-269. [PMID: 28089245 DOI: 10.1016/j.ejrad.2016.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/11/2016] [Accepted: 08/02/2016] [Indexed: 11/23/2022]
Abstract
Background Postmortem imaging has been used for more than a century as a complement to medico-legal autopsies. The technique has also emerged as a possible alternative to compensate for the continuous decline in the number of clinical autopsies. To evaluate the diagnostic accuracy of postmortem imaging for various types of findings, we performed this systematic literature review. Data sources The literature search was performed in the databases PubMed, Embase and Cochrane Library through January 7, 2015. Relevant publications were assessed for risk of bias using the QUADAS tool and were classified as low, moderate or high risk of bias according to pre-defined criteria. Autopsy and/or histopathology were used as reference standard. Findings The search generated 2600 abstracts, of which 340 were assessed as possibly relevant and read in full-text. After further evaluation 71 studies were finally included, of which 49 were assessed as having high risk of bias and 22 as moderate risk of bias. Due to considerable heterogeneity - in populations, techniques, analyses and reporting - of included studies it was impossible to combine data to get a summary estimate of the diagnostic accuracy of the various findings. Individual studies indicate, however, that imaging techniques might be useful for determining organ weights, and that the techniques seem superior to autopsy for detecting gas Conclusions and Implications In general, based on the current scientific literature, it was not possible to determine the diagnostic accuracy of postmortem imaging and its usefulness in conjunction with, or as an alternative to autopsy. To correctly determine the usefulness of postmortem imaging, future studies need improved planning, improved methodological quality and larger materials, preferentially obtained from multi-center studies.
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Carlotti APCP, Bachette LG, Carmona F, Manso PH, Vicente WVA, Ramalho FS. Discrepancies Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children: A Prospective Study. Am J Clin Pathol 2016; 146:701-708. [PMID: 27940427 DOI: 10.1093/ajcp/aqw187] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To evaluate the discrepancies between clinical and autopsy diagnoses in patients who died in the pediatric intensive care units (PICUs) of a tertiary care university hospital. METHODS A prospective study of all consecutive autopsies discussed at monthly mortality conferences over 5 years. Discrepancies between premortem and autopsy diagnoses were classified according to modified Goldman et al criteria. RESULTS From January 1, 2011, to December 31, 2015, a total of 2,679 children were admitted to the two PICUs of our hospital; 257 (9.6%) died, 150 (58.4%) underwent autopsy, and 123 were included. Complete concordance between clinical and postmortem diagnoses was observed in 86 (69.9%) patients; 20 (16.3%) had a class I discrepancy, and eight (6.5%) had a class II discrepancy. Comparing 2011 and 2015, the rate of major discrepancies decreased from 31.6% to 15%. CONCLUSIONS Our results emphasize the importance of autopsy to clarify the cause of death and its potential contribution to improvement of team performance and quality of care.
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Affiliation(s)
| | - Letícia G Bachette
- Division of Anesthesiology, Department of Biomechanics, Medicine, and Rehabilitation of the Locomotor Apparatus
| | - Fabio Carmona
- From the Division of Pediatric Critical Care, Department of Pediatrics
| | - Paulo H Manso
- Division of Pediatric Cardiology, Department of Pediatrics
| | - Walter V A Vicente
- Division of Pediatric Cardiovascular Surgery, Department of Surgery and Anatomy
| | - Fernando S Ramalho
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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