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Marcoen B, Blot KH, Vogelaers D, Blot S. Clinical vs. autopsy diagnostic discrepancies in the intensive care unit: a systematic review and meta-analysis of autopsy series. Intensive Care Med 2024:10.1007/s00134-024-07641-y. [PMID: 39287650 DOI: 10.1007/s00134-024-07641-y] [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: 06/06/2024] [Accepted: 08/29/2024] [Indexed: 09/19/2024]
Abstract
PURPOSE The aim of this study was to assess whether there is a discrepancy between clinical and autopsy-based diagnoses in adult intensive care unit (ICU) patients. METHODS We conducted a systematic review of cohort studies reporting on conventional autopsy-confirmed missed diagnoses. The discrepancy rate was per study calculated by dividing the number of patients with a missed diagnosis by the number of autopsies. Missed diagnoses were classified according to the Goldman classification as 'major' and 'minor' with major missed diagnoses further differentiated into Class I missed diagnoses (i.e., diagnoses that may have altered therapy or survival) and Class II missed diagnoses (i.e., diagnoses that would not have altered therapy or survival). Class I missed diagnoses constitute the primary outcome of interest. Pooled estimates for discrepancy rates (95% confidence intervals) were calculated using a mixed-effects logistic regression model with 'study' as random effect. Meta-regression was used to assess relationships between major discrepancy rates and autopsy rates, start year of study, and ICU type. RESULTS Forty-two studies were identified totaling 6305 analyzed autopsies and 1759 patients with missed diagnoses. The pooled discrepancy rates for Class I and major missed diagnoses were 6.5% (5-8.5) and 19.3% (15.3-24), respectively. Meta-regression analysis revealed that autopsy rate was inversely associated with discrepancy rate. Class I discrepancy rates did not change over time. Burn and trauma ICUs had lower discrepancy rates as compared to medical ICUs, possibly because of higher autopsy rates. CONCLUSIONS Missed diagnoses remain common in ICUs. A higher autopsy rate does not reveal more major diagnostic errors. These data support a clinically driven autopsy policy rather than a systematic autopsy policy.
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Affiliation(s)
- Britt Marcoen
- Department of Internal Medicine and Pediatrics, Ghent University, Campus UZ Gent, Ghent, Belgium
| | | | - Dirk Vogelaers
- Department of Internal Medicine and Pediatrics, Ghent University, Campus UZ Gent, Ghent, Belgium
- Department of General Internal Medicine and Infectious Diseases, AZ Delta, Roeselare, Belgium
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Ghent University, Campus UZ Gent, Ghent, Belgium.
- Faculty of Medicine, UQ Centre of Clinical Research, The University of Queensland, Brisbane, Australia.
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Suresh D, Rastogi P, Bal A, Lad D, Naseem S, Jain A, Khadwal AR, Malhotra P. Bridging the gap: understanding contemporary autopsies in acute leukemia by comparing ante-mortem and post-mortem profiles. Leuk Lymphoma 2024:1-16. [PMID: 38949830 DOI: 10.1080/10428194.2024.2372408] [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: 02/26/2024] [Accepted: 06/20/2024] [Indexed: 07/02/2024]
Abstract
This study investigates acute myeloid leukemia/lymphoblastic leukemia (AML/ALL) through a 14-year analysis (2009-2022) of 46 autopsied cases (age >12 years). B-ALL was the dominant subtype (34.8%). Liver and spleen were the common sites of active leukemia (63% cases). Symptoms like dyspnea and altered sensorium associated significantly with heart (p = .031) and brain leukostasis (p = .006). Measurable residual disease (MRD) negativity correlated with disease-free status outside the bone marrow, while MRD-positive cases displayed leukemic infiltrates. Infections were identified in 23 autopsied cases, notably linked to post-induction and post-transplant fatalities. Surprisingly, 18 of these 23 cases had unexpected infections mainly fungal (13 cases) with Aspergillus species as the most common. Diagnostic discrepancies were identified in 48% of cases. Malignant infiltration (46%) and infections (25%) were the leading causes of death. This research sheds light on leukemia in extra-medullary tissues, uncovers novel clinical-pathological associations, and highlights overlooked therapy side effects, offering insights for future case management.
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Affiliation(s)
- Deepthi Suresh
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pulkit Rastogi
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shano Naseem
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Rani Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Leulseged H, A Rees C, Alemu A, A Tippett Barr B, Dheresa M, Madrid L, Scott A, Assefa N. The discrepancy of antemortem clinical diagnosis and postmortem autopsy diagnosis of lung pathologies in under-five deaths and the reasons for discrepancies: a case series analysis. BMC Pediatr 2024; 24:365. [PMID: 38807044 PMCID: PMC11131180 DOI: 10.1186/s12887-024-04854-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/23/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Diagnostic autopsy is the most reliable approach to definitively ascertain the cause of death and evaluate the accuracy of antemortem clinical diagnoses. Identifying diagnostic discrepancies is vital to understanding common gaps in antemortem clinical diagnoses and modifying antemortem diagnostic approaches to increase the accuracy of clinical diagnosis. The objective of this study was to determine the frequency of diagnostic discrepancies between antemortem clinical diagnoses and postmortem autopsies on lung pathologies and to understand the reasons for diagnostic discrepancies among cases included in Child Health and Mortality Prevention Surveillance (CHAMPS) in Ethiopia. METHODS A clinical case series study of deaths among children under-five in the CHAMPS study at three sites in Ethiopia between October 2019 and April 2022 was conducted. The antemortem clinical diagnoses and postmortem pathological diagnoses of the lung were compared for each case. Two senior physicians assessed the findings for both agreement and disagreement. McNemar's test was used to assess for statistically significant differences between antemortem and postmortem diagnoses. RESULTS Seventy-five cases were included (73.3% male). Over half (54.7%) died between the 1st and 7th day of life. Sepsis (66.7%), pneumonia (6.7%), and meconium aspiration syndrome (5.0%) were the most common immediate causes of death. Half (52%) of cases were correctly diagnosed antemortem. The magnitude of diagnostic discrepancy was 35% (95% CI: 20-47%). The most common contributing factors to diagnostic discrepancy were gaps in knowledge (22/75, 35.5%) and problems in consultation and teamwork (22/75, 35.5%). CONCLUSIONS Misdiagnoses were common among young children who died with positive lung pathology findings. In-service education initiatives and multidisciplinary collaboration are needed to mitigate high rates of diagnostic discrepancies among young children to potentially prevent future deaths.
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Affiliation(s)
- Haleluya Leulseged
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia.
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia.
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Addisu Alemu
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
| | - Beth A Tippett Barr
- Nyanja Health Research Institute, Salima, Malawi
- London School of Hygiene and Tropical Medicine, London, UK
| | - Merga Dheresa
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
| | - Lola Madrid
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anthony Scott
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nega Assefa
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
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Zhao B, Huepenbecker S, Zhu G, Rajan SS, Fujimoto K, Luo X. Comorbidity network analysis using graphical models for electronic health records. Front Big Data 2023; 6:846202. [PMID: 37663273 PMCID: PMC10470017 DOI: 10.3389/fdata.2023.846202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 07/25/2023] [Indexed: 09/05/2023] Open
Abstract
Importance The comorbidity network represents multiple diseases and their relationships in a graph. Understanding comorbidity networks among critical care unit (CCU) patients can help doctors diagnose patients faster, minimize missed diagnoses, and potentially decrease morbidity and mortality. Objective The main objective of this study was to identify the comorbidity network among CCU patients using a novel application of a machine learning method (graphical modeling method). The second objective was to compare the machine learning method with a traditional pairwise method in simulation. Method This cross-sectional study used CCU patients' data from Medical Information Mart for the Intensive Care-3 (MIMIC-3) dataset, an electronic health record (EHR) of patients with CCU hospitalizations within Beth Israel Deaconess Hospital from 2001 to 2012. A machine learning method (graphical modeling method) was applied to identify the comorbidity network of 654 diagnosis categories among 46,511 patients. Results Out of the 654 diagnosis categories, the graphical modeling method identified a comorbidity network of 2,806 associations in 510 diagnosis categories. Two medical professionals reviewed the comorbidity network and confirmed that the associations were consistent with current medical understanding. Moreover, the strongest association in our network was between "poisoning by psychotropic agents" and "accidental poisoning by tranquilizers" (logOR 8.16), and the most connected diagnosis was "disorders of fluid, electrolyte, and acid-base balance" (63 associated diagnosis categories). Our method outperformed traditional pairwise comorbidity network methods in simulation studies. Some strongest associations between diagnosis categories were also identified, for example, "diagnoses of mitral and aortic valve" and "other rheumatic heart disease" (logOR: 5.15). Furthermore, our method identified diagnosis categories that were connected with most other diagnosis categories, for example, "disorders of fluid, electrolyte, and acid-base balance" was associated with 63 other diagnosis categories. Additionally, using a data-driven approach, our method partitioned the diagnosis categories into 14 modularity classes. Conclusion and relevance Our graphical modeling method inferred a logical comorbidity network whose associations were consistent with current medical understanding and outperformed traditional network methods in simulation. Our comorbidity network method can potentially assist CCU doctors in diagnosing patients faster and minimizing missed diagnoses.
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Affiliation(s)
- Bo Zhao
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Sarah Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gen Zhu
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Suja S. Rajan
- Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Kayo Fujimoto
- Department of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
| | - Xi Luo
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center, Houston, TX, United States
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Cohen J, Fischetti AJ, Daverio H. Veterinary radiologic error rate as determined by necropsy. Vet Radiol Ultrasound 2023. [PMID: 37296079 DOI: 10.1111/vru.13259] [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: 03/11/2023] [Revised: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 06/12/2023] Open
Abstract
A large-scale postmortem auditing of antemortem imaging diagnoses has yet to be accomplished in veterinary medicine. For this retrospective, observational, single-center, diagnostic accuracy study, necropsy reports for patients of The Schwarzman Animal Medical Center were collected over a 1-year period. Each necropsy diagnosis was determined to be either correctly diagnosed or discrepant with its corresponding antemortem diagnostic imaging, and discrepancies were categorized. The radiologic error rate was calculated to include only clinically significant missed diagnoses (lesion was not reported but was retrospectively visible on the image) and misinterpretations (lesion was noted but was incorrectly diagnosed). Nonerror discrepancies, such as temporal indeterminacy, microscopic limitations, sensitivity limitations, and study-type limitations were not included in the error rate. A total of 1099 necropsy diagnoses had corresponding antemortem imaging; 440 diagnoses were classified as major diagnoses, of which 176 were discrepant, for a major discrepancy rate of 40%, similar to reports in people. Seventeen major discrepancies were diagnoses that were missed or misinterpreted by the radiologist, for a calculated radiologic error rate of 4.6%, comparable with error rates of 3%-5% reported in people. From 2020 to 2021, nearly half of all clinically significant abnormalities noted at necropsy went undetected by antemortem imaging, though most discrepancies owed to factors other than radiologic error. Identifying common patterns of misdiagnosis and discrepancy will help radiologists refine their analysis of imaging studies to potentially reduce interpretive error.
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Affiliation(s)
- Jonathan Cohen
- Department of Radiology, MedVet Medical and Cancer Centers for Pets, Fairfax, Ohio, USA
| | - Anthony J Fischetti
- Department of Diagnostic Imaging, Schwarzman Animal Medical Center, New York City, New York, USA
| | - Heather Daverio
- Department of Anatomic Pathology, Schwarzman Animal Medical Center, New York City, New York, USA
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Russell L, Weihe S, Madsen EK, Hvas CL, Leistner JW, Michelsen J, Brøchner AC, Bastiansen A, Nielsen FM, Meier N, Andreasen AS, Ribergaard N, Rasmussen BS, Sølling CG, Buck DL, Bundgaard H, Pedersen HS, Darfelt IS, Poulsen LM, Ibsen M, Plovsing RR, Sigurdsson ST, Iversen S, Hildebrandt T, Mohr T, Espelund US, Jørgensen V, Haase N, Perner A. Thromboembolic and bleeding events in ICU patients with COVID-19: A nationwide, observational study. Acta Anaesthesiol Scand 2023; 67:76-85. [PMID: 36263897 PMCID: PMC9874434 DOI: 10.1111/aas.14157] [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] [Received: 08/13/2022] [Revised: 10/08/2022] [Accepted: 10/13/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients with Coronavirus disease 2019 (COVID-19) have an increased risk of thromboembolic complications. We describe the occurrence of thromboembolic and bleeding events in all ICU patients with COVID-19 in Denmark during the first and second waves of the pandemic. METHODS This was a sub-study of the Danish Intensive Care Covid database, in which all patients with SARS-CoV-2 admitted to Danish ICUs from 10th March 2020 to 30th June 2021 were included. We registered coagulation variables at admission, and all thromboembolic and bleeding events, and the use of heparins during ICU stay. Variables associated with thrombosis and bleeding and any association with 90-day mortality were estimated using Cox regression analyses. RESULTS We included 1369 patients in this sub-study; 158 (12%, 95% confidence interval 10-13) had a thromboembolic event in ICU and 309 (23%, 20-25) had a bleeding event, among whom 81 patients (6%, 4.8-7.3) had major bleeding. We found that mechanical ventilation and increased D-dimer were associated with thrombosis and mechanical ventilation, low platelet count and presence of haematological malignancy were associated with bleeding. Most patients (76%) received increased doses of thromboprophylaxis during their ICU stay. Thromboembolic events were not associated with mortality in adjusted analysis (hazard ratio 1.35 [0.91-2.01, p = .14], whereas bleeding events were 1.55 [1.18-2.05, p = .002]). CONCLUSIONS Both thromboembolic and bleeding events frequently occurred in ICU patients with COVID-19. Based on these data, it is not apparent that increased doses of thromboprophylaxis were beneficial.
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Affiliation(s)
- Lene Russell
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Sarah Weihe
- Department of AnaesthesiologyZealand University HospitalRoskildeDenmark
| | - Emilie Kabel Madsen
- Department of Anaesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
| | | | - Jens Wolfgang Leistner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Jens Michelsen
- Department of Anaesthesiology and Intensive CareOdense University HospitalOdenseDenmark
| | - Anne Craveiro Brøchner
- Department of Anaesthesiology and Intensive CareUniversity Hospital of Southern DenmarkKoldingDenmark
| | - Anders Bastiansen
- Department of Anaesthesiology and Intensive CareBispebjerg HospitalCopenhagenDenmark
| | | | - Nick Meier
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | | | - Niels‐Erik Ribergaard
- Department of Anaesthesiology and Intensive CareHjørring Regional HospitalHjørringDenmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive CareAalborg University HospitalAalborgDenmark
| | | | - David Levarett Buck
- Department of Anaesthesiology and Intensive CareHolbæk HospitalHolbækDenmark
| | - Helle Bundgaard
- Department of Anaesthesiology and Intensive CareRanders Regional HospitalRandersDenmark
| | - Helle Scharling Pedersen
- Department of Anaesthesiology and Intensive CareNykøbing Falster HospitalNykøbing FalsterDenmark
| | - Iben Strøm Darfelt
- Department of Anaesthesiology and Intensive CareRegionshospitalet GødstrupHerningDenmark
| | | | - Michael Ibsen
- Department of Anaesthesiology and Intensive CareNorth Zealand HospitalHillerødDenmark
| | - Ronni R. Plovsing
- Department of Anaesthesiology and Intensive CareHvidovre HospitalHvidovreDenmark
| | | | - Susanne Iversen
- Department of Anaesthesiology and Intensive CareSlagelse HospitalSlagelseDenmark
| | - Thomas Hildebrandt
- Department of Anaesthesiology and Intensive CareZealand University HospitalRoskildeDenmark
| | - Thomas Mohr
- Department of Anaesthesiology and Intensive CareGentofte HospitalGentofteDenmark
| | | | - Vibeke Jørgensen
- Department of Cardiothoracic Anaesthesiology, RigshospitaletCopenhagenDenmark
| | - Nicolai Haase
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Anders Perner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
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Nistal-Nuño B. Developing machine learning models for prediction of mortality in the medical intensive care unit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 216:106663. [PMID: 35123348 DOI: 10.1016/j.cmpb.2022.106663] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/22/2021] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Alert of patient deterioration is essential for prompt medical intervention in the Medical Intensive Care Unit (MICU). Logistic Regression (LR) has been used for the development of most conventional severity-of-illness scoring systems to anticipate the risk of mortality in the MICU. Machine Learning (ML) models such as probabilistic graphical models and Extreme Gradient Boosting (XGB) have demonstrated improved prediction accuracy in patient outcomes compared to LR. The aim was to compare three ML models to the SAPS, SAPS II, SAPS III, SOFA, serial SOFA, LODS, and OASIS for prediction of MICU mortality. METHODS A Bayesian Network (BN), Naïve Bayes network (NB), and a XGB model were developed. 9893 adult MICU-stays from the MIMIC-III database were studied. The primary outcome was MICU mortality prediction and the secondary outcome was 1-year mortality prediction. Data analyzed consisted on routine physiological measurements collected during 5 hours in the MICU, demographic and diagnoses/procedure features. The performance was evaluated by accuracy statistics, discrimination and calibration measures. Limitations of the study were discussed. RESULTS The AUROC for MICU mortality prediction was 0.919 for XGB, 0.905 for BN, and 0.864 for NB, while the conventional systems displayed much lower values with the serial SOFA having the best value (0.814). The Diagnostic Odds Ratio was ≤7.099 for all the conventional systems, reaching values of 30.115 for XGB and 22.648 for BN. The XGB achieved a sensitivity of 0.831 and specificity of 0.86 assuring an acceptable precision (0.528), whose values were much lower for the conventional systems. The Brier score was better for the ML models, except for the NB (0.119), with 0.072 for XGB and 0.081 for BN. CONCLUSIONS The XGB and BN substantially outperformed the conventional systems for discrimination, calibration and the accuracy statistics assessed. The NB showed inferior performance to the XGB and BN but improved the discrimination and all accuracy statistics of the conventional systems except for an inferior calibration and 1-year mortality discrimination. The XGB showed the best performance among all models. These ML models have the potential to improve the monitoring of MICU patients, which must be evaluated in future studies.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anesthesiology, Complejo Hospitalario Universitario de Pontevedra. Mourente s/n, 36071, Pontevedra. Spain.
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Singh D, Tiwari RC, Kumar A, Bhute AR, Meshram RP, Dikshit M, Sharma VB, Mittal B. A Comprehensive Review of Pathological Examination in Forensic Medicine: Past, Present, and Future. Cureus 2022; 14:e22740. [PMID: 35382189 PMCID: PMC8975612 DOI: 10.7759/cureus.22740] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/05/2022] Open
Abstract
Pathological examination (PE) encompasses a gross or macroscopy and histopathological or microscopic examination. It is prudent in finding the cause of death (COD) in clinical and medicolegal autopsies. There are various auxiliary techniques in the form of clinical history, communication, specialized training, and protocols for consolidation of the PE results. After a thorough search of the literature in PubMed with relevant keywords along with further analysis of the results, it emerged that even with the modernization of forensic medicine, a PE is unbeatable in detecting the COD. It has various useful aspects, apart from regular finding the COD, such as in student teaching, epidemiology of disease, audit tool, and quality assurance. There are also limitations of PE, which should be dealt with great caution. Hence, limitations must be understood by a forensic expert as well as a pathologist. In this review, all factors that are related to PE in any manner are discussed in detail, and the scope for improving the quality of PE to be relevant in the present scenario is reviewed. It is a comprehensive reassessment of the literature review that also casts light on the future along with a critical analysis of the facts that deal with PE.
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Feys S, Almyroudi MP, Braspenning R, Lagrou K, Spriet I, Dimopoulos G, Wauters J. A Visual and Comprehensive Review on COVID-19-Associated Pulmonary Aspergillosis (CAPA). J Fungi (Basel) 2021; 7:1067. [PMID: 34947049 PMCID: PMC8708864 DOI: 10.3390/jof7121067] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 19 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a severe fungal infection complicating critically ill COVID-19 patients. Numerous retrospective and prospective studies have been performed to get a better grasp on this lethal co-infection. We performed a qualitative review and summarized data from 48 studies in which 7047 patients had been included, of whom 820 had CAPA. The pooled incidence of proven, probable or putative CAPA was 15.1% among 2953 ICU-admitted COVID-19 patients included in 18 prospective studies. Incidences showed great variability due to multiple factors such as discrepancies in the rate and depth of the fungal work-up. The pathophysiology and risk factors for CAPA are ill-defined, but therapy with corticosteroids and anti-interleukin-6 therapy potentially confer the biggest risk. Sampling for mycological work-up using bronchoscopy is the cornerstone for diagnosis, as imaging is often aspecific. CAPA is associated with an increased mortality, but we do not have conclusive data whether therapy contributes to an increased survival in these patients. We conclude our review with a comparison between influenza-associated pulmonary aspergillosis (IAPA) and CAPA.
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Affiliation(s)
- Simon Feys
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Reinout Braspenning
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
- Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
| | - George Dimopoulos
- ICU of 1st Department of Critical Care, Sotiria Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
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10
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Domschikowski J, Koch K, Schmalz C. Cause of Death in Patients in Radiation Oncology. Front Oncol 2021; 11:763629. [PMID: 34746005 PMCID: PMC8566939 DOI: 10.3389/fonc.2021.763629] [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] [Received: 08/24/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background The accurate attribution of death in oncologic patients is a difficult task. The patient's death is often attributed to his or her underlying cancer and therefore judged as cancer-related. We hypothesized that even though our patient's cancers were either advanced or metastatic, not all patients had died simply because of their cancer. Methods A total of 105 patients were included in this retrospective analysis. Patient data were collected from digital and paper-based records. Cause of death was assessed from death certificate and compared to the medical autopsy reports. Discrepancies between premortem and postmortem diagnoses were classified as class I and II discrepancies. Results Of 105 patients included, autopsy consent was obtained in 56 cases (53%). Among them, 32 of 56 were palliatively sedated, and 42/56 patients died cancer-related as confirmed by autopsy. The most common cause of death by autopsy report was multiorgan failure followed by a combination of tumor and infection, predominantly lung cancer with pneumonia. Here, 21/56 cases (37%) showed major missed diagnoses: seven cases showed class I, 10 class II, and both discrepancies. The most commonly missed diagnoses in both categories were infections, again mainly pneumonia. Conclusions Cancer was the leading cause of death in our study population. A quarter of the patients, however, did not die due to their advanced or metastatic cancers but of potentially curable causes. We therefore conclude that it is important to consider competing causes of death when treating palliative cancer patients. In a palliative setting, the treatment of a potentially curable complication should be discussed with the patients and their families in a shared decision-making process. From our experience, many patients will decline treatment or even further diagnostics when given the option of best supportive care.
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Affiliation(s)
- Justus Domschikowski
- Department of Radiation Oncology, University-Hospital Schleswig-Holstein, Kiel, Germany
| | - Karoline Koch
- Department of Pathology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University-Hospital Schleswig-Holstein, Kiel, Germany
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Frequency and Significance of Pathologic Pulmonary Findings in Postmortem Examinations-A Single Center Experience before COVID-19. Diagnostics (Basel) 2021; 11:diagnostics11050894. [PMID: 34069794 PMCID: PMC8157293 DOI: 10.3390/diagnostics11050894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has shown the importance of postmortem investigation of deceased patients. For a correct interpretation of the pulmonary findings in this new era, it is, however, crucial to be familiar with pathologic pulmonary conditions observed in postmortem investigations in general. Adequate postmortem histopathological evaluation of the lungs may be affected by suboptimal gross work up, autolysis or poor fixation. Using a standardized preparation approach which consisted in instillation of 4% buffered formaldehyde through the large bronchi for proper fixation and preparing large frontal tissue sections of 1-2 cm thickness after at least 24 h fixation, we comprehensively analyzed postmortem pulmonary findings from consecutive adult autopsies of a two-year period before the occurrence of COVID-19 (2016-2017). In total, significant pathological findings were observed in 97/189 patients (51%), with 28 patients showing more than one pathologic condition. Acute pneumonia was diagnosed 33/128 times (26%), embolism 24 times (19%), primary pulmonary neoplasms 18 times (14%), organizing pneumonia and other fibrosing conditions 14 times (11%), pulmonary metastases 13 times (10%), diffuse alveolar damage 12 times (9%), severe emphysema 9 times (7%) and other pathologies, e.g., amyloidosis 5/128 times (4%). Pulmonary/cardiopulmonary disease was the cause of death in 60 patients (32%). Clinical and pathological diagnoses regarding lung findings correlated completely in 75 patients (40%). Autopsy led to confirmation of a clinically suspected pulmonary diagnosis in 57 patients (39%) and clarification of an unclear clinical lung finding in 16 patients (8%). Major discrepant findings regarding the lungs (N = 31; 16%) comprised cases with clinical suspicions that could not be confirmed or new findings not diagnosed intra vitam. A significant proportion of acute pneumonias (N = 8; 24% of all cases with this diagnosis; p = 0.011) was not diagnosed clinically. We confirmed the frequent occurrence of pulmonary pathologies in autopsies, including inflammatory and neoplastic lesions as the most frequent pathological findings. Acute pneumonia was an important cause for discrepancy between clinical and postmortem diagnostics.
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Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients. Virchows Arch 2021; 478:1179-1185. [PMID: 33392797 DOI: 10.1007/s00428-020-03002-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/12/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
Prevalence of discrepancies between antemortem clinical diagnoses and postmortem autopsy findings is uncertain in pediatric oncology given improving diagnostic capabilities over time. Primary objective was to describe discrepancies between antemortem and postmortem diagnosis of pediatric cancer deaths. Secondary objective was to compare clinical characteristics of deaths with and without major diagnostic discrepancies. This was a retrospective study that included pediatric cancer patients diagnosed and treated in Ontario and who died from 2003 to 2012. Antemortem clinical diagnoses associated with mortality were determined by reviewing the patient's health records 2 weeks prior to death while the postmortem diagnoses were determined by the autopsy report. Discrepancies among these diagnoses were classified using the Goldman criteria where major discrepancies were directly related to the cause of death in contrast to minor discrepancies. Among the 821 patients who died, 118 (14%) had an autopsy and were included. Of these autopsies, 12 (10%) had a major diagnostic discrepancy between antemortem and postmortem diagnoses. Major discrepancies consisted of opportunistic infections (n = 5), missed cancer diagnosis (n = 3), and organ complications (n = 4). Death in a high acuity setting (12/12, 100% vs. 60/106, 57%; P = 0.003) and treatment-related mortality (12/12, 100% vs. 60/106, 57%; P = 0.003) were significantly associated with major discrepancy. Major diagnostic discrepancy was found in 10% of pediatric oncology autopsies. Missed infections and organ complications were predominant etiologies. Death in a high acuity setting and treatment-related mortality were associated with major diagnostic discrepancies. Autopsies continue to be important for improving diagnostic insight and may improve future clinical care.
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Missed diagnosis and misdiagnosis of infectious diseases in hematopoietic cell transplant recipients: an autopsy study. Blood Adv 2020; 3:3602-3612. [PMID: 31743391 DOI: 10.1182/bloodadvances.2019000634] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/10/2019] [Indexed: 01/20/2023] Open
Abstract
Hematopoietic cell transplantation (HCT) is potentially curative for patients with hematologic disorders, but carries significant risks of infection-related morbidity and mortality. Infectious diseases are the second most common cause of death in HCT recipients, surpassed only by progression of underlying disease. Many infectious diseases are difficult to diagnose and treat, and may only be first identified by autopsy. However, autopsy rates are decreasing despite their value. The clinical and autopsy records of adult HCT recipients at our center who underwent autopsy between 1 January 2000 and 31 December 2017 were reviewed. Discrepancies between premortem clinical diagnoses and postmortem autopsy diagnoses were evaluated. Of 185 patients who underwent autopsy, 35 patients (18.8%) had a total of 41 missed infections. Five patients (2.7%) had >1 missed infection. Of the 41 missed infections, 18 (43.9%) were viral, 16 (39.0%) were fungal, 5 (12.2%) were bacterial, and 2 (4.9%) were parasitic. According to the Goldman criteria, 31 discrepancies (75.6%) were class I, 5 (12.2%) were class II, 1 (2.4%) was class III, and 4 (9.8%) were class IV. Autopsies of HCT recipients frequently identify clinically significant infectious diseases that were not suspected premortem. Had these infections been suspected, a change in management might have improved patient survival in many of these cases. Autopsy is underutilized and should be performed regularly to help improve infection-related morbidity and mortality. Illustrative cases are presented and the lessons learned from them are also discussed.
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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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Autopsy among recipients of stem cell transplant for hematologic malignancies in the modern era. Bone Marrow Transplant 2020; 56:282-284. [PMID: 32641800 DOI: 10.1038/s41409-020-0992-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/13/2020] [Accepted: 06/25/2020] [Indexed: 11/08/2022]
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Frequency, Risk Factors, Causes, and Consequences of Diagnostic Errors in Critically Ill Medical Patients: A Retrospective Cohort Study. Crit Care Med 2020; 47:e902-e910. [PMID: 31524644 DOI: 10.1097/ccm.0000000000003976] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Diagnostic errors are a source of significant morbidity and mortality but understudied in the critically ill. We sought to characterize the frequency, causes, consequences, and risk factors of diagnostic errors among unplanned ICU admissions. DESIGN We conducted a retrospective cohort study of randomly selected nonsurgical ICU admissions between July 2015 and June 2016. SETTING Medical ICU at a tertiary academic medical center. SUBJECTS Critically ill adults with unplanned admission to the medical ICU. MEASUREMENTS AND MAIN RESULTS The primary investigator reviewed patient records using a modified version of the Safer Dx instrument, a validated instrument for detecting diagnostic error. Two intensivists performed secondary reviews of possible errors, and reviewers met periodically to adjudicate errors by consensus. For each confirmed error, we judged harm on a 1-6 rating scale. We also collected detailed demographic and clinical data for each patient. We analyzed 256 unplanned ICU admissions and identified 18 diagnostic errors (7% of admissions). All errors were associated with harm, and only six errors (33%) were recognized by the ICU team within the first 24 hours. More women than men experienced a diagnostic error (11.7% vs 2.7%; p = 0.015, χ test). On multivariable logistic regression analysis, female sex remained independently associated with risk of diagnostic error both at admission (odds ratio, 5.18; 95% CI, 1.34-20.08) and at 24 hours (odds ratio, 11.6; 95% CI, 1.37-98.6). Similarly, Quick Sequential Organ Failure Assessment score greater than or equal to 2 at admission was independently associated with diagnostic error (odds ratio, 5.73; 95% CI, 1.72-19.01). CONCLUSIONS Diagnostic errors may be an underappreciated source of ICU-related harm. Women and higher acuity patients appear to be at increased risk for such errors. Further research is merited to define the scope of error-associated harm and to clarify risk factors for diagnostic errors among the critically ill.
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Ishida M, Gonoi W, Shirota G, Abe H, Shintani-Domoto Y, Ikemura M, Ushiku T, Abe O. Utility of unenhanced postmortem computed tomography for investigation of in-hospital nontraumatic death in children up to 3 years of age at a single Japanese tertiary care hospital. Medicine (Baltimore) 2020; 99:e20130. [PMID: 32384493 PMCID: PMC7220630 DOI: 10.1097/md.0000000000020130] [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: 12/19/2022] Open
Abstract
To evaluate the utility of unenhanced postmortem computed tomography (PMCT) for the investigation of in-hospital nontraumatic death in children up to 3 years of age.This study included the cadavers of children who died from intrinsic diseases before 3 years of age. The major underlying disease and the main organ-disease systems associated with the immediate causes of death were determined by clinical evaluation, PMCT, and autopsy, which were used as a reference standard. The rates of concordance between the former two methods and autopsy were calculated for all cases.In total, 22 cadavers (12 male and 10 female; mean age, 6.1 ± 8.2 months) were included. The rates of concordance between clinical evaluation/PMCT and autopsy for diagnosis of the major underlying disease and main organ-disease systems associated with the immediate causes of death were 100%/36% (P = .0015) and 59%/41% (P = .37), respectively. In cases where the respiratory system was associated with the immediate cause of death, PMCT showed greater diagnostic sensitivity (90%) than did clinical evaluation (20%). In contrast, the diagnostic sensitivity of PMCT was lower than that of clinical evaluation in cases involving disorders of the cardiac system and multiple organ systems (0% vs 100% for both).The findings of this study suggest that the use of unenhanced PMCT with clinical evaluation can result in improved detection of the immediate cause of death in select cases of in-hospital nontraumatic death before 3 years of age.
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Affiliation(s)
| | | | | | - Hiroyuki Abe
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yukako Shintani-Domoto
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Masako Ikemura
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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[Analysis of the major clinical-pathological discrepancies in autopsies of adults in a tertiary referral hospital between 2008-2017]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2020; 54:92-101. [PMID: 33726896 DOI: 10.1016/j.patol.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/23/2020] [Accepted: 02/24/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare and contrast clinical diagnoses with autopsy findings in order to identify unexpected, relevant discrepancies. MATERIAL AND METHOD A retrospective observational study of the revision of autopsies of adults and their respective medical records in order to classify them according to referral department and Goldman's classification was carried out at the Central University Hospital of Asturias between 2008-2017. RESULTS 694 (52.6%) of 1320 autopsies were included in the study. Discrepancies were observed in 57.6% of cases, although the majority (39.3%) were minor. Type I discrepancies were identified in 63 autopsies (9.1%); malignant neoplasms being the main pathology observed (57.1%), mainly of gastrointestinal origin (about 28%). The second most common discrepancy was found in cases of infectious diseases (23.8%) followed by pulmonary embolism (15.9%). 64 autopsies were classified as type II discrepancies (9.2%), with myocardial infarct the most common (37.5%), especially acute myocardial infarction (18 cases), followed by bronchoaspirations (18.7%), DIC (15.6%), massive haemorrhages (9.4%) and other conditions. It was considered that both the ICU and the Internal Medicine Service were responsible for the largest number of major discrepancies (type I and II), accounting for about 45% of type I and slightly more than 56% for type II. CONCLUSION Autopsies are an essential means of identifying ante-mortem clinical errors. The incidence of major discrepancies in the Central University Hospital of Asturias (18.3%) is comparable to that of leading hospitals worldwide.
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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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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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Sklar J. The Clinical Autopsy and Genomic Testing. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:1682-1685. [DOI: 10.1016/j.ajpath.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/24/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022]
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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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Van de Louw A, Lewis AM, Yang Z. Autopsy findings in patients with acute myeloid leukemia and non-Hodgkin lymphoma in the modern era: a focus on lung pathology and acute respiratory failure. Ann Hematol 2018; 98:119-129. [PMID: 30218164 DOI: 10.1007/s00277-018-3494-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/09/2018] [Indexed: 12/21/2022]
Abstract
We aimed to report autopsy findings in patients with acute myeloid leukemia (AML) and non-Hodgkin lymphoma (NHL) in the modern era, and also to focus on lung pathology in the subgroup of patients with acute respiratory failure (ARF) of unknown etiology, which is associated with especially high mortality rates. Charts and autopsy reports of 107 patients (59 AML and 48 NHL) autopsied between 2003 and 2018 were reviewed. More than 50% of patients had missed major diagnoses found at autopsy with 95% of lungs displaying abnormal findings. Malignant infiltration in at least one organ was observed in about 70% of patients with either no complete remission or relapse at the time of death (n = 92) versus 20% in patients without signs of active malignancy (n = 15) (p = 0.001). In patients with ARF of unknown etiology (n = 59), the proportion of malignant lung infiltration was 27% and equilibrated with bacterial pneumonias (29%), fungal pneumonias represented 8%, and isolated alveolar damage or pulmonary edema were the only findings in 32% of patients. Overall, 85% of patients with ARF of unknown etiology had either relapsed or not achieved remission at time of death and 80% of patients with malignant lung infiltration had ARF of unknown etiology. Ninety percent of malignant infiltration and fungal infections were observed in patients with no complete remission or relapse. Autopsy remains valuable in AML and NHL patients; besides infections, malignant infiltration is a significant contributor to ARF of unknown etiology and is rarely diagnosed ante mortem.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - Allyson M Lewis
- Department of Pathology, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Zhaohai Yang
- Department of Pathology, Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
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Harris B, Geyer AI. Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:317-331. [PMID: 28477642 PMCID: PMC7172342 DOI: 10.1016/j.ccm.2016.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.
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Affiliation(s)
- Bianca Harris
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Alexander I Geyer
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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Shimabukuro-Vornhagen A, Böll B, Kochanek M, Azoulay É, von Bergwelt-Baildon MS. Critical care of patients with cancer. CA Cancer J Clin 2016; 66:496-517. [PMID: 27348695 DOI: 10.3322/caac.21351] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Consultant, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Head of Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Éli Azoulay
- Director, Medical Intensive Care Unit, St. Louis Hospital, Paris, France
- Professor of Medicine, Teaching and Research Unit, Department of Medicine, Paris Diderot University, Paris, France
- Chair, Study Group for Respiratory Intensive Care in Malignancies, St. Louis Hospital, Paris, France
| | - Michael S von Bergwelt-Baildon
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Professor, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
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Postmortem CT is more accurate than clinical diagnosis for identifying the immediate cause of death in hospitalized patients: a prospective autopsy-based study. Virchows Arch 2016; 469:101-9. [PMID: 27085336 PMCID: PMC4923108 DOI: 10.1007/s00428-016-1937-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 01/04/2016] [Accepted: 03/29/2016] [Indexed: 10/25/2022]
Abstract
Despite 75 to 90 % physician accuracy in determining the underlying cause of death, precision of determination of the immediate cause of death is approximately 40 %. In contrast, two thirds of immediate causes of death in hospitalized patients are correctly diagnosed by postmortem computed tomography (CT). Postmortem CT might provide an alternative approach to verifying the immediate cause of death. To evaluate the effectiveness of postmortem CT as an alternative method to determine the immediate cause of death in hospitalized patients, an autopsy-based prospective study was performed. Of 563 deaths from September 2011 to August 2013, 50 consecutive cadavers undergoing hospital autopsies with consent for additional postmortem CT at the University of Fukui were enrolled. The accuracy of determination of the immediate cause of death by postmortem CT was evaluated in these patients. Diagnostic discrepancy was also compared between radiologists and attending physicians. The immediate cause of death was correctly diagnosed in 37 of 50 subjects using postmortem CT (74 %), concerning 29 cases of respiratory failure, 4 of hemorrhage, 3 of liver failure and 1 of septic shock. Six cases of organ failure involving 13 patients were not identified as the cause of death by postmortem CT. Regarding the immediate cause of death, accuracy of clinical diagnosis was significantly lower than that of postmortem CT (46 vs 74 %, P < 0.01). Postmortem CT may be more useful than clinical diagnosis for identifying the immediate cause of death in hospitalized patients not undergoing autopsy.
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THE ROLE OF AUTOPSY IN MEDICAL INTENSIVE CARE UNIT: COMPARISON OF CLINICAL AND POSTMORTEM DIAGNOSES. ACTA ACUST UNITED AC 2016. [DOI: 10.14260/jemds/2016/242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Val-Bernal JF. [The current role of autopsy in current clinical practice]. Med Clin (Barc) 2015; 145:313-6. [PMID: 25851915 DOI: 10.1016/j.medcli.2015.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 02/25/2015] [Accepted: 02/27/2015] [Indexed: 11/17/2022]
Affiliation(s)
- José Fernando Val-Bernal
- Unidad de Patología, Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Cantabria, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, España.
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Assessing the accuracy of death records and pre-mortem clinical diagnoses in children diagnosed with brain tumors: A retrospective chart review of children in British Columbia, Canada. Pathol Res Pract 2015; 211:748-53. [PMID: 26342938 DOI: 10.1016/j.prp.2015.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/05/2015] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
Abstract
The advantages of autopsy have been demonstrated in pediatric oncology; however, it is unknown to what extent the utility of autopsy is in deceased children diagnosed with a pediatric brain tumor (PBT). The purpose of this study was to describe the frequency of autopsy, prevalence of clinical discrepancies, and accuracy of cancer registry death records for deceased children diagnosed with a PBT in British Columbia, Canada. A retrospective chart review was performed of medical records and autopsy reports of pediatric patients diagnosed with a PBT that died between 1982 and 2012 in British Columbia. Clinical discrepancies between pre- and post-mortem findings were classified based on a modified classification system of the Goldman Criteria. The overall autopsy rate was 15.5% (32 of 206) during 1982-2012, with a significant (P=0.001) decrease of 22.4% observed between decade 1 (32.8%) and decade 2 (10.4%) and a further slight decrease (4.5%) between decade 2 (10.4%) and decade 3 (5.9%) (P=0.379). A third of patients had discrepancies between pre-mortem and post-mortem clinical diagnoses, with slightly over 10% of these cases revealing information that would have altered the probability of survival had it been known prior to death. More than half (59.3%) of cases had discordant cause of death as recorded in the cancer registry when compared to autopsy findings. Autopsy for children diagnosed with a PBT can provide health care professionals with important information about the accuracy of their diagnoses and evaluate the efficacy of therapy.
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van den Tweel JG, Wittekind C. The medical autopsy as quality assurance tool in clinical medicine: dreams and realities. Virchows Arch 2015; 468:75-81. [PMID: 26316183 PMCID: PMC4751188 DOI: 10.1007/s00428-015-1833-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/27/2015] [Accepted: 08/11/2015] [Indexed: 11/30/2022]
Abstract
The purpose of medical autopsy has changed to issues of quality assurance today. In addition, autopsies are considered valuable in medical education, e.g., delivering cases for problem-based learning for students. Many studies underscore the need for autopsies also in the era of technical progress emphasizing the continuing discrepancies between antemortem and post mortem diagnoses. Despite these important tasks, we face a decline of autopsy for several reasons with complex interactions. The role of all persons involved in this decline is evaluated and suggestions for changes are proposed. Last but not least, the future of the autopsy is in the hands of pathology itself.
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Affiliation(s)
- Jan G van den Tweel
- Department of Pathology, University Medical Center Utrecht, H4-312, 3584 CX, Utrecht, The Netherlands.
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Abstract
Many health care providers believe that the autopsy is no longer relevant in high-technology medicine era. This has fueled a decline in the hospital autopsy rate. Although it seems that advanced diagnostic tests answer all clinical questions, studies repeatedly demonstrate that an autopsy uncovers as many undiagnosed conditions today as in the past. The forensic autopsy rate has also declined, although not as precipitously. Pathologists are still performing a nineteenth century autopsy procedure that remains essentially unchanged. Informatics offers several potential answers that will evolve the low-tech autopsy into the high-tech autopsy.
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Affiliation(s)
- Bruce Levy
- Department of Pathology, University of Illinois at Chicago, MC847, 840 South Wood Street 130 CSN, Chicago, IL 60612, USA.
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Bieri U, Moch H, Dehler S, Korol D, Rohrmann S. Changes in autopsy rates among cancer patients and their impact on cancer statistics from a public health point of view: a longitudinal study from 1980 to 2010 with data from Cancer Registry Zurich. Virchows Arch 2015; 466:637-43. [PMID: 25749838 DOI: 10.1007/s00428-015-1734-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 11/24/2022]
Abstract
During the last decades, autopsy rates have dramatically decreased in many countries. The Cancer Registry Zurich, which exists since 1980, provides the opportunity to address to what extent the number of autopsies in cancer patients has changed over a longer period of time and how often autopsies provide a diagnosis of clinically undetected cancer. Data from the Cancer Registry Zurich consisting of 102,434 cancer cases among 89,933 deceased patients between 1980 and 2010 were analyzed by means of descriptive statistics. The autopsy rate declined from 60 % in 1980 to 7 % in 2010. The total number of autopsies performed decreased from 1179 in 1986 to 220 in 2010. Furthermore, there was also a decline in the rate of newly detected tumours based on autopsy information. In 1980, the rate of newly detected tumours through autopsy was 42 % compared with 2010, when the rate had declined to 17 %. A consequence of the reduced autopsy rate is the reduction of incidental findings at autopsy in cancer registration. However, this reduction has not negatively affected the total incidence of cancer. It seems that the state-of-the-art diagnostic tools used for tumour detection are sufficiently reliable, allowing the scientific community to trust the quality of data provided by cancer registries in spite of decreasing autopsy rates.
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Affiliation(s)
- Uwe Bieri
- Division of Chronic Disease Epidemiology, Epidemiology, Biostatistics and Prevention Institute (EPBI), University of Zurich, Hirschengraben 84, 8001, Zürich, Switzerland
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Plu I, Sazdovitch V, Duyckaerts C, Seilhean D. Quelle place pour l’autopsie médicale en 2015 ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-015-1070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Costache M, Lazaroiu AM, Contolenco A, Costache D, George S, Sajin M, Patrascu OM. Clinical or postmortem? The importance of the autopsy; a retrospective study. MAEDICA 2014; 9:261-265. [PMID: 25705288 PMCID: PMC4305994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/29/2014] [Indexed: 06/04/2023]
Abstract
Medicine is continually evolving; the new technologies of diagnosis and treatment continue to improve the life expectancy and lead to new information concerning various pathologies. The autopsy is viewed more and more as an ultimate branch of medicine and used only in extreme cases or for forensic purposes. Nevertheless, many studies, including this one, prove the utility and indispensability of the autopsies, without which a complete and accurate diagnosis cannot be made. Finally, the autopsy followed by histopathological examination of the tissues remains the ultimate and most important step for the apprehension of the diseases and for further evolution of medicine. This study reveals the correspondence rate between the clinical and the postmortem diagnosis, as well as between macroscopic and histopathological diagnosis.
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Affiliation(s)
- Mariana Costache
- Department of Pathology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania ; Department of Pathology, Emergency University Hospital Bucharest, Romania
| | - Anca Mihaela Lazaroiu
- Department of Pathology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania ; Department of Pathology, Emergency University Hospital Bucharest, Romania
| | - Andreea Contolenco
- Department of Pathology, Emergency University Hospital Bucharest, Romania
| | - Diana Costache
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Simion George
- Department of Pathology, Emergency University Hospital Bucharest, Romania
| | - Maria Sajin
- Department of Pathology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania ; Department of Pathology, Emergency University Hospital Bucharest, Romania
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Andersen GN, Viset A, Mjølstad OC, Salvesen Ø, Dalen H, Haugen BO. Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students. BMC MEDICAL EDUCATION 2014; 14:156. [PMID: 25070529 PMCID: PMC4131775 DOI: 10.1186/1472-6920-14-156] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 07/17/2014] [Indexed: 05/10/2023]
Abstract
BACKGROUND Point-of-care ultrasound performed by clinicians is a useful supplement in the treatment and assessment of patients. We aimed to investigate whether medical students with minimal training were able to successfully acquire and interpret ultrasound images using a pocket-size imaging device (PSID) as a supplement to their clinical practice. METHODS Thirty 5th year (of six) medical students volunteered to participate. They were each given a personal PSID device to use as a supplement to their physical examination during their allocated hospital terms. Prior to clinical placement the students were given three evenings of hands-on training with PSID by a board certified radiologist/cardiologist, including three short lectures (<20 min). The students were shown basic ultrasound techniques and taught to assess for basic, clinically relevant pathology. They were specifically instructed to assess for the presence or absence of reduced left ventricular function (assessed as mitral annular excursion < 10 mm), pericardial effusion, pleural effusion, lung comets, hydronephrosis, bladder distension, gallstones, abdominal free-fluid, cholecystitis, and estimate the diameter of abdominal aorta and inferior vena cava. RESULTS A total of 211 patients were examined creating 1151 ultrasound recordings. Acceptable organ presentation was 73.8% (95% CI 63.1-82.6) for cardiovascular and 88.4% (95% CI: 80.6-93.6) for radiological structures. Diagnostic accuracy was 93.5% (95% CI: 89.0-96.2) and 93.2% (95% CI: 87.4-96.5) respectively. CONCLUSION Medical students with minimal training were able to use PSID as a supplement to standard physical examination and successfully acquire acceptable relevant organ recordings for presentation and correctly interpret these with great accuracy.
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Affiliation(s)
- Garrett Newton Andersen
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway
- Levanger Hospital, Nord-Trøndelag Health Trust, 7600 Levanger, Norway
| | - Annja Viset
- Clinic of Radiology and Nuclear Medicine, St. Olav Trondheim University Hospital, Trondheim, Norway
| | - Ole Christian Mjølstad
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway
- Clinic of Cardiology, St. Olav Trondheim University Hospital, Trondheim, Norway
| | - Øyvind Salvesen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Håvard Dalen
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway
- Levanger Hospital, Nord-Trøndelag Health Trust, 7600 Levanger, Norway
| | - Bjørn Olav Haugen
- MI Lab and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway
- Clinic of Cardiology, St. Olav Trondheim University Hospital, Trondheim, Norway
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Are autopsy findings still relevant to the management of critically ill patients in the modern era? Crit Care Med 2014; 42:336-43. [PMID: 23989180 DOI: 10.1097/ccm.0b013e3182a275b1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the accuracy of clinical diagnoses compared to autopsy findings in critically ill patients in the current medical era. DESIGN We conducted a retrospective, blinded review of matched medical records and postmortem findings in patients who died between June 2006 and June 2011. SETTING An ICU of a major university teaching hospital in Dublin, Ireland. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS A modification of the Goldman criteria was used to classify diagnostic error. There were 629 ICU deaths during the study period. Two hundred and seven patients underwent autopsy and 204 records were available for review. The mean age was 59 ± 18.1 years, 62% were male, 70% were postoperative patients, and median length of ICU stay was 3 days. Admission diagnosis, admission source, and admission specialty were similar between autopsy and nonautopsy patients. Five patients (2.4%; CI, 0.8-5.6%) had a class I discrepancy and 11 patients (5.4%; CI, 2.4-9.7%) had a class II discrepancy. Minor missed diagnoses were present in 31 patients (15.2%; CI, 4.5-12.4%). There was complete concordance between clinical and postmortem findings (class V) in 161 patients (79%; CI, 72.7-84.3%). In more than half the cases of discrepancy, it was not possible for physicians to make the diagnosis antemortem in the time available, despite appropriate investigations. CONCLUSIONS We detected a lower rate of clinicopathological discrepancy in critically ill patients than previously reported. Potential reasons for such findings include advances in diagnostic techniques and the use of a more robust definition to classify diagnostic discrepancies. Autopsy can still identify discrepancies in diagnosis even in patients who have undergone appropriate investigations. Prospective research is required to accurately define discrepancy rates in the critically ill population and to identify the patient subgroups in whom autopsy will continue to yield valuable information.
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Khawaja O, Khalil M, Zmeili O, Soubani AO. Major discrepancies between clinical and postmortem diagnoses in critically ill cancer patients: Is autopsy still useful? Avicenna J Med 2013; 3:63-7. [PMID: 24251233 PMCID: PMC3818781 DOI: 10.4103/2231-0770.118460] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Describe the major discrepancies between the clinical and postmortem findings in critically ill cancer patients admitted to the medical intensive care unit (MICU). MATERIALS AND METHODS Retrospectively review of the medical records of all cancer patients who were admitted to the MICU and underwent postmortem examination over 6 year period. The records were reviewed for demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, clinical cause of death, and postmortem findings. RESULTS There were 70 patients who had complete medical records. Mean age was 54.7 years (standard deviation (SD) ±14.8 years). Twenty-six patients had hematopoeitic stem cell transplantation (group I), 21 patients had hematological malignancies (group II), and 23 patients had solid malignancies (group III). The APACHE II score on admission to the MICU was 24.2 ± 8.0. Sixty-seven patients were mechanically ventilated, and the MICU stay was (mean ± SD) 9.0 ± 11.6 days. Major discrepancies between the clinical and postmortem diagnoses (Goldman classes I and II) were detected in 15 patients (21%). The most common missed diagnoses were aspergillosis, pulmonary embolism, and cancer recurrence. There were no differences between groups regarding the rate of major discrepancies. CONCLUSION Despite the advances in the diagnosis and treatment of critically ill cancer patients, autopsies continue to show major discrepancies between the clinical and postmortem diagnoses. Autopsy is still useful in this patient population.
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Affiliation(s)
- Owais Khawaja
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
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Chang CH, Kao KC, Hu HC, Hung CY, Li LF, Wu CY, Wang CW, Fu JY, Huang CC, Chen NH, Yang CT, Tsai YH. The utility of surgical lung biopsy in cancer patients with acute respiratory distress syndrome. J Cardiothorac Surg 2013; 8:128. [PMID: 23680446 PMCID: PMC3716885 DOI: 10.1186/1749-8090-8-128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/13/2013] [Indexed: 11/19/2022] Open
Abstract
Background This retrospective study evaluated the utility and safety of surgical lung biopsy (SLB) in cancer patients with acute respiratory distress syndrome (ARDS). Methods All cases of critically ill patients with cancer and diagnosed with ARDS who underwent SLB in a tertiary care hospital from January 2002 to July 2009 were reviewed. Clinical data including patient baseline characteristics, surgical complications, pathological findings, treatment alterations, and survival outcomes were retrospectively collected and analyzed. Results A total of 16 critically ill patients with cancer diagnosed with ARDS who underwent SLB were enrolled. The meantime from ARDS onset to SLB was 3.0 ± 1.5 days. All SLB specimens offered a pathological diagnosis, and specific diagnoses were made in 9 of 16 patients. Biopsy findings resulted in a change in therapy in 11 of 16 patients. Overall, the SLB surgical complication rate was 19% (3/16). SLB did not directly cause the observed operative mortality. The ICU mortality rate was 38% (6/16). Patients who switched therapies after SLB had a trend toward decreased mortality than patients without a change in therapy (27% versus 60%; P = 0.299). Conclusions In selected critically ill cancer patients with ARDS, SLB had a high diagnostic yield rate and an acceptable surgical complication rate.
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Alabran JL, Hooper JE, Hill M, Smith SE, Spady KK, Davis LE, Peterson LS, Malempati S, Ryan CW, Acosta R, Spunt SL, Keller C. Overcoming autopsy barriers in pediatric cancer research. Pediatr Blood Cancer 2013; 60:204-9. [PMID: 23015377 PMCID: PMC3522778 DOI: 10.1002/pbc.24320] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/16/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND More than 13,000 children annually in the United States and Canada under the age of 20 will be diagnosed with cancer at a mortality approaching 20% 1,2. Tumor samples obtained by autopsy provide an innovative way to study tumor progression, potentially aiding in the discovery of new treatments and increased survival rates. The purpose of this study was to identify barriers to autopsies and develop guidelines for requesting autopsies for research purposes. PROCEDURE Families of children treated for childhood cancer were referred by patient advocacy groups and surveyed about attitudes and experiences with research autopsies. From 60 interviews, barriers to autopsy and tumor banking were identified. An additional 14 interviews were conducted with medical and scientific experts. RESULTS Ninety-three percent of parents of deceased children did or would have consented to a research autopsy if presented with the option; however, only half of these families were given the opportunity to donate autopsy tissue for research. The most significant barriers were the physicians' reluctance to ask a grieving family and lack of awareness about research opportunities. CONCLUSIONS The value of donating tumor samples to research via an autopsy should be promoted to all groups managing pediatric cancer patients. Not only does autopsy tumor banking offer a potentially important medical and scientific impact, but the opportunity to contribute this Legacy Gift of autopsy tumor tissue also creates a positive outlet for the grieving family. Taking these findings into account, our multidisciplinary team has developed a curriculum addressing key barriers.
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Affiliation(s)
- Jennifer L. Alabran
- Pediatric Cancer Biology Program, Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239 USA,Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA
| | - Jody E. Hooper
- Department of Pathology, Oregon Health & Science University, Portland, OR 97239 USA
| | - Melissa Hill
- Northwest Sarcoma Foundation, Portland, OR 97291 USA
| | | | | | - Lara E. Davis
- Pediatric Cancer Biology Program, Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239 USA,Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA,Division of Pediatric Hematology/Oncology, Oregon Health & Science University, Portland, OR 97239 USA
| | - Lauren S. Peterson
- Pediatric Cancer Biology Program, Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239 USA,Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA
| | - Suman Malempati
- Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA,Division of Pediatric Hematology/Oncology, Oregon Health & Science University, Portland, OR 97239 USA
| | - Christopher W. Ryan
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239 USA,Division of Hematology/Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR 97239 USA
| | - Rae Acosta
- Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA,Division of Pediatric Hematology/Oncology, Oregon Health & Science University, Portland, OR 97239 USA
| | - Sheri L. Spunt
- Department of Oncology, St. Jude Children’s Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN 38105 USA
| | - Charles Keller
- Pediatric Cancer Biology Program, Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR 97239 USA,Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239 USA,Corresponding author address: Pediatric Cancer Biology Program, Papé Family Pediatrics Research Institute, Department of Pediatrics, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, MC-L321, Portland, OR 97239-3098 USA, Tel: (503)494-1210, Fax: (503)418-5044,
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García Soler P, Martínez-Ferriz M, Martín Carballido S, Milano Manso G. Estado actual y utilidad de la autopsia clínica en una unidad de cuidados intensivos pediátricos. An Pediatr (Barc) 2013; 78:81-7. [DOI: 10.1016/j.anpedi.2012.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 11/30/2022] Open
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Abstract
CONTEXT The causes of death for patients with lung cancer are inadequately described. OBJECTIVE To categorize the immediate and contributing causes of death for patients with lung cancer. DESIGN The autopsies from 100 patients who died of lung cancer between 1990 and February 2011 were analyzed. RESULTS Tumor burden was judged the immediate cause of death in 30 cases, including 26 cases of extensive metastases and 4 cases with wholly or primarily lung tumor burden (causing respiratory failure). Infection was the immediate cause of death for 20 patients, including 8 with sepsis and 12 with pneumonia. Complications of metastatic disease were the immediate causes of death in 18 cases, including 6 cases of hemopericardium from pericardial metastases, 3 from myocardial metastases, 3 from liver metastases, and 3 from brain metastases. Other immediate causes of death were pulmonary hemorrhage (12 cases), pulmonary embolism (10 cases, 2 tumor emboli), and pulmonary diffuse alveolar damage (7 cases). From a functional (pathophysiologic) perspective, respiratory failure could be regarded as the immediate cause of death (or mechanism of death) in 38 cases, usually because of a combination of lung conditions, including emphysema, airway obstruction, pneumonia, hemorrhage, embolism, resection, and lung injury in addition to the tumor. For 94 of the 100 patients, there were contributing causes of death, with an average of 2.5 contributing causes and up to 6 contributing causes of death. CONCLUSIONS The numerous and complex ways lung cancer kills patients pose a challenge for efforts to extend and improve their lives.
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Affiliation(s)
- Larry Nichols
- Department of Pathology, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, Pennsylvania, USA.
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43
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Weber R, Ruppik M, Rickenbach M, Spoerri A, Furrer H, Battegay M, Cavassini M, Calmy A, Bernasconi E, Schmid P, Flepp M, Kowalska J, Ledergerber B. Decreasing mortality and changing patterns of causes of death in the Swiss HIV Cohort Study. HIV Med 2012; 14:195-207. [PMID: 22998068 DOI: 10.1111/j.1468-1293.2012.01051.x] [Citation(s) in RCA: 297] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Mortality among HIV-infected persons is decreasing, and causes of death are changing. Classification of deaths is hampered because of low autopsy rates, frequent deaths outside of hospitals, and shortcomings of International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding. METHODS We studied mortality among Swiss HIV Cohort Study (SHCS) participants (1988-2010) and causes of death using the Coding Causes of Death in HIV (CoDe) protocol (2005-2009). Furthermore, we linked the SHCS data to the Swiss National Cohort (SNC) cause of death registry. RESULTS AIDS-related mortality peaked in 1992 [11.0/100 person-years (PY)] and decreased to 0.144/100 PY (2006); non-AIDS-related mortality ranged between 1.74 (1993) and 0.776/100 PY (2006); mortality of unknown cause ranged between 2.33 and 0.206/100 PY. From 2005 to 2009, 459 of 9053 participants (5.1%) died. Underlying causes of deaths were: non-AIDS malignancies [total, 85 (19%) of 446 deceased persons with known hepatitis C virus (HCV) status; HCV-negative persons, 59 (24%); HCV-coinfected persons, 26 (13%)]; AIDS [73 (16%); 50 (21%); 23 (11%)]; liver failure [67 (15%); 12 (5%); 55 (27%)]; non-AIDS infections [42 (9%); 13 (5%); 29 (14%)]; substance use [31 (7%); 9 (4%); 22 (11%)]; suicide [28 (6%); 17 (7%), 11 (6%)]; myocardial infarction [28 (6%); 24 (10%), 4 (2%)]. Characteristics of deceased persons differed in 2005 vs. 2009: median age (45 vs. 49 years, respectively); median CD4 count (257 vs. 321 cells/μL, respectively); the percentage of individuals who were antiretroviral therapy-naïve (13 vs. 5%, respectively); the percentage of deaths that were AIDS-related (23 vs. 9%, respectively); and the percentage of deaths from non-AIDS-related malignancies (13 vs. 24%, respectively). Concordance in the classification of deaths was 72% between CoDe and ICD-10 coding in the SHCS; and 60% between the SHCS and the SNC registry. CONCLUSIONS Mortality in HIV-positive persons decreased to 1.33/100 PY in 2010. Hepatitis B or C virus coinfections increased the risk of death. Between 2005 and 2009, 84% of deaths were non-AIDS-related. Causes of deaths varied according to data source and coding system.
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Affiliation(s)
- R Weber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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44
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Tissue Diagnosis of Invasive Fungal Infections: Current Limitations and the Emerging Use of Molecular Techniques. CURRENT FUNGAL INFECTION REPORTS 2012. [DOI: 10.1007/s12281-012-0098-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Penninckx B, Van de Voorde WM, Casado A, Reed N, Moulin C, Karrasch M. A systemic review of toxic death in clinical oncology trials: an Achilles' heel in safety reporting revisited. Br J Cancer 2012; 107:1-6. [PMID: 22677904 PMCID: PMC3389431 DOI: 10.1038/bjc.2012.252] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 05/04/2012] [Accepted: 05/11/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Toxic death is defined as study treatment-related mortality and as such is considered as an iatrogenic death. This belongs to unnatural death where an autopsy is advised. Until now, conventional autopsy is the gold standard to discriminate between pre- and post-mortem discrepancies. METHODS The consequences of lack of systematically performing an autopsy will be explored in the setting of oncological clinical trials. RESULTS During more than one decade, 6428 Serious Adverse Events have been registered in the EORTC Safety database on a total of 34 734 subjects. The number of deaths were 764 (mortality rate of 2.2%) whereof 255 (rate of 0.7%) toxic deaths. In 89.8% of these toxic deaths, no autopsy has been done; in 25.1% (64 cases) an inconsistent cause of death was found based on studying of the medical narrative. The autopsy rate was only 10.2% (26 out of 255) and, in 46.2% of the performed autopsies, there was a clinical pathological discrepancy. CONCLUSION When no autopsy is performed, there is a high risk for a wrong diagnosis in case of suspected toxic death. The high discrepancy rate, possibly due to a low autopsy rate, shows that toxic death is an Achilles' heel in iatrogenic mortality.
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Affiliation(s)
- B Penninckx
- Medical Department, EORTC Headquarters, E. Mounierlaan 83/11, 1200 Brussels, Belgium.
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46
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Lott Limbach AA, Prayson RA. Utility of autopsy in uncovering unexpected neuropathology. Ann Diagn Pathol 2012; 16:350-3. [PMID: 22520718 DOI: 10.1016/j.anndiagpath.2012.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 02/23/2012] [Accepted: 02/23/2012] [Indexed: 11/18/2022]
Abstract
Autopsy rates have declined in the last several decades for a variety of reasons. The purpose of this study is to compare autopsy neuropathologic findings from 2 periods to assess the prevalence of unexpected neuropathologic findings and unexpected neuropathologic diagnoses determined to be the major cause of death. Retrospective review of autopsies with examination of the central nervous system was performed in 2007 to 2008 (n = 289) and 1984 to 1985 (n = 328). Unexpected neuropathologic diagnoses were found at autopsy in 42.4% of cases from 1984 to 1985 vs 38.8% of cases from 2007 to 2008. The neuropathology was felt to contribute to the cause of death in 22% of cases from 1984 to 1985 vs 19.7% of cases from 2007 to 2008. Unexpected neuropathologic findings were the cause of death in 5.2% of cases from 1984 to 1985 vs 3.1% of cases from 2007 to 2008. These findings underscore the continued use of brain and spinal cord examination at autopsy despite advances in "modern" medicine.
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Polednak AP. Recent decline in the U.S. death rate from myeloproliferative neoplasms, 1999–2006. Cancer Epidemiol 2012; 36:133-6. [DOI: 10.1016/j.canep.2011.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 05/03/2011] [Accepted: 05/24/2011] [Indexed: 11/29/2022]
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Thaker HM, Vernon DD. The autopsy: underutilized weapon in the pediatric intensive care unit. Pediatr Crit Care Med 2011; 12:675-6. [PMID: 22067814 DOI: 10.1097/pcc.0b013e3182071277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Spunt SL, Vargas SO, Coffin CM, Skapek SX, Parham DM, Darling J, Hawkins DS, Keller C. The clinical, research, and social value of autopsy after any cancer death: a perspective from the Children's Oncology Group Soft Tissue Sarcoma Committee. Cancer 2011; 118:3002-9. [PMID: 22006470 DOI: 10.1002/cncr.26620] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 08/21/2011] [Accepted: 09/13/2011] [Indexed: 01/04/2023]
Affiliation(s)
- Sheri L Spunt
- Department of Oncology, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee 38105-3678, USA.
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50
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Rigaud JP, Quenot JP, Borel M, Plu I, Hervé C, Moutel G. Post mortem scientific sampling and the search for causes of death in intensive care: what information should be given and what consent should be obtained? JOURNAL OF MEDICAL ETHICS 2011; 37:132-136. [PMID: 21186206 PMCID: PMC3317884 DOI: 10.1136/jme.2010.037739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
PURPOSE The search for cause of death is important to improve knowledge and provide answers for the relatives of the deceased. Medical autopsy following unexplained death in hospital is one way to identify cause of death but is difficult to carry out routinely. Post mortem sampling (PMS) of tissues via thin biopsy needle or 'mini incisions' in the skin may be a useful alternative. A study was undertaken to assess how this approach is perceived by intensive care doctors and also to evaluate how this practice is considered in ethical terms in France. METHODS A study of PMS practices immediately after death in 10 intensive care departments was performed. The medical director of each centre was interviewed by telephone and asked to describe practices in their unit and to outline the questions raised by this practice. RESULTS PMS is routinely performed in 70% of the units which responded, without systematically obtaining formal consent and without precise rules for communicating results. Approaches to PMS differed between centres, but all physicians felt that PMS is useful for the scientific information it gives and also for the information it provides for relatives. All physicians regret the lack of standards to structure PMS practices. CONCLUSION Information from post mortem examinations is important for society to inform about causes of death, for doctors to improve practices and for decision-makers responsible for organising care. Debate persists regarding the balance between individual rights and community interests. It is suggested that an approach for identifying cause of death could easily be integrated into the relationship between carers and relatives, provided full transparency is maintained.
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Affiliation(s)
- J P Rigaud
- Réanimation Polyvalente, Centre Hospitalier Dieppe, Avenue Pasteur, BP 219, Dieppe 76200, France.
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