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PubMed2006

Perinatal and infant autopsy.

OBJECTIVES: To measure perinatal and infant autopsy rate in Wales over a 10-year period and study factors influencing the decision to perform an autopsy. DESIGN: Retrospective cohort analysis of data from the All Wales Perinatal Survey. METHODS: Autopsy rates were calculated over a 10-year period (1994-2003), and reasons for not performing an autopsy were noted. Two time periods, 1994-1996 and 2001-2003 were compared, to study changing autopsy patterns. RESULTS: Over the 10-year period, there were 4393 perinatal and infant deaths, with data available for 4306 (98%) cases. Consent for autopsy was requested in 89% of cases and granted in 68%. When compared, the 3-year cumulative autopsy rate fell from 67.5% (95% confidence interval (CI) 65% to 69%) in 1994-1996, to 52.7% (CI 49% to 55%) in 2001-2003. The difference in the proportion of autopsies performed between the two time periods was 14.8% (CI 11% to 18%). Parental consent was granted in 76.2% (CI 73% to 78%) of cases in 1994-1996 and 60% (CI 57% to 63%) of cases in 2001-2003. The difference in proportion in consent for autopsy in the two time periods was 16% (CI 12% to 20%). CONCLUSIONS: A decrease in perinatal and infant autopsy rates has been found in Wales over the past 10 years. Parental refusal has been the main cause of this decline.

Autopsy↗
PubMed1996

The consortium to establish a registry for Alzheimer's Disease (CERAD). Part XIII. Obtaining autopsy in Alzheimer's disease.

Although autopsy rates in the United States have been decreasing steadily, the necessity for brain autopsy to confirm Alzheimer's disease (AD) remains. Of 308 consecutively deceased AD patients at 24 CERAD (Consortium to Establish a Registry for Alzheimer's Disease) sites, 167 (54%) were autopsied; 141 (46%) were not. The autopsied and nonautopsied groups were comparable in gender (men, 57.5% versus 49.7%), marital status (married, 69.3% versus 67.1%), age at entry (73 versus 74 years), age at death (76 versus 77 years), and stage of disease at entry (mild, 46% versus 43%). However, the autopsied patients were significantly more likely to be white (94.5% versus 82.1%), to be better educated (13.1 versus 11.3 years), to have been in the study longer (mean, 3.3 versus 2.6 years), and to have had longer total duration of AD (8.1 versus 6.7 years). Of the 24 CERAD sites, 13 stressed the importance of autopsy by dedicating a staff member to seek autopsy and by providing free autopsy and transportation; 11 did not. Logistic regression analysis showed that white race (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.10-6.83), increased education (OR = 1.12; 95% CI = 1.04-1.21), and emphasis on autopsy (OR = 4.69; 95% CI = 2.67-8.25) were the only significant factors. Although race and education were important, autopsy was more likely to be obtained when sites dedicated resources to this endeavor.

Aged↗
PubMed2004

[Comparison of clinical data of two autopsy series, 1938-1951 and 1990-2002, at the Debrecen University Department of Neurology].

BACKGROUND: The clinical parameters of autopsied brains in two periods (1938-1951 and 1990-2002) were analyzed and compared. METHODS: Gender distribution, age, clinical diagnosis, treatment length of 695 (1938-1951) and 1378 (1990-2002) autopsies of Department of Neurology, Debrecen, Hungary were investigated. RESULT: Between 1938-1951 mean 49.6 +/- 15.5 autopsies/year were performed while in the 1990-2002 the autopsies raised to 106 +/- 19.6 /year. In the first period almost all deceased patient has been autopsied, but the ratio decreased on 68.9% between 1990-2002. The average age of autopsied patients (39.1 +/- 2.9 years) almost doubled after 40 years (69.5 +/- 2.0 years). In the first period (1938-1951) the infectious and tumorous cases were most frequent (33.6% and 31.2%), while in the second one, the cerebrovascular diseases dominated (84.5%). There was no significant difference between the treatment lengths of two periods (18.1 and 14.5 days, respectively). CONCLUSIONS: While the absolute number of autopsies raised after 40 years, the ratio decreased at our department (from 100% to 68.9%), similarly to the worldwide trends. The significantly higher age of autopsied patients and the different spectrum of clinical diagnosis reflects the decrease of infectious diseases and increase of stroke frequency and the ageing of the Hungarian population. Authors sustain with literary data that autopsy should not be ignored, and are convinced, together with professor Mohr, that "autopsy is the ultimate audit of medicine, the yardstick of clinical care and research. To dispence with autopsy is an unfortunate trend that certainly endangers the value of clinical research."

Adult↗
PubMed2006

Issues surrounding a reduction in the use of internal autopsy in the coronial system.

In 2003 it was estimated that 2,700 full internal coronial autopsies were performed in Queensland at a cost of approximately A$5.3 million. This large number of internal coronial autopsies (almost 95% of all matters referred to the coroner) is of concern not only due to the economic cost but also because of the public heath risks, availability of specialist staff and significant religious and cultural sensitivities surrounding internal autopsies. In 2005 the authors began research funded by the Australian Research Council (ARC) to determine if unnecessary internal autopsies are being performed in Queensland and to establish guidelines for when an internal autopsy is required. This article highlights areas of potential concern when the issue of autopsy is reviewed within the coronial system through an examination of international literature on the issue of autopsy diagnosis and error rates more generally, and through preliminary discussion of the data obtained. The article considers the role and purpose of the autopsy generally as well as within the coronial system specifically; compares diagnostic error rates in hospital autopsies with those in the coronial system; the current situation internationally with regard to internal autopsies; and finally the specific circumstances existing in Queensland.

Autopsy↗
PubMed1995

Autopsy training programs. To right a wrong.

Autopsy rates have decreased from a peak of 41.1% in 1964 to less than 5% in many hospitals today. This disaster has stimulated many symposia and articles on the values of the autopsy, the reasons for its fall, and possible remedies. The many benefits of the autopsy include quality assessment of clinical diagnoses; added knowledge about new diseases, environmental hazards, and genetic disorders; and evaluation of new technologies. The autopsy is also a powerful educational tool. The main reasons for its decline include fear of medical litigation and professional discreditation due to unexpected findings, the unsubstantiated notion that technologic advances have rendered the autopsy obsolete, cost-cutting pressures, and inadequate compensation for pathologists. This essay addresses a remedy for another major contributing problem: clinicians' frustration at poorly performed autopsies due to defective training of autopsy pathologists. Requirements for excellent autopsy training programs include an intensive review of anatomy applied to dissection methods, including sequences of dissection; direct supervision of early cases by a competent and responsible senior pathologist at the autopsy table, with full responsibility assigned to the trainee only after completion of this apprenticeship; review of all cases with clinical staff at regularly scheduled gross organ conferences; and a sustained commitment by department heads to make necessary programmatic changes to meet these standards. Pathologists must demonstrate pursuit of excellence in performance of the autopsy before other ambitious elements are sought for its revival.

Autopsy↗
PubMed1997

The autopsy.

The autopsy can be divided into medico-legal and academic autopsies. The autopsy has proven its value in the elucidation of the cause of death, medical audit, clinical quality control, education and the continuing understanding of disease pathogenesis. In addition, the medico-legal autopsy plays an important role in the administration of justice. While the rate of medico-legal autopsies remains relatively stable, all over the world there has been a steady decline in the rate of academic autopsies. Most studies show an unsatisfactory agreement between the clinical diagnosis and the autopsy diagnosis. When the pattern of autopsies is skewed towards deaths of medico-legal significance, health statistics based on death certificates on which healthcare policies are formulated may not be useful. Therefore, the decline in autopsy rates should be reversed. All health professionals, hospital administrators, medical students and relatives should be educated about the relevance of the autopsy to each of them. There must be increased communication between the clinician and the pathologist.

Autopsy↗
PubMed1997

Acute pancreatitis in marrow transplant patients: prevalence at autopsy and risk factor analysis.

Pancreatitis has been described as an infrequent complication of marrow transplantation. This study investigated the prevalence of pancreatitis at autopsy in marrow transplant patients and determined risk factors for its development. We reviewed consecutive autopsy reports from 1991 to 1993. Medical records and laboratory reports were reviewed for analysis of clinical variables. Autopsy findings and clinical variables were correlated with the autopsy diagnosis of pancreatitis. Pancreatitis was found in 51 of 184 (28%) patients at autopsy. Of those with pancreatitis, 35% had abdominal pain, 10% had measurements of serum pancreatic enzymes, and 20% had abdominal imaging studies in the week prior to death. By univariable analysis, risk factors associated with development of pancreatitis included clinical grades 3 and 4 GVHD, GVHD at autopsy, liver GVHD at autopsy, major infection at autopsy, and increasing days of survival. By multivariable analysis, independent risk factors for its development included any GVHD at autopsy, increasing length of survival after transplantation, and major infection at autopsy. We conclude that pancreatitis is a common but often subclinical complication of marrow transplantation. Its development may be associated with a high prevalence of biliary sludge and prolonged treatment of GVHD with cyclosporine and prednisone.

Abdominal Pain↗
PubMed1986

Autopsy. High yield in neonatal population.

The value of the autopsy in the practice of clinical medicine continues to be debated. While the yield of the autopsy in adults is well documented, similar studies in infants and children are lacking. To understand how frequently the neonatal autopsy provides useful information, we studied all deaths in a level III neonatal Intensive care unit over a three-year period. Clinically active problems at the time of death were tabulated and compared with the final diagnoses obtained from the autopsy report. During the three-year study period, there were 113 deaths with autopsies performed in 71 (63%) of the cases. Significant findings were noted in 39% of patients. These included congenital anomalies (16 patients), Infections (nine patients), unsuspected iatrogenic complications (five patients), and others (11 patients). In 16% of the cases, the autopsy provided the definitive explanation for the cause of death by substantiating an unproved or unsuspected diagnosis. In an additional 18.3% of the cases, the autopsy findings influenced genetic counseling or were important in monitoring patient care. The gross examination was the most useful component of the autopsy, providing 63% of the significant findings. This high rate of return supports a continued high rate of neonatal autopsy.

Autopsy↗
PubMed1983

An autopsy study of histologic progression in non-Hodgkin's lymphomas. 192 cases from the National Cancer Institute.

Histologic slides were reviewed from 192 autopsies of patients with non-Hodgkin's lymphomas admitted to the National Cancer Institute (NCI) from 1953 to 1975. Each autopsy was classified according to the systems of Rappaport and Lukes-Collins. Comparisons with the initial diagnosis were made. The initial histologic diagnoses of the autopsied population were similar in distribution to other published series of non-Hodgkin's lymphomas. Of the 56 cases which initially demonstrated nodular patterns of growth, the following distribution was found at autopsy: 25%, no lymphoma; 6%, nodular lymphoma; 32%, diffuse histiocytic (large cell) lymphoma (DHL); 21%, diffuse undifferentiated (non-Burkitt's) lymphoma (DUL); and 16%, the remaining diffuse morphologies. Of the 136 patients with initial diagnosis of diffuse lymphoma, the following distributions were observed at autopsy: 20%, no lymphoma; 0%, nodular lymphoma; 31%, diffuse histiocytic (large cell) lymphoma; 12%, diffuse undifferentiated (non-Burkitt's) lymphoma; 9%, Burkitt's tumor; 14%, diffuse poorly differentiated lymphocytic lymphoma; and 14%, the remaining diffuse morphologic types. One hundred and thirty-four cases which were initially diagnosed as follicular center cell type within the Lukes-Collins classification gave the following distribution at autopsy: 21%, no lymphoma; 25%, small noncleaved type; 17%, large noncleaved type; 23%, non-follicular center cell lymphomas (17% immunoblastic B); and the remaining 13% were distributed among the other follicular center cell types. This autopsy review demonstrates the rarity of nodular (follicular) lymphomas at autopsy, and the predominance of the diffuse histiocytic or "transformed" type. This study provides a comparison of the rate of histologic progression of lymphomas in the same patient population at autopsy with a previously published study of progression during life.

Adolescent↗
PubMed1994

Attitudes of senior pathologists towards the autopsy.

The attitudes of 205 consultant British pathologists in four regions were assessed by a postal questionnaire in which they were asked to indicate their level of agreement with 15 statements relating to autopsies. A total of 144 pathologists completed the questionnaire (response rate 70 per cent). Senior pathologists strongly agreed with statements relating to the importance of autopsies within pathology workloads, medical audit, and accreditation for training posts. There was strong support for the attendance of clinicians at autopsy demonstrations and for the suggestion that material from medico-legal autopsies should be made available for teaching and research. There was strong disagreement with the suggestions that advances in diagnostic techniques have diminished the role of autopsies, that performing autopsies does not further pathologists' education, that the cost of autopsies may not be justifiable within a limited budget, and that the autopsy should no longer be part of the MRCPath examination. These results are discussed in the context of the current status of the autopsy in general.

Attitude of Health Personnel↗
PubMed2006

Correlation between prenatal ultrasound and autopsy findings: A study of second-trimester abortions.

OBJECTIVE: To evaluate discrepancies between sonographic and autopsy findings following termination of pregnancy (TOP) in the second trimester. METHODS: This retrospective report is based on 288 consecutive second-trimester abortions carried out because of fetal malformations diagnosed by ultrasound examination at a tertiary referral center. The correlation between the results from the ultrasound and autopsy examinations was evaluated. RESULTS: Autopsy was performed in 274 cases. In 160 of the 274 pregnancies (58.4%) there was full agreement between the two examination methods. Findings detected by autopsy (in addition to those leading to termination) were not observed by ultrasonography in 86 (31.4%) of the pregnancies; of the 64 malformations that occurred, 30 (46.9%) were judged as 'detectable'. In 27 (9.9%) pregnancies, observations made by ultrasound (in addition to those leading to termination) were not confirmed at autopsy. In one pregnancy, postmortem radiology examination-but not autopsy-confirmed the ultrasound observations. No pregnancies were terminated because of false positive ultrasound observations. The correlation between ultrasound and autopsy findings was evaluated by three investigators; the inter-rater agreement was high (kappa = 0.85). CONCLUSION: Discrepancies between ultrasound and autopsy findings were observed in about 40% of the pregnancies. These discrepancies confirm the need for autopsy following TOP.

Abnormalities, Multiple↗
PubMedDate not supplied

The autopsy: its role in the evaluation of patient care.

OBJECTIVE: To determine whether autopsies improve the detection of major clinical errors. DESIGN: Retrospective chart review of all deaths for a 30-month period to detect major clinical errors when a correct diagnosis and institution of proper therapy would have prolonged the patient's life, with comparison of autopsied patients with those without an autopsy. SETTING: Small government hospital inpatient medical service. PATIENTS: 335 consecutive deaths with 141 [42%] autopsies. MAIN RESULTS: Review of the clinical records of cases without autopsy led to the discovery of only two major clinical errors [1%], whereas 19 major clinical errors [13%] were detected in autopsy cases. Three of the 19 errors in autopsy patients would have been detected by chart review alone. Thirteen of the 19 clinical errors in autopsied patients were related to infections that were missed or were not treated appropriately because of misdiagnosis. CONCLUSION: Autopsies continue to reveal unanticipated and important information that is essential for internal medicine residency training and for the evaluation of the quality of medical care.

Autopsy↗
PubMed2001

Laparoscopic autopsies.

BACKGROUND: In recent years, autopsy consent rates have fallen nationwide. In our institution they have declined from 15% to 7% in 10 years. We perceived that family reluctance to grant permission for autopsy was related to the invasiveness of the open procedure, so we began to do autopsies by needle biopsy, with an increase in consents to 25% during the first year. However, the procedure is inherently inaccurate, so we recently have introduced minimally invasive laparoscopic autopsy. METHODS: From July through October 1999, needle biopsy was performed on 25 patients who died at our institution, which was followed by laparoscopic evaluation. Consent for full conventional autopsy had been granted in nine cases, and these then were performed. Data from these autopsies were compared with those from the laparoscopic procedures. RESULTS: Of the patients for whom consent was obtained for open autopsy, there was complete agreement as to cause of death between the laparoscopic and conventional procedures. In one case, a liver hemangioma was missed by laparoscopy, and in two other cases, colon polyps were not discovered. Biopsies of internal organs were accurately performed on the pancreas, kidneys, and adrenals, all of which had been troublesome for needle biopsy alone. CONCLUSIONS: Laparoscopic autopsy is much more acceptable to the families of patients than the conventional form, resulting in a higher consent rate. On the basis of our study group, this procedure provides accurate data concerning the cause of death. In addition, performing these autopsies gives surgical residents invaluable training in laparoscopic skills.

Adult↗
PubMed1995

Diagnosis of malignant tumor: comparison between clinical and autopsy diagnoses.

A review was made of the results of 1,036 consecutive autopsies (average patient age, 75 years; 617 male and 419 female patients; autopsy rate, 40.2%) done at the Hospital of Monfalcone from January 1986 through December 1991. In 457 autopsies (44%) one or more malignant neoplasms were found (single tumor in 382, dual tumor in 69, and triple tumor in six) for a total of 538 tumors. In the corresponding death certificates the clinical diagnosis of malignancy was found in 302 autopsies for a total of 310 tumors (single in 294 and dual in eight). The number of clinically unrecognized malignancies was 228 (42%) and the number of patients with undiagnosed tumors was 155 (34%). The neoplasms were subdivided into four stages according to their extension at autopsy: stage 0 (85 tumors), microscopic neoplasm; stage I (146 tumors), neoplasm localized at the site of origin; stage II (43 tumors), local advanced neoplasm; and stage III (264 tumors), neoplasm with metastases. The rate of correct clinical diagnoses increased according to the level of stage; (stage 0, 1%; stage I, 40%; stage II, 58%; and stage III, 66%). The greatest numbers of tumors found at autopsy were located in the gastroenteric apparatus (170), the respiratory apparatus (149), and the urogenital apparatus (130). The number of clinically undiagnosed neoplasms was high with respect to the urogenital apparatus (77% overall and 51% excluding stage 0) and the gastroenteric apparatus (41% and 38% excluding stage 0); in contrast, the number was low for the respiratory apparatus (17%). The rate of correct diagnoses was higher in patients younger than 65 years (65%) than in those older than 65 (54%), but the difference was not significant. The duration of hospitalization in the 12 months before death was statistically higher (P < .001) in patients with a correct diagnosis (36 days) than in undiagnosed patients (14 days). Even taking into account the biases that affect selection of patients for autopsy, the notable discrepancy found between clinical and autopsy diagnoses underlines the fact that autopsy, despite improvements in diagnostic techniques, maintains its fundamental importance in assessing the reliability of clinical diagnoses and furthermore shows the underestimation of the incidence of tumors in epidemiological studies based solely on death certificates.

Adult↗
PubMed1990

Application of the verbal autopsy during a clinical trial.

During a community-based treatment trial of onchocerciasis with ivermectin, verbal autopsies were employed as one method to assess the safety of the drug. The verbal autopsy questionnaire was designed to determine causes of death and mortality differentials in the treated population. During the 8 months of surveillance here reported, 25 individuals died, yet only 9 of these deaths were certified. Seven of the deaths occurred to individuals who had been treated with ivermectin and the majority of the deaths occurred to children under 5, who were excluded from treatment. The verbal autopsy method was evaluated and validated by comparing the verbal autopsy diagnosis of cause of death to death certificate diagnosis, when available. In addition, verbal autopsies were retrospectively performed for all deaths which had occurred at the hospital during the 6 months preceding the start of the study, if these deaths were traceable to households in the surveillance population. We found that in 80% of the adult deaths, the verbal autopsy and death certificate diagnoses of underlying cause of death agreed. The verbal autopsy was less accurate in diagnosing child deaths which we attribute to the design of the verbal autopsy (being to detect potential drug related deaths in adults) and to the delay between death and interview. We conclude that verbal autopsies are an important addition to surveillance systems in remote areas where the absence or inadequacy of health information systems does not allow a thorough follow-up of all subjects in drug studies.

Autopsy↗
PubMed2000

Hodgkin's disease: correlation between causes of death at autopsy and clinical diagnosis.

PURPOSE: The causes of mortality in Hodgkin's disease patients are insufficiently known. Autopsy study is the fundamental procedure in the investigation of these causes. The present study analyzes the autopsies performed in a series of patients diagnosed as having Hodgkin's disease, determining the cause of death in each case and comparing the premortem clinical data and the postmortem findings. PATIENTS AND METHODS: A total of 486 patients diagnosed as having Hodgkin's disease between 1967 and 1996 were assessed. Autopsy was performed in 40 of the 144 deceased patients (28%). We reviewed the pathological findings, effects of treatment, discordance between the clinical diagnosis and the outcome of autopsy, and cause of death in each case. RESULTS: The most common clinical causes of death in those patients with autopsy study were tumor progression (37%) and infections (43%) in those patients with autopsy study. The rate of discordance between the clinical and autopsy diagnoses in this study was 43%. The most frequent location of residual Hodgkin's disease was in the lymph nodes. CONCLUSIONS: Autopsy study in Hodgkin's disease confirms a high rate of discrepancy between final clinical diagnosis and postmortem lesions despite advances in diagnostic methods. Autopsy revealed causes of death directly related to the treatment, as well as some lesions directly related to patient death and secondary to treatment. Infectious processes are likely to remain undetected and their symptoms can mimic tumor progression.

Adult↗
PubMed2005

Maintaining high autopsy rates in a Canadian blood and marrow transplant program: preserving a diagnostic and research tool.

Autopsy series have revealed patterns of injury in graft-versus-host disease and provided insight into infectious and toxic complications following hematopoietic stem cell transplantation (HSCT). Overall autopsy rates have declined significantly in recent decades including specialized services such as neonatal medicine and cardiac care. However, rates of post-mortem exams at HSCT centers have not been specifically documented. We reviewed hospital records between 1992 and 2002 to determine overall autopsy rates at our hospital and within the HSCT program. Although the overall autopsy rate declined steadily from 24% in 1992 to 9% in 2002, rates of post-mortem exams in the HSCT program remained relatively stable at 32% (24-46%). Autopsy rates were not significantly different for recipients of allogeneic vs autologous transplants and no clear difference was observed for the proportion of autopsies requested on weekdays compared with weekends. Autopsies confirmed major clinical diagnoses and/or suspected causes of death in 45 of 61 autopsies (74%) and yielded major or minor disagreements in clinical diagnosis in 10 cases (16%) and seven cases (11%), respectively. The preservation of high rates of autopsy within our HSCT program demonstrates that specialized programs are able to maintain elevated rates of post-mortem examinations despite overall declining rates.

Autopsy↗
PubMed2003

Accuracy of magnetic resonance imaging in determining cause of sudden death in adults: comparison with conventional autopsy.

AIM: To determine the accuracy and define the limitations of post mortem magnetic resonance imaging (MRI) in determining the cause of sudden death in adults. METHODS AND RESULTS: Sudden unexpected adult deaths in the community, reported to the Coroner (n = 10), excluding suspicious, violent or potentially drug-related deaths, were submitted to whole body MRI, followed by full invasive autopsy. The MRI scans were reported independently by four radiologists, blinded to the autopsy findings; two had previous experience of post mortem MRI. An abnormality that related to the cause of death as identified at autopsy, was identified by at least one radiologist in eight cases. These were pulmonary consolidation (autopsy finding pneumonia) (n = 1), pneumoperitoneum (autopsy finding perforated peptic ulcer) (n = 2), left ventricular failure (autopsy finding ischaemic heart disease) (n = 4), and disseminated bronchial carcinoma (n = 1). However, in only one case were all radiologists able to provide a confident cause of death (disseminated bronchial carcinoma). In two cases, in which death occurred 2-6 days and 3-6 days before MRI, early decomposition prevented interpretation of the images. Severe coronary artery atheroma was detected at autopsy in 7/10, but these lesions were not detected by MRI. Previous experience in reporting post mortem MRI, without autopsy comparison, did not result in more accurate interpretation of the images. CONCLUSIONS: This pilot study suggests that post mortem MRI can identify some abnormalities relating to the common causes of sudden death in adults, but there is a need for greater experience in correlating MRI with autopsy findings before a reliable cause of death can be made by MRI alone. Inability to image coronary artery lesions, differentiating thrombus from clot and pulmonary oedema from pneumonic exudates, are specific problems that may be corrected with greater experience and higher resolution scans.

Adult↗