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PubMed2003

Introduction of autopsy imaging redefines the concept of autopsy: 37 cases of clinical experience.

A new autopsy imaging (AI) system was introduced at the Research Center Hospital for Charged Particle Therapy (RCCPT) in January 2000. Autopsy imaging is a postmortem and preautopsy diagnostic procedure using magnetic resonance imaging (MRI). Scanning is performed with a 1.5 Tesla MRI system before autopsy. The AI results are reported to the pathologist and, in light of this information, autopsy is performed with minute precision. Autopsy imaging was performed on 37 cancer cases. In seven cases, AI was less informative than the autopsy, but in 30 cases, more precise reports on the final diagnosis were available with the combined application of autopsy and AI than autopsy alone, particularly in eight limited autopsy cases. Thus, AI provides critical and supplementary information for autopsy; furthermore, AI itself is a unique imaging system of great importance.

Aged↗
PubMed1999

The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions.

OBJECTIVE: To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. DESIGN: Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. SETTING AND PARTICIPANTS: Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. MAIN OUTCOME MEASURES: Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. RESULTS: In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient's death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. CONCLUSION: This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient's death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance.

Autopsy↗
PubMed1989

[Decline of autopsy rates in Japan and the significance of autopsy in gastric carcinoma].

In recent years, the significance of autopsy seems to have gradually declined, because of advances in diagnostic technology. However, rediscovery of the value of autopsy has been recently emphasized by many foreign authors, and in some reports concerning diagnostic accuracy, no significant difference was observed between the three decades of the Sixties, Seventies and Eighties. Comparing the autopsy rates in 1977 and 1986 in Japan, one notes a decrease from 37.8% to 28.5%. And this declining tendency will continue for the foreseeable future. In order to confirm the value of autopsy, 100 sequential autopsy cases of gastric carcinoma in Kanto Teishin Hospital were reviewed. The autopsy rate of gastric carcinoma was 66.1% over the past decade. In 38 autopsy cases, some notable findings were provided by postmortem examination, and they may be summarized as follows. Clinically incorrect diagnosis for primary organ in 2 cases; unexpected spread of carcinoma in 2; improper cancer therapy in 8; favourable effects of anticancer drug in 4; underestimation of clinical observation in 11; latent tumors in 7; confirmation of other pathological findings than cancer in 4. The results suggest that autopsy plays an important part in the progress of medical care. In order to stop this declining trend, the department of pathology must be legally recognized as an essential unit in a hospital. Thus the autopsies should be performed not only with a view to research, but as one of the routine tasks in medical care. And cooperative efforts by both clinicians and pathologists are necessary to maintain the autopsy rates.

Autopsy↗
PubMed1996

A prototype Internet autopsy database. 1625 consecutive fetal and neonatal autopsy facesheets spanning 20 years.

OBJECTIVE: To demonstrate that cause-of-death statements can be generated by a computer algorithm from an autopsy database composed of diagnostic terms. DATA SOURCES: Over 49 000 autopsy facesheets contributed by over a dozen institutions were collected from a publicly accessible Internet autopsy database. This database is available at the following web site: http:@www.med.jhu.edu/pathology/iad.html STUDY SELECTION: To test the feasibility of creating and using a publicly available autopsy database, and to identify the technical and medicolegal problems that may arise with such a novel resource, a prototype study was designed by selecting autopsy facesheets from fetal and neonatal deaths. An algorithm was developed to determine the cause of death from the listing of anatomic diagnoses. DATA EXTRACTION: One thousand six hundred twenty-five fetal and neonatal autopsy facesheets were selected encompassing fetal and neonatal deaths occurring up to 28 days after birth. DATA SYNTHESIS: The algorithm determined causes of death from autopsy facesheet data in all cases. On review by an experienced pediatric pathologist, these automatically generated cause-of-death statements required no modification or only slight modification in over 90% of cases. CONCLUSIONS: A large multi-institutional autopsy database composed of demographic and diagnostic information has been deposited on the Internet. This information can be freely downloaded and used by any researcher without violating patient confidentiality. As a demonstration of one possible application of the database, fetal and neonatal autopsies generated cause-of-death statements using a computer algorithm. One can anticipate that the wealth of information contained in autopsy facesheets can be assembled into a database that will serve the public interest.

Algorithms↗
PubMed1999

Postoperative death should be followed by autopsy - an analysis of the autopsy findings of the years 1990 and 1991 in a heart surgery center.

BACKGROUND: In this retrospective analysis of all autopsies performed in 1990 and 1991 on cardiac surgery patients who died before discharge from our university hospital, we intended to test the use of postmortem examination among cardiac surgery patients. METHODS: Perioperative data of all patients who underwent autopsy because of postoperative death during this time period were collected using a retrospective analysis of hospital and autopsy records. RESULTS: In 1990 and 1991 a total of 2407 patients underwent cardiac surgery with extracorporeal circulation at our institution. The in-hospital mortality was 2.9% (n=36) in 1990 and 3.3% (n=40) in 1991. For most of all patients who died during the postoperative course, we found a highly symptomatic cardiac disease and significant co-morbid conditions. The autopsy rate was 46.1% (35/76 patients). Cardiac failure with shock symptoms was the leading course of death (68.6%). In 22.9% of these patients (n=8) the autopsy provided information which had not been clinically recognized (e.g. myocardial infarction, thrombosis of bypass grafts, pneumonia) but might have altered the postoperative therapy if it had been. CONCLUSIONS: Despite the well-known trend of decreasing autopsy rates in the western world we believe that the postmortem examination is a most valuable diagnostic tool in the setting of a university cardiac surgery unit. Our results confirm the importance of autopsies for all patients who die after the operation, because a significant part of autopsies reveals major discrepancies between clinical and postmortem diagnoses. In an effort to maintain a high quality of treatment and education the autopsy rate of a hospital is of utmost interest.

Adolescent↗
PubMed1994

[Importance of the autopsy rate. A comparison between clinical assessment and findings at autopsies during the periods: 1 July 1908--30 June 1981 and 1 July 1990--30 June 1991].

On the 1.7.1990 a new law was introduced in Denmark whereby specific consent had to be obtained from the deceased's relatives before autopsy could be performed. Autopsy records from two periods before and after this date, namely from 1.7.1980 to 1.7.1981 and from 1.7.1990 to 30.6.1991, are examined here with respect to autopsy rate and agreement/disagreement between clinical assessment as to cause of death and findings on autopsy. With an autopsy rate of 82.7% before and 10.3% after the new law we found that there was significantly more disagreement between the clinical assessment and the autopsy findings in the 1990/1991 period, presumably because of a selection bias towards difficult cases. The autopsy material from 1990/1991 could only be used for statistics in a limited fashion. A very low autopsy rate of about 10% implies that 25-30% of all death certificates from hospitals must be assumed to be incorrect as concerning serious diseases. The study shows that there is a considerable need for the performance of autopsies for the sake of medical statistics.

Adult↗
PubMed1993

Decrease in the frequency of autopsies in Denmark after the introduction of a new autopsy act.

UNLABELLED: New techniques have influenced the attitude to the autopsy and contribute to a de-emphasis on the importance of post-mortem examination. Since 1990, new Danish legislation has provoked a dramatic fall in the autopsy rate, which had already declined from 45% in 1970 to 35% in 1980. In the first half of 1990 the rate was 24% in the second half of that same year it had fallen to 16% ( SOURCE: The Danish National Institute of Health, 1992). The clinicians now seem to manage without the autopsy to confirm or correct their daily diagnostics. They also seem to be of the opinion that they do well without this "final checklist". The autopsy, however, is still an important tool in understanding, correcting and improving future diagnosis. Therefore, post-mortems should again be carried out as a matter of course and common practice. The following proposals are all aimed at obtaining a higher autopsy rate: The 1990 legislation on autopsy should be changed so that permission to perform a post-mortem can be given in due time, before the supposed death, preferably by the patient himself and obviously with the right to a subsequent change of mind. It is of great importance that the Public Health Service informs both the public and health workers in general about the nature and importance of the autopsy. Likewise, doctors and health workers in general should be educated in how best to give information to patients. Pathologists should, through a more uniform and exact practice, encourage the clinicians to a renewal of the close collaboration concerning the facts revealed by the autopsy, both in their everyday practice and in scientific projects in general.

Attitude of Health Personnel↗
PubMed2001

A study of consecutive autopsies in a medical ICU : a comparison of clinical cause of death and autopsy diagnosis.

OBJECTIVE: To determine the degree of concordance between clinical cause of death and autopsy diagnosis in a medical ICU (MICU) setting. DESIGN: Retrospective medical chart and autopsy report review. SETTING: MICU in a tertiary referral hospital. PATIENTS: Consecutive admissions to an MICU over a 2-year period from January 1, 1994, to December 31, 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One thousand eight hundred patients were admitted to the MICU during the study period. There were 401 in-ICU deaths (22.3%). The autopsy rate was 22.7% (91 of 401). The mean +/- SD age of the autopsied patients (55.1 +/- 13.5 years) was lower than those without autopsy (62.4 +/- 15.2 years; p < 0.001). The two groups were otherwise similar with regard to sex, race, APACHE (acute physiology and chronic health evaluation) III scores, and lengths of stay in the MICU and hospital. The discordance between clinical and postmortem diagnoses was 19.8% (95% confidence interval, 12 to 29%). There were no differences in age, sex, APACHE III scores, predicted mortality, and lengths of stay in MICU hospital between patients with concordant and discordant diagnoses. In 44.4% (8 of 18) of the discordant cases, management would have been modified had the autopsied diagnosis been made premortem. Seven of the autopsied patients had organ transplantation. Three of the patients who had organ transplantation had discordant diagnoses, including two patients with disseminated fungal infection that was not diagnosed clinically. Although the observed discordance in transplant patients (43%) was higher than in those without transplant (19%), the difference was not statistically significant (p = 0.15). CONCLUSION: Younger patients tended to have a higher autopsy rate than older patients. The discordance between the clinical cause of death and postmortem diagnosis was 19.8%. In 44.4% of the discordant cases, knowledge of the correct diagnosis would have altered therapy.

APACHE↗
PubMed2001

[Age distribution of hospital autopsies 1977-1996. The relative frequency of autopsies on younger people has increased since the 1990 amendment].

INTRODUCTION: Since the new law on autopsies was passed in 1990, the frequency of autopsy has fallen. We have carried out an analysis to illustrate the conditions/proportions for various age groups before and after the law came into force. METHOD: All the figures for deaths and autopsies during the period of 1977-1996 were reviewed. This includes the figures from the Danish Board of National Health and from the Department of Pathology at Rigshospitalet, Copenhagen. The frequency of autopsy was calculated for all groups, both before and after the amendment, and the results are discussed. RESULTS: The figures showed not only a significant decrease in the frequency of autopsy in almost all groups, but also a considerable decrease in the groups of the elderly as compared to the younger groups. DISCUSSION: The frequency of autopsy decreased during the period of 1977-1996. The most significant fall was seen around 1990, both in the general figures registered in connection with the cause of death and in the figures from the Department of Pathology at Rigshospitalet, Copenhagen. We also found that the decrease in the frequency of autopsies was greater in the groups of the elderly, when different age groups were examined. The percentage of autopsies performed on younger people has increased since the 1990 amendment.

Adolescent↗
PubMed1982

Annual of pathological autopsy cases in Japan. Computerization of autopsy data from 1974 to 1979 and their statistical study.

The Japanese Pathological Society has established a unique registration system for autopsy cases since 1958. The autopsy data are published every year as an annual which numbers 22 volumes and includes 443,604 cases. This annual entitled Annual of Pathological Autopsy Cases in Japan is composed of 2 parts. One is the description part in which autopsy records of individual cases (institution, autopsy number, age, sex, address, occupation, clinics, clinical diagnosis, pathological diagnosis, and remarks) are summarized in a formula with 108 Japanese characters. The other is the statistical part in which disease-specific frequency with age distribution, combination of multiple malignancies are recorded. For this statistical study, computerization of the autopsy data was started from 1974. Modified MOTNAC codes are used for malignant neoplasms and modified ICD codes for the other diseases. Computerization of autopsy data has led to accurate statistical studies of autopsy cases in Japan and will contribute to the development of medical science.

Adolescent↗
PubMed2001

[The different varieties of autopsy. Proposal for a renewed medical and scientific autopsy].

Five main varieties of autopsies can be distinguished in France: the forensic pathology autopsy, medical and scientific autopsies, the "gift of corpse to the University", and the sanitary autopsy. The main rules and the shortcomings of French regulations ant its implementation are recalled. The disappearance of medical and scientific autopsies is of concern for three reasons: in some cases, the predictive value of clinical diagnosis is still poor and the proportion of unexpected findings that may have modified the patient therapy (20/25%) has remained unchanged for many years; autopsy is an important piece of the health watch, i.e. of public welfare; the modern post-genomic research needs tissue samples that often cannot be obtained by other means for ethical reasons. Numerous patients associations campaign for making easier the gift of organs for research purpose. The prerequisites for a renewing of autopsy, the modifications of regulations and practices that are required, the procedures to explain its importance in the hospital, among medical doctors and care givers, and in the society are considered.

Autopsy↗
PubMed1997

[The value of autopsy in current health care. An analysis of autopsies performed during one year at the Regionsykehuset in Trondheim].

We have reviewed the reports from 222 autopsies performed during one year (1994) at our Department of Pathology. The majority (74%) of all autopsies were performed on patients from the Department of Internal medicine at our hospital. Autopsy findings were correlated with the clinically suspected causes of death, as revealed by the death certificates and the clinical information in the written requests for autopsies. The direct cause of death, as found at autopsy, had been suspected by the clinicians in 70% of cases. The underlying cause of death, as found by the pathologists at autopsy, had been diagnosed by the clinicians in 75% of the cases. In 26 cases (12%) the underlying cause of death had neither been diagnosed nor suspected by the clinicians. In the last mentioned group, 77% of the patients were more than 70 years of age. In six cases where the underlying cause of death had not been diagnosed or suspected by the clinicians, the findings at autopsy were classified as type-1 findings. These are findings, if they had been known when the patient was still alive would probably have led to therapy that night have improved the prognosis.

Autopsy↗
PubMed1999

Autopsy findings and clinical diagnoses: retrospective study of 3,117 autopsies.

AIM: To determine the extent of agreement between clinical and autopsy findings. METHODS: A 14-year retrospective study (1982-1995) of autopsies from the Departments of Internal Medicine and Surgery was performed at the Zagreb University Hospital Center, Croatia. The autopsy findings were compared with the clinical diagnoses. RESULTS: The autopsy rate among hospital deaths ranged between 23% and 33%. The overall rate of major discrepancies was 11.6% for all autopsy reports. The most common cause of death were cardiovascular diseases (40.9%), followed by malignancies (25.2%) and infections (12.9%). Among all cardiovascular diseases, myocardial infarction was the most frequently diagnosed (17.9%) and was misdiagnosed by clinicians in 16.5% of the cases. Incorrectly diagnosed malignancies were found in only 5.7% of the cases; hematological and lymphoid malignancies (48.8%) were the most common neoplasms and were usually confirmed before death. Infections were found in 46.9% of all autopsies. Bacterial pneumonias and peritonitis were overlooked in 67.5% and 23. 5% of the cases, respectively, in which they existed together with another serious condition. CONCLUSIONS: Modern technology has not improved the overall accuracy of clinical diagnoses. When an autopsy should be performed is still a matter of discussion.

Adolescent↗
PubMed1984

An autopsy case of miliary tuberculosis and review of autopsy cases in Japan.

Presented is an autopsy case of a 79 year-old male who died of miliary tuberculosis. The patient was admitted to the University Hospital with an unknown fever and suspicion of leukemia. He expired on the 13th day of hospitalization. Postmortem examination revealed generalized miliary tuberculosis. The diagnosis of tuberculosis was established only after autopsy. Difficulty in diagnosis of miliary tuberculosis is discussed. Also discussed is a probable association of acute interstitial nephritis with chemotherapy or miliary tuberculosis. Leukemoid reaction is thought to be associated with miliary tuberculosis. The present case reminds us that miliary tuberculosis should never be forgotten when treating a patient having a fever of unknown origin. Cases with tuberculosis were compiled from the Annual of Pathological Autopsy Cases in Japan during 1974 through 1981. There were 3,242 cases of tuberculosis (1.4%) out of 235,095 autopsies recorded in the Annual of Pathological Autopsy Cases in Japan during the above 8 years. Of 3,242 cases 618 were miliary tuberculosis. The latter figure indicates 19.0% of all tuberculosis and 0.26% of all autopsies. Although all age groups were not spared, the 7th and 8th decades were more affected than the others. Tuberculosis has markedly declined since the advent of antituberculous antibiotics. But, autopsy cases with tuberculosis have not recently decreased in number. Clearly, increased awareness of the continuing presence of tuberculosis is needed.

Aged↗
PubMed2002

The role of the autopsy in medical malpractice cases, II: controversy related to autopsy performance and reporting.

CONTEXT: We studied 99 appellate court records in cases of alleged medical malpractice and found no relationship between discrepant clinical and autopsy findings and outcome of litigation. Standard-of-care issues and not diagnostic accuracy were at the heart of every case. OBJECTIVE: To characterize and discuss issues related to the autopsy and/or pathologist behavior that were raised in court records of medical malpractice litigation. DESIGN: In 18 appellate court records, issues were raised about quality of autopsy performance and reporting or about death certification. The details of these controversies are succinctly reported here in a manner intended to be instructive to pathologists who perform autopsies in a hospital setting or on a private fee-for-service basis. CONCLUSION: Autopsy reports are intended to provide objective medical information in a coherent format to the patient's medical record, to the attending physician and other concerned staff physicians, to other health care professionals, and to the families of the deceased. Inevitably, occasions arise that require legal counsel to be added to this list of parties with a legitimate interest. Our findings emphasize that incomplete, incoherent, obfuscated, or delayed reporting of autopsy findings do not meet professional standards, are unethical if intentional, and may be counterproductive.

Adult↗
PubMed1980

Comparison between predicted cause of death and cause of death found at autopsy in medicolegal autopsy material.

The question whether an autopsy could have been omitted without adversely affecting diagnostic accuracy in cases in which an unnatural death was not suspected, was investigated by evaluating data from the files of cases handled in 1977 at the Government Department of Forensic Medicine in Uppsala in which the police had requested a simple medicolegal examination. The police report and the result of an external examination were evaluated blindly and cases divided into three groups. In 95 cases (12%) no autopsy, in 360 cases (45%) a partial autopsy, and in 346 cases (43%) a complete autopsy was considered necessary. In three of the 95 cases and in four of the 360 cases a wrong diagnosis was made. In 59 cases (7%) a complete medicolegal examination was performed. In 21 of the latter the circumstances of death were obscure and in 11 of these an unnatural cause of death was found. The investigation confirms that all cases must be handled by skilled medicolegal experts, that the extent of the medicolegal examination can well be assessed by the physician in charge, and that the autopsy procedure can be simplified in many cases and omitted in some, especially in a situation where resources are limited, without significantly affecting diagnostic accuracy in the individual case. However this policy adversely affects scientific studies on larger autopsy material.

Autopsy↗
PubMed1986

Correlation of clinical diagnoses with autopsy findings: a retrospective study of 2,145 consecutive autopsies.

The protocols of 2,145 autopsies were retrospectively reviewed and the findings compared with the clinical diagnoses. A sudden decline in the autopsy rate that occurred during the period studied was followed by a highly statistically significant difference in clinical accuracy (P less than 0.01), in favor of the predecline period. The overall rate of major discrepancies was 29 per cent. The most frequently missed diagnoses were infections, which were found in 26 per cent of all autopsies and had not been diagnosed clinically in 63 per cent of these cases. Malignancies occupied second place among overlooked diagnoses in the selected disease categories; in 99 per cent of the cases the malignancy was the principal diagnosis, and it had been misdiagnosed clinically in 42 per cent of these cases. Cerebrovascular disorders were correctly diagnosed in most cases (87 per cent of the patients in this group). Among autopsy diagnoses labeled as the immediate causes of death, the most frequently overlooked were pulmonary embolism and gastrointestinal hemorrhage, which were not recognized in 84 and 78 per cent, respectively. In cases in which clinicians were not entirely confident in their impressions, their diagnoses were usually confirmed at autopsy. In these cases 15 per cent of the patients died soon after admission to the hospital, with accurate diagnoses in 71 per cent. The discrepancies disclosed should be regarded as sufficiently large to mandate continued emphasis on autopsy evaluation as the basis for the control of the quality of patient care.

Autopsy↗