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PubMed2003

The autopsy in modern undergraduate medical education: a qualitative study of uses and curriculum considerations.

AIM: Medical education has undergone dramatic changes over the past decade. In the UK, the General Medical Council (GMC), the driving force behind curriculum reform, now requires curricula to be founded on a base of educational theory and research. This qualitative study investigated the roles of the autopsy within the context of the modern medical curriculum. METHODS: Using a phenomenological methodology, a non-representative 'theoretical sample' was selected to include medical educators with a wide range of teaching experience and responsibilities and disparate views both for and against the autopsy. Semistructured, tape-recorded interviews were undertaken to investigate the roles of the autopsy within the medical curriculum. Anonymised interview transcripts were subjected to a themed content analysis. RESULTS: Theoretical saturation was reached after 9 interviews. No new themes were added by a further 5 interviews. All the interviews were polythematic. In all, 43 themes were identified. In addition to confirming overt uses of the autopsy reported in previous studies, educators identified issues of curriculum design and development, the impact on the hidden curriculum, and a range of disadvantages and alternatives to the autopsy. CONCLUSIONS: Educators continue to perceive the autopsy as having a multifactorial role in providing the doctors of tomorrow with the appropriate knowledge and attitudes needed for the practice of medicine in the 21st century.

Autopsy↗
PubMed1997

Increasing autopsy rates at a public hospital.

Despite the acknowledged value of autopsies, autopsy rates are low in American hospitals. We developed an extensive intervention to increase the autopsy rate on the medical service of our urban teaching hospital and to identify obstacles to obtaining permission for autopsy. The 6-month intervention increased the autopsy rate from 7.5% during the previous 2 years to 16.8%, but this effect disappeared after the intervention. Among patients for whom permission for autopsy was nor obtained, physicians failed to request permission for 31% and families refused permission for 69%.

Autopsy↗
PubMed2001

[Attitudes of students of medicine, sociology and jurisprudence towards autopsy].

UNLABELLED: Attitudes of students of medicine, sociology and jurisprudence towards autopsy. SUBJECT: The autopsy is an important instrument of quality control in medicine. Nevertheless, we observe a dramatic decrease of post-mortem examinations. Because physicians take a important role as mediators, we tried to examine the attitudes of medical students towards autopsy and possible differences to students of other faculties. PROBANDS AND METHODS: Data of medical students (n = 335), students of jurisprudence (n = 95), and of sociology (n = 26) at Leipzig University were collected with the help of a specially elaborated questionnaire >>Post-mortem Examination<< (Fragebogen zur Sektion, FBZS), and two questionnaires >>Death and Dying<< (Fragebogen zu Tod und Sterben, FIMEST) and >>Personality<< (Persönlichkeitsfragebogen, Giessen-Test). RESULTS: Referring to the attitudes towards post-mortem examination there is only a slight difference between students of the above-mentioned faculties. Even preclinical students showed no difference with their attitudes towards autopsy compared to the students of other faculties and they showed lack of knowledge and ethical doubts towards autopsy. CONCLUSION: Due to the significant lack of knowledge of the medical students of the University of Leipzig it seems questionable, if they will be able to convince relatives to give consent to an autopsy in later activity as physicians. More instructional work during study and further medical education should be done.

Attitude to Death↗
PubMed1978

The autopsy: its decline and a suggestion for its revival.

The hospital autopsy rate in the United States dropped from 41 per cent in 1964 to 22 per cent in 1975. This reduction is attributable to a declining interest for many reasons by clinicians, surgeons, pathologists, families of the deceased and hospital administrators and hospital accreditors. Various advances in medicine and surgery in recent years have not replaced the value of the autopsy; indeed they have increased the potential information to be gained from it. For interest in autopsies to be revived among physicians and surgeons, pathologists must provide more expert information from the autopsy. To provide the type of information sought from autopsies by physicians and surgeons, the training of pathologists must be altered so that there can be more specialization in anatomic pathology and more subspecialization in the various organ systems, as in internal medicine. In addition, the means of communication between anatomic pathologists and clinicians needs altering so that important clinical questions are recognized by pathologists, and the answers sought and promptly, understandably and diplomatically communicated to physicians and surgeons. Moreover, the large body of information obtained in recent years from autopsies alone needs to be better recognized by clinicians so that they may better understand the value of these examinations.

Attitude↗
PubMedDate not supplied

The role of autopsy on patients with burns.

Burn center verification requires the use of autopsy as one method of quality assurance in a burn center. Because of the decreasing rates of autopsies worldwide and improved diagnostic accuracy in our critical care units, we tested the hypothesis that autopsy diagnosis would not alter our clinical diagnosis. A chart review of all deaths (N = 94) that occurred during a 6-year period (1989-1994) was performed. The clinical diagnoses from the hospital charts and autopsy reports for the patients were reviewed, and diagnostic discrepancies were classified as class I or class II errors. Class I diagnostic errors might have altered the clinical outcome. Class II errors were attributable to the burn injuries but were believed to have had little impact on the clinical outcome. The overall autopsy rate was 93.6% (n = 88). Clinical diagnostic errors were found in 16 (18%) of 88 patients. Five class I errors were found in 4 patients (4.5%), and 15 class II errors were found in 13 patients (14.7%). Although the rate of potentially serious errors was low (only 4.5% of the patients in this study) postmortem examinations revealed clinical diagnostic errors. The results of this study support the continued use of autopsies as a means of quality assurance, despite our ability to closely monitor our critically ill patients with burns.

Adolescent↗
PubMed2006

Comparison of ultrasound and autopsy findings in pregnancies terminated due to fetal anomalies.

OBJECTIVE: To compare antenatal diagnoses with autopsy findings in pregnancies terminated after ultrasound detection of fetal anomalies. A second aim was to study the quality of antenatal fetal diagnosis over time. DESIGN: Retrospective, multicenter study over two consecutive six-year periods in Uppsala and Stockholm. SETTING: Cases were identified through fetal autopsy reports. SUBJECTS: Three hundred and twenty-eight fetuses from pregnancies terminated between 1992 and 2003 because of ultrasonographically diagnosed anomalies. MAIN OUTCOME MEASURES: The findings at the last ultrasound examination were compared with the autopsy reports. RESULTS: In 299 cases (91.2%) ultrasound findings either exactly matched or were essentially similar to the autopsy findings. In 23 cases (7%) ultrasound findings were not confirmed at autopsy, but the postnatal findings were at least as severe as the antenatal ones. In six cases (1.8%) termination was performed for an anomaly which proved to be less severe than was predicted by ultrasound. The number of such cases was the same in both six-year periods, while the total number of cases increased from 113 in the first to 215 in the second period. Fetal examination provided further diagnostic information in 47% of the cases. In 10% a syndrome was disclosed. CONCLUSION: Termination of pregnancy was not always based on a correct antenatal diagnosis. All fetuses but one from terminated pregnancies had evident anomalies. In six cases (1.8%) the decision to terminate was based on suboptimal prognostic and diagnostic information. Fetal autopsy by an experienced perinatal pathologist is essential to provide a definitive diagnosis.

Abnormalities, Multiple↗
PubMed1999

Improved RNA analysis for immediate autopsy of temporal bone soft tissues.

RNA analysis is essential for understanding biological activities of a cell or tissue. Unfortunately, retrieval of RNA from existing archives of human temporal bones has proven extremely difficult due to degradation of RNA molecules. The major factors that contribute to degradation of RNA in specimens from autopsied temporal bones are tissue autolysis due to time elapsed before autopsy, and technical problems in processing the bones after harvest. We therefore focused on improving the survival of RNA in human temporal bones by shortening the time to autopsy and through modification of the processing technique by removing targeted tissues directly from the temporal bones and by avoiding time-consuming decalcification and celloidin-embedding. Eight temporal bones collected at immediate autopsies were used in this study. Representative mRNAs, ranging from high (MUC5B, physically unstable) to low (beta-actin, physically stable) molecular weights, and from abundant (MUC5B) to non-abundant (MUC1) RNA, were studied by in situ hybridization, Northern blot technique, or both. Using this modified protocol in autopsies performed up to 6 h after death, the existence of mRNAs was demonstrated in all bones studied. This improved method demonstrates the feasibility of the use of autopsied temporal bone tissues for RNA analysis.

Autopsy↗
PubMed2006

Diffuse pulmonary ossification: an uncommon incidental autopsy finding.

AIM: To determine the incidence of diffuse pulmonary ossification (DPO) and its subtypes at autopsy and correlation with clinical and histological features. METHODS: Autopsy reports from our institution over a 64-month period were reviewed for findings of DPO. The pattern of ossification, demographics and clinical data were obtained from both paraffin sections and final autopsy reports. In a selected case, chest radiograph and wet tissue were obtained. RESULTS: Seventeen histologically confirmed cases of DPO were found in 10,426 autopsy cases, representing an incidence of 1.63 cases/1000 autopsies. There was a predilection in males (88%) and underlying pulmonary disease (88%). In contrast to published studies, dendriform DPO was more common than the nodular type in our cohort (11 and 6 cases, respectively). The dendriform type was more commonly associated with marrow elements. CONCLUSIONS: Diffuse pulmonary ossification is uncommon and rarely diagnosed during life, but can easily be identified when sectioning the lungs at autopsy. There is recent renewed interest in diagnosing and determining the significance of DPO using high resolution computed tomography and thoracoscopic biopsy.

Adult↗
PubMed1998

Are autopsies obsolete?

To determine the current frequency of discovering important diagnoses at autopsy, the diagnoses made in all complete or "no head" autopsies during 1994 at a major tertiary care transplantation referral center were retrospectively compared with the diagnoses made antemortem. Of 176 autopsies, 79 (44.9%) revealed 1 or more undiagnosed causes of death. Of the 123 undiagnosed causes of death, 13 were sole immediate causes of death, 72 were one of multiple immediate causes, 22 were intervening causes, and 16 were underlying causes. The causes of death were as follows: infections, 34; infarctions, 11; malignant neoplasms, 8; pulmonary emboli, 7; gastrointestinal ulcers, 7; hemorrhages, 6; thromboses, 3; amyloidosis, 1; genetic hemochromatosis, 1; and cardiac tamponade, 1. Of 35 autopsies of transplant recipients, 16 (46%) disclosed undiagnosed causes of death, compared with 63 (44.7%) of 141 autopsies of patients who had not received transplants. Approximately two thirds of the undiagnosed causes of death were judged to be treatable conditions. This and similar studies suggest that old-fashioned low-technology autopsies can uncover many important diagnoses missed by modern high-technology medicine.

Adult↗
PubMed1986

A comprehensive quality assessment program on the autopsy service.

Many previous studies have established the value of the autopsy in assessing clinical diagnostic accuracy. None has described, however, the use of the autopsy as an ongoing, prospective audit of clinical and pathologic performance. The authors herein outline the process and report the initial results of a comprehensive quality assessment program on their autopsy service. Particular emphasis was placed on evaluation of the responsiveness of the autopsy to clinical questions and interests. The four parts of the overall program included an epidemiologic survey of causes of death in the authors' patient population, a determination of the clinical significance of autopsy findings, an assessment of clinical factors that may have contributed to death, and a quality control mechanism of the autopsy itself. The process can be adapted to a variety of hospital settings.

Autopsy↗
PubMed2001

Correlation between clinical diagnoses at the time of death and autopsy findings in critically sick neonates at a regional neonatal intensive care unit in India.

This study was carried out to examine the correlation between clinical diagnoses at the time of death and autopsy findings in newborn babies who died in the regional Neonatal Intensive Care Unit (NICU) of King Edward VII Memorial Hospital affiliated to Bombay University. A consecutive sample of 240 newborns that died during the study period constituted the study cohort. Of these 240 (172 born in the hospital and 68 born outside) newborns who died during the study period, 197 (82.1 per cent) had autopsies performed. The mean Rushton's score for all the autopsies was 307+/-25.8 (range 300-400). There were 24 cases (12.2 per cent) where autopsy revealed a major finding (class I) that, if known prior to death, would have altered clinical management and could have resulted in cure or prolonged survival. In 53 patients (26.9 per cent) the autopsy revealed a major finding (class II) that, if known prior to death, would not have altered clinical management because specific therapy was unavailable or the patient had received appropriate therapy. It is concluded that a good quality autopsy continues to yield valuable and unsuspected information in a substantial number of newborn deaths.

Autopsy↗
PubMed1991

The uses and value of autopsy in medical education as seen by pathology educators.

A national meeting of pathology educators in 1989 provided the impetus for an exploration of new uses of autopsy in medical education. A month before the conference, the authors sent a questionnaire about the uses and value of autopsy in medical education to 120 persons registered to attend the conference. They used the 98 responses, representing 69 U.S. and Canadian medical schools, as the basis of a workshop on the place of autopsy in future medical education. The present article is a report of the authors' findings from the questionnaire and workshop. They found that the uses of autopsy go far beyond the traditional uses in teaching clinical pathophysiology, clinico-pathologic correlations, clinical anatomy, gross and microscopic anatomy of disease, and visual skills. Emphasis was placed on the potential role of autopsy in education regarding legal/judicial proceedings, vital statistics, epidemiologic investigations, and public health, and in the understanding of such complex matters as medical fallibility, medical uncertainty, and grief. These purposes were seen as congruent with current societal concerns about the need to reverse the trend toward dehumanization of medicine and physicians. The inability to realize these aims in the face of a precipitous drop in the autopsy rate is discussed.

Autopsy↗
PubMed1991

Comparing the case materials available from a teaching hospital's autopsies in 1968 and 20 years later.

The Accreditation Committee on Graduate Medical Education requires both sufficient volume and variety of necropsy material for training in anatomic pathology. Since the number of autopsies has declined markedly in the last 20 years, the author sought to determine whether the variety of case material available from the autopsies performed at his teaching hospital had changed during that time span. Major diagnoses were abstracted from the reports of 200 autopsies of adults performed in 1968 and from a period 20 years later (1987, 1988, and part of 1989). Comparison between the two eras' diagnoses revealed very few changes in the incidences of various diseases. This was true even though the racial mix of patients had changed markedly. While declining autopsy rates are of concern, this study suggests that medical educators may not need to be concerned over the variety of autopsy case material. The author makes several suggestions for maximizing the teaching impact of each autopsy.

Adult↗
PubMed1992

AIDS-defining diseases in 250 HIV-infected patients; a comparative study of clinical and autopsy diagnoses.

OBJECTIVE: To evaluate the correlation between clinical and autopsy findings in 250 AIDS patients. METHODS: Clinical and autopsy diagnoses of AIDS-defining diseases in 250 AIDS patients who died in Milan between May 1984 and February 1991 were compared. RESULTS: Pneumocystis carinii (PCP) and oesophageal candidiasis were the most frequent clinical diagnoses, while cytomegalovirus (CMV) infection was observed in almost half of the autopsies. Forty-seven per cent of the diseases found at autopsy had not been diagnosed during life; CMV infection, mycoses, HIV-specific brain lesions, cerebral lymphomas and progressive multifocal leukoencephalopathy (PML) had a higher rate of non-diagnosis in life. CMV visceral infection accounted for the majority of the diseases not recognized in life. In contrast, clinically diagnosed PCP, oesophageal candidiasis and, to a lesser degree, brain toxoplasmosis were often not found at autopsy, possibly indicating a significant rate of recovery and prevention of relapse. Finally, bacterial pneumonia and sepsis, although not AIDS indicator diseases, were observed in approximately one-third of the autopsies. CONCLUSION: Considerable differences in the frequency and type of the AIDS-defining diseases diagnosed during life and at post mortem were found.

AIDS-Related Opportunistic Infections↗
PubMed1998

Do autopsies of critically ill patients reveal important findings that were clinically undetected?

OBJECTIVE: To determine if autopsies performed on patients who die in the medical intensive care unit (ICU) provide clinically important new information. DESIGN: Retrospective review. SETTING: A 16-bed medical-coronary ICU. PATIENTS: Patients who underwent autopsy during a 1-yr period. INTERVENTIONS: Pre mortem diagnoses were determined from the medical record. Autopsy results were obtained from the final pathology report. A panel of three physicians with certification of added qualifications in critical care medicine reviewed the findings. MEASUREMENTS AND MAIN RESULTS: These questions were asked: a) Is the primary clinical diagnosis confirmed? b) Are the clinical and pathologic causes of death the same? c) Are new active diagnoses revealed? and d) If the new findings had been known before death, would the clinical management have differed? Forty-one autopsies (31% of deaths) were done that showed: a) the same primary clinical diagnosis and post mortem diagnosis in 34 (83%) patients; b) the same clinical and pathologic cause of death in 27 (66%) patients; c) new active diagnoses in 37 (90%) patients; and d) findings that would have changed medical ICU therapy had the findings been known in 11 (27%) patients. CONCLUSIONS: Although the primary clinical diagnosis was accurate in most cases before death, the cause of death was frequently unknown. Almost all autopsies demonstrated new diagnoses, and knowledge of these new findings would have changed medical ICU therapy in many cases. In the critical care setting, autopsies continue to provide information that could be important for education and quality patient care.

Adolescent↗
PubMed1976

Metastatic carcinoma in histologic sections of aspirated bone marrow: a comparative autopsy study.

The incidence of metastatic carcinoma in bone marrow was studied by two different approaches in 220 consecutive autopsies of patients with carcinoma: histologic sections of aspirates from the iliac spine, as usually done in living patients; and gross and microscopic examination of the thoracolumbar spine. Ten percent of the autopsies showed bone marrow metastases by the aspiration technic as contrasted with 34.5% by the autopsy technic. Three cases had positive bone marrow aspirates in the absence of metastases demonstrable by routine autopsy. The combination of autopsy and aspiration technics yielded an incidence of metastatic marrow involvement of 35.9%. Of patients with marrow metastases at autopsy, 25% also had positive aspirates. This study establishes a norm for the comparison of the efficiency of discovery of metastatic carcinoma by different modalities of clinical bone marrow sampling.

Autopsy↗
PubMed2003

Accuracy of cause of death determination without forensic autopsy examination.

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.

Adult↗
PubMed1986

Age and the declining rate of autopsy.

To better understand declining autopsy rates, data have been gathered prospectively on 1080 consecutive deaths over six years among patients admitted to a medical intensive care/coronary care unit. Overall autopsy rate was 36%. Autopsy rates declined sharply with age from 60% for those aged 16 to 34 years to 23% for those 85 and over (P less than .001). The highest rates by diagnosis were aortic aneurysm (70%), hepatic failure (52%), heart rhythm disturbance (48%), pulmonary embolism (45%), and sepsis (41%). Patients receiving major procedures had a significantly higher autopsy rate (38 versus 29%, P less than .05) but rates bore little relation to prognoses given at admission by house officers, suddenness of death, sex, marital status or year of admission. Even among intensively treated patients, autopsy rates decline strikingly with age, demanding honest re-appraisal to restore the place of autopsy in medical education, clinical research, and quality of care assessment for an increasingly elderly population.

Adolescent↗