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PubMed1985

How--and why--to request an autopsy.

Autopsy remains the touch-stone of diagnosis, but clinicians are often reluctant to request the procedure because of their discomfort in approaching the family. Fundamental to a successful autopsy request is sensitivity for the family's feelings, which bespeaks respect for the deceased and the family. For example, in announcing the death and requesting autopsy, the clinician should bring the family to the hospital and talk with them privately. If they have questions or reservations about autopsy, the clinician should answer honestly and simply, stressing the benefits of the procedure to the family and society as a whole. Since the manner of request influences the family's decision in about one third of cases, efforts at overcoming personal reluctance in requesting autopsy are worthwhile. Clinical excellence develops through effort and practice in this activity as in any other.

Autopsy↗
PubMedDate not supplied

An autopsy case of minamata disease (methylmercury poisoning)--pathological viewpoints of peripheral nerves.

The outbreak of methylmercury poisoning in the geographic areas around Minamata Bay, Kumamoto, Japan in the 1950s has become known as Minamata disease. Based on earlier reports and extensive pathological studies on autopsied cases at the Kumamoto University School of Medicine, destructive lesions in the anterior portion of the calcarine cortex and depletion predominantly of granular cells in the cerebellar cortex came to be recognized as the hallmark and diagnostic yardstick of methylmercury poisoning in humans. As the number of autopsy cases of Minamata disease increased, it became apparent that the cerebral lesion was not restricted to the calcarine cortex but was relatively widespread. Less severe lesions, believed to be responsible for the motor symptoms of Minamata patients, were often found in the precentral, postcentral, and lateral temporal cortices. These patients also frequently presented with signs of sensory neuropathy affecting the distal extremities. Because of few sufficiently comprehensive studies, peripheral nerve degeneration has not been universally accepted as a cause of the sensory disturbances in Minamata patients. The present paper describes both biopsy and autopsy findings of the peripheral nerves in a male fisherman who died at the age of 64 years and showed the characteristic central nervous system lesions of Minamata disease at autopsy. A sural nerve biopsy with electron microscopy performed 1 month prior to his death showed endoneurial fibrosis and regenerated myelin sheaths. At autopsy the dorsal roots and sural nerve showed endoneurial fibrosis, loss of nerve fibers, and presence of Büngner's bands. The spinal cord showed Wallerian degeneration of the fasciculus gracilis (Goll's tract) with relative preservation of neurons in sensory ganglia. These findings support the contention that there is peripheral nerve degeneration in Minamata patients due to toxic injury from methylmercury.

Autopsy↗
PubMed1994

The limitations of verbal autopsy in a malaria-endemic region.

Verbal autopsies are being used widely to describe the causes of mortality and to assess the effect of interventions against specific diseases in developing countries where many deaths occur at home. A verbal autopsy has been in use in the Upper River Division of The Gambia since 1988. In this paper we present the results of a validation study of this technique. One hundred and forty-one verbal autopsies were reviewed on two occasions by the same three physicians. In 38 (27%) of the cases, the first and subsequent diagnoses differed. In 94 children admitted to Basse Health Centre, the results of verbal autopsies were compared with the diagnoses made by a paediatrician--only 44 (47%) matched. The poor sensitivity and specificity of the verbal autopsy in this study may have been due to the confounding effect of malaria, which can be difficult to distinguish from other causes of death in this community.

Autopsy↗
PubMed2005

Biosafety level 3 laboratory for autopsies of patients with severe acute respiratory syndrome: principles, practices, and prospects.

BACKGROUND: During the outbreak of the emergent severe acute respiratory syndrome (SARS) infection, >30% of the approximately 8000 infected persons were health care workers. The highly infectious nature of SARS coronavirus (SARS-CoV) compelled our pathologists to consider biosafety issues in the autopsy room and for tissue processing procedures. METHODS: A specially designed biosafety level 3 (BSL-3) autopsy laboratory was constructed and divided into a clean area, a semicontaminated area, a contaminated area, and 2 buffer zones. High-efficiency particulate air filters were placed in the air supply and exhaust systems. Laminar air flow was from the clean areas to the less clean areas. The negative pressures of the contaminated, semicontaminated, and clean areas were approximately -50 pa, -25 pa, and -5 pa, respectively. Personal protective equipment, including gas mask, impermeable protective clothing, and 3 layers of gloves worn during autopsies; the equipment was decontaminated before it was allowed to exit the facility. Strict BSL-3 practices were followed. RESULTS: When a given concentration of particulate sarin simulant was introduced into the contaminated area, it could not be detected in either the semicontaminated area or clean area, and particles >0.3 microm in size were not detected in the exhaust air. A total of 16 complete postmortem examinations for probable and suspected SARS were performed during a 2-month period. Of these, 7 reported confirmed cases of SARS. None of the 23 pathologists and technicians who participated in these autopsies was infected with SARS-CoV. CONCLUSIONS: Our experience suggests that BSL-3 laboratory operating principles should be among the special requirements for performing autopsies of contaminated bodies and that they can safeguard the clinicians and the environment involved in these procedures.

Autopsy↗
PubMed1996

American Society of Clinical Pathologists--Resident Physician Section. Results of autopsy survey (Winter 1994-1995)

The recent debate on autopsy and the role of this unique doctor-patient relationship in the modern medical profession prompted the Resident Physician Section of the American Society of Clinical Pathologists to conduct a survey on postmortem practice as it relates to pathology residents. A total of 102 of 176 (58%) Resident Physician Section (RPS) liaisons from pathology residency programs in the United States, Canada, and Puerto Rico responded to a survey that consisted of 30 questions. The findings of the survey confirm the decrease in autopsy numbers, highlighting the problem of providing sufficient autopsy training to pathology residents. Interestingly, the majority of programs showed a striking similarity with regard to basic autopsy protocol procedures. Liaisons identified incorporation of clinical pathology, basic science, and clinicopathologic interaction as areas of weakness. In the final analysis, the majority of liaisons had a favorable opinion of their autopsy experience.

Autopsy↗
PubMed1999

Autopsy findings in umbilical cord blood transplant recipients.

Human umbilical cord blood stem cells have been used to reconstitute hematopoiesis in patients with malignant and nonmalignant diseases. The immunologic immaturity of cord blood cells confers peculiar characteristics to these hematopoietic precursors. Autopsy reports from January 1, 1988, through June 30, 1998, were searched for patients who had received an umbilical cord blood transplant (UCBT). Thirty-two patients (19 male, 13 female) were identified with a mean age at autopsy of 13.0 years with a range from 1 to 52 years. Most patients (24) underwent UCBT for treatment of a malignant neoplasm, while the remainder were treated for immunodeficiencies (4), Lesch-Nyhan syndrome (2), Hurler syndrome (1), and Diamond-Blackfan syndrome (1). Sixteen patients had at least 1 infectious complication, and 8 patients had multiple infections. Organisms included mycoses (7 patients), viruses (8 patients), bacteria (3 patients), and Toxoplasma (2 patients). Hemorrhagic complications, such as intra-alveolar hemorrhage and gastrointestinal tract hemorrhage, were found in 24 patients. Other frequent findings at autopsy included diffuse alveolar damage (15 patients), hepatic veno-occlusive disease (11 patients), and acute or chronic graft-vs-host disease (9 patients). Patients who have received UCBT represent a unique population of immunosuppressed patients. Infectious and hemorrhagic complications frequently are encountered at autopsy, and pathologists performing autopsies on these patients should be alert to unusual pathogens.

Adolescent↗
PubMed1992

Autopsy findings in cardiac transplant patients. A 10-year experience.

Findings from 44 autopsy examinations of cardiac transplant patients during a 10-year period were reviewed. The autopsy rate was 85%. One half of the autopsy patients underwent original transplantation for ischemic heart disease and 34% for cardiomyopathy. Survival after transplantation ranged from 0 (intraoperative) to 91 months. Rejection (including hyperacute rejection) was responsible for 41% of deaths, followed by infection (25%), and intraoperative deaths at first transplantation (9%). Most of the remaining complications were related to surgery or artificial heart support, accelerated allograft atherosclerosis, and lymphoma. Infections were not only responsible for a substantial percentage of deaths but were also a co-morbid finding in a number of patients who died primarily of other causes. Pulmonary infections represented the most common anatomic site. Twenty-five percent of the autopsy patients had gastrointestinal and/or pancreatic abnormalities, principally mucosal inflammation, erosions or hemorrhage, and pancreatitis. Review of premortem rejection history indicated that 64% of patients who died of or with rejection at autopsy had had an episode of rejection 3 weeks after transplantation and/or at least one episode of severe rejection.

Adolescent↗
PubMed1993

An autopsy-based quality assessment program for improvement of diagnostic accuracy.

A program for quality assessment of medical diagnostics is proposed, based on detailed, ongoing comparison of clinical diagnoses with autopsy diagnoses. The model requires that the autopsy service itself be subjected to quality control to assure the reliability of the autopsy findings, including the quality of diagnoses made postmortem, and the quality of autopsy reports. Discrepancies between premortem and postmortem diagnoses are classified as to cause and magnitude; for each disease, the total diagnostic experience is collected, and sensitivity and specificity of clinical diagnostics are computed. These are compared with control ranges of sensitivity and specificity, prospectively arrived at through analysis of thousands of cases. Statistically acceptable sampling for autopsy, and review of findings by an independent body are also discussed. The findings generated by this program would be of great value in programs for quality improvement of medical care. The model has the following advantages: (1) it recognises that there is an unavoidable baseline of diagnostic errors; (2) the control levels, based on current medical practice, are prospectively established; (3) it avoids placing blame in a single case; and (4) it provides a fairly high power scrutiny that can focus on diagnostics for single diseases rather than the entire spectrum of medical practice.

Autopsy↗
PubMed1999

Mountaineering fatalities on Mount Rainier, Washington, 1977-1997: autopsy and investigative findings.

Mountain climbing is a popular recreational activity with a growing number of participants and associated fatalities. To define the characteristics of these fatal incidents and the typical autopsy findings in the victims, we reviewed the autopsy and investigative findings of all fatalities that occurred on Mount Rainier from 1977 through 1997. A total of 50 deaths occurred in 29 separate incidents. Fifty-eight percent of accident victims died as the result of a fall; another 34% died as a result of an avalanche. The incidents leading to death occurred at an average altitude of 3652 m (11,977 feet); range, 2073 to 4389 m (6800-14,400 feet). The average age of the victims was 31.2 years (range, 17-55 years), and 47 of the 50 were men (94%). Bodies were not recovered in 13 cases (26%). Autopsies were performed in 30 of the remaining 37 cases. At autopsy, the cause of death was ascribed to multiple injuries in 12 cases (40%), isolated head and neck injuries in 7 cases (23%), and chest injuries in 1 case (3%). Asphyxia and hypothermia were the cause of death in 8 cases (27%) and 2 cases (7%), respectively. The frequency of specific injuries is presented by anatomic region. The unique autopsy and investigative features of mountaineering deaths are discussed.

Accidental Falls↗
PubMed1996

Unanticipated diagnoses found at autopsy in an urban public teaching hospital.

The authors set out to evaluate the use of the autopsy in an urban public teaching hospital setting during the AIDS era. Demographic and length of hospital stay data were obtained from weekly mortality review reports on all patients dying on the medicine service between 1/1/92 and 12/31/93. Clinical and autopsy diagnoses were compared for those patients who had autopsies. The autopsy rate was 16% (152/974). Significant, unsuspected diagnoses were found in 35% (53/152) of the cases, with infections, pulmonary emboli, and myocardial infarctions being most common. Human immunodeficiency virus-infected patients had a greater percentage of unsuspected findings (55%, 23/42), and many of these also were from an infectious etiology. The authors conclude that valuable, unsuspected information frequently can be obtained from autopsies in this clinical setting.

Acquired Immunodeficiency Syndrome↗
PubMed1992

The spectrum of clinical and pathological manifestations of AIDS in a consecutive series of autopsied patients in Mexico.

OBJECTIVE: Little is known about the clinical profile of AIDS in Latin American populations. This study characterizes the clinical and pathological manifestations of AIDS in a representative series of Mexican AIDS patients at autopsy. DESIGN: The clinical and pathological findings were abstracted retrospectively for a sequential series of autopsied AIDS patients. SETTING: Autopsies were conducted at the four major tertiary level hospitals that serve the majority of AIDS patients in Mexico City. PATIENTS: Subjects included 177 consecutive patients diagnosed with AIDS between March 1984 and January 1989 who subsequently died and were autopsied in the same period in the study hospitals. MAIN OUTCOME MEASURES: Demographic characteristics, including age, gender, residence, socioeconomic status, and risk group; clinical presentation and autopsy findings, including opportunistic infections and malignancies. RESULTS: Sixty per cent of the AIDS patients presented with wasting syndrome. The most common infections were cytomegalovirus (69%), tuberculosis (25%), and Pneumocystis carinii pneumonia (24%). Central nervous system infections were also common and included toxoplasmosis (19%) and cryptococcoses (10%). Kaposi's sarcoma was present in 30% of cases and non-Hodgkin's lymphoma in 9%. CONCLUSION: Clinical manifestation, and types and frequency of opportunistic infections in our Mexican AIDS patients were more similar to those seen in AIDS patients in Africa and Haiti than in the United States and Europe. These findings suggest that the AIDS epidemic in Mexico has an 'intermediate' pattern and may be a prototype for Latin American countries.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Sites of tuberculous involvement in patients with AIDS. Autopsy findings and evaluation of gallium imaging.

The purpose of this study was to review autopsy and gallium scan findings in two different acquired immune deficiency syndrome (AIDS) patient populations who had a confirmed diagnosis of tuberculosis (TB) to identify organs involved and accuracy of clinical diagnosis. The first group was comprised of 29 autopsies between January 1982 and December 1994, including only 18 patients who were diagnosed before death. Organs most commonly involved were the lymph nodes (59%), lungs (56%), spleen (53%), liver (45%), and kidneys (37%). Other opportunistic infections were present in 18 (59%) of autopsies, with more than one opportunistic infection present in 11 (37%) of the autopsies. Lungs were involved in 79% of all autopsies. The second population group included 94 patients with AIDS with a proven diagnosis of TB, only 24 of whom had gallium scans in the period between January 1992 and December 1994. Chest x-ray results were negative in 4 patients (17%); gallium scan results were positive in 16 patients (66%). The reasons for false-negative gallium scan results were due to anti-tuberculous treatment for periods varying from 2-21 months in 7 patients or the presence of extra pulmonary tuberculosis. The sites of TB involvement in the chest were: lung parenchyma in 5 patients (19%, 4 in mid and lower lung, and 1 in upper fields). There was lymph node involvement in all 16 patients (24 locations with mediastinal involvement in 23%, supraclavicular 23%, axillary 11%, retroperitoneal 11%, and inguinal region in 4%. We conclude that (1) tuberculosis in patients with AIDS behaves similar to primary tuberculosis; (2) the combination of chest x-ray and gallium imaging is sensitive for the diagnosis of pulmonary tuberculosis in patients with AIDS; (3) the involvement of mediastinal lymph nodes in gallium scans in the presence or absence of chest x-ray abnormalities should raise the possibility of TB involvement in patients with human immunodeficiency virus; (4) anti-TB treatment decreases the sensitivity of gallium scan.

AIDS-Related Opportunistic Infections↗
PubMed1996

Association of pre mortem diagnosis and autopsy findings in pediatric intensive care unit versus emergency department versus ward patients.

OBJECTIVE: As part of the overall quality assurance program for the Department of Pediatrics, we determined whether there were differences in the rates of unexpected autopsy findings between pediatric intensive care unit (ICU), emergency department, and ward patients. DESIGN: Prospective, descriptive study. SETTING: Tertiary care children's hospital. PATIENTS: Pediatric deaths (n = 212). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Autopsies were obtained more frequently in emergency department patients (27/29 [93%]) compared with pediatric ICU (88/121 [73%] and ward (42/62 [68%]) patients (p = .03). The medical examiner's cases were more frequently from emergency department patients (22/27 [81%]) compared with pediatric ICU (39/88 [44%]) or ward (11/42 [26%]) patients (p < .001). We found unexpected autopsy findings in 19 (12%) of 157 patients. There were no unexpected findings from the medical examiner's cases. The most common unexpected findings were unidentified infections (n = 7 [three fungal, three viral, and one nonspecific]) and unrecognized cardiac malformations (n = 4). Unexpected findings occurred more frequently in pediatric ICU patients (16/88 [18%]) vs. emergency department (2/27 [7%]) or ward (1/42 [2%]) patients (p = .03). The occurrence rates of major unexpected findings (Class I and II) in pediatric ICU (7/79 [9%]), emergency department (2/27 [7%]), and ward (1/42 [2%]) patients were similar (p = .4). There were two Goldman's Class I unexpected findings in the pediatric ICU and emergency department patients, and one Goldman's Class I unexpected finding in the ward patients. CONCLUSIONS: Autopsies were performed more frequently in emergency department patients. Class I through IV unexpected findings occurred more frequently in pediatric ICU patients compared with emergency department or ward patients. Autopsy examinations are an especially valuable diagnostic tool for pediatric ICU patients and physicians.

Autopsy↗
PubMedDate not supplied

Deaths from ischaemic heart disease in Helsinki in the years 1959-1968. Vital statistics and medico-legally autopsied sudden deaths.

According to the official vital statistics, altogether 10910 deaths from ischaemic heart disease (IHD) occurred in persons resident in Helsinki during the 10-year period 1959-68. A significant increase was found in the incidence of IHD deaths in both sexes even though changes in the structure of the population were taken into account. The increase in the age-dependent incidence of IHD deaths was most conspicuous at middle age in both sexes and in young males. Altogether 3044 IHD deaths occurring unwitnessed or within 24 hours of the onset of the fatal attack were autopsied medico-legally during the 10-year period of the study. The medico-legally autopsied cases obviously represented a high proportion of sudden IHD deaths occurring outside hospitals in Helsinki. A clear male preponderance was found in the autopsy material as compared with all IHD deaths. The prevalence of cases of acute myocardial infarction varied in different years from 27 to 49 percent at medico-legal autopsies. No significant change occurred during the 10-year period in the distribution of the medico-legally autopsied IHD deaths into social groups, in the suddenness or place of death. The home was the most common place of death. From 1963 onwards the patients dying from an ischaemic heart attack during transportation to hospital or in an outpatient department constituted 6-7 percent of all annual IHD deaths.

Acute Disease↗
PubMed2006

Validity of verbal autopsy procedures for determining cause of death in Tanzania.

OBJECTIVES: To validate verbal autopsy (VA) procedures for use in sample vital registration. Verbal autopsy is an important method for deriving cause-specific mortality estimates where disease burdens are greatest and routine cause-specific mortality data do not exist. METHODS: Verbal autopsies and medical records (MR) were collected for 3123 deaths in the perinatal/neonatal period, post-neonatal <5 age group, and for ages of 5 years and over in Tanzania. Causes of death were assigned by physician panels using the International Classification of Disease, revision 10. Validity was measured by: cause-specific mortality fractions (CSMF); sensitivity; specificity and positive predictive value. Medical record diagnoses were scored for degree of uncertainty, and sensitivity and specificity adjusted. Criteria for evaluating VA performance in generating true proportional mortality were applied. RESULTS: Verbal autopsy produced accurate CSMFs for nine causes in different age groups: birth asphyxia; intrauterine complications; pneumonia; HIV/AIDS; malaria (adults); tuberculosis; cerebrovascular diseases; injuries and direct maternal causes. Results for 20 other causes approached the threshold for good performance. CONCLUSIONS: Verbal autopsy reliably estimated CSMFs for diseases of public health importance in all age groups. Further validation is needed to assess reasons for lack of positive results for some conditions.

Adolescent↗
PubMed2006

Resuscitating the autopsy in Australian hospitals.

Previous studies have consistently shown that autopsy examination after surgery can identify a significant rate of discrepant and/or erroneous diagnoses. Findings gleaned from autopsies can be invaluable for the medical community and science as a whole, ultimately leading to improvements in quality surgical care. Despite the proven benefits of this underused tool, the number of autopsies carried out in Australian hospitals is declining dramatically, with autopsy rates plummeting from 21% in 1992-1993 to 12% in 2002-2003. This notable decline ought to be a genuine source of concern and deserves further examination. This review seeks to address the reasons for decline, while reasserting the value and relevance of autopsies within modern surgical practice Down Under.

Australia↗
PubMed1983

The value of the autopsy in medical audit--a combined clinical and pathological assessment of 100 cases.

We retrospectively reviewed 100 consecutive autopsies performed at the Royal Adelaide Hospital in 1979. The review was made jointly by a clinician, surgical pathologist and forensic pathologist. The mean patient age was 64.5 years. Sixteen percent of premortem anatomical diagnoses were not confirmed at autopsy. Autopsy revealed 171 new anatomical diagnoses. Of these, 33 diagnoses in 27 patients were important in relation to the cause of death and if known premortem would have altered therapy and possibly outcome in two patients. In 11 cases the missed major diagnoses should have been entertained on the basis of available clinical data. Of the 19 sudden deaths, the cause of death was not included in the clinical differential diagnosis in seven cases. Autopsy resulted in a substantial change in the death certification of 43 cases. The data indicate that the autopsy has a great deal to offer in correcting clinical diagnoses and effecting scientific discipline for clinicians.

Adult↗
PubMed1991

West Midlands perinatal mortality survey, 1987. An audit of 300 perinatal autopsies.

As part of the West Midlands regional perinatal mortality survey an audit of perinatal autopsies was performed in 10 of 20 districts in the region. Autopsy reports were available from 300 of the 426 deaths (70%) reported in these districts. These were coded for 8 aspects including the clinical summary, body measurements, descriptive content, organ weights, post mortem radiology and microbiology, histology and other relevant investigations e.g., biochemistry, cytogenetics. Overall 44% of the autopsies failed to attain an arbitrary minimum score of 300, the mean score being 299. Excluding those autopsies performed at the regional centre these figures were 50% and 268 respectively. These data indicate that a high autopsy rate does not necessarily reflect a high quality of service and further emphasise the concerns that have been expressed by obstetricians, paediatricians, geneticists, parents and parliamentarians about the perinatal pathology services in the United Kingdom.

Autopsy↗