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PubMed2006

Pneumocystis jirovecii pneumonia in African miners at autopsy.

SETTING: Deceased miners from South Africa whose cardio-respiratory organs were submitted for autopsy for compensation for occupational lung diseases from 1996 to 2000. OBJECTIVES: 1) To document the incidence of Pneumocystis jirovecii pneumonia (PJP) in autopsied miners; 2) to compare the incidence of PJP over a 5-year period; 3) to record the incidence of concomitant lower respiratory tract infection in a group of PJP-infected deceased miners coming to autopsy from 1996 to 2000; and 4) to describe the accuracy of the in-life diagnosis of PJP in this group. DESIGN: Case series of 328 deceased Black miners with histological evidence of PJP at autopsy. RESULTS: Of the 328 miners with PJP at autopsy, 107 (32.6%) had a concomitant respiratory infection, the most common being cryptococcal pneumonia (46.7%), followed by bacterial pneumonia (34.6%) and pulmonary tuberculosis (13.1%). Overall, Pneumocystis pneumonia was unsuspected prior to death in 89% of cases; however, diagnostic accuracy in life improved from 7% in 1996 to 21% in 2000. CONCLUSION: The high rate of undiagnosed PJP is cause for concern. Clinicians should have a heightened awareness for PJP in Africa, particularly as the disease is treatable at low cost and effective prophylaxis is available.

Autopsy↗
PubMed1991

The attitudes of second- and third-year medical students to the autopsy. A survey by postal questionnaire.

Questionnaires were mailed to medical students in the cohorts who had just completed the second and third years of their courses. These included 52 attitude statements to which students indicated their responses on five-point Likert scales. Significant differences were found between the responses of the two cohorts to 18 statements. The results indicate a good general acceptance of the principle of autopsy in both groups, but the senior cohort was more reluctant to become personally involved, despite being more aware of the value of the autopsy in clinical audit, more aware that the autopsy has nonforensic uses, and more aware that autopsies remain useful in elderly subjects. Additionally, they were considerably less likely to want autopsies on close relatives.

Attitude of Health Personnel↗
PubMed1991

The perinatal autopsy: a neglected source of discovery.

The perinatal autopsy is frequently viewed by pathologists as being scientifically unrewarding and contributing little to patient care. To emphasize its importance in patient management, genetic counselling and specific research, a ten-year review (1979-88) was made of the perinatal autopsy experience at Loyola University Medical Center. The 657 deaths included late fetal deaths (22%), early neonatal deaths (51%), late neonatal deaths (10%) and deaths between 29 days and one year (17%). Comparison of the principal causes of death in various groups categorized by birth weight and age revealed significant trends. There has been a steady decline in mortality from immediate complications of immaturity, while the mortality rate from long-term complications of immaturity has not increased. There were increased frequencies of congenital diaphragmatic hernia and cardiac malformations, while the frequency of renal malformations decreased; the etiological significance of these changes requires further evaluation. A correlation of clinical observations with post-mortem findings indicates that newer diagnostic procedures, such as ultrasound, echocardiography and cardiac catheterization, are of limited value for accurate diagnosis of complex anomalies, cystic renal disease and chromosomal anomalies. A substudy included cases up to 18 years of age. The frequency of childhood neoplasia was low (17 cases), and among these cases there was a predominance of haematological malignancies (11 cases). Even with these small numbers, a shift in cause of death from disseminated malignancy to overwhelming infection was apparent. This paper includes the essential elements of a protocol for perinatal autopsies, with illustrations of specific applications. The perinatal autopsy is clearly an undervalued source of information and discovery. Little or no information is available from developing countries, where autopsies could provide information on causes of paediatric mortality and permit recognition of disease patterns, which is so critical to the planning of health services.

Autopsy↗
PubMed1991

Selection for necropsy: evaluation of 321 autopsied cases from 3041 consecutive deaths among residents of a defined geographical area.

By undertaking to act as 'medico necroscopo' (the medical doctors in charge of authorizing every burial) in the Unità Socio-Sanitaria Locale (USSL) 70, a region containing 92,500 inhabitants, we were able to collect over a four-year period (1985-88) information on 3371 deaths among residents of the area. Of these, 68.1% died at home, 12.6% in hospital with no autopsy, 9.5% in hospital with an autopsy and 9.8% outside of the USSL region. For the analysis, age, sex and leading cause of death were considered as explanatory variables and place of death and proportion of autopsied cases as the response variables. The factors found to be associated with deaths occurring in hospital were non-neoplastic (particularly cardiovascular and digestive) pathological conditions in patients under the age of 60. People with malignant neoplasms usually died at home, especially when they had a gastric or breast cancer. Factors associated with autopsy were: death at a young age, short length of hospitalization and death from a cardiovascular disease. Sex did not appear to play a direct role in selection for necropsy. Our results indicate that, in our and similar regions, the cases selected for autopsy form a subset that is so specific that any extrapolation to the total deceased population is misleading.

Adult↗
PubMed1991

Autopsy diagnosis versus clinical diagnosis, particularly in malignant disease. Comparison of two periods: 1961-70 and 1978-87.

We present a comparison of autopsy records in the Institute of Pathology of Münster University during 1961-70 with those from 1978-87. The study was based on 11,716 autopsy cases in which reliable documentation of clinical diagnosis could be adequately correlated and compared with the respective autopsy diagnoses. In the decade 1961-70, 34% of the clinical diagnoses were correct, 15% were nearly correct and 23%, incorrect (24% had to be supplemented without relevance to therapy or prognosis, 4% side diagnoses). In the decade 1978-87, 50% of the clinical diagnoses were correct, 15% nearly correct and 18% incorrect (17% supplemented). With respect to malignant tumours, in 1961-70 clinical diagnoses were correct in 37% of cases and incorrect for 26%; in 1978-87, 47% were correct and 15% incorrect. This comparison covered all major tumour locations. The difference in incorrect clinical diagnoses between the two periods is statistically significant. With respect to infectious diseases, the concordance between clinical and autopsy diagnoses is even poorer. Lues (syphilis) is now rarely recognized in clinical diagnoses, even though it may be fatal; 50% of tuberculosis patients die from miliary tuberculosis without a correct diagnosis. Endocarditis in all its forms was underdiagnosed clinically in 75% of cases. These data provide substantial arguments in favour of autopsy control of clinical diagnosis, also including histological findings in biopsy specimens.

Autopsy↗
PubMed1991

Cultural differences and ethical issues in the problem of autopsy requests.

Cross-cultural ethical issues pervade medical care in Texas. This preliminary study concerns the particular issues that arise when an Anglo-American physician requests an autopsy from a Mexican-American family. The study quantified differences in autopsy rates between Mexican-American and Anglo-American patients at one San Antonio hospital. Mexican-Americans had higher rates for patients dying between the ages of 21 and 40, and after 80. Anglo-Americans had higher rates for all other age groups. Differences in autopsy rates between Mexican-American and Anglo-Americans ranged from 5 to 18 autopsies per 100 deaths and varied by age group. The study also involved 33 interviews concerning Mexican-American and Anglo-American culture. Interviewees identified four sources of relevant differences: (1) medicine's professional values, (2) beliefs about the power of medical science to control disease, (3) beliefs about keeping cadavers whole and unmutilated, and (4) beliefs about the sentence of the soul after bodily death. An appreciation of these value differences is the basis for requesting autopsies in culturally sensitive ways.

Adolescent↗
PubMed1991

Pathologists and the autopsy.

Autopsy practice today remains rooted in the fabric of medicine as it developed through the 18th and 19th centuries. Recent developments in medicine and society have left autopsy practice behind and have led to the decline of the autopsy. Potential new values of autopsies point strongly to the need for revitalized modern autopsy services, services focused on objectives and problems related to patients, their physicians, and the attendant societal issues. There are real values for pathology and pathologists, but only if major realignments in purposes and outcomes are forthcoming.

Autopsy↗
PubMed1990

[Comparison of 2 series of autopsies observed at Johns-Hopkins Medical Center, Baltimore (JHMI) and at the Neuchâtel Institute of Pathology (INAP)].

We are reporting the first results of a comparative study of 100 consecutive autopsies and their clinical diagnoses, observed at the Johns Hopkins Medical Institutions (JHMI) and at the Institut neuchâtelois d'anatomie pathologique (INAP). The diagnoses of the two series were coded according to the two different systems used currently at the two institutions. The data from Baltimore were automatically classified by a special "key word method" using the categories of the Index Medicus (MeSH = Medical subject headings). We proceeded then to a second recording by SNOMED codes, introduced into the computer system in the same way as we document the autopsy diagnoses in Neuchâtel. The two series could be compared in detail according to topographical, morphological and aetiological parameters. The over-all repartition of the examined cases shows a higher incidence of newborns in Baltimore (23), in Neuchâtel we observed only 7 newborn autopsies. The mean age was inferior in Baltimore (males: 53.5 years for JHMI, 73.1 years for INAP; females: 58.4 years for JHMI, 66.2 years for INAP). The number of diagnoses per autopsy was 31.9 at JHMI, and 50.1 in Neuchâtel. The topographical distribution of clinical and autopsy diagnoses showed a higher frequency of central nervous system lesions in JHMI which might be explained by the activity of a neuropathological division. Findings concerning the morphological categories revealed a higher frequency in JHMI for traumatic abnormalities (7.2% vs 2.5%), malformations (4.3% vs 0.8%), whereas inflammation and fibrosis and degenerative lesions were more often encountered in Neuchâtel. The differences in morphological observations could be attributed to a higher proportion of newborn cases in JHMI with complex malformation syndromes.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

[Study of the morbidity structure by analyses of data from 6668 autopsied cases].

In a retrospective study, autopsy data of 6668 cases were collected from the first affiliated hospital, West China University of Medical Sciences, to assess the changes in autopsy rate between 1952 and 1987. The autopsy rate of dead patients was 14.3%, with two peaks obtained in the periods of 1954-1956 and 1964-1966 respectively. Anyhow, the autopsy rate declined sharply after 1967. The agreement of clinical diagnosis and pathological findings in this group was 68.9%. The most common diseases in this series were infectious and parasitic diseases' diseases of respiratory system, diseases of digestive system, neoplasms and diseases of cardio-vascular system. Accompanying the increase of age of the autopsied patients, neoplasia and cardio-vascular diseases were more frequently seen in this series.

Autopsy↗
PubMed1986

Post-mortem bacterial culture of bronchial mucus and heart blood in hospital and non-hospital autopsies: effect of morgue time and length of hospitalization.

We studied cultures of 109 bronchial mucus and 67 heart blood specimens from unselected hospital autopsies and 40 bronchial mucus and heart blood specimens from unselected non-hospital (forensic) autopsies, performed 1-11 days after death. The most prevalent bacterium was Streptococcus viridans. No association was found between morgue time and the number of species isolated from each bronchial mucus or heart blood specimen in either hospital or non-hospital autopsies, nor between morgue time and the number of occasions different species were isolated from the bronchial mucus or heart blood specimens in either series. Bronchial mucus and heart blood cultures from the hospital autopsies gave more often gram negative rods and less often other microbes in result than those from the non-hospital autopsies (p less than 0.05 and p less than 0.025 respectively). There was a highly significant association between the length of hospitalization and the occurrence of gram negative rods both in the bronchial mucus and heart blood (p less than 0.001 and p less than 0.0001 respectively), a result which probably reflects the ante-mortem colonization of the respiratory tract with gram negative bacilli among hospitalized patients.

Adolescent↗
PubMed1988

Pulmonary disease at autopsy in patients with the acquired immunodeficiency syndrome.

To characterize the postmortem pulmonary disease and analyze the effectiveness of antemortem diagnosis, we examined the clinical records and autopsy material from 54 patients who died of the acquired immunodeficiency syndrome. At autopsy, all patients had pulmonary disease. One or more specific diagnoses were made in 53, including opportunistic infection, nonopportunistic infection, and Kaposi's sarcoma. Multiple postmortem pulmonary diagnoses were established in 37. Respiratory failure was the most common cause of death. Of the 97 pulmonary disorders discovered at autopsy, only 31 were diagnosed before death. The frequency with which infections were diagnosed during life varied according to the organism, and was significantly higher for Pneumocystis carinii than for cytomegalovirus or bacterial agents. Pulmonary Kaposi's sarcoma was diagnosed in only 7% of patients with autopsy documentation. The yield of diagnostic procedures also varied according to the disease present. Sputum culture was relatively effective in detecting Cryptococcus neoformans and Mycobacterium avium-intracellulare, fiber-optic bronchoscopy was extremely useful for diagnosing P Carinii, and one or more diagnoses were provided in 4 of 7 patients who underwent thoracotomy, but significant disease including cytomegalovirus infection and pulmonary Kaposi's sarcoma was frequently missed. Although the spectrum of lung disease found at autopsy is similar to that observed during life, the frequency of some pathologic processes including cytomegalovirus infection and Kaposi's sarcoma may be underrepresented in antemortem series.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Sarcoidosis autopsies in Japan. Frequency and trend in the last 28 years.

Records of sarcoidosis autopsies were collected from data books of all the autopsies in Japan, which have been published yearly by the Japanese Society of Pathology since 1958. The rate of sarcoidosis in comparison to total autopsies showed about a two-fold increase between the 1958-'63 period and 1979-'85, and a significant difference was noted between the rate in the previous 16 years and that in the following 12 years. Age distribution among both the sexes showed significant higher rates in the females of over 40 years of age than among the males of the same age group, due to the higher rates of cardiac sarcoidosis among the older females. The disease was thought to be increasing in all age groups. In over half of the sarcoidosis autopsies death from sarcoidosis was noted, among which cardiac sarcoidosis was the main cause of death. Clinical diagnosis for sarcoidosis had been obtained in only one third of the sarcoidosis as well as non-sarcoidosis deaths, indicating the difficulty in clinical diagnosis for cardiac sarcoidosis and the presence of many subclinical cases. The rate of sarcoidosis to total autopsy was three-fold or more of the prevalence rate of sarcoidosis in Japan.

Adult↗
PubMed1987

Autopsy. A comprehensive review of current issues. Council on Scientific Affairs.

This report reviews the effects of decreased utilization of autopsy (less than 15% in 1985) on medical education and research, quality assurance programs, insurance claims processing, and cost containment. Recommendations to promote change include the innovative integration of postmortem examinations with new technology for education and research and the promotion of standards of accreditation of programs that include autopsy for graduate and undergraduate medical education. The use of autopsy to assess technological methods of diagnosis seems to be a reasonable expectation. Methods of reimbursement to validate autopsy as a medical act should be sought, and voluntary and government regulation to assure the role of autopsy in quality assurance programs is suggested.

American Medical Association↗
PubMed1987

Autopsy legislation and practice in various countries.

Information concerning autopsy laws, regulations, rates, and practice was collected from 29 industrialized countries. In many countries, laws have been revised in recent years, introducing more restrictive rules, with consent required from the next-of-kin. With one exception (Finland), introduction of a requirement for consent was followed by a decline in the autopsy rate. Experiences in various countries are discussed. It is apparent that the problem of decreasing autopsy rates is an international one. Efforts to inform and educate the public about the benefits of autopsy are necessary, if the decision whether to perform autopsy is to remain their responsibility.

Australia↗
PubMed1986

[Frequency and value of autopsy in perinatal death].

In the province of Hainaut (Belgium), a study was undertaken in order to assess a pediatric pathology department, organized at the regional level. The study concerned 182 perinatal deaths, occurring among the 16,071 births in 9 maternity hospitals, in 1982 and 1983. The frequency of autopsies was 51%, both for stillbirths and for early neonatal deaths. It was 76% in the group of deaths related to congenital malformations and 48% in the group of deaths of unknown cause. The lack of an autopsy was explained in 20% of cases by the parents' refusal, in 8% of cases by the state of maceration of the fetus and by the obviousness of the diagnosis in 24%. In 46% of cases, no etiology was found and it appeared that the degree of physician interest was an important factor in the frequency of autopsies. Dissection alone revealed the cause of death in 13 of the 94 autopsies. In children presenting with congenital malformations, the performance of a complete pathologic study almost always led to genetic counseling for the parents. This counseling was almost never given when autopsy was not performed.

Autopsy↗
PubMed1984

Lay perceptions of autopsy.

The lay public's exposure to information on the purposes and value of the autopsy is sparse. When approached for consent to perform an autopsy, they are often indifferent and uncooperative. If the autopsy is worthy of revitalization as the ultimate medical consultation, pathologists must know what the general public is exposed to, what they think, and what their perceptions about autopsy are. There have been mass media and some specialized media contributions during the years 1977 through 1982. I studied the public's areas of concern regarding the topic and detailed the perceptions and unspoken thoughts of laymen. There are steps that can be taken to join the lay community and pathologists together in renewed efforts to revitalize the role of the autopsy while simultaneously educating the public about the advantages and needs of medical education.

Attitude to Death↗
PubMed1982

[Autopsies with unsatisfactory results].

Autopsies are intended to provide information about the main disease process and the cause of death, and also to disclose relevant secondary findings. A review of 3076 autopsy protocols yielded 113 cases (3.7%) with unsatisfactory results. Of these, 56% constituted a first group in which substantial findings concerning the underlying disease or cause of death were absent. Most often they were cases of sudden death; in many others, however, diseases of obvious duration but uncertain nature were not manifest pathologically. In the second group, representing 44%, the morphologic findings contributed by autopsy did little to clarify the clinical picture. Here the large majority were cancer patients, while other clinical pictures were only rarely left unexplained. In half of all cases the case of such autopsy failures relates to the limitations of the procedure itself as a method of morphologic examination. In about 35% a delayed autopsy, the restricted application of modern investigation methods and, not infrequently, superficial information by the clinician may well play a significant role. The remaining 15% of all cases incorporate all the above-mentioned factors in yielding unsatisfactory results. If justice is to be done to ever-increasing demands, the development of pathology specialties with a corresponding increase in staff cannot be avoided.

Adult↗
PubMed1994

[Correlation between clinical and autopsy diagnoses at a general hospital].

In the past years, the number of hospital clinical autopsies have significantly decreased, with the risk of loosing some of the functions of this procedure, among which the evaluation of the diagnostic accuracy, which has been considered as a health care quality index, stands out. In this paper, the consistency between clinical diagnosis and autopsies in a general hospital is studied, as well as its association to some potentially relevant factors. We review 91 autopsies performed in patients dying in the Service of Internal Medicine during a period of six years. Each case was classified though consensus among a clinician and a pathologist into: mayor clinicopathological discrepancy, minor discrepancy or complete consistency. The relationship between consistency and age, sex, average length of stay in the hospital and study period was analyzed. The 91 autopsies were performed on 64 men and 27 women. The mean age was 63 years and the average length of study in the hospital was 9.7 days. The global consistency was 71.4%. In 15 (16.5%) cases, a major discrepancy was observed and in 11 (12.1%), a minor discrepancy. No differences were observed in the degree of consistency with respect to age, sex, average length of stay and study period. Cardiovascular diseases showed the greatest proportion of major discrepancies at the expense of three cases of pulmonary thromboembolism. We conclude that the degree of concordance in this study is consistent with other studies and we discuss the relevance of clinical autopsies regarding several aspects of health care.

Adult↗