Clinical and autopsy diagnoses in the intensive care unit: a prospective study

Efficacy of postmortem CT and tissue sampling in establishing the cause of death in clinical practice: a prospective observational study

AIMS

The aim of this study is to evaluate whether agreement with autopsy-determined cause of death (COD) increases by use of postmortem CT (PMCT) or PMCT in combination with postmortem sampling (PMS), when compared with clinical assessment only.

METHODS

This prospective observational study included deceased patients from the intensive care unit and internal medicine wards between October 2013 and August 2017. The primary outcome was percentage agreement on COD between the reference standard (autopsy) and the alternative postmortem examinations (clinical assessment vs PMCT or PMCT+PMS). In addition, the COD of patient groups with and without conventional autopsy were compared with respect to involved organ systems and pathologies.

RESULTS

Of 730 eligible cases, 144 could be included for analysis: 63 underwent PCMT without autopsy and 81 underwent both PMCT and autopsy. Agreement with autopsy-determined COD was significantly higher for both PMCT with PMS (42/57, 74%), and PMCT alone (53/81, 65%) than for clinical assessment (40/81, 51%; p=0.007 and p=0.03, respectively). The difference in agreement between PMCT with PMS and PMCT alone was not significant (p=0.13). The group with autopsy had a significantly higher prevalence of circulatory system involvement and perfusion disorders, and a lower prevalence of pulmonary system involvement.

CONCLUSION

PMCT and PMS confer additional diagnostic value in establishing the COD. Shortcomings in detecting vascular occlusions and perfusion disorders and susceptibility to pulmonary postmortem changes could in future be improved by additional techniques. Both PMCT and PMS are feasible in clinical practice and an alternative when autopsy cannot be performed.

Comorbidity network analysis using graphical models for electronic health records

Importance

The comorbidity network represents multiple diseases and their relationships in a graph. Understanding comorbidity networks among critical care unit (CCU) patients can help doctors diagnose patients faster, minimize missed diagnoses, and potentially decrease morbidity and mortality.

Objective

The main objective of this study was to identify the comorbidity network among CCU patients using a novel application of a machine learning method (graphical modeling method). The second objective was to compare the machine learning method with a traditional pairwise method in simulation.

Method

This cross-sectional study used CCU patients' data from Medical Information Mart for the Intensive Care-3 (MIMIC-3) dataset, an electronic health record (EHR) of patients with CCU hospitalizations within Beth Israel Deaconess Hospital from 2001 to 2012. A machine learning method (graphical modeling method) was applied to identify the comorbidity network of 654 diagnosis categories among 46,511 patients.

Results

Out of the 654 diagnosis categories, the graphical modeling method identified a comorbidity network of 2,806 associations in 510 diagnosis categories. Two medical professionals reviewed the comorbidity network and confirmed that the associations were consistent with current medical understanding. Moreover, the strongest association in our network was between "poisoning by psychotropic agents" and "accidental poisoning by tranquilizers" (logOR 8.16), and the most connected diagnosis was "disorders of fluid, electrolyte, and acid-base balance" (63 associated diagnosis categories). Our method outperformed traditional pairwise comorbidity network methods in simulation studies. Some strongest associations between diagnosis categories were also identified, for example, "diagnoses of mitral and aortic valve" and "other rheumatic heart disease" (logOR: 5.15). Furthermore, our method identified diagnosis categories that were connected with most other diagnosis categories, for example, "disorders of fluid, electrolyte, and acid-base balance" was associated with 63 other diagnosis categories. Additionally, using a data-driven approach, our method partitioned the diagnosis categories into 14 modularity classes.

Conclusion and relevance

Our graphical modeling method inferred a logical comorbidity network whose associations were consistent with current medical understanding and outperformed traditional network methods in simulation. Our comorbidity network method can potentially assist CCU doctors in diagnosing patients faster and minimizing missed diagnoses.

When is a postmortem examination carried out? A retrospective analysis of all Swedish deaths 1999-2018

The objective of this study was to assess who is merited an autopsy in Sweden. Data from the Swedish cause of death (COD) registry over a period of 20 years was retrieved and analysed. A multinominal logistic regression analysis was performed to identify the variables that were most strongly associated with the performance of a clinical or forensic autopsy (CA/FA).A definite COD, i.e. a COD based on autopsy findings, was registered in 12.6% of all deceased during the investigated period. In the remaining cases, the COD was presumed by the clinicians. Being male, born in the Nordic region, dying in a private residence, and unnatural death were most strongly associated with the performance of CA/FA. In contrast, being female, dying from dementia, dying at a nursing home, being born outside of Europe, or living in a small city or rural area seldom led to the performance of CA/FA.The above is certainly surprising as an autopsy provides an opportunity to investigate the cause of death, validate clinical diagnoses, detect unexpected aberrations, audit health care, and provide feedback to clinicians to facilitate their continuing education.

[Comparison of the final clinical and autopsy detected diagnoses in sepsis]

With sepsis, more than a third of patients die, while the immediate causes of death may remain unknown. Autopsy largely helps to establish them.

OBJECTIVE

Identification of discrepancies in the final clinical and autopsy detected diagnoses in patients with sepsis who died in the surgical intensive care unit.

MATERIAL AND METHODS

107 cases of patients with sepsis who died in the Department of Surgical Resuscitation of the Republican Scientific Center for Emergency Medical Care in 2020-2021 were studied. Autopsy was performed in 60 (56%) of the deceased. The autopsy was performed within 24 hours after the death was pronounced. The final clinical and pathoanatomic diagnoses were compared in accordance with the International Goldman System and the Russian Classification of categories of diagnosis discrepancies.

RESULTS

As a result of autopsies, 3 (5%) of the deceased had a discrepancy in the diagnoses of class I and 14 (23%) - class II according to the International Goldman System. During his lifetime, diseases or their complications were not recognized in 17 (28%) cases, mainly acute myocardial infarction of type 2 (3 cases) and liver abscesses (3 cases).

CONCLUSION

A pathoanatomic autopsy is a modern and important diagnostic tool that can clarify the causes of death.

The impact of autopsy participation on clinical residency

Background

Autopsy has had an essential role in ensuring the quality of education and medical care. However, its role in clinical residency has not been clarified. This study assessed actual autopsy circumstances during clinical residency and evaluated the association between autopsy and clinical knowledge.

Methods

We conducted a cross‐sectional study involving postgraduate second year residents in Japan who took the General Medicine In‐Training Examination in 2019. We modeled the General Medicine In‐Training Examination scores of the residents to examine their association with autopsy experiences and the number of autopsy experiences to assess its predictors.

Results

Of 2715 postgraduate second year residents, 353 (13.8%) had no autopsy participation, and 1015 (39.7%) had only one experience. Although autopsy participation was not related to the mean General Medicine In‐Training Examination score, the residents' clinicopathological conference participation, self‐study for more than 60 min per day, and wish to be pathologists were significantly associated with autopsy experiences. They experienced more autopsies when they belonged to small‐sized hospitals in rural areas performing many autopsies.

Conclusion

We reported the current status of autopsy in clinical residency and showed that more than half of the residents experienced no or only one autopsy. General Medicine In‐Training Examination scores were not correlated with the number of autopsy experiences.

Prevalence of delayed diagnosis of acute ischemic stroke in an acute care hospital: A single-center cross-sectional study in Japan

BACKGROUNDS

Given the short therapeutic window for evidence-based therapies such as thrombolysis and endovascular treatment, it is important to immediately diagnose ischemic stroke. We investigated the prevalence of missed ischemic stroke diagnoses at initial contact and the proportion of potentially treatable patients without a delayed diagnosis.

METHODS

A cross-sectional study was conducted. A total of 408 consecutive patients hospitalized due to acute ischemic stroke were included. The primary outcome was a delayed diagnosis of ischemic stroke at initial contact. A diagnosis of stroke was judged to be delayed unless physicians made a diagnosis and initiated treatment for ischemic stroke during the initial contact. The secondary outcome was ischemic stroke with a missed therapeutic window for effective treatment due to delayed diagnosis.

RESULTS

The median patient age was 78 years old, and the median time from onset to presentation was nine hours. A diagnosis of stroke was deemed delayed in 49 (12.0%) patients. In the multivariable analysis, presentation 48 hours or more after stroke onset (OR 2.45) and the improvement of neurological symptoms prior to presentation (OR 3.11) were independently associated with delayed diagnosis of ischemic stroke. Opportunities for effective treatment were missed in 18 (36.7%) of the 49 delayed diagnosis cases, although no patients missed opportunities for thrombectomy due to delayed diagnosis.

CONCLUSIONS

Even in the modern era, one out of every eight ischemic stroke cases was missed at the initial visit, and one-third of missed stroke cases might be candidates for effective treatment without diagnostic delay.

Comparison of antemortem clinical diagnosis and post-mortem findings in intensive care unit patients

Autopsy is an important quality assurance indicator and a tool to advance medical knowledge. This study aims to compare the premortem clinical and postmortem pathology findings in patients who died in the Intensive Care Unit (ICU), to analyze if there are any discrepancies between them, and to compare the results to two similar studies performed in our institution in 2004 and 2007. Between January 1, 2016, and December 31, 2018, 888 patients died in the ICU and 473 underwent post-mortem examination (PME) of whom 437 were included in the present study. Autopsies revealed discrepancies between clinical diagnosis and pathologic findings according to in 101 cases (23.1%) according to Goldman classification. Forty-eight major discrepancies (class I and class II) were identified in 44 cases and the most frequent identified discrepancies were pulmonary embolism (3/12) as class I and malignancies (13/35) as class II. They were more frequent in patients hospitalized for less than 10 days then in the group with more than 10 days of hospitalization (13.8% vs 4.5%; p = 0.002). No statistical difference has been noticed concerning age, gender, and ICU stay. We observed an increase of performed autopsies and a total discrepancy rate similar to the studies performed in the same institution in 2004 (22.5%) and 2007 (21%). In conclusion, discrepancies between clinical and PME diagnoses persist despite the medical progress. Secondly, the autopsy after a short hospital stay may reveal unexpected findings whose diagnosis is challenging even if it may be suspected by the intensivist.

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study

Early death in sepsis occurs frequently; however, specific causes are largely unknown. An autopsy can contribute to ascertain causes of death. The objective of the study was to determine discrepancies in clinical diagnosis and postmortem findings in septic intensive care unit (ICU) patients deceased within 48 h after ICU admission. All septic ICU patients who deceased within 48 h after ICU admission were identified and included. Four intensivists determined the clinical cause of death by medical record review. An autopsy was performed within 24 h of death. Clinical diagnosis and postmortem findings were compared and classified as autopsy-identified missed clinical diagnoses and autopsy-refuted diagnoses. Class I and II missed major diagnoses using the Goldman criteria were scored. Between 2012 and 2017, 1107 septic patients were admitted to ICU. Of these, 344 patients (31%) died, of which 97 patients (28%) deceased within 48 h. In 32 (33%) early deceased patients, an autopsy was agreed. There were 26 autopsy-identified missed clinical diagnoses found, mostly myocardial infarction (n = 4) and pneumonia (n = 4). In four patients (13%), a class I discrepancy was found. In fourteen patients (42%), a class II discrepancy was found. In conclusion, an autopsy is an important diagnostic tool that can identify definite causes of death. These diagnoses deviate from diagnoses established during admission in early deceased sepsis patients.

COVID-19 Outbreak: Pathogenesis, Current Therapies, and Potentials for Future Management

At the end of 2019, a novel coronavirus (CoV) was found at the seafood market of Hubei province in Wuhan, China, and this virus was officially named coronavirus diseases 2019 (COVID-19) by World Health Organization (WHO). COVID-19 is mainly characterized by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) and creates public health concerns as well as significant threats to the economy around the world. Unfortunately, the pathogenesis of COVID-19 is unclear and there is no effective treatment of this newly life-threatening and devastating virus. Therefore, it is crucial to search for alternative methods that alleviate or inhibit the spread of COVID-19. In this review, we try to find out the etiology, epidemiology, symptoms as well as transmissions of this novel virus. We also summarize therapeutic interventions and suggest antiviral treatments, immune-enhancing candidates, general supplements, and CoV specific treatments that control replication and reproduction of SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV).

Early ICU-mortality in sepsis - causes, influencing factors and variability in clinical judgement: a retrospective cohort study

BACKGROUND

Sepsis is a global health care problem with a high mortality. Early death seems common; however, data are sparse. The objective of the present study was to report causes and influencing factors of early death in sepsis and septic shock.

METHODS

All septic ICU patients were included from 2012 to 2017. Early death was predefined as occurring within 48 h. Causes and factors leading up to death were reported by a panel of four intensivists, independently reviewing the medical files. Following factors were assessed: (1) delay in ICU admission; (2) futile ICU treatment; (3) missed diagnosis or inadequate treatment on the ICU. Fleiss kappa was used to assess inter-observer agreement.

RESULTS

1107 septic patients (APACHE II score 25 ± 8) were included. 344 patients died of which 97 (28%) within 48 h. In 33% an autopsy was performed. Primary causes of early death were multiple organ failure, mesenteric ischaemia and death after cardio-pulmonary resuscitation (CPR). Delay in ICU admission was scored in 32% of early deaths with slight agreement (κ = 0.180), futile ICU treatment in 29% with moderate agreement (κ = 0.415) and missed diagnosis or treatment in 7% of cases with slight agreement (κ = 0.122).

CONCLUSIONS

Early death after ICU admission in sepsis is common and primarily caused by multiple organ failure, mesenteric ischaemia and death after unsuccessful CPR. Influencing factors were delay in ICU admission and futile ICU admission. Fleiss kappa indicates substantial variability in clinical judgement between intensivists, strengthening the necessity for shared decision making.

Introduction of postmortem CT increases the postmortem examination rate without negatively impacting the rate of traditional autopsy in daily practice: an implementation study

AIM

The aim of this implementation study was to assess the effect of postmortem CT (PMCT) and postmortem sampling (PMS) on (traditional) autopsy and postmortem examination rates. Additionally, the feasibility of PMCT and PMS in daily practice was assessed.

METHODS

For a period of 23 months, PMCT and PMS were used as additional modalities to the autopsy at the Department of Internal Medicine. The next of kin provided consent for 123 postmortem examinations. Autopsy rates were derived from the Dutch Pathology Registry, and postmortem examination rates were calculated for the period before, during and after the study period, and the exclusion rate, table time, time interval to informing the referring clinicians with results and the time interval to the Multidisciplinary Mortality Review Board (MMRB) meeting were objectified to assess the feasibility.

RESULTS

The postmortem examination rate increased (from 18.8% to 32.5%, p<0.001) without a decline in the autopsy rate. The autopsy rate did not change substantially after implementation (0.2% decrease). The exclusion rate was 2%, the table time was 23 min, and a median time interval of 4.1 hours between PMCT and discussing its results with the referring clinicians was observed. Additionally, more than 80% of the MMRB meetings were held within 8 weeks after the death of the patient.

CONCLUSIONS

Our study shows that the implementation of a multidisciplinary postmortem examination is feasible in daily practice and does not adversely affect the autopsy rate, while increasing the postmortem examination rate.

No Autopsies on COVID-19 Deaths: A Missed Opportunity and the Lockdown of Science

BACKGROUND

The current outbreak of COVID-19 infection, which started in Wuhan, Hubei province, China, in December 2019, is an ongoing challenge and a significant threat to public health requiring surveillance, prompt diagnosis, and research efforts to understand a new, emergent, and unknown pathogen and to develop effective therapies. Despite the increasing number of published studies on COVID-19, in all the examined studies the lack of a well-defined pathophysiology of death among patients who died following COVID-19 infection is evident. Autopsy should be considered mandatory to define the exact cause of death, thus providing useful clinical and epidemiologic information as well as pathophysiological insights to further provide therapeutic tools.

METHODS

A literature review was performed on PubMed database, using the key terms: "COVID-19", "nCov 19", and "Sars Cov 2". 9709 articles were retrieved; by excluding all duplicated articles, additional criteria were then applied: articles or abstracts in English and articles containing one of the following words: "death", "died", "comorbidity", "cause of death", "biopsy", "autopsy", or "pathological".

RESULTS

A total of 50 articles met the inclusion criteria. However, only 7 of these studies reported autopsy-based data.

DISCUSSION

The analysis of the main data from the selected studies concerns the complete analysis of 12,954 patients, of whom 2269 died (with a mortality rate of 17.52%). Laboratory confirmation of COVID-19 infection was obtained in all cases and comorbidities were fully reported in 46 studies. The most common comorbidities were: cardiovascular diseases (hypertension and coronary artery disease), metabolic disorders (diabetes, overweight, or obesity), respiratory disorders (chronic obstructive pulmonary disease), and cancer. The most common reported complications were: acute respiratory distress syndrome (ARDS), acute kidney injury, cardiac injury, liver insufficiency, and septic shock. Only 7 papers reported histological investigations. Nevertheless, only two complete autopsies are described and the cause of death was listed as COVID-19 in only one of them. The lack of postmortem investigation did not allow a definition of the exact cause of death to determine the pathways of this infection. Based on the few histopathological findings reported in the analyzed studies, it seems to be a clear alteration of the coagulation system: frequently prothrombotic activity with consequent thromboembolism was described in COVID-19 patients. As a scientific community, we are called on to face this global threat, and to defeat it with all the available tools necessary. Despite the improvement and reinforcement of any method of study in every field of medicine and science, encouraging the autopsy practice as a tool of investigation could also therefore, help physicians to define an effective treatment to reduce mortality.

Soluble Intercellular Adhesion Molecule- (sICAM-) 1, Thrombospondin-1, and Vinculin for the Identification of Septic Shock Patients Suffering from an Invasive Fungal Infection

Background. Nowadays, invasive fungal infections (IFI) are of increasing importance and associated with an increased mortality. However, reliable diagnostic tools for the identification of patients suffering from an IFI are rare and associated with relevant weaknesses.Methods. Within this secondary analysis of an observational clinical study, an innovative biomarker panel (consisting of 62 biomarkers in total) was screened for the identification of septic shock patients suffering from an IFI. Fungal growth in blood cultures, intraoperative swabs, andAspergillusspp. in deep respiratory tract specimens with accompanying pulmonary infiltrates were classified as infection, whereasCandidaspp. in the respiratory tract or in fluids from drainages were classified as colonization. Plasma samples of 50 septic shock patients at six predefined timepoints within a period of 28 days following the onset of septic shock were available.Results. In total, 11 out of the 50 patients (22%) were shown to suffer from an IFI, whereas 22 patients (44%) presented with a fungal colonization. Within the presented biomarker panel, plasma levels of soluble intercellular adhesion molecule- (sICAM-) 1, thrombospondin-1, and vinculin were shown to be the most promising. sICAM-1 was shown to be increased in patients with an IFI, whereas thrombospondin-1 and vinculin revealed decreased plasma levels as compared to colonized patients as well as patients without any fungal findings at any time.Conclusion. Plasmatic measurements of sICAM-1, thrombospondin-1, and vinculin may help to facilitate the diagnosis of an IFI in human septic shock and to identify patients with an increased risk for an IFI. This trial is registered withDRKS00005463.

Venous thromboembolism in the critically ill: A prospective observational study of occurrence, risk factors and outcome

BACKGROUND

The aim of the study was to explore occurrence, risk factors and outcome of venous thromboembolism (VTE) in intensive care unit (ICU) patients.

METHODS

Prospective observational study of ICU patients receiving thromboprophylaxis at Oslo University Hospital in Norway. Adult medical and surgical patients with ICU length of stay (LOS) longer than 48 hours were included. For detection of VTE, Doppler ultrasound screening of neck, upper and lower extremity veins was used, and computed tomography angiography when clinically indicated for any medical reason.

RESULTS

Among 70 included patients, 79% were males and mean age was 62 (±12.1) years. All received thromboprophylaxis with dalteparin, and 44 (63%) used graduated compression stockings. VTE was found in 19 (27%) patients; deep vein thrombosis in 15 (21%) and pulmonary embolism in 4 (6%). Among the VTEs, 11 (58%) presented within the first 48 hours after admission, two (11%) were located in the lower limbs and five (26%) were symptomatic. Risk factors for VTE in multivariable analyses were malignancy, abdominal surgery and SAPS II score <41 with an AuROC (95% CI) of 0.72 (0.58-0.85, P = 0.01). Patients with and without VTE had comparable ICU LOS (13 vs 11 days, P = 0.27) and mortality (16% vs 20%, P = 0.72).

CONCLUSION

Venous thromboembolism was observed in 27% of ICU patients receiving thromboprophylaxis. Factors associated with increased risk of VTE were malignancy, abdominal surgery and SAPS II score <41. Presence of VTE did not impact on patient outcome.

Questionnaire study on the utility of autopsy case conferences related to emergency medicine practices

We examined whether and how conferences on cases of medico-legal autopsy after emergency medicine (EM) practices improved the diagnostic accuracy and expertise of emergency medicine practitioners (EMPs) and forensic pathologists (FPs); we also examined the necessity of imaging in autopsy diagnoses. We additionally discuss whether imaging could replace autopsy.An unsigned, self-administered questionnaire was distributed to the attendees of monthly case conferences during which EMPs and FPs discussed EM-associated autopsy cases. The questionnaire addressed the following 6 questions: was the conference useful for forensic medicine or EM practices, was autopsy necessary for each case, were the autopsy and clinical diagnoses consistent, was imaging necessary for autopsy diagnosis, and should autopsy results be disclosed to the public. Participants were autopsy operators, third-party EMPs, and FPs, primarily from universities in and near Tokyo.Fifty-two cases were discussed; more than 80% of the attendees acknowledged the usefulness of autopsy and the conferences, and 33.6% corrected their diagnoses by considering autopsy information. Major clinical misdiagnoses were corrected by autopsy in 35.3% of cases, including procedure-related hemorrhage, intoxication, asphyxia, fat embolism, diabetes, organ injuries, and subarachnoid hemorrhage (SAH). Approximately 75% of the attendees recognized the usefulness of imaging for autopsy. However, in a series of four SAH cases, the clinical diagnoses were corrected after the conferences more often by EMPs than by FPs. In a violence-related case, false legal judgment was prevented because the conference discussion corrected the clinical diagnosis from traumatic to natural.In conclusion, the conference improved the accuracy and expertise of diagnoses provided by EMPs and FPs; conference participation led to the correction of major clinical misdiagnoses as well as that of the first diagnoses issued by attendees in more than one-third cases. The usefulness of imaging for autopsy was acknowledged by two thirds of the attendees. Our results also suggested that imaging cannot replace autopsy in deaths related to procedure or violence and in several categories of deaths such as intoxication and asphyxia.

Autopsy findings in patients with acute myeloid leukemia and non-Hodgkin lymphoma in the modern era: a focus on lung pathology and acute respiratory failure

We aimed to report autopsy findings in patients with acute myeloid leukemia (AML) and non-Hodgkin lymphoma (NHL) in the modern era, and also to focus on lung pathology in the subgroup of patients with acute respiratory failure (ARF) of unknown etiology, which is associated with especially high mortality rates. Charts and autopsy reports of 107 patients (59 AML and 48 NHL) autopsied between 2003 and 2018 were reviewed. More than 50% of patients had missed major diagnoses found at autopsy with 95% of lungs displaying abnormal findings. Malignant infiltration in at least one organ was observed in about 70% of patients with either no complete remission or relapse at the time of death (n = 92) versus 20% in patients without signs of active malignancy (n = 15) (p = 0.001). In patients with ARF of unknown etiology (n = 59), the proportion of malignant lung infiltration was 27% and equilibrated with bacterial pneumonias (29%), fungal pneumonias represented 8%, and isolated alveolar damage or pulmonary edema were the only findings in 32% of patients. Overall, 85% of patients with ARF of unknown etiology had either relapsed or not achieved remission at time of death and 80% of patients with malignant lung infiltration had ARF of unknown etiology. Ninety percent of malignant infiltration and fungal infections were observed in patients with no complete remission or relapse. Autopsy remains valuable in AML and NHL patients; besides infections, malignant infiltration is a significant contributor to ARF of unknown etiology and is rarely diagnosed ante mortem.

Tracking Progress in Improving Diagnosis: A Framework for Defining Undesirable Diagnostic Events

Diagnostic error is a prevalent, harmful, and costly phenomenon. Multiple national health care and governmental organizations have recently identified the need to improve diagnostic safety as a high priority. A major barrier, however, is the lack of standardized, reliable methods for measuring diagnostic safety. Given the absence of reliable and valid measures for diagnostic errors, we need methods to help establish some type of baseline diagnostic performance across health systems, as well as to enable researchers and health systems to determine the impact of interventions for improving the diagnostic process. Multiple approaches have been suggested but none widely adopted. We propose a new framework for identifying "undesirable diagnostic events" (UDEs) that health systems, professional organizations, and researchers could further define and develop to enable standardized measurement and reporting related to diagnostic safety. We propose an outline for UDEs that identifies both conditions prone to diagnostic error and the contexts of care in which these errors are likely to occur. Refinement and adoption of this framework across health systems can facilitate standardized measurement and reporting of diagnostic safety.

Unexpected findings and misdiagnoses in coroner's autopsies performed for trauma at the University of the West Indies, Kingston, Jamaica

There has been significant improvement in medical diagnostic technology, but discrepancy rates between clinical and postmortem diagnoses remain relatively high. This study aimed to identify misdiagnoses and missed (unexpected) findings documented during complete coroner's autopsies performed for trauma at the University of the West Indies (UWI) and evaluate their influence on patient outcome. We retrospectively reviewed the reports of all coroner's autopsies performed for trauma, between 2003 and 2012, at the UWI. For each case, we extracted age, gender, trauma type, mechanism and topography, clinical and postmortem diagnoses and hospitalization duration. The data were used to calculate frequencies, proportions and discrepancy rates. 955 coroner's autopsies were performed during the 10-year period; reports were available for 933. 396 of these were performed for trauma; 365 met the inclusion criteria. 260 (71.2%) of the 365 autopsies had at least one discrepancy. There were 746 clinical and 1118 autopsy diagnoses; 382 were discrepant (372 missed [unexpected] diagnoses, 6 mis-diagnoses and 4 over-diagnoses). The discrepancy rate (misdiagnoses and missed diagnoses) was 33.8%, and the majority (55%) occurred in patients hospitalized for <1 day. Cardiopulmonary diseases were the most commonly missed diagnoses. The discrepancy rate was intermediate to those previously reported in the literature. The short hospitalization duration in most patients suggests that limited time for clinical investigation may be a contributor to discrepancy. However, increased awareness among clinicians of the common major missed diagnoses should enhance their early diagnosis, even when clinical signs are subtle, hopefully producing improved patient outcome.

Prospective study of device-related complications in intensive care unit detected by virtual autopsy

BACKGROUND

There has been increasing use of invasive techniques, such as extracorporeal organ support, in intensive care units (ICU), and declining autopsy rates. Thus, new measures are needed to maintain high-quality standards. We investigated the potential of computed tomography (CT)-based virtual autopsy to substitute for medical autopsy in this setting.

METHODS

We investigated the potential of virtual autopsy by post-mortem CT to identify complications associated with medical devices in a prospective study of patients who had died in the ICU. Clinical records were reviewed to determine the number and types of medical devices used, and findings from medical and virtual autopsies, related and unrelated to the medical devices, were compared.

RESULTS

Medical and virtual autopsies could be performed in 61 patients (Group M/V), and virtual autopsy only in 101 patients (Group V). In Group M/V, 41 device-related complications and 30 device malpositions were identified, but only with a low inter-method agreement. Major findings unrelated to a device were identified in about 25% of patients with a high level of agreement between methods. In Group V, 8 device complications and 36 device malpositions were identified.

CONCLUSIONS

Device-related complications are frequent in ICU patients. Virtual and medical autopsies showed clear differences in the detection of complications and device malpositions. Both methods should supplement each other rather than one alone for quality control of medical devices in the ICU. Further studies should focus on the identification of special patient populations in which virtual autopsy might be of particular benefit.

CLINICAL TRIAL REGISTRATION

NCT01541982.

Autopsy-detected diagnostic errors over time in the intensive care unit

We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.

Pocket-sized point-of-care cardiac ultrasound devices : Role in the emergency department

BACKGROUND

Acute breathlessness accounts for 8% of accident and emergency attendances. Point-of-care cardiac ultrasound (US) effectively reduces time to diagnosis. Fast and practical information via pocket-sized cardiac US devices may better the diagnosis in this complex patient group.

METHODS

We prospectively enrolled 40 consecutive patients presenting with shortness of breath at the emergency department (ED). Divided into two groups were all adult patients over 18 with acute breathing difficulties (triage category 1-3): 21 patients received a short focused cardiac US scan using a pocket-sized Vscan and 19 patients received no scan. Data were obtained regarding the time taken for diagnosis and treatment, patient length of stay, inpatient mortality and 30-day mortality.

RESULTS

In the scanned group 33% of patients had significantly abnormal Vscan results that had the potential to aid diagnosis and guide management. The difference of 20 min between the means of the time to diagnosis between the groups was not significant.

DISCUSSION

The individual knowledge of UK emergency physicians regarding basic echocardiography varies greatly. An intuitive approach following a brief tutorial on pocket-size echocardiography was shown to improve diagnostic accuracy in addition to history taking and physical examination by medical students and junior doctors with no previous exposure to echocardiography. Increasing evidence shows the feasibility and benefit of FOCUS echo in the ED and the pocket-sized devices could play a large role.

CONCLUSION

The Vscan is a practical, portable device that provides rapid diagnostic information. One third of patients had significant findings on the scans to possibly aid diagnosis and prevent misdiagnosis. This has the potential to reduce time to diagnosis in the ED.

Autopsy relevance determining hemochromatosis: Case report

RATIONALE

Hemochromatosis is a disorder, associated with an abnormal accumulation of iron leading to toxic organ damage. Clinical symptoms develop during a long period of time, thus, determining accidental or late diagnosis, usually when complications are evident.

PATIENT CONCERNS

A 53-year-old man was brought to the emergency unit with symptoms of hypovolemic shock without any apparent cause, which ultimately led to multiple organ failure, severe metabolic acidosis.

DIAGNOSES

The final diagnosis of hemochromatosis was determined after the autopsy.

INTERVENTIONS

Abnormal findings included a black-grayish pancreas, without any surrounding tissue reaction, and a dilated congestive cardiomyopathy. Histological findings revealed significant hemosiderin deposits in the internal organs, which were more distinct in the pancreas, liver, and kidneys.

OUTCOMES

Patient death in less than 12 hours.

LESSONS

The necessity of a genetic examination after the autopsy, regarding this case was undeniable, especially focusing on the first-degree relatives, helping to diagnose and prescribe an adequate and early treatment.

Immune-Response Patterns and Next Generation Sequencing Diagnostics for the Detection of Mycoses in Patients with Septic Shock-Results of a Combined Clinical and Experimental Investigation

Fungi are of increasing importance in sepsis. However, culture-based diagnostic procedures are associated with relevant weaknesses. Therefore, culture- and next-generation sequencing (NGS)-based fungal findings as well as corresponding plasma levels of β-d-glucan, interferon gamma (INF-γ), tumor necrosis factor alpha (TNF-α), interleukin (IL)-2, -4, -6, -10, -17A, and mid-regional proadrenomedullin (MR-proADM) were evaluated in 50 septic patients at six consecutive time points within 28 days after sepsis onset. Furthermore, immune-response patterns during infections with Candida spp. were studied in a reconstituted human epithelium model. In total, 22% (n = 11) of patients suffered from a fungal infection. An NGS-based diagnostic approach appeared to be suitable for the identification of fungal pathogens in patients suffering from fungemia as well as in patients with negative blood cultures. Moreover, MR-proADM and IL-17A in plasma proved suitable for the identification of patients with a fungal infection. Using RNA-seq., adrenomedullin (ADM) was shown to be a target gene which is upregulated early after an epithelial infection with Candida spp. In summary, an NGS-based diagnostic approach was able to close the diagnostic gap of routinely used culture-based diagnostic procedures, which can be further facilitated by plasmatic measurements of MR-proADM and IL-17A. In addition, ADM was identified as an early target gene in response to epithelial infections with Candida spp.

The efficacy of bedside chest ultrasound: from accuracy to outcomes

For many respiratory physicians, point-of-care chest ultrasound is now an integral part of clinical practice. The diagnostic accuracy of ultrasound to detect abnormalities of the pleura, the lung parenchyma and the thoracic musculoskeletal system is well described. However, the efficacy of a test extends beyond just diagnostic accuracy. The true value of a test depends on the degree to which diagnostic accuracy efficacy influences decision-making efficacy, and the subsequent extent to which this impacts health outcome efficacy. We therefore reviewed the demonstrable levels of test efficacy for bedside ultrasound of the pleura, lung parenchyma and thoracic musculoskeletal system.For bedside ultrasound of the pleura, there is evidence supporting diagnostic accuracy efficacy, decision-making efficacy and health outcome efficacy, predominantly in guiding pleural interventions. For the lung parenchyma, chest ultrasound has an impact on diagnostic accuracy and decision-making for patients presenting with acute respiratory failure or breathlessness, but there are no data as yet on actual health outcomes. For ultrasound of the thoracic musculoskeletal system, there is robust evidence only for diagnostic accuracy efficacy.We therefore outline avenues to further validate bedside chest ultrasound beyond diagnostic accuracy, with an emphasis on confirming enhanced health outcomes.

The role of post-mortem MRI in the neonatal intensive care unit

OBJECTIVE

Post-mortem examination can provide important information about the cause of death and play a significant role in the bereavement process. Autopsies reveal previous unknown medical problems approximately 20 to 30% of the time. A non-invasive magnetic resonance imaging-based post-mortem examination (PM-MRI) may provide an alternative for families who do not consent to an autopsy.

STUDY DESIGN

This study was a prospective observational study of recently expired neonates and infants. Subjects underwent a full body MRI scan (brain, chest, abdomen and pelvis) followed by conventional autopsy if the family desired to have one. MRI results were compared with autopsy findings and the ante-mortem clinical diagnosis. A follow-up survey was conducted to investigate family perceptions of the PM-MRI process.

RESULTS

Thirty-one infants underwent full PM-MRI. Of 31 infants, 19 (61%) had complete agreement between the clinician's impression and PM-MRI. Twenty-four infants also had conventional autopsy, with 14/24 (58%) infants having PM-MRI results consistent with autopsy findings. PM-MRI was superior at detection of free intraperitoneal/intrathoracic air and hepatic iron overload. Whole-body PM-MRI did not have the resolution to detect focal/microscopic injury, vascular remodeling and some forms of brain injury. Of those families who remembered the PM-MRI findings, the majority felt that the information was useful.

CONCLUSIONS

PM-MRI studies may provide an important adjunct to conventional autopsy and a substitute when the latter is not possible for personal or religious reasons. Clinicians should be aware of, and communicate with the family, the resolution limits of the whole-body PM-MRI to detect certain types of injury.

Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study

Background

The lack of a patent source of infection after 24 hours of management of shock considered septic is a common and disturbing scenario. We aimed to determine the prevalence and the causes of shock with no diagnosis 24 hours after its onset, and to compare the outcomes of patients with early-confirmed septic shock to those of others.

Methods

We conducted a pragmatic, prospective, multicenter observational cohort study in ten intensive care units (ICU) in France. We included all consecutive patients admitted to the ICU with suspected septic shock defined by clinical suspicion of infection leading to antibiotic prescription plus acute circulatory failure requiring vasopressor support.

Results

A total of 508 patients were admitted with suspected septic shock. Among them, 374 (74 %) had early-confirmed septic shock, while the 134 others (26 %) had no source of infection identified nor microbiological documentation retrieved 24 hours after shock onset. Among these, 37/134 (28 %) had late-confirmed septic shock diagnosed after 24 hours, 59/134 (44 %) had a condition mimicking septic (septic shock mimicker, mainly related to adverse drug reactions, acute mesenteric ischemia and malignancies) and 38/134 (28 %) had shock of unknown origin by the end of the ICU stay. There were no differences between patients with early-confirmed septic shock and the remainder in ICU mortality and the median duration of ICU stay, of tracheal intubation and of vasopressor support. The multivariable Cox model showed that the risk of day-60 mortality did not differ between patients with or without early-confirmed septic shock. A sensitivity analysis was performed in the subgroup (n = 369/508) of patients meeting the Sepsis-3 definition criteria and displayed consistent results.

Conclusions

One quarter of the patients admitted in the ICU with suspected septic shock had no infection identified 24 hours after its onset and almost half of them were eventually diagnosed with a septic shock mimicker. Outcome did not differ between patients with early-confirmed septic shock and other patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1537-5) contains supplementary material, which is available to authorized users.

Resuscitating the Dying Autopsy

Clara Menéndez and colleagues consider the importance of conducting autopsies and possible alternative methods for determining cause of death in resource-limited settings.

The impact of antemortem computed tomographic scanning on postmortem examination rate and frequency of missed diagnosis: A retrospective analysis of postmortem examination data

PURPOSE

The present study was conducted to explore the impact of computed tomographic (CT) scanning on the diagnostic discrepancy rate.

MATERIALS AND METHODS

This single-center, retrospective study reviewed postmortem examination results, clinical diagnoses, and radiologic imaging data for patients admitted to the intensive care unit (ICU) in 2008 to 2013. The Goldman criteria were used to classify diagnostic discrepancies.

RESULTS

The data of 577 patients who died during their ICU stay were retrieved. The postmortem examination rate was 42.9% (n=248). Significant diagnostic discrepancies (Goldman I and II) were recorded in 24 cases (9.7%). The postmortem examination rate decreased significantly from the first half (n=143; 51.1%) to the second half (n=105; 35.4%) of the study period (P<.0001). Among those with postmortem examinations, the use of antemortem body CT scans increased significantly from the first half (n=59; 41.3%) to the second half (n=64; 51.0%; P=.002) of the study period. The significant diagnostic discrepancy rate did not change with time (8.4% vs 11.4%, respectively; P=.424).

CONCLUSION

The postmortem examination rate has decreased, whereas antemortem CT scans has increased.

Timing and causes of death in septic shock

Background

Most studies about septic shock report a crude mortality rate that neither distinguishes between early and late deaths nor addresses the direct causes of death. We herein aimed to determine the modalities of death in septic shock.

Methods

This was a 6-year (2008–2013) monocenter retrospective study. All consecutive patients diagnosed for septic shock within the first 48 h of intensive care unit (ICU) admission were included. Early and late deaths were defined as occurring within or after 3 days following ICU admission, respectively. The main cause of death in the ICU was determined from medical files. A multinomial logistic regression analysis using the status alive as the reference category was performed to identify the prognostic factors associated with early and late deaths.

Results

Five hundred forty-three patients were included, with a mean age of 66 ± 15 years and a high proportion (67 %) of comorbidities. The in-ICU and in-hospital mortality rates were 37.2 and 45 %, respectively. Deaths occurred early for 78 (32 %) and later on for 166 (68 %) patients in the ICU (n = 124) or in the hospital (n = 42). Early deaths were mainly attributable to intractable multiple organ failure related to the primary infection (82 %) and to mesenteric ischemia (6.4 %). In-ICU late deaths were directly related to end-of-life decisions in 29 % of patients and otherwise mostly related to ICU-acquired complications, including nosocomial infections (20.4 %) and mesenteric ischemia (16.6 %). Independent determinants of early death were age, malignancy, diabetes mellitus, no pathogen identification, and initial severity. Among 3-day survivors, independent risk factors for late death were age, cirrhosis, no pathogen identification, and previous corticosteroid treatment.

Conclusions

Our study provides a comprehensive assessment of septic shock-related deaths. Identification of risk factors of early and late deaths may determine differential prognostic patterns.

Diagnostic influence of routine point-of-care pocket-size ultrasound examinations performed by medical residents

OBJECTIVES

We aimed to investigate the potential benefit of adding goal-directed ultrasound examinations performed by on-call medical residents using a pocket-size imaging device in patients admitted to a medical department.

METHODS

A total of 992 emergency admissions to the medical department at a nonuniversity hospital in Norway were included. Patients admitted on dates with an on-call medical resident randomized to use a pocket-size imaging device were eligible for pocket-size cardiac and abdominal ultrasound examinations or standard care. The cardiac examination included estimation of right and left ventricular sizes and global systolic function and regional left ventricular systolic function, evaluation for pleural and pericardial effusion, and valvular disease. The abdominal examination looked for signs of gross abnormalities of the liver, gallbladder, abdominal aorta, inferior vena cava, and urinary system. Six of 12 medical residents with limited ultrasound experience were randomized to perform the examinations. Diagnostic corrections were made, and findings were confirmed by reference standard diagnostics.

RESULTS

A total of 199 patients were examined. Median times used were 5.7 minutes for the cardiac examination and 4.7 minutes for the abdominal examination. In 13 patients (6.5%), the examination resulted in a major change in the primary diagnosis. In 21 patients (10.5%), the diagnosis was verified, and in 48 (24.0%), an additional important diagnosis was made.

CONCLUSIONS

By implementing pocket-size ultrasound examinations that took less than 11 minutes to the usual care, we corrected, verified, or added important diagnoses in more than 1 of 3 emergency medical admissions. Point-of-care examinations with a pocket-size imaging device increased medical residents' diagnostic accuracy and capability.

Brain volume estimation from post-mortem newborn and fetal MRI

Objective

Minimally invasive autopsy using post-mortem magnetic resonance imaging (MRI) is a valid alternative to conventional autopsy in fetuses and infants. Estimation of brain weight is an integral part of autopsy, but manual segmentation of organ volumes on MRI is labor intensive and prone to errors, therefore unsuitable for routine clinical practice. In this paper we aim to show that volumetric measurements of the post-mortem fetal and neonatal brain can be accurately estimated using semi-automatic techniques and a high correlation can be found with the weights measured from conventional autopsy results.

Methods

The brains of 17 newborn subjects, part of Magnetic Resonance Imaging Autopsy Study (MaRIAS), were segmented from post-mortem MR images into cerebrum, cerebellum and brainstem using a publicly available neonate brain atlas and semi-automatic segmentation algorithm. The results of the segmentation were averaged to create a new atlas, which was then used for the automated atlas-based segmentation of 17 MaRIAS fetus subjects. As validation, we manually segmented the MR images from 8 subjects of each cohort and compared them with the automatic ones. The semi-automatic estimation of cerebrum weight was compared with the results of the conventional autopsy.

Results

The Dice overlaps between the manual and automatic segmentations are 0.991 and 0.992 for cerebrum, 0.873 and 0.888 for cerebellum and 0.819 and 0.815 for brainstem, for newborns and fetuses, respectively. Excellent agreement was obtained between the estimated MR weights and autopsy gold standard ones: mean absolute difference of 5 g and 2% maximum error for the fetus cohort and mean absolute difference of 20 g and 11% maximum error for the newborn one.

Conclusions

The high correlation between the obtained segmentation and autopsy weights strengthens the idea of using post-mortem MRI as an alternative for conventional autopsy of the brain.

•

We segment the cerebrum of 17 newborns and 17 fetuses from postmortem MR.

•

There is high correlation between the autopsy and MR segmentation brain volumes.

•

Postmortem MR can be a non-invasive alternative to conventional autopsy of infants.

Infective and non-infective endocarditis in critically ill patients: a clinical-pathological study

The aims of this study are to estimate the incidence, the outcome and the associated risk factors of infective and non-infective endocarditis (IE and NIE, respectively) in intensive care unit (ICU) patients. We studied the post-mortem findings and the clinical data of the patients who died in our ICU between 1996 and 2010. Of the 765 reviewed autopsies, 21 patients (2.7%) presented cardiac vegetations. These cases consisted of 12 IEs and 9 NIEs. Three patients with IE had a mechanical prosthetic valve, and in 11 cases invasive devices had been used. Multiple peripheral embolisms were discovered at autopsy. In particular, the brain appeared to be more affected in patients with IE, while pulmonary embolisms were commonly associated with NIE. Blood cultures were positive in nine patients with IE. The imaging diagnostics (transthoracic and transesophageal echocardiography) which were seldom performed in both groups, proved to be of little help. As a consequence, an IE was correctly diagnosed before death in three patients (25%) and suspected in two other cases (17%), while a NIE was diagnosed before death in one patient alone. In conclusions, critically ill patients admitted to general ICUs, multiple factors related both to the underlying conditions and to performed procedures can facilitate the occurrence of IE and NIE making, at the same time, their diagnosis challenging. Many cases, in fact, are diagnosed only at autopsy. Yet again, post-mortem examination proves to be an invaluable tool for the evaluation of diagnostic accuracy in critical care.

Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis

BACKGROUND

The clinical profile with regard to sex and the influences on outcomes in patients who have been hospitalized for acute pericarditis is largely uncharacterized.

METHODS AND RESULTS

We studied all patients aged ≥16 years admitted to the hospital because of acute pericarditis (postpericardiotomy and myocardial infarction associated pericarditis were excluded). Data were collected from a Finnish national registry that included data on all cardiovascular admissions (670 409) during 9.5 years in 29 hospitals nationwide. During the study period, there were 1361 admissions for acute pericarditis. Pericarditis patients were more likely to be male (64.9% of patients) than female (35.1%), with an age-adjusted likelihood ratio of 1.85 (95% confidence interval [CI], 1.65-2.06; P<0.0001) for male sex. The standardized incidence rate of hospitalizations for acute pericarditis was 3.32 per 100 000 person-years. Men 16 to 65 years of age were at higher risk for pericarditis (relative risk, 2.02; 95% CI, 1.81-2.26; P<0.0001) than women in the general admitted population, with the highest risk difference among young adults. Acute pericarditis caused 0.20% (95% CI, 0.19%-0.22%) of all cardiovascular admissions. The proportion of pericarditis-caused admissions declined by an estimated 51% per 10-year increase in age. The in-hospital mortality rate for acute pericarditis was 1.1% (95% CI, 0.6%-1.8%). Mortality increased with age (hazard ratio, 3.26; 95% CI, 1.78-5.95 per 10-year increase in age; P=0.0001) and severe coinfection (pneumonia or septicemia; hazard ratio, 13.46; 95% CI, 2.26-80.01; P<0.005) but was not associated with sex in multivariate analysis.

CONCLUSIONS

Patients hospitalized for acute pericarditis are more commonly male. Increasing age and severe coinfection are associated with greater in-hospital mortality in hospitalized acute pericarditis patients.

Death certificates underestimate infections as proximal causes of death in the U.S

Background

Death certificates are a primary data source for assessing the population burden of diseases; however, there are concerns regarding their accuracy. Diagnosis-Related Group (DRG) coding of a terminal hospitalization may provide an alternative view. We analyzed the rate and patterns of disagreement between death certificate data and hospital claims for patients who died during an inpatient hospitalization.

Methods

We studied respondents from the Health and Retirement Study (a nationally representative sample of older Americans who had an inpatient death documented in the linked Medicare claims from 1993–2007). Causes of death abstracted from death certificates were aggregated to the standard National Center for Health Statistics List of 50 Rankable Causes of Death. Centers for Medicare and Medicaid Services (CMS)-DRGs were manually aggregated into a parallel classification. We then compared the two systems via 2×2, focusing on concordance. Our primary analysis was agreement between the two data sources, assessed with percentages and Cohen's kappa statistic.

Results

2074 inpatient deaths were included in our analysis. 36.6% of death certificate cause-of-death codes agreed with the reason for the terminal hospitalization in the Medicare claims at the broad category level; when re-classifying DRGs without clear alignment as agreements, the concordance only increased to 61%. Overall Kappa was 0.21, or “fair.” Death certificates in this cohort redemonstrated the conventional top 3 causes of death as diseases of the heart, malignancy, and cerebrovascular disease. However, hospitalization claims data showed infections, diseases of the heart, and cerebrovascular disease as the most common diagnoses for the same terminal hospitalizations.

Conclusion

There are significant differences between Medicare claims and death certificate data in assigning cause of death for inpatients. The importance of infections as proximal causes of death is underestimated by current death certificate-based strategies.

Invasive aspergillosis in intensive care unit patients in Iran

We assessed the intensive care unit (ICU) patients for Invasive aspergillosis (IA) with culture and non-culture based diagnostic methods from Iran. Thirty-six ICU patients with underlying predisposing conditions for IA were enrolled in the study. Sixty eight Bronchoalveolar lavage (BAL) samples were collected by bronchoscope twice a weekly. BAL samples were analyzed by microscopic examination, fungal culture and galactomannan (GM) detection. The Platelia Aspergillus GM EIA was used to quantify GM indices. Samples with a BAL GM index > or = 1 were considered as positive for GM. Patients were classified as having probable or possible IA. Out of 36 suspected patients to IA, 36.1% of cases showed IA which were categorized as: 4 cases of possible IA and 9 of probable IA. 76.2% of BAL samples were positive for GM. From 13 patients with IA, 11 (84.6%) had at least one positive BAL GM index. Of these patients, 9 (81.8%) showed probable IA. The main underlying predisposing conditions were neutropenia (53.8%) and COPD (30.8%). Our study has indicated that COPD must be considered as one of the main predisposing condition for occurrence of aspergillosis in ICU patients. Our data have also revealed that GM detection in BAL samples play a significant role to IA diagnosis.

Are autopsy findings still relevant to the management of critically ill patients in the modern era?

OBJECTIVES

The purpose of this study was to determine the accuracy of clinical diagnoses compared to autopsy findings in critically ill patients in the current medical era.

DESIGN

We conducted a retrospective, blinded review of matched medical records and postmortem findings in patients who died between June 2006 and June 2011.

SETTING

An ICU of a major university teaching hospital in Dublin, Ireland.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

A modification of the Goldman criteria was used to classify diagnostic error. There were 629 ICU deaths during the study period. Two hundred and seven patients underwent autopsy and 204 records were available for review. The mean age was 59 ± 18.1 years, 62% were male, 70% were postoperative patients, and median length of ICU stay was 3 days. Admission diagnosis, admission source, and admission specialty were similar between autopsy and nonautopsy patients. Five patients (2.4%; CI, 0.8-5.6%) had a class I discrepancy and 11 patients (5.4%; CI, 2.4-9.7%) had a class II discrepancy. Minor missed diagnoses were present in 31 patients (15.2%; CI, 4.5-12.4%). There was complete concordance between clinical and postmortem findings (class V) in 161 patients (79%; CI, 72.7-84.3%). In more than half the cases of discrepancy, it was not possible for physicians to make the diagnosis antemortem in the time available, despite appropriate investigations.

CONCLUSIONS

We detected a lower rate of clinicopathological discrepancy in critically ill patients than previously reported. Potential reasons for such findings include advances in diagnostic techniques and the use of a more robust definition to classify diagnostic discrepancies. Autopsy can still identify discrepancies in diagnosis even in patients who have undergone appropriate investigations. Prospective research is required to accurately define discrepancy rates in the critically ill population and to identify the patient subgroups in whom autopsy will continue to yield valuable information.

The value of autopsies in the era of high-tech medicine: discrepant findings persist

AIMS

Although the autopsy is still the gold standard for quality assessment of clinical diagnoses, autopsy rates have been declining over the last decades to <10%. The aim of this study was to investigate the value of autopsies in the high-tech medicine era by determining the frequency of discrepancies between clinical and autopsy diagnoses.

METHODS

We classified all adult autopsy cases (n=460), performed at Symbiant, Pathology Expert Centre, in 2007 and 2012/2013, as having major, or minor discrepancy or total concordance. The roles of possible contributory factors were analysed. Finally, we assessed the role of microscopic examination in identifying cause of death.

RESULTS

Major and minor discrepancies were found in 23.5% and 32.6% of the classifiable autopsies, respectively. Most commonly observed major discrepancies were myocardial infarction, pulmonary embolism and pneumonia. Improper imaging and discontinuation of active treatment were significantly associated with a higher and a lower frequency of major discrepancies, respectively. Comparing 2007 and 2012/2013, the frequency of minor discrepancies significantly increased from 26.8% to 39.3%. Final admission length of >2 days was significantly associated with a lower frequency of class III minor discrepancies. Microscopic examination contributed to establishing cause of death in 19.6% of the cases.

CONCLUSIONS

Discrepant findings persist at autopsy, even in the era of high-tech medicine. Therefore, autopsies still should serve as a very important part of quality control in clinical diagnosis and treatment. Learning from individual and system-related diagnostic errors can aid in improving patient safety.

Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement

There is consensus that physicians, health professionals and health care organizations should discuss harm that results from health care delivery (adverse events), including the reasons for harm, with patients and their families. Thought leaders and policy makers in the USA and Canada support this goal. However, there are gaps in both countries between patients and physicians in their attitudes about how errors should be handled, and between disclosure policies and their implementation in practice. This paper reviews the state of disclosure policy and practice in the two countries, and the barriers to full disclosure. Important barriers include fear of consequences, attitudes about disclosure, lack of skill and role models, and lack of peer and institutional support. The paper also describes the problem of the second victim, a corollary of disclosure whereby health care workers are also traumatized by the same events that harm patients. The presence of multiple practical and personal barriers to disclosure suggests the need for a comprehensive solution directed at multiple levels of the health care system, including health departments, institutions, local managers, professional staff, patients and families, and including legal, health system and local institutional support. At the local level, implementation could be based on a translating-evidence-into-practice framework. Applying this framework would involve the formation of teams, training, measurement and identification of local barriers to achieving universal disclosure of adverse events.

Major discrepancies between clinical and postmortem diagnoses in critically ill cancer patients: Is autopsy still useful?

OBJECTIVE

Describe the major discrepancies between the clinical and postmortem findings in critically ill cancer patients admitted to the medical intensive care unit (MICU).

MATERIALS AND METHODS

Retrospectively review of the medical records of all cancer patients who were admitted to the MICU and underwent postmortem examination over 6 year period. The records were reviewed for demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, clinical cause of death, and postmortem findings.

RESULTS

There were 70 patients who had complete medical records. Mean age was 54.7 years (standard deviation (SD) ±14.8 years). Twenty-six patients had hematopoeitic stem cell transplantation (group I), 21 patients had hematological malignancies (group II), and 23 patients had solid malignancies (group III). The APACHE II score on admission to the MICU was 24.2 ± 8.0. Sixty-seven patients were mechanically ventilated, and the MICU stay was (mean ± SD) 9.0 ± 11.6 days. Major discrepancies between the clinical and postmortem diagnoses (Goldman classes I and II) were detected in 15 patients (21%). The most common missed diagnoses were aspergillosis, pulmonary embolism, and cancer recurrence. There were no differences between groups regarding the rate of major discrepancies.

CONCLUSION

Despite the advances in the diagnosis and treatment of critically ill cancer patients, autopsies continue to show major discrepancies between the clinical and postmortem diagnoses. Autopsy is still useful in this patient population.

Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents

Aims

To study the feasibility and reliability of pocket-size hand-held echocardiography (PHHE) by medical residents with limited experience in ultrasound.

Methods and results

A total of 199 patients admitted to a non-university medical department were examined with PHHE. Six out of 14 medical residents were randomized to use a focused protocol and examine the heart, pericardium, pleural space, and abdominal large vessels. Diagnostic corrections were made and findings were confirmed by standard diagnostics. The median time consumption for the examination was 5.7 min. Each resident performed a median of 27 examinations. The left ventricle was assessed to satisfaction in 97% and the pericardium in all patients. The aortic and atrioventricular valves were assessed in at least 76% and the abdominal aorta in 50%, respectively. Global left-ventricular function, pleural, and pericardial effusion showed very strong correlation with reference method (Spearman's r ≥ 0.8). Quantification of aortic stenosis and regurgitation showed strong correlation with r = 0.7. Regurgitations in the atrioventricular valves showed moderate correlations, r = 0.5 and r = 0.6 for mitral and tricuspid regurgitation, respectively, similar to dilatation of the left atrium (r = 0.6) and detection of regional dysfunction (r = 0.6). Quantification of the abdominal aorta (aneurysmatic or not) showed strong correlation, r = 0.7, while the inferior vena cava diameter correlated moderately, r = 0.5.

Conclusion

By adding a PHHE examination to standard care, medical residents were able to obtain reliable information of important cardiovascular structures in patients admitted to a medical department. Thus, focused examinations with PHHE performed by residents after a training period have the potential to improve in-hospital diagnostic procedures.

Occult pulmonary embolism in intensive care unit patients undergoing chest computed tomography scan: incidence and effect on outcomes

OBJECTIVE

To determine the incidence of occult pulmonary embolism (PE) and the associated morbidity in an intensive care unit (ICU).

DESIGN

Retrospective study.

SETTING

Fifteen-bed ICU of a university hospital.

PARTICIPANTS

Two hundred patients who underwent chest computed tomography (CT) scans with administration of contrast.

INTERVENTIONS

The patients were classified into 3 groups: (1) Occult PE if the chest CT scan was not taken, specifically for elucidating the diagnosis of PE, but it confirmed this diagnosis; (2) non-occult PE if the chest CT scan was taken to elucidate a suspected diagnosis of PE and confirmed this diagnosis; and (3) the chest CT scan did not confirm this diagnosis. The analysis was conducted to identify the effect of a diagnosis of occult PE on the outcomes of patients.

MEASUREMENTS AND MAIN RESULTS

Among the 200 patients who underwent chest CT scan, 27 (13%) patients had PE, in whom 18 (9%) were classified as occult PE and 9 (4.5%) as non-occult PE. The duration of ICU stay was increased in patients with PE, as compared with the controls (23 [18-48] days v 17 [10-20] days v 14 [7-29] days; p = 0.02 for occult PE, non-occult PE, and controls, respectively). No difference was observed in mortality rate among the 3 groups.

CONCLUSION

Occult PE was found in 9% of the cohort. This emphasized the need for developing diagnostic strategies in high-risk patients. Future studies should aim at assessing interventions for preventing this event.