Prospective study of necropsy audit of geriatric inpatient deaths

Evaluating the long-term consequences of air pollution in early life: geographical correlations between coal consumption in 1951/1952 and current mortality in England and Wales

OBJECTIVE

To evaluate associations between early life air pollution and subsequent mortality.

DESIGN

Geographical study.

SETTING

Local government districts within England and Wales.

EXPOSURE

Routinely collected geographical data on the use of coal and related solid fuels in 1951-1952 were used as an index of air pollution.

MAIN OUTCOME MEASURES

We evaluated the relationship between these data and both all-cause and disease-specific mortality among men and women aged 35-74 years in local government districts between 1993 and 2012.

RESULTS

Domestic (household) coal consumption had the most powerful associations with mortality. There were strong correlations between domestic coal use and all-cause mortality (relative risk per SD increase in fuel use 1.124, 95% CI 1.123 to 1.126), and respiratory (1.238, 95% CI 1.234 to 1.242), cardiovascular (1.138, 95% CI 1.136 to 1.140) and cancer mortality (1.073, 95% CI 1.071 to 1.075). These effects persisted after adjustment for socioeconomic indicators in 1951, current socioeconomic indicators and current pollution levels.

CONCLUSION

Coal was the major cause of pollution in the UK until the Clean Air Act of 1956 led to a rapid decline in consumption. These data suggest that coal-based pollution, experienced over 60 years ago in early life, affects human health now by increasing mortality from a wide variety of diseases.

Comparison of clinical and pathological diagnoses in dogs

Clinical and pathological diagnoses were compared in a prospective study of 145 dogs. A diagnostic work up had been performed on all dogs of which 36 (24.8%) died and 109 (75.2%) were euthanatized. In 119 dogs (82.1%) both a clinical and patholical diagnosis was made, in 20 dogs (13.8%) no pathological diagnosis could be made and in 6 dogs (4.1%) no clinical diagnosis was established. In the 119 dogs the agreement level between clinical and pathological diagnosis was scored by the referring veterinarian together with a pathologist. Total agreement was found in 61 cases (51.3%) and disagreement in 31 cases (26.0%). In the remaining cases (27=22.7%) the pathological diagnosis further specified the clinical diagnosis. Consecutive submission appeared difficult to achieve by the participating veterinarians. However, no major differences in agreement level was present between the veterinarian which succeeded in almost consecutive submissions and the other veterinarians. At necropsy 42 cases were diagnosed as neoplasia, of which 52.4% had been diagnosed clinically. As to infectious diseases 55.0% of these diseases diagnosed at necropsy had been diagnosed clinically. In about 20% of the cases the differences were of clinical significance according to the referring veterinarians. In addition, it was indicated by the clinicians that about 50% of the necropsies revealed findings which could amend future patient care. The results of the study stress the relevance of postmortem examination as crucial part of continuing education and of quality monitoring and assurance in veterinary medicine.

Infectious diseases detected at autopsy at an urban public hospital, 1996-2001

Previous studies have demonstrated significant discrepancy rates between clinical and autopsy diagnoses. However, infectious diseases have not received emphasis in these studies. We conducted a study to determine whether the clinical and autopsy diagnoses of infectious diseases are concordant or discrepant and to determine discrepancy rates. Retrospective reviews of the records of 276 patients (adults, 182; fetuses and neonates, 94) who underwent autopsy during the years 1996 through 2001 were performed. Comparison of clinical and autopsy diagnoses was performed using the Goldman classification scheme. Of 182 adult patients, 137 (75.3%) had an infectious disease at autopsy. In 59 (43.1%) of 137 patients, the infectious disease diagnoses were unknown clinically. Of 94 fetuses and neonates, 45 (48%) had an infectious disease at autopsy. In 26 (58%) of 45 patients, the infectious disease diagnoses were unknown before death. There are substantial discrepancies between clinical and autopsy diagnoses of infectious diseases. In adults, acute bronchopneumonia is the infectious disease most often missed clinically; in fetuses and neonates, it is acute chorioamnionitis.

The relation of C-reactive protein levels to total and cardiovascular mortality in older U.S. women

PURPOSE

To determine whether serum C-reactive protein levels, a sensitive indicator of inflammation, are associated with the risk of cardiovascular mortality among older women.

METHODS

We conducted a case-cohort study within the Study of Osteoporotic Fractures, a population-based study involving 9,704 women aged > or = 65 years from four U.S. centers. We randomly selected 400 women from the entire cohort plus an additional random sample of 92 women from the 1,125 women in the cohort who had died during the first 6 years of follow-up. Baseline serum C-reactive protein levels were measured using a high-sensitivity immunoassay. Cause-specific mortality was ascertained by review of death certificates and hospitalization records. Multivariable Cox proportional hazards regression was used to determine the association between C-reactive protein levels and cardiovascular mortality.

RESULTS

During 6 years of follow-up, 150 of the 492 women died, including 52 who died of cardiovascular disease. After adjusting for potential confounders, women with C-reactive protein levels in the highest quartile (>3.0 mg/L) had a 8.0-fold (95% confidence interval [CI]: 2.2 to 29) greater risk of cardiovascular mortality than those in the lowest quartile (< or = 1.0 mg/L). The association remained strong in women who did not smoke or take estrogen, and when early deaths were excluded. Women who smoked and whose C-reactive protein levels were above the first quartile had a very high risk of cardiovascular mortality (relative risk [RR] = 13; 95% CI: 3.4 to 47). C-reactive protein levels were not associated with noncardiovascular mortality (RR = 0.92; 95% CI: 0.4 to 2.1).

CONCLUSION

C-reactive protein level was an independent predictor of cardiovascular mortality in older women.

Postmortem examinations in patients of a geriatric hospital

The rate of postmortem examinations (PME) especially in elderly patients is continuously declining, mostly due to the low interest of the medical staff and the reluctance of relatives. We surveyed PME performed over a 20-year period in patients of a geriatric hospital in Israel. The 93 autopsies represent a rate of 2.8% in the first five years which went down to 0.25% in the later years. In 58% of the cases, clinical cause of death was confirmed by the PME. Pulmonary embolism had the lowest confirmation rate, and was more frequently found in females (28%) than in males (10%) (p<0.03). Undiagnosed conditions in the elderly present a clinical challenge that increases with the patient's age. However, despite progress in diagnostic technology, confirmation rates of death causes have not changed much. Therefore, as the age of death rises, it is important to preserve and foster PMEs, the most reliable source of medical evidence.

The forensic pathology of nonagenarians and centenarians: do they die of old age? (The Auckland experience)

The aim of this study is to provide awareness of the common causes of death and their associated trends in the very aged. Forensic autopsies on patients aged >90 years were reviewed. The study lasted from January 1, 1988 to December 11, 1998 and was done in Auckland, New Zealand, the population of which is 1.3 million. Cases were divided into natural or unnatural deaths. Of the total of 319 cases, 272 (85%) deaths were natural. Of those, only 13 (5%) were "written off" as being attributed to old age or senile debility. The most common causes of death were ischemic heart disease (IHD), 74 cases (23%); bronchopneumonia, 37 cases (12%); fractures, 28 cases (9%); acute myocardial infarction, 25 cases (8%); cerebrovascular accident, 19 cases (6%); and ruptured aneurysm, 17 cases (5%); 61 (19%) deaths were multifactorial. Fractures, either as the primary cause of death or as a complicating factor, accounted for 29 cases, third only to IHD and bronchopneumonia. Forty-seven deaths (15%) were unnatural; of those, 43 were accidents, 3 were suicides, and 1 was a homicide. From these results it is clear that the very elderly succumb to disease; they do not often die of old age.

Toxoplasma gondii--an unusual cause of myocarditis in old age

We report the case of an 86-year-old man who was admitted with congestive cardiac failure and chronic renal failure. He was previously known to have a thoracic aortic aneurysm and chronic bronchitis. There was no history of myocardial infarction but his heart failure was assumed to be due to ischaemic heart disease. Despite treatment of the heart failure the patient died. At post-mortem he was found to have Toxoplasma gondii myocarditis.

Attitudes of junior medical staff to requesting permission for autopsy

The attitudes of junior medical staff in a university teaching hospital to requesting postmortem examination were assessed. Following completion of 100 death certificates, autopsy was sought in only 28 cases (and refused in 18). The majority of staff were unaware of the reported benefits of autopsy, despite their inclusion in the local medical handbook and had received no training in how to seek permission for a necropsy. Formal education programmes have been shown to improve hospital autopsy rates and the results of this study suggest that these would be welcomed by junior medical staff.

Causes of death in a hospitalized geriatric population: an autopsy study of 3000 patients

Macroscopic and histological studies of 3000 consecutive autopsies (43.9% of the registered deaths) were performed by the same pathologist in a geriatric institution over a period of 20 years. Bronchopneumonia (42.9%), malignant neoplasms--mainly of the gastrointestinal tract and its annexae and the lungs (28.1%)-pulmonary thrombo-embolism (21.2%) and acute myocardial infarction (19.6%), were the most prevalent fatal conditions observed. Next, in decreasing order were: urinary tract infection (12.3%), acute cerebrovascular disease (6.5%), internal haemorrhage (5.5%), and congestive cardiac failure (3.3%). Some "rare" causes of death noted included trauma, metabolic disease, acute asphyxia from foreign body obstruction of the upper respiratory tract and degenerative neurological diseases. Some potentially treatable disorders which led to death were unsuspected clinically: for example, acute pyelonephritis (87%), pulmonary thrombo-embolism (74%), acute myocardial infarction (74%) and active pulmonary tuberculosis (61%). With advancing age there is an increased frequency of multiple pathological processes in a given subject and interactions play an important role in morbidity and mortality. We observed that two or more co-existing conditions often determine the fatal event. We also emphasize the relevance of post-mortem examination to prevention of disease and to therapeutic medicine in a hospitalized geriatric setting.