Clinical Diagnoses and Autopsy Findings: A Retrospective Analysis of 252 Cases in Greece

IPPASOS: The first digital forensic information system in Greece

OBJECTIVE

This article describes the first digital clinical information system tailored to support the operational needs of a forensic unit in Greece and to maintain its archives.

METHOD

The development of our system was initiated towards the end of 2018, as a close collaboration between the Medical School of the University of Crete and the Forensic Medicine Unit of the University Hospital of Heraklion, Crete, where forensic pathologists assumed active roles during the specification and testing of the system.

RESULTS

The final prototype of the system was able to manage the life cycle of any forensic case by allowing users to create new records, assign them to forensic pathologists, upload reports, multimedia and any required files; mark the end of processing, issue certificates or appropriate legal documents, produce reports and generate statistics. For the first 4 years of digitised data (2017-2021), the system recorded 2936 forensic examinations categorised as 106 crime scene investigations, 259 external examinations, 912 autopsies, 102 post-mortem CT examinations, 804 histological examinations, 116 clinical examinations, 12 anthropological examinations and 625 embalmings.

CONCLUSION

This research represents the first systematic effort to record forensic cases through a digital clinical information system in Greece, and to demonstrate its effectiveness, daily usability and vast potential for data extraction and for future research.

Utility and diagnostic value of postmortem microbiology associated with histology for forensic purposes

Nowadays, the diagnostic value of postmortem microbiological investigations is still a debated topic, but postmortem microbiology (PMM) remains a discipline with great forensic potential. To evaluate the usefulness and diagnostic-forensic value of postmortem microbiological cultures, it has been conducted a study on cadaveric material sampled during autopsy aiming to identify the correct cause of death. The study analyzed 45 cadavers subjected to judicial autopsy, divided into two groups based on the presence or absence of external or internal macroscopic autopsy signs suggesting infectious pathology. In the same cases, both the microbiological and conventional histological investigations have been simultaneously carried out. From the investigations, mono-bacterial, mono-fungal, mixed and negative cultures were observed. In mono-species microbiological growth, the histological epicrisis confirmed an infectious cause of death due to the presence of signs of acute infection with an aggressive infectious agent. In cases where growth was mixed, it was possible to distinguish between simple postmortal contamination and perimortem colonization. Finally, in some cases where the microbiology was negative, this has been essential in highlighting signs of a vital reaction to viral or parasitic infection. The joint and integrated evaluation of the laboratory results made it possible to correctly understand even those peculiar situations in which the PMM results alone would not have been significant. These methods, when combined, constitute an optimal forensic approach for the identification of the real cause of death and thus reduce the number of unsolved cases.

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.

[Analysis of the major clinical-pathological discrepancies in autopsies of adults in a tertiary referral hospital between 2008-2017]

OBJECTIVE

To compare and contrast clinical diagnoses with autopsy findings in order to identify unexpected, relevant discrepancies.

MATERIAL AND METHOD

A retrospective observational study of the revision of autopsies of adults and their respective medical records in order to classify them according to referral department and Goldman's classification was carried out at the Central University Hospital of Asturias between 2008-2017.

RESULTS

694 (52.6%) of 1320 autopsies were included in the study. Discrepancies were observed in 57.6% of cases, although the majority (39.3%) were minor. Type I discrepancies were identified in 63 autopsies (9.1%); malignant neoplasms being the main pathology observed (57.1%), mainly of gastrointestinal origin (about 28%). The second most common discrepancy was found in cases of infectious diseases (23.8%) followed by pulmonary embolism (15.9%). 64 autopsies were classified as type II discrepancies (9.2%), with myocardial infarct the most common (37.5%), especially acute myocardial infarction (18 cases), followed by bronchoaspirations (18.7%), DIC (15.6%), massive haemorrhages (9.4%) and other conditions. It was considered that both the ICU and the Internal Medicine Service were responsible for the largest number of major discrepancies (type I and II), accounting for about 45% of type I and slightly more than 56% for type II.

CONCLUSION

Autopsies are an essential means of identifying ante-mortem clinical errors. The incidence of major discrepancies in the Central University Hospital of Asturias (18.3%) is comparable to that of leading hospitals worldwide.

Deontological examination as a criterion for the assessment of personal healthcare professional quality: A Strobe compliant retrospective study

Discrepancies between clinical and autopsy diagnoses range from 30% to 37%. The significance of deontological examinations remains high. In the pursuit of proper evaluation of diagnostic discrepancies, the establishment of pathogenesis, the mechanism of death, and a correct diagnosis are of particular importance.A retrospective study of deontological examinations, aimed at the detection of medical errors and carried out by the State Forensic Medicine Service during the period 1989 to 2016, was performed. The clinical and autopsy data from 1007 cases were collected in compliance with the research protocol.The number of deontological examinations tends to increase. In 60% of cases, the deceased were men. Most cases were in the age group of 50 to 59 years. Most examinations were carried out in relation to improperly provided healthcare services and the patient's death in surgery, admission, intensive care and obstetrics-gynecology departments. In 13% of cases, the diagnosis did not coincide and, in 79% of cases, the diagnoses fully coincided. In 68% of cases, the medical error was disproved.The number of deontological examinations is increasing. In most cases, clinical and autopsy diagnoses fully matched. Incorrectly clinically diagnosed intracranial injuries were the most common diagnostic mistakes. The data are similar to the results of research in other countries and would be relevant to ensuring the prevention of medical mistakes and the improvement of healthcare quality.

Discordance between clinical and post-mortem diagnoses at a tertiary hospital

Advances in modern medicine and more accurate and precise diagnostic procedures have been considered to be the main reason for the reduction in autopsy rates. However, there is still a discrepancy between clinical and autopsy diagnoses. This retrospective study, designed as a cross-sectional study, included a sample of 931 patients who died at the Clinical Hospital Centre ‘Zemun’. We analysed sex, age, length of hospitalisation and clinical and post-mortem diagnoses, including the discrepancies between them. In 314 (34%) cases, there was complete agreement between the clinical and autopsy diagnoses, complete disagreement in the same percentage and incomplete agreement in 303 (32%) cases. In people aged >60 years, the risk of misdiagnosis was 2.5-fold higher than in the those aged <60 years (odds ratio (OR)=2.522, p<0.001), while the influence of sex on the risk of misdiagnosis was not statistically significant (OR=0.981, p>0.05). An increase in the number of autopsies would be one of the best methods to make discrepancies between clinical and post-mortem diagnoses visible, and a good method for continuous evaluation of diagnostic tests, as well as for providing a wider perspective on presentations of different clinical conditions.

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.

Comparison of Clinical Diagnoses and Autopsy Findings: Six-Year Retrospective Study

CONTEXT

- The frequency of autopsies has declined in most developed countries beginning in the latter half of the 20th century. During this time period the technology of medicine made significant advances; however, it is important to regularly reevaluate the role of the autopsy to confirm suspected diagnoses and identify unsuspected findings.

OBJECTIVE

- To determine what portion of autopsies reveal clinically meaningful unexpected findings.

DESIGN

- Reports that included clinical histories of autopsies performed at Jackson Memorial Hospital during the 6 years between 2009 and 2014 were reviewed by 2 pathologists. Each case was classified using the Goldman Classification.

RESULTS

- In the given time period, 923 autopsies were performed; 512 patients (55.5%) were adults. A total of 334 cases were subject to review after excluding those with a short (<1 day) hospital stay, restriction to a single organ or body cavity, and cases referred from other facilities. A total of 33 of 334 cases (9.9%) were identified as class I discrepancy, where the autopsy revealed a discrepant diagnosis with a potential impact on survival or treatment. Critical findings, such as untreated infection (15 of 33 cases; 45.5%), pulmonary embolism (8 of 33 cases; 24.2%), and undiagnosed malignancy (6 of 33 cases; 18.2%), were found in these cases. Major significant findings that had not been clinically detected, whether clinically manageable or not (class I and II), were found in 65 of 334 cases (19.5%).

CONCLUSION

- Despite intensive modern clinical investigations, autopsies continue to reveal major antemortem diagnostic errors in a significant number of cases.

Diagnostic test accuracy of D-dimer for acute aortic syndrome: systematic review and meta-analysis of 22 studies with 5000 subjects

Diagnostic test accuracy of D-dimer for acute aortic dissection (AAD) has not been evaluated by meta-analysis with the bivariate model methodology. Four databases were electrically searched. We included both case-control and cohort studies that could provide sufficient data concerning both sensitivity and specificity of D-dimer for AAD. Non-English language articles and conference abstract were allowed. Intramural hematoma and penetrating aortic ulcer were regarded as AAD. Based on 22 eligible articles consisting of 1140 AAD subjects and 3860 non-AAD subjects, the diagnostic odds ratio was 28.5 (95% CI 17.6-46.3, I(2) = 17.4%) and the area under curve was 0.946 (95% CI 0.903-0.994). Based on 833 AAD subjects and 1994 non-AAD subjects constituting 12 studies that used the cutoff value of 500 ng/ml, the sensitivity was 0.952 (95% CI 0.901-0.978), the specificity was 0.604 (95% CI 0.485-0.712), positive likelihood ratio was 2.4 (95% CI 1.8-3.3), and negative likelihood ratio was 0.079 (95% CI 0.036-0.172). Sensitivity analysis using data of three high-quality studies almost replicated these results. In conclusion, D-dimer has very good overall accuracy. D-dimer <500 ng/ml largely decreases the possibility of AAD. D-dimer >500 ng/ml moderately increases the possibility of AAD.

Chronic illness: a revisionist account

This article challenges the generally accepted thesis that the emergence and dominance of chronic illness over the last half century is due to the receding tide of acute infectious diseases and an ageing population. Instead, through an analysis of contemporary reports in the Journal of the American Medical Association, it is argued that the construct of chronic illness emerged as part of a new focus on the downstream consequences of disease and as a means of transferring what had been seen as the natural processes of ageing and senescence into an explanatory model based on pathological processes. The widely accepted idea of an epidemiological transition in illness prevalence has served to conceal the ways in which medicine has extended its remit and suppressed alternative explanatory frameworks.

Influence of age, gender, and prodromal symptoms on sudden death in a tertiary care hospital, eastern Saudi Arabia

Background:

Sudden death (SD) remains an important worldwide public health problem. The incidence of SD and causes vary in different societies, and these differences are influenced also by demographic and clinical factors such as age, gender and prodromal symptoms and signs. This six-year study describes the influence of these factors on SD.

Materials and Methods:

This is a retrospective study of SD in all age groups undertaken in King Fahd Hospital of the University (KFHU), Eastern Saudi Arabia. All cases of death (1273 total, 1050 expected death and 223 cases of sudden unexpected death) that occurred between January 1, 2000 and December 31, 2005 were investigated and subsequently analyzed on demographic and clinical parameters of the deceased patients. The statistical analysis was performed as appropriate to illustrate any possible association between different demographic variables and SD.

Results:

There were 223 cases of SD (17.5%) out of 1273 total deaths in KFHU in the 6-year study period. There was a definite influence of age on the incidence of sudden death (SD) as it increased clearly at the two ends of the age spectrum, 32.2% of the cases were infants (from birth to 12 months), and 31.4% were elderly (> 60 year-old). However, among infantile age group, the highest frequency of SD (22.2% of the cases) was among the neonates. There was also a significant trend of gender influence on the incidence of SD which was higher in men than women (56% vs. 42%). The influence of prodromal symptoms and signs on SD was variable. Dyspnea and cough as major symptoms of cardiovascular and respiratory disease were the most frequent presenting symptoms in 32.3% of the cases, followed by fever as a sign of infections in 11.7%, premature infants in 10.8%, circulatory collapse in 9.4%, and angina in 7.6% of the cases.

Conclusion:

The current study indicated a definite influence of age, gender and prodromal symptoms on the incidence of SD. The highest incidence occurred in the two extremes of age scale as compared to other age groups. Incidence was also higher in men than women. Meanwhile, the major prodromal symptoms and signs were dyspnea and cough, fever, premature birth, circulatory collapse, and angina pectoris..

Clinico-pathological discrepancies in a general university hospital in São Paulo, Brazil

INTRODUCTION

The autopsy rate has continuously diminished over the past few decades, reducing the quality of medical care and the accuracy of statistical health data.

OBJECTIVE

To assess the accuracy of clinical diagnoses by comparing pre- and postmortem findings, and to identify potential risk factors for misdiagnoses.

METHODS

Retrospective evaluations performed between June 2001 and June 2003 in a 2,500-bed tertiary university hospital in São Paulo, Brazil, including 288 patients who died at that institution and had a postmortem examination.

RESULTS

Clinical and autopsy records were reviewed and compared for categorization using the adapted Goldman criteria. The overall major and minor discrepancy rates were 16.3% and 28.1%, respectively. The most common missed diagnoses were pulmonary embolism, pneumonia, and myocardial infarction, and the most prevalent underlying diseases were infectious diseases, cerebro-cardiovascular conditions, and malignancies. Patients age 60 or older had an increased risk of diagnostic disagreement, as did female patients. The period of hospitalization, last admission unit at the hospital and underlying disease were not significantly related to the pre-mortem diagnostic accuracy.

DISCUSSION

The discrepancy rate found in this study is similar to those reported globally. The factors influencing diagnostic accuracy as well as the most commonly missed diagnoses are also consistent with the literature.

CONCLUSION

Autopsy remains a crucial tool for improving medical care, and effort must be focused on increasing its practice worldwide.

Trends in prevalence of fatal surgical diseases at forensic autopsy

BACKGROUND

In 1992, there were major changes in Swedish law of the deceased, which had led to a dramatic decrease in autopsy rates. The aim of this study was to investigate the prevalence of fatal or potential fatal surgical diseases within a Swedish forensic autopsy cohort, before and after this change in legislation.

METHODS

Deaths referred for forensic autopsy at the Institution of Forensic Medicine, Lund University Hospital, Sweden, between 1970-1982 and 2000-2004, were studied regarding the prevalence of aorto-iliac diseases, acute abdomen and abdominal cancer.

RESULTS

The forensic autopsy rates in the population during the two time periods were 14.0% (29 399 patients) and 5.3% (4487 patients), respectively. The total prevalence of surgical diseases has increased significantly from 67.3 (95% confidence interval 64.3-70.2) to 83.4 (74.9-91.8) per 1000 autopsies, respectively. The cause-specific mortality ratios in patients with fatal acute abdomen increased significantly from 16.5 (15.1-18.0) to 39.0 (33.2-44.8) per 1000 autopsies, respectively, and there was almost a three-time increase in patients with fatal gastrointestinal haemorrhage and acute alcohol-related pancreatitis.

CONCLUSION

Forensic autopsy data continues to be invaluable, despite changes in legislation in Sweden, for epidemiological studies on fatal or potential fatal surgical diseases.

High rate of discordance between clinical and autopsy diagnoses in blood and marrow transplantation

We analyzed autopsies performed in a Canadian blood and marrow transplantation (BMT) program. We aimed to assess variables that predict the performance of an autopsy, whether rates of autopsy are changing, and the rate of discordance between clinical and autopsy diagnoses. All deceased adult patients from January 1990 to December 2004 were reviewed. Autopsy rates were compared to a large teaching hospital. Of 476 myeloablative BMT patients, 225 died and 48 (27%) underwent autopsy. Autopsy was more likely in patients dying: <100 days post-BMT, in the intensive care unit, after allografting, and on weekends. Autopsy rates among BMT patients declined during the three time periods (1990-1994, 1995-1999, 2000-2004). The autopsy rate at the teaching hospital showed a similar downward temporal trend. Major and minor disagreements at autopsy were present in 16 (34%) and 14 (30%) of cases, respectively. There was no change in discordance rates over time. Thus, despite advances in diagnostic procedures, high levels of disagreement between clinical and autopsy diagnoses for BMT patients persist as autopsy rates decline. We recommend that the autopsy regains its role as a valuable investigation. This may become especially relevant in an era where patients with medical comorbidities are undergoing reduced-intensity BMT.

Emergency department deaths despite active management: experience from a tertiary care centre in a low-income country

OBJECTIVE

To determine the frequency and causes of ED deaths despite active management, in a tertiary care centre of a low-income country.

METHODS

We conducted a retrospective chart review over a 2 year period (January 2001-December 2002) for all patients who died despite active management in an ED in Karachi, Pakistan.

RESULTS

Of the 78,418 patient visits, 601 patients (0.7%) were pronounced dead. Of these, 577 patients had complete records. Seventy per cent of these were dead-on-arrival, 1% had do-not-resuscitate orders and 29% (n = 166; 95% confidence interval [CI] 25-32%) died despite active management. Initial vital signs were found to be abnormal in almost all cases (98%). The leading causes of death were sepsis (23%; 95% CI 19-26%), myocardial infarction (19.7%; 95% CI 16-22%), cerebrovascular accident (10.7%; 95% CI 8-13%) and pneumonia (8.2%; 95% CI 6-10%) among adults and sepsis (36.4%; 95% CI 32-40%), myocarditis (15.9%; 95% CI 13-18%) and pneumonia (9.1%; 95% CI 6-11%) among children.

CONCLUSION

Sepsis is the leading cause of death in patients of all age groups in the ED of this hospital.

Evaluation of a quantitative D-dimer latex immunoassay for acute pulmonary embolism diagnosed by computed tomographic angiography

OBJECTIVE

To determine the sensitivity and specificity of a quantitative plasma fibrin D-dimer latex immunoassay (LIA) for the diagnosis of acute pulmonary embolism.

SUBJECTS AND METHODS

Study subjects were Mayo Clinic Rochester inpatients and outpatients with suspected acute pulmonary embolism; all had undergone quantitative D-dimer LIA testing and multidetector-row computed tomographic (CT) angiography between August 3, 2001, and November 10, 2003. Multidetector-row CT angiography was the diagnostic reference standard.

RESULTS

Of 1355 CT studies, 208 (15%) were positive for acute pulmonary embolism. Median D-dimer levels were significantly higher for patients with acute pulmonary embolism (1425 ng/mL) than for patients without (500 ng/mL) (P<.001). The highest specificity that optimizes sensitivity for acute pulmonary embolism was achieved by using a discriminant value of 300 ng/mL, which yielded a sensitivity of 0.94 (95% confidence interval [CI], 0.89-0.97), a specificity of 0.27 (95% CI, 0.25-0.30), and a negative predictive value of 0.96 (95% CI, 0.93-0.98).

CONCLUSION

The quantitative D-dimer LIA with a discriminant value of 300 ng/mL had high sensitivity and high negative predictive value but low specificity for the diagnosis of acute pulmonary embolism. On the basis of these results, we believe that a negative quantitative D-dimer LIA result and a low pretest probability of thromboembolism together are sufficient to exclude acute pulmonary embolism.

Toll-like receptor 4 polymorphism is associated with coronary stenosis but not with the occurrence of acute or old myocardial infarctions

OBJECTIVE

Atherosclerosis is considered to be a chronic inflammatory disease. Toll-like receptor 4 (TLR-4), a key mediator in activating inflammatory cascade, has an A-to-G functional polymorphism that changes aspartic acid to glycine at position 299. TLR-4 is activated by, for example, lipopolysaccharides. The purpose of this study was to investigate the role of a common Asp299Gly polymorphism of the TLR-4 gene in atherosclerosis.

MATERIAL AND METHODS

The study comprised autopsy material from 657 men (the Helsinki Sudden Death Study; mean age 53, range 33-70 years).

RESULTS

Fewer G-allele carriers had 3-vessel coronary artery disease compared with AA homozygotes (OR 0.32; 95 % CI, 0.12-0.88, p = 0.027), and they also had a lower mean value for maximal coronary stenosis (p = 0.019). TLR-4 polymorphism was not significantly associated with the occurrence of acute or old myocardial infarction (MI).

CONCLUSIONS

The G allele of the TLR-4 gene, which is associated with a lower inflammation response, was associated with a lower risk of coronary stenosis but not with the occurrence of MI and hence is not a major factor in the development of coronary atherosclerosis.

Myocardial Scars More Frequent Than Expected

OBJECTIVES

The aim of this study was to investigate the prevalence of clinically recognized myocardial infarctions (RMIs) and unrecognized myocardial infarctions (UMIs) in 70-year-old subjects, assessed with magnetic resonance imaging (MRI), and to relate the findings to cardiac function and morbidity.

BACKGROUND

Late enhancement MRI identifies myocardial scars and thereby has the potential to detect UMI.

METHODS

Cardiac MRI was performed on 259 randomly chosen 70-year-old subjects. Late enhancement and cine sequences were acquired, and the ejection fraction and left ventricular (LV) mass were calculated. Late enhancement involving the subendocardial layer was considered to represent myocardial infarction (MI) scars, and their volumes were calculated. Information on cardiac morbidity and risk factors was collected from medical records and from a health examination. Subjects with MI scars, with or without a hospital diagnosis of MI were classified as RMI or UMI, respectively.

RESULTS

The images from 248 subjects (123 women, 125 men) were assessable. Myocardial infarction scars were found in 60 subjects (24.2%), in 49 of whom (19.8%) they were UMIs. The volumes of the UMIs were significantly smaller than those of the RMIs. There was an increased frequency of chest pain symptoms among the subjects with UMI or RMI compared with those without MI scars. Ejection fraction was significantly lower and LV mass significantly larger in the subjects with UMI or RMI than in those without MI scars.

CONCLUSIONS

Unrecognized MI detected with MRI was more frequent than expected in 70-year-old subjects. The subjects displaying these UMIs may represent a previously unknown potential risk group for future cardiovascular events.