Epidemiology of Adult Polycystic Kidney Disease,Olmsted County,Minnesota: 1935–1980

Between January 1, 1935 and December 31, 1980, adult polycystic kidney disease (APKD) was diagnosed in 40 residents of Olmsted County, Minnesota, resulting in an ageand sex-adjusted annual incidence rate of 1.38/100,000 person-years. In addition, 16 cases were detected at autopsy, increasing the rate to 2.06. It is estimated that 16 additional cases would have been discovered had all deaths come to autopsy, resulting in a rate of 2.75, or approximately twice the incidence rate of cases diagnosed during life . Because of improvements in medical care and diagnostic techniques, APKD has been diagnosed earlier and more frequently in the recent decades. This, along with therapeutic advances, explains the improvement in kidney and patient survival for the patients diagnosed during 1956–1980, as compared to those diagnosed during 1935-1955. Normotension at diagnosis tended to be associated with better kidney and/or patient survival. Cardiovascular disease was the leading cause of death.     

Coronary heart disease in the Pima Indians. Electrocardiographic findings and postmortem evidence of myocardial infarction in a population with a high prevalence of diabetes mellitus.

The frequency of electrocardiographic evidence of coronary heart disease (CHD) and the rate of autopsy-proved myocardial infarction were determined in the Pima, a tribe of American Indians with a high prevalence of diabetes mellitus. The electrocardiograms of 701 Pimas, aged 40 years and over (85 per cent of the adult reservation population, 45 per cent of whom had diabetes) were read according to the Minnesota Code, and 120 postmortem examinations were reviewed for evidence of myocardial infarction. The frequency of CHD as evidenced by major Q-wave changes in the Pima (1.6/100) was about one-half that found in Tecumseh, Michigan (p less than 0.10). The relatively low rate of myocardial infarction at autopsy (15 per cent of males and 8 per cent of females aged 40 years and over) was consistent with the low prevalence of Q-wave changes. The subjects with diabetes had a higher rate of CHD than nondiabetics, both electrocardiographically and at postmortem examination, although the differences were not statistically significant. The low prevalence of CHD in the living Pima and the low rate of infarction at autopsy indicate that this tribe has a low frequency of CHD despite the extraordinarily high prevalence of diabetes mellitus.     

The prevalence of renal cell carcinoma diagnosed at autopsy

OBJECTIVE: To compare the rate of renal cell carcinoma (RCC) detected only at autopsy, from two periods, to determine if the apparent recent increase in RCC in the USA is a true increase or mainly a result of improved imaging techniques, as a true increase in the clinical incidence of RCC should not affect the number of previously undiscovered RCC found only at autopsy. PATIENTS AND METHODS: We identified all individuals who underwent autopsy in two periods, 1955-60 (3307) and 1991-2001 (2938), and who were identified with renal tumour either before or after death. Information was obtained on age, sex, histological type and size of tumour, and whether the tumour was identified before or only after death. All cases of RCC detected at autopsy were reviewed for this analysis by one pathologist (L.D.). RESULTS: Between 1955-60 and 1991-2001 there was a 55% reduction in the mean annual number of autopsies. The proportion of malignant renal masses (RCC) did not change significantly (35.4% to 32.8%). The rate of previously unsuspected RCC detected only at autopsy did not change significantly (0.91 vs 0.72 per 100 autopsies). CONCLUSION: The number of renal masses, both benign and malignant, discovered only at autopsy is declining, possibly because of better detection before death. However, the rate of occult kidney cancer per 100 autopsies did not change significantly between the two periods, suggesting a true increase in the frequency of clinically detected kidney cancer.     

胎儿颜面部畸形高频超声尸体解剖学研究

目的研究胎儿尸体颜面部畸形产后高频超声检查的准确性。方法对产前超声检查诊断为严重畸形或染色体检查为异常而引产、且其父母同意尸体解剖的71例引产胎儿颜面部行产后高频超声检查，并将结果与尸体解剖对比。结果产后超声发现71例中共有24例胎儿存在颜面部畸形，共有颜面部畸形51处，经尸体解剖证实，PMFU灵敏度、准确率均达100％。从不破坏尸体完整性、操作的简便性、获得结果的快捷性方面进行评估，51处颜面部畸形中，PM—FU在22处优于尸体解剖。结论产后超声检查为胎儿尸体解剖学检查开辟了新领域，可以作为尸体检查的选择方法之一，在胎儿尸体解剖遇到障碍时代替运用，或在尸体解剖前运用作为尸体解剖思路、步骤、方法等的指导。     

Surgical audit without autopsy: tales of the unexpected.

To establish our current practice and the potential value of the autopsy in general surgery, a retrospective review of general surgical autopsies was performed at one district general hospital from January 1989 to August 1991. There was considerable interconsultant variation in autopsy practice with a low 25% overall autopsy rate reflecting a low autopsy request rate. There were discrepancies between the clinical and pathological cause of death in 40 (63%) cases. There were important discrepancies which may have changed management in life in 18 (28%) autopsies, 7 (39%) of which were untreated visceral perforations. Autopsy is an important part of the surgical audit and will disclose considerable unsuspected pathology. Present autopsy rates are low and need to be improved. The unexpected finding of seven untreated visceral perforations requires further study.     

Gallstones at autopsy and cholecystectomy: a comparative study

An examination of 613 post-mortems gave a prevalence of biliary disease at autopsy of 36.5%, higher than reported previously in Australia. This consisted of an asymptomatic gallstone prevalence of 18.9%, with a further 5.7% of the autopsies having granular biliary sludge and 11.9% having had a previous cholecystectomy. Although the rate of occurrence of cholesterol gallstones was approximately half that of the pigment gallstones and pigment biliary sludge combined, no significant association between the sex of the postmortems and stone type was observed at autopsy (chi 2(1) = 0.1: P greater than 0.05). The ratio of biliary disease between females and males was approximately 2:1. Gallstones and biliary sludge from 310 cholecystectomy patients showed that cholesterol gallstones were approximately twice as common in men, and approximately six times as common in women than pigment gallstones. In this group of patients there was a significant association between the sex of the patient and the rate of occurrence of stone type. The rate of occurrence of cholesterol gallstones was significantly higher than pigment gallstones in both the males and females at cholecystectomy (chi 1(2) = 18.97; P less than 0.0001). A female to male ratio of approximately 2:1 was also observed. A statistically significant higher rate of pigmented biliary disease was observed at autopsy than at cholecystectomy. (chi 2 = 101.0; P less than 0.0001). Analyses on biliary sludge, a filterable, fine granular pigmented material in bile, suggest that it may be the direct precursor for a number of different gallstone types.     

Solitary aneurysms of the iliac arterial system: an estimate of their frequency of occurrence

Solitary iliac artery aneurysms are rare, and most reports have been presented as case reports. By combining autopsy records and operating records, a total of 13 cases were found: during a 15-year period (1971 to 1985), 42,010 of the inhabitants of Malm? died (population 230,000) and 35,265 (including 9014 forensic autopsies) underwent autopsy (84%). Solitary iliac artery aneurysms were found in seven (0.03%) of the 26,251 patients who underwent autopsy at the hospital; six of those had been asymptomatic and one was ruptured. Among the 9014 persons who underwent forensic medical autopsy, there were two with ruptured solitary iliac artery aneurysms. Four patients had clinically detected solitary iliac artery aneurysms, three of which were ruptured. All patients underwent surgery, and two of the three patients with ruptured solitary iliac artery aneurysms left the hospital well. The rupture rate of iliac aneurysm among those found at autopsy was one of seven (14%) and among those clinically detected three of four.     

Continuous peritoneal lavage after experimental caecal perforation. Increase in survival prevented by lack of adhesion formation

The effect of continuous peritoneal irrigation on adhesion formation and survival rate was investigated in rats with faecal peritonitis induced by a caecal perforation. When no treatment was thereafter given, extensive adhesion formation and covering of the perforation were found at autopsy. Continuous peritoneal lavage did not increase the survival rate, but at autopsy no adhesion formation was seen and the perforation was wide open, permitting continued soiling.     

Laparoscopic autopsies

Background: In recent years, autopsy consent rates have fallen nationwide. In our institution they have declined from 15% to 7% in 10 years. We perceived that family reluctance to grant permission for autopsy was related to the invasiveness of the open procedure, so we began to do autopsies by needle biopsy, with an increase in consents to 25% during the first year. However, the procedure is inherently inaccurate, so we recently have introduced minimally invasive laparoscopic autopsy. Methods: From July through October 1999, needle biopsy was performed on 25 patients who died at our institution, which was followed by laparoscopic evaluation. Consent for full conventional autopsy had been granted in nine cases, and these then were performed. Data from these autopsies were compared with those from the laparoscopic procedures. Results: Of the patients for whom consent was obtained for open autopsy, there was complete agreement as to cause of death between the laparoscopic and conventional procedures. In one case, a liver hemangioma was missed by laparoscopy, and in two other cases, colon polyps were not discovered. Biopsies of internal organs were accurately performed on the pancreas, kidneys, and adrenals, all of which had been troublesome for needle biopsy alone. Conclusions: Laparoscopic autopsy is much more acceptable to the families of patients than the conventional form, resulting in a higher consent rate. On the basis of our study group, this procedure provides accurate data concerning the cause of death. In addition, performing these autopsies gives surgical residents invaluable training in laparoscopic skills. apd: 13 March 2001     

Resuscitating the autopsy in Australian hospitals

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

Autopsy in general surgery practice.

This study evaluates the impact of the autopsy on a general surgical training program from 1984 through 1988. We have retrospectively examined the charts of all patients who died during this period. Included in this analysis are the records of patients from the general, cardiac, pediatric, and transplant surgery departments during this 5-year period. In all, 628 patients were evaluated. The overall autopsy rate was 73%. The clinical impressions prior to death are correlated with the anatomic diagnoses found during autopsy. Significant diagnostic discrepancies (errors unrecognized and directly related to or associated with the cause of death) were determined. On a yearly basis, diagnostic discrepancies range between 23% to 39%. Gross and histologic examination of surgical patients reveals significant information concerning the cause of death. These data confirm the educational benefit of autopsy despite escalating utilization of sophisticated, noninvasive diagnostic modalities. It is our opinion that the mortality conference, with formal autopsy presentation, is a vital forum for the discussion of patient care and quality assurance issues. Autopsy remains the most specific indicator of errors in diagnosis, management, judgment, and technique in surgical practice today.     

Septicemia as a cause of death in burns: an autopsy study

In burn victims, invasion by the bacteria is not unexpected, despite advances in antibiotics, and it has been reported that in the absence of topical therapy, the superficial areas of burn wound contain up to 100 million organisms per gram of tissue within 48h following the injury. We examined the autopsy reports of 334 cases who died because of complicated burns and who underwent medico-legal autopsy during a period of 5 years to study the rate of infection/sepsis. It was observed that in 65% of fatal burn cases, septicemia was the cause of death. Pseudomonas aeuroginosa and Klebsiella sp. were the most common organism, isolated either singly or in combination in 29% and 28% cases, respectively. High mortality from burns in young married women has been recognized as an alarming and contentious problem in India, particularly among the low socio-economic groups. We found that the females aged 21-25 were the most common victims accounting for 37% of burn fatalities due to septicemia. It was concluded that to carry out periodic review of patterns of isolation and susceptibility profiles of microorganisms infecting burn wounds should be a routine in all burn units. In view of the limited resources of developing countries, we recommend the use of available scoring systems to estimate burn outcome so that the best care can be directed to those who have a better chance of improvement.     

Electrocardiographic and Hemodynamic Changes and Their Association with Myocardial Infarction during Coronary Artery Bypass Surgery: A Multicenter Study

Background: Electrocardiographic (ECG) changes during coronary artery bypass graft surgery have not been described in detail in a large multicenter population. The authors describe these ECG changes and evaluate them, along with demographic and clinical characteristics and intraoperative hemodynamic alterations, as predictors of myocardial infarction (MI) as defined by two sets of criteria.

Methods: Data from 566 patients at 20 clinical sites, collected as part of a clinical trial to evaluate the efficacy of acadesine for reducing MI, were analyzed at core laboratories. Perioperative ECG changes were identified using continuous three-lead Holter ECG. Systolic blood pressure, diastolic blood pressure, and heart rate were recorded each minute during operation. The occurrence of MI by Q wave or myocardial fraction of creatine kinase (CK-MB) or autopsy criteria, and by (Q wave and CK-MB) or autopsy criteria was determined.

Results: During perioperative Holter monitoring, episodes of ST segment deviation, major cardiac conduction changes greater or equal to 30 min, or use of ventricular pacing greater or equal to 30 min occurred in 58% patients, primarily in the first 8 h after release of aortic occlusion. Of the 25% patients who met the Q wave or CK-MB or autopsy criteria for MI, 19% had increased CK-MB as well as ECG changes. (Q wave and CK-MB) or autopsy criteria for MI were met by 4% of patients. The CK-MB concentration generally peaked by 16 h after release of aortic occlusion. In patients with (n = 187) and without a perioperative episode of ST segment deviation, the incidence of MI was 36% and 19%, respectively (P < 0.01), by Q wave or CK-MB or autopsy criteria, and 6% and 3%, respectively (P = 0.055), by (Q wave and CK-MB) or autopsy criteria. Multiple logistic regression analysis showed that intraoperative ST segment deviation, intraventricular conduction defect, left bundle branch block, duration of hypotension (systolic blood pressure < 90 mmHg) after cardiopulmonary bypass, and duration of cardiopulmonary bypass are independent predictors of Q wave or CK-MB or autopsy MI. The independent predictors of (Q wave and CK-MB) or autopsy MI are intraoperative ST segment deviation and duration of aortic occlusion.     

GALLSTONES AT AUTOPSY AND CHOLECYSTECTOMY: A COMPARATIVE STUDY*

An examination of 613 post-mortems gave a prevalence of biliary disease at autopsy of 36.5%. higher than reported previously in Australia. This consisted of an asymptomatic gallstone prevalence of 18.9%. with a further 5.78 of the autopsies having granular biliary sludge and 11.9% having had a previous cholecystec-toniy. Although the rate of occurrence of cholesterol gallstones was approximately half that of the pigment gallstones and pigment biliary sludge combined. no significant association between the sex of the postmortems and stone type was observed at autopsy (χ²₁= 0.1; P > 0.05). The ratio of biliary disease between females and males was approximately 2:1. Gallstones and biliary sludge from 310 cholecystectomy patients showed that cholesterol gallstones were approximately twice as common in men, and approximately six times as common in women than pigment gallstones. In this group of patients there was a significant association between the sex of the patient and the rate of occurrence of stone type. The rate of occurrence of cholesterol gallstones was significantly higher than pigment gallstones in both the males and females at cholecystectomy (χ²₁⁼ 18.97; P < 0.0001). A female to male ratio of approximately 2:1 was also observed. A statistically significantly higher rate of pigmented biliary disease was observed at autopsy than at cholecystectomy. (χ²₁= 101.0; P< 0.0001). Analyses on biliary sludge. a filterable, fine granular pigmented material in bile. suggest that it may be the direct precursor for a number of different gallstone types.     

Unexpected findings in trauma patients dying in the intensive care unit: results of 153 consecutive autopsies

BACKGROUND: The true incidence of missed injuries in trauma-related deaths is unknown, because in only about 60% of injury-related deaths nationwide is an autopsy performed. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. We attempted to evaluate the incidence and nature of missed injuries and complications in trauma- and burn-related deaths in our ICU given an autopsy rate of close to 100%. STUDY DESIGN: The medical records of all trauma- and burn-related deaths in the ICU over a 2-year period were reviewed retrospectively. Missed diagnoses were classified as class 1: major diagnosis that if recognized and treated appropriately might have changed outcomes; class II: major diagnosis that if recognized and treated appropriately would not have changed outcomes; and class III: minor diagnosis. RESULTS: Complete antemortem records were available for 158 patients, of which 153 (97%) underwent autopsy. Mean age was 50 years, and 72% were males. Mean ICU stay was 10 15 days. Four (3%) patients had class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) patients had class II diagnoses, and 12 (8%) patients had class III diagnoses. Overall, 81% of 153 patients had either class III diagnoses or no missed injuries or complications. Pneumonia was the most common missed diagnosis. CONCLUSIONS: With an autopsy rate of 97%, 3% of deaths bad missed major diagnoses that might have affected outcomes if recognized antemortem. Autopsy findings can still provide valuable feedback in Improving the quality of care of critically ill trauma patients.     

The role of acute pancreatitis in pediatric burn patients

Few publications recognize acute pancreatitis as a complication after large burns, consequently the incidence and outcome acute pancreatitis after burn in children is not well defined. The aim of this study was to determine the incidence, morbidity, and mortality relating to acute pancreatitis in a pediatric burn population and to correlate clinical diagnosis with autopsy findings to determine the incidence of unrecognized pancreatitis. Records of 2699 patients with acute burns were reviewed. Acute pancreatitis was defined as abdominal pain and/or feeding intolerance in addition to a three-fold elevation of amylase and/or lipase. One-hundred twenty-seven burned children served as the control cohort. To assess the presence of autopsy confirmed AP in pediatric burn patients, we evaluated autopsy reports of 78 children who died from burns, looking for reported evidence of pancreatic inflammation, and fat/parenchymal necrosis. Our data show that acute pancreatitis in children has a low incidence after burn. The study included 2699 patients of which 13 were suffering acute pancreatitis (13/2699 = 0.05%). Mortality is significantly higher for the acute pancreatitis group vs. the control group, p < 0.05. Autopsy reports established 11 of 78 patients with evidence of pancreatitis, resulting in an incidence of 0.17% for pancreatitis at autopsy. Although it has low incidence, acute pancreatitis is associated with increased mortality in severely burned pediatric patients, which underlines the importance of increased vigilance in the evaluation and treatment of pancreatitis in burned children.     

Behandlungsfehlervorwürfe in der Notfall- und Rettungsmedizin sowie der Notaufnahme

Based on a retrospective multicenter autopsy study on medical malpractice claims cases concerning emergency physicians and ambulance officers will be addressed. Malpractice claims against emergency physicians are not as frequent as against emergency service doctors. Claims are mainly due to wrong diagnosis and treatment, missed diagnosis or missing hospital admission. Especially myocardial infarctions are misdiagnosed not seldom. The rate of confirmed cases of medical malpractice is for emergency physicians with 10.2% behind other medical disciplines. Ambulance officers are mainly confronted with claims of omitted admission to hospitals or information of an emergency physician. Malpractice claims with approved causality for death are very rare. Autopsy findings are in most cases in favor of doctors. Therefore in suspicious cases a medico-legal autopsy should be strived for by qualifying the manner of death as unnatural.     

新生儿先天性心脏病围手术期死因的尸检病理分析

目的从病理学角度分析新生儿先天性心脏病围手术期的死亡原因。方法收集15例围手术期死亡的新生儿先天性心脏病尸检病例，复查病理资料，分析其死亡原因。结果先天性心脏病新生儿围手术期病死率为28．6％，尸检率为62．5％。临床与尸检病理诊断符合率为86．67％，主要死因包括心脏原因（9例），肺部感染（4例）及应激性肾上腺出血（2例）。结论加强新生儿先天性心脏病围手术期的心肺保护，加强尸检意识，有助提高手术成功率。     

Atherosclerosis and vascular calcification in chronic renal failure

Cardiovascular complications are a major clinical problem in patients with chronic kidney disease and end-stage renal failure; cardiac death accounts for approximately 40-50% of all deaths in these patients. Death from cardiovascular causes is up to 20 times more common in uremic patients than in the general population with the risk being even higher than in patients with diabetes mellitus. A high rate of myocardial infarction and excessive cardiac mortality have repeatedly been documented in patients with kidney disease and renal failure. Not only is the prevalence of myocardial infarction high, but also the case fatality rate is significantly higher in uremic patients with and without diabetes, respectively, compared to nonuremic patients. This is of particular interest since the prevalence of coronary atheroma in uremic patients was shown to be approximately 30% by autopsy and coronary angiography studies. Thus, coronary factors, i.e. atherosclerosis, and non-coronary factors may play an important role in the genesis of cardiac complications in the renal patient. In addition, renal failure recently has also be identified as a predictor of mortality in different stages of peripheral vascular disease. In particular, marked differences in the pathogenesis, morphology and course of atherosclerosis and arteriosclerosis under the conditions of renal failure have been documented. Among others increased plaque formation and particularly higher proportion and intensity of vascular calcification have been found in clinical and autopsy studies. In addition to the so-called classical or traditional risk factors, an important role for nonclassical risk factors such as microinflammation, hyperphosphatemia and oxidative stress has been documented in patients with renal failure and is discussed in detail.