Correlation of clinical diagnoses with autopsy findings: A retrospective study of 2,145 consecutive autopsies

The protocols of 2,145 autopsies were retrospectively reviewed and the findings compared with the clinical diagnoses. A sudden decline in the autopsy rate that occurred during the period studied was followed by a highly statistically significant difference in clinical accuracy (P less than 0.01), in favor of the predecline period. The overall rate of major discrepancies was 29 per cent. The most frequently missed diagnoses were infections, which were found in 26 per cent of all autopsies and had not been diagnosed clinically in 63 per cent of these cases. Malignancies occupied second place among overlooked diagnoses in the selected disease categories; in 99 per cent of the cases the malignancy was the principal diagnosis, and it had been misdiagnosed clinically in 42 per cent of these cases. Cerebrovascular disorders were correctly diagnosed in most cases (87 per cent of the patients in this group). Among autopsy diagnoses labeled as the immediate causes of death, the most frequently overlooked were pulmonary embolism and gastrointestinal hemorrhage, which were not recognized in 84 and 78 per cent, respectively. In cases in which clinicians were not entirely confident in their impressions, their diagnoses were usually confirmed at autopsy. In these cases 15 per cent of the patients died soon after admission to the hospital, with accurate diagnoses in 71 per cent. The discrepancies disclosed should be regarded as sufficiently large to mandate continued emphasis on autopsy evaluation as the basis for the control of the quality of patient care.     

Geriatric autopsy pathology in centenarians

The determinate causes of death, physical findings, and major pathologic findings in the organ systems of 32 patients, aged 100 years or older who died between 1921 and 1983, on whom autopsies were performed, are described. Atherosclerosis, neoplasia, and bronchopneumonia were common, but diabetes mellitus, obesity, hypertension, and cerebrovascular accident were absent or rare. Deaths from infection were fewer in the era of antibiotic usage, while cardiovascular and neoplastic deaths became more frequent during that time. The pathologic findings in our series of centenarians indicate that few of these patients died from debilitating diseases and that mortality from infection has been modified by antibiotic usage.     

Immunohistochemistry utilization in autopsy pathology: a Canadian experience

Immunohistochemistry (IHC) is an important part of the diagnostic work-up in surgical pathology, but the use of IHC in autopsy pathology is poorly defined. We measured IHC utilization by pathologists performing 609 consecutive non-medicolegal, hospital-based, adult autopsies over a three-year period. IHC requests on non-neurologic and neurologic material were analyzed separately. Total stains, number of tissue blocks, specific antibody requests, resident trainee involvement, and ordering pathologist were recorded. For all autopsies on which IHC was requested, the final autopsy report was reviewed. IHC was requested on 345 cases (57%), and a total of 4612 stains were performed (mean 13.5 per autopsy). For non-neurologic autopsy tissues, IHC was used most commonly for the accurate diagnosis of malignancy. For neuropathologic autopsy examinations, IHC was employed most commonly to exclude neurodegenerative conditions and correlate ante-mortem clinical neurologic findings. Resident involvement did not significantly impact utilization. Individual pathologists demonstrated a wide variation in IHC utilization. We conclude that IHC is used extensively in Canadian non-medicolegal autopsy pathology reflecting the complexity, extent, and severity of disease in patients dying in a tertiary-care, academic hospital setting. Utilization is strongly influenced by the neuropathology component of these autopsies. The results provide a point of reference for IHC utilization in autopsy pathology.     

The autopsy pathology of sepsis-related death

There is a clinico-pathological continuum of infection-driven sepsis syndromes, the most severe being septic shock with multi-organ failure. The organ dysfunctions are due to inflammatory cytokines from remote sources (the site of infection) and constitute the systemic inflammatory response syndrome (SIRS). The common causes are Gram-positive and Gram-negative infections; the common infection sites are (in descending frequency) lung, blood stream, intra-abdominal disease, urological sepsis and surgical wounds; the commonest organ dysfunctions are systemic shock, kidney, lung, and heart. The differential diagnosis of severe sepsis includes disseminated malignancy, atherosclerosis, and haemophagocytic syndrome. New treatments for severe sepsis are being trialled to raise the poor survival rates in intensive care. The role of the autopsy is to describe carefully the organ lesions, provide microbiological evidence of infection, and to correlate these with the clinical features and therapeutic variables.     

Occult thyroid pathology in the young adult: an autopsy study of 138 patients without clinical thyroid disease

Thyroid glands from autopsies on 138 adults, ages 20 to 40 years, with no known clinical or laboratory evidence of thyroid disease, were serially sectioned at 2 mm intervals and microscopically examined for occult thyroid disease and anatomic variations. Occult papillary carcinoma was found in 3% of the glands, along with a single case of medullary carcinoma. The prevalence of occult thyroid carcinoma in this group of young adults is significantly less than that reported in the literature in people over forty (P less than .001). The glands demonstrated a number of other morphologic changes of importance to surgical pathologists. The thyroid capsule was incomplete in 62% of the glands. Thyroid follicles were found in the capsule in 14% of cases and thyroid follicles or nodules were outside the gland in perithyroid connective tissue in 88% of cases. Thyroid follicles were identified in 7% of cases in perithyroid strap muscles attached to the pyramidal lobe. A number of other, less common anatomic variations were also seen.     

Virtual microscopy in systems pathology

Genomics and proteomics have evolved towards systems biology. The general goal here is the construction of complex, functional models of biological systems on the basis of molecular networks. Such models enable improved quality in interpretation and evaluation of quantitative measurements and afford a substantially deeper functional understanding. Systems pathology differs from systems biology by attaching the same importance to spatial modelling of tissue alterations as to gene regulatory modelling. In this way, systems pathology is able to deploy disease models for improved diagnosis, prognosis and therapy. In the present work a generic process for systems pathology is created, integrating gene regulatory and morphological models towards molecular disease models. For this purpose, fluorescent virtual microscopy will be essential as it delivers morphological and molecular tissue data with high spatial resolution and high throughput. Using epidermal differentiation as an example, it is shown how - using virtual microscopy - the spatiotemporal expression of biomarkers can be modelled by reconstructing protein networks from fluorescent tissue sections.     

The pathology of combined heart-lung transplantation: An autopsy study

Clinical heart-lung transplantation (HLT) began at Stanford University (Stanford, CA) in 1981, and since then, over 40 HLTs have been performed. There is now a worldwide total of 250 HLTs. While much of the pathology that occurs in patients receiving an HLT is similar to that which develops in patients with other transplanted organ systems, these patients also develop unique clinical complications and pathologic processes that deserve emphasis. We report the autopsy findings of 20 HLT recipients, of whom 12 died in hospital one day to 4 months post-HLT. A major contributing factor in five of these postoperative deaths was pleural hemorrhage from adhesions due to prior chest surgery. Overwhelming viral and fungal infections accounted for six deaths. The seventh patient died as a result of adult respiratory distress syndrome (ARDS). Two patients showed histologic evidence of the reimplantation response. Six long-term survivors died (mean survival, 22 months) with obliterative bronchiolitis (OB). In four patients, OB was the immediate cause of death, while one patient died of an intercurrent myocardial infarct, and the other patient died of complications from an appendectomy. Two long-term survivors died without OB, one of iatrogenic causes at 63 months and the second due to unexplained ARDS at 52 months. Both patients without OB had virtually normal underlying pulmonary parenchyma. All of the long-term survivors had either coronary arterial or pulmonary vascular intimal sclerosis, and renal lesions attributable to cyclosporine A toxicity. Although histologic features of mild acute pulmonary and cardiac rejection were observed in four patients overall, these did not contribute to the cause of death in any case. Although OB is a major threat to its success, HLT is a viable option for patients with endstage pulmonary disease.     

Improvements in education in pathology: Virtual 3D specimens

Virtual three-dimensional (3D) specimens correspond to 3D visualizations of real pathological specimens on a computer display. We describe a simple method for the digitalization of such specimens from high-quality digital images. The images were taken during a whole rotation of a specimen, and merged together into a JPEG2000 multi-document file. The files were made available in the internet (http://patho.med.uni-magdeburg.de/research.shtml) and obtained very positive ratings by medical students. Virtual 3D specimens expand the application of digital techniques in pathology, and will contribute significantly to the successful introduction of knowledge databases and electronic learning platforms.     

Virtual surgical pathology in underdeveloped countries: The Zambia Project

Only 1 surgical pathology laboratory is available in Zambia, a country with a population of 12 million people. Since 2004 the Italian association of pathologists Patologi Oltre Frontiera has been working to create a virtual laboratory through the use of telemedicine. The project has involved staining histologic preparations on site, with the interpretation of imaged slides performed abroad through telepathology. Starting in April 2007, all surgical specimens obtained in Mtendere Mission Hospital, Chirundu, Zambia, were submitted for microscopic examination through whole-slide scans. Two independent Italian pathologists evaluated the cases by means of satellite connection and the final diagnoses were sent to Zambian clinicians via the internet. This article describes the spectrum of diagnoses made via telepathology for the Zambian population. Also, we analyze the concordant and discordant data between this telepathology method and traditional microscopy in a developing country. Moreover, we provide possible solutions for providing pathology services in other underdeveloped countries.     

Quality assurance of autopsy face sheet reporting,final autopsy report turnaround time,and autopsy rates: a College of American Pathologists Q-Probes study of 10003 autopsies from 418 institutions

OBJECTIVE: To develop a multi-institutional reference database of autopsy practice and performance for quality improvement purposes. DESIGN: In 1990, participants in the Q-Probes quality improvement program of the College of American Pathologists (CAP) each retrospectively evaluated the 25 most recently completed consecutive autopsy reports and determined the number of deaths and autopsies that occurred in their institutions during 1989. SETTING: Hospital-based autopsies excluding forensic cases and stillborn infants. PARTICIPANTS: Four hundred ten institutions in the United States and eight institutions in Canada. MAIN OUTCOME MEASURES: Completeness of face sheet information contained in final autopsy reports, turnaround time for completion of final reports, and institutional autopsy rates. RESULTS: In the aggregate database of 10003 autopsies, the following six data items (from a total of 21) were present in 95% to 100% of the final autopsy reports in at least 85% of the participating institutions: institution where autopsy was performed, patient's name, patient's sex, autopsy number, autopsy date, and prosecter's name. The turnaround times for the final autopsy reports were as follows: 30 days or less in 47.6% of the cases, 31 to 60 days in 28.8%, and more than 60 days in 23.7%. A higher median percentage of autopsy final reports were completed in 30 days or less in institutions with the following characteristics: nonteaching (P < .004), no pathology residency program (P < .002), and rural location (P < .027). A lower number of autopsies performed in 1989 was associated with a higher median percentage of final reports completed in 30 days or less (P < .007). The aggregate autopsy rate for all participating institutions was 12.4%, and the median rate was 8.3%. Median autopsy rates for teaching institutions and institutions with pathology residency training programs were 15% and 19%, respectively. CONCLUSIONS: This multi-institutional study identified a core group of face sheet data items that were consistently present on final autopsy reports. However, the majority of the face sheet data items examined were inconsistently recorded. Approximately 75% of final autopsy report turnaround times were within the standard established by the Joint Commission on Accreditation of Healthcare Organizations. Nearly two thirds of the institutions reported autopsy rates for 1989 of 0% to 10%.     

Cone-beam volume CT breast imaging: feasibility study

X-ray projection mammography, using a film/screen combination, or digital techniques, has proven to be the most effective imaging modality currently available for early detection of breast cancer. However, the inherent superimposition of structures makes a small carcinoma (a few millimeters in size) difficult to detect when it is occult or in dense breasts, leading to a high false-positive biopsy rate. Cone-beam x-ray-projection-based volume imaging using flat panel detectors (FPDs) may allow obtaining three-dimensional breast images, resulting in more accurate diagnosis of structures and patterns of lesions while eliminating the hard compression of breasts. This article presents a novel cone-beam volume computed tomographic breast imaging (CBVCTBI) technique based on the above techniques. Through a variety of computer simulations, the key issues of the system and imaging techniques were addressed, including the x-ray imaging geometry and corresponding reconstruction algorithms, x-ray characteristics of breast tissue and lesions, x-ray setting techniques, the absorbed dose estimation, and the quantitative effect of x-ray scattering on image quality. The preliminary simulation results support the proposed CVBCTBI modality for breast imaging in respect to its feasibility and practicability. The absorbed dose level is comparable to that of current mammography and will not be a prominent problem for this imaging technique. Compared to conventional mammography, the proposed imaging technique with isotropic spatial resolution will potentially provide significantly better low-contrast detectability of breast tumors and more accurate location of breast lesions.