Mortality in acute peritonitis as revealed by postmortem examination findings

Acute peritonitis has been found present on 512 out of 4303 serial postmortem examinations performed over the past 10 years in the city of Izhevsk, giving the overall rate of 11.9%, but the rates were higher in older age groups. The conditions more commonly complicated by peritonitis were inflammatory and neoplastic diseases of abdominal organs. In 47% of the cases, peritonitis developed postoperatively, predominantly as a result of incompetence of anastomotic suture lines. In 26.9% of the cases, the peritonitis was not recognized during the patient's life, and in a majority of these it was in an early phase of development. The nature and extent of peritonitis varied both with the bodily reactivity and with the site and duration of the peritonitis itself. The peritoneal inflammations arising in inflammatory destructive conditions were generally of short duration and serous or serofibrous in type, whereas those of neoplastic or other origins were longer-lasting and displayed a purulent exudate. In cases where the peritonitis was in an early phase, the immediate causes were more diverse and included, in addition to intoxication (detailed mechanisms of which remain undisclosed), shock, thromboembolism, hepatorenal or cardiovascular failure, sepsis, and hemorrhage.     

Unexpected autopsy findings arising from postmortem ocular examination

BACKGROUND: A full autopsy at our institution includes removal of the eyes for pathologic examination. To our knowledge, the rate of ophthalmic findings at autopsy has not been documented previously. DESIGN: We retrospectively reviewed 277 consecutive autopsies conducted between 1995 and 1999 in which the eyes were removed for examination. Ophthalmic findings were placed in the following categories: I, major findings included those that contributed to the patient's death, would have changed patient management, and/or may have important medical implications for close relatives; II, expected findings after ophthalmologic surgery and minor findings that may have eventually required treatment; and III, incidental findings. RESULTS: Major findings (category I) were found in 32% of autopsies. Minor findings (category II) and incidental findings (category III) were documented in 62% and 34% of autopsies, respectively. Only 14% of autopsies revealed no ophthalmologic diagnoses. CONCLUSION: In our series, postmortem ocular examination revealed a number of important findings, including several heritable and rare conditions. Eighty-six percent of autopsies disclosed at least one pathologic ophthalmologic finding, approximately one third of which demonstrated findings significant enough to have likely required management. Diabetic retinopathy was the most frequent major finding. Malignant melanoma of the choroid was the most commonly found intraocular neoplasm. Chronic uveitis was the most common minor finding. We conclude that important, often unexpected ophthalmic findings are frequently encountered at autopsy, underscoring the relevance of routine postmortem examination of the eyes.     

Defining clinically significant prostate cancer on the basis of pathological findings

The definition of clinically significant prostate cancer is a dynamic process that was initiated many decades ago, when there was already evidence that a great proportion of patients with prostate cancer diagnosed at autopsy never had any clinical symptoms. Autopsy studies led to examinations of radical prostatectomy (RP) specimens and the establishment of the definition of significant cancer at RP: tumour volume of 0.5 cm³, Gleason grade 6 [Grade Group (GrG) 1], and organ‐confined disease. RP studies were then used to develop prediction models for significant cancer by the use of needle biopsies. The first such model was used to delineate the first active surveillance (AS) criteria, known as the ‘Epstein’ criteria, in which patients with a cancer Gleason score of 3 + 3 = 6 (GrG1) involving fewer than two cores, and <50% of any given core, and a prostate‐specific antigen density of <0.15 ng/ml per cm³ had a minimal risk of significant cancer at RP. These were adopted as components of the ‘very‐low‐risk category’ of the National Comprehensive Cancer Network guidelines, in which AS is supported as a management option. With the increase in the popularity of AS, much research has been carried out to better define significant/insignificant cancer, in order to be able to safely offer AS to a larger proportion of patients without the risk of undertreatment. Research has focused on allowing higher volume tumours, focal extraprostatic extension, and a limited amount of Gleason pattern 4, and the significance of different morphological patterns of Gleason 4. Other areas of research that will probably impact on the field but that are not covered in this review include the molecular classification of tumours and imaging techniques.     

Managing clinically significant findings in research: the UK10K example

Recent advances in sequencing technology allow data on the human genome to be generated more quickly and in greater detail than ever before. Such detail includes findings that may be of significance to the health of the research participant involved. Although research studies generally do not feed back information on clinically significant findings (CSFs) to participants, this stance is increasingly being questioned. There may be difficulties and risks in feeding clinically significant information back to research participants, however, the UK10K consortium sought to address these by creating a detailed management pathway. This was not intended to create any obligation upon the researchers to feed back any CSFs they discovered. Instead, it provides a mechanism to ensure that any such findings can be passed on to the participant where appropriate. This paper describes this mechanism and the specific criteria, which must be fulfilled in order for a finding and participant to qualify for feedback. This mechanism could be used by future research consortia, and may also assist in the development of sound principles for dealing with CSFs.     

Cultivation of clinically significant hemoflagellates

The hemoflagellates, Trypanosoma spp. and Leishmania spp., are causal agents of a number of parasitic diseases having a major impact on humans and domestic animals over vast areas of the globe. Among the diseases are some of the most pernicious and deadly of human afflictions: African sleeping sickness, Chagas' disease, kala-azar, and Oriental sore. The organisms have complex, pleomorphic life cycles typically involving a vertebrate and an invertebrate host, the latter serving as a vector. In the vertebrate host, they are primarily blood and tissue parasites. In their transition from one host to another, the hemoflagellates undergo morphological, physiological, and biochemical changes that facilitate their growth and subsequent transmission. A major goal in the study of the hemoflagellates has been the cultivation in vitro of both vertebrate and invertebrate stages of the organisms. The first types of media used in their cultivation, and still useful for establishment of cultures, were undefined and contained a complex of ingredients. These gave way to semidefined formulations which included tissue culture media as a base and, as a next step, addition of tissue culture cells as a feeder layer to promote parasite growth. More recently developed media are completely defined, having replaced the feeder cells with various supplements. Serum, a sometimes-variable component of the media, can be replaced by various serum substitutes. This review focuses on the hemoflagellates that infect humans, describing stages in the development of media leading to the fully defined formulations that are now available for the cultivation of many of these organisms.     

Characterization of clinically significant strains of coagulase-negative staphylococci

On occasion, a patient may have two or more clinical cultures yielding a coagulase-negative staphylococcus If these multiple isolates have the same phenotype, one might conclude that the same strain was reisolated from the patient, indicating its persistent and pathological presence. We examined the validity of this conclusion when we applied a number of characterizing systems to a collection of 143 isolates of coagulase-negative staphylococci collected during an outbreak of intravascular catheter-associated sepsis. The probability of classifying two random isolates as the same phenotype or species was as follows: P = 0.356 for phage typing, P = 0.348 for Baird-Parker biotyping, P = 0.346 for the API STAPH-IDENT (Analytab Products) system, P = 0.327 for Bentley et al. biotyping, and P = 0.077 for antimicrobial susceptibility patterns. Although antimicrobial susceptibility patterns had the lowest probability, a variability in test results of 7.7% and a tendency for strains to have similar antibiograms effectively raised the probability to P = 0.897. The combination of the API STAPH-IDENT with antibiograms resulted in a probability of P = 0.037 to P = 0.147. When all of the above methods were used together a probability of P = 0.014 was achieved. Five patients had isolates from two or more blood cultures spaced more than 1 day apart that were identical by all of the above criteria, thus confirming prolonged bacteremia. The collection was also examined for the incidence of slime production. Slime production was not associated with any of the above groups, but was associated with symptomatic infections (P less than 0.05) and gentamicin resistance (P less than 0.01). Slime production was strain stable and was of assistance in typing strains of coagulase-negative staphylococci.     

Identification of clinically significant Mycobacterium fortuitum complex isolates

Recent outbreaks of nosocomial infections caused by organisms identified as the Mycobacterium fortuitum complex suggest that species and subspecies identification is epidemiologically important. In a study of 170 strains, M. fortuitum was differentiated from M. chelonei by nitrate reduction and iron uptake. M. fortuitum was further divided into biovariant fortuitum, biovar peregrinum, and an unnamed third biovar by inositol and mannitol utilization. M. chelonei was further divided into subsp. chelonei, subsp. abscessus, and an unnamed subspecies by tolerance to 5% sodium chloride, utilization of mannitol and sodium citrate, and uptake of iron.     

Utilization of the postmortem examination with emphasis on audiovisual aids

With the present trend in decreased requests for autopsies to be performed, the method of plastination and videotaping coupled with more traditional teaching methods provides a way to expand the information and knowledge that may be obtained from each autopsy in an academic medical center. Plastinated specimens and videotapes can be retained on a permanent basis to be used over and over, with nearly the same impact as the original autopsy.     

Laboratory aspects of clinically significant rapidly growing mycobacteria

The pathogenic potential of the rapidly growing mycobacteria (RGM) has started being recognized. This is due to more sensitive and specific techniques in the laboratory. The RGM are generally defined as nontuberculous species of mycobacteria that show visible growth on agar media within 7 days. RGM are widely distributed in nature and have been isolated from natural water, tap water, and soil. Several biochemical tests, high performance liquid chromatography, and molecular techniques have been developed for rapid identification of these species. The American Thoracic Society and the Infectious Disease Society of America recommend that RGM should be identified to the species level using a recognized acceptable methodology such as polymerase chain reaction restriction enzyme analysis or biochemical testing and routine susceptibility testing of RGM should include amikacin, imipenem, doxycycline, the fluorinated quinolones, a sulphonamide or trimethoprim-sulphamethoxazole, cefoxitin, clarithromycin, linezolid, and tobramycin. The diseases caused by these organisms have varied manifestations. They have been responsible for a number of healthcare-associated outbreaks and pseudo-outbreaks. For recognition of outbreaks, it is important to be familiar with the causative organisms like RGM which are most frequently involved in healthcare-associated outbreaks and pseudo outbreaks. It is essential to intervene as soon as possible to interrupt this transmission. Large gaps still exist in our knowledge of RGM. Unquestionably more studies are required. Through this review, we wish to emphasize that reporting of RGM from clinical settings along with their sensitivity patterns is an absolute need of the hour.     

Incidental detection of filaria in fine-needle aspirates: a cytologic study of 14 clinically unsuspected cases at different sites

Filariasis is a major health problem in tropical countries like India. Detection of microfilariae or adult worm or egg in FNAC is very unusual despite the high incidence of this parasite in endemic zone. The aim of this study was to document the value of fine-needle aspiration cytology (FNAC) in diagnosis of filaria at all possible sites presenting as mass or swelling. Fourteen patients (nine males and five females) in the age range of 14-61 years were subjected to FNAC. FNA from swellings was done using 22-gauge needles fitted with 10 or 20 ml disposable plastic syringes. The slides were stained with May-Grunwald-Giemsa stain, Haematoxylin and Eosin (H&E) stain, and Papanicolaou (Pap) stain. In total, 14 cases of filariasis were detected, which included subcutaneous swellings (six cases), epididymis/spermatic cord nodules (four cases), breast lumps (two cases), lymph nodes (one case), and thyroid swelling (one case). Larvae (microfilariae), eggs, and adult worms were detected in cytological smears. Microfilaria was present in all 14 cases whereas adult worm was found in three cases only. In four cases, eggs were seen in the smears. None of the patients was microfilariaemic and significant eosinophilia (>10%) was seen seen in two patients. Filarisis should be considered as one of the differential diagnosis of swelling in endemic area. Identification of the parasite, Wuchereria bancrofti, in FNA smears and accurate diagnosis of filaria is important to employ proper treatment. Early diagnosis and treatment prevents the more severe manifestation of the disease, lymphatic filariasis.     

A study of coagulase-negative staphylococci isolated from clinically significant infections at an Australian teaching hospital

Some 151 isolates of coagulase-negative staphylococci isolated from patients at an Australian teaching hospital were characterized by biochemical analysis, antibiotic sensitivity patterns and slime production. S. epidermidis was the predominant species (64%) isolated from clinically significant infections, and all S. epidermidis isolates from true bacteremias produced slime. Forty-nine per cent were resistant to methicillin and 61% to gentamicin. S. haemolyticus isolates from clinically significant infections also showed antibiotic resistance and 80% were resistant to more than five antibiotics. The importance of coagulase-negative staphylococci as pathogens in this large teaching hospital was confirmed.     

Knowledge and attitude of medical students in Delhi on postmortem examination

A survey proforma with multiple choice questionnaire was designed and asked to be filled in by two hundred medical students belonging to 3rd and 4th year of MBBS curriculum of a University medical college in Delhi. One hundred thirty-three (66.5) students responded. A large majority of 129 (96.9%) students were aware of the major use of the postmortem examination/autopsy. All students have the knowledge that postmortem involves examination of a body in detail both externally and internally. Sixty-four (48.1%) feel that it does not cause disfigurement of the body. One hundred fifteen (86.4%) students were the view that they possess satisfactory level of knowledge on postmortems. The main source of knowledge and information on the subject is teaching during medical curriculum as informed by 76 (57.1%) students. More than 50% were willing ti permit autopsy on the self/relative. While, only 7 (5.3% students showed reluctance to watch autopsy.     

Characterization of two unusual clinically significant Francisella strains.

We have isolated two phenotypically distinct nonfastidious Francisella strains (Fx1 and Fx2) from the blood of compromised patients with pneumonia and compared them with eight other Francisella strains, including Francisella tularensis biovar tularensis, F. tularensis biovar novicida, and F. philomiragia. Our isolates grew well on sheep blood agar, chocolate agar, modified Thayer-Martin agar, and Trypticase soy agar. Fx1 and Fx2 were determined to be within the Francisella genus by cellular fatty acid analysis and by the utilization of glucose, production of H2S and catalase, and lack of motility, oxidase, nitrate reductase, and gelatinase. They were additionally shown to belong to the species F. tularensis by sequencing of two variable regions comprising approximately 500 nucleotides of the 16S rRNA gene. Also, RNA probe hybridization confirmed their belonging to the species F. tularensis. However, the new strains, which are not identical, are distinguished from other F. tularensis strains by growth characteristics, repetitive extragenic palindromic PCR fragment pattern, and some biochemical tests. Key biochemical differences included the findings that Fx1 was positive for beta-galactosidase and arabinose hydrolysis and that both strains were citrulline ureidase positive and glycerol negative. Commercial F. tularensis antiserum agglutinated stock F. tularensis strains but not Fx1, Fx2, F. tularensis biovar novicida, or F. philomiragia; serum from either patient failed to agglutinate or only weakly agglutinated commercial antigen but showed agglutination when tested against each patient's respective isolate. Fx1 and Fx2 produced beta-lactamase. Because of their good growth, negative serology, and biochemical profile, the organisms could be misidentified in the clinical laboratory if standard strategies or commercial identification systems are used.     

Development of targeted indicators of quality in postmortem examination

The indicators of quality for impartial quantitative assessment of postmortem examination have been suggested. These indicators were based on ratio of achievement and target indexes of pathologicoanatomic activity. The indicators are necessary for decision making for enhancement of pathologicoanatomic service quality in the health-care agencies.     

An autopsy case of misdiagnosis based on postmortem computed tomography findings

A middle-aged man was found lying beside his bicycle on an early winter morning. The cause of death was diagnosed by clinicians as traumatic intracerebral hemorrhage and cerebral contusion with frontal bone fracture based on the findings of Computed Tomography (CT) of the head. However, forensic autopsy revealed that there were no evidences of intracerebral hemorrhage and left frontal bone fracture but the defect of golf ball size on the frontal lobe which was considered to be a complication from the old cerebral contusion and old bone fracture. The bleeding and pooling blood from subarachnoid hemorrhage (SAH) to the frontal lobe defect had the appearance of an intracerebral hemorrhage. Disruption of left renal artery was found and the cause of death was diagnosed as massive hemorrhage due to this rupture. Although postmortem CT is a useful tool for obtaining information on the body prior to conducting an autopsy, it should be used with extreme caution.