心性猝死—4例主动脉瘤破裂的法医病理学鉴定

目的:探讨主动脉瘤破裂猝死的发病特点和病理学基础,为临床医师提供帮助。方法:对本系2002年12月至2006年l2月期间,所作450例法医病理检案的4例主动脉瘤破裂猝死案例进行分析研究。结果:4例主动脉瘤破裂致死占尸体解剖总数的0.89%,占SCD的4.1%,其中,DAA3例;2例DAA与AS有关。结论:主动脉瘤破裂病程短骤、凶险,是心性猝死的病因之一,早期症状与冠心病酷似,且病死率极高,因此应引起临床医师的高度重视,提高诊治水平。     

The four horsemen: clinicopathological correlation in 407 hospital autopsies

Background: Few previous papers comparing clinical diagnoses with autopsy findings present sensitivities and positive predictive values for individual conditions. The aim of this study is to determine the sensitivity and positive predictive value of current clinical diagnosis both overall and for individual conditions. Methods: Retrospective review of hospital records of a consecutive series of patients undergoing hospital autopsy at two metropolitan teaching hospitals over a 7‐year period (407 patients). Comparison was made with autopsy reports to allocate one of three outcome measures (true‐positive, false‐positive, false‐negative) to each condition. Results: The overall sensitivity and positive predictive value of clinical diagnosis were 0.74 and 0.93 respectively. Pneumonia, acute myocardial infarction, bowel ischaemia and pulmonary embolism were each present in greater than 10% of patients and had sensitivities below 0.70 and positive predictive values below 0.90. Conclusion: There exists a large burden of clinically undiagnosed and incorrectly diagnosed disease in hospital. Pneumonia, acute myocardial infarction, bowel ischaemia and pulmonary embolism represent important and difficult diagnostic challenges.     

Youth suicide: A psychological autopsy study of completers and controls

The objective of this study was to investigate risk factors that could help to differentiate between 14–25-year-old suicide attempters who survive the attempt and those who do not. Using a case–control psychological autopsy method, 29 cases (completers) and 23 controls (survivors) matched for age and sex were included. Survivors, parents and a close friend participated independently in semistructured interviews. Kiddie-Schedule for Affective Disorders and Schizophrenia Lifetime, stress scales, medical records and a sociodemographic inventory were used to reach a consensus best estimate DSM-IV five-axis diagnosis for each subject. A conditional logistic regression was used with the PHREG procedure in SAS to investigate the relationship between the binary outcome (survival/death) and the set of putative risk factors. No significant Axis I diagnostic differences were found between groups. Based on odds ratios, school suspension and irritability provide the best predictive factors for survival. Together with an Axis II cluster C diagnosis (avoidant, dependent and obsessive-compulsive personality disorder), high Global Assessment of Functioning scale, reactivity of depressed mood and level of obsessions were associated significantly with suicide completers. Cases appear to show more of an ‘internalizer’ profile, compared to controls who were more of the ‘externalizer’ profile. Dissatisfaction with physical appearance, rejection from others and feelings of isolation were highly prevalent in all subjects. Seventy-two per cent of cases died on their first attempt. The vast majority of subjects sought general medical care in the months preceding the suicidal behaviour. A mental health professional was consulted within the previous year by a greater proportion of controls, compared with cases. Our research emphasizes that the combination of psychopathology (diagnosed or not) and previous high level of functioning (in individuals who internalize their conflicts) represents an at-risk group for youth completing suicide. These findings underscore the importance of mental health evaluation as part of the general medical care assessment.     

The cause of death in patients with glioblastoma is multifactorial:

To delineate the causes of death (COD) in adults with supratentorial glioblastoma multiforme (GM) we reviewed 117 consecutive cases examined at autopsy over a nineteen year period at the University of Washington. Twenty cases (17%) had expired unexpectedly without ante mortem diagnosis, 5 patients (4%) had been diagnosed as having lower grade astrocytomas prior to death. Other than the 20 patients without ante mortem diagnosis, all patients had a surgical procedure for treatment and/or diagnosis (biopsy 10%, craniotomy 90%). Postsurgical therapy varied, but there was no significant difference in median length of survival among the different treatment groups. Factors considered as potential COD were: herniation (axial, transtentorial, subfalcine, tonsillar), surgical complications (death within thirty days of surgery secondary to cerebral hemorrhage and/or edema), severe systemic illness, brainstem invasion by tumor, and neutron-induced cerebral injury (cerebral and brainstem gliosis were evident in these cases). A potential COD could be identified in 93% of patients. Patients with no ante mortem diagnosis were likely to have herniated (p = 0.01), whereas patients who underwent neutron irradiation were unlikely to have herniated (p = 0.001). No other variables were statistically significant predictors of herniation, including multifocal tumors (20 patients), and brainstem invasion by tumor (18 patients). No patients died as a result of treatment except those who underwent neutron radiotherapy and those who died postoperatively. Although significant mass effect, as evidenced by herniation, was apparent in 61% of patients, most of these patients had an additional identifiable COD. We conclude that the COD in patients with GM varies and is often multifactorial.     

Autopsy Findings and Syndromic Diagnoses: Bayesian Calculations for Pediatric Pathologists

Application of a standard statistical method knoiun as a Bayesian calculation to the findings in pediatric anatomic pathology may help the pediatric pathologist to recognize and express the likelihood of syndromic diagnoses. This assessment can be useful in counseling and deciding which (if any) confirmatory tests are ivarranted. An example shows the method and its utility.     

Demonstration of Respiratory Syncytial Virus in an Autopsy Series

Respiratory syncytial virus (RSV) antigen was demonstrated in formalin-fixed, paraffin-embedded autopsy tissue using an immunoperoxidase technique. Eighteen autopsy cases were selected on the basis of one of the following criteria: a positive culture for RSV, antemortem or postmortem; positive ELISA test for RSV, antemortem or postmortem; or postmortem histology suggestive of paramyxovirus infection. Controls included three cases from which parainfluenza or influenza virus had been cultured and a case in which the clinical diagnosis of measles was firmly established. Sections of formalin-fixed, paraffin-embedded tissue were stained with a rabbit anti-RSV antibody (Dako) using an immunoperoxidase technique. Staining was achieved in 12 cases. This included 6 of 7 cases selected because of positive cultures or ELISA tests for RSV. The other 6 cases in which RSV was identified by the described technique lacked culture or ELISA confirmation. Granular and globular staining was seen in the cytoplasm of respiratory epithelial cells and syncytial giant cells. None of the control cases stained for RSV. The histology of RSV lungs was consistent with changes described in the literature for RSV infection, although pneumonic consolidation and syncytial giant cells were more prominent in this series.     

Liquid Chromatography-tandem Mass Spectrometry for Analysis of Acylcarnitines in Dried Blood Specimens Collected at Autopsy from Neonatal Intensive Care Unit

Objective To investigate the feasibility of analyzing acylcarnitine in dry filter-paper blood spots by liquid chromatography-tandem mass spectrometry（LC-MS/MS） which could be applied to detect inborn errors of metabolism in neonates.Methods We obtained filter-paper blood from 26 dead infants from a neonatal intensive care unit（NICU） between October 1,2008 and September 30,2009.Acylcarnitine and amino acid profiles were obtained with LC-MS/MS.Four infants underwent routine autopsy.The postmortem blood specimens were compared with newborn blood specimens,and with specimens obtained from older infants with metabolic disorders.Results Of all the 26 patients,5（19.2%） were diagnosed as having different kinds of diseases：3 with methylmalonic acidemia（the concentration of C3,and the ratio of C3/C16,C3/C2 increased）,1 with maple syrup urine disease（the concentration of leucine and isoleucine increased）,and 1 with isovaleric aci-demia（the concentration of C5 increased）.Conclusions Postmortem metabolic test can explain infant deaths and provide estimates of deaths attributable to inborn errors of metabolism in NICU.LC-MS/MS is suitable for analysis of postmortem specimens and can be considered for routine application in NICU autopsy.     

Autopsy in critical illness: is it obsolete?

The autopsy continues to have important implications for patient management in critical illness. It is not obsolete. Autopsy data help us to track shifts in disease prevalence over time and to heighten surveillance for serious diagnoses that are commonly missed. These data help us to identify important contributors to death that may be remediated through quality assurance and control programs. In discrete patient subsets, information from autopsies may reinforce the degree of certainty surrounding end-of-life decision-making.     

58例医疗纠纷尸体解剖病理学分析

目的:探讨涉及医疗纠纷病人死亡的原因,分析死亡所发生的病理学特点。方法:对58例不明死因的尸体进行系统解剖与组织病理学检验,部分做法医学毒物分析。结果:在58例尸检中,病理性死亡52例,心血管系统疾病最多,其次为呼吸系统疾病;机械性外力导致死亡4例。猝死42例。结论:科学的尸体解剖,准确的死因分析,不但为医疗事故的鉴别、判定及医疗事故的处理提供医学依据,而且丰富和发展了相关临床学科的内容。