Emyr W. Benbow

Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study

Summary Background Public objection to autopsy has led to a search for minimally invasive alternatives. Imaging has potential, but its accuracy is unknown. We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in a large series of adult deaths. Methods This study was undertaken at two UK centres in Manchester and Oxford between April, 2006, and November, 2008. We used whole-body CT and MRI followed by full autopsy to investigate a series of adult deaths that were reported to the coroner. CT and MRI scans were reported independently, each by two radiologists who were masked to the autopsy findings. All four radiologists then produced a consensus report based on both techniques, recorded their confidence in cause of death, and identified whether autopsy was needed. Findings We assessed 182 unselected cases. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26–40) for CT, 43% (36–50) for MRI, and 30% (24–37) for the consensus radiology report; 10% (3–17) lower for CT than for MRI. Radiologists indicated that autopsy was not needed in 62 (34%; 95% CI 28–41) of 182 cases for CT reports, 76 (42%; 35–49) of 182 cases for MRI reports, and 88 (48%; 41–56) of 182 cases for consensus reports. Of these cases, the major discrepancy rate compared with autopsy was 16% (95% CI 9–27), 21% (13–32), and 16% (10–25), respectively, which is significantly lower (p<0·0001) than for cases with no definite cause of death. The most common imaging errors in identification of cause of death were ischaemic heart disease (n=27), pulmonary embolism (11), pneumonia (13), and intra-abdominal lesions (16). Interpretation We found that, compared with traditional autopsy, CT was a more accurate imaging technique than MRI for providing a cause of death. The error rate when radiologists provided a confident cause of death was similar to that for clinical death certificates, and could therefore be acceptable for medicolegal purposes. However, common causes of sudden death are frequently missed on CT and MRI, and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy. Funding Policy Research Programme, Department of Health, UK.

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review.

The autopsy is in decline, despite the fact that accurate mortality statistics remain essential for public health and health service planning. The falling autopsy rate combined with the Coroners Review and Human Tissue Act have contributed to this decline, and to a falling use of autopsy histology, with potential impact on clinical audit and mortality statistics. At a time when the need for reform and improvement in the death certification process is so prominent, we felt it important to assess the value of the autopsy and autopsy histology. We carried out a meta‐analysis of discrepancies between clinical and autopsy diagnoses and the contribution of autopsy histology. There has been little improvement in the overall rate of discrepancies between the 1960s and the present. At least a third of death certificates are likely to be incorrect and 50% of autopsies produce findings unsuspected before death. In addition, the cases which give rise to discrepancies cannot be identified prior to autopsy. Over 20% of clinically unexpected autopsy findings, including 5% of major findings, can be correctly diagnosed only by histological examination. Although the autopsy and particularly autopsy histology are being undermined, they are still the most accurate method of determining the cause of death and auditing accuracy of clinical diagnosis, diagnostic tests and death certification.

Accuracy of magnetic resonance imaging in determining cause of sudden death in adults: comparison with conventional autopsy.

Aim:  To determine the accuracy and define the limitations of post mortem magnetic resonance imaging (MRI) in determining the cause of sudden death in adults.

Familial hypercholesterolaemia commonly presents with achilles tenosynovitis

Background: Patients with heterozygous familial hypercholesterolaemia (HeFH) develop tendon xanthomata (TX), most commonly in their Achilles tendons. Even before tendons are chronically enlarged, tenosynovitis may occur and medical advice be sought. Untreated HeFH carries a high risk of premature coronary heart disease, which can be ameliorated by early diagnosis. Objective: To determine the prevalence of episodes of Achilles tendon pain in HeFH before its diagnosis. Methods: Patients with definite HeFH (Simon Broome criteria) attending a lipid clinic were identified. They completed a questionnaire asking about symptoms relating to their Achilles tendons. Unaffected spouses or cohabiting partners served as controls. Results: 133 patients (47% men) and 87 controls (51% men) participated. TX had been recognised by the referring physicians in <5% of cases. However, 62 (46.6% (95% confidence interval (CI) 38.1 to 55.1)) patients had experienced one or more episodes of pain in one or both Achilles tendons lasting >3 days, whereas only 6 (6.9% (1.6 to 12.2)) controls had done so (difference p<0.001; likelihood ratio 6.75). Typically, in the patients with HeFH the pain lasted 4 days (median). It was described as severe or very severe in 24/62 (38.7% (30.4 to 47.0)) patients with HeFH, but never more than moderate in controls. 35 (26.3% (18.8 to 33.8)) patients with HeFH had consulted a doctor about Achilles tendon pain, but in no case had this led to a diagnosis of HeFH. None of the controls had consulted a doctor. Conclusions: Measurement of serum cholesterol in patients presenting with painful Achilles tendon could lead to early diagnosis of HeFH.

Simultaneous xanthogranulomatous cholecystitis and primary adenocarcinoma of gallbladder

We describe the clinicopathological features of xanthogranulomatous cholecystitis and adenocarcinoma arising in the same gallbladder, a circumstance only briefly alluded to in the existing literature.

Mortality from pulmonary embolism is decreasing in hospital patients.

Objectives Pulmonary embolism is believed to be a common cause of death of hospital inpatients. The aims of this study were to estimate the number of deaths caused by pulmonary embolism and the potential to reduce this by the use of caval filters according to accepted indications. Design Review of autopsy reports and death notification records from 2007 and 2008. When pulmonary embolism was given as cause of death (in the autopsy report or in section 1 a-c or part 2 of the Medical Certificate of the Cause of Death), hospital records were reviewed for evidence of pre-mortem diagnosis of pulmonary embolism or deep vein thrombosis (DVT) and for evidence of accepted indications for caval filter placement. Setting Large UK teaching hospital. Participants Hospital inpatients whose deaths were attributed to pulmonary embolism. Main outcome measures Proportion of deaths adjudged at autopsy to be due to pulmonary embolism; evidence of pre-mortem diagnosis of DVT or pulmonary embolism; total number of hospital admission and deaths. Results From a total of 186,517 adult inpatient admissions there were 2583 (1.4%) adult inpatient deaths of which 696 (27%) underwent autopsy. Of those undergoing autopsy, 14 (2.0%, 95% CI 1.2–3.3%) deaths were caused by pulmonary embolism. Pulmonary embolism was recorded as a cause of death in a further 12 (0.7%) of 1773 patients who did not undergo autopsy. Of these, five had a pre-mortem diagnosis of DVT or pulmonary embolism. Conclusions The proportion of deaths caused by pulmonary embolism appears to be considerably lower than the widely published rate, and of this small number, few have a pre-mortem diagnosis of DVT or pulmonary embolism. There is little scope for further reduction of pulmonary embolism mortality through use of caval filters according to guidelines. Current policy on pulmonary embolism risk prevention appears to be based on an over-estimate of the level of risk.

Human salivary gland glycoconjugates: a lectin histochemical study

SummaryThe glycoconjugate content of normal salivary glands has been extensively investigated in humans by biochemical means and in non-human mammals by histochemical methods. However, there have been few histochemical studies of human tissues. This paper describes the findings obtained in parotid, submandibular and minor salivary glands by applying a panel of 13 biotinylated lectins, directed against a range ofn-linked, fucosylated and galactosylated sequences, using an avidin-peroxidase technique, with appropriate enzymatic and inhibitory sugar controls. The results were generally in accord with those observed in biochemical assays but the use of lectin histochemistry permitted the localizationin situ of small amounts of oligosaccharide and, therefore, allowed the recognition of subtle tissue differences. This study expands the current knowledge on the glycoconjugate composition of salivary glands and their lectin histochemistry and serves as a baseline for further studies, particularly in the field of neoplasia.

Viral Detection in Hydrops Fetalis, Spontaneous Abortion, and Unexplained Fetal Death In Utero

This study was undertaken to investigate the occurrence of viral infection in fetal death by examining tissues for the presence of DNA of several viral agents. Tissue specimens including heart, kidney, liver, lung, and placenta of 73 cases of fetal death were examined with 27 cases of elective termination of pregnancy as a control group. DNA extracted from these samples was tested for the presence of HSV, CMV, EBV, VZV, HHV‐6, HHV‐7, and PVB19. Viral DNA was found in one or more tissue samples from 25/73 cases (34%): CMV in 20, HSV in 5, parvovirus B19 in 5, HHV‐7 in 3, and HHV‐6 in 2. The presence of HHV‐6 in fetal tissue has been reported rarely. No study so far has reported the detection of HHV‐7 in fetal tissues with normal or adverse outcomes. Viral DNA was not found in any of the termination of pregnancy samples. Among the positive cases, eight had dual infection. One further case was positive for three viruses: HSV, CMV, and HHV‐7. HHV‐6 was the sole infectious agent in two cases, HHV‐7 in one case, PVB19 in three, and CMV in ten cases. The finding of multiple viral DNA in 12% of the cases suggests the involvement of complex risk factors in cases of fetal loss. Although the cause of fetal death often includes other factors (e.g., chromosomal abnormalities) these data suggest the incidence of viral infective etiology may be higher than considered previously. However, larger studies are required to establish this link. J. Med. Virol. 83:679–684, 2011.

The autopsy: complete or not complete?

Less invasive or non‐invasive alternatives to the complete autopsy have been sought for some time, and a range of methods, ranging from needle sampling to endoscopy to magnetic resonance imaging, have been considered. Evaluations of these methods are few and far between, but generally confirm the predictable conclusion that incomplete autopsies provide incomplete information. It is not difficult to envisage a situation whereby pressure for non‐invasive autopsies will allow them to become prevalent, whether properly evaluated or not. However, used appropriately, non‐invasive or less invasive autopsies may be valuable tools capable of answering specific questions in situations where it is not possible to perform a complete autopsy.

Pyoderma gangrenosum in a thoracotomy wound associated with a pulmonary cavitating lesion

Summary We present a patient with both pyoderma gangrenosum in a thoracotomy wound and a pulmonary cavitating lesion with the histological features of Wegeners granulomatosis. An ulcer with blue undermined edges developed in our patients thoracotomy scar after a lobectomy was carried out for the cavitating lung lesion and c Antineutrophil Cytoplasmic Antibodies (cANCA), which is highly specific for active Wegeners granulomatosis but was negative at the time of her skin lesion. This suggests that our patient had cutaneous pyoderma gangrenosum rather than cutaneous Wegeners granulomatosis, although the two conditions may occasionally have similar clinical and histological features.