Nicholas J. Hardin

Death certification errors at an academic institution.

CONTEXT The correctly completed death certificate provides invaluable personal, epidemiologic, and legal information and should be thorough and accurate. Death certification errors are common and range from minor to severe. OBJECTIVE To determine the frequency and type of errors by nonpathologist physicians at a university-affiliated medical center. DESIGN Fifty random patients were identified who died at this academic medical center between January 2002 and December 2003 and did not undergo an autopsy. From medical chart review, clinical summaries were produced. Two pathologists used these summaries to create mock death certificates. The original and mock death certificates were then compared to identify errors in the original certificate. Errors were graded on a I to IV scale, with grade IV being the most severe. RESULTS Of the 50 death certificates reviewed, grade I, II, and III errors were noted in 72%, 32%, and 30%, respectively. Seventeen certificates (34%) had grade IV errors (wrong cause or manner of death). Multiple errors were identified in 82% of the death certificates reviewed. CONCLUSIONS The rate of major (grade IV) death certification errors at this academic setting is high and is consistent with major error rates reported by other academic institutions. We attribute errors to house staff inexperience, fatigue, time constraints, unfamiliarity with the deceased, and perceived lack of importance of the death certificate. To counter these factors, we recommend a multifaceted approach, including an annual course in death certification and discussion of the death certificate for each deceased patient during physician rounds. These measures should result in increased accuracy of this important document.

Angiogenesis as a Prognostic Marker in Early Head and Neck Cancer

Experimental evidence suggests that tumor growth beyond the earliest stages is dependent on angiogenesis, or neovascularization, and that angiogenesis may also promote metastasis. Recent clinical studies demonstrate that angiogenesis is a prognostic marker in breast, lung, and prostate cancer. To investigate whether tumor angiogenesis also correlates with metastasis and survival in early head and neck carcinoma, we quantified the microvascularity of 106 primary carcinomas prior to treatment and correlated the counts with eventual outcome after 3 to 15 years of follow-up. Microvessels were stained immunocytochemically for von Willebrand factor and then counted by light microscopy. Microvessels were counted per 200x and 400x fields, and their density was graded from 1 to 4, in the area of most intense neovascularization. We found that neither microvessel counts nor density grades correlated with metastatic disease, local recurrence, or survival in early head and neck carcinoma. These results are in contradistinction to those recently reported for other tumor sites.

The nasogastric tube syndrome

The nasogastric tube can produce sudden, life‐threatening bilateral vocal cord paralysis and is often an unrecognized cause of this clinical entity. The pathophysiologic mechanism is thought to be paresis of the posterior cri‐coarytenoid muscles secondary to ulceration and infection over the posterior lamina of the cricoid. Since our initial report of this entity in 1981, several cases have been photo‐documented. Study of whole organ sections of an involved larynx have demonstrated the histopathology. Diabetic renal transplant patients appear to be particularly susceptible to the condition, due to prolonged gastroparesis and requirement for nasogastric tube drainage. Esophagoscopy should be performed promptly in these patients when pha‐ryngodynia, hoarseness, or evolving stridor present in the postoperative period.

Parathyroid Cysts: Diagnosis and Management

INTRODUCTION Parathyroid cysts are uncommon lesions of the neck and superior mediastinum, rarely large enough to be of clinical significance. In 1880, Sandstrom reported the first parathyroid cyst. In 1905, Goris performed the first operative procedure to remove a parathyroid cyst. Two cases of parathyroid cysts treated at Fletcher Allen Health Care (FAHC)/ University of Vermont are reported here. In both cases, preoperative diagnosis was made by using fine needle aspiration with parathyroid hormone assay of the fluid sample.

Fatal Hemorrhage Caused by Varicose Veins

Varicose veins are a common, worldwide medical problem, but are generally considered non-life-threatening. We report three cases of fatal hemorrhage resulting from varicose veins and review the literature. The pathology of acute perforations onto the skin surface in varicose venous disease is described.

Autopsy Analysis of the Implantation Site of a Permanent Selective Direct His Bundle Pacing Lead

To date, there has not been direct visualization of the anatomic location of direct His bundle pacing (DHBP) leads in the human heart. The absence of such data has contributed to disagreement about the location of DHBP leads with respect to the plane of the tricuspid valve.1,2 We present an autopsy study of a patient who had previously had a DHBP lead implanted, showing unequivocally that the lead is implanted on the atrial side of the tricuspid annulus. An 81-year-old man with diabetes died of sepsis secondary to a lower-extremity infection. Two years prior, the patient presented with symptoms of congestive heart failure and presyncope. He had a history of coronary artery bypass graft and myocardial infarction with mild to moderate left ventricular dysfunction (ejection fraction, 40%–45%). β-blockade therapy was limited by sinus bradycardia and frequent Wenckebach block. The patient was noninducible for ventricular arrhythmias, and a pacemaker was recommended for chronotropic incompetence and AV block. To prevent pacemaker-induced electric dyssynchrony, we implanted a DHBP lead. DHBP lead implantation was performed as previously described.3 Briefly, an octapolar mapping catheter was used to map the His bundle. A pacing lead was actively fixed adjacent to bipolar electrodes recording a His potential (SelectSecure lead, model 3830, delivered …

Sudden Unexpected Death Due to Asymptomatic Cardiac Rhabdomyoma

A case of cardiac rhabdomyoma producing sudden unexpected death in an asymptomatic six-year-old boy is reported. Cardiac rhabdomyoma is a rare tumor, and its ability to cause sudden unexpected death in children beyond infancy is not generally known. The great majority of afflicted patients die in the early infancy; few survive beyond five years of age. The signs and symptoms present in most cases are said to be due to interference of interaction blood flow or to interruption of the cardiac conduction system. Numerous cases have been clinically misdiagnosed because of this tumors ability to mimic other cardiac disease.

Reduced Immune Response to Borrelia burgdorferi in the Absence of γδ T Cells

ABSTRACT Little is known regarding the function of γδ T cells, although they accumulate at sites of inflammation in infections and autoimmune disorders. We previously observed that γδ T cells in vitro are activated by Borrelia burgdorferi in a TLR2-dependent manner. We now observe that the activated γδ T cells can in turn stimulate dendritic cells in vitro to produce cytokines and chemokines that are important for the adaptive immune response. This suggested that in vivo γδ T cells may assist in activating the adaptive immune response. We examined this possibility in vivo and observed that γδ T cells are activated and expand in number during Borrelia infection, and this was reduced in the absence of TLR2. Furthermore, in the absence of γδ T cells, there was a significantly blunted response of adaptive immunity, as reflected in reduced expansion of T and B cells and reduced serum levels of anti-Borrelia antibodies, cytokines, and chemokines. This paralleled a greater Borrelia burden in γδ-deficient mice as well as more cardiac inflammation. These findings are consistent with a model of γδ T cells functioning to promote the adaptive immune response during infection.

Can Ki-67 Predict Recurrence of N0 Squamous Cell Carcinoma of the Tongue?

Objectives: Ki-67 is a molecular marker of cellular proliferation that predicts prognosis of some head and neck tumors. Studies of Ki-67 in oropharyngeal cancer have yielded conflicting findings. This study was designed to test Ki-67 as a marker for poor prognosis in N0 tongue squamous cell carcinoma. Methods: We examined 29 cases in a retrospective cohort to test the hypothesis that a high rate of tumor cell proliferation (high levels of Ki-67 staining) at the invasive edge of N0 squamous cell carcinoma of the tongue correlates with increased risk of recurrence. Results: There were 14 cases of recurrence. The average age of the patients with recurrence was 58 years. The average time to recurrence was 13.1 months. A 0% to 33% uptake of Ki-67 at the tumors leading edge was associated with a 6-times-greater risk of recurrence. The mean length of survival for the group with 0% to 33% uptake was 21 months; for the group with >33% uptake, it was 33 months. Overall uptake of Ki-67 and histologic grade did not correlate with risk of recurrence. Conclusions: In this sample, low rates of Ki-67 staining at the invasive edge of the tumor predicted a risk of recurrence. These results need to be confirmed before Ki-67 can be used for predicting recurrence of tongue squamous cell carcinoma.

Hypersensitivity myocarditis and hepatitis associated with imipramine and its metabolite, desipramine.

We present two cases of myocarditis and hepatitis with histologic characteristics of hypersensitivity-mediated drug reactions associated with imipramine and its metabolite, desipramine. In one case, death was directly attributed to myocarditis; in the second case, the patient died of an acute myocardial infarct, but myocarditis may have played a contributory role. One patient was taking imipramine, and therapeutic concentrations of imipramine and desipramine were documented in postmortem blood. The other patient was receiving desipramine documented by in-patient hospital medication records. Both cases had liver lesions associated in the medical literature with adverse drug reaction to imipramine. Although myocarditis has been previously associated with amitriptyline, these cases appear to be the first reported in association with imipramine/desipramine. The fact that one patient was taking only desipramine suggests that it may be the offending agent.