Impact of medical autopsy on final diagnosis

Objective: To determine the difference between diagnosis and misdiagnosis after medical autopsy

Study Design: Prospective study

Place and Duration of Study: Histopathology Dept Army Medical College Rawalpindi and Military Hospital [MH] Rawalpindi from Jan 2009 to May 2012

Material and Methods: A retrospective cross sectional descriptive study of medical autopsies was conducted on patients at Histopathology Department Army Medical College and MH Rawalpindi who expired at or was brought in dead at MH Rawalpindi during a 41 months period between January 2009 to May 2012. Permission from the ethical committee was obtained for the study. Autopsy for medical purpose was performed on the deceased after receiving written consent from the next of kin. Medical autopsies were performed to determine and find the medical cause of death and to evaluate any disease or injury that may be present. Total of 72 medical autopsies were conducted during the above period. All these consecutive autopsies were included in the study. Ratio of total autopsies done was 0.17% of total hospital deaths at MH Rawalpindi in the duration of study. All subjects were male, military persons, aged between 19 and 50 years. Mean age was 35.5 years. Data was analyzed in excel. Descriptive statistics was applied on qualita ive variables. Frequency and parentages was used

Results: Ante mortem diagnosis confirmed as correct on total of 25/72 Autopsies. Clinically missed / wrong diagnosis was found on 47/72 autopsies

Conclusion: Medical autopsy even today in the environment of a tertiary care hospital has irrefutable contribution in establishing final diagnosis and determining errors and omissions. Consequently it has pivotal role in continued improvement in medical care and in study of evolving disease patterns in real time

Placental morphology at different maternal hemoglobin levels: a histopathological study

To evaluate the histopathological parameters of the placenta like weight, infarct and syncytial knots, at different maternal hemoglobin levels, in both qualitative and quantitative manner. Descriptive study. Army Medical College, National University of Sciences and Technology in collaboration with Department of Obstehics and Gynecology, Military Hospital, Rawalpindi, Pakistan, from December 2011 to November 2012. A total of 75 placentas were included, that were collected from full term mothers at the time of childbirth. Placental weight was taken without umbilical cord and gross placental infarcts were noted. Samples of placental tissue were taken and stained by haematoxylin and eosin [H and E]. Microscopic study was done to evaluate placental infarcts and syncytial knots. Mean placental weight at normal and low maternal hemoglobin was 581.67 +/- 83.97 g and 482.58 +/- 104.74 g respectively. Gross placental infarcts were found in all cases having low maternal hemoglobin concentration [60% cases]. Syncytial knots were found in all placentas but they were considerably more at decreasing levels of maternal hemoglobin [19.79 +/- 5.22]. The present study showed decrease in placental weight, increase in placental infarcts and syncytial knot hyperplasia at low maternal hemoglobin concentration, displaying adaptive alterations

histopathologic analysis of chronic inflammatory infiltrate in patients of H. pylori associated chronic gastritis

To determine the relationship between H. pylori density with severity of chronic inflammatory infiltrate. A cross-sectional study. The study was carried out in the Department of Pathology [Histopathology], Army Medical College, National University of Sciences and Technology [NUST] Islamabad, from Nov 2011 to Nov 2012. Gastric antral biopsies of H. pylori associated chronic gastritis were included in the study. Demographic characteristics and relevant clinical information were collected. First hundred biopsies of H. pylori associated chronic gastritis were assessed for density of H. pylori and chronic inflammatory infiltrate. Histopathological features like lymphoid aggregates, ulcer slough, superficial epithelial damage, dysplasia and nuclear reactive changes were simply assessed in case of their presence or absence. A sigruficant moderate positive correlation was found between grades of H. pylori and chronic inflammatory infiltrate [rs= 0.636]. Insigruficant correlation was found with lymphoid aggregates, superficial epithelial damage, dysplasia and nuclear reactive changes. In conclusion this study corroborated the determination of histopathological parameters and depicted that, the greater the density of H. pylori mfection, the greater the degrees of chronic inflammatory infiltrate

Pattern of acid base abnormalities in critically ill patients

To find out the pattern of acid base abnormalities in critically ill patients in a tertiary care health Sacility. A descriptive study. The study was carried out in the department of pathology, Combined Military Hospital Kharian from January 2013 to June 2013. Two hundred and fifty patients suffering from various diseases and presenting with exacerbation of their clinical conditions were studied. These patients were hospitalized and managed in acute care units of the hospital. Arterial blood gases were analysed to detect acid base status and their correlation with their clinical condition. Concomitant analysis of electrolytes was carried out. Tests related to concurrent illnesses e.g. renal and liver function tests, cardiac enzymes and plasma glucose were assayed by routine end point and kinetic methods. Standard reference materials were used to ensure internal quantify control of analyses. Two hundred and fifteen patients out of 250 studied suffered from acid base disorders. Gender distribution showed a higher percentage of male patients and the mean age was 70.5 +/- 17.4 years. Double acid base disorders were the commonest disorders [34%] followed by metabolic acidosis [30%]. Anion gap was calculated to further stratify metabolic acidosis and cases of diabetic ketoacidosis were the commonest in this category [47%]. Other simpie acid base disorders were relatively less frequent. Delta bicarbonate was calculated to unmask the superimposition of respiratory alkalosis or acidosis with metabolic acidosis and metabolic alkalosis. Though triple acid base disorders were noted in a small percentage of cases [05%], but n7ere found to be the most complicated and challenging. Mixed acid base disorders were associated with high mortality. A large number of critically ill patients manifested acid base abnormalities over the full spectrum of these disorders. Mixed acid base disorders were commonest and were bad prognostic indicators, most often associated with high mortality. This warrants a high index of suspicion, a thorough clinical assessment of patient and a structured approach to analyze the relevant laboratory data in the given clinical setting. Only with prompt detection of an acid base disorder, clinician can formulate an appropriate management strategy for the patient

Frequency of thrombocytopenia in plasmodium vivax malaria

To determine the frequency of thrombocytopenia in Plasmodium vivax [P.vivax] malaria cases at two hospitals. Cross-sectional descriptive study. The study was conducted at the departments of Pathology, Combined Military Hospitals Malir and Sibi, Pakistan from Jul 2011 to Mar 2012. A total of 2709 samples were collected from febrile patients for detection of malaria parasite [944 from CMH Malir and 1765 from CMH Sibi]. Cases having infection with P. falciparum alone or having mixed infection with P. vivax and P. falciparum were excluded from the study. Both thick and thin film microscopy and immunochromatographic method [OptiMAL-IT] were used for detection of malarial parasite. Platelet counts were done using automated haematology analyser [Sysmex KX 21] with re-evaluation of low counts with manual methods. Total of 170 patients were found positive for P. vivax malaria [44 from CMH Malir and 126 from CMH Sibi]. Platelet counts ranged from 21 - 457 x loyi with a mean of 134 x loyi. Ninety five [2.1%] from CMH Malir and 4.2% from CMH Sibi out of 170 patients had thrombocytopenia, and the difference in thrombocytopenia at the two hospitals was insignificant [0.017]. Thrombocytopenia in patients with P. vivax infection is equally prevalent in the two hospitals, representing a widely different geographical area and should prompt a more thorough search for malarial parasite

Diagnostic accuracy of pipelle biopsy in endometrial pathologies

To evaluate the diagnostic accuracy of Pipelle biopsy as compared to endometrium of hysterectomy specimen [gold standard] in various gynaecological abnormalities pertaining to endometrium. This validation study was carried out in the Department of Histopathology, Army Medical College in collaboration with Department of Gynaecology, Military Hospital Rawalpindi from Feb 2008 to Jan 2009. Consenting 100 patients undergoing hysterectomy for various indications at Military Hospital Rawalpindi during the study period fitting the inclusion criteria were incorporated. The preoperative Pipelle and subsequent hysterectomy samples were both delivered to the laboratory in 10% formal saline. Pipelle samples were embedded as such. From the hysterectomy specimen, three representative sections were taken from endomyometrium. Both the samples were processed in automated tissue processor. Paraffin blocks of Pipelle and gold standard were made in paraffin embedding machine. Through rotary microtome, 3-5 micrometer thickness sections were made. Sections were stained by haematoxylin and eosin in autostainer and then mounted. The slides were then examined by resident histopathologist and final diagnosis was given by consultant histopathologist. Endometrial hyperplasia without atypia was a frequent pathology detected on Pipelle accounting for 16% of all cases. Diagnostic accuracy of Pipelle sampling in chronic endometritis, endometrial hyperplasia

Assessment of atherosclerotic plaque vulnerability of coronary arteries in cases of sudden cardiac death

To study the plaque vulnerability in coronary arteries taken from autopsy specimens, of individuals dying of ischemic heart disease in our setup and to compare it with atheroma of those who died of non-cardiac causes. Case control study. Study was carried out in the department of Pathology [Histopathology], Army Medical College, Rawalpindi and National University of Sciences and Technology [NUST], from June 2008 to June 2009. Sixty coronary arteries having atherosclerosis, from autopsies of patients who died of sudden cardiac death were divided into case and control groups. Case group included thirty coronary arteries having atherosclerosis from autopsies of patients of whose death was attributable to Ischemic Heart Disease [IHD]. Control group included thirty coronary arteries where atherosclerotic changes were found by chance [death not attributable to ischemic heart disease]. Plaques were assessed for fibrous cap thickness, foam cells; mean percentage of inflammatory cells on Haemotoxylin and Eosin [H and E] stained slides whereas immunohistochemical [IHC] markers for T-Cells were done by IHC stain method. In present study, foam cells are significantly more in study group than in control group [P=0.007]. Fibrous cap thickness fulfilling the criteria of vulnerable plaque was more in study group as compared to control group [P<0.001]. The present study demonstrated that there was insignificant difference [P=0.152], in the mean percentage of inflammatory cells in case group and control group. An overall significant association was found between vulnerable plaque and death due to ischemic heart disease [P<0.001]. Patients dying of ischemic heart disease have more vulnerable plaque in their coronary arteries as compared to those dying from non ischemic cause. Although this is an autopsy study but the significance of in this study can be very important to guide cardiologists to identify patients at high risk of acute coronary syndrome and use new diagnostic modalities like intravascular ultrasonography and therapeutic strategies like genomic and proteomic techniques. This will help the early detection and treatment of such cases and may ultimately reduce the incidence of sudden cardiac death

Liver biopsy in chronic hepatitis C: An assessment of inter and intra-observer's variability

To evaluate the inter and intraobserver variability in the histological grading and staging according to modified Knodell scoring system. A cross-sectional comparative study. Histopathology department Army Medical College, Rawalpindi, Pakistan from June 2006 to December 2006, at the Slides and original reports of already reported chronic hepatitis C cases were retrieved from the case files. A total of 52 liver biopsies of patients were reevaluated by two pathologists. The inter and intraobserver reproducibility for grade of necroinflammation and stage of fibrosis were calculated by using kappa statistics. For grades of necroinflammation a substantial level of interobserver [kappa=0.802] and intra-observer [kappa= 0.749] reproducibility was found. Disagreement in the interobserver results was detected in 11.5% cases, with difference of only one grade in all the cases. Disagreement in the intraobserver diagnosis was noted in 15.4% cases, again with the difference of only one grade of necroinflammation. Similarly for the stage of fibrosis, a substantial level of interobserver [kappa= 0.66] and intra-observer [kappa=0.77] reproducibility was present. Main disagreement for interobserver results was of stage 2 and 3 fibrosis. For intraobserver stage of fibrosis, disagreement was found in 9 cases [17.3%]. There was disagreement in 6 of the 9 cases with fibrosis stage 3, where original histological stage was reported 4. There were 3 [5.8%] cases where presence of steatosis was missed [all in non-tabulated form of reports]. Substantial level of inter and intra-observer agreement can be achieved, both for the necroinflammatory grade and stage of fibrosis, if the scoring system of chronic hepatitis is strictly followed

Frequency and pattern of intestinal parasitic infestation in upper neelum valley

The public health importance of intestinal parasitic infestations can not be denied because of their high prevalence and global distribution. It is an established fact that intestinal parasitic infestations can lead to a number of adverse affects like anaemia, stunted physical and mental growth, abdominal colic, cholestasis, cholecystitis and pancreatitis. To assess the frequency and pattern of intestinal parasitic infestation in upper Neelum Valley [Azad Kashmir]. The study was conducted at Military Field Hospital Neelum Valley Azad Kashmir from July 2004 to Jun 2006. The patients presenting with various abdominal complaints were included in the study. The stool samples of a total of 638 patients were examined by Direct Microscopy as well as by Formal Ether Concentration Method wherever necessary. One hundred and fifteen 155 [18.02%] non duplicate stool samples were positive for intestinal parasites. There was no statistically significant difference in incidence with regard to age or gender [P > 0.05]. Ascaris lumbricoides was the most common parasite 58 [50.43%] cases followed by Tinea saginata 31 [26.96%] cases and Giardia lamblia 11 [9.57%] cases. Hymenolepis nana 6 [5.22%] cases, Trichuris trichura 5 [4.35%] cases, Entrobius vermicularis 3 [2.60%] and Entamoeba histolytica 1 [0.87%] cases were less frequent. No case of Hookworm was seen. The percentage of intestinal parasites [18.03%] is quite high in upper Neelum Valley. The helminthes are more common than protozoa. Ascaris lumbricoides is the most common parasite followed by Tinea saginata and others. Appropriate steps be taken at District level for provision of safe drinking water schemes and improvement in local sanitary conditions. The Health and Education departments should help by inculcating awareness among the general public about importance of safe drinking water, environmental and personnel hygiene alongwith periodic de-worming programmes. These measures would help in reducing the occurrence of intestinal parasites and associated adverse affects

Clinicopathological study of 762 ovarian neoplasms at Army Medical College Rawalpindi

A retrospective cross sectional study was carried out at Pathology Department of Army Medical College Rawalpindi from January 1995 to December 2003 to see the morphological pattern of benign and malignant ovarian tumours. A total of 762 ovarian tumours were studied during a period of nine years. Of these, 498 [65.35%] were benign, 33 [4.33%] of borderline malignancy and 231 [30.31%] were malignant. The relative frequency of malignant ovarian tumours of all gynaecologic malignancies was found to be 24.01%. The age range of ovarian tumours was 9 to 80 years. Maximum number [66.88%] of benign tumours were in younger patients [<40 years], whereas majority of malignant tumours [65.83%] were seen in 5th to 6th decades. Histologically, the major categories included surface epithelial tumours 527 [69.16%], germ cell tumours 201 [26.37%], sex cord- stromal tumours 34 [4.46%] and miscellaneous 4 [0.52%]. Amongst the malignant tumours, the most common entity was serous cystadenocarcinoma [46.75%], followed by mucinous cystadenocarcinoma [22.94%], dysgerminoma [6.06%], granulosa cell tumours [5.62%] and endometrioid carcinoma [4.76%]. In this study, ovarian tumours were seen in younger age and serous tumours were relatively more common than experienced in the western world. Overall trends for other malignancies are more or less similar to other Pakistani studies except for mucinous carcinoma