The Role of Autopsy in Quality Assurance: Pilot Study of a Method for Prospective Reporting of Diagnostic Errors Discovered at Autopsy.

ABSTRACT: Hospital autopsies frequently reveal errors in diagnosis that could have affected the patient's clinical outcome. The aims of this study were (1) to investigate the ability of autopsy at our institution to elucidate unrecognized antemortem diagnoses and (2) to pilot a method for tabulating diagnostic discrepancies on a prospective basis. The study sample consisted of 296 cases from our hybrid hospital/forensic autopsy service during the period 2016 to 2018. Discrepancies in autopsy and clinical diagnosis were reported by pathologists at the time of autopsy report generation using a standard form. The rates of major discrepancies between autopsy and clinical diagnoses were 37.5% for in-hospital cases and 25% for patients who died outside our hospital (P < 0.05). The most common discrepant category was infection. The overall rates of discrepant causes of death were 14% (in hospital) and 8% (out of hospital) (ns). Overall percentages of cases with major diagnostic discrepancies were higher in our study than have been previously reported. It is possible that the nature of our patient population plays a role in this result. This study describes an important prospective reporting tool that will allow us to track rates of medical errors and improve diagnosis and treatment of the critically ill.

Incomplete Kawasaki disease with development of fatal coronary artery thrombosis in a 13-year-old male.

Kawasaki disease (KD) is among one of the most common causes of vasculitis in children. Since KD was first described in 1967, there have been several reports of patients who did not meet the full diagnostic criteria for KD but who ultimately developed significant coronary artery lesions. Children with incomplete KD are at similar risk of developing coronary artery abnormalities to those with complete Kawasaki. A previously healthy 13-year-old Asian male was seen at a clinic for fever, pharyngitis, and conjunctivitis. He was given antibiotics for a presumed streptococcal pharyngitis. Two weeks later, the decedent complained of chest pain, collapsed, and was transported by Emergency Medical Services to a nearby hospital where he was pronounced deceased on arrival. A complete autopsy was done by the local medical examiner. Histologically, all three coronary arteries showed varying degrees of severe transmural lymphoplasmacytic inflammation, marked vascular smooth muscle intimal proliferation, focal destruction of muscular and elastic layers, and luminal stenosis. Some vessels had recent thrombi. We present an example of incomplete KD in an older child and reiterate the importance of obtaining relevant medical history in sudden death cases that come to the Medical Examiner Office, especially in the pediatric age group.

A Case of Previously Unsuspected Cardiac Sarcoidosis Diagnosed at Autopsy and 23-Year Review of One Institution's Sarcoidosis Deaths.

Sarcoidosis is a noncaseating granulomatous disease of unknown etiology. The incidence is 11 per 100 000 white individuals and 34 per 100 000 black individuals. Cardiac involvement is seen in 2% to 5% of patients with systemic sarcoidosis and is often clinically undetected. This may be due to relative rarity of cardiac involvement, variability in presentation, or that there are no good clinical criteria for the diagnosis of cardiac sarcoidosis. Patients may be totally asymptomatic or have heart block, myocardial infarctions, heart failure, or sudden cardiac death, which may be due to involvement of the conduction system by sarcoidosis. We present a case of a 54-year-old black male with hypertension and hyperlipidemia. Prior to his death, he was witnessed to suddenly stand up, grab his chest, and collapse. His clinical cause of death was hypertensive and atherosclerotic cardiovascular disease. A retrospective review of autopsy cases over the last 23 years (1995-2018) at our institution (n = 6900) was undertaken. This case illustrates a rare disease and highlights the importance of complete autopsy even in patients who might otherwise be signed out as an external exam or records review only.

Chest wall resection for a giant angiomatosis lesion: A case report.

INTRODUCTION: Angiomatosis is a rare and benign vascular lesion which can be located in various sites throughout the body, most commonly diagnosed in females in the first two decades of life. PRESENTATION OF CASE: A 54-year-old female with no previous medical history presented with significant pain and discomfort associated with a 12.3 × 11.3 × 4.4 cm posterior chest wall mass invading the 4th and 5th ribs and extending into the thoracic cavity. DISCUSSION: Angiomatosis is a benign vascular lesion that can affect any soft tissue in the body. Typically, it has a female predilection and tends to involve the lower extremities. It is histologically characterized by a proliferation of blood vessels of varying sizes and has a high recurrence rate after excision. Significant blood loss can occur during resection. CONCLUSION: Management of these lesions is challenging based on the infiltrative and vascular nature of the disease. Neoadjuvant therapy can be considered in select cases. Close surveillance is recommended due to high rates of recurrence.

Comparison of the Alere i Strep A Test and the BD Veritor System in the Detection of Group A Streptococcus and the Hypothetical Impact of Results on Antibiotic Utilization.

Rapid detection of group A Streptococcus (GAS) is an integral component of treatment decisions in the clinic, especially in the pediatric population. We prospectively collected 216 specimens from symptomatic, predominantly pediatric patients and evaluated the performance of the Alere i Strep A test (Alere i; Alere Inc., Scarborough, ME) and the BD Veritor system (BD Veritor; Becton, Dickinson and Company, Sparks, MD), with culture results being used as a comparator. Real-time PCR (RT-PCR) was performed as an arbiter in discordant cases. Comprehensive chart review was also done to determine the hypothetical impact of the results on antibiotic use. Alere i had a sensitivity and a specificity of 100% and 91.3%, respectively, and BD Veritor had a sensitivity and a specificity of 76.2% and 93.6%, respectively, when the results were compared to those of GAS culture. Further analysis of discordant results using RT-PCR revealed that while BD Veritor missed 13 confirmed positive cases, Alere i detected 100% (n = 13) of the same cases. Analysis of assay agreement showed that Alere i and BD Veritor had only moderate agreement (agreement = 0.888 [95% confidence interval {CI}, 0.838 to 0.927]; kappa index = 0.689 [95% CI, 0.91 to 0.974]). We also found both the underutilization and the overutilization of antibiotics based on the results of molecular testing. Overall, Alere i showed superior performance over BD Veritor in the detection of GAS pharyngitis and could potentially assist in better antibiotic utilization.

Fatal Ludwig's Angina: Cases of Lethal Spread of Odontogenic Infection.

We report two cases of deaths resulting from complications of odontogenic infections/submandibular space infections. In one case, the decedent had a history of toothache as well as facial and tongue swelling; autopsy revealed inflammation involving the tongue and larynx. In the second case, the decedent had a history of toothache, and at autopsy there was spread of infection to the mediastinum. Ludwig's angina is a form of submandibular space infection, which often is a result of odontogenic infection. The infection can spread into the deep spaces of the neck, producing complications including edema of the tongue and pharynx (causing airway obstruction), descending mediastinitis, pericarditis, necrotizing fasciitis, pleural empyema, and pneumonia. Gross findings at autopsy might reveal a dental abscess or other forms of infection of the head and neck, necrosis of the neck muscles and larynx, and infrequently, infection extending to the chest cavity. Microscopically, there is acute inflammation with necrosis and/or granulation tissue predominantly within the fascia. Without treatment, submandibular space infections can be life threatening and progression to death can be swift. These cases demonstrate the lethal effects of odontogenic infections. Without a clinical history of toothache or dental abscess, one can be alerted to a possible submandibular space infection by identifying isolated necrosis of the neck musculature.

Liquid Biopsies in the Management of Bladder Cancer: Next-Generation Biomarkers for Diagnosis, Surveillance, and Treatment-Response Prediction.

In this review, we discuss the types of liquid biopsies currently available, and their recent and potential clinical applications, especially as they relate to the detection of molecular biomarkers of bladder cancer. The advances in research using high-throughput next-generation genomic techniques have identified a number of promising molecular biomarkers of bladder urothelial carcinoma. Liquid biopsy has recently received enormous attention as a potential tool for real-time monitoring of disease status in cancer patients, and genomic profiles are reported to closely match those of corresponding tumors. It is noninvasive and easily repeated, and allows monitoring during treatment and detection of different genomic alterations that are potentially accessible to targeted therapy or are associated with treatment resistance in bladder cancer patients. Moreover, liquid biopsy is a tool that allows rapid access to biomarker assessment in patients for whom solid biopsies are not available. Liquid biopsy will be widely applied to daily clinical practice and serve as an important tool for the screening, surveillance, prediction of outcomes, and selection of effective targeted therapies in bladder carcinoma.

A Case of Previously Unsuspected Huntington Disease Diagnosed at Autopsy.

Huntington disease (HD) is a neurodegenerative disorder with a worldwide prevalence of four to ten per 100 000. It is characterized by choreiform movements, behavioral/psychiatric disturbances, and eventual cognitive decline. Symptoms usually present between 30 and 50 years of age and the diagnosis is based on the combination of clinical symptoms, family history, and genetic testing. A variation of HD, juvenile Huntington disease (JHD), presents earlier, with more severe symptoms and with a worse prognosis. Symptoms are different in JHD, with personality changes and learning difficulties being the predominant presenting features. Seizures are common in JHD, and chorea is uncommon; movement disorders at presentation of JHD are predominantly nonchoreiform. The inheritance pattern for both HD and JHD is autosomal dominant and the disease is caused by an elongation of the CAG repeat in the huntingtin gene. There are many published case reports of Huntington disease that were confirmed at autopsy, but to our knowledge, there are no reports in the literature where the diagnosis of Huntington disease was first made at autopsy. We present a case of a 28-year-old African-American male who was in a state of neglect due to a lifetime of abuse, cognitive difficulties, and seizures, whose cause of death was pneumonia. The gross autopsy findings included bilateral caudate nucleus atrophy and lateral ventricular dilation. Microscopically, severe bilateral neuronal loss and gliosis of the caudate and putamen nuclei were seen. Genetic testing for the number of CAG repeats confirmed the diagnosis and was consistent with JHD.

Comparative Evaluation of Potentially Radiolucent Projectile Components by Radiographs and Computed Tomography.

Projectile components that are traditionally radiolucent can be of considerable importance in determination of weapon type and caliber, but they are often missed on evaluation of postmortem radiographs. We hypothesized that these components would be significantly better visualized by evaluation of computed tomography (CT) scans compared to the practice standard of radiography alone. In this project, potentially radiolucent projectile components were both pulled apart and fired, and the radiolucent components were recovered. These components were embedded in blocks of ballistics gelatin and were imaged using both radiography and CT. The scans were evaluated by three blinded, board-certified radiologists for the presence/absence of projectile components and true-negative regions in each block. If a radiologist indicated visualization of a projectile component, they were further requested to describe their observation. It was found that traditionally radiolucent projectile components are not significantly more often identified on CT scans than radiography (p < 0.05).