Cause of death and the autopsy rate in an elderly population.

Autopsy rates are declining, while major discrepancies between autopsies and clinical diagnoses remain. Still, little is known about the impact of suspected underlying diseases, for example, a diagnosis of cancer, on the autopsy rate. The aim of this study was to investigate the relation between the clinical cause of death, a history of cancer, and the medical autopsy rate using data from the Netherlands Cohort Study on Diet and Cancer (NLCS), a large prospective cohort study with a long follow-up. The NLCS is a prospective study initiated in 1986 and includes 120,852 persons (58,279 males and 62,573 females), 55-69 years of age at the time of enrollment. The NLCS was linked with the Dutch Nationwide Pathology Databank (PALGA), the Dutch Population Register (GBA), the Netherlands Cancer Registry, and the causes of death registry (Statistics Netherlands). If applicable, the 95% confidence intervals were calculated. During the follow-up of the NLCS, 59,760 deaths were recorded by linkage with the GBA from 1991 until 2009. Of these, a medical autopsy was performed on 3736 deceased according to linkage with PALGA, resulting in an overall autopsy rate of 6.3%. Major variations in the autopsy rate were observed according to the cause of death. The autopsy rate increased according to the number of contributing causes of death. Lastly, a diagnosis of cancer affected the autopsy rate. The clinical cause of death and a history of cancer both influenced the medical autopsy rate in a large national cohort. The insight this study provides may help clinicians and pathologists counteracting the further downfall of the medical autopsy.

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

Early death in sepsis occurs frequently; however, specific causes are largely unknown. An autopsy can contribute to ascertain causes of death. The objective of the study was to determine discrepancies in clinical diagnosis and postmortem findings in septic intensive care unit (ICU) patients deceased within 48 h after ICU admission. All septic ICU patients who deceased within 48 h after ICU admission were identified and included. Four intensivists determined the clinical cause of death by medical record review. An autopsy was performed within 24 h of death. Clinical diagnosis and postmortem findings were compared and classified as autopsy-identified missed clinical diagnoses and autopsy-refuted diagnoses. Class I and II missed major diagnoses using the Goldman criteria were scored. Between 2012 and 2017, 1107 septic patients were admitted to ICU. Of these, 344 patients (31%) died, of which 97 patients (28%) deceased within 48 h. In 32 (33%) early deceased patients, an autopsy was agreed. There were 26 autopsy-identified missed clinical diagnoses found, mostly myocardial infarction (n = 4) and pneumonia (n = 4). In four patients (13%), a class I discrepancy was found. In fourteen patients (42%), a class II discrepancy was found. In conclusion, an autopsy is an important diagnostic tool that can identify definite causes of death. These diagnoses deviate from diagnoses established during admission in early deceased sepsis patients.

Clinical Relevance of Unexpected Findings of Post-Mortem Computed Tomography in Hospitalized Patients: An Observational Study.

Background and objective: The current literature describing the use of minimally invasive autopsy in clinical care is mainly focused on the cause of death. However, the identification of unexpected findings is equally important for the evaluation and improvement of daily clinical care. The purpose of this study was to analyze unexpected post-mortem computed tomography (PMCT) findings of hospitalized patients and assess their clinical relevance. Materials and methods: This observational study included patients admitted to the internal medicine ward. Consent for PMCT and autopsy was requested from the next of kin. Decedents were included when consent for at least PMCT was obtained. Consent for autopsy was not obtained for all decedents. All findings reported by PMCT were coded with an International Classification of Diseases (ICD) code. Unexpected findings were identified and subsequently categorized for their clinical relevance by the Goldman classification. Goldman class I and III were considered clinically relevant. Additionally, correlation with autopsy results and ante-mortem imaging was performed. Results: In total, 120 decedents were included and evaluated for unexpected findings on PMCT. Of them, 57 decedents also underwent an autopsy. A total of 1020 findings were identified; 111 correlated with the cause of death (10.9%), 508 were previously reported (49.8%), 99 were interpreted as post-mortem changes (9.7%), and 302 were classified as unexpected findings (29.6%). After correlation with autopsy (in 57 decedents), 24 clinically relevant unexpected findings remained. These findings were reported in 18 of 57 decedents (32%). Interestingly, 25% of all unexpected findings were not reported by autopsy. Conclusion: Many unexpected findings are reported by PMCT in hospitalized patients, a substantial portion of which is clinically relevant. Additionally, PMCT is able to identify pathology and injuries not reported by conventional autopsy. A combination of PMCT and autopsy can thus be considered a more comprehensive and complete post-mortem examination.

A quarter century of decline of autopsies in the Netherlands.

OBJECTIVE: Autopsy rates have been declining worldwide. The present study reports the outcome of a retrospective analysis of all non-forensic autopsies in the Netherlands over a course of 25 years, and compares these with the most recent Dutch study. METHOD: Retrospectively, 25 years of data on clinical autopsies from the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands (PALGA) was paired with the mortality registry (Statistics Netherlands). RESULTS: The crude prevalence of autopsies declined from 7.07% in 1991 to 2.73% in 2015. After adjusting for age at death, there was no difference in autopsy rate between males and females. An increasing age significantly decreased the autopsy rate. CONCLUSION: In the Netherlands, clinical autopsies have been declining over the last quarter century. Age at death, but not sex, was associated with the autopsy rate. These different results stress the importance of correct collection and analysis methods of data.

The needle in the haystack: Histology of post-mortem computed tomography guided biopsies versus autopsy derived tissue.

OBJECTIVE: The last decennia autopsies have been declining worldwide, whereas non-invasive methods have been proposed as an alternative for the conventional autopsy. Some of these methods add needle biopsies to imaging techniques to provide an alternative to histological examination of autopsy-derived tissue. The aim of this study was to investigate the representativeness of the histology of computed tomography (CT) -guided post-mortem needle biopsies in comparison to autopsy derived tissue from the same organ. METHOD: Consent of next of kin was obtained from relatives of deceased within the department of Internal Medicine to perform an autopsy, postmortem CT and CT-guided needle biopsies. The lungs and the liver were routinely sampled with CT-guided postmortem biopsies and during the autopsy. In some cases extra CT-guided biopsies of lesions reported on the CT were sampled. The biopsy and the autopsy reports were independently reported and retrospectively coded according to the Nationwide Network and Registry of Histo- and Cytopathology in the Netherlands (PALGA). Three pathologists with an interest in autopsy pathology and three physicians of the department of internal medicine separately and independently interpreted all histological results in relation to the cause of death as formulated in the autopsy report. Fleiss's Kappa was calculated and a consensus grade was defined. RESULTS: Fleiss's Kappa showed substantial agreement in both lungs and moderate agreement in the liver. Of the 60 included cases 44% of the CT-guided postmortem biopsies in the left lung and 30% in the right lung showed false negative findings, primarily concerning a bronchopneumonia. In contrast, 91% of the liver biopsies showed concordant results, however only 22% of all liver biopsies concerned a major diagnosis related to the cause of death. The positive predictive value of the biopsies of the left lung, right lung and the liver were respectively 86.6%, 88.8% and 100%. The negative predictive values of these biopsies were 32.4%, 50% and 92.7%. CONCLUSION: CT-guided postmortem biopsies of the lungs have a mediocre predictive value. Due to a low prevalence of relevant findings the overall usefulness of biopsies of the liver are limited. Conventional autopsy should still be preferred to biopsy-based postmortem examination. Postmortem biopsies are only an alternative if consent for an autopsy cannot be obtained. In the forensic setting, where no consent of the relatives is necessary, complete autopsy should always be the method of choice.