The autopsy: still important in cardiac surgery

BACKGROUND: This study examined the ability of autopsy to confirm or dispute presumptive cause of death among cardiac surgery patients. METHODS: Autopsy reports were compared with mortality conference notes that were dictated prospectively before autopsy results were available. Between January 1985 and December 1995, there were 600 hospital deaths among 13,029 adult cardiac surgery patients (4.6% mortality). Of these 600 deaths, 147 (24.5%) had postmortem examination. RESULTS: Annual autopsy rate remained constant over the course of the study. Autopsied patients were younger (60.4 +/- 15 versus 66.7 +/- 13 years [mean +/- standard error of the mean]; p < 0.0001), but their race and sex distributions were similar to deceased patients not having autopsy. Autopsy confirmed clinical presumptive cause of death in 52% (76), disputed clinical diagnosis in 9.5% (14), provided definitive diagnosis in the absence of clinical diagnosis in 13.6% (20), and failed to provide definitive diagnosis in 25% (37). One third of autopsies (39%; 57) provided information that was clinically unrecognized and might have altered therapy and outcome if known premortem. As determined by autopsy, common causes of death were cardiac (27%; 39), unknown (25%; 37), sepsis (14%; 21), stroke (8.8%; 13), cholesterol embolism (4.1%; 6), pulmonary embolism (4.1%; 6), and adult respiratory distress syndrome (4.1%; 6). CONCLUSIONS: Autopsy reveals or confirms cause of death in nearly three quarters of cardiac surgical deaths and provides information that differs significantly from premortem clinical impression more than 20% of the time. As such, the autopsy remains important to quality assurance in cardiac surgical care.     

The medicolegal autopsy

Considerable disparity exists from area to area in the United States in the quality of medicolegal investigation. Much of this type of investigation in this country is still conducted by physicians in general practice, who possess neither specialized medicolegal training nor experience. Forensic autopsies are being performed mostly by hospital pathologists without forensic expertise, who conduct these autopsies in their spare time or as a paid hobby. This article provides guidelines for improved medicolegal investigation and formulation of autopsy reports, including opinions, which have been found to be advantageous in a medicolegal setting of a major metropolitan area and are, in my opinion, also applicable to smaller, even rural, types of jurisdiction.     

The question of organicity: Is it still functional?

Contends that neuropsychological assessment that exclusively addresses the question of whether a patient has an organic or functional disorder has little clinical utility. Organicity is not a single entity, and brain diseases and disorders are manifested in many ways. Revolutionary advances in neuroradiological techniques since the early 1970s have dramatically improved the detection of structural and physiological brain abnormalities. Many disorders once considered functional, such as schizophrenia and psychotic depression are also observed in organic psychosis. If cognitive functions are delineated by a multidimensional assessment, specific and useful treatment and rehabilitation recommendations can be made. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The experimenter: A (still) neglected stimulus object.

Examination of all of the applicable research articles published during the one year in three A.P.A. journals showed that the number of experimenters was specified in just 11% of studies. A mail survey of authors showed that usage and systematic variation of multiple experimenters occurred in only 6% of studies. The implications of this figure, in light of about 40 years of rhetoric and a decade of intensive data collection on experimenter effects, were discussed. In addition, data were presented on ages, sexes, relationships to investigators and bases of selection of experimenters. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The jury is still out: A reply to Deffenbacher.

Responds to comments by K. A. Deffenbacher (see record 1985-20010-001) concerning the present authors' (see record 1984-06612-001) arguments against the use of psychological testimony on eyewitness reliability. It is argued that there is currently no sufficient basis for the conclusion that jurors need to be made more skeptical of eyewitness testimony or that psychology can provide useful information concerning areas such as the decline of retention with time or the effect of arousal levels on eyewitness performance. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The etiology of Balkan endemic nephropathy: still more questions than answers

Balkan endemic nephropathy (BEN) has attracted increasing attention as a possible environmental disease, and a significant amount of research from complementary scientific fields has been dedicated to its etiology. There are two actual competing theories attempting to explain the cause of this kidney disease: 1) the mycotoxin hypothesis, which considers that BEN is produced by ochratoxin A ingested intermittently in small amounts by the individuals in the endemic regions, and 2) the Pliocene lignite hypothesis, which proposes that the disease is caused by long-term exposure to polycyclic aromatic hydrocarbons and other toxic organic compounds leaching into the well drinking water from low rank coals underlying or proximal to the endemic settlements. We outline the current developments and future prospects in the study of BEN and differentiate possible factors and cofactors in disease etiology.     

The dorsal raphe: an important nucleus in pain modulation

The dorsal raphe nucleus (DRN) is an important nucleus in pain modulation. It has abundant 5-HT neurons and many other neurotransmitter and/or neuromodulator containing neurons. Its vast fiber connections to other parts of the central nervous system provide a morphological basis for its pain modulating function. Its descending projections, via the nucleus raphe magnus or directly, modulate the responses caused by noxious stimulation of the spinal dorsal horn neurons. In ascending projections, it directly modulates the responses of pain sensitive neurons in the thalamus. It can also be involved in analgesia effects induced by the arcuate nucleus of the hypothalamus. Neurophysiologic and neuropharmacologic results suggest that 5-HT neurons and ENKergic neurons in the DRN are pain inhibitory, and GABA neurons are the opposite. The studies of the intrinsic synapses between ENKergic neurons, GABAergic neurons, and 5-HT neurons within the DRN throw light on their relations in pain modulation functions, and further explain their functions in pain mediation.     

The neuropathology of orthotopic liver transplantation: an autopsy series of 16 patients

OBJECTIVE: To examine the neuropathologic findings seen in the setting of orthotopic liver transplantation (OLT) and to asses the role, if any, that the neuropathology had in the patient's death. DESIGN: Retrospective autopsy series of 16 patients. SETTING: Tertiary referral center with a high volume of liver transplantation. PATIENTS: Sixteen OLT patients who died and in whom a complete autopsy, including examination of the brain and spinal cord, was performed. RESULTS: Sixteen patients, including 13 women and 3 men, comprised the study group. Patients ranged in age from 25 to 64 years (mean 44.8 years). Postoperative OLT survival ranged from 1 to 1962 days (mean 236 days). Reasons for the initial OLT included hepatitis (n = 6), fulminant hepatic failure (n = 4), cryptogenic cirrhosis (n = 2), methotrexate toxicity (n = 1), postoperative complication (n = 1), primary biliary cirrhosis (n = 1), and hepatocellular carcinoma (n = 1). Autopsies in 13 (81%) patients showed neuropathology; in only 2 patients, however, was the primary cause of death attributable to these findings. The most common neuropathology was related to anoxia or infarction, specifically, ischemia or focal neuronal necrosis (n = 9), infarction (n = 4), and diffuse anoxic encephalopathy (n = 3). Other central nervous system findings included infection with Aspergillus, Candida, and Toxoplasma (n = 3). The most common cause of death was infection-related in 8 patients. One patient died of pulmonary hypertension, 1 of acute rejection, and 1 of possible hyperacute rejection. Two patients died directly as a consequence of neuropathology findings; one had massive central edema with herniation, and the other had a large intracerebral hemorrhage with herniation. The exact cause of death was unclear in 3 patients. CONCLUSIONS: The most common neuropathology findings in this series were related to ischemia and infarction. Neuropathology findings are a significant cause of morbidity, but were only rarely the main cause of death (n = 2) in the OLT patients in this study.