Hospital Autopsy Research Articles

Preclinical Medical Student Perspectives on Nonforensic Autopsy Presentations as Instruments for Understanding Basic Medical Sciences: A Small-Scale Study at an International College of Medicine in Thailand

Background: Autopsies have played critical roles in understanding the pathological basis of diseases. Currently, non-forensic autopsy, which are also known as hospital autopsy, rates at several medical centers have declined. This trend could affect students’ learning opportunities, particularly those at medical schools, where the number of autopsies has significantly decreased. Objective: To evaluate the preclinical medical student perspectives on the autopsy presentation, together with the trend of non-forensic autopsies at Thammasat University Hospital. Materials and Methods: The present study was divided into two parts. Firstly, the author performed a five-year retrospective review of the trend of non-forensic autopsies at Thammasat University Hospital. Secondly, an autopsy presentation was conducted as an interactive lecture session. Participants were third-year medical students enrolled in a medical sciences applications course. Autopsy cases were selected based upon the medical competency assessment criteria for the national license. The clinicopathological correlation was emphasized. At the end of the class, students were asked to complete an online questionnaire with a five-point Likert-type scale. Student satisfaction and suggestions about the autopsy presentation were analyzed. Results: As in other medical centers, the rate of non-forensic autopsies at Thammasat University Hospital has been decreasing. The number of pediatric, particularly perinatal, autopsies dramatically outnumber that of adult autopsies. Most medical students agreed that autopsy presentation helps stimulate problem-based thinking (mean: 4.5 on the five-point Likert scale), learning clinicopathological correlations (4.4), improving understanding of pathophysiology (4.2), and refreshing knowledge of human anatomy (4.2). Conclusion: Despite the declining trend in hospital autopsies, autopsy presentation is considered as a potential instrument for understanding clinical contexts by preclinical medical students whose clinical experience are limited. Careful preparation is needed to maximize the benefits of autopsy presentations. Keywords: Non-forensic autopsy, Preclinical medical students, Clinicopathological correlation

Naegleria Fowleri Diagnosed with Hospital Autopsy in a Toddler: A Case Study

Abstract Casestudy Naegleria fowleri, an amoeba, is typically found in warm freshwater lakes, ponds, rivers and hot springs. It is responsible for causing the incredibly rare and lethal central nervous system infection called Primary Amoebic Meningoencephalitis (PAM). In the United States, 145 confirmed cases have been documented since 1962. Most cases are associated with freshwater lakes, ponds and reservoirs, while only a handful have been linked to artificial recreational venues such as pools, interactive water play-grounds, and spas. In addition to highlighting a rare amoebic disease, this case illustrates the continued importance of hospital autopsies especially given recent ruling to eliminate the autopsy requirement by the Centers for Medicare and Medicaid Services. Results An otherwise healthy toddler had upper respiratory symptoms and otitis media days after returning from an artificial recreational water venue, becoming increasingly lethargic and febrile over the next few days. At the hospital, cerebrospinal fluid (CSF) abnormalities were suggestive but not consistent with bacterial meningitis. A meningoencephalitis panel, a Computed Tomograph (CT) scan of the head, and chest-x-ray were negative for abnormalities. Appropriate antimicrobial therapy was initiated. Three days after hospital admission, his symptoms worsened including development of dysconjugate gaze and signs of cerebellitis. He became increasingly hemodynamically unstable, suffered an arrest, and passed away days later. Conclusion Since this death did not fall under the state’s statutes mandating medicolegal autopsy, a hospital- requested autopsy was performed. Cerebral edema and a light gray to light green exudate was along the inferior and lateral left temporal lobe, brain stem, and cerebellum. An exuberant lymphoplasmacytic infiltrate with scattered polymorphonuclear leukocytes expanded the meninges. Small histiocyte-like cells with distinct eccentric nuclei and granular, vacuolated cytoplasm, confirmed by Centers for Disease Control and Prevention (CDC) to be Naegleria fowleri, were best visualized in the Virchow-Robin spaces and deeper parenchyma.

Urgent Need for Studies of the Late Effects of SARS-CoV-2 on the Cardiovascular System.

Urgent Need for Studies of the Late Effects of SARS-CoV-2 on the Cardiovascular System.

Reclaiming the Autopsy as the Practice of Medicine: A Pathway to Remediation of the Forensic Pathology Workforce Shortage?

The historically constricted forensic pathology workforce pipeline is facing an existential crisis. Pathology residents are exposed to forensic pathology through the American Council of Graduate Medical Education autopsy requirement. In 1950, autopsies were conducted in one half of the patients dying in American hospitals and 90% in teaching hospitals, but they have dwindled to fewer than 5%. Elimination of funding for autopsies is a major contributor to the lack of support for autopsies in departments of pathology. Funding may require reclaiming the autopsy as the practice of medicine. Funding of autopsies would rekindle interest in hospital autopsies and strengthen the forensic pathology workforce pipeline.

Implications for forensic death investigations from first Swiss post-mortem CT in a case of non-hospital treatment with COVID-19

• 3D Visualisation of lung pathology allows to better estimate the distribution of aerated, poorly aerated and non-aerated lung regions • Forensic COVID-19 autopsy apparently showing a different (higher) degree of pathology than hospital autopsy reports compared to SARS-COV-2, but on par with SARS. Case details: A case of a 50-year old HIV-positive man is presented, with focus on visualization of post-mortem computed tomography (PMCT) of the lungs, in comparison to a forensic control case. He had been found dead at home, a day after his nasopharyngeal swab had returned positive for SARS-COV-2, three days after the sample had been taken as an outpatient, over five weeks after first exhibiting possible symptoms. 3D-visualization was performed by visually discriminating correlates for aerated, poorly aerated and non-aerated lung regions. The visual side-by-side comparison with a control case shows the deterioration beyond any ”normal” post-mortem finding, however. The PMCT findings in the lungs resemble those of patients with acute respiratory distress syndrome (ARDS), while histologically identified inflammation also shows, in part binuclear, lymphocytes. In addition, acute liver dystrophy and acute tubular necrosis in the kidneys were found. Except coronary artery atherosclerosis, there appeared to be no remarkable pathology of the heart. Comment: With the pandemic impact of SARS-COV-2, a range of issues unfolds, also for medicolegal investigations into deaths, as we report the first Swiss case with post-mortem CT where death had occurred due to a SARS-COV-2 infection, with features of a severe acute respiratory distress syndrome, as an outpatient. As this pandemic from the view of risk assessment does constitute a black swan, underestimated fat tails as technical reason should be addressed by also analyzing apparent extreme single observations. This case of an outpatient (without hospital or intensive-care treatment) shows a pulmonary progression beyond the typical findings of COVID-19, to a non-specific picture of ARDS, where histologically, in part binuclear lymphocytes were remarked. What appeared to be an initially slow progression with final rapid escalation raises the question whether nasopharyngeal swabs alone or added pulmonary CT might be better for screening high-risk patients. The reported symptoms and relatively late medical consultation in this case appeared to contrast with the extensive pathology, raising the question whether any search for super-spreaders should not just focus on asymptomatic but under-reported symptomatic patients, and whether their prolonged circulation in everyday life would justify measures such as for example more extensive face mask policies. As post-mortem testing for SARS-COV-2 may not be available for every case, PMCT may provide sensitive testing for lung changes related to COVID-19. In order to allow for more precise medicolegal investigations in the context of COVID-19, however, any more specific extra tests may have to be financed by stakeholders in epidemiology, infectious disease or policy.

Resurrecting the Hospital Autopsy: Impact of an Office of Decedent Affairs on Consent Rates, Providers, and Next-of-Kin.

Autopsy rates have decreased dramatically despite providing important clinical information to medical practices and social benefits to decedents' families. To assess the impact of an institutional Office of Decedent Affairs (ODA), a direct communication link between pathology and decedents' families, on hospital autopsy consent rates, autopsy-related communication, practitioner views, and next-of-kin experiences. A before and after study involving all hospital decedents whose deaths did not fall within the jurisdiction of the medical examiner's office from 2013 to 2018. A pathology-run ODA launched in May 2016 to guide next-of-kin through the hospital death process (including autopsy-related decisions) and serve as the next-of-kin's contact for any subsequent autopsy-related communication. Critical care and hematology/oncology practitioners were assessed for their autopsy-related views and decedents' next-of-kin were assessed for their autopsy-related experiences. Autopsy consent rates for non-medical examiner hospital deaths, autopsy-related communication rates, practitioner views on the role and value of autopsy, and next-of-kin autopsy experiences and decisions factors were compared prior to and after ODA launch. Autopsy consent rates significantly increased from 13.2% to 17.3% (480 of 3647 deaths versus 544 of 3148 deaths; P < .001). There were significant increases in the rate of autopsy-related discussions and bereavement counseling provided to decedents' families. Practitioner views on the positive role of autopsy for any hospital death and those with advanced stage cancer also significantly increased. Next-of-kin indicated more consistent autopsy-related discussions with the potential benefits of autopsy discussed becoming key decision factors. An ODA improves hospital autopsy consent rates, autopsy-related communication, providers' autopsy-related views, and next-of-kins autopsy experiences.

Body of Evidence: Do Autopsy Findings Impact Medical Malpractice Claim Outcomes?

Clinicians may hesitate to advocate for autopsies out of concern for increased malpractice risk if the pathological findings at time of death differ from the clinical findings. We aimed to understand the impact of autopsy findings on malpractice claim outcomes. Closed malpractice claims with loss dates between 1995 and 2015 involving death related to inpatient care at 3 Harvard Medical School hospitals were extracted from a captive malpractice insurer's database. These claims were linked to patients' electronic health records and their autopsy reports. Using the Goldman classification system, 2 physician reviewers blinded to claim outcome determined whether there was major, minor, or no discordance between the final clinical diagnoses and pathologic diagnoses. Claims were compared depending on whether an autopsy was performed and whether there was major versus minor/no clinical-pathologic discordance. Primary outcomes included percentage of claims paid through settlement or plaintiff verdict and the amount of indemnity paid, inflation adjusted. Of 293 malpractice claims related to an inpatient death that could be linked to patients' electronic health records, 89 claims (30%) had an autopsy performed by either the hospital or medical examiner. The most common claim allegation was an issue with clinician diagnosis, which was statistically less common in the autopsy group (18% versus 38%, P = 0.001). There was no difference in percentage of claims paid whether an autopsy was performed or not (42% versus 41%, P = 0.90) and no difference in median indemnity of paid claims after adjusting for number of defendants ($1,180,537 versus $906,518, P = 0.15). Thirty-one percent of claims with hospital autopsies performed demonstrated major discordance between autopsy and clinical findings. Claims with major clinical-pathologic discordance also did not have a statistically significant difference in percentage paid (44% versus 41%, P > 0.99) or amount paid ($895,954 versus $1,494,120, P = 0.10) compared with claims with minor or no discordance. Although multiple factors determine malpractice claim outcome, in this cohort, claims in which an autopsy was performed did not result in more paid outcomes, even when there was major discordance between clinical and pathologic diagnoses.

English

Mortality data necessary for proper healthcare planning, policy formulation, and implementation is hampered by a decline in hospital autopsy practice. Therefore, non-autopsy based death profile reviews provide a framework for the presentation and discussion of reliable mortality data. This study aims to present the general mortality profile of the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria. This was a retrospective review of deaths recorded among patients admitted into various wards and emergency units of the University of Port Harcourt Teaching Hospital between 1st January, 2012 and 31st December, 2017. Decedent causes of death were eluted from case notes and death certificates, and were systemically classified using the ICD10 disease coding scheme. SPSS version 23 and Minitab version 16 were used for data and trend analysis respectively. A total of 1902 mortalities were recorded in the following order: Diseases of the cardiovascular system - 566 (29.8%), infectious diseases - 360 (18.9%), external causes of morbidity and mortality - 271 (14.2%), malignant neoplasms - 221 (11.6%) and diseases of the endocrine system - 112 deaths (5.9%). Males constituted 989 (52.1%) while females constituted 913 (47.9%). The overall mean age was 46.64± 0.42, range was 1 month to 98 years. Children and adolescents aged 0-19 years recorded 123 (6.5%) deaths while adults aged 20-59 years recorded 1245 (65.5%) and the elderly, aged 60 years and above constituted 556 (28.1%). With due consideration to the possible forces of general population evolution, it was observed that although the trend was undulating, there was an overall increase in mortality over the years, with an upward skew. The study thus showed that diseases of the cardiovascular system have overtaken infectious diseases as the commonest causes of deaths in Port Harcourt, Nigeria, hence the channeling of appropriate health resources towards combating this epidemiological shift is advocated. Key words: Mortality, cardiovascular, diseases, infectious, Port Harcourt, Nigeria.

Autopsy Service Death Certificate Review.

Despite the importance of accurate death statistics for epidemiologic studies and public health initiatives, there remains a high frequency of errors in death certification. This deficiency can be addressed by the hospital autopsy service. To improve the quality and accuracy of death certificates issued in the hospital and improve resident and clinician education by initiating a death certificate review process, performed by pathology residents while on their hospital autopsy rotation. A resident reviewed all death certificates issued in the hospital daily through the state electronic death certificate filing system and correlated with the decedent's medical record. When errors were found, the resident filed an amended death certificate with the state. If applicable, the Office of the Medical Examiner was contacted to investigate. The original certifying physician was then contacted via email with an explanation for the amendment. In 12 months, 590 death certificates were issued by the hospital. Eighty-eight of 590 (15%) were amended. Of those 88 amended, 41 (47%) were missing an underlying cause of death, 7 (8%) had an inaccurate cause of death, 41 (47%) failed to include relevant contributory causes of death, and 17 (19%) had major typographic errors. Of 88, 24 (27%) fell under the Office of the Medical Examiner's jurisdiction and were reported with a subsequent change in the manner of death in 23 of 88 cases (26%). Death certificate review by the autopsy service improves the accuracy of death certification, impacts resident and clinician education, and serves as quality assurance for both the hospital and the state.

Ultrasound-guided minimally invasive autopsies: A protocol for the study of pulmonary and systemic involvement of COVID-19

INTRODUCTION Over the last few decades, there has been a dramatic decrease in the number of hospital autopsies conducted around the world. However, autopsies are important for increasing our understanding of novel diseases. For example, autopsies were of vital importance in understanding acquired immunodeficiency syndrome (AIDS) and H1N1. There is a lack of literature on autopsies conducted on patients that have died of COVID-19 despite the high number of deaths worldwide. This is probably due to the risk of contagion, [...]

Autopsy Brain Removal Training Using Virtual Reality Simulation

Hospital autopsy is important for diagnosing neurodegenerative disease in deceased patients. Despite its importance, training autopsy brain removal is challenging for autopsy assistants due to lack of availability of real specimens, initial hesitation to perform the procedure because of proximity to the face, and limited teaching tools. To address these deficits, a virtual reality (VR) simulation was created to teach proper methods to perform the steps of the procedure. This simulation features real-time visual feedback of user performance during the step of opening the cranium with an oscillating saw in order to assist in skill improvement. It also provides an immersive VR interactive experience using realistic virtual patient models, sound effects, and haptic responses.

Learning from the non-survivors

Intensive care unit has a high mortality rate where despite best of the efforts by the healthcare staff, some patients will not survive. Autopsy studies have shown that missed diagnosis is not an infrequent occurrence. However, the rates of hospital autopsies are variable. ‘Digital autopsy’ is a recent modality, which can reduce the need for open autopsies, besides providing useful information about the cause of death instantaneously. Resource constraints mean that it is not universally applicable at present. Apart from correct diagnosis, the ‘process of care’ is also vital to successful outcome. ‘Mortality review’ or audit of all deaths in intensive care should look at this aspect, which in turn will help identify areas for individual, team and system improvements.Citation: Kannan S. Learning from the non-survivors. Anaesth Pain &amp; Intensive Care 2018;22 Suppl 1:S1-S3 Received: 30 May 2018 Reviewed: 2 Jul 2018 Corrected: 12 Jul 2018 Accepted: 12 Jul 2018

Observations of the Morphological Evolution of Neuronal Intranuclear Rods in the Human Substantia Nigra Across the Age Spectrum

Abstract Objectives Parkinson’s disease (PD) is a neurodegenerative disease characterized by a depletion of dopaminergic neurons in the substansia nigra (SN). Loss of SN neurons occurs at a rate of up to 10% per decade in nonpathological aging. Other age-related changes in nigral neurons include accumulation of intranuclear inclusions called Marinesco bodies (MBs). MBs have been shown to associate with a distinct type of neuronal intranuclear body called the intranuclear rod (INR). At what point in the aging process INRs develop, and when they give rise to MBs, are questions that remain unanswered. In this observational study, we set out to determine whether SN INRs display changes in their morphology across the human age spectrum. Methods The laboratory information system was searched for hospital and forensic autopsies conducted from 2010-2017 that had midbrain sections taken. Ten slides were cut from each of 11 age groups from ages ranging from 1 month to 80 years of age. Sections were immunostained with glucocorticoid receptor (GR) to identify INRs. Results There was a progressive age-associated transition in INR morphology from long, linear intranuclear structures in the youngest age groups (infants), to shorter linear structures at middle ages, culminating in small, dot-like juxtanucleolar structures in elderly subjects. A proportion of short INRs displayed contact with MBs in the middle age groups. Conclusion We demonstrated a striking progressive, age-dependent alteration in INR morphology. These results suggest that INRs give rise to MBs in the SN during middle ages. As a follow-up of this preliminary observational study, quantitative analysis of INR frequency and size is currently being performed in our lab. Ultimately, we plan to expand our cases for the creation of a human SN tissue microarray, which we hope will shed light on the cellular mechanisms of neuronal ageing and degeneration in the SN.

Quality Assurance of the Gallbladder and Relationship Between Gallstones and Abdominal Panniculus Thickness in Adult Hospital Autopsies

Abstract Objectives Inconsistency in the autopsy report can be a liability issue. We studied the discordance between the presence of the gallbladder and a corresponding abdominal scar and suggest how to improve this error. To our knowledge, the relationship between abdominal panniculus thickness in adult hospital autopsies and the presence of gallstones has not been reported in the literature. We report the correlation between age, sex, average panniculus thickness, and gallstones. Methods The laboratory information system was searched for autopsies performed between 1/1/09 and 12/21/18. Patients &lt;18 years old and partial, nonabdominal autopsies were excluded. Autopsy reports were reviewed, and the following data were recorded: age, sex, presence or absence of gallbladder, abdominal scars, abdominal panniculus thickness, and gallbladder pathology. Results Out of 385 autopsies reviewed, 48 (12.5%) had cholecystectomies. Of these 48 patients, 6 (12.5%) abdominal scars were not documented. The presence of the gallbladder was not mentioned in 6 (1.6%) reports. The most common pathology was gallstones, 78 (20.3%); cholesterolosis, 9 (2.3%); and cholecystitis, 6 (1.6%). The average age of females and males with gallstones was 68.9 and 66.4 years, respectively. The average abdominal panniculus thickness in males with and without gallstones and in females without gallstones was 3.3 cm. In contrast, the average abdominal panniculus thickness in females with gallstones was 4.0 cm. Conclusion Our study demonstrated that 12.5% of our autopsy reports failed to document the presence of abdominal scars in patients who surgically lacked a gallbladder. There is a need to improve documentation of abdominal scars and the presence or absence of the gallbladder. This can be achieved by creating mandatory fields (eg, gallbladder present/surgically absent) in the autopsy report template. Also, our study found that females with gallstones have a thicker abdominal panniculus than females without gallstones and males with or without gallstones.

Reaffirming the Value of the Autopsy.

To determine characteristic features of myocardial infarction (MI) diagnosed at autopsy and establish the incidence of discrepancy. Autopsy cases at a tertiary hospital with a pathologic diagnosis of acute MI were evaluated for clinicopathologic features. Modified Goldman's classification was used to classify discrepant cases. Of 529 autopsy cases, 19 (3.6%) demonstrated acute/subacute MI as a pathologic diagnosis. Thrombosis was identified in a minority of cases (3/19, 15.8%). Major clinicopathologic discrepancies were identified in four (21.1%) cases. Although acute MI is an uncommon diagnosis rendered at hospital autopsy, a notable subset of cases demonstrates diagnostic discrepancy between the clinical impression and ultimate pathologic diagnosis. Interestingly, most MI cases in this series are not related to plaque disruption and thus best classified as a type 2 MI, which is associated with imbalance between oxygen demand and supply.

Iatrogenic embolization following cardiac intervention: postmortem analysis of 110 cases.

Iatrogenic embolization following cardiac investigative procedures may result from hydrophilic polymer emboli (HPE) from catheter valve and vessel wall calcifications, and air embolism from open heart surgery. This retrospective clinical pathologic analysis was undertaken to ascertain the frequency and extent of these potentially fatal complications. This retrospective clinical pathologic autopsy analysis with premortem diagnostic imaging correlation identified 110 individuals who had undergone endovascular procedures between 2010 and 2016 within 90 days of death and followed by hospital autopsy. Clinical outcomes, radiologic studies, and autopsy materials were reviewed. Iatrogenic emboli were assessed as causing death in 9/110 autopsy cases (8.2%) and 9/34 (26.5%) cases with proven iatrogenic emboli. Iatrogenic emboli caused strokes in 10/110 (9.1%) autopsy cases including calcified emboli (CE, n=6), HPE (n=2), cardiac valvular tissue (n=1), and air embolism (n=1). Seven cases of calcified emboli complicating endovascular procedures were identified: four of the CE were thought to be the cause of death due to fatal strokes (n=2) and fatal myocardial (n=1) and colonic infarction (n=1). The CE likely originated from calcified aortic valves and atherosclerotic aortic plaques. Histologic evidence of HPE was found in 23% (25/110) of cases; 54% (26/48) showed evidence of infarction in postprocedural imaging, with radiologic evidence of infarction in 32% (8/25) of cases with HPE histology. Endovascular aortic repair was associated with the greatest density/distribution of HPE. HPE material showed degradation with time and was often associated with an inflammatory response. HPE directly contributed to death in three cases. One fatal air embolism followed open heart surgery, and one cardiac tissue embolus resulted in a major stroke. We advocate for greater awareness of these underrecognized and occasionally fatal complications of endovascular procedures. Targeted postprocedural imaging has a role in the identification of iatrogenic embolic infarcts.

Autopsy Standardized Mortality Review: A Pilot Study Offering a Methodology for Improved Patient Outcomes

A standardized mortality review of hospital autopsies identified discrepancies between clinical diagnoses and autopsy findings, unexpected deaths, adequacy of diagnostic workup, presence of adverse event, and type of a quality issue if present. The standardized review elements were chosen based on a review of quality metrics commonly used by hospitals. The review was completed by the pathologist based on their initial autopsy findings. The final autopsy report was later reviewed to confirm the initial review findings. Major discrepancies in diagnosis were categorized as class I or II based on the modified Goldman criteria. Ninety-six hospital autopsy cases from January 2015 to February 2018 were included in the study. The overall major discrepancy rate was 27%. Class I discrepancies, where a diagnosis found at autopsy might have improved survival had it been made premortem, were identified in 16% of cases. Categories associated with increased discrepancy rates included unexpected deaths, inadequate workup, abnormal labs or imaging not addressed, and certain quality issues. Deaths not expected at admission but expected at the time of death, those with adverse events, those within 48 hours of a procedure, those within 48 hours of admission, those with physician-specific quality issues, and those with system or process issues were not significantly related to diagnostic accuracy.

Position Paper From the Association of Pathology Chairs: Assessing Autopsy Competency in Pathology Residency Training

Declining numbers of hospital autopsies performed in US pathology residency training programs and perceived declining practice of autopsy by many pathologists has caused stakeholder organizations to reassess the role of autopsy training in pathology residency. A working group convened by the stakeholder organizations has delivered the results of a detailed study of current practice of autopsy education in US pathology programs, along with recommendations for the future of autopsy education. Accepting the report of the Working Group, the Association of Pathology Chairs here publishes its position paper on the proposed recommendations.

A 20-Year Review of Hospital Autopsies in a Nigerian Tertiary Hospital

A 20-Year Review of Hospital Autopsies in a Nigerian Tertiary Hospital

Autopsy 2018: Still Necessary, Even if Occasionally Not Sufficient.

The average autopsy rate in US hospitals was ≈50% in the 1940s and 41% in 1970, just before the Joint Commission on the Accreditation of Hospitals eliminated the requirement for a 20% autopsy rate. Since that time, autopsy rates have been in free fall, with estimated rates currently ≈8% overall, including forensic cases, but only 4% among in-hospital deaths. About 700 000 Americans die in acute-care hospitals each year, so these percentages translate into ≈28 000 hospital autopsies annually. Three explanations are commonly proposed for these falling rates: the lack of reimbursement for autopsies, the fear of disclosing mistakes that would lead to malpractice suits, and the belief that advances in medical technology, including but not limited to computed tomographic scans and magnetic resonance imaging, have made autopsies obsolete. The first 2 rationales could easily be resolved by effective legislation, such as Medicare reimbursement for autopsies, or regulation, such as reinstatement of a minimum required autopsy rate. From a scientific perspective, however, the key issue is whether autopsies remain as critical for measuring the quality of care and advancing medicine as they were 80 or even 50 years ago. The autopsy is the ultimate diagnostic test, typically the gold standard, with an assumed 100% sensitivity for finding causes of death and 100% specificity for excluding them. Of course, no test is perfect; any gold standard is simply the current best. Diagnosis in isolation, although interesting, …