Permission For Autopsy Research Articles

Decisions to consent for autopsy after stillbirth: Aboriginal and Torres Strait Islander women's experiences.

The stillbirth rate for Australian Aboriginal and Torres Strait Islander infants is twice that for non-Indigenous infants. Autopsy is the gold standard for fetal investigation; however, parental consent is often not given. There is little research investigating the drivers of parents' decision-making for autopsy after stillbirth. The current study explored the reasons why Aboriginal and Torres Strait Islander women did or did not give permission to autopsy after stillbirth. Five Aboriginal and/or Torres Strait Islander women participated in semi-structured interviews. Thematic analysis was conducted within a phenomenological framework. Five themes were identified as reasons for giving permission - to find out why the baby died; to confirm diagnosis; to understand future risk; to help others; and doubt about maternal causes. Four themes were identified as reasons for declining permission - not asked in a sensitive manner; not enough time to think; distress about the autopsy procedure; and unwilling to agree. There was a lack of acceptability of the lengthy timeframe for the availability of autopsy results as families usually wait between three and nine months. This lengthy waiting period negatively impacted upon families' health and wellbeing. It is important for health professionals to understand the factors that parents consider when giving permission for autopsy after stillbirth. It is hoped that an increase in autopsy rate will enhance the understanding of the causes of stillbirth and ultimately decrease the stillbirth rate for Aboriginal and Torres Strait Islander families.

Motivational interviewing increases autopsy rates.

Autopsies are a crucial source of medical knowledge. Unfortunately, autopsy rates have decreased markedly in Switzerland and many other countries. Communication between clinicians and the deceased’s sceptical relatives is crucial to obtain autopsy permission. This survey investigates the personal views of multimorbid patients and their relatives on autopsies. In addition, the study examines whether motivational interviewing of the decedent’s relatives according to Miller and Rollnick can be used to increase autopsy rates. At the Department of Medicine of the Kantonsspital Winterthur, Switzerland, the views of multimorbid patients and their relatives on autopsies were surveyed between 1 September 2014 and 31 December 2015 (14 months) using a standardised questionnaire. All physicians participated in a 1-hour tutorial on motivational interviewing. From November 2014 to October 2015, motivational interviewing was used to improve the communication between physicians and the decedent’s relatives and to obtain autopsy permission. Autopsy rates before, during and after this intervention were compared. Questionnaires were completed by 135 multimorbid patients and 82 corresponding relatives. Views on autopsies were mostly positive. Before the intervention, there had been a steady decline in the number of autopsies ranging from 18.9% (412 deaths and 78 autopsies) in 2010, to 12.8% (489 deaths and 53 autopsies) in the 12-month period prior to the intervention. During the intervention (motivational interviewing of the decedents’ relatives in asking for autopsy permission), 489 deaths occurred and 132 autopsies were performed (26.9%). This increase was highly statistically significant (p <0.0001). During the 12-month period after motivational interviewing was terminated, the autopsy rate dropped to 23.3% (statistically not significant; p = 0.174). The positive views on autopsies expressed by multimorbid patients and their relatives contrasts with the low and steadily declining autopsy rates at our institution and in general. Motivational interviewing is an easy-to-learn and effective technique to increase autopsy rates. Physicians should be taught how to communicate better with grieving relatives when asking for autopsy consent.

子宮体部未分化癌の大腸血管浸潤が原因であった虚血性腸炎の1例

An 84-year-old female was referred to our hospital complaining of lower abdominal pain. She had undergone surgery for sigmoid-colon cancer a year ago. Abdominal CT revealed enlargement of the uterine body. Colonoscopy revealed only an inflammatory polyp in the anastomosis, and no evidence of other inflammation or recurrence was observed. Ultrasonography and cervical cytology revealed no evidence of malignancy. Since the lower abdominal pain was persistent, we repeated the colonoscopy one week later, which revealed erosion, redness and necrosis of the mucous membrane over the entire circumference of the descending colon. Based on the findings, the patient was diagnosed as having ischemic colitis. Subsequently, the patient died of acute renal failure, and we requested permission for autopsy to determine the cause of death. Autopsy revealed the death as being due to undifferentiated carcinoma of the uterine body, and that the ischemic colitis was caused by infiltration of the colonic wall vessels by the uterine body cancer. This case serves to emphasize that in the etiopathogenesis of ischemic colitis, possible involvement of a malignant tumor must not be overlooked.

Massive dissemination of adult glioblastomas.

Recent autopsy data suggests a high incidence of leptomeningeal metastases (LM), Acta Neuropathologica 2014; 128: 573 and subventricular spread (SVS), Acta Neuropathologica 2014; 127: 605 in pediatric diffuse intrinsic pontine gliomas, but both LM and SVS also occur in adult glioblastoma (GBM). Autopsy is required to fully appreciate this tumor behavior. From January 1, 2014 to January 3, 2015 we conducted 239 adult autopsies, 8 of which were identified on search to be GBMs. Of these 8 GBMs, one-half showed bulky spread (SVS (n = 2), LM (n = 2), bone marrow (n = 1)), and 2 of these 4 additionally had microscopic LM. In patient 1 GBM with a very minor epithelioid component on the surgical specimen spread evolved to a predominantly epithelioid GBM (E-GBM) phenotype in the clinically-unsuspected LM at autopsy. Patient 2, with malignant glioma with primitive neuroectodermal tumor (MGPNET), had a secondary GBM with a noncanonical isocitrate dehydrogenase 1 (IDH1) mutation and 11-year-survival; autopsy showed encasement of the entire bilateral ventricular system by SVS. Patient 3, also with an IDH1- positive secondary GBM, had survived 10 years, only to develop thrombocytopenia and succumb to extensive bone marrow replacement by his tumor. Patient 4 had a radiation-induced posterior fossa GBM that demonstrated LM/SVS spread pattern identical to that described in pediatric diffuse pontine gliomas. Several subtypes of adult GBM (MG-PNET, posterior fossa GBMs, E-GBMs) have recently been recognized to have a propensity for LM; autopsy permission should especially be sought for these tumor types. Correlation between genetics and LM/SVS is now possible and may shed further light on this behavior.

Neuropathologic assessment of participants in two multi-center longitudinal observational studies: the Alzheimer Disease Neuroimaging Initiative (ADNI) and the Dominantly Inherited Alzheimer Network (DIAN).

It has been hypothesized that the relatively rare autosomal dominant Alzheimer disease (ADAD) may be a useful model of the more frequent, sporadic, late-onset AD (LOAD). Individuals with ADAD have a predictable age at onset and the biomarker profile of ADAD participants in the preclinical stage may be used to predict disease progression and clinical onset. However, the extent to which the pathogenesis and neuropathology of ADAD overlaps with that of LOAD is equivocal. To address this uncertainty, two multicenter longitudinal observational studies, the Alzheimer Disease Neuroimaging Initiative (ADNI) and the Dominantly Inherited Alzheimer Network (DIAN), leveraged the expertise and resources of the existing Knight Alzheimer Disease Research Center (ADRC) at Washington University School of Medicine, St. Louis, Missouri, USA, to establish a Neuropathology Core (NPC). The ADNI/DIAN-NPC is systematically examining the brains of all participants who come to autopsy at the 59 ADNI sites in the USA and Canada and the 14 DIAN sites in the USA (eight), Australia (three), UK (one) and Germany (two). By 2014, 41 ADNI and 24 DIAN autopsies (involving nine participants and 15 family members) had been performed. The autopsy rate in the ADNI cohort in the most recent year was 93% (total since NPC inception: 70%). In summary, the ADNI/DIAN NPC has implemented a standard protocol for all sites to solicit permission for brain autopsy and to send brain tissue to the NPC for a standardized, uniform and state-of-the-art neuropathologic assessment. The benefit to ADNI and DIAN of the implementation of the NPC is very clear. The NPC provides final "gold standard" neuropathological diagnoses and data against which the antecedent observations and measurements of ADNI and DIAN can be compared.

HIV-Associated Disseminated Emmonsiosis, Johannesburg, South Africa

HIV-Associated Disseminated Emmonsiosis, Johannesburg, South Africa

Erfelijkheidsonderzoek bij plotselinge dood

Background: Sudden death in people younger than 45 years is often a consequence of inherited heart disease. For this reason, autopsy and genetic testing of relatives for familial heart diseases is recommended. However, in the Netherlands these procedures are performed in the minority of cases only. The aim of this study was to investigate what factors hinder implementation of recommended procedures. Methods: During four semi-structured focus group meetings with 7-9 general practitioners (GPs) and/or coroners, participants discussed problems they encountered at different times during these procedures: certifying death due to natural causes, asking permission from relatives to perform an autopsy, and, in the case of GPs, referring relatives for genetic testing. Participants were also asked about possible solutions to these problems. Results: There were several logistic, financial, and emotional difficulties to providing a medical certificate of the cause of death as being from natural causes and asking permission for autopsy, as well as problems in the interaction between GPs and coroners. GPs had little experience with the recommended procedures and were often insufficiently aware of the importance of familial screening in the case of sudden death. Coroners often felt they are unjustifiably placed in the role of healthcare provider if GPs left the issuing of the medical death certificate and the request for autopsy to them. The participants suggested several solutions for these problems. Conclusion: Several factors hinder the implementation of recommended procedures in the case of sudden death in young individuals. A national guideline seems ineffective, but a different system for the reimbursement of costs, information for GPs, and the appointment of national case managers to ensure that legal and medical aspects are handled according to recommended procedures might increase the number of autopsies performed in the case of sudden death and possibly reduce the number of sudden deaths. © 2013 Bohn, Stafleu van Loghum.

1723 Newborn Autopsies: Experience of a Referral Level III Neonatal Intensive Care Unit in Turkey

AimNeonatal autopsies is a guide to explore the causes of the perinatal mortalities which is important marker for evaluation of the health policies. Multidisciplinary approach which includes obstetrician, pediatrician, pathologist...

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

Autopsy consent, brain collection, and standardized neuropathologic assessment of ADNI participants: The essential role of the Neuropathology Core

Background Our objectives are to facilitate autopsy consent, brain collection, and perform standardized neuropathologic assessments of all Alzheimer's Disease Neuroimaging Initiative (ADNI) participants who come to autopsy at the 58 ADNI sites in the USA and Canada. Methods Building on the expertise and resources of the existing Alzheimer's Disease Research Center (ADRC) at Washington University School of Medicine, St. Louis, MO, a Neuropathology Core (NPC) to serve ADNI was established with one new highly motivated research coordinator. The ADNI-NPC coordinator provides training materials and protocols to assist clinicians at ADNI sites in obtaining voluntary consent for brain autopsy in ADNI participants. Secondly, the ADNI-NPC maintains a central laboratory to provide uniform neuropathologic assessments using the operational criteria for the classification of AD and other pathologies defined by the National Alzheimer Coordinating Center (NACC). Thirdly, the ADNI-NPC maintains a state-of-the-art brain bank of ADNI-derived brain tissue to promote biomarker and multi-disciplinary clinicopathologic studies. Results During the initial year of funding of the ADNI Neuropathology Core, there was notable improvement in the autopsy rate to 44.4%. In the most recent year of funding (September 1 st, 2008 to August 31 st 2009), our autopsy rate improved to 71.5%. Although the overall numbers to date are small, these data demonstrate that the Neuropathology Core has established the administrative organization with the participating sites to harvest brains from ADNI participants who come to autopsy. Conclusions Within two years of operation, the Neuropathology Core has: (1) implemented a protocol to solicit permission for brain autopsy in ADNI participants at all 58 sites who die and (2) to send appropriate brain tissue from the decedents to the Neuropathology Core for a standardized, uniform, and state-of-the-art neuropathologic assessment. The benefit to ADNI of the implementation of the NPC is very clear. Prior to the establishment of the NPC in September 2007, there were 6 deaths but no autopsies in ADNI participants. Subsequent to the establishment of the Core there have been 17 deaths of ADNI participants and 10 autopsies. Hence, the autopsy rate has gone from 0% to 59%. The third major accomplishment is the detection of co-existent pathologies with AD in the autopsied cases. It is possible that these co-morbidities may contribute to any variance in ADNI data.

Mosaic trisomy 1q: The longest surviving case

We present the longest known surviving case of a male infant with a mosaic complete trisomy 1q. Born at 39 weeks of gestation with respiratory distress, his weight was 3,330 g (25th centile); he had micrognathia, a posterior cleft of palate, abnormal ears and left thumb, syndactyly, and an absent corpus callosum. Initial blood karyotype was normal (46,XY). He died at age 5 months. Autopsy suggested aspiration as the primary cause of death and confirmed the antemortem findings of an absent corpus callosum and atrial septal defect. It also identified some central nervous system, cardiac, gastrointestinal, and lung anomalies not previously recognized. Cytogenetic analysis of skin fibroblasts obtained at autopsy showed a de novo unbalanced translocation between chromosomes 1 and 22: 46,XY,+1,der(1;22)(q10;q10)[25]/46,XY[65] in the cells examined. The previously reported cases had a similar phenotype with birth weight above the 50th centile for gestational age, small mouth, micrognathia, abnormal ears, abnormal fingers, microphthalmia, and hydrocephalus. The present case and a review of the literature delineates the phenotype in trisomy 1q, and reinforces the critical importance of effective communication between specialists, and obtaining permission for autopsy and skin biopsy, in the pursuit of a diagnosis.

Accidental fatal asphyxiation by sand inhalation

A 36 year old laborer was pronounced dead by the casualty doctor on arrival to the hospital. To avoid blame, witnesses and fellow workers fabricated a scenario that resulted in the doctor certify death as due to myocardial infarction. The body was then taken to the mortuary of the Department of Forensic Medicine as a routine procedure to furnish a medico-legal report, which is a pre-requisite for bodies to be taken out of the country. No external injuries were found by the authors who noted deposition of sand all over the clothed body of the deceased. Some sand was also seen inside eyes, mouth and external ear canals. X-ray examination showed radio-opacities in pharynx, larynx, trachea, bronchi and esophagus. The forensic medical examiners (authors) requested permission for autopsy from the director of public prosecution. Autopsy demonstrated that death was due to asphyxiation due to inhalation and swallowing of sand. Consequent on the opinion of the forensic medical examiners the police opened an inquiry. It was established that the deceased was accidentally buried alive when a wheeled loading shovel emptied its load of sand over him at a construction site. The initial misdiagnosis was attributed to failure of the hospital doctor to realize the significance of the presence of sand in exposed orifices. The false account of the circumstances of death had also contributed to that misdiagnosis.

Tension pneumopericardium leads to cardiac tamponade during hand-assisted ventilation in patients with uremia

Tension pneumopericardium is a rare disease and may indeed be life threatening. It usually occurs in patients receiving assisted ventilation. We report a case of tension pneumopericardium in a patient during computer tomographic scanning. The CT scanning provides us with the necessary images during the development of tension pneumopericardium. Clinical Summary A 62-year-old female patient with a diagnosis of chronic renal insufficiency, uremia, renal anemia, and renal hypertension was admitted to the First Affiliated Hospital, School of Medicine, Zhejiand University on May 1, 2006. At 6 PM on May 6, the patient experienced palpitations after continuous renal replacement therapy was performed, and an atrial fibrillation was observed. After the administration of 5 mg of diltiazem, the patient’s heart rate decreased and returned to sinus rhythm. At 1:30 AM on May 7, the patient began to cough blood sputum and showed chest distress and tachypnea. The life monitor showed a molecular oxygen saturation of 85% to 92%, and moist rales were heard in both sides of the lung. The patient was transferred to the intensive care unit for further observation and management. Shortly afterward, the patient was intubated with mechanical ventilation support. On May 15, the intubated patient underwent a chest computed tomography (CT) scan with hand-assisted ventilation through an Ambu bag. During the examination, the patent’s pulse oxygen saturation decreased dramatically and heart rate decreased gradually. Subcutaneous emphysema developed from the chest to the neck. The CT scan revealed that rightsided pneumothorax,pneumomediastinum, andtensionpneumopericardium were developing (Figures 1 and 2). Two 16-gauge cannulas were punctured into both sides of the patient’s chest, and compelled air was released from the right side of the chest. Epinephrin was injected intravenously, and chest compression was performed; the patient’s heart rate, blood pressure, and oxygen saturation continued to decrease. Ventricular fibrillation occurred, and lidocaine was not effective. Percutaneous pericardiocentesis via the subxiphoid route was performed by the cardiac surgeon later. The patient’s response was observed, but her pupils were diffused. The patient was returned to the intensive care unit after resuscitation, but she never regained consciousness. Six hours later, the patient’s condition worsened; the cardiopulmonary resuscitation procedure and further attempts were unsuccessful. Permission for autopsy was denied.

THE CLASSIC: Intrapelvic Protrusion of the Acetabular Component Following Total Hip Replacement

THE CLASSIC: Intrapelvic Protrusion of the Acetabular Component Following Total Hip Replacement

Circumstances surrounding dying in the paediatric intensive care unit.

BackgroundDeath is inevitable in the paediatric intensive care unit (PICU). We aimed to describe the circumstances surrounding dying in a PICU.MethodThe chart records of all patients less than 18 years of age who died at the PICU between January first 2000 and July first 2005 were retrospectively analyzed. Information regarding sex, age, length of stay, admission, diagnosis, and the way a patient died was registered. Post mortem information regarding natural versus unnatural death, autopsy and donation was obtained. Non-survivors were allocated in five groups: do-not-resuscitate (DNR), withholding and/or withdrawal of therapy (W/W), failed cardiopulmonary resuscitation (failed CPR), brain death (BD), and terminal organ failure (TOF).ResultsDuring the study period 87 (4.4%) of the 1995 admitted patients died. Non-survivors were more often admitted during the day (54%) and the week (68%). W/W was found in 27.6%, TOF in 26.4%, BD in 23.0%, failed CPR in 18.4%, and DNR in 4.6%. Forty-three percent died in the first two days, of which BD (40.5%) and failed CPR (37.8%) were most common. Seventy-five children (86%) died due to a natural cause. Autopsy permission was obtained in 19 of 54 patients (35%). The autopsies confirmed the clinical diagnosis in 11 patients, revealed new information in 5 patients, and in 3 patients the autopsy did not provide additional information. Nine patients were medically suitable for organ donation and 24 patients for tissue donation, whereas consent was only obtained in 2 cases in both groups.ConclusionWe observed that 43% of the patients died within the first two days of admission due to BD and failed CPR, whereas after 4 days most patients died after W/W. Autopsy remains an useful tool to confirm clinical diagnoses or to provide new information. Only a small percentage of the deceased children is suitable for organ donation.

Focally Elevated Creatine Detected in Amyloid Precursor Protein (APP) Transgenic Mice and Alzheimer Disease Brain Tissue

The creatine/phosphocreatine system, regulated by creatine kinase, plays an important role in maintaining energy balance in the brain. Energy metabolism and the function of creatine kinase are known to be affected in Alzheimer diseased brain and in cells exposed to the beta-amyloid peptide. We used infrared microspectroscopy to examine hippocampal, cortical, and caudal tissue from 21-89-week-old transgenic mice expressing doubly mutant (K670N/M671L and V717F) amyloid precursor protein and displaying robust pathology from an early age. Microcrystalline deposits of creatine, suggestive of perturbed energetic status, were detected by infrared microspectroscopy in all animals with advanced plaque pathology. Relatively large creatine deposits were also found in hippocampal sections from post-mortem Alzheimer diseased human brain, compared with hippocampus from non-demented brain. We therefore speculate that this molecule is a marker of the disease process.

Severe hypotension and fetal death due to tocolysis with nifedipine

A 23 year old woman of African origin was referred from a peripheral unit at 26 weeks and five days of gestation in her second pregnancy because of preterm labour. She had previously had an uncomplicated pregnancy. On admission, we continued the tocolytic therapy with atosiban and the administration of steroids to mature the fetal lungs, which had already been started in the referring hospital. The uterine contractions continued and indomethacin was combined with atosiban for 24 hours. Finally, the contractions ceased. Ultrasound investigation showed one fetus with no obvious abnormalities. The estimated fetal weight was 800 g (10th– 25th centile). The membranes were intact and there were no signs of infection: no fever and the urine sample and vaginal swab showed no abnormalities. On admission, her blood pressure was 115/75 mmHg and remained stable. After 48 hours, the atosiban was discontinued and 5 hours later the uterine contractions started again. On examination per vaginam the cervix was fully effaced and the os uterine was 3 cm dilated. Because of severe prematurity, tocolytic therapy was restarted with orally administered nifedipine as outlined in the following regimen: first dose nifedipine 10 mg tablet chewed, followed by three further doses of nifedipine 10 mg every 15 minutes, followed by nifedipine slow release 20 mg every 3 or 4 hours depending on uterine activity. After the second dose, fetal cardiotocography became difficult to interpret due to a poor quality record and the blood pressure dropped without symptoms to 73/30 mmHg. Ultrasound examination showed severe bradycardia soon followed by fetal death. Tocolytic therapy was discontinued and colloid infusion started and after 6 hours the blood pressure reached its normal level again. The next day, labour was induced with vaginally administered misoprostol. A stillborn girl of 780 g was born (10th–25th centile). No obvious abnormalities were seen, apart from a marginal insertion of the umbilical cord to the placenta. The placenta weighted 150 g. The umbilical cord showed two arteries and one vein. On histopathology, 20% placental infarction was reported. Permission for autopsy was not obtained.

Ischemic stroke in patients with glioblastoma multiforme

Sirs: Tumor-related ischemic strokes are most unusual in patients with malignant gliomas [1–3]. We report here two adult patients with supratentorial glioblastoma who developed an ischemic stroke on the tumor side. Patient 1: In March 2000, a 60year-old man became confused. MRI revealed a right temporal tumor which was partially resected and found to be a glioblastoma. Focal radiotherapy was administered. Four months later, intravenous BCNU was started because of tumor progression. On 13 February, 2001, he developed acutely a left hemiplegia. CT showed an extensive infarct in the territory of the right middle cerebral artery (MCA) (Fig. 1). He became comatous and died on 22 February, 2001. Patient 2: In July 1994, a 41-yearold man developed intracranial hypertension. MRI disclosed a right temporal tumor which was partially resected and found to be a glioblastoma. A course of focal radiotherapy was administered. Three months later, he had a sudden left hemiplegia and MRI showed a right lenticulostriate infarct related to an occlusion of the right supraclinoid internal carotid artery (ICA) shown by angiography. The patient died on 5 April, 1995. Permission for autopsy was not granted for either patient. These two patients suffering from a right temporal glioblastoma presented an ischemic stroke in the right ICA-MCA territories. To explain these acute events three hypotheses were considered: 1) A fortuitous association between glioma and stroke in the same location. This hypothesis is unlikely since both patients had no cerebrovascular risk factors and the angiogram in patient 2 showed no atheroma in the cervical or cerebral vessels. 2) Radiation damage to the large intracranial cerebral vessels was also considered but the very short delay between the completion of RT (5 and 3 months) and the stroke makes this hypothesis unlikely. Indeed, radiation-induced damage to the large vessels always occurs many years after RT (mean 7 years [4–6]). 3) The third possibility is a primary role for the underlying gliomas in the development of stroke. Vasospasm with multifocal infarcts has been incriminated previously in one patient with leptomeningeal gliomatosis [7] but this hypothesis can be excluded, at least in our second patient who had a persistent ICA thrombosis three months after the stroke. A hypercoagulable state (procoagulant factors secreted by gliomas) is common and partly accounts for the high incidence of deep vein thromLETTER TO THE EDITORS

Subclassification of Anencephalic Human Fetuses According to Morphology of the Posterior Cranial Fossa

Anencephaly is a designation for congenital absence of the cranial vault with cerebral hemispheres completely missing or decreased to small masses attached to the base of the skull. The etiology is unknown. Whether the bony tissue or soft brain tissue is a primary factor is also unknown. The present study has focused on the posterior cranial fossa in anencephaly. The goal is to determine whether differences in the posterior cranial fossa could provide a basis for subclassification of anencephalic fetal skeletons. Twenty-three human anencephalic fetuses, at gestational ages 13 to 22 weeks, were studied. Radiologic and cephalometric analyses, including measurements of bone sizes and different angles, were performed. Permission for autopsy of the central nervous system was not available. For comparison of anencephalic findings with normal conditions, standards from a recent publication were used. Foot length served as a parameter for age comparison. The study showed 2 morphologic types of the posterior cranial fossa. One type had a fossa cranial morphology close to normal morphology, whereas the other had a malformed and much smaller posterior cranial fossa. The latter condition was presumed to be due to a primary error in chondral and cranial development. The current skeletal subgrouping might be essential for clinicians' or pathologists' future assessment of the autopsy results. The skeletal subgrouping should, if possible, be associated with karyotyping and analysis of the central nervous system. The goal is to distinguish between congenital conditions resulting in anencephaly and acquired conditions resulting in anencephaly.

Mortality after peripheral bypass surgery: value of a mortality scoring system in evaluating the quality of care.

The objective of this study was to determine the role of a mortality registration in the quality control of patients who died after peripheral bypass surgery. We developed a mortality registration to classify causes of death, to evaluate shortcomings in treatment, and to determine the extent of agreement between pre- and postmortem findings. In a 10-year period, 28 of the 1,022 patients (2.7%) who underwent peripheral arterial reconstruction died. Fifty-three percent of the patients died owing to postoperative complications, most frequently a myocardial infarction. A shortcoming in the medical treatment was observed in only one patient. Forty-three percent of the relatives gave permission for an autopsy. In only two cases, the autopsy report revealed a myocardial infarction that had remained unnoticed during the clinical course. In this selected group of patients undergoing a peripheral bypass operation, the causes of death and the shortcomings in medical care could usually be identified without the help of autopsy data.