Massive right atrial thrombus associated with a Chiari network and a Hickman catheter.

The Chiari network is an embryologic remnant that is said to be present in only 1.5-3% of adults. It is rarely of clinical importance but may, very infrequently, be the site of thrombosis. The authors describe a patient in whom a massive right atrial thrombus formed on a Chiari network, leading to intermittent tricuspid obstruction. The thrombus had formed after the use of a Hickman catheter for the administration of cytotoxic chemotherapy. They can find no previously recorded examples of sufficient thrombus forming on a Chiari network to threaten life by obstructing the flow of blood through the heart.

Simultaneous acute inflammation in entopic and ectopic pancreas.

The necropsy findings in an elderly woman, who had been treated with methyldopa and who had died during treatment for accidental hypothermia, showed acute periductal inflammation of obviously similar duration in an entopic pancreas in the wall of the jejunum and in the ectopic pancreas. This supports the hypothesis that attempted drug detoxification by pancreatic tissue can cause pancreatitis.

Medical students' views on necropsies.

Second and third year medical students were invited to write down their comments about necropsies during a pilot study of a postal questionnaire on the subject. Their comments were analysed in detail on the following aspects: about how useful and necessary a procedure the necropsy is in medical practice and in education; their personal distaste for the procedure; whether attendance at a necropsy should remain a compulsory part of a medical education; staff attitudes; observance of relatives' wishes; and feelings about necropsies carried out on self or relatives. The data collated from the questionnaire showed that, although students regard the necropsy as useful in clinical practice, a single demonstration does not clarify what its uses are. For some, the necropsy represents disrespect to its subject, and few students seemed aware of the use of the necropsy as an instrument of quality control. It is concluded that the unpleasant aspects of a necropsy demonstration should be kept to a minimum to encourage attendance and promote a sense of its value, and that it might be useful to influence and modify students' opinions before they become entrenched, perhaps by giving a higher priority to training in discussing dying and death in the medical curricula.

Myocardial infarction caused by cardiac disease in disseminated zygomycosis.

A case of disseminated zygomycosis is described, in which myocardial infarction rather than coincident coronary or heart disease was seen at necropsy. As zygomycosis is an opportunistic fungal infection, which tends to invade blood vessels, thereby causing thrombosis and infarction, it is surprising that cardiac disease is unusual and that premortem evidence of such disease has only rarely been reported.

Speeding up necropsy histology reports in a teaching hospital.

A programme of repeated personal reminders substantially reduced the delay in producing final histological reports for necropsy cases. The proportion delayed for over four weeks was reduced from 69.7% to 46.7%, and the proportion delayed for over 10 weeks was reduced from 38.6% to 11.7%. This improvement may contribute to halting and reversing the now established trend in the decline of necropsy rates.

Conversion of a traditional image archive into an image resource on compact disc.

The conversion of a traditional archive of pathology images was organised on 35 mm slides into a database of images stored on compact disc (CD-ROM), and textual descriptions were added to each image record. Students on a didactic pathology course found this resource useful as an aid to revision, despite relative computer illiteracy, and it is anticipated that students on a new problem based learning course, which incorporates experience with information technology, will benefit even more readily when they use the database as an educational resource. A text and image database on CD-ROM can be updated repeatedly, and the content manipulated to reflect the content and style of the courses it supports.

A survey of general practitioners' views on autopsy reports.

AIMS: To study the views of general practitioners on the quality and utility of autopsy reports, and on autopsies in general. METHODS: For a period of six months, a questionnaire was enclosed with each autopsy report sent to a general practitioner from the mortuary at Manchester Royal Infirmary. RESULTS: Most (93.3%) general practitioners found the autopsy report useful, and many (66.7%) thought the bereaved relatives would do so too. However, only a minority (25.2%) would discuss the report with the relatives. A considerable proportion (20.0%) found the cause of death surprising, and a significant number (10.4%) felt the report would modify their future clinical practice. There was approval of autopsies in general, with most (88.6%) agreeing that autopsies reveal lesions not detected in life, and many (74.4%) indicating that loss of the autopsy would impair severely the monitoring of clinical standards. CONCLUSIONS: General practitioners appreciate autopsy reports, which may have a significant impact on clinical practice. Autopsy reports provide both case audit and information for relatives.

Sudden postoperative death caused by unheralded Mallory Weiss tears.

Mallory Weiss tears are a common cause of upper gastrointestinal bleeding, typically reported as following repeated vomiting after an alcoholic binge. This association may have been overemphasised, and these lesions could be caused by a wide range of spontaneous and iatrogenic events. A case of sudden postoperative death caused by massive haematemesis, unheralded by any evidence of vomiting or retching, as a result of Mallory Weiss tears is reported.

What is a natural cause of death? A survey of how coroners in England and Wales approach borderline cases.

AIM: Many deaths fall in the "grey" area between those that are clearly natural and those that are unnatural. There are no guidelines to help doctors in dealing with such cases and death certification is often arbitrary and inconsistent. In an attempt to initiate debate on these difficult areas, and with the ultimate aim of achieving national consensus, the views of coroners in England and Wales were sought. METHODS: Sixteen clinical scenarios, with causes of death, were circulated to all coroners in England and Wales. For each case they were asked to provide a verdict, with explanation. The deaths fell into three groups: (1) postoperative, (2) a combination of trauma and natural disease, and (3) infectious disease. RESULTS: Sixty four questionnaires were returned. There was near consensus (> 80% concordance) in only two of the 16 cases. In five, there was no significant agreement between coroners in the verdicts returned ("natural causes" versus "misadventure/accidental"). These included all three cases in which death resulted from a combination of trauma and natural disease (a fall after a grand mal fit; falls resulting in fractures of bones affected by metastatic carcinoma and osteoporosis), bronchopneumonia after hip replacement for osteoarthritis, and new variant Creutzfeldt-Jakob disease. The comments made for each case indicate that the variation between coroners in whether or not to hold an inquest, and the verdict arrived at, reflect the lack of a definition for natural causes, together with differences in the personal attitudes of each coroner. CONCLUSIONS: There is considerable variation in the way in which coroners approach these borderline cases, many of which are common in clinical practice. This study indicates a need for discussion, working towards a national consensus on such issues. It highlights the importance of good communication between coroners and medical staff at a local level.

Disseminated zygomycosis associated with erythroleukaemia: confirmation by lectin stains.

Zygomycosis is not often diagnosed in the United Kingdom, and so the possible importance of the findings in a patient with disseminated zygomycosis who had been treated with chemotherapy for erythroleukaemia was not appreciated until histological examination of specimens obtained at necropsy provided a presumptive diagnosis. No attempt had therefore been made to identify the organism by culture, and lectin binding methods were used to try to compensate for this. The characteristics of the hyphae on staining with lectins were similar to those previously shown in Rhizopus oryzae and were unlike those of a wide range of other hyphal fungi. Although definite speciation of the fungus was not achieved, these findings confirm that this was a case of zygomycosis and would seem to represent the first such reported confirmation in the absence of culture.

Pulmonary infarction, myocardial infarction, and acute disseminated intravascular coagulation.

Pulmonary and myocardial damage are frequently cited as manifestations of disseminated intravascular coagulation (DIC), but rarely as causes. Three elderly cases of severe DIC due to pulmonary and myocardial infarction are reported. All three patients died. Necropsy showed extensive pulmonary emboli in each case with large pulmonary infarcts in cases 1 and 2 and a ventricular aneurysm containing thrombus in cases 2 and 3. Early diagnosis and treatment of pulmonary embolism requires a high degree of clinical suspicion but may prevent progression to the irreversible stage of severe DIC.

Method for showing human spermatogenesis using Arachis hypogaea (AHA) lectin.

Using biotinylated Arachis hypogaea agglutinin (AHA) or peanut lectin (PNA) and an avidin-peroxidase procedure, the various stages of spermatid development were visualised with great clarity; a light haematoxylin counterstain permitted the easy recognition of spermatogenic cells in the same section. This method is particularly useful in the interpretation of poorly fixed material and may be helpful in studies of cyclical maturation of spermatozoa, irrespective of whether the material is obtained at biopsy or necropsy.

Can histopathologists diagnose bronchopneumonia?

OBJECTIVES: To assess histopathologists' ability to accurately diagnose bronchopneumonia, both on naked eye and microscopic examination; to extrapolate from the error rate to determine whether the role of the necropsy in monitoring the epidemiology of clinical error might be compromised. METHODS: Review of archival histological sections and necropsy reports from two teaching hospitals in Manchester. The main outcome measures identified were the proportions of macroscopic diagnoses of bronchopneumonia which were confirmed by the original pathologist on histological examination, and which could be confirmed on histological review by independent pathologists, together with the proportion of discrepant diagnoses remedied in the final report by the original pathologist. RESULTS: Of 279 cases where a macroscopic diagnosis of bronchopneumonia had been noted in the original provisional necropsy report, the original histopathologist described bronchopneumonia in only 206 (73.8%) in the subsequent final report, which took histology into account. Bronchopneumonia could be confirmed on independent histological review in only 193 (69.2%) of these cases. The original histopathologist diagnosed 74 cases of bronchopneumonia on histological grounds only, of which only 57 (77.0%) could be confirmed on review. Of a total of 160 discrepancies between the original naked eye diagnoses and the final reviewed diagnoses, only 130 (81.3%) had been remedied by the original pathologist. CONCLUSIONS: There is a considerable discrepancy rate between naked eye diagnoses of bronchopneumonia at necropsy and diagnoses confirmed on microscopy. If this discrepancy rate is extrapolated to other common lesions, then the role of the necropsy in clinical audit may be compromised. Pathologists need to take steps to monitor and improve their own diagnostic standards.

Foreign body giant cell reactions and ossification associated with benign melanocytic naevi.

AIMS: To assess the incidence of foreign body giant cell reactions and ossification in benign/melanocytic naevi; and to examine their pathological features to gain an insight into their pathogenesis. METHODS: Intradermal (n = 185) and compound naevi (n = 110) from a routine histology service, together with 60 naevi submitted to an ophthalmic pathologist, were examined for foreign body reactions and ossification. Additional cases were identified prospectively in the course of routine reporting. The clinical and pathological features of positive cases were assessed. RESULTS: Foreign body reactions were identified in nine (4.9%) intradermal and four (3.6%) compound naevi, but in none of the naevi from around the eye. One intradermal naevus showed ossification. A further 11 naevi showing foreign body reaction and five showing ossification alone were identified prospectively. The 24 naevi showing a foreign body reaction had a similar age and sex distribution to controls but were more likely to occur on the head and neck. The reaction usually occurred deep to the naevus, sometimes in relation to a hair follicle, and fragments of hair or keratin were identified in most. Osteoid or bone was present within the reaction in five. In six other naevi, all from the head and neck of women, osteoid or mature bone was present deep to the naevus in the absence of a giant cell reaction. CONCLUSIONS: Foreign body giant cell reactions occur not uncommonly in relation to benign naevi, as a result of follicular damage, possibly due to trauma. The similar siting of foci of bone suggests that ossification occurs as a secondary phenomenon in these cases.

Adenocarcinoma of the pancreas with osteoclast-like giant cells: a case report with immunocytochemistry.

Histological examination of a tumor centered in the body of the pancreas of a 65-year-old Iranian man revealed it to have a substantial component in which osteoclast-like giant cells were set within a stroma of pleomorphic mononuclear cells though other areas were composed of conventional adenocarcinoma. Immunocytochemistry was used to investigate the differentiation of the various component cells of the tumor. The carcinoma cells of the usual type expressed epithelial antigens (EMA and cytokeratin). The giant cells expressed vimentin and showed membrane staining with anti-LCA, in common with examples of cells originating from the mononuclear phagocytic system, including normal osteoclasts. The accompanying stromal cells expressed vimentin only. This implies that the giant cells are likely to have their origin in the bone marrow, whereas the mononuclear stromal cells that separate them may represent tumor cells that have lost their epithelial phenotype. The giant cells are therefore an unusual tissue response to the presence of the carcinoma.

Aspergillus fumigatus catalases: cloning of an Aspergillus nidulans catalase B homologue and evidence for at least three catalases.

The presence of catalases in the water soluble fractions of three Aspergillus fumigatus strains was investigated using non-denaturing and denaturing polyacrylamide gel electrophoresis and Western analysis. Using non-denaturing polyacrylamide gel electrophoresis and staining for catalase activity, three separate catalases were identified. An A. fumigatus catalase gene (catB) was cloned from genomic DNA using the Aspergillus niger catR gene as a probe. Polyclonal antibodies were raised to a glutathione S-transferase-CatB fusion product expressed in Escherichia coli. Western analysis indicated that, under denaturing conditions, the polyclonal antibody recognised a 90-kDa band and under non-denaturing conditions, two separate bands were identified. These results indicate that A. fumigatus in addition to CatB, produces at least two other catalases, one of which is similar in size to CatB. The polyclonal antibody was also used to observe catalase expression in mice, experimentally infected with A. fumigatus. Staining was observed heterogeneously throughout the fungal hyphae. This result indicates that catalase is produced by A. fumigatus during invasive aspergillosis.

Differential inhibition of a cell surface protease on normal and tumour cells.

This report is concerned with a cell surface protease which may be important for cell migration. We investigated the molecular recognition of this protease on pancreatic carcinoma cells by proteins (a) extractable from the cells of normal pancreas, and (b) present in normal serum. We then compared these data with results obtained from studies on lung carcinoma cells.

The attitudes of second- and third-year medical students to the autopsy. A survey by postal questionnaire.

Questionnaires were mailed to medical students in the cohorts who had just completed the second and third years of their courses. These included 52 attitude statements to which students indicated their responses on five-point Likert scales. Significant differences were found between the responses of the two cohorts to 18 statements. The results indicate a good general acceptance of the principle of autopsy in both groups, but the senior cohort was more reluctant to become personally involved, despite being more aware of the value of the autopsy in clinical audit, more aware that the autopsy has nonforensic uses, and more aware that autopsies remain useful in elderly subjects. Additionally, they were considerably less likely to want autopsies on close relatives.

"Bones of Contention". The donation of temporal bones for dissection after the organ-retention scandals.

It is essential for the Otologist in training to become familiar with the anatomy of the temporal bone. Generations of trainees have acquired this knowledge, together with basic surgical skills and techniques by dissection of cadaver temporal bones. In recent years, however, the supply of temporal bones for dissection has become a contentious issue in many British hospitals. Media and public attention has recently focused on issues surrounding the retention of human tissues following post-mortem examinations. In response, the Chief Medical Officer, the Royal College of Pathologists in the UK, the Faculty of Pathology of the Royal College of Physicians in Ireland, the British Medical Association, and other bodies have issued new guidelines that are of relevance to the Otolaryngologist. This paper gives details of some of the UK guidelines and where they can be accessed. A copy of the Royal College of Pathologists preferred post-mortem consent form is presented. The authors' experience in Manchester is discussed and details of an information leaflet on the subject of temporal bone donation are given. It is concluded that, with knowledge of the existing guidelines and good communication with other hospital colleagues, as well as families of the deceased, it is still possible legally to obtain temporal bones for dissection.

Post-irradiation leiomyosarcoma of the maxilla.

Primary malignant smooth muscle tumours of the maxilla are extremely rare. A case of leiomyosarcoma of the maxilla associated with previous irradiation is presented. The aetiology, pathology and clinical aspects of this tumour are reviewed.