Clinical setting and extent of premortem evaluation do not predict autopsy discrepancy rates.

Autopsy rates have been affected by a number of factors, including technological advances and clinician beliefs of the diminished value of the autopsy. Such factors have resulted in a cultural shift in medicine away from the autopsy. Despite this shift, a number of studies have shown significant differences between antemortem clinical diagnoses and postmortem findings. Surveys of clinician beliefs about the autopsy have pointed toward antemortem diagnostic advancements as an important factor in declining rates. No study to date has addressed the hypothesis that such perceptions in diagnostic certainty have been matched by an actual decay in the yield of valuable or new information obtained by the autopsy. To address this hypothesis, we retrospectively compared the class I and class II discrepancies identified in 284 patients who died in three clinical settings with differing intensities of antemortem diagnostic workup. Despite a significantly different intensity of antemortem workup for patients in each clinical setting, including patients on a medical intensive care unit, patients on a surgical service and patients in an affiliated nursing home, discrepancy rates were found to be similar. Overall discrepancy rates for the medical intensive care unit, surgery service and nursing home patients were 27.8, 32.7 and 31.3%, respectively (P=0.84). In addition, we found no statistical difference in the complexity of workup in discrepant and nondiscrepant cases in each clinical setting. Our study data refute the hypothesis that the intensity of antemortem diagnostic evaluation correlates with an actual decrease in the rate of major diagnostic discrepancies identified at autopsy.

Natural, unexpected deaths: reliability of a presumptive diagnosis.

We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy-derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.

Intravascular epithelioid hemangioendothelioma of the inferior vena cava: case report of an unusual and unpredictable vascular tumor.

Vascular neoplasms are uncommon and pose a diagnostic and treatment challenge to the pathologist and surgeon, respectively. Epithelioid hemangioendothelioma is a rare neoplasm of vascular origin with an unknown etiology. Its biologic behavior lies somewhere between that of a benign hemangioma and that of a malignant angiosarcoma; however, it is unpredictable at best. Intravascular epithelioid hemangioendotheliomas have been described more often in veins than arteries, and there are only about 30 reports in the English literature. We report here the case of an epithelioid hemangioendothelioma of the inferior vena cava, which presented with abdominal pain, ascites and pedal edema.

Candidate sulfonated and sulfated topical microbicides: comparison of anti-human immunodeficiency virus activities and mechanisms of action.

Poly(styrene 4-sulfonate), cellulose sulfate, polymethylenehydroquinone, and PRO 2000 are sulfated or sulfonated polymers (SPs) under development as topical microbicides. They are presumed to work through similar mechanisms of action, although to date there has been no extensive comparison of their anti-human immunodeficiency virus activities. To determine whether any of these candidate microbicides offers a potential advantage, their in vitro activities, mechanisms of action, stabilities in biological secretions, and toxicities were compared. All four compounds were found to be active against X4, R5, and dualtropic primary isolates and against X4 and R5 laboratory-adapted strains in CD4+ T cells, macrophages, and single-coreceptor cell lines. Our single-cycle experiments using pseudotyped virus suggest that all four SPs function at the binding and entry stages of the viral life cycle but differ in degree of postentry effect. Surface plasmon resonance analyses demonstrate that SPs bind to X4 and R5 monomeric glycoprotein 120 with similar high binding affinities. When mixed with cervicovaginal lavage fluid, SPs maintain inhibitory activity at concentrations achievable in formulations.