|Year : 2015 | Volume
| Issue : 2 | Page : 49-56
Relevance of clinical auto psy in medical practice in Sub-Saharan Africa
Victor James Ekanem1, Clement O Vhriterhire2
1 Department of Pathology, University of Benin, Benin City, Edo State, Nigeria
2 Department of Morbid Anatomy, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Web Publication||14-Jul-2015|
Dr. Victor James Ekanem
Department of Pathology, College of Medical Sciences, University of Benin, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Autopsy is very important in medical practice and is being increasingly relegated both in the developed and developing countries. Though autopsy rate has been on the decline, the exact rates are difficult to determine because various reports are influenced by many factors. The danger of the decline in the developing countries is that equipment for proper diagnosis is not yet available, therefore, most diagnoses are not made and the cause of death would not have been known. This article reviews the benefits of autopsy in modern practice, the importance of perinatal autopsy and the shortcomings of modern technology in the diagnosis and determination of the cause of death. Electronic literature search combined with the review of both local publications and relevant texts were carried out. Clinicians should endeavor to request for postmortem examination as the benefits far outweigh the reasons proffered for the decline in the autopsy rate.
Keywords: Autopsy, perinatal autopsy, postmortem
|How to cite this article:|
Ekanem VJ, Vhriterhire CO. Relevance of clinical auto psy in medical practice in Sub-Saharan Africa. Sahel Med J 2015;18:49-56
| Introduction|| |
Autopsy, a word which is synonymous with necropsy and postmortem examination is derived from the Greek word "autopsia" which literally means "to see for oneself." It entails a detailed examination which includes external examination of the corpse, evisceration of organs, and subsequent careful dissection of the contents of the cranial, thoracic, abdominal, and pelvic cavities. Examinations restricted to a particular body cavity (either due to the relatives wishes or because of some infectious hazard), or to the sampling of the organs in the unopened body with a biopsy needle are also regarded as autopsy examination. 
| Brief History of the Autopsy|| |
Autopsy has a long history that has been influenced by the prevailing medical models of the time as well as superstitions and religious beliefs in earlier times. Human dissections in ancient Egypt were confined to the process of mummification in which embalmers attempted to preserve the body intact. In classical Greek times, though there were animal and some human dissections, there was little medical intent in the autopsy since diseases were believed to result from the imbalance of theoretical "humors" which were not considered to have a simple anatomical basis. In Anglo-Saxon England, the prevailing belief was that disease was due to magical causes and that further investigation of the body was not only fruitless but might also be positively dangerous. The autopsy examination in its modern form is traceable to Giovanni Battista Morgagni (1682-1771) who emphasized the importance of and correlation of clinical and pathological findings. 
Xavier Bichat at the close of the 18 th century revolutionized autopsy examination by recognizing the importance of tissue examination and not just organs in the understanding of disease. The father of modern day autopsy is widely regarded to be Karl Rokitansky (1804-1878). He initiated the concept of thorough and systematic autopsy examination that ensured that every part of the body would be examined in identical fashion regardless of the clinical history. 
The 19 th century marked the golden era of autopsy when tens of thousands of autopsies on adults provided the database that underlies modern adult medicine. The medical science of pediatrics developed in a similar way with much of that knowledge being gained from pediatric autopsies. More recently, the specialties of neonatology and perinatology have benefited from autopsies on infants, neonates, and fetuses. ,
Kinds of autopsy
Autopsies can be categorized as either hospital (clinical) autopsy or coroner (forensic/medico-legal) autopsy.
Hospital autopsy is often performed on individuals in whom the disease causing death is known, but the course to death is not known. In such cases, the purpose of the autopsy would be to determine the extent of the disease and/or the effects of therapy and the presence of any undiagnosed disease of interest that might have contributed to death. The next of kin must give permission for the autopsy and may limit the extent of the dissection. 
Forensic autopsy is ordered by the coroner or medical examiner as authorized by law with the statutory purpose of establishing the cause of death and answer other medico-legal questions. The next of kin is not required to authorize and may not limit the extent of the autopsy. 
Benefits of the autopsy
In both clinical and forensic autopsies, the procedure is instrumental in accurately establishing the cause and manner of death. Autopsies also allow confirmation, classification, and correction of ante-mortem diagnosis as well as identification of new and re-emerging diseases. Thus, they are important for protecting public health and improving accuracy of vital statistics. 
From a public health perspective, autopsies have proven particularly important as epidemiologic tools for establishing risk factors and identifying potential disease outbreaks. A case in point is the 1999 outbreak of encephalitis that occurred in New York City, in which the etiological agent was found to be the West Nile virus. 
Autopsy can be used for quality assessment. It actually acts as the "gold standard" for which the accuracies of current diagnostic techniques are evaluated for their test specificities and sensitivities.  The autopsy is also able to serve as a quality assurance tool to assess standards of clinical practice. Autopsy studies have documented significant discrepancies between clinical diagnoses and autopsy diagnoses that have important implications in terms of clinical care.  In terms of benefit for the family, a clearer understanding behind the cause of death can help in the grieving process. In rare situations, there may be the discovery of genetic diseases which enables family counseling on the implications and subsequent management of further pregnancies. 
The autopsy also provides medical students a better opportunity to learn anatomy, gross pathology and sharpen observational skills. Students are also able to learn soft skills such as professionalism and attitude of respect. This desensitization process when observing autopsies is obviously of help in preparing students for the future when they will have to care for dying patients. 
| Challenges in Contemporary Autopsy Practice|| |
The challenge in contemporary autopsy practice revolves around the issue of declining rates of autopsy practice and improvement in diagnosis due to the advancement in modern technology.
Declining rates of autopsy
Autopsy rates have been on the decline on a global basis over the past decades.  The exact rates are difficult to determine owing to differences in the reporting of data and to the fact that no institution is singularly responsible for collecting autopsy data systematically.
Numerous factors influence the differences in the autopsy rate reporting amongst institutions; for instance whether forensic, outside bodies, stillbirths, and perinatal deaths are included in the reported rates. 
It has been estimated that in the United States before 1970, autopsies were performed in 40-60% of all cases involving hospital deaths; in recent years, this number has decreased to approximately 5%.  In Australia, the rate decreased approximately 50% between 1992 and 2003.  Reports from Denmark also show that autopsy rate had been on the decline. The rate decreased from 45% in 1970 to 16% in 1990. 
In a Nigerian report from the University College Hospital Ibadan, an autopsy rate for the year 1996 was 39.60% with coroner's and noncoroner cases constituting 68.17% and 31.85% respectively.  Autopsy rate has remained consistently low. The pediatric age group is not exempted from the general decline in autopsy rates as they have shown a downward trend also. However, the pediatric autopsy rates are not declining as fast as adult autopsy rates.  Rates as high as 26-40% were reported in the decade spanning the early 1980s to early 1990s in studies in the United States. ,, The overall pediatric autopsy rate in year 2000 was 40% in Salt Lake City USA.  In a study in Wales, there was a decline from a rate of 66.5% in 1994 to 47.97% in 2003.  In one of the publications from a British center on neonatal autopsy rates, Porter and Keeling calculated the rate to be 90% in Oxford during the early 1980s.  In Scotland, the autopsy rate for stillbirths and neonatal deaths in 2001 was noted to have declined to 50.8% from a rate of 72.4% in 1997.  Brodlie et al. in 2002 reviewed the case records of 314 neonatal deaths in Edinburgh between 1990 and 1999. An autopsy was performed in 67% of cases, but the rate declined throughout the decade by an average of 2.8%/year. 
However, despite the general downward trend in autopsy rate, policy decisions at the level of individual hospitals coupled with involvement of all necessary staff and adequate staff training on the methods of and importance of the procedure can lead to rise in consent rates. In Edinburgh, there was a steady increase from 38% in 2001 to 79% in 2004 for neonatal autopsy rates through appropriate policy directions. 
In developing countries, pediatric autopsy rates are generally low compared to the developed nations. In the greater part of the 2 nd half of the first decade of the 21 st century, the perinatal autopsy rate in Malaysia is as low as 4.5%.  In Nigerian studies, pediatric autopsy rates are generally modest and is similar to other parts of the developing world. In fact, Oluwasola et al.  documented that there had been a remarkable decline in hospital autopsy rate in the University College Hospital Ibadan over two decades (1984-2003). The decline affected both adult and pediatric patients  In a review of childhood mortality at the University College Hospital Ibadan annual pediatric autopsies fell from 60% of cases in 1961 to 18% in 1988,  while a rate of 7.4% was found for the years 1996-2000.  A study in Lagos (October 1993-September 1994) revealed a pediatric autopsy rate of 24.8%,  however by the end of the 1990s (1996-2000) perinatal autopsy rate in Lagos University Teaching Hospital was 20.1%.  A retrospective review spanning 2006-2010 from the University of Benin Teaching Hospital showed a 0.8% neonatal autopsy rate. 
Ideally, all pediatric cases should be submitted for postmortem examination. An autopsy rate of at least 75%, especially in cases of perinatal death, is necessary to achieve educational, quality control, and research goals. 
Reasons for the decline in the autopsy rate
Reasons for the continuing decline in the autopsy rate are complex and multifaceted. Attitudes among health care professionals are certainly a factor in declining autopsy rates. Perhaps the main reason for the decline is that clinicians are not asking for consent to have an autopsy done on their patients; most times this responsibility is delegated to the most junior member of the team. , Many residents, even chief residents, report that they have received no instructions on the autopsy procedure, obtaining consent, and the role of religious or cultural background in attitudes toward autopsy. ,
One study found that clinicians attributed the decline in autopsy rates in part to the difficulty in obtaining permission from the family. , Some clinicians may not approach grieving relatives for permission for autopsy because they have their own reservations or because they do not have confidence in their communication skills. , The way a family is asked for autopsy consent goes a long way in determining if consent will be given or not. If the clinician is uncomfortable and ill-informed, it is likely that this will be communicated to the family, who, in turn, will be less likely to consent to the autopsy.
Many clinicians are not requesting an autopsy because they are confident of the cause of death;  this is as a result of over-reliance on available high technology diagnostic modalities yielding better premortem diagnoses. ,, This, however, is not supported by the data, which indicate that unexpected, clinically significant diseases or complications are found in 22-33% of autopsied patients, a figure that has not changed in 100 years.  A discordance rate of 18.13% was seen in Ibadan for the year 1996. 
The primary reasons families decline autopsy are fear of disfigurement, concern that the procedure will delay funeral arrangement, religious objections, lack of knowledge about the procedure and a feeling that the deceased has suffered enough.  Cost, lack of rapport with the physician, stress around the time of death, and lack of consensus with other family members regarding the procedure have also been reported as barriers to obtaining consent from the next of kin. ,
Religious objection to the autopsy is another commonly encountered barrier to autopsy. Different religions have placed different limitations on autopsy. For Judaism, an autopsy may be performed when the cause of death is undetermined, when the autopsy may help to save the lives of others, or when relatives might benefit from the knowledge gained by autopsy.  Catholicism and most Protestant religions accept autopsy on almost any occasion but specify that the body must be treated with respect, and the family's consent must be obtained.  There are divergent opinions on the appropriateness of autopsy among Muslims. Most Muslim leaders do not condone autopsy because of the need to bury as soon as possible after death. Consent for autopsy is usually declined unless the death is suspicious. , However, there have been Muslim legal opinions (fatwa) stating that autopsies are acceptable because they benefit the living. 
The problem of the decline in autopsy rates has been compounded in recent times by the public resistance to autopsies due to the considerable adverse media attention to the retention of organs, particularly hearts and brains.  The recent changes in medical undergraduate curricula in some western nations are resulting in many medical students graduating from some medical schools without ever having seen an autopsy. This means that in many cases, future doctors will have even less knowledge of the role of autopsy in the verifying cause of death. Neither will these new doctors have had any personal experience of autopsies to enable them to give informed answers to the concerns of relatives whose agreement is being requested. 
Autopsy and modern technology
Modern diagnostic imaging techniques have been advanced as one of the formidable reasons why autopsy rates have continued to decline as they offer highly reliable ante-mortem diagnoses. However, the usefulness of autopsy practice still stands. Advances in technology and availability of sophisticated diagnostic methods have resulted in a reduction in class I errors detected at autopsy in the past four decades.  Despite this reduction, class I errors continue to be reported in up to 12% and class II errors in up to 29% of neonatal and pediatric autopsies.  It is also established that clinicians cannot reliably predict which autopsy will yield major unexpected findings despite extensive investigations. 
Modern diagnostic methods such as computerized tomography (CT) and magnetic resonance imaging (MRI), are all still incapable of reducing diagnostic errors to an extent of rendering the autopsy irrelevant. CT scans have been reported to have very high rates of false positives, and cannot detect contusions or superficial lesions such as small hematomas or lacerations. 
Similarly, MRI is limited by image resolution and can only offer less precise diagnosis. For instance, where an autopsy would be able to provide a diagnosis of acute myocardial infarction secondary to coronary artery thrombosis, an MRI would only be able to determine ischemic heart disease.  Imaging alone is also unable to sample the body for toxins or microorganisms or to provide tissue samples for histopathological studies or microbiological testing. Furthermore, an MRI autopsy is not cost effective and puts extra demand on resources with numerous competing interests. 
It is pertinent to note however that there is a prominent place for these other modalities in the autopsy. The X-ray has on occasion have clearly shown bullets where these have been difficult to find by meticulous dissection at autopsy. CT scans are also better at detecting gas embolism and small pneumothoraces than standard autopsies. Moreover, MRI and other noninvasive postmortem modalities may serve as an adequate alternative when consent for a full autopsy is declined. 
| Classification of Autopsy Diagnoses and Findings|| |
Autopsy studies have documented significant discrepancies between clinical diagnoses and autopsy diagnoses that have important implications in terms of clinical care. ,,,,,,, These discrepancies do not necessarily reflect clinician error but may reflect misinterpretation of test results, failure to respond appropriately to abnormal clinical findings, atypical clinical presentation, and the limits of current diagnostic techniques. Various studies look at different aspects and types of discrepancy and classify discrepancies in different ways. Goldman et al.  suggested a useful method of classification in 1983. Veress and Alafuzoff devised another system of classification.  Use of a defined classification system allows comparability of different research findings.
The Goldman classification has emerged as a useful classification system in that it differentiates between major and minor discrepancies and identifies those deaths where the discrepancy had an impact on patient survival. The drawback of the Goldman classification scheme is that it relies on both objective and subjective interpretation of the findings and some assumptions must be made regarding the theoretical impact of missed or incorrect diagnosis; however, there is no practical alternative approach. 
| The Goldman Classification|| |
The Goldman classification  is in five classes (I to V) and is composed of:
Class I: Missed major diagnoses for which detection before death would in all probability have led to a change in management that might have resulted in cure or prolonged survival. The diagnosis was missed because it was not suspected, or because test results were inconclusive
Class II: Missed major diagnoses for which detection before death would probably not have led to a change in management, because no therapy had been available at the time or the patient had already received appropriate therapy, even though the diagnosis was not known, or because the patient had refused further evaluation or therapy
Class III: Missed minor diagnoses that were related to the terminal disease process, but were not directly related to death
Class IV: Missed minor diagnoses that were either important unrelated diagnosis that might eventually have affected prognosis or processes that contributed to death in a terminally ill patient
Class V: Complete concordance between ante-mortem diagnoses and autopsy findings.
| Procedure for Obtaining an Autopsy Consent|| |
It is of utmost importance that the family be approached in a highly professional way, ideally by the most senior physician available. However, the degree of prior clinician contact and rapport must also be considered in determining who approaches the family. The family member identified as the person who must give written permission should be the focus of discussions. The setting should be neutral and the fewer uninvolved parties who may be disruptive and raise irrelevant questions, the better. 
Misconceptions about the autopsy should be addressed. It should be clarified that autopsy studies are done by pathologists, who are specialists in the study of disease, and the body is not "experimented with" or "practiced upon" or in any way mutilated or desecrated. Religious concerns should be addressed. The family should be told that there will be no delay in or interference with funeral arrangements and no disfigurement. In order to honor some timing restrictions, special adjustments may have to be made by the Pathology Department to expedite the autopsy. ,
It is important that the family understands the value of the autopsy; among several, it helps by dispelling lingering questions about the exact cause of death and assuring that care was appropriate. There may be a question of hereditary disease that can be settled, providing reassurance to the family. ,
After these explanations, the next of kin should receive the postmortem consent form to read, and they should be encouraged to ask questions and make comments. Questions should be dealt with on an individual basis by answering them directly, truthfully, and nonforcefully in a straightforward, tactful, educational way. 
Finally, the family should be informed that the result of the autopsy will be discussed with them by the clinician at the time of their choice. This conference should be undertaken without undue delay to assist with the bereavement process. ,
| Role of Histology at Autopsy|| |
The histopathological examination of lesions seen macroscopically is an integral component of the autopsy. The Royal College of Pathologists recommends that histology should be done on all major organs, and any identified lesion provided sufficient consent have been obtained. This will confirm the macroscopic diagnosis, refine the cause of death, and assist in clinical audit.  Diagnosis made only after histology account for up to 23% of unexpected autopsy diagnoses.  Diseases such as neurodegenerative disease, myocarditis, abnormalities of the cardiac conduction system, and glomerulonephritis cannot be accurately diagnosed by macroscopic examination of tissue alone. 
Macroscopic diagnosis of bronchopneumonia is especially inaccurate, Roulson et al.  reported that the diagnosis of pneumonia could be confirmed microscopically in 23% of cases and the macroscopic diagnosis was overturned by histology in 31% of cases. Pneumonia can be easily confused with acute respiratory distress syndrome and some form of neoplastic associations. 
Ideally, all tissue blocks and slides from all autopsies should be archived as part of a permanent medical record. 
| The Perinatal Autopsy|| |
Purpose of the perinatal autopsy and placenta examination
In perinatal deaths, the purpose of the autopsy and placenta examination is to address the following issues: 
- Independent, objective assessment of gestational age and appropriateness of development for age
- Quantitative evaluation of diseases in the newborn with respect to the approximate time of onset and duration of influence. An estimation of the interval between intrauterine death and delivery should be included, as well as a distinction between long-standing intrauterine disease, intrapartum disease, and postnatal disease
- Identification of intrinsic abnormalities of the fetus incompatible with life
- Identification and classification of developmental disorders, including a determination of whether they are genetic, acquired, both or unknown
- Identification or confirmation of abnormalities of placenta or cord that may have compromised the fetus, such as amniotic bands, cord insertion abnormalities, obstruction or rupture of vessels of the umbilical cord, premature separation, extensive infarction or atrophy caused by deficient maternal-placental perfusion, or degeneration of villi
- Verification of infection as contributory to premature labor and perinatal mortality
- Assessment of intrauterine exposure to any maternal diseases that can adversely affect the outcome of a pregnancy, such as hypertension, diabetes mellitus, infections or disorders of coagulation, or exposure to drugs or toxins.
| The Perinatal Autopsy|| |
Radiology has been established to be of immense value in the practice of perinatal autopsy. This is particularly so where there are congenital malformations, and radiology should be considered an essential part of the perinatal autopsy.  X-ray examination, including antero-posterior and lateral views of the entire body, is necessary using a Faxitron. Conventional X-ray studies can be performed if a Faxitron is not available. Some diagnoses cannot be made without X-ray examination. This applies particularly to bone dysplasias. The Faxitron is not limited to bony surveys and can be used to demonstrate visceral anomalies by injection studies. By injecting a radiopaque liquid such as barium or an ionotropic contrast, fistulas can be demonstrated. This technique is particularly helpful in identifying bronchial morphology and extrahepatic and intrahepatic biliary ducts, without disrupting the anatomy. 
Photographs are of the utmost importance when performing an embryonic, fetal, or infant autopsy. The external features may provide the only information necessary to make the diagnosis of a malformation syndrome. The photographs must be close enough to depict the abnormal features with adequate points of reference remaining in the field and minimum background. In situ photographs can be very helpful, preserving anatomical relationships and depicting visceral lesions before evisceration and fixation. In a pediatric autopsy, a good photograph is often more valuable than any number of microscopic sections. 
A complete examination cannot be performed without the important clinical information.  A basic obstetric and neonatal history must always be specifically sought.  Personal communication with the clinician in order to emphasize the specialist consultancy nature of the autopsy and the pathologist's contribution as part of the perinatal care team should be sought. Hospital records should be examined in detail and all relevant laboratory results available before or during the autopsy.
| External Examination and Dissection|| |
The objective of autopsy differs substantially between perinatal and adult autopsies, with the need to document congenital malformations in detail determining most of the differences in technique. It is essential to carry out a very detailed external examination and record in texts and photographs, all external abnormalities. Good photographs, including details of hands and feet and a record of facial and other growth parameters can be invaluable if later review by a medical geneticist is required.
Assessment of appropriateness of fetal growth in relation to clinically assessed gestational age should take place. All the internal organs should be examined in situ initially noting anatomical positions with photographs of any anomaly. Careful examination of the dural folds for significant tears and the posterior fossa for hemorrhage is important to adequately assess birth trauma. 
| Tissue Sampling and Histological Examination|| |
In the nonmacerated stillbirth and neonate, sampling of all organs is desirable as unexpected findings such as evidence of unsuspected viral infections, iatrogenic diseases or unusual developmental malformations of potential genetic significance are common. Assessment of the time course of intrauterine events before death can be made using fat stains on the fetal adrenal as well as assessing the presence of phagocytosed meconium pigment in chorionic macrophages. 
In the severely macerated fetus, histological examination can be more limited and is sometimes best achieved with connective tissue stains. 
Examination of the placenta
Examination of the placenta as a key component of the perinatal autopsy had become a routine and regular practice in the field of pediatric pathology. Various practice guidelines had emphasized the need for placental examination in conjunction with the autopsy in determining the cause of death. ,
In evaluating the importance of the placental examination as a component of the perinatal autopsy, relevant questions for consideration are:
- Is it possible for the cause of perinatal deaths to be revealed by placental examination and autopsy?
- Is it possible for placental examination alone to explain the cause of perinatal deaths?
- Is it possible for autopsy alone to explain all perinatal deaths?
| Conclusion|| |
Autopsy examination has enabled us to correlate the clinical and pathological findings. The importance of clinical autopsy cannot be overemphasized especially in developing countries as it allows confirmation, classification, and correction of ante-mortem diagnosis as well as the identification of new and re-emerging diseases. It is also good to note that newer sophisticated methods of diagnosis are deficient and as such improvement in diagnostic techniques should not cause a decline in the autopsy rate. Prenatal diagnosis is deficient in many centers in developing countries therefore autopsy examination should be performed in all these cases. This will eventually help in protecting public health and thus improve accuracy of available vital statistics.
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