Clinical case of angiosarcoma of pericardium and pleura

Primary heart tumors are an extremely rare pathology, previously detected only by autopsy data and detected in 0.001%-0.03% of cases. Primary angiosarcomas of the pericardium are even more rare and are presented in the literature with isolated descriptions. The article describes a clinical case of epithelioid angiosarcoma of the pericardium and pleura of high malignancy in a 57-year-old man. The diagnosis was confirmed by immunohistochemical examination and positron emission tomography. For today, chemotherapeutic treatment of angiosarcomas localized in the chest cavity is a palliative treatment method. In this patient, the most effective scheme was the one containing anthracyclines (doxorubicin). Despite the ongoing therapy, the patient died 15 months after the diagnosis was made, with increasing signs of respiratory and heart failure. Thus, when patients, especially young and middle-aged men, show signs of hydropericardium without established etiological prerequisites, it is necessary to remember about the possibility of developing a primary malignant tumor of the heart and / or pericardium as the cause of this condition and include it in the standard diagnostic search.

The Demographic Analyses of Undiagnosed and Misdiagnosed Cancer Cases via Autopsy Data

Cancer is one of the most common causes of death. Recent increases in undiagnosed and misdiagnosed cancer cases at autopsies suggests that the presence of cancer is more prevalent in the general population than previously thought. Such cases may be different in certain populations with regard to key demographic characteristics (age, race, gender, etc.). Therefore, this study aimed to identify trends in these undiagnosed cases of different cancer types. The data suggest that cancers of the lung, gastrointestinal tract, and prostate gland were frequently undiagnosed/misdiagnosed, while cancers of the breast and brain are rarely missed. The data also show that the presence of undetected prostate cancer is likely not different, to a significant degree, in younger versus older age groups. This indicates that cancer possibly manifests early in human life but remains undetected for several decades. However, further research is required to confirm this hypothesis. The data suggests that the prevalence of undetected cancer is highest in African-Americans compared to other races/ethnicities such as European and Asian. With regard to gender, the prevalence of undetected cancer appears to be higher in men than women. To conclusively validate these findings, further research is needed including concurrent and prospective analyses on live cases.

Multiorgan tropism of SARS-CoV-2 lineage B.1.1.7

Due to the development of novel functionalities, distinct SARS-CoV-2 variants such as B.1.1.7 fuel the current pandemic. B.1.1.7 is not only more transmissible, but may also cause an increased mortality compared to previous SARS-CoV-2 variants. Human tissue analysis of the SARS-CoV-2 lineage B.1.1.7 is urgently needed, and we here present autopsy data from 7 consecutive SARS-CoV-2 B.1.1.7 cases. The initial RT-qPCR analyses from nasopharyngeal swabs taken post mortem included typing assays for B.1.1.7. We quantitated SARS-CoV-2 B.1.1.7 viral load in autopsy tissue of multiple organs. Highest levels of SARS-CoV-2 B.1.1.7 copies normalized to ß-globin were detected in the respiratory system (lung and pharynx), followed by the liver and heart. Importantly, SARS-CoV-2 lineage B.1.1.7 was found in 100% of cases in the lungs and in 85.7% in pharynx tissue. Detection also in the kidney and brain highlighting a pronounced organ tropism. Comparison of the given results to a former cohort of SARS-CoV-2 deaths during the first wave in spring 2020 showed resembling organ tropism. Our results indicate that also SARS-CoV-2 B.1.1.7 has a relevant organ tropism beyond the respiratory tract. We speculate that B.1.1.7 spike protein’s affinity to human ACE2 facilitates transmission, organ tropism, and ultimately morbidity and mortality. Further studies and larger cohorts are obligatory to proof this link.

The ethical implications of verbal autopsy: responding to emotional and moral distress

Background Verbal autopsy is a pragmatic approach for generating cause-of-death data in contexts without well-functioning civil registration and vital statistics systems. It has primarily been conducted in health and demographic surveillance systems (HDSS) in Africa and Asia. Although significant resources have been invested to develop the technical aspects of verbal autopsy, ethical issues have received little attention. We explored the benefits and burdens of verbal autopsy in HDSS settings and identified potential strategies to respond to the ethical issues identified. Methods This research was based on a case study approach centred on two contrasting HDSS in Kenya and followed the Mapping-Framing-Shaping Framework for empirical bioethics research. Data were collected through individual interviews, focus group discussions, document reviews and non-participant observations. 115 participants were involved, including 86 community members (HDSS residents and community representatives), and 29 research staff (HDSS managers, researchers, census field workers and verbal autopsy interviewers). Results The use of verbal autopsy data for research and public health was described as the most common potential benefit of verbal autopsy in HDSS. Community members mentioned the potential uses of verbal autopsy data in addressing immediate public health problems for the local population while research staff emphasized the benefits of verbal autopsy to research and the wider public. The most prominent burden associated with the verbal autopsy was emotional distress for verbal autopsy interviewers and respondents. Moral events linked to the interview, such as being unsure of the right thing to do (moral uncertainty) or knowing the right thing to do and being constrained from acting (moral constraint), emerged as key causes of emotional distress for verbal autopsy interviewers. Conclusions The collection of cause-of-death data through verbal autopsy in HDSS settings presents important ethical and emotional challenges for verbal autopsy interviewers and respondents. These challenges include emotional distress for respondents and moral distress for interviewers. This empirical ethics study provides detailed accounts of the distress caused by verbal autopsy and highlights ethical tensions between potential population benefits and risks to individuals. It includes recommendations for policy and practice to address emotional and moral distress in verbal autopsy.

Characterisation of tuberculosis mortality in informal settlements in Nairobi, Kenya: analysis of data between 2002 and 2016

Background Tuberculosis (TB) remains one of the key public health problems in Africa. Due to multifaceted challenges, its burden is poorly described in informal settlements. We describe tuberculosis mortality in two informal settlements in Nairobi, Kenya. Methods This is a secondary analysis of 2002–2016 verbal autopsy data from informal settlements in the Nairobi Urban Health Demographic Surveillance System (NUHDSS). A descriptive analysis of deaths assigned as caused by TB was done. Pearson chi-square tests were used to determine differences between socio-demographic factors. Logistic regression was carried out to examine the risk of death from TB within the characteristics. Results There were 6218 deaths in the NUHDSS within the period of analysis, of which 930 (14.96%) were deaths from TB. The average number of TB deaths per year was 62(SD 23.9). There was a reduction in TB deaths from 21.2% in 2005 to 1.7% in 2016. Males had 1.39 higher odds of dying from TB than females (AOR 1.39; 95% CI 1.18–1.64; p-value < 0.001). Compared to those aged 30–39 years, the ≥50-year-olds had a 42% lower chance of dying from TB (AOR 0.57; 95% CI 0.47–0.73; p-value < 0.001). Those dying at home had 1.39 odds of dying from TB as compared to those who died in a health facility(AOR 1.93; 95% CI 1.17–1.64; p value< 0.001). Conclusion There was a reduction in TB deaths over the study period. Males had the highest risk of death. There is a need to strengthen TB surveillance and access to TB diagnosis and treatment within informal settlements to enhance early diagnosis and treatment.

Mortality among involuntary inpatients of psychiatric hospital

Background Mortality is often used as an indicator of public health efforts. Even if mortality in psychiatric hospitals decreased since the introduction of modern treatment, the death toll is still high. The authors have analyzed the forensic autopsy data and the medical documentation regarding 115 death cases from psychiatric hospitals in south-eastern Romania during the period of 2000–2020. Results The average annual mortality rate was 5.13‰, the necropsy data corroborated with those from the medical documentary material indicates acute myocardial infarction as the dominant cause, with 65 (56.5%) cases, followed by upper respiratory tract occlusion with 23 cases (20%) and pulmonary thromboembolism in 4 cases (12.2%). Furthermore, in 6 cases (5.2%) the cause of death was traumatic: 4 cases of cranio-cerebral trauma and 2 cases of hanging. Conclusions In the mortality structure of psychiatric patients, cardiac death predominated, being influenced by the cardiotoxic effect of medication administered for the specific pathology; hence, an early involvement of cardiologists in the follow-up of patients and the finding of treatment schemes with a reduced cardiotoxic effect are required.

Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

ObjectivesCardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.DesignA mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.SettingThis study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.ParticipantsDeaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.ResultsBetween 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).ConclusionsThe temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

TBE in Lithuania

The first case of tick-borne encephalitis (TBE) in Lithuania, diagnosed by clinical and epidemiologic criteria only, was reported in 1953. A forest worker became ill with the disease in April after a tick bite, had a typical clinical presentation with shoulder girdle muscle paralysis and bulbar syndrome, and died after 12 days from the start of clinical symptoms. Autopsy data were compatible with viral encephalitis.1 Serological diagnosis of TBE in Lithuania was started in 1970.2

Pathological drivers of neurodegeneration in suspected non-Alzheimer’s disease pathophysiology

Background Little is known about the heterogeneous etiology of suspected non-Alzheimer’s pathophysiology (SNAP), a group of subjects with neurodegeneration in the absence of β-amyloid. Using antemortem MRI and pathological data, we investigated the etiology of SNAP and the association of neurodegenerative pathologies with structural medial temporal lobe (MTL) measures in β-amyloid-negative subjects. Methods Subjects with antemortem MRI and autopsy data were selected from ADNI (n=63) and the University of Pennsylvania (n=156). Pathological diagnoses and semi-quantitative scores of MTL tau, neuritic plaques, α-synuclein, and TDP-43 pathology and MTL structural MRI measures from antemortem T1-weighted MRI scans were obtained. β-amyloid status (A+/A−) was determined by CERAD score and neurodegeneration status (N+/N−) by hippocampal volume. Results SNAP reflects a heterogeneous group of pathological diagnoses. In ADNI, SNAP (A−N+) had significantly more neuropathological diagnoses than A+N+. In the A− group, tau pathology was associated with hippocampal, entorhinal cortex, and Brodmann area 35 volume/thickness and TDP-43 pathology with hippocampal volume. Conclusion SNAP had a heterogeneous profile with more mixed pathologies than A+N+. Moreover, a role for TDP-43 and tau pathology in driving MTL neurodegeneration in the absence of β-amyloid was supported.

Autopsy and premortem diagnostic discrepancy review in an Irish tertiary PICU.

Objective: 1) Review ante- and post-mortem diagnoses and assign a Goldman error classification. 2) Establish autopsy rates. Design: A retrospective analysis of autopsies performed on patients who died in Paediatric intensive care unit (PICU) between November 13th 2012 and October 31st 2018. We reviewed medical and autopsy data of all patients and Goldman classification of discrepancy between ante- and post-mortem diagnoses was assigned. Setting: Tertiary PICU. Patients: All patients that died in PICU within the designated timeframe. Interventions: Goldman error classification assignment. Measurements and main results: 396 deaths occurred in PICU from 8,329 (4.75%) admissions. 99 (25%) had an autopsy, 75 required by the coroner. All were included in the study. Fifty-three were male and 46 females. Fifty-three patients were transfers from external hospitals, 46 from our centre. Forty-one were neonates, 32 were <1 year of age, and 26 were >1 year of age. Median length of stay was 3 days. Eighteen were post cardiac surgery, and three post cardiac catheter procedure. Major diagnostic errors (Class I/II) were identified in 14 (14.1%), 2 (2%) Class I, and 12 (12.1%) were Class II errors. Class III and IV errors occurred in 28 (28.2%) patients. Complete concordance (Class V) occurred in 57 (57.5%) cases. Conclusion: The autopsy rate and the diagnostic discrepancy rate within our PICU is comparable to those previously reported. Our findings show the continuing value of autopsy in determining cause of death and providing greater diagnostic clarity. Given their value, post-mortem examinations, where indicated, should be considered part of a physician’s duty of care to families and future patients.