The current role of autopsy in current clinical practice | Medicina Clínica (English Edition)

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It has contributed significantly to the advance in medical knowledge in many crucial areas over many years. However, since 1960 the CA rate has been declining gradually in Europe and USA. In the U. M. Valdecilla Hospital it has decreased from 12.6% in 1998–2004 to 7.6% in the last five years. However, major teaching hospitals generally have a higher rate and a higher absolute number of postmortem examinations than non-teaching hospitals.Several factors have favored the decreasing CA rate. The main factors, today more relevant than ever, are listed concisely in the following paragraphs<a class="elsevierStyleCrossRefs" href="#bib0190">1–3</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Confidence in antemortem diagnosis. This appears to be one of the most important factors in the decline of autopsies. With the development and rapid improvement in laboratory and imaging diagnostic procedures, and algorithms, many clinicians see CA as an inefficient, irrelevant and unnecessary practice.</li><li class="elsevierStyleListItem" id="lsti0010">2.CA lacks adequate incentives. Postmortem examination has inadequate productivity compensation. It is a practice that takes time and effort. Resident physicians perceive over time CA has poor social and professional significance, it is unrewarding, potentially dangerous, and is not a priority. Moreover, there is a much more intense care pressure on biopsies, surgical and cytology devices, and a growing environmental pressure over time devoted to research. It has been estimated that CAs contribute little to the Pathology Department scientific performance, since only 6% of the papers published are based on CA findings.<a class="elsevierStyleCrossRef" href="#bib0205">4</a></li><li class="elsevierStyleListItem" id="lsti0015">3.Delayed CA report release. Although the provisional findings are issued within 48h, the final ones, with microscopic examination, often take more than 45 days. This creates disinterest in the applicant clinician because a recent problem becomes a remote problem, barely reminded.</li><li class="elsevierStyleListItem" id="lsti0020">4.Lack of communication between pathologists and clinicians and between clinicians and family. The lack of response to antemortem clinical problems and the lack of clinicopathological correlation among some of the CA reports are factors of disagreement. Unpredicted death makes the person in charge for requesting CA be unknown to the family. In this situation, the patient's relatives are more likely to oppose, and the requesting clinician is often unmotivated.</li><li class="elsevierStyleListItem" id="lsti0025">5.CA defective reports unresponsive to previous clinical approaches. Some CAs are performed by untrained pathologists, with inadequate supervision. Moreover, it should be noted that, technically, appropriate CAs fail to find the cause of death in 1–5% cases.<a class="elsevierStyleCrossRef" href="#bib0210">5</a></li><li class="elsevierStyleListItem" id="lsti0030">6.Fear of discrediting the clinical professional due to unexpected findings, or litigation due to negligence.</li><li class="elsevierStyleListItem" id="lsti0035">7.Lack of training in the application of CA and ignorance of the administrative process.</li><li class="elsevierStyleListItem" id="lsti0040">8.Hospital managers consider that CA is not a priority and they only care when social problems arise. Lack of an overall strategic plan by the health administration including hospital accreditation, productivity, resources, quality control, mortality commission and various other actions in relation to CA.</li><li class="elsevierStyleListItem" id="lsti0045">9.Health authorities believe that CA is a technical matter within the hospital environment, with little or no impact on the scope of their jurisdiction.</li><li class="elsevierStyleListItem" id="lsti0050">10.Family concern at the delay in handing over the body, the possible disfiguration of the deceased and possible additional cost. There are also religious objections by various communities.</li></ul>Based on these considerations we believe it is necessary to review critically recent medical literature on postmortem examination to assess the role of CA in current clinical medicine.Materials and methodsWe searched for articles published from 2007 to 2014 studying the discrepancies between clinical and autopsy diagnoses using Medline. The articles were examined to obtain the following information: number of patients, average age, hospital autopsy rate, diagnostic discrepancy and grouping patients according to their specific features.Diagnostic discrepancies were classified according to the criteria provided by Goldman et al.<a class="elsevierStyleCrossRef" href="#bib0215">6</a>, modified by Battle et al.<a class="elsevierStyleCrossRef" href="#bib0220">7</a> and Schwanda-Burger et al.<a class="elsevierStyleCrossRef" href="#bib0225">8</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows a classification of these discrepancies.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>ResultsAfter searching through Medline, 15 articles met all or most of the required information. This literature included 6337 CAs,<a class="elsevierStyleCrossRefs" href="#bib0225">8–12</a> whose data are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Using the major discrepancy criteria (classes 1+2) it can be seen that the discrepancy rates range from 7 to 56%, with a 25.6% weighted average. The 4 most frequent discordant diagnoses included acute myocardial infarction, pneumonia, intestinal infarction and pulmonary thromboembolism. Other frequent discordant primary diagnoses included: cardiac tamponade, abdominal hemorrhage, endocarditis, surgical complications, ruptured aortic aneurysm, neoplasm (metastatic carcinoma, lymphoma, mesothelioma) and miliary tuberculosis. The discrepancy rates were higher in patients aged over 60.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionThe belief in the futility of CA contradicts the discrepancies after studying antemortem diagnosis. It should be noted that the decreasing CA rate may cause some bias, with increased percentage of discrepancies, provided that the cases chosen for autopsy tend to be the most problematic and complex cases.The data in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> have the limitations of retrospective studies. However, Combes et al.<a class="elsevierStyleCrossRef" href="#bib0300">23</a> conducted a prospective study for 3 years in intensive care unit. In 167 patients (53% CA rate) they observed a 31.7% diagnostic discrepancy (class 1+clase 2). Heriot et al.<a class="elsevierStyleCrossRef" href="#bib0305">24</a>, in a study of 407 autopsied patients, estimated the overall sensitivity and positive predictive value of clinical diagnoses. The respective values were 0.74 and 0.93. Pneumonia, acute myocardial infarction, intestinal ischemia and pulmonary embolism had sensitivity below 0.70 and positive predictive values below 0.90. Therefore, it is evident that the percentage of discrepant diagnoses remains high despite the significant technical advances in diagnostic methods.In this paper we have avoided the term “diagnostic error”. This term misunderstands the diagnostic discrepancy, suggesting a single causality of individual type. However, despite best medical practice, there are many inherent limitations influencing the clinical reasoning and decision making.<a class="elsevierStyleCrossRef" href="#bib0270">17</a> Thus, diagnostic tools used today have limited sensitivity and specificity. Computed tomography and ultrasonography can yield false positive or false negative diagnoses in 6 to 9% patients.<a class="elsevierStyleCrossRef" href="#bib0310">25</a>For CA to be effective the following requirements should be met: (a) be encouraged by the managers of the Pathology Departement; (b) provide a quality control and report timing with a CA manager assisted by other qualified physicians<a class="elsevierStyleCrossRef" href="#bib0315">26</a>; (c) support to residents by technicians, and close monitoring by the relevant specialists; (d) CA should be clinically customized, responding to all the problems arising antemortem; (e) systematic review of all CAs after 24h (at a preset fixed time) on a macroscopic lecture attended by the relevant clinicians; (f) the provisional report should be available to all clinicians in charge of the case after 48h; (g) the final report after the microscopic examination should not take longer than 45 days; (h) CA should be practiced without delay right after the authorization has been obtained; and (i) provide a permanent surveillance service in the Department of Pathology, assisting intraoperative biopsies, transplant biopsies and CAs.Specific training on how to request CAs to the family should be provided to all the doctors of the institution, including residents. This training, as it happens with organ donation for transplantation, should be part of an active and well-defined policy of the center. Moreover, the institution should publish a CA protocol including the administrative procedure. The protocol should be delivered to all the health personnel.<a class="elsevierStyleCrossRef" href="#bib0320">27</a>It is imperative that the autopsy authorization is accompanied by clinical diagnoses, clearly expressed, cause of death and the clinical problems the autopsy should resolve.Autopsy pathology should be acknowledged as a subspecialty of pathology. Autopsies require good training in anatomy, physiology, pathophysiology, especially the circulatory, respiratory and renal systems, and in general pathological anatomy. In addition, the autopsy pathologist needs to be familiar with the complications, and treatment of patients admitted to intensive care units to assess the lesions found. Particular attention is required, for example, in the injury differentiation by shock in postmortem changes.<a class="elsevierStyleCrossRef" href="#bib0315">26</a> When autopsies are performed by specialists or with special dedication, reporting id faster,<a class="elsevierStyleCrossRefs" href="#bib0315">26,28</a> report quality improves, with good clinicopathological correlation, and information to the family becomes systematic and of best quality.Today, the fear that a CA shows negligent actions that could lead to malpractice litigation is more a hypothesis than a fact. Only exceptionally CAs show malpractice that had not been clinically proven before the CA; and CAs are very rarely used as evidence in court. In a survey about how significant a CA might be, the threat of litigation for malpractice was not a deterrent among clinicians.<a class="elsevierStyleCrossRef" href="#bib0330">29</a> CAs prove facts and replace guesswork of the lawyers and possible suspicions of relatives. In this context, the request for a CA should be understood as interesting for a clinician in order to clarify a complicated case.<a class="elsevierStyleCrossRef" href="#bib0335">30</a>The hospital manager should promote CAs in the clinical sector and in the Pathology Department. Hospital Management should worry about the causes and mechanisms of death among their hospitalized patients. CAs should be included in negotiations for healthcare and productivity improvement. Attention to detail is important when dealing with the families who authorize CAs, and postmortem examination should be improved. It is helpful that the hospital management favors monthly summaries containing the CAs performed to patients who died in the various departments of the hospital, prepared by the Department of Pathology. This document should be delivered to all the personnel in charge of the care units.Health authorities are responsible for public hospitals to set a minimum CA rate. This minimum rate should be part of the accreditation of the various hospital departments and the hospital as a whole, and be taken into account in healthcare improvement plans.CA currently (a) provides a diagnosis in cases of sudden death or rapid evolution disease in which clinical research has been inadequate; (b) sheds light on difficult cases where the biopsy was unable to provide the diagnosis; (c) helps to learn new ways of occurrence in the known diseases; (d) it is useful in the description of new entities, providing full pathological description; (e) allows the application of current research techniques such as molecular pathology; (f) allows to control the safety of current diagnostic techniques; (g) assess the consequences and results of new therapeutic modalities; (h) remains a major educational tool and should be maintained as part of the training program for residents; (i) provides material for research (tissue banks, particularly brain) and for the completion of phD thesis<a class="elsevierStyleCrossRef" href="#bib0340">31</a>; (j) allows epidemiological and statistical studies on real bases; (k) usually protects clinicians from malpractice litigation, providing objective data; (l) provides valuable information to the families of the deceased, and (m) is crucial to ensure the quality of care. In fact, doctors in contact with CAs might be involved in future cases and gain valuable experience. In developed countries the CAs should be universal.An important reason for maintaining CAs is that when performed correctly they are the final test of quality control in medical practice. High quality is one of the pillars for hospital accreditation. It is therefore paradoxical that the emphasis on hospital quality is consistent with the lowest CA rates in the last decade.Some professionals have used CT scans to supplement conventional CAs. This imaging test has shown significant accuracy in the diagnosis of air embolism, emphysema and pneumothorax.<a class="elsevierStyleCrossRef" href="#bib0345">32</a> However, the most frequent causes of sudden death remain largely undiagnosed for both, computed tomography and magnetic resonance imaging.<a class="elsevierStyleCrossRef" href="#bib0350">33</a> While investigating alternatives to conventional CAs,<a class="elsevierStyleCrossRefs" href="#bib0355">34–36</a> the conventional postmortem examination to microscope remains the most reliable method to determine the main diagnosis and cause of death.CA remains a crucial procedure in current medicine. CA is the procedure where the truth can be sought, found and told without any conflicts of interest.<a class="elsevierStyleCrossRef" href="#bib0370">37</a>FundingExternal funding has not been obtained to carry out this work.Conflict of interestsThe author reports no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-02-16" "fechaAceptado" => "2015-02-27" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Val-Bernal JF. El papel de la autopsia en la práctica clínica actual. Med Clin (Barc). 2015;145:313–316." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Goldman et al.,<a class="elsevierStyleCrossRef" href="#bib0215">6</a> Battle et al.<a class="elsevierStyleCrossRef" href="#bib0220">7</a> and Schwanda-Burger et al.<a class="elsevierStyleCrossRef" href="#bib0225">8</a>" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discrepancy in primary diagnosis with potential impact on survival (examples: pulmonary infarction treated as pneumonia, fungal pneumonia treated as bacterial infection) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discrepancy in primary diagnosis with doubtful or no impact on survival (e.g. biventricular heart failure for severe aortic stenosis with undiagnosed pulmonary embolism) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discrepancy in a secondary diagnosis, not directly related to the cause of death, which could have been diagnosed and treated antemortem, and could affect prognosis (e.g. lung carcinoma in patients with ruptured infrarenal aortic aneurysm) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discrepancy in a secondary, hidden, non diagnosable diagnosis of potential epidemiological or genetic significance (examples: asymptomatic gallstones, microscopic papillary thyroid carcinoma) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nondiscrepant diagnoses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unclassifiable cases Unsatisfactory autopsy with unclear findings. Undiagnosed after reviewing the clinical and autopsy data \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1024705.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of discrepancies between clinical diagnoses and autopsy." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "NA: not available." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author and reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean or median agea \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autopsy rate, % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Discrepancy, % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group of patients \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pastores et al.<a class="elsevierStyleCrossRef" href="#bib0230">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intensive care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pinto Carvalho et al.<a class="elsevierStyleCrossRef" href="#bib0235">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kotovicz et al.<a class="elsevierStyleCrossRef" href="#bib0240">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">288 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tavora et al.<a class="elsevierStyleCrossRef" href="#bib0245">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">291 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thurnheer et al.<a class="elsevierStyleCrossRef" href="#bib0250">13</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">970 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Akindipe et al.<a class="elsevierStyleCrossRef" href="#bib0255">14</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary transplant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bürgesser et al.<a class="elsevierStyleCrossRef" href="#bib0260">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fares et al.<a class="elsevierStyleCrossRef" href="#bib0265">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">409 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults, cardiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schwanda-Burger et al.<a class="elsevierStyleCrossRef" href="#bib0225">8</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wittschieber et al.<a class="elsevierStyleCrossRef" href="#bib0270">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fröhlich et al.<a class="elsevierStyleCrossRef" href="#bib0275">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Liver transplant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Papadodima et al.<a class="elsevierStyleCrossRef" href="#bib0280">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">641 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fröhlich et al.<a class="elsevierStyleCrossRef" href="#bib0285">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">204 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intensive care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sblano et al.<a class="elsevierStyleCrossRef" href="#bib0290">21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">879 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kuijpers et al.<a class="elsevierStyleCrossRef" href="#bib0295">22</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">460 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1024706.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Major clinicopathological discrepancies (classes 1+2) in recent autopsy series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0190" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La autopsia clínica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. 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The current role of autopsy in current clinical practice

El papel de la autopsia en la práctica clínica actual

José Fernando Val-Bernal

Unidad de Patología, Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Cantabria, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain

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    "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
    "titulo" => "The current role of autopsy in current clinical practice"
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      0 => array:3 [
        "autoresLista" => "Jos&#233; Fernando Val-Bernal"
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            "nombre" => "Jos&#233; Fernando"
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              0 => "apavbj&#64;humv&#46;es"
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        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Unidad de Patolog&#237;a&#44; Departamento de Ciencias M&#233;dicas y Quir&#250;rgicas&#44; Universidad de Cantabria&#44; Instituto de Investigaci&#243;n Sanitaria Valdecilla &#40;IDIVAL&#41;&#44; Santander&#44; Spain"
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        "titulo" => "El papel de la autopsia en la pr&#225;ctica cl&#237;nica actual"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical autopsy &#40;CA&#41; has a brilliant history&#46; It has contributed significantly to the advance in medical knowledge in many crucial areas over many years&#46; However&#44; since 1960 the CA rate has been declining gradually in Europe and USA&#46; In the U&#46; M&#46; Valdecilla Hospital it has decreased from 12&#46;6&#37; in 1998&#8211;2004 to 7&#46;6&#37; in the last five years&#46; However&#44; major teaching hospitals generally have a higher rate and a higher absolute number of postmortem examinations than non-teaching hospitals&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several factors have favored the decreasing CA rate&#46; The main factors&#44; today more relevant than ever&#44; are listed concisely in the following paragraphs<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#8211;3</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Confidence in antemortem diagnosis&#46; This appears to be one of the most important factors in the decline of autopsies&#46; With the development and rapid improvement in laboratory and imaging diagnostic procedures&#44; and algorithms&#44; many clinicians see CA as an inefficient&#44; irrelevant and unnecessary practice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">CA lacks adequate incentives&#46; Postmortem examination has inadequate productivity compensation&#46; It is a practice that takes time and effort&#46; Resident physicians perceive over time CA has poor social and professional significance&#44; it is unrewarding&#44; potentially dangerous&#44; and is not a priority&#46; Moreover&#44; there is a much more intense care pressure on biopsies&#44; surgical and cytology devices&#44; and a growing environmental pressure over time devoted to research&#46; It has been estimated that CAs contribute little to the Pathology Department scientific performance&#44; since only 6&#37; of the papers published are based on CA findings&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Delayed CA report release&#46; Although the provisional findings are issued within 48<span class="elsevierStyleHsp" style=""></span>h&#44; the final ones&#44; with microscopic examination&#44; often take more than 45 days&#46; This creates disinterest in the applicant clinician because a recent problem becomes a remote problem&#44; barely reminded&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lack of communication between pathologists and clinicians and between clinicians and family&#46; The lack of response to antemortem clinical problems and the lack of clinicopathological correlation among some of the CA reports are factors of disagreement&#46; Unpredicted death makes the person in charge for requesting CA be unknown to the family&#46; In this situation&#44; the patient&#39;s relatives are more likely to oppose&#44; and the requesting clinician is often unmotivated&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">CA defective reports unresponsive to previous clinical approaches&#46; Some CAs are performed by untrained pathologists&#44; with inadequate supervision&#46; Moreover&#44; it should be noted that&#44; technically&#44; appropriate CAs fail to find the cause of death in 1&#8211;5&#37; cases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Fear of discrediting the clinical professional due to unexpected findings&#44; or litigation due to negligence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Lack of training in the application of CA and ignorance of the administrative process&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Hospital managers consider that CA is not a priority and they only care when social problems arise&#46; Lack of an overall strategic plan by the health administration including hospital accreditation&#44; productivity&#44; resources&#44; quality control&#44; mortality commission and various other actions in relation to CA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Health authorities believe that CA is a technical matter within the hospital environment&#44; with little or no impact on the scope of their jurisdiction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Family concern at the delay in handing over the body&#44; the possible disfiguration of the deceased and possible additional cost&#46; There are also religious objections by various communities&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Based on these considerations we believe it is necessary to review critically recent medical literature on postmortem examination to assess the role of CA in current clinical medicine&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Materials and methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">We searched for articles published from 2007 to 2014 studying the discrepancies between clinical and autopsy diagnoses using Medline&#46; The articles were examined to obtain the following information&#58; number of patients&#44; average age&#44; hospital autopsy rate&#44; diagnostic discrepancy and grouping patients according to their specific features&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Diagnostic discrepancies were classified according to the criteria provided by Goldman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a>&#44; modified by Battle et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a> and Schwanda-Burger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows a classification of these discrepancies&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">After searching through Medline&#44; 15 articles met all or most of the required information&#46; This literature included 6337 CAs&#44;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">8&#8211;12</span></a> whose data are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Using the major discrepancy criteria &#40;classes 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#41; it can be seen that the discrepancy rates range from 7 to 56&#37;&#44; with a 25&#46;6&#37; weighted average&#46; The 4 most frequent discordant diagnoses included acute myocardial infarction&#44; pneumonia&#44; intestinal infarction and pulmonary thromboembolism&#46; Other frequent discordant primary diagnoses included&#58; cardiac tamponade&#44; abdominal hemorrhage&#44; endocarditis&#44; surgical complications&#44; ruptured aortic aneurysm&#44; neoplasm &#40;metastatic carcinoma&#44; lymphoma&#44; mesothelioma&#41; and miliary tuberculosis&#46; The discrepancy rates were higher in patients aged over 60&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The belief in the futility of CA contradicts the discrepancies after studying antemortem diagnosis&#46; It should be noted that the decreasing CA rate may cause some bias&#44; with increased percentage of discrepancies&#44; provided that the cases chosen for autopsy tend to be the most problematic and complex cases&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The data in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> have the limitations of retrospective studies&#46; However&#44; Combes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> conducted a prospective study for 3 years in intensive care unit&#46; In 167 patients &#40;53&#37; CA rate&#41; they observed a 31&#46;7&#37; diagnostic discrepancy &#40;class 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>clase 2&#41;&#46; Heriot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a>&#44; in a study of 407 autopsied patients&#44; estimated the overall sensitivity and positive predictive value of clinical diagnoses&#46; The respective values were 0&#46;74 and 0&#46;93&#46; Pneumonia&#44; acute myocardial infarction&#44; intestinal ischemia and pulmonary embolism had sensitivity below 0&#46;70 and positive predictive values below 0&#46;90&#46; Therefore&#44; it is evident that the percentage of discrepant diagnoses remains high despite the significant technical advances in diagnostic methods&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In this paper we have avoided the term &#8220;diagnostic error&#8221;&#46; This term misunderstands the diagnostic discrepancy&#44; suggesting a single causality of individual type&#46; However&#44; despite best medical practice&#44; there are many inherent limitations influencing the clinical reasoning and decision making&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a> Thus&#44; diagnostic tools used today have limited sensitivity and specificity&#46; Computed tomography and ultrasonography can yield false positive or false negative diagnoses in 6 to 9&#37; patients&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">For CA to be effective the following requirements should be met&#58; &#40;a&#41; be encouraged by the managers of the Pathology Departement&#59; &#40;b&#41; provide a quality control and report timing with a CA manager assisted by other qualified physicians<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a>&#59; &#40;c&#41; support to residents by technicians&#44; and close monitoring by the relevant specialists&#59; &#40;d&#41; CA should be clinically customized&#44; responding to all the problems arising antemortem&#59; &#40;e&#41; systematic review of all CAs after 24<span class="elsevierStyleHsp" style=""></span>h &#40;at a preset fixed time&#41; on a macroscopic lecture attended by the relevant clinicians&#59; &#40;f&#41; the provisional report should be available to all clinicians in charge of the case after 48<span class="elsevierStyleHsp" style=""></span>h&#59; &#40;g&#41; the final report after the microscopic examination should not take longer than 45 days&#59; &#40;h&#41; CA should be practiced without delay right after the authorization has been obtained&#59; and &#40;i&#41; provide a permanent surveillance service in the Department of Pathology&#44; assisting intraoperative biopsies&#44; transplant biopsies and CAs&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Specific training on how to request CAs to the family should be provided to all the doctors of the institution&#44; including residents&#46; This training&#44; as it happens with organ donation for transplantation&#44; should be part of an active and well-defined policy of the center&#46; Moreover&#44; the institution should publish a CA protocol including the administrative procedure&#46; The protocol should be delivered to all the health personnel&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">It is imperative that the autopsy authorization is accompanied by clinical diagnoses&#44; clearly expressed&#44; cause of death and the clinical problems the autopsy should resolve&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Autopsy pathology should be acknowledged as a subspecialty of pathology&#46; Autopsies require good training in anatomy&#44; physiology&#44; pathophysiology&#44; especially the circulatory&#44; respiratory and renal systems&#44; and in general pathological anatomy&#46; In addition&#44; the autopsy pathologist needs to be familiar with the complications&#44; and treatment of patients admitted to intensive care units to assess the lesions found&#46; Particular attention is required&#44; for example&#44; in the injury differentiation by shock in postmortem changes&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> When autopsies are performed by specialists or with special dedication&#44; reporting id faster&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">26&#44;28</span></a> report quality improves&#44; with good clinicopathological correlation&#44; and information to the family becomes systematic and of best quality&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Today&#44; the fear that a CA shows negligent actions that could lead to malpractice litigation is more a hypothesis than a fact&#46; Only exceptionally CAs show malpractice that had not been clinically proven before the CA&#59; and CAs are very rarely used as evidence in court&#46; In a survey about how significant a CA might be&#44; the threat of litigation for malpractice was not a deterrent among clinicians&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> CAs prove facts and replace guesswork of the lawyers and possible suspicions of relatives&#46; In this context&#44; the request for a CA should be understood as interesting for a clinician in order to clarify a complicated case&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The hospital manager should promote CAs in the clinical sector and in the Pathology Department&#46; Hospital Management should worry about the causes and mechanisms of death among their hospitalized patients&#46; CAs should be included in negotiations for healthcare and productivity improvement&#46; Attention to detail is important when dealing with the families who authorize CAs&#44; and postmortem examination should be improved&#46; It is helpful that the hospital management favors monthly summaries containing the CAs performed to patients who died in the various departments of the hospital&#44; prepared by the Department of Pathology&#46; This document should be delivered to all the personnel in charge of the care units&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Health authorities are responsible for public hospitals to set a minimum CA rate&#46; This minimum rate should be part of the accreditation of the various hospital departments and the hospital as a whole&#44; and be taken into account in healthcare improvement plans&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">CA currently &#40;a&#41; provides a diagnosis in cases of sudden death or rapid evolution disease in which clinical research has been inadequate&#59; &#40;b&#41; sheds light on difficult cases where the biopsy was unable to provide the diagnosis&#59; &#40;c&#41; helps to learn new ways of occurrence in the known diseases&#59; &#40;d&#41; it is useful in the description of new entities&#44; providing full pathological description&#59; &#40;e&#41; allows the application of current research techniques such as molecular pathology&#59; &#40;f&#41; allows to control the safety of current diagnostic techniques&#59; &#40;g&#41; assess the consequences and results of new therapeutic modalities&#59; &#40;h&#41; remains a major educational tool and should be maintained as part of the training program for residents&#59; &#40;i&#41; provides material for research &#40;tissue banks&#44; particularly brain&#41; and for the completion of phD thesis<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">31</span></a>&#59; &#40;j&#41; allows epidemiological and statistical studies on real bases&#59; &#40;k&#41; usually protects clinicians from malpractice litigation&#44; providing objective data&#59; &#40;l&#41; provides valuable information to the families of the deceased&#44; and &#40;m&#41; is crucial to ensure the quality of care&#46; In fact&#44; doctors in contact with CAs might be involved in future cases and gain valuable experience&#46; In developed countries the CAs should be universal&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">An important reason for maintaining CAs is that when performed correctly they are the final test of quality control in medical practice&#46; High quality is one of the pillars for hospital accreditation&#46; It is therefore paradoxical that the emphasis on hospital quality is consistent with the lowest CA rates in the last decade&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Some professionals have used CT scans to supplement conventional CAs&#46; This imaging test has shown significant accuracy in the diagnosis of air embolism&#44; emphysema and pneumothorax&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> However&#44; the most frequent causes of sudden death remain largely undiagnosed for both&#44; computed tomography and magnetic resonance imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">33</span></a> While investigating alternatives to conventional CAs&#44;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">34&#8211;36</span></a> the conventional postmortem examination to microscope remains the most reliable method to determine the main diagnosis and cause of death&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">CA remains a crucial procedure in current medicine&#46; CA is the procedure where the truth can be sought&#44; found and told without any conflicts of interest&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">External funding has not been obtained to carry out this work&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interests</span><p id="par0165" class="elsevierStylePara elsevierViewall">The author reports no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Val-Bernal JF&#46; El papel de la autopsia en la pr&#225;ctica cl&#237;nica actual&#46; Med Clin &#40;Barc&#41;&#46; 2015&#59;145&#58;313&#8211;316&#46;</p>"
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        "fuente" => "Source&#58; Goldman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> Battle et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a> and Schwanda-Burger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discrepancy in primary diagnosis with potential impact on survival &#40;examples&#58; pulmonary infarction treated as pneumonia&#44; fungal pneumonia treated as bacterial infection&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discrepancy in primary diagnosis with doubtful or no impact on survival &#40;e&#46;g&#46; biventricular heart failure for severe aortic stenosis with undiagnosed pulmonary embolism&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discrepancy in a secondary diagnosis&#44; not directly related to the cause of death&#44; which could have been diagnosed and treated antemortem&#44; and could affect prognosis &#40;e&#46;g&#46; lung carcinoma in patients with ruptured infrarenal aortic aneurysm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discrepancy in a secondary&#44; hidden&#44; non diagnosable diagnosis of potential epidemiological or genetic significance &#40;examples&#58; asymptomatic gallstones&#44; microscopic papillary thyroid carcinoma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nondiscrepant diagnoses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unclassifiable cases Unsatisfactory autopsy with unclear findings&#46; Undiagnosed after reviewing the clinical and autopsy data&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author and reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean or median age<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autopsy rate&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Discrepancy&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pastores et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intensive care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pinto Carvalho et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kotovicz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tavora et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">291&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thurnheer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">970&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Akindipe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pulmonary transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">B&#252;rgesser et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fares et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">409&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&#44; cardiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schwanda-Burger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wittschieber et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fr&#246;hlich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Liver transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Papadodima et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">641&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fr&#246;hlich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">204&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intensive care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sblano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">879&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kuijpers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">460&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1024706.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Major clinicopathological discrepancies &#40;classes 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#41; in recent autopsy series&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:37 [
            0 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "La autopsia cl&#237;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;A&#46; Bomb&#237;"
                            1 => "A&#46; Cardesa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
                        "fecha" => "1986"
                        "volumen" => "86"
                        "paginaInicial" => "328"
                        "paginaFinal" => "333"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "La autopsia cl&#237;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46;P&#46; Arce Mateos"
                            1 => "F&#46;A&#46; Fern&#225;ndez Fern&#225;ndez"
                            2 => "M&#46;M&#46; Mayorga Fern&#225;ndez"
                            3 => "J&#46; G&#243;mez Rom&#225;n"
                            4 => "J&#46;F&#46; Val Bernal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:6 [
                        "titulo" => "Libro Blanco de la Anatom&#237;a Patol&#243;gica en Espa&#241;a 2009"
                        "fecha" => "2009"
                        "paginaInicial" => "125"
                        "paginaFinal" => "146"
                        "editorial" => "Sociedad Espa&#241;ola de Anatom&#237;a Patol&#243;gica"
                        "editorialLocalizacion" => "Zaragoza"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Objetivos e indicaciones de la autopsia cl&#237;nica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Fern&#225;ndez Fern&#225;ndez"
                            1 => "A&#46; Est&#233;banez Gallo"
                            2 => "M&#46; Mayorga Fern&#225;ndez"
                            3 => "I&#46; Guerra Merino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "REMI"
                        "fecha" => "2004"
                        "volumen" => "4"
                        "paginaInicial" => "1"
                        "paginaFinal" => "9"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Declining autopsy rate in a French hospital&#58; physician&#39;s attitudes to the autopsy and use of autopsy material in research publications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Chariot"
                            1 => "K&#46; Witt"
                            2 => "V&#46; Pautot"
                            3 => "R&#46; Porcher"
                            4 => "G&#46; Thomas"
                            5 => "E&#46;S&#46; Zafrani"
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