Letter to the Editor
Reply
Respuesta
José-Fernando Val-Bernal
Unidad de Patología, Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Cantabria e Instituto de Investigación Sanitaria de Cantabria (IDIVAL), Santander, Spain
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The CA registered are those in which the question “was an autopsy was performed?” on the death certificate was completed with the “yes” option. To determine the estimated CA, first the proportion of CA registered in connection with deaths without legal intervention was calculated using the question: “was an autopsy performed?” that was completed (“yes” or “no”); second, this ratio was applied to the number of deaths without legal intervention using the question “was an autopsy performed?” that was not completed; and finally, the result of the number of registered CAs. The percentage of deaths without legal intervention with the question “was an autopsy performed?” was not completed in 54.3% in 2009, 31.7% in 2010, 30.5% in 2011, 29.7% in 2012 and 27.1% in 2013. 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The high percentage of non-completion in 2009 was due to the still frequent use of the former statistical death bulletin, which saw 38.1% of total deaths without legal intervention in that year, a figure which fell to 2.4% in 2010, 0.5% in 2011, 0.3% in 2012 and 0.2% in 2013. <span class="elsevierStyleItalic">Information sources</span>: For FA the Institute of Legal Medicine of Catalonia; For CA The Mortality Register of Catalonia (Servei d’Informació i Estudis, Departament de Salut, Generalitat de Catalunya).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alexandre Xifró, Eneko Barbería, Anna Puigdefàbregas, Adriana Freitas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alexandre" "apellidos" => "Xifró" ] 1 => array:2 [ "nombre" => "Eneko" "apellidos" => "Barbería" ] 2 => array:2 [ "nombre" => "Anna" "apellidos" => "Puigdefàbregas" ] 3 => array:2 [ "nombre" => "Adriana" "apellidos" => "Freitas" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S002577531500487X" "doi" => "10.1016/j.medcli.2015.07.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577531500487X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061630119X?idApp=UINPBA00004N" "url" => "/23870206/0000014600000004/v1_201606140021/S238702061630119X/v1_201606140021/en/main.assets" ] ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "186" "paginaFinal" => "187" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "José-Fernando Val-Bernal" "autores" => array:1 [ 0 => array:3 [ "nombre" => "José-Fernando" "apellidos" => "Val-Bernal" "email" => array:1 [ 0 => "pavbj@humv.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Patología, Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Cantabria e Instituto de Investigación Sanitaria de Cantabria (IDIVAL), Santander, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I wish to thank the interest and valuable comments made by Xifró et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> regarding my special article on the role of autopsy in medicine today.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> I agree with these authors when they note that both forensic autopsy (FA) and clinical autopsy (CA) must remain an important part of today's personalised medicine, because of their relevant role in care and patient safety. The autopsy continues to deliver unexpected findings on a regular basis, even in this 21st century of high-technology medicine. For example, the study of patients’ brain with Alzheimer's dementia has shown that black patients more frequently have a mixed process (association with Lewy bodies, chronic infarction, arteriolar sclerosis and atherosclerosis) than those of white patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This study has important implications for therapy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An autopsy is well positioned to ensure the reliability of mortality statistics, it is a source of knowledge for new entities, elucidates the changing face of known diseases, controls new methods of diagnosis and treatment, provides material for research, and has great potential for pre- and post-graduate medical education. The National Violent Death Reporting System in the USA is an excellent example of how the collection of FA data can be used for public health purposes.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, the continuing decline, especially of CA, has triggered alarms in the anatomopathological community. CA in many industrialised countries is on the verge of extinction, even in hospitals that teach medicine. A recent article from the United Kingdom stated that CAs were carried out only on only 0.69 of hospital deaths, and this post mortem examination appears to be completely eradicated in 23% of National Health Service hospitals in the United Kingdom.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In addition, it has been noted that a dramatic decline in autopsy rates could cause a failure in detecting homicide.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The fall in the rate of autopsies has another secondary effect: the disappearance of the post mortem examination impacts on the education of undergraduate students, resident doctors and even in the continuing education of hospital medical staff. A well-structured education that includes autopsies by enthusiastic, well-trained pathologists and technicians who are skilled in dissection, in an aesthetic environment, would be very beneficial for the student. The benefits, in terms of impact on knowledge, skills and attitudes (the so-called hidden curriculum), of including both CA and FA<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> are great.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One of the greatest enemies of autopsies is the delay of issuing reports. The application of the lean production method has led some authors to define 12 essential processes in the autopsy practice, resulting in a drastic reduction in delivery times for reports, from an average of 57 days to 4.8.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> This system greatly increases the usefulness of autopsies.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A review of the autopsies carried out in Cantabria for the 2009–2014 period (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) has revealed that there has been a slight decrease in the percentage of FA over recent years, mainly due to the decline in violent deaths. The FA average for this period was 299 per year, with an average rate of 5.3%. The CAs carried out in the Marqués de Valdecilla University Hospital of Santander have also experienced a slight decline. Their average CA has been 113 per year, with an average percentage during the aforementioned period of 8.0%. The absolute number of natural death autopsies performed by forensic specialists in Cantabria exceeds the absolute number of CA carried out at the university hospital of the community. Therefore, our study shows that the forensic pathologist is in a prime position to study sudden unexpected death (SUD). SUD is a major cause of premature death in young adults and children. Many cases of SUD are due to genetic heart conditions, including structural lesions (hypertrophic cardiomyopathy) and arrhythmogenic abnormalities (e.g., long QT syndrome and Brugada syndrome).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Genetic and molecular autopsy studies revealed that a significant number of these deaths are detected by these new techniques that are a major challenge for the forensic pathologist and which require a multidisciplinary approach.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, autopsies are generally the benchmark for measurable clinical decision-making processes, diagnostic methods and treatments. They also play an important role in research and teaching. Autopsies not only help establish the cause of death, but also influence the prevention of future processes that lead to death.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author declares no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:2 [ "identificador" => "xack227165" "titulo" => "Acknowledgements" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Val-Bernala J-F. Respuesta. Med Clin (Barc). 2016;146:186–187.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "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=""><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">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">Deaths in Cantabria \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">Forensic autopsies \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">Percentage of forensic autopsies \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">Violent deaths (percentage) \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">Natural deaths (percentage) \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">Deaths in the U.H. Marqués de Valdecilla \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">Clinical autopsies \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">Percentage of clinical autopsies \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">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5513 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">339 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 (2.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">173 (3.14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1431 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.62 \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">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5546 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">347 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">158 (2.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">187 (3.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1393 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.55 \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">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5606 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">299 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">133 (2.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">161 (2.87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1462 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">128 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.75 \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">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5812 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">273 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">132 (2.27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140 (2.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1363 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.78 \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">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5603 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">259 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108 (1.93) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">143 (2.55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1418 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.47 \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">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5892 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">276 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119 (2.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">156 (2.65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1429 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.65 \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">Total (Average) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33,972 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1793 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(5.29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">810 (2.40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">960 (2.83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8496 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">677 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(7.97) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1103600.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Forensic autopsies in Cantabria and clinical autopsies in the Marqués de Valdecilla University Hospital in Santander.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autopsia judicial y autopsia clínica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. 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Fernández and Martha Mayorga Department of Pathology, University Hospital Marqués de Valdecilla of Santander.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014600000004/v1_201606140021/S2387020616301188/v1_201606140021/en/main.assets" "Apartado" => array:4 [ "identificador" => "46463" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014600000004/v1_201606140021/S2387020616301188/v1_201606140021/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616301188?idApp=UINPBA00004N" ]
