|Year : 2020 | Volume
| Issue : 2 | Page : 128-131
Contribution of pediatric autopsies to clinical care: Utilization among physicians in a Nigerian tertiary hospital in the past decade
Adaobi I Bisi-Onyemaechi1, Ikenna Ndu2, Obinna Nduagubam2, Ugo N Chikani1, Okechukwu C Okafor1, Anthony O Eni3, Uzoamaka Muoneke1
1 College of Medicine, University of Nigeria Ituku-Ozalla, Enugu, Nigeria
2 College of Medicine, Enugu State Teaching Hospital Parklane, Enugu, Nigeria
3 Department of Histopathology, University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu, Nigeria
|Date of Submission||16-Dec-2019|
|Date of Decision||23-Jan-2020|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||29-Jul-2020|
Adaobi I Bisi-Onyemaechi
Department of Paediatrics College of Medicine, University of Nigeria Ituku-Ozalla, Enugu.
Source of Support: None, Conflict of Interest: None
Objective: The usefulness of autopsy includes the determination of the cause of death and risk factors of a disease, ascertaining the chances of recurrence and the consequences for relatives, genetic counseling, and planning for future cases and for research. Its utilization has, however, been on the decline in most parts of the world. The researchers set out to determine how much autopsies of pediatric patients are being utilized in a tertiary health facility in Enugu, Nigeria, and the degree of correlation between the clinical and pathologic diagnosis. Design: This was a descriptive cross-sectional study of case notes of pediatric deaths and all pediatric autopsies in the preceding 10 years, noting clinical diagnosis and requests for autopsies and its outcome, and comparing it with pathological diagnosis. Settings: The study was conducted in the departments of pediatrics and histopathology of the University of Nigeria, Ituku-Ozalla campus. Results: There were 1962 deaths with 12 autopsies performed within the period of study. Evidence of request for a postmortem was documented in only four case notes whereas reasons for decline or otherwise were also not noted. There was a 100% correlation of pathological and clinical diagnosis from the available case notes. Conclusions: Autopsies of pediatric patients are almost nonexistent in a university teaching hospital, resulting to poor utilization by physicians. A follow-up study is required to ascertain and manage the cause of the apathy displayed by the attending physicians to the usefulness of autopsies in patient care.
Keywords: Nigeria, pathologic diagnosis, pediatric autopsy, utilization
|How to cite this article:|
Bisi-Onyemaechi AI, Ndu I, Nduagubam O, Chikani UN, Okafor OC, Eni AO, Muoneke U. Contribution of pediatric autopsies to clinical care: Utilization among physicians in a Nigerian tertiary hospital in the past decade. Int J Med Health Dev 2020;25:128-31
|How to cite this URL:|
Bisi-Onyemaechi AI, Ndu I, Nduagubam O, Chikani UN, Okafor OC, Eni AO, Muoneke U. Contribution of pediatric autopsies to clinical care: Utilization among physicians in a Nigerian tertiary hospital in the past decade. Int J Med Health Dev [serial online] 2020 [cited 2020 Oct 29];25:128-31. Available from: https://www.ijmhdev.com/text.asp?2020/25/2/128/291061
| Introduction|| |
Parents need to know the cause of death of their child. Autopsy provides an important source of information in determining why any child died. It is also important to counsel relatives in cases of diseases that are genetic, determine the risk factors of a disease, assess the risk of recurrence, and determine plan for new cases and for research.,, Findings from autopsy are sometimes conflicting with clinical cause of death in up to 3%–20% of cases.,, In some of these cases, outcome would have been different if recognized antemortem, emphasizing the need for autopsies.,, To improve the quality of clinical practice, it is recommended that at least 75% of deaths should be audited with an autopsy. Autopsy also provides medical students another opportunity to learn anatomy and gross pathology, and to improve their observational skills. It also helps students learn professionalism and attitude of respect, and subsequently desensitizes and prepares them to care for the terminally ill in the future. Despite these numerous benefits, uptake has remained low or nonexistent and has generally been on the decrease globally.,,
Different reasons have been attributed for the decline and low uptake of autopsy, and these include unfavorable disposition to autopsy by health workers, religious and traditional beliefs, cost to the family, and lack of qualified personnel.,
Pediatric autopsies have been documented to provide new knowledge in up to 21%–76% of cases,, though it is very challenging to obtain consent from grieving parents/loved ones.
Aim and objectives
Uptake of pediatric autopsies has remained very low in Nigeria due to some of the aforementioned reasons.,, Considering the numerous benefits of autopsies, the researchers intend to determine the extent to which autopsies of pediatric patients are being utilized in a tertiary health facility in Enugu, Nigeria, and the degree of correlation between autopsy and clinical findings.
| Materials and Methods|| |
Study design: This was a descriptive cross-sectional study of all autopsies of pediatric patients (0–17 years) in the preceding 10 years (January 1, 2009, to December 31, 2018).
Settings: The study was conducted at the pediatric and histopathology departments of University of Nigeria Teaching Hospital (UNTH), a tertiary hospital in southeast Nigeria.
Study population and sampling strategy: Cases of all pediatric autopsies performed were retrieved from the histopathology department (with no selection bias), and case notes were retrieved from medical records department. Information obtained from the case notes was entered into a study pro forma. Relevant information such as age, sex, duration of illness, clinical diagnosis at time of death, evidence of post mortem request, and result were retrieved. Case files of all pediatric deaths were retrieved to check for evidence of request for a postmortem and subsequent findings. Rate of physician request for autopsy and rate of autopsy performed were also determined. Clinicopathological discrepancies according to the classification by Goldman et al. and modified by Battle et al. and non-classifiable cases by Bellwald were used to compare and classify clinical and autopsy findings.
Class I: Discrepancies in major diagnoses. Knowledge of diagnosis before death would have led to changes in management that could have prolonged survival or cured the patient (e.g., pulmonary infarction treated as pneumonia and fungal pneumonia treated as bacterial infection).
Class II: Discrepancies in major diagnoses whose detection before death would not have changed survival even with correct treatment or due to no treatment available at the time.
Class III: Discrepancies in minor diagnoses not directly related to cause of death, but with symptoms that should have been treated or would have eventually affected prognosis.
Class IV: Discrepancies in minor occult diagnoses (non-diagnosable) but with possible epidemiological or genetic importance (e.g., symptomless gallstones, goiter).
Class V: Non-discrepant diagnoses.
Class VI: Patient died immediately after admission with no diagnostic procedures, or refused any diagnostic procedures or treatment. Autopsy was unsatisfactory with no clear findings and no diagnosis could be established after review of clinical and necropsy data.
Statistical analysis was both basic and descriptive. Data analysis was carried out using SPSS (IBM, Armonk, NY), version 21.0, for Windows. Confidentiality was maintained at all stages of the study.
Ethical approval: Ethical consent was obtained from the Ethics and Research Committee of University of Nigeria Teaching Hospital, Enugu.
| Results|| |
During this period, a total of 1962 deaths occurred, giving an average annual pediatric death rate of 196 per annum.
Majority, 919 (46.8%), were neonatal deaths whereas 645 (32.9%) occurred in the children emergency room. Three hundred and ninety eight deaths occurred in the wards.
More than a quarter (26.6%, 521) of these deaths occurred within 24h of presentation whereas 20% of the coroner’s deaths were neonatal.
Among the 1962 documented deaths, only 1431 case files could be retrieved. A documented evidence of autopsy request was seen only in 57 case notes. A decline was documented in 11 of these case notes, whereas nothing was written as the outcome of the request in the other 46. The reasons for the decline were not noted in any of these 11 cases.
The rate of autopsy request by attending physicians was 0.04.
Among these deaths, there were only 12 autopsies performed with a crude pediatric autopsy rate of 0.006 and an annual pediatric autopsy rate of 1.2.
A quarter (three) of the autopsies was neonatal; one autopsy was performed in a 28-week intrauterine death.
Only one of the deaths among the 12 autopsies occurred within 24h of presentation to the hospital (coroner’s case). There were no gender associations with autopsy.
The underlying causes of death include respiratory failure and complications, and multi-organ failure [Table 1]. Two of the autopsies (17%) were forensic.
Four case files of the 12 autopsies were retrievable. Similarly, documented evidence of request for a postmortem was seen only in one; response was not noted and the findings from the autopsy were not documented in the case notes. The 12 autopsy reports were available only from the histopathology department.
The pathological findings in all the four retrieved case files of postmortem corroborated the clinical diagnosis [Table 1].
| Discussion|| |
The pattern of deaths is in consonance with the pattern of child mortality in Nigeria where neonatal deaths still constitute a majority of child mortality, though Nduagubam et al. reported a higher rate of child deaths in the emergency room than in the neonatal unit.
The rate of pediatric autopsies is abysmally low and is not different from previous reports in this environment and beyond. Ijezie et al. reported 0% in Uyo, Nigeria, and Nduagubam et al. reported 0.4% in Parklane, Enugu, Nigeria. Higher rates have been documented with adult autopsies., These are far less from the recommended 75% required for optimal learning and research. Considering the immense benefits of a postmortem study, more policies should be formulated and implemented at the level of the Ministry of Health and the various institutions to reverse this trend.
A significant portion of the deaths was coroner’s deaths and constitutes indications for an autopsy. The higher rates of pediatric autopsies reported in some centers such as Lagos and Benin may be due to institutional policies requiring autopsies to be performed for all deaths within 24h of presentation. The rates of autopsies for pediatric deaths would improve if such policies are adopted by most institutions. This would confirm cause of death, and preventive and better management measures can be subsequently instituted.
The audit of the available case files revealed either a poor request for autopsies by attending physicians or a poor documentation of postmortem events with the former being more likely. This attitude has also been reported previously,, and it reflects an imbalance between comprehension of the usefulness of autopsies in advancing clinical knowledge and research and inconveniencies (obtaining consent and administrative challenges and delays that may be associated with obtaining one). Fear of discrepancy and possible litigation have also been postulated as a possible reason for not requesting autopsy by physicians. Discussions about a possible autopsy should be initiated in a very sensitive manner terminally and responses and reasons documented duly. Common barriers to autopsy such as religious and cultural practices can be overcome with sustained and sensitive counseling on the benefits of autopsy especially in cases of suspected genetic diseases. This would require the training of physician in issues around requesting for autopsies from the bereaved in order to increase the chances of getting consent as it has been suggested to contribute to the poor request by doctors.
A poor record keeping attitude was also demonstrated in this study because as much as 36% of the case notes of the deaths could not be retrieved. Similarly only a quarter of the case files of the autopsies performed could be retrieved. This would have enabled classification of the rate of discrepancy between clinical and postmortem findings in all the 12 cases.
The low prevalence of forensic autopsy would not make for a robust forensic medicine department in the university teaching hospital, which is a key component of crime investigation.
The finding of 100% non-discrepancy between clinical and postmortem diagnosis is a reflection of high-quality underutilized human resource that should be harnessed to improve the quality of clinical practice and plan management of future cases.
Limitation of the study
The limited number of autopsies performed may have influenced the results of correlation between clinicaland pathologic findings.
| Conclusion|| |
In conclusion, pediatric autopsies are almost nonexistent in UNTH, probably due to poor request for it by physicians or difficulty in obtaining consent. Poor documentation of postmortem events could be the reason for the apparent poor request of autopsies by physicians. A follow-up study is required to ascertain and manage the cause of the apparent apathy displayed by the attending physicians to the usefulness of autopsies in patient care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical approval was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu, Nigeria (NHREC/05/01/200BB-FWA00002458-1RB00002323).
| References|| |
Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M The value of the autopsy in three medical eras. N Engl J Med 1983;308:1000-5.
Kumar P, Taxy J, Angst DB Autopsies in children are they still useful? Arch Pediatr Adolesc Med 1998;152:558-63.
Newton D, Coffin CM, Clark EB, Lomchik A How the paediatric autopsy yield valuable information in a vertically integrated health care system. Arch Path Lab Med 2004;128:239-46.
Ekanem VJ, Vhriterihire CO Relevance of clinical autopsy in medical practice in sub-Saharan Africa. Sahel Med J 2015;18:49-56.
Ong AW, Cohn SM, Kelly C, Jaramillo D, Rakesh P, McKeany M, et al
. Unexpected findings in trauma patients dying in the ICU. Results of 153 consecutive autopsies. J Am Coll Surg 2002;194:401-6.
Roosen JE, Frans A, Wilmer DC, Knockref , Bobbers H Comparison of premortem clinical diagnosis in critically ill patients and subsequent autopsy findings. Mayo Clin Proc 2000;75:562-7.
Burton JL, Underwood J Clinical, educational, and epidemiological value of autopsy. Lancet 2007;369:1471-80.
Khong TY Falling neonatal autopsy rates. BMJ 2002;324:749-50.
Cox JA, Lukande RL, Kateregga A, Mayanja-Kizza H, Manabe YC, Colebunders R Autopsy acceptance rate and reasons for decline in Mulago Hospital, Kampala, Uganda. Trop Med Int Health 2011;16:1015-8.
Mittleman RE, Dans JH, Kaszti W, Graves WM Jr. Practical approach to investigate ethics and religious objections to autopsy. J Forensic Sc 1992;37:824-9.
Gordjon SJ, Erwich JJ, Khong JY Value of the perinatal autopsy. Critique Pediatr Dev Path 2002;5:480-8.
Feinstein JA, Ernest LM, Ganesh J, Feudner C What new information paediatric autopsies can provide. A retrospective evaluation of 100 consecutive autopsies using family centered criteria. Arch Paedtr Adolesc Med 2007;161:1190-6.
Eke FU, Frank-Briggs A, Offor J Childhood mortality in Port Harcourt Nigeria. Anil Aggrawal’s Internet Journal of Forensic Medicine & Toxicology 2001;2. Available from: https://www.anilaggrawal.com/ij/vol_002_no_002/papers/paper003.html. [Last accessed on 2019 August 21].
Nwafor CC, Abali C, Nnoli MA Childhood mortality in FMC Umuahia South East Nigeria. Oman Med J 2014;29:320-4.
Battle RM, Pathak D, Humble CG, Key CR, Vanatta PR, Hill RB, et al
. Factors influencing discrepancies between premortem and postmortem diagnoses. JAMA 1987;258:339-44.
Bellwald M Autopsies with unsatisfactory results. Schweiz Med Wochenschr 1982;112:75-82.
Nduagubam OC, Ndu IK, Bisi-Onyemaechi A, Ohayi SR, Asinobi IN, Ekwochi U, et al
. Paediatric mortality and autopsies in Enugu State University Teaching Hospital, Esuth/Parklane, Enugu, Nigeria: A 5-year review. J Exp Res 2018;6:73-8.
Ijezie E, Okpokowuruk FS, Nwafor CC Pediatric death audit with special emphasis on autopsy at the University of Uyo Teaching Hospital, Uyo, Nigeria: A 6-year review. Pediatric Review: International Journal of Pediatric Research 2015;2:80-7.
Ngbea OD, Dzuachii T, Nyaga BS, Otene RA, Vhriterhire MD, Ayuba BM, et al
. A 18 year retrospective review of medico-legal autopsies in Jos, North Central Nigeria. J Dent Med Sci 2015;14:91-5.
Amin SM, AzuSonnie EH, Ogungbayi T Profile of autopsy in a tertiary hospital in Abuja, Nigeria: A ten year review. Ann Trop Pathol 2016;7:43-8.
Ekanem VJ, Gerry IE Attitude of Nigerian resident doctors towards clinical autopsy. Niger Postgrad Med J 2007;14:8-11.
Oluwasola AO, Fawole OI, Otegbayo JA, Ayede IA, Ogun GO, Ukah CO, et al
. Trends in clinical autopsy rate in a Nigerian tertiary hospital. Afr J Med Med Sci 2007;36:267-72.
Bore KE, Iery C; Autopsy Committee, College of American Pathologists. The role of the autopsy in Medical malpractice cases 1: A review of 99 appeal court decisions. Arch Path Lab Med 2002;126:1023-31.