Discrepancia diagnóstica clínico-anatomopatológica de la diabetes mellitus como causa básica de muerte Translated title: Clinical and anatomopathological diagnostic discrepancy of diabetes mellitus as a basic cause of death

To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.

La diabetes mellitus representa un serio problema de salud. El aumento de su incidencia y prevalencia, su carácter complejo y la severidad de los impactos económicos, sanitarios y psicosociales que genera, legitiman la importancia de reflexionar sobre sus efectos desde el espacio individual y social más inmediato a las personas que viven con esta enfermedad. El trabajo trata algunos de los aspectos que desde los procesos de salud-enfermedad, y basados en los significados construidos a propósito de estos, se relacionan con las respuestas psicológicas más comunes a la diabetes: la comunicación del diagnóstico, el mundo psicológico de la persona con diabetes, los significados subyacentes a este, el proceso de atención de salud, y los aspectos y momentos críticos en el tratamiento de la enfermedad. Se concluye que los procesos de salud de personas con diabetes incluyen experiencias con potencial para causar severos impactos psicológicos y sociales, relacionados con los significados, de base psicosociocultural, estructurados a partir de estas vivencias. Se comparten recomendaciones para incidir positivamente en el bienestar de personas con diabetes, desde los espacios y servicios de salud.

The national decline in hospital autopsy cases negatively impacts physician education and medical quality control to an unknown degree. The current non-medicolegal autopsy rate is less than 5% of hospital deaths. This study compares internal medicine and pathology resident physician perceptions of the autopsy, including the importance, procurement, technique, and the pathologist-internist interaction. An 84-item survey based on autopsy literature was designed, piloted, and distributed to 214 residents at a single 800+ bed tertiary care academic teaching hospital (Massachusetts General Hospital, Boston) to accomplish this goal. Completed surveys were obtained from 72% of medicine (n = 118) and 84% of pathology (n = 42) residents. Residents strongly agree on the importance of autopsies for education, answering clinical questions, public health, and research. Autopsy rates are deemed inadequate. Internists are comfortable requesting autopsies, but report insufficient guidance and difficulty with answering technical questions. Although not requested on all hospital deaths, internists are more likely to initiate an autopsy request than a decedent's family, and worry significantly less about institutional costs and malpractice litigation than pathologists believe. Internists expressed interest in having an instructional brochure to give families, observing an autopsy, and having increased communication and support with autopsies from pathology residents. The main reasons why autopsy consent is not requested (it is unpleasant, cause of death is known, family is upset or seems unwilling) and why families refuse (patient has suffered enough, body may be handled disrespectfully, religious/moral objections, lack information) were similar for both resident groups. Despite their decline, autopsies still remain important to medicine as indicated by internal medicine and pathology residents at a large academic center. Improving autopsy education, enhancing availability of resources, and strengthening the pathologist-internist collaboration may serve to heighten awareness and ultimately procurement.