To determine the extent of agreement on underlying cause of death between death certificates and autopsy reports, we analyzed 272 randomly selected autopsy reports and corresponding death certificates from among all such data on autopsies performed in Connecticut in 1980. In 29 per cent of the deaths, a major disagreement on the underlying cause of death led to reclassification of the death in a different International Classification of Diseases major disease category. In an additional 26 per cent, the death certificate and autopsy report agreed on the major disease category but attributed the death to a different specific disease. Deaths due to neoplasms were most accurately diagnosed, with a sensitivity of 87 per cent and a positive predictive value of 85 per cent. Deaths resulting from diseases of the respiratory or digestive system were associated with the highest rates of disagreement. Diseases most commonly overdiagnosed were circulatory disorders, ill-defined conditions, and respiratory diseases. Diseases most commonly underdiagnosed as the cause of death on the death certificate were specific traumatic conditions and gastrointestinal disorders. The autopsy remains an important method for ensuring the quality of mortality statistics.

Mortality statistics derived from death certificates are the only continuously collected, population-based, disease-related information available in most parts of the world, including the United States. For this reason, every effort must be made to ensure that the most specific, accurate, and complete information regarding cause of death is registered on death certificates. This article discusses identification of the underlying and immediate causes of death, the mechanism and manner of death, and completion of the medical certification section of the death certificate. Examples are given to illustrate the appropriate sequencing of causal information and the selection of the proper underlying cause of death.

Two thirds of patients hospitalized to rule out acute myocardial infarction (AMI) are eventually found to have a non-AMI diagnosis, whereas 2% to 8% of patients with AMI are inappropriately discharged from the emergency department. Myoglobin has been shown to increase within 2 to 3 hours of myocardial injury. This study evaluates the usefulness of myoglobin in acute chest pain. Serial blood samples were obtained from 89 suspected AMI patients evaluated in the emergency department. Testing included creatine kinase (CK), a creatine kinase isoenzyme (CK-MB), and myoglobin. Twenty five of 89 patients (28%) had a diagnosis of AMI. The sensitivity of myoglobin for the detection of AMI was 56% at the time of admission and 100% 2 hours after admission. Thirteen of 25 AMI patients (52%) had a positive myoglobin before increases in CK or CK-MB, including one patient discharged from the emergency department. More importantly, the negative predictive value for myoglobin at the time of admission was 83% and was 100% two hours after admission. This potential for 100% predictability in excluding AMI by the use of serial myoglobin determinations will be very helpful in the correct triage of patients presenting with acute chest pain.

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Diffuse, alimentary tract ganglioneuromatosis-lipomatosis, bilateral adrenal myelolipomas, pancreatic telangiectasias, and a multinodular thyroid goiter were found at autopsy in a 56-year-old, white male with a history of insulin-dependent diabetes, hypertension, peptic ulcer, and remote cerebral infarction. The degree of atherosclerosis, arterionephrosclerosis, and cardiac disease found at autopsy did not correlate with the patient's history or his sudden death. The typical features of the multiple endocrine neoplasia syndrome, type II-B, were not identified. The findings in this patient may represent a variant of the multiple endocrine neoplasia complex, or a separate, previously unrecognized syndrome.