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Der Pathologe Mar 2021The COVID-19 pandemic represents a so far unknown challenge for the medical community. Autopsies are important for studying this disease, but their safety was... (Review)
Review
BACKGROUND
The COVID-19 pandemic represents a so far unknown challenge for the medical community. Autopsies are important for studying this disease, but their safety was challenged at the beginning of the pandemic.
OBJECTIVES
To determine whether COVID-19 autopsies can be performed under existing legal conditions and which safety standards are required.
MATERIALS AND METHODS
The autopsy procedure undertaken in five institutions in Germany, Austria, and Switzerland is detailed with respect to legal and safety standards.
RESULTS
In all institutions the autopsies were performed in technically feasible rooms. The personal equipment consisted of functional clothing including a disposable gown and apron, a surgical cap, eye protection, FFP‑3 masks, and two pairs of gloves. In four institutions, complete autopsies were performed; in one institution the ultrasound-guided biopsy within the postmortal imaging and biopsy program. The latter does not allow the appreciation of gross organ pathology; however, it is able to retrieve standardized biopsies for diagnostic and research purposes. Several scientific articles in highly ranked journals resulted from these autopsies and allowed deep insights into organ damage and conclusions to better understand the pathomechanisms. Viral RNA was frequently detectable in the COVID-19 deceased, but the issue of infectivity remains unresolved and it is questionable if Ct values are greater than 30.
CONCLUSIONS
With appropriate safeguards, autopsies of people who have died from COVID-19 can be performed safely and are highly relevant to medical research.
Topics: Austria; Autopsy; COVID-19; Germany; Humans; Pandemics; SARS-CoV-2; Switzerland
PubMed: 33625535
DOI: 10.1007/s00292-021-00925-w -
Der Pathologe Nov 2021Analyses for the presence of SARS-CoV‑2 in the tissues of COVID-19 patients is important in order to improve our understanding of the disease pathophysiology for... (Review)
Review
BACKGROUND
Analyses for the presence of SARS-CoV‑2 in the tissues of COVID-19 patients is important in order to improve our understanding of the disease pathophysiology for interpretation of diagnostic histopathological findings in autopsies, biopsies, or surgical specimens and to assess the potential for occupational infectious hazard.
MATERIAL AND METHODS
In this review we identified 136 published studies in PubMed's curated literature database LitCovid on SARS-CoV‑2 detection methods in tissues and evaluated them regarding sources of error, specificity, and sensitivity of the methods, taking into account our own experience.
RESULTS
Currently, no sufficiently specific histomorphological alterations or diagnostic features for COVID-19 are known. Therefore, three approaches for SARS-CoV‑2 detection are used: RNA, proteins/antigens, or morphological detection by electron microscopy. In the preanalytical phase, the dominant source of error is tissue quality, especially the different intervals between sample collection and processing or fixation (and its duration) and specifically the interval between death and sample collection in autopsies. However, this information is found in less than half of the studies (e.g., in only 42% of autopsy studies). Our own experience and first studies prove the significantly higher sensitivity and specificity of RNA-based detection methods compared to antigen or protein detection by immunohistochemistry or immunofluorescence. Detection by electron microscopy is time consuming and difficult to interpret.
CONCLUSIONS
Different methods are available for the detection of SARS-CoV‑2 in tissue. Currently, RNA detection by RT-PCR is the method of choice. However, extensive validation studies and method harmonization are not available and are absolutely necessary.
Topics: Autopsy; COVID-19; Humans; RNA, Viral; SARS-CoV-2; Sensitivity and Specificity
PubMed: 33770236
DOI: 10.1007/s00292-021-00920-1 -
Journal of Patient Safety Dec 2021Clinicians may hesitate to advocate for autopsies out of concern for increased malpractice risk if the pathological findings at time of death differ from the clinical...
OBJECTIVE
Clinicians may hesitate to advocate for autopsies out of concern for increased malpractice risk if the pathological findings at time of death differ from the clinical findings. We aimed to understand the impact of autopsy findings on malpractice claim outcomes.
METHODS
Closed malpractice claims with loss dates between 1995 and 2015 involving death related to inpatient care at 3 Harvard Medical School hospitals were extracted from a captive malpractice insurer's database. These claims were linked to patients' electronic health records and their autopsy reports. Using the Goldman classification system, 2 physician reviewers blinded to claim outcome determined whether there was major, minor, or no discordance between the final clinical diagnoses and pathologic diagnoses. Claims were compared depending on whether an autopsy was performed and whether there was major versus minor/no clinical-pathologic discordance. Primary outcomes included percentage of claims paid through settlement or plaintiff verdict and the amount of indemnity paid, inflation adjusted.
RESULTS
Of 293 malpractice claims related to an inpatient death that could be linked to patients' electronic health records, 89 claims (30%) had an autopsy performed by either the hospital or medical examiner. The most common claim allegation was an issue with clinician diagnosis, which was statistically less common in the autopsy group (18% versus 38%, P = 0.001). There was no difference in percentage of claims paid whether an autopsy was performed or not (42% versus 41%, P = 0.90) and no difference in median indemnity of paid claims after adjusting for number of defendants ($1,180,537 versus $906,518, P = 0.15). Thirty-one percent of claims with hospital autopsies performed demonstrated major discordance between autopsy and clinical findings. Claims with major clinical-pathologic discordance also did not have a statistically significant difference in percentage paid (44% versus 41%, P > 0.99) or amount paid ($895,954 versus $1,494,120, P = 0.10) compared with claims with minor or no discordance.
CONCLUSIONS
Although multiple factors determine malpractice claim outcome, in this cohort, claims in which an autopsy was performed did not result in more paid outcomes, even when there was major discordance between clinical and pathologic diagnoses.
Topics: Autopsy; Databases, Factual; Hospitalization; Humans; Malpractice; Physicians
PubMed: 32209947
DOI: 10.1097/PTS.0000000000000686 -
Geriatrics Dec 2008The autopsy is the ultimate "peer review." Yet the autopsy has nearly disappeared from hospitals in the United States and around the world. It is rarely performed in the... (Review)
Review
The autopsy is the ultimate "peer review." Yet the autopsy has nearly disappeared from hospitals in the United States and around the world. It is rarely performed in the nursing home or other long-term care (LTC) setting. As a result, all of society has lost much, in terms of quality of health care, the skills of physicians, and insights gained through autopsy-based research. The elderly have the lowest rate of autopsies of any age group. This is a paradox, since the greatest quality and quantity of knowledge would accrue from the often surprising findings revealed at autopsy that reflect the acknowledged "multiple simultaneous illnesses" occurring in older persons. This review and analysis describe why autopsy rates have fallen in hospitals and offer rationales and solutions for reversing this trend in the nursing home and other LTC settings.
Topics: Advance Directives; Age Factors; Aged; Autopsy; Clinical Competence; Cost-Benefit Analysis; Homes for the Aged; Hospitals; Humans; Long-Term Care; Nursing Homes; Physician's Role; Practice Guidelines as Topic; Quality of Health Care; Quality of Life; Religion; Residential Facilities; United States
PubMed: 19061275
DOI: No ID Found -
Tidsskrift For Den Norske Laegeforening... Aug 2021Medical autopsies are rarely made subject to quality assurance. We have investigated the quality of autopsy reports in Norway and assessed the impact of errors on the...
BACKGROUND
Medical autopsies are rarely made subject to quality assurance. We have investigated the quality of autopsy reports in Norway and assessed the impact of errors on the cause of death statistics.
MATERIAL AND METHOD
Every fifth medical autopsy report for adults (> 2 years) in 2014 was reviewed. The significance of the autopsy result for the registration of cause of death was studied by comparing the death certificate issued by the clinician with the coding in the Cause of Death Registry after the autopsy.
RESULTS
A total of 389 autopsy reports from 15 departments of pathology were reviewed. The autopsy request, as well as the death certificate and the codes for the cause of death from the Cause of Death Registry were available for 339 and 360 cases respectively. Ninety-five requests had specified clinical questions, but were commented on by the pathologist in 33 cases. Obesity was rarely reported as a finding, even in cases of pathological deviations from a normal weight. A post-mortem virus examination or toxicology had been performed in 1 and 28 autopsies respectively. The average turnaround time for autopsies without and with a neuropathological examination was 99 and 138 days respectively. Errors in reporting the cause of death or inadequate reporting were evident in 69 cases (18 %), most frequently for deaths from cardiovascular diseases. The autopsy result led to a change to the cause of death in the Cause of Death Registry in 206 out of 360 (57 %) cases for which coding data were available. Errors in the formulation of the autopsy result resulted in erroneous coding of the cause of death in 22 out of 47 (47 %) of cases with errors.
INTERPRETATION
The proportion of autopsy reports with errors in the formulation of the cause of death was unexpectedly high and may have consequences for the cause of death statistics. Long turnaround times for autopsies complicate communication with the clinician about the findings.
Topics: Adult; Autopsy; Cause of Death; Diagnostic Tests, Routine; Humans; Medical Records; Norway; Registries
PubMed: 34423952
DOI: 10.4045/tidsskr.20.1000 -
Deutsches Arzteblatt International Sep 2018Autopsies are considered an important quality assurance instrument in medicine, yet autopsy rates in many countries have been declining for many years. The proper role... (Review)
Review
BACKGROUND
Autopsies are considered an important quality assurance instrument in medicine, yet autopsy rates in many countries have been declining for many years. The proper role of the post-mortem examination in modern medicine is a matter deserving of study.
METHODS
This review is based on a selective search of the literature for publications on the role of autopsies as a quality assurance instrument.
RESULTS
Multiple studies have revealed substantial rates of discrepancy between pre- and post-mortem diagnoses, with reported rates lying in the range of 10% to 40%. The frequen- cy of so-called Goldman I erroneous diagnoses, i.e., those that are determined at autopsy and might have influenced the patient's survival, ranges from 2.4% to 10.7%. It can be as- sumed that the rate of serious diagnostic errors revealed by autopsy would fall if autopsy rates were to rise. Independently of the above-mentioned studies, a large-scale study of data from the period 1988-2008 revealed a decline in the rate of Goldman I erroneous diagnoses by more than half. The qualitative effects of autopsies, however, are difficult to measure. At present, imaging studies and minimally invasive or endoscopic diagnostic procedures can be performed post mortem as well, but the available studies show that these methods do not yet suffice to enable a coherent pathogenetic classification of disease processes.
CONCLUSION
Autopsies should still be performed in the interest of quality assurance in medicine. Uniform standards in the performance and reporting of autopsies could lead to im- provement in the use of the data acquired through them.
Topics: Autopsy; Cause of Death; Humans; Quality Improvement
PubMed: 30375329
DOI: 10.3238/arztebl.2018.0653 -
Journal of the American Dental... Mar 2023Autopsy has benefited the practice of medicine for centuries; however, its use to advance the practice of oral health care is relatively limited. In the era of precision... (Review)
Review
BACKGROUND
Autopsy has benefited the practice of medicine for centuries; however, its use to advance the practice of oral health care is relatively limited. In the era of precision oral medicine, the research autopsy is poised to play an important role in understanding oral-systemic health, including infectious disease, autoimmunity, craniofacial genetics, and cancer.
TYPES OF STUDIES REVIEWED
The authors reviewed relevant articles that used medical and dental research autopsies to summarize the advantages of minimally invasive autopsies of dental, oral, and craniofacial tissues and to outline practices for supporting research autopsies of the oral and craniofacial complex.
RESULTS
The authors provide a historical summary of research autopsy in dentistry and provide a perspective on the value of autopsies for high-resolution multiomic studies to benefit precision oral medicine. As the promise of high-resolution multiomics is being realized, there is a need to integrate the oral and craniofacial complex into the practice of autopsy in medicine. Furthermore, the collaboration of autopsy centers with researchers will accelerate the understanding of dental, oral, and craniofacial tissues as part of the whole body.
CONCLUSIONS
Autopsies must integrate oral and craniofacial tissues as part of biobanking procedures. As new technologies allow for high-resolution, multimodal phenotyping of human samples, using optimized sampling procedures will allow for unprecedented understanding of common and rare dental, oral, and craniofacial diseases in the future.
PRACTICAL IMPLICATIONS
The COVID-19 pandemic highlighted the oral cavity as a site for viral infection and transmission potential; this was only discovered via clinical autopsies. The realization of the integrated autopsy's value in full body health initiatives will benefit patients across the globe.
Topics: Humans; Autopsy; Biological Specimen Banks; Pandemics; COVID-19; Oral Health
PubMed: 36710158
DOI: 10.1016/j.adaj.2022.11.017 -
Jornal de Pediatria 2022To evaluate neonatal autopsy rates at a tertiary hospital in southern Brazil ascertain the level of agreement between premortem and postmortem diagnosis.
OBJECTIVES
To evaluate neonatal autopsy rates at a tertiary hospital in southern Brazil ascertain the level of agreement between premortem and postmortem diagnosis.
METHODS
The authors reviewed all neonatal autopsies performed over a 10-year period and described the percentage of neonates who died and underwent autopsy. The authors tested for agreement between autopsy findings and the cause of death as defined by the neonatologist. Agreement between clinical diagnosis and autopsy findings was classified using the modified Goldman criteria. Additional findings at autopsy were grouped by organ system. Linear regression and multiple comparisons were used for statistical analyses.
RESULTS
During the study period, 382 neonates died at the Neonatal Intensive Care Unit (NICU). Consent to perform an autopsy was obtained for 73 (19.1%). The complete agreement between autopsy findings and the neonatologist's premortem diagnosis was found in 48 patients (65.8%). Additional findings were obtained at autopsy in 25 cases (34.2%). In 5 cases (6.9%), the autopsy findings contributed to subsequent genetic counseling. Seven autopsies (9.6%) revealed a diagnosis that would have changed patient management if established premortem. The autopsy rate increased by an average of 1.87% each year.
CONCLUSION
Despite a high level of agreement between clinical diagnosis and pathological findings, autopsies provided relevant data regarding the cause of death, providing additional clinical information to neonatologists and allowing genetic counseling of family members.
Topics: Autopsy; Brazil; Cause of Death; Humans; Infant, Newborn; Intensive Care Units, Neonatal; Linear Models; Retrospective Studies
PubMed: 35189081
DOI: 10.1016/j.jped.2022.01.002 -
Rhode Island Medical Journal (2013) Dec 2021Autopsy training is required for board certification by the American Board of Pathology and may be affected by autopsy rate. It is unclear whether the COVID-19 pandemic...
Autopsy training is required for board certification by the American Board of Pathology and may be affected by autopsy rate. It is unclear whether the COVID-19 pandemic has affected autopsy education and rate. Prior to the pandemic, our autopsy gross organ review lectures at the Brown University pathology residency program were in-person and used a detective style to discover the pathological lesions followed by an integrated discussion of anatomic and clinical pathology. During the COVID-19 pandemic, these lectures became remote and there was a noticeable impact on the involvement and responsiveness of the audience compared to in-person teaching. Certain qualities of face-to-face teaching can be difficult to be reproduced through virtual teaching, including the detective style to look for pathological lesions and the ability to palpate lesions from gross specimens. Our results showed that the autopsy case number increased during the COVID-19 pandemic, but the overall autopsy rate did not significantly change.
Topics: Autopsy; COVID-19; Humans; Internship and Residency; Pandemics; SARS-CoV-2
PubMed: 34846378
DOI: No ID Found -
Medical Ultrasonography Mar 2023The vast majority of clinicians associate diagnostic ultrasound with a tool that is designed for the living patient. However, it is of course possible to apply this... (Review)
Review
The vast majority of clinicians associate diagnostic ultrasound with a tool that is designed for the living patient. However, it is of course possible to apply this imaging technology to evaluate the recently deceased patient for postmortem diagnosis, or even just examine postmortem tissue. We describe several cases in which ultrasound-enabled providers obtain answers in postmortem examinations and discuss potential future strategies and applications. In addition, we will also illustrate the use of sonography in minimally invasive post-mortem tissue sampling (MITS), an approach that can be used in post-mortem minimally invasive autopsies as well as for establishing ultrasound diagnostic parameters in new medical fields such as periodontal and dental implant specialties.
Topics: Humans; Ultrasonography; Autopsy
PubMed: 34762719
DOI: 10.11152/mu-3490