Reliability of body size measurements obtained at autopsy: impact on the pathologic assessment of the heart

Postmortem Computed Tomography Is a Reliable, Reproducible, and Accurate Method in Measuring Body Length

ABSTRACT

Currently, traditional body length measurement at postmortem analysis involves processes, which are susceptible to human error and not reviewable or reproducible in case of data loss. Many facilities are now adopting routine postmortem computed tomography (PMCT) scanning, which provides a permanent and reviewable radiological record of body dimensions. Previous literature has validated the use of PMCT in estimating body and organ weights, but not in body length measurement. This retrospective study aimed to determine whether body length can be accurately and reliably measured when compared with traditional measurements in 50 consecutive adult cases. Our findings revealed that body length measured using PMCT had high intrarater and interrater reliability across different experience levels in raters (Pearson correlation coefficient and interclass correlation: >0.99, P < 0.01). Although body lengths measured using PMCT were significantly shorter (mean, -1.2 cm; 95% confidence interval, -1.75 to -0.65 cm; P < 0.05), it was deemed clinically insignificant and correlated well with those measured at postmortem examination (Pearson correlation coefficient and interclass correlation, >0.97; P < 0.01). While care will need to be taken to ensure the body in the body bag is in reasonable anatomical position for scanning purposes, overall, body length measured uniform PMCT is reliable, reproducible, and accurate.

Impact of anthropometry training and feasibility of 3D imaging on anthropometry data quality among children under five years in a postmortem setting

BACKGROUND

The Child Health and Mortality Prevention Surveillance Network (CHAMPS) identifies causes of under-5 mortality in high mortality countries.

OBJECTIVE

To address challenges in postmortem nutritional assessment, we evaluated the impact of anthropometry training and the feasibility of 3D imaging on data quality within the CHAMPS Kenya site.

DESIGN

Staff were trained using World Health Organization (WHO)-recommended manual anthropometry equipment and novel 3D imaging methods to collect postmortem measurements. Following training, 76 deceased children were measured in duplicate and were compared to measurements of 75 pre-training deceased children. Outcomes included measures of data quality (standard deviations of anthropometric indices and digit preference scores (DPS)), precision (absolute and relative technical errors of measurement, TEMs or rTEMs), and accuracy (Bland-Altman plots). WHO growth standards were used to produce anthropometric indices. Post-training surveys and in-depth interviews collected qualitative feedback on measurer experience with performing manual anthropometry and ease of using 3D imaging software.

RESULTS

Manual anthropometry data quality improved after training, as indicated by DPS. Standard deviations of anthropometric indices exceeded limits for high data quality when using the WHO growth standards. Reliability of measurements post-training was high as indicated by rTEMs below 1.5%. 3D imaging was highly correlated with manual measurements; however, on average 3D scans overestimated length and head circumference by 1.61 cm and 2.27 cm, respectively. Site staff preferred manual anthropometry to 3D imaging, as the imaging technology required adequate lighting and additional considerations when performing the measurements.

CONCLUSIONS

Manual anthropometry was feasible and reliable postmortem in the presence of rigor mortis. 3D imaging may be an accurate alternative to manual anthropometry, but technology adjustments are needed to ensure accuracy and usability.

Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology

Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.

Guidance for Systematic Integration of Undernutrition in Attributing Cause of Death in Children

Minimally invasive tissue sampling (MITS) is increasingly being used to better understand causes of death in low-resource settings. Undernutrition (eg, wasting, stunting) is prevalent among children globally and yet not consistently coded or uniformly included on death certificates in MITS studies when present. Consistent and accurate attribution of undernutrition is fundamental to understanding its contribution to child deaths. In May 2020, members of the MITS Alliance Cause of Death Technical Working Group convened a panel of experts in public health, child health, nutrition, infectious diseases, and MITS to develop guidance for systematic integration of undernutrition, as assessed by anthropometry, in cause of death coding, including as part of the causal chain or as a contributing condition, in children <5 years of age. The guidance presented here will support MITS and other researchers, public health practitioners, and clinicians with a systematic approach to assigning and interpreting undernutrition in death certification.

Factors associated with myocardial SARS-CoV-2 infection, myocarditis, and cardiac inflammation in patients with COVID-19

COVID-19 has been associated with cardiac injury and dysfunction. While both myocardial inflammatory cell infiltration and myocarditis with myocyte injury have been reported in patients with fatal COVID-19, clinical-pathologic correlations remain limited. The objective was to determine the relationships between cardiac pathological changes in patients dying from COVID-19 and cardiac infection by SARS-CoV-2, laboratory measurements, clinical features, and treatments. In a retrospective study, 41 consecutive autopsies of patients with fatal COVID-19 were analyzed for the associations between cardiac inflammation, myocarditis, cardiac infection by SARS-CoV-2, clinical features, laboratory measurements, and treatments. Cardiac infection was assessed by in situ hybridization and NanoString transcriptomic profiling. Cardiac infection by SARS-CoV-2 was present in 30/41 cases: virus⁺ with myocarditis (n = 4), virus⁺ without myocarditis (n = 26), and virus^- without myocarditis (n = 11). In the cases with cardiac infection, SARS-CoV-2⁺ cells in the myocardium were rare, with a median density of 1 cell/cm². Virus⁺ cases showed higher densities of myocardial CD68⁺ macrophages and CD3⁺ lymphocytes, as well as more electrocardiographic changes (23/27 vs 4/10; P = 0.01). Myocarditis was more prevalent with IL-6 blockade than with nonbiologic immunosuppression, primarily glucocorticoids (2/3 vs 0/14; P = 0.02). Overall, SARS-CoV-2 cardiac infection was less prevalent in patients treated with nonbiologic immunosuppression (7/14 vs 21/24; P = 0.02). Myocardial macrophage and lymphocyte densities overall were positively correlated with the duration of symptoms but not with underlying comorbidities. In summary, cardiac infection with SARS-CoV-2 is common among patients dying from COVID-19 but often with only rare infected cells. Cardiac infection by SARS-CoV-2 is associated with more cardiac inflammation and electrocardiographic changes. Nonbiologic immunosuppression is associated with lower incidences of myocarditis and cardiac infection by SARS-CoV-2.

Infants with congenital heart defects have reduced brain volumes

Children with congenital heart defects (CHDs) have increased risk of cognitive disabilities for reasons not fully understood. Previous studies have indicated signs of disrupted fetal brain growth from mid-gestation measured with ultrasound and magnetic resonance imaging (MRI) and infants with CHDs have decreased brain volumes at birth. We measured the total and regional brain volumes of infants with and without CHDs using MRI to investigate, if certain areas of the brain are at particular risk of disrupted growth. MRI brain volumetry analyses were performed on 20 infants; 10 with- (postmenstrual age 39–54 weeks, mean 44 weeks + 5 days) and 10 without CHDs (postmenstrual age 39–52 weeks, mean 43 weeks + 5 days). In six infants with- and eight infants without CHDs grey and white matter were also differentiated. Infants with CHDs had smaller brains (48 ml smaller; 95% CI, 6.1–90; p = 0.03), cerebrums (37.8 ml smaller; 95% CI, 0.8–74.8; p = 0.04), and cerebral grey matter (25.8 ml smaller; 95% CI, 3.5–48; p = 0.03) than infants without CHD. Brain volume differences observed within weeks after birth in children with CHDs confirm that the brain impact, which increase the risk of cognitive disabilities, may begin during pregnancy.

Cardiac iron overload following liver transplantation in patients without hereditary hemochromatosis or severe hepatic iron deposition

BACKGROUND

Cardiac iron overload following liver transplantation in patients without hemochromatosis but with severe hepatic iron deposition has been reported to result in heart failure and/or death in case reports and small case series. However, the frequency and causes of cardiac iron overload following liver transplantation and its relationship to cardiac dysfunction in patients without severe hepatic iron deposition are unclear.

METHODS

The primary inclusion criteria for this study were liver transplantation followed by autopsy or cardiac transplantation within 1 year. Cases of known hemochromatosis were excluded. Iron stains were performed on left ventricular myocardium from either the autopsy or surgically resected heart, as well as the surgically resected liver.

RESULTS

Nineteen cases met the study criteria: 18 autopsies and 1 case of cardiac transplantation. None of the resected livers evaluated showed severe iron deposition. Myocardial iron deposition was identified in 7 (37%) of the cases. The presence of myocardial iron deposition was not significantly associated with the grade of hepatic iron deposition, or the pre-liver transplantation serum iron or ferritin levels. However, in the patients with myocardial iron deposition, there were trends toward higher pretransplant transferrin saturation (TSAT) and more units of red blood cells transfused (uRBC). The product of the TSAT multiplied by the uRBC was significantly greater in the patients with myocardial iron deposition [4700 (3100-9800) vs. 680 (400-2300), median (interquartile range), P=.003]. New reduced left ventricular ejection fraction (<50%) following liver transplantation occurred in four of five patients with myocardial iron deposition, compared with zero of eight patients without myocardial iron deposition (P=.007).

CONCLUSIONS

In this series of patients without severe hepatic iron deposition, cardiac iron overload was associated with cardiac dysfunction following liver transplantation and was related to the product of the pre-liver transplant TSAT multiplied by the number of uRBC transfused during and following the surgery.