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Kisbye LW, Rickert A, Hasselstrøm JB, Andersen CU, Lund HA, Rohde MC, Boel LWT. Enhanced autopsy triage (EA-Triage) in drug-related deaths: integrating quick toxicological analysis and postmortem computed tomography. Forensic Sci Med Pathol 2024:10.1007/s12024-024-00819-2. [PMID: 38683282 DOI: 10.1007/s12024-024-00819-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
The objective was to assess the diagnostic accuracy of an enhanced autopsy triage (EA-Triage) setup consisting of postmortem computed tomography (PMCT), simulated quick toxicological analysis (sQTA), external examination, and case information in determining cause of death (COD) in persons with past or current use of illegal drugs (drug-related deaths). Information on drug-related deaths selected for medico-legal autopsy in 2020-2021 at the Department of Forensic Medicine, Aarhus University, Denmark, was analyzed retrospectively. The included cases underwent conventional autopsy, PMCT, and systematic toxicological analysis. A board-certified forensic pathologist, who was blinded to the internal examination and COD from the medico-legal autopsy, determined COD based on the EA-Triage setup. 154 cases with a median age of 40.6 years (range 17-70 years, 82% males) were included. The COD determined by medico-legal autopsy and that determined by EA-Triage matched in 113 cases (73%), including those with an unknown COD. EA-Triage and medico-legal autopsy determined unknown COD in 45 (29%) and 5 cases (3%), respectively. Excluding cases with an unknown COD, EA-Triage predicted COD in 109 cases (71%); of those, 72 (66%) had no unexplained case circumstances or suspicion of a criminal act. In these 72 cases, the CODs determined by EA-Triage and medico-legal autopsy matched in 71 cases (99%), and the sensitivity and specificity for detecting lethal intoxication were 100% and 90%, respectively. EA-Triage showed strong diagnostic accuracy for determining COD in drug-related deaths. This method may be suitable for enhancing preautopsy triage and guiding police investigations at an early stage.
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Affiliation(s)
- Lea Wold Kisbye
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark.
| | - Annika Rickert
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Jørgen Bo Hasselstrøm
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Charlotte Uggerhøj Andersen
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Henriette Askjær Lund
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Marianne Cathrine Rohde
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Lene Warner Thorup Boel
- Department of Forensic Medicine, Aarhus University, Palle Juul- Jensens Boulevard 99, Aarhus N, 8200, Denmark
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Melvinsdottir I, Solomon N, Wadia R, Muniraj T, Huber S, Sinusas AJ. Massive Air Embolism Following Necrotizing Pancreatitis and COVID-19 Infection-The Role of Postmortem Computed Tomography. Acad Forensic Pathol 2022; 12:31-38. [PMID: 35694008 PMCID: PMC9178998 DOI: 10.1177/19253621211073284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/02/2021] [Indexed: 02/04/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that caused the COVID-19 pandemic raised important questions about workplace exposures to the virus, including postmortem exposures. The complexity of COVID-19 disease and its numerous unanticipated complications made autopsy even more vital in determining the pathophysiology of the disease. Performing traditional autopsy, however, carries risk of exposure. The following report describes an unusual case in which a patient diagnosed with COVID-19 and necrotizing pancreatitis underwent postmortem computed tomography (PMCT) prior to limited traditional autopsy and was unexpectedly found via PMCT to have large and diffuse venous air emboli and a new peripancreatic hematoma. In this case, not only did PMCT play a crucial role in determining the cause of death but also it allowed for a limited autopsy, thereby reducing the exposure to SARS-CoV-2 and associated risk to the autopsy staff and pathologists.
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Affiliation(s)
| | | | | | | | | | - Albert J. Sinusas
- Albert J. Sinusas, MD, Medicine and Radiology & Biomedical Imaging and Biomedical Engineering; Yale Translational Research Imaging Center (Y-TRIC), Yale University School of Medicine, Section Cardiovascular Medicine, DANA3, P.O. Box 208017, New Haven, CT 06520,
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Nolte KB, Muller TB, Denmark AM, Burstein R, Villalobos YA. Design and Construction of a Biosafety Level 3 Autopsy Laboratory. Arch Pathol Lab Med 2021; 145:407-414. [PMID: 33307551 DOI: 10.5858/arpa.2020-0644-sa] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Autopsy pathologists, including medical examiners, provide valuable public health support for infectious disease deaths through surveillance for deaths of public health concern including emerging infections, identifying causative organisms for unexplained deaths, and providing insights into the pathology and pathogenesis of novel or unusual infections. However, autopsy poses biosafety risks to workers within and outside the laboratory. The highest rates of laboratory-acquired infections occur in autopsy workers. OBJECTIVE.— To design and construct an appropriately biosafe autopsy laboratory. DESIGN.— We conducted a biosafety risk assessment for autopsy workers using the process developed by the US Centers for Disease Control and Prevention and National Institutes of Health and applied these findings as the basis of laboratory design and construction. RESULTS.— Autopsy workers are unpredictably exposed to a variety of infectious organisms, including hepatitis C virus, HIV, and Mycobacterium tuberculosis. Hazardous autopsy procedures include using and encountering sharp objects and the generation of aerosols from dissection, fluid aspiration, rinsing tissues, and dividing bone with an oscillating saw. CONCLUSIONS.— Exposure to blood-borne and airborne pathogens from procedures that can cause cutaneous inoculation and inhalation of aerosols indicates that human autopsies should be performed at biosafety level 3. We designed a large, entirely biosafety level 3 medical examiner autopsy laboratory using design principles and characteristics that can be scaled to accommodate smaller academic or other hospital-based autopsy spaces. Containment was achieved through a concentric ring design, with access control at interface zones. As new autopsy laboratories are planned, we strongly recommend that they be designed to function uniformly at biosafety level 3.
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Affiliation(s)
- Kurt B Nolte
- From the Office of the Medical Investigator and Departments of Pathology and Radiology (Nolte [https://orcid.org/0000-0003-0257-6284]), University of New Mexico Health Science Center, Albuquerque
| | - Timothy B Muller
- The Office of Research (Muller), University of New Mexico Health Science Center, Albuquerque
| | - Adam M Denmark
- The Department of Science and Technology, SmithGroup, Phoenix, Arizona (Denmark)
| | - Ron Burstein
- Studio Southwest Architects, Inc, Albuquerque, New Mexico (Burstein)
| | - Yvonne A Villalobos
- The Office of the Medical Investigator (Villalobos), University of New Mexico Health Science Center, Albuquerque
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Saegeman V, Cohen MC, Burton JL, Martinez MJ, Rakislova N, Offiah AC, Fernandez-Rodriguez A. Microbiology in minimally invasive autopsy: best techniques to detect infection. ESGFOR (ESCMID study group of forensic and post-mortem microbiology) guidelines. Forensic Sci Med Pathol 2021; 17:87-100. [PMID: 33464531 PMCID: PMC7814172 DOI: 10.1007/s12024-020-00337-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
This manuscript aims to: 1) provide specific guidelines on PMM techniques in the setting of minimally invasive autopsy (MIA), both for pathologists collecting samples and for microbiologists advising pathologists and interpreting the results and 2) introduce standardization in PMM sampling at MIA. Post-mortem microbiology (PMM) is crucial to identify the causative organism in deaths due to infection. MIA including the use of post-mortem (PM) computed tomography (CT) and PM magnetic resonance imaging (MRI), is increasingly carried out as a complement or replacement for the traditional PM. In this setting, mirroring the traditional autopsy, PMM aims to: detect infectious organisms causing sudden unexpected deaths; confirm clinically suspected but unproven infection; evaluate the efficacy of antimicrobial therapy; identify emergent pathogens; and recognize medical diagnostic errors. Meaningful interpretation of PMM results requires careful evaluation in the context of the clinical history, macroscopic and microscopic findings.
These guidelines were developed by a multidisciplinary team with experts in various fields of microbiology and pathology on behalf of the ESGFOR (ESCMID – European Society of Clinical Microbiology and Infectious Diseases - Study Group of Forensic and Post-mortem Microbiology, in collaboration with the ESP -European Society of Pathology-) based on a literature search and the author’s expertise. Microbiological sampling methods for MIA are presented for various scenarios: adults, children, developed and developing countries. Concordance between MIA and conventional invasive autopsy is substantial for children and adults and moderate for neonates and maternal deaths. Networking and closer collaboration among microbiologists and pathologists is vital to maximize the yield of PMM in MIA.
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Affiliation(s)
- Veroniek Saegeman
- Clinical Laboratory, Sint-Niklaas, and Infection Control Department, AZ Nikolaas, University Hospitals Leuven, Moerlandstraat 1Herestraat 49, 91003000, Leuven, Belgium
| | - Marta C Cohen
- FT. Histopathology Department. Western Bank, Sheffield Children's Hospital NHS, Sheffield, S10 2TH, UK
| | | | - Miguel J Martinez
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
- Department of Microbiology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Natalia Rakislova
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
- Department of Pathology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Amaka C Offiah
- Department of Oncology and Metabolism, Department of Radiology, Academic Unit of Child Health, Sheffield Children's NHS FT, University of Sheffield, Sheffield, UK
| | - Amparo Fernandez-Rodriguez
- Microbiology Laboratory, Biology Department, Instituto Nacional de Toxicología y Ciencias Forenses, Las Rozas de Madrid, Madrid, Spain.
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A review on the evolution and characteristics of post-mortem imaging techniques. FORENSIC IMAGING 2020. [DOI: 10.1016/j.fri.2020.200420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zheng J, Liu X, Yang S, Wei C, Feng X. Risk identification and protection during high-risk forensic autopsy. JOURNAL OF FORENSIC SCIENCE AND MEDICINE 2020. [DOI: 10.4103/jfsm.jfsm_25_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Implementation of modern tools in autopsy practice-the way towards contemporary postmortal diagnostics. Virchows Arch 2018; 474:149-158. [PMID: 30426205 DOI: 10.1007/s00428-018-2482-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/11/2018] [Accepted: 11/01/2018] [Indexed: 10/27/2022]
Abstract
Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33 days to 15 days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1 year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.
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Blokker BM, Wagensveld IM, Weustink AC, Oosterhuis JW, Hunink MGM. Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review. Eur Radiol 2015. [PMID: 26210206 PMCID: PMC4778156 DOI: 10.1007/s00330-015-3908-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Autopsies are used for healthcare quality control and improving medical knowledge. Because autopsy rates are declining worldwide, various non-invasive or minimally invasive autopsy methods are now being developed. To investigate whether these might replace the invasive autopsies conventionally performed in naturally deceased adults, we systematically reviewed original prospective validation studies. MATERIALS AND METHODS We searched six databases. Two reviewers independently selected articles and extracted data. Methods and patient groups were too heterogeneous for meaningful meta-analysis of outcomes. RESULTS Sixteen of 1538 articles met our inclusion criteria. Eight studies used a blinded comparison; ten included less than 30 appropriate cases. Thirteen studies used radiological imaging (seven dealt solely with non-invasive procedures), two thoracoscopy and laparoscopy, and one sampling without imaging. Combining CT and MR was the best non-invasive method (agreement for cause of death: 70 %, 95%CI: 62.6; 76.4), but minimally invasive methods surpassed non-invasive methods. The highest sensitivity for cause of death (90.9 %, 95%CI: 74.5; 97.6, suspected duplicates excluded) was achieved in recent studies combining CT, CT-angiography and biopsies. CONCLUSION Minimally invasive autopsies including biopsies performed best. To establish a feasible alternative to conventional autopsy and to increase consent to post-mortem investigations, further research in larger study groups is needed. KEY POINTS • Health care quality control benefits from clinical feedback provided by (alternative) autopsies. • So far, sixteen studies investigated alternative autopsy methods for naturally deceased adults. • Thirteen studies used radiological imaging modalities, eight tissue biopsies, and three CT-angiography. • Combined CT, CT-angiography and biopsies were most sensitive diagnosing cause of death.
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Affiliation(s)
- Britt M Blokker
- Department of Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Clinical Epidemiology, Erasmus University Medical Centre, Room Na-2818, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ivo M Wagensveld
- Department of Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Clinical Epidemiology, Erasmus University Medical Centre, Room Na-2818, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Annick C Weustink
- Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J Wolter Oosterhuis
- Department of Pathology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M G Myriam Hunink
- Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands. .,Department of Clinical Epidemiology, Erasmus University Medical Centre, Room Na-2818, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. .,Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
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Times have changed! Forensic radiology--a new challenge for radiology and forensic pathology. AJR Am J Roentgenol 2014; 202:W325-34. [PMID: 24660730 DOI: 10.2214/ajr.12.10283] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The ongoing development of imaging and the recent integration of cross-sectional imaging methods into the medicolegal workflow have resulted in an increasing number of forensic institutes acquiring dedicated CT and MRI scanners. The purpose of this article is to evaluate the different aspects of postmortem imaging and to detail the necessary cooperation between radiologists and forensic pathologists for mutual learning and accurate science to form a new subspecialty: forensic radiology. CONCLUSION; Forensic radiology must integrate the expertise of forensic pathologists and radiologists. The challenge is to unite these two disciplines first by direct and intense communications and second by a basic understanding of forensic pathology by radiologists as well as a foundational knowledge of postmortem imaging by forensic pathologists, in combination with the establishment of educational and reporting guidelines.
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Flach PM, Gascho D, Schweitzer W, Ruder TD, Berger N, Ross SG, Thali MJ, Ampanozi G. Imaging in forensic radiology: an illustrated guide for postmortem computed tomography technique and protocols. Forensic Sci Med Pathol 2014; 10:583-606. [DOI: 10.1007/s12024-014-9555-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2014] [Indexed: 11/30/2022]
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12
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Winklhofer S, Surer E, Ampanozi G, Ruder T, Stolzmann P, Elliott M, Oestreich A, Kraemer T, Thali M, Alkadhi H, Schweitzer W. Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy. Eur Radiol 2014; 24:1276-82. [DOI: 10.1007/s00330-014-3128-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 02/07/2014] [Accepted: 02/12/2014] [Indexed: 11/30/2022]
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Roberts ISD, Traill ZC. Minimally invasive autopsy employing post-mortem CT and targeted coronary angiography: evaluation of its application to a routine Coronial service. Histopathology 2013; 64:211-7. [PMID: 24164418 DOI: 10.1111/his.12271] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/28/2013] [Indexed: 11/26/2022]
Abstract
AIMS Post-mortem imaging is a potential alternative to traditional medicolegal autopsy. We investigate the reduction in number of invasive autopsies required by use of post-mortem CT ± coronary angiography. METHODS AND RESULTS A total of 120 adult deaths referred to the Coroner were investigated by CT, with coronary angiography employed only for the second series of 60 cases, in order to determine the added value of angiography. The confidence of imaging cause of death was classified as definite (no autopsy), probable, possible or unascertained. Invasive autopsy was not required in 38% of cases without coronary angiography and 70% of cases with angiography. Full autopsy, including brain dissection, was required in only 9% of cases. There was complete agreement between autopsy and radiological causes of death in the cases with a 'probable' imaging cause of death, indicating that cases for which imaging provides an accurate cause of death without autopsy were identified correctly. In two patients, CT demonstrated unsuspected fractures, not detected at subsequent autopsy. CONCLUSIONS A two-thirds reduction in the number of invasive coronial autopsies can be achieved by use of post-mortem CT plus coronary angiography. At the same time, use of post-mortem CT may improve accuracy of diagnosis, particularly for traumatic deaths.
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Affiliation(s)
- Ian S D Roberts
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
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