Effect of minimally invasive autopsy and ethnic background on acceptance of clinical postmortem investigation in adults

A scoping review on virtual autopsy: Main concepts, qualified professionals and future prospects

The beginning of post-mortem evaluation studies through minimally invasive procedures began between 1800 and 1930. It started with Dr. Howard Kelly and was later followed by Décio Parreiras and Werneck Genofre, due to the yellow fever outbreak in Brazil. However, despite its early beginnings, the intensification of the research on this field occurred around 2010, when the publications about this subject became three times more frequent than before. There are basically two classifications for this procedure. The first one is virtual non-invasive autopsy, which is based only on imaging exams; the second is the minimally invasive autopsy, in which imaging exams are associated with other techniques such as biopsy and angiography. The main objective of the present study is to evaluate the existent data published about virtual autopsy from 2010, and highlight the key concepts related to this theme. A search was conducted in PUBMED, MEDLINE, and LILACS databases using the descriptors "virtual autopsy" and "minimally invasive autopsy", the review protocol has been registered on Open Science Framework (OSF), the total number of studies included were 28, and the data was presented through the PRISMA-ScR flowchart. Although, it is well known that this theme is recent in research fields and, because of that, there is still a lot to explore.

Usefulness of minimally invasive autopsy in the diagnosis of arboviruses to increase the sensitivity of the Epidemiological Surveillance System in Ceará, Brazil

OBJECTIVE

To create a protocol for performing minimally invasive autopsies (MIA) in detecting deaths from arboviruses and report preliminary data from its application in Ceará state, Brazil.

METHODS

Training was provided to medical pathologists on MIA.

RESULTS

A protocol was established for performing MIA, defining criteria for sample collection, storage methods, and diagnoses to be carried out according to the type of biological sample; 43 MIAs were performed in three months. Of these, 21 (48.8%) arrived at the Death Verification Service (SVO) with arboviruses as a diagnostic hypothesis, and seven (16.3%) were confirmed (six chikungunya cases and one dengue case); cases of COVID-19 (n = 9), tuberculosis (n = 5), meningitis (n = 4), cryptococcosis (n = 1), Creutzfeldt-Jakob disease (n = 1), breast cancer (n = 1), and human rabies (n = 1) were also confirmed.

CONCLUSION

The protocol implemented enabled identification of a larger number of suspected arbovirus-related deaths, as well as confirmation of other diseases of interest for surveillance.

MAIN RESULTS

A protocol was developed to perform minimally invasive autopsies (MIAs) in Death Verification Services (SVO), capable of expanding the system's capacity to identify a greater number of deaths suspected to be due to arboviruses.

IMPLICATIONS FOR SERVICES

The experience suggests that in-service trained health professionals are able to perform MIA, and that use of this technique in SVOs has been shown to be capable of increasing the system's sensitivity in detecting deaths of interest to public health.

PERSPECTIVES

Trained professionals will be able to collect biological material in hospitals, through MIA, in cases of interest for health surveillance and when family members do not allow a complete conventional autopsy to be performed.

Postmortem Minimally Invasive Autopsy in Critically Ill COVID-19 Patients at the Bedside: A Proof-of-Concept Study at the ICU

BACKGROUND

Economic restrictions and workforce cuts have continually challenged conventional autopsies. Recently, the COVID-19 pandemic has added tissue quality and safety requirements to the investigation of this disease, thereby launching efforts to upgrade autopsy strategies.

METHODS

In this proof-of-concept study, we performed bedside ultrasound-guided minimally invasive autopsy (US-MIA) in the ICU of critically ill COVID-19 patients using a structured protocol to obtain non-autolyzed tissue. Biopsies were assessed for their quality (vitality) and length of biopsy (mm) and for diagnosis. The efficiency of the procedure was monitored in five cases by recording the time of each step and safety issues by swabbing personal protective equipment and devices for viral contamination.

FINDINGS

Ultrasound examination and tissue procurement required a mean time period of 13 min and 54 min, respectively. A total of 318 multiorgan biopsies were obtained from five patients. Quality and vitality standards were fulfilled, which not only allowed for specific histopathological diagnosis but also the reliable detection of SARS-CoV-2 virions in unexpected organs using electronic microscopy and RNA-expressing techniques.

INTERPRETATION

Bedside multidisciplinary US-MIA allows for the fast and efficient acquisition of autolytic-free tissue and offers unappreciated potential to overcome the limitations of research in postmortem studies.

How to conceive the dignity of the dead? A dispositional account

In dealing with human corpses, notions of dignity play a decisive role, especially within legal texts that regulate a corpse's handling. However, it is quite unclear how the claim "Treat human corpses with dignity!" should be understood and justified. Drawing upon examples and problems from forensic medicine, this paper explores three possible lines of interpreting such demands: (a) positions that closely link the dignity of the human corpse to the dignity of the former living persons and (b) accounts that derive the dignity of the dead from consequentialist considerations. We argue that both lines heavily rely on contestable metaphysical claims and therefore propose an alternative account for the dignity of the dead. Our proposal (c) focuses on action-guiding attitudes and the symbolic value of the dead. Such a conception allows for a variety of morally appropriate groundings of individual attitudes. It avoids metaphysically troublesome premises and, at the same time, allows to classify certain actions and manners of acting as clearly inappropriate and blameworthy.

Minimally invasive autopsies for the investigation of pulmonary pathology of COVID-19-experiences of a longitudinal series of 92 patients

Minimally invasive autopsies (MIAs) allow the collection of tissue samples for diagnostic and research purposes in special situations, e.g., when there is a high risk of infection which is the case in the context of COVID-19 or restrictions due to legal or personal reasons. We performed MIA to analyze lung tissue from 92 COVID-19 patients (mean age 78 years; range 48-98; 35 women, 57 men), representing 44% of all patients who died from the disease between October 2020 and April 2021. An intercostal approach was used with removal of a 5-cm rib section followed by manual collection of four lung tissue samples (5-8 cm in size). Diffuse alveolar damage (DAD) was found in 89 (97%) patients at various stages. Exudative DAD (eDAD) predominated in 18 (20%) patients, proliferative DAD (pDAD) in 43 (47%) patients, and mixed DAD (mDAD) in 31 (34%) patients. There were no significant differences in the predominant DAD pattern between tissue samples from the same patient. Additional purulent components were present in 46 (50%) cases. Fungi were detected in 11 (12%) patients. The pDAD pattern was associated with longer hospital stay including intensive care unit (p=0.026 and p<0.001) and younger age (p=0.019). Positive bronchoalveolar lavage and blood cultures were observed more frequently in pDAD patterns (p<0.001; p=0.018). In contrast, there was no significant association between intravital positive microbiological results and superimposed bronchopneumonia or fungal infection at autopsy. Having demonstrated the characteristic lung changes in a large longitudinal autopsy series, we conclude that the presented MIA approach can be considered a reliable and safe method for performing post mortem lung diagnostics in COVID-19 and other high-risk situations. The lack of correlation between histological changes indicative of bacterial or fungal superinfection and microbiology could have clinical implications for disease and treatment surveillance.

External challenges for specialists dealing with forensic autopsies

BACKGROUND

In addition to poor infrastructure, and human resource constraints, forensic medicine specialists in developing countries face many external challenges.

OBJECTIVES

We aimed to investigate the prevalence, type, and source of external challenges confronting them including sex, age, religion, deceased's place of residence and the number of accompanying relatives.

MATERIALS AND METHODS

This cross-sectional, observational study was conducted between August 2020 and July 2022 at the Mortuary of AIIMS, Bhubaneswar with the approval of the ethical committee.

RESULTS

Of note, forensic medicine specialists faced external challenges in about one in five cases (20.5%). Most demands were to either minimise the autopsy procedure (n = 65) or to conduct the autopsy at inappropriate times (n = 58). The demands to minimise the autopsy procedure were significantly associated with the deceased's age (p = 0.046), religion (p = 0.010), socioeconomic class (p = 0.020) and manner of death (p = 0.019).

CONCLUSIONS

Our study found that forensic medicine specialists in India face significant external challenges. Avoiding unnecessary complete autopsies, implementing night autopsies, and embracing minimally invasive autopsies are recommended to mitigate these challenges.

The need for integrated research autopsies in the era of precision oral medicine

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.

All-Body-Cavity (ABC)-scopy-An approach for a feasible method of minimally invasive autopsy to allow for postmortem tissue sampling in cases where a conventional autopsy is denied

OBJECTIVES

The decreasing autopsy numbers in many western countries have been partially attributed to the invasiveness of the autopsy, which causes relatives to decline postmortem examination. This issue has been addressed by developing methods of minimally or non-invasive autopsy, which could be shown to increase acceptance for autopsies. The aim of this study is to compare the All-Body-Cavity-scopy (ABC-scopy) to conventional autopsies for diagnostic accuracy.

METHODS

The ABC-scopy is an endoscopic approach for minimally invasive autopsy involving laparoscopic and thoracoscopic evaluation of the accessible organs, followed by excision biopsies of relevant organs and conspicuous findings. The method was performed in 10 cases on deceased patients scheduled for autopsy, each followed by a conventional autopsy.

RESULTS

The results gathered from ABC-scopy through observation and histopathological evaluation provided an acceptable diagnostic accuracy in 9 out of 10 autopsies when compared to those of the conventional autopsy for diagnostic findings.

CONCLUSIONS

The ABC-scopy is a feasible approach for minimally invasive autopsy that provides acceptable diagnostic value. Despite its minimally invasive nature, the procedure enables representative histology through providing large size excision biopsies from intraabdominal and thoracic organs, which is especially useful for examining disseminated diseases such as metastasized tumors.

Ultrasound in legal medicine-a missed opportunity or simply too late? A narrative review of ultrasonic applications in forensic contexts

Objectives

Conventional autopsies remain the gold standard of postmortem healthcare quality assurance and help gathering extended knowledge on diseases. In answer to constantly declining autopsy rates non- or minimally invasive autopsy methods were introduced. Ultrasound is a well-established tool for imaging commonly used in clinical practice. This narrative review aims to summarize the current literature regarding the feasibility and validity of ultrasound in a forensic context.

Material and methods

A PubMed database search was carried out. Abstracts were scanned for pre-defined ex- and inclusion criteria, followed by a snowball search procedure applied to the primarily included articles.

Results

Forty-five publications met our inclusion criteria. The selected articles concern the feasibility of ultrasound in pre- or postmortem settings, forensic age estimation, and minimally invasive approaches. For imaging, ultrasound was deemed a reliable tool for the examination of epiphyses und superficial wounds, with limitations regarding internal organs and image quality due to postmortem changes. Ultrasound-guided minimally invasive approaches yielded higher success rates for adequate tissue sampling. Many investigations were carried out in low- and middle-income countries focusing on infectious diseases.

Conclusion

Ultrasound seems a promising but underutilized imaging tool in legal medicine to date. Promising approaches on its feasibility have been conducted. Especially for minimally invasive methods, ultrasound offered significant improvements on qualified biopsy sampling and thus appropriate diagnostics. Moreover, ultrasonic evaluation of epiphyses for age estimation offered valuable results. Nevertheless, further assessment of ultrasonic feasibility in forensic contexts is needed.