Minimally invasive autopsy for fetuses and children based on a combination of post-mortem MRI and endoscopic examination: a feasibility study

BACKGROUND

Less invasive perinatal and paediatric autopsy methods, such as imaging alongside targeted endoscopy and organ biopsy, may address declining consent rates for traditional autopsy, but their acceptability and accuracy are not known.

OBJECTIVES

The aims of this study were to provide empirical data on the acceptability and likely uptake for different types of autopsy among key stakeholders (study 1); and to analyse existing autopsy data sources to provide estimates of the potential efficacy of less invasive autopsy (LIA) and its projected utility in clinical practice (study 2).

REVIEW METHODS

Study 1: this was a mixed-methods study. Parents were involved in research design and interpretation of findings. Substudy 1: a cross-sectional survey of 859 parents who had experienced miscarriage, termination of pregnancy for fetal anomaly, stillbirth, infant or child death, and interviews with 20 responders. Substudy 2: interviews with 25 health professionals and four coroners. Substudy 3: interviews with 16 religious leaders and eight focus groups, with 76 members of the Muslim and Jewish community. Study 2: a retrospective analysis of national data in addition to detailed information from an existing in-house autopsy database of > 5000 clinical cases that had undergone standard autopsy to determine the proportion of cases by clinical indication group for which tissue sampling of specific internal organs significantly contributed to the diagnosis.

RESULTS

Substudy 1: 91% of participants indicated that they would consent to some form of LIA, 54% would consent to standard autopsy, 74% to minimally invasive autopsy (MIA) and 77% to non-invasive autopsy (NIA). Substudy 2: participants viewed LIA as a positive development, but had concerns around the limitations of the technology and de-skilling the workforce. Cost implications, skills and training requirements were identified as implementation challenges. Substudy 3: religious leaders agreed that NIA was religiously permissible, but MIA was considered less acceptable. Community members indicated that they might consent to NIA if the body could be returned for burial within 24 hours. Study 2: in 5-10% of cases of sudden unexplained death in childhood and sudden unexplained death in infants, the final cause of death is determined by routine histological sampling of macroscopically normal organs, predominantly the heart and lungs, and in this group routine histological sampling therefore remains an important aspect of investigation. In contrast, routine histological examination of macroscopically normal organs rarely (< 0.5%) provides the cause of death in fetal cases, making LIA and NIA approaches potentially highly applicable.

LIMITATIONS

A key limitation of the empirical research is that it is hypothetical. Further research is required to determine actual uptake. Furthermore, because of the retrospective nature of the autopsy data set, findings regarding the likely contribution of organ sampling to final diagnosis are based on extrapolation of findings from historical autopsies, and prospective data collection is required to validate the conclusions.

CONCLUSIONS

LIA is viable and acceptable (except for unexplained deaths), and likely to increase uptake. Further health economic, performance and implementation studies are required to determine the optimal service configuration required to offer this as routine clinical care.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Clinical and Autopsy Diagnoses of Visceral Affections of Patients Who Died Because of Complicated Burns with Multi-organ Failure

The anatomicopathological investigations carried out in a total number of 186 cadavers during the last decade were reviewed. In these retrospective studies of necropsy protocols related to different affections of visceral organ systems that evolved asymptomatically, 30.1% involved the neurological system, 36.0% the uropoiesis system, 34.4% the gastrointestinal system, 52.0% the hepatobiliary system, and 39.7% the cardiovascular system, with a prevalence in the pulmonary system of 64.2%. A comparative analysis of the incidence of affections detected in various visceral organs (on the basis of necropsy data in the 186 burn patients) and the incidence of their clinical manifestations showed that in 35% of patients with extensive and deep burns all of these conditions developed asymptomatically and were diagnosed only through autopsy.

A CLINICOPATHOLOGIC AUTOPSY STUDY OF 100 CASES, 1950 TO 1960

The major clinical and pathologic features of 100 cases of syphilitic aortitis, autopsied from 1950 to 1960, are reviewed. Decreasing incidence, changing patterns of lesions, and reasons for the frequent failure to diagnose syphilitic heart disease are considered. Aortic insufficiency or aneurysm of the thoracic aorta, or both, accompanied by a history of syphilis or reactive serology are required to establish a definitive diagnosis. Syphilis still remains a real threat, and, until it is eradicated, it will continue to cause clinical and subclinical cardiovascular disease.

CARCINOMATOUS METASTASIS TO THE VERTEBRAL BODIES

The spread of carcinoma to the vertebral bodies has been studied by the long vertebral slice technique. Vertebral secondaries were found in one third of all patients with carcinoma, and in almost one half of those dying with distant metastases. Haematogenous dissemination and direct lymphatic spread both appeared to produce vertebral metastases. Radiology and less effective investigation of the skeleton at necropsy underestimate the incidence of bony metastases. This method is recommended as an easy and rapid one of examining the bone marrow, and gives a good indication of the presence of metastases in the whole of the skeletal system.

ISLET-CELL CARCINOMA (ZOLLINGER-ELLISON SYNDROME) WITH FULMINATING ADRENOCORTICAL HYPERFUNCTION AND HYPOKALEMIA

The production of ACTH-like material by tumours arising in non-endocrine tissue may initiate severe adrenocortical hyperfunction. The pathogenesis and clinical and laboratory features of Cushing's syndrome associated with such tumours are characteristic. The autonomous production by the tumour of ACTH-like material cannot be suppressed by exogenous corticoids. The onset of clinical symptoms is rapid; muscle wasting, general weakness, thirst and peripheral edema predominate, and the classical signs of Cushing's syndrome may be absent. High levels of plasma 17-hydroxycorticosteroids and urinary 17-hydroxycorticosteroids and 17-ketosteroids, usually with normal levels of urinary aldosterone, commonly occur. Hypokalemic alkalosis unresponsive to replacement therapy may cause death. In the case reported herein, the intriguing possibility exists that two hormone-like substances were produced by the primary growth and its metastases: one, ACTH-like, to account for the adrenal hyperplasia and Cushing's syndrome; and another, gastrin-like, giving rise to the ulcerogenic diathesis.

POSTMORTEM BLOOD SUGAR AND BLOOD UREA NITROGEN DETERMINATIONS

Glucose and urea nitrogen determinations were made on blood and cerebrospinal fluid samples collected during 160 postmortem examinations in order to determine the usefulness of such tests in diagnosing diabetes and uremia at the time of autopsy. The results indicated that: (1) Blood is unsuitable for postmortem glucose determination, and no postmortem normal can be established. (2) Cerebrospinal fluid gave more uniform but very low glucose values. (3) Diabetics as a group had very high postmortem glucose levels but showed a marked overlap with non-diabetics. (4) Infants less than 3 months of age showed high postmortem glucose values. (5) Postmortem blood urea nitrogen and cerebrospinal fluid urea nitrogen levels were within normal limits in previously healthy persons who died suddenly from accidental causes. (6) Hospital autopsy cases had high urea nitrogen levels. (7) Postmortem urea nitrogen levels higher than 100 mg.% were indicative of uremia.