Determinants for autopsy after unexplained deaths possibly resulting from infectious causes, United States

No Autopsies on COVID-19 Deaths: A Missed Opportunity and the Lockdown of Science

BACKGROUND

The current outbreak of COVID-19 infection, which started in Wuhan, Hubei province, China, in December 2019, is an ongoing challenge and a significant threat to public health requiring surveillance, prompt diagnosis, and research efforts to understand a new, emergent, and unknown pathogen and to develop effective therapies. Despite the increasing number of published studies on COVID-19, in all the examined studies the lack of a well-defined pathophysiology of death among patients who died following COVID-19 infection is evident. Autopsy should be considered mandatory to define the exact cause of death, thus providing useful clinical and epidemiologic information as well as pathophysiological insights to further provide therapeutic tools.

METHODS

A literature review was performed on PubMed database, using the key terms: "COVID-19", "nCov 19", and "Sars Cov 2". 9709 articles were retrieved; by excluding all duplicated articles, additional criteria were then applied: articles or abstracts in English and articles containing one of the following words: "death", "died", "comorbidity", "cause of death", "biopsy", "autopsy", or "pathological".

RESULTS

A total of 50 articles met the inclusion criteria. However, only 7 of these studies reported autopsy-based data.

DISCUSSION

The analysis of the main data from the selected studies concerns the complete analysis of 12,954 patients, of whom 2269 died (with a mortality rate of 17.52%). Laboratory confirmation of COVID-19 infection was obtained in all cases and comorbidities were fully reported in 46 studies. The most common comorbidities were: cardiovascular diseases (hypertension and coronary artery disease), metabolic disorders (diabetes, overweight, or obesity), respiratory disorders (chronic obstructive pulmonary disease), and cancer. The most common reported complications were: acute respiratory distress syndrome (ARDS), acute kidney injury, cardiac injury, liver insufficiency, and septic shock. Only 7 papers reported histological investigations. Nevertheless, only two complete autopsies are described and the cause of death was listed as COVID-19 in only one of them. The lack of postmortem investigation did not allow a definition of the exact cause of death to determine the pathways of this infection. Based on the few histopathological findings reported in the analyzed studies, it seems to be a clear alteration of the coagulation system: frequently prothrombotic activity with consequent thromboembolism was described in COVID-19 patients. As a scientific community, we are called on to face this global threat, and to defeat it with all the available tools necessary. Despite the improvement and reinforcement of any method of study in every field of medicine and science, encouraging the autopsy practice as a tool of investigation could also therefore, help physicians to define an effective treatment to reduce mortality.

The Importance of the Autopsy in Medicine: Perspectives of Pathology Colleagues

This article presents a perspective on the importance of the autopsy in medical practice and science based on experiences of the authors as physician-scientists involved in autopsy practice. Our perspectives are presented on the seminal contributions of the autopsy in the areas of cardiovascular disease, including congenital heart disease, atherosclerosis, coronary artery disease, and myocardial infarction, and infectious disease, including tuberculosis and viral infections. On the positive side of the future of the autopsy, we discuss the tremendous opportunities for important research to be done by application of advanced molecular biological techniques to formalin-fixed, paraffin-embedded tissue blocks obtained at autopsy. We also note with concern the countervailing forces impacting the influence of pathology in education and clinical practice at our academic medical centers, which also present impediments to increasing autopsy rates. Our challenge as academic pathologists, whose careers have been molded by involvement in the autopsy, is to counter these trends. The challenges are great but the benefits for medicine and society are enormous.

The importance of microbiological testing for establishing cause of death in 42 forensic autopsies

Microorganisms have always been one of the great challenges of humankind, being responsible for both high morbidity and mortality throughout history. In a forensic setting microbiological information will always be difficult to interpret due to lack of antemortem information and changes in flora postmortem. With this study we aim to review the use of microbiological procedures at our forensic institute. In a retrospective study including 42 autopsies performed at our Institute, where microbiological test had been applied, analyses were made with regard to: type of microbiological tests performed, microorganisms found, histological findings, antemortem information, C-reactive protein measurement and cause of death. Fiftyone different microorganisms were found distributed among 37 cases, bacteria being the most abundant. Nineteen of the cases were classified as having a microbiological related cause of death. C-reactive protein levels were raised in 14 cases of the 19 cases, histological findings either supported or were a decisive factor for the classification of microbiologically related cause of death in 14 cases. As a multitude of abundant microorganisms are able to cause infection under the right circumstances, all findings should be compared to anamnestic antemortem information, before conclusions are drawn. A definite list of true pathogens is nearly impossible to compile.

The use of coroner's autopsy reports to validate the use of targeted swabbing rather than tissue collection for rapid confirmation of virological causes of sudden death in the community

BACKGROUND AND OBJECTIVES

In this study, coroner's autopsy reports were used to validate results obtained from respiratory virus screening of swabs rather than tissue collected during autopsy in cases of adult death of unknown cause.

STUDY DESIGN

Coroner's autopsy samples collected for respiratory virus screening between October 2010 and February 2011, were identified. Autopsy reports were requested from cases positive for a virus. Each report was reviewed to correlate findings at autopsy with the virology result and to determine whether the virus found was listed as a contributing factor in the death.

RESULTS

Sixty-four coroner's autopsy cases were identified and a respiratory virus was found in 25 cases. Influenza A(H1N1)pdm09 virus was found most frequently, then RSV and influenza B with a dual influenza A and B infection and a parainfluenza type 1. Where multiple sites were swabbed, the virus was detected in all sites. Autopsy reports for 12 cases were obtained each reporting findings consistent with respiratory infection. Influenza A was always listed as a contributing factor in the death whereas RSV was listed once and influenza B was omitted in one case. The quality of the reports was variable and full histology was less likely to be performed in the elderly.

CONCLUSIONS

While coroner's reports supported the use of swabbing rather than tissue collection, the lack of consistency and omission of the virology findings as contributing factors to death means that the burden of viruses on mortality statistics will remain under-estimated particularly in the elderly.

A cause of Sudden Cardiac Deaths on Autopsy Findings; a Four-Year Report

INTRODUCTION

Incidence of sudden cardiac death (SCD) has been steadily increasing all over the world. While knowing the cause of SCD is one of the favorites of the physicians involved with these cases, it is very difficult and challenging task for the forensic physician. The present report is a prospective study regarding cause of SCDs on autopsy examination in four-year period, Bangalore, India.

METHODS

The present prospective study is based on autopsy observations, carried out for four-year period from 2008 to 2011, and analyzed for cause of SCDs. The cases were chosen as per the definition of sudden death and autopsied. The material was divided into natural and unnatural groups. Finally, on histopathology, gross examination, hospital details, circumstantial, and police reports the cause of death was inferred.

RESULTS

A total of 2449 autopsy was conducted of which 204 cases were due to SCD. The highest SCDs were reported in 50-60 years age group (62.24%; n-127), followed closely by the age group 60-69 (28.43%; n-58). Male to female ratio was around 10:1. The maximum number of deaths (n=78) was within few hours (6 hours) after the onset of signs and symptoms. In 24 (11.8%) cases major narrowing was noted in both the main coronaries, in 87 (42.6%) cases in the left anterior descending coronary artery (LAD), and in 18 (51.5%) cases in the right coronary artery (RCA). The major cardiac pathology resulting in sudden death was coronary artery disease (n-116; 56.86%) and myocardial infarction (n-104; 50.9%). most of the SCDs occurred in the place of residence (n-80; 39.2%) followed closely by death in hospital (n-49; 24.01%).

CONCLUSION

Coronary occlusion was the major contributory cause of sudden death with cardiac origin and the highest number of deaths were reported in the age 50-59 years with male to female ratio of 10:1.

Influenza as a proportion of pneumonia mortality: United States, 1959-2009

As causes of death, influenza and pneumonia are typically analyzed together. We quantify influenza's contribution to the combined pneumonia and influenza mortality time series for the United States, 1959-2009. A key statistic is I/(P + I), the proportion of pneumonia and influenza mortality accounted for by influenza. Year-to-year, I/(P + I) is highly variable and shows long-term decline. Extreme values of I/(P + I) are associated with extreme P + I death rates and vice versa, but I/(P + I) is a weak predictor of P + I mortality overall. Prominence of influenza in the medical news is associated with high I/(P + I). Influenza and pneumonia should be analyzed as a combined cause.