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

Postmortem CT: Applications in Clinical and Forensic Medicine

Just as radiography has been used in forensic medicine since shortly after the discovery of x-rays in 1895, CT was introduced to postmortem investigation not long after its introduction to medicine in the 1970s. In recent decades, forensic radiology has declared itself as a new subspecialty capable of revolutionizing death investigation and research. A variety of postmortem imaging techniques have emerged. Postmortem CT (PMCT) is widely accepted around the world as a supplementary tool and, in specific cases and settings, an alternative to full autopsy. As its popularity grows, however, it is important for radiologists and pathologists to expand their understanding of the applications, benefits, and limitations of these techniques, as well as the unique nuances of postmortem imaging interpretation. This will ensure high-quality interpretations and avoid potential pitfalls that could result in premature or erroneous conclusions. The authors introduce the reader, particularly the radiologist, to the growing subspecialty of forensic imaging (focusing on imaging of the deceased), specifically focusing on PMCT and its applications in death investigation in both clinical and forensic settings. The authors also discuss the benefits and limitations of PMCT as well as important nuances of PMCT interpretation, emphasizing the similarities and differences between clinical and postmortem studies, the necessity of conducting thorough death investigations, and the importance of pursuing specialized education or training in postmortem imaging interpretation. Applications of more specialized imaging techniques to postmortem and forensic investigations are described, including developing research in this area. ©RSNA, 2025 Supplemental material is available for this article.

The evolution of postmortem investigation: a historical perspective on autopsy's decline and imaging's role in its revival

Autopsy is generally regarded as the gold standard for cause of death determination, the most accurate contributor to mortality data. Despite this, autopsy rates have substantially declined, and death certificates are more frequently completed by clinicians. Substantial discrepancies between clinician-presumed and autopsy-determined cause of death impact quality control in hospitals, accuracy of mortality data, and, subsequently, the applicability and effectiveness of public health efforts. This problem is compounded by wavering support for the practice of autopsy by accrediting bodies and academic bodies governing pathology specialty training. In forensic settings, critical workforce shortages combined with increased workloads further threaten sustainability of the practice. Postmortem imaging (PMI) can help mitigate these ongoing problems. Postmortem computed tomography can help clarify manner and cause of death in a variety of situations and has undeniable advantages, including cost reduction, the potential to review data, expedient reporting, archived unaltered enduring evidence (available for expert opinion, further review, demonstrative aids, and education), and (when feasible) adherence to cultural and religious objections to autopsy. Integration of radiology and pathology is driving a transformative shift in medicolegal death investigations, enabling innovative approaches that enhance diagnostic accuracy, expedite results, and improve public health outcomes. This synergy addresses declining autopsy rates, the forensic pathologist shortage, and the need for efficient diagnostic tools. By combining advanced imaging techniques with traditional pathology, this collaboration elevates the quality of examinations and advances public health, vital statistics, and compassionate care, positioning radiology and pathology as pivotal partners in shaping the future of death investigations.

The impact of the COVID-19 pandemic on forensic pathology services in Limpopo province, South Africa

BACKGROUND

To evaluate the effects of coronavirus disease 2019 (COVID-19) and the preventative measures taken, especially how they affect forensic pathology services in rural South Africa.

METHODS

This retrospective analysis includes referred post-mortem cases from all forensic pathology services in Limpopo province, comparing the period before the COVID-19 pandemic (01 January 2019 to 31 December 2019) with the pandemic period (01 January 2020 to 31 December 2020). Data analysis was performed using STATA 16.0 software (StataCorp; College Station, TX). Chi-square test was employed for comparison, with a p-value 0.05 deemed statistically significant.

RESULTS

Approximately 9319 cases were submitted for post-mortem examinations, with 4857 occurring before the pandemic and 4462 during it, marking an 8.1% decrease. There was a decrease in the number of unnatural death cases, while the instances of natural deaths rose. Cases under investigation saw a notable increase. There was a marked decrease in referrals for forensic examinations across all districts. In addition, except for one facility, there was a decline in the number of cases sent for autopsies at all facilities.

CONCLUSION

In conclusion, forensic pathology services in this province had been severely disrupted by the COVID-19 outbreak and the lockdown that followed, especially in the tertiary hospital. It has led to new challenges for case management and necessitated changes to operating procedures.Contribution: It has required modifications to operational procedures and has introduced various challenges in case management.

Inpatient autopsy rate and associated factors in a Chinese megacity: a population-based retrospective cohort study

OBJECTIVES

This study investigated the autopsy rate of hospital deaths in Shenzhen megacity and identified factors that may impact the decision to perform an autopsy in hospital deaths.

DESIGN

This is a population-based retrospective cohort study.

SETTING

Shenzhen is a megacity in China with a population of more than 17 million and a total of 151 hospitals. The official dataset of the inpatient medical record home page was used. Demographic, clinical and hospital information was extracted.

PARTICIPANTS

All the 35 272 inpatient deaths between 2016 and 2022 with known autopsy status were included to calculate the overall autopsy rate. Among them, a total of 34 577 cases with complete data, classified hospital and Chinese nationality, were included for further multivariable rare events logistic regression and Poisson pseudo maximum likelihood regression.

OUTCOME MEASURES

Whether the inpatient death was autopsied or not.

RESULTS

The autopsy procedure was performed in 0.9% (319/35 272) of hospital deaths. The autopsy decision was significantly and positively associated with being married (OR= 1.60, 95% CI: 1.16 to 2.21), self-paying (OR=1.56, 95% CI: 1.07 to 2.26), death due to external causes of injury and poisoning (OR=1.69, 95% CI: 1.02 to 2.81) and pregnancy (OR=13.58, 95% CI: 4.94 to 37.36), but negatively associated with age (OR=0.97, 95% CI: 0.96 to 0.98), emergency admission (OR=0.66, 95% CI: 0.49 to 0.88), referral (OR=0.47, 95% CI: 0.25 to 0.88), neoplasms (OR=0.35, 95% CI: 0.22 to 0.56), respiratory diseases (OR=0.49, 95% CI: 0.26 to 0.95) and for-profit hospitals (OR=0.45, 95% CI: 0.23 to 0.91). There were no statistically significant differences in autopsy rates between large teaching hospitals and other hospitals.

CONCLUSIONS

The autopsy rate of hospital deaths was extremely low, largely due to healthcare providers. Even large teaching hospitals do not request more autopsies compared with other hospitals, after controlling for the patient characteristics. More efforts are urged to encourage hospitals and healthcare providers to proactively request autopsies, helping to revive this important procedure.

Burnout and Stress in Forensic Science Jobs: A Systematic Review

BACKGROUND/OBJECTIVES

Burnout and occupational stress are significant issues among forensic professionals, impacting their well-being and job performance. This systematic review aims to provide an up-to-date overview of the occupational stress and burnout experienced by forensic personnel, exploring the profound and multifaceted impact on their physical, mental, professional, and interpersonal well-being.

METHODS

A systematic review was conducted following PRISMA guidelines using Scopus and WOS databases to search for articles published from 1 January 2000 to 31 August 2024. The search used keywords related to burnout and forensic professions. Inclusion criteria were original articles in English and French, while reviews, book chapters, editorials, and notes were excluded. A total of 10 studies were included after eliminating duplicates and excluding irrelevant articles.

RESULTS

The review identified seven key findings. (1) High levels of occupational stress and burnout among forensic personnel necessitate effective stress management strategies and resilience training; (2) autopsy technicians in Romania experience burnout and alexithymia, particularly related to traumatic events involving children, highlighting the need for specialized support systems; (3) disparities in burnout and post-traumatic stress disorder (PTSD) symptoms were observed in autopsy technicians and resident doctors, suggesting tailored mental health resources; (4) organizational factors, such as peer support and compensation satisfaction, significantly impact burnout and secondary traumatic stress (STS) among sexual assault nurse examiners; (5) burnout among forensic physicians, both in Romania and Egypt, is linked to personality traits, job satisfaction, and socio-demographic factors; (6) pathologists face a range of health issues, including musculoskeletal problems and psychological disorders, underscoring the need for industry-specific health measures; and (7) the lack of wellness resources for forensic professionals calls for improved mental health support and training.

CONCLUSIONS

The findings highlight the pervasive issue of burnout and stress among forensic professionals globally. Addressing these challenges requires comprehensive stress management programs, tailored mental health resources, and organizational support. Future research should focus on developing and implementing effective interventions to enhance resilience and job satisfaction within this high-stress field.

Autoimmune inflammatory reactions triggered by the COVID-19 genetic vaccines in terminally differentiated tissues

As a result of the spread of SARS-CoV-2, a global pandemic was declared. Indiscriminate COVID-19 vaccination has been extended to include age groups and naturally immune people with minimal danger of suffering serious complications due to COVID-19. Solid immuno-histopathological evidence demonstrates that the COVID-19 genetic vaccines can display a wide distribution within the body, affecting tissues that are terminally differentiated and far away from the injection site. These include the heart and brain, which may incur in situ production of spike protein eliciting a strong autoimmunological inflammatory response. Due to the fact that every human cell which synthesises non-self antigens, inevitably becomes the target of the immune system, and since the human body is not a strictly compartmentalised system, accurate pharmacokinetic and pharmacodynamic studies are needed in order to determine precisely which tissues can be harmed. Therefore, our article aims to draw the attention of the scientific and regulatory communities to the critical need for biodistribution studies for the genetic vaccines against COVID-19, as well as for rational harm-benefit assessments by age group.

Trends in mortality from non-natural causes in children and adolescents (0-19 years) in Europe from 2000 to 2018

BACKGROUND

Non-natural mortality in children and adolescents is a global public health problem that varies widely from country to country. Data on child and adolescent maltreatment are not readily available, and mortality due to violent causes is also underestimated.

METHODS

Injury-related mortality rates (overall and by specific causes) from 2000 to 2018 in selected European countries were analysed to observe mortality patterns in children and adolescents using data from the Eurostat database. Age-standardized mortality rates per 100,000 person-years were calculated for each country. Joinpoint regression analysis with a significance level of 0.05 and 95% confidence intervals was performed for mortality trends.

RESULTS

Children and adolescent mortality from non-natural causes decreased significantly in Europe from 10.48 around 2005 to 5.91 around 2015. The Eastern countries (Romania, Bulgaria, Poland, Slovakia, Czech Republic) had higher rates; while Spain, Denmark, Italy, and the United Kingdom had the lowest. Rates for European Country declined by 5.10% per year over the entire period. Larger downward trends were observed in Ireland, Spain and Portugal; smaller downward trends were observed for Eastern countries (Bulgaria, Czech Republic, Poland, Slovakia) and Finland. Among specific causes of death, the largest decreases were observed for accidental causes (-5.9%) and traffic accidents (-6.8%).

CONCLUSIONS

Mortality among children and adolescents due to non-natural causes has decreased significantly over the past two decades. Accidental events and transport accidents recorded the greatest decline in mortality rates, although there are still some European countries where the number of deaths among children and adolescents from non-natural causes is high. Social, cultural, and health-related reasons may explain the observed differences between countries.

Post-mortem findings in Spanish patients with COVID-19; a special focus on superinfections

Introduction

Whole-body autopsies may be crucial to understand coronavirus disease 2019 (COVID-19) pathophysiology. We aimed to analyze pathological findings in a large series of full-body autopsies, with a special focus on superinfections.

Methods

This was a prospective multicenter study that included 70 COVID-19 autopsies performed between April 2020 and February 2021. Epidemiological, clinical and pathological information was collected using a standardized case report form.

Results

Median (IQR) age was 70 (range 63.75-74.25) years and 76% of cases were males. Most patients (90%,) had at least one comorbidity prior to COVID-19 diagnosis, with vascular risk factors being the most frequent. Infectious complications were developed by 65.71% of the patients during their follow-up. Mechanical ventilation was required in most patients (75.71%) and was mainly invasive. In multivariate analyses, length of hospital stay and invasive mechanical ventilation were significantly associated with infections (p = 0.036 and p = 0.013, respectively). Necropsy findings revealed diffuse alveolar damage in the lungs, left ventricular hypertrophy in the heart, liver steatosis and pre-infection arteriosclerosis in the heart and kidneys.

Conclusion

Our study confirms the main necropsy histopathological findings attributed to COVID-19 in a large patient series, while underlining the importance of both comorbid conditions and superinfections in the pathology.

Unpacking the Complexity of COVID-19 Fatalities: Adverse Events as Contributing Factors-A Single-Center, Retrospective Analysis of the First Two Years of the Pandemic

In a retrospective analysis of 477 fatal COVID-19 cases hospitalised at a single medical centre during the period from 6 March 2020 to 30 June 2022, several factors defining those patients at admission were assessed, as well as the course of the hospitalisation and factors contributing to death. There was a predominance of men (59.3% (283)) burdened by comorbidities, with increased inflammation at admission. Patients aged ≥ 81 years were significantly more likely to be admitted to and die in infectious diseases units (IDU) due to respiratory failure, their hospital stays were shorter, and they were most likely not to receive specialist treatment. The most common COVID-19 complications included acute kidney injury in 31.2% (149) patients and thromboembolic complications in 23.5% (112). The course of hospitalisation was complicated by healthcare-associated infections (HAI) in 33.3% (159) of cases, more often in those treated with baricitinib (p < 0.001). The initial use of an antibiotic, although common (94.8% (452)), was unwarranted in almost half of the cases (47.6% (215)). Complications of hospitalisation (46.1% (220)) and adverse events involving staff (49.7% (237)) were found in almost half of the patients. In 88.7% (423) of the cases, death was due to respiratory failure in the course of SARS-CoV-2 infection. Adverse events during hospitalisation should be considered as an additional factor that, in addition to the infection itself, may have influenced the death of patients.

Postmortem lung and heart examination of COVID-19 patients in a case series from Jordan

BACKGROUND

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic for more than 2 years. Autopsy examination is an invaluable tool to understand the pathogenesis of emerging infections and their consequent mortalities. The aim of the current study was to present the lung and heart pathological findings of COVID-19-positive autopsies performed in Jordan.

METHODS

The study involved medicolegal cases, where the cause of death was unclear and autopsy examination was mandated by law. We included the clinical and pathologic findings of routine gross and microscopic examination of cases that were positive for COVID-19 at time of death. Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was confirmed through molecular detection by real-time polymerase chain reaction, serologic testing for IgM and electron microscope examination of lung samples.

RESULTS

Seventeen autopsies were included, with male predominance (76.5%), Jordanians (70.6%), and 50 years as the mean age at time of death. Nine out of 16 cases (56.3%) had co-morbidities, with one case lacking such data. Histologic examination of lung tissue revealed diffuse alveolar damage in 13/17 cases (76.5%), and pulmonary microthrombi in 8/17 cases (47.1%). Microscopic cardiac findings were scarcely detected. Two patients died as a direct result of acute cardiac disease with limited pulmonary findings.

CONCLUSIONS

The detection of SARS-CoV-2 in postmortem examination can be an incidental or contributory finding which highlights the value of autopsy examination to determine the exact cause of death in controversial cases.

COVID-19-related excess mortality - an overview of the current evidence

Analysis of excess deaths, defined as the difference in the total number of deaths in an emergency compared to the number of deaths expected under normal conditions, allows a more reliable assessment of the impact on health systems caused by the global threat of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). So far, data for the two years of the pandemic (2020-2021) indicates the occurrence of 14.9 million excess deaths according to WHO (World Health Organization) estimates. The purpose of the analysis conducted was to define the concept and identify the causes of excess mortality during the COVID-19 pandemic. Inconsistent and unreliable death registration systems; overburdened health systems in low- and middle-income countries; reduced access to medical services for patients with health problems other than COVID-19; the introduction of social distancing and lockdown rules, which translated into increased deaths from psychiatric illnesses and addictions; political considerations and media messages that interfered with vaccination acceptance and adherence; and the additional impact of other natural disasters (hurricanes, floods, drought) were identified as the most important reasons for excess deaths occurrence. The correct identification of country-specific factors and the correct response and countermeasures taken appear crucial in terms of limiting the negative impact of the current pandemic, but also of future threats of a similar nature, in order to reduce excess deaths.

Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Comparison of mucormycosis infection between patients with and without a history of COVID-19 infection: a retrospective cohort study

BACKGROUND

Mucormycosis infection is a complication seen in some coronavirus disease 2019 (COVID-19) patients. This study compares the characteristics of mucormycosis infection between COVID-19 and non-COVID-19 patients.

METHODS

This retrospective cohort comprised 87 patients with mucormycosis divided into two groups. The first included 44 patients who had COVID-19 recently before hospitalization due to mucormycosis at Namazi Hospital, Shiraz, Iran, between February 2019 and August 2021. The second group included all 43 patients hospitalized at the same hospital due to mucormycosis between 2010 and 2019 (pre-pandemic).

RESULTS

Mucormycosis patients with a history of recent COVID-19 infection had a higher rate of diabetes mellitus, fewer malignancies and higher blood glucose, erythrocyte sedimentation rate and C-reactive protein levels (p<0.05). Glucocorticoid use was common (77%) in the COVID-19 group.

CONCLUSIONS

In the pre-COVID-19 era, mucormycosis mainly affected immunodeficient patients like those receiving chemotherapy due to malignancy but now seems to affect COVID-19 patients with uncontrolled blood glucose and glucocorticoids use. Special care must be taken in prescribing glucocorticoids and controlling the blood glucose levels of COVID-19 patients.

High viral loads: what drives fatal cases of COVID-19 in vaccinees? - an autopsy study

The rate of SARS-CoV-2 infections in vaccinees has become a relevant serious issue. This study aimed to determine the causes of death, histological organ alteration, and viral spread in relation to demographic, clinical-pathological, viral variants, and vaccine types for deceased individuals with proven SARS-CoV-2 infection after vaccination who died between January and November 2021. Twenty-nine consecutively collected cases were analyzed and compared to 141 nonvaccinated control cases. Autopsies were performed on 16 partially and 13 fully vaccinated individuals. Most patients were elderly and suffered from several relevant comorbidities. Real-time RT-PCR (RT-qPCR) identified a significantly increased rate of generalized viral dissemination within organ systems in vaccinated cases versus nonvaccinated cases (45% vs. 16%, respectively; P = 0.008) mainly with Ct-values of higher than 25 in non-respiratory samples. However, vaccinated cases also showed high viral loads, reaching Ct-values below 10, especially in the upper airways and lungs. This was accompanied by high rates of pulmonal bacterial or mycotic superinfections and the occurrence of immunocompromising factors, such as malignancies, immunosuppressive drug intake, or decreased immunoglobulin levels. All these findings were particularly accentuated in partially vaccinated patients compared to fully vaccinated individuals. The virus dissemination observed in our case study may indicate that patients with an impaired immune system have a decreased ability to eliminate the virus. However, the potential role of antibody-dependent enhancement must also be ruled out in future studies. Fatal cases of COVID-19 in vaccinees were rare and often associated with severe comorbidities or other immunosuppressive conditions.

COVID-19 Inpatient Deaths and Brought-in-Dead Cases in Malaysia

Coronavirus disease 2019 (COVID-19) deaths can occur in hospitals or otherwise. In Malaysia, COVID-19 deaths occurring outside of the hospital and subsequently brought to the hospital are known as brought-in-dead (BID) cases. To date, the characteristics of BID COVID-19 cases in Malaysia are not clear. The objectives of this study are 2-fold: to explore the characteristics of 29,155 mortality cases in Malaysia and determine the factors associated with the high probability of BID, using the multilevel logistic regression model. Data on COVID-19 mortality cases from the entire country between March 17, 2020 and November 3, 2021 were retrieved from a national open data source. Of the 29,155 COVID-19 mortality cases, 5,903 (20.2%) were BID. A higher probability of BID (p < 0.05) was seen among individuals aged between 18 and 59 years, non-Malaysians, had no comorbidities, did not receive COVID-19 vaccination, and the interval between the date of death and diagnosis. A high prevalence of BID is an alarming public health issue, as this may signal health system failure at one or several levels and, hence, need urgent attention from relevant stakeholders. Based on the findings of this study, increasing the intensity of the vaccination campaign, addressing any issues faced by noncitizens about to COVID-19 management in- and out-of-hospital, increasing the awareness of signs and symptoms of worsening COVID-19 and, hence, the significance of self-monitoring, and determining the potential gaps in the health system may contribute to their increased risk of deaths.

A randomised pilot trial of virtual reality-based relaxation for enhancement of perioperative well-being, mood and quality of life

A cancer diagnosis and subsequent treatment can trigger distress, negatively impact coping resources, and affect well-being as well as quality of life. The aim of this pilot study was to investigate feasibility and clinical effects of a VR intervention on quality of life, well-being and mood in cancer patients undergoing surgery compared to a non-VR intervention and a control group. 54 patients with colorectal cancer or liver metastases from colorectal cancer undergoing elective curatively intended surgery were recruited and randomised to one of two intervention groups or a control group receiving standard treatment. Participants assigned to one of the intervention groups either received a VR-based intervention twice daily or listened to music twice daily. Adherence to the intervention was 64.6% in the music group and 81.6% in the VR group. The VR intervention significantly reduced heart rate (- 1.2 bpm; 95% CI - 2.24 to - 0.22; p = 0.02) and respiratory rate (- 0.7 brpm; 95% CI - 1.08 to - 0.25; p = 0.01). Self-reported overall mood improved in both groups (VR: + 0.79 pts; 95% CI 0.37-1.21; p = 0.001; music: + 0.59 pts; 95% CI 0.22-0.97; p = 0.004). There was no difference in quality of life between the three groups. Both interventions groups reported changes in feelings. Adherence rates favoured the VR intervention over the music group. Observed clinical outcomes showed stronger intragroup effects on mood, feelings, and vital signs in the VR group. The study demonstrated feasibility of a VR intervention in cancer patients undergoing surgery and should encourage further research investigating the potential of VR interventions to positively influence well-being and mood in cancer patients.

Case report of a Japanese patient with chronic renal failure who developed SARS-CoV-2 in a hospital cluster during treatment for acute respiratory failure: An autopsy report

This article reports a clinical and histopathological perspective which noted not only COVID-19 pneumonia but also exacerbation of chronic renal failure potentially caused by thrombus in the kidney, possibly COVID-19-related lesions. The accumulation of autopsy cases will elucidate the pathogenesis of COVID-19 and aid in the development of effective therapeutics.

The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries

Reports of COVID-19-associated mucormycosis have been increasing in frequency since early 2021, particularly among patients with uncontrolled diabetes. Patients with diabetes and hyperglycaemia often have an inflammatory state that could be potentiated by the activation of antiviral immunity to SARS-CoV2, which might favour secondary infections. In this Review, we analysed 80 published and unpublished cases of COVID-19-associated mucormycosis. Uncontrolled diabetes, as well as systemic corticosteroid treatment, were present in most patients with COVID-19-associated mucormycosis, and rhino-orbital cerebral mucormycosis was the most frequent disease. Mortality was high at 49%, which was particularly due to patients with pulmonary or disseminated mucormycosis or cerebral involvement. Furthermore, a substantial proportion of patients who survived had life-changing morbidities (eg, loss of vision in 46% of survivors). Our Review indicates that COVID-19-associated mucormycosis is associated with high morbidity and mortality. Diagnosis of pulmonary mucormycosis is particularly challenging, and might be frequently missed in India.

Histopathological Findings in COVID-19 Cases: A Systematic Review

The ongoing coronavirus disease 2019 (COVID-19) pandemic has turned into one of the most serious public health crises of the last few decades. Although the disease can result in diverse and multiorgan pathologies, very few studies have addressed the postmortem pathological findings of COVID-19 cases. Active autopsy findings amid this pandemic could be an essential tool for diagnosis, surveillance, and research. We aimed to provide a comprehensive picture of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) histopathological features of different body organs through a systematic review of the published literature. A systematic search of electronic databases (PubMed, ScienceDirect, Google Scholar, medRxiv, and bioRxiv) for journal articles of different study designs reporting postmortem pathological findings in COVID-19 cases was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for conducting the review. A total of 50 articles reporting 430 cases were included in our analysis. Postmortem pathological findings were reported for different body organs: pulmonary system (42 articles), cardiovascular system (23 articles), hepatobiliary system (22 articles), kidney (16 articles), spleen and lymph nodes (12 articles), and central nervous system (seven articles). In lung samples, diffuse alveolar damage (DAD) was the most commonly reported finding in 239 cases (84.4%). Myocardial hypertrophy (87 cases, 51.2%), arteriosclerosis (121 cases, 62%), and steatosis (118 cases, 59.3%) were the most commonly reported pathological findings in the heart, kidney, and the hepatobiliary system respectively. Autopsy examination as an investigation tool could lead to a better understanding of SARS-CoV-2 pathophysiology, diagnosis, and management, subsequently improving patient care.

Resistance Training before, during, and after COVID-19 Infection: What Have We Learned So Far?

At the end of 2019, a severe acute respiratory syndrome caused by SARS-CoV-2 started a pandemic, leading to millions of deaths and many important political and social changes. Even in the absence of contamination, the mobility reduction, social distancing and closing of exercise facilities negatively affected physical activity and conditioning, which is associated with muscle atrophy, loss of muscle strength, and reductions in functional capacity. In cases of infection, it has been shown that increased physical capacity is associated with decreased hospitalization and mortality risk. Although millions of people have died from COVID-19, most contaminated individuals survived the infection, but carried different sequelae, such as the severe loss of physical function and a reduced quality of life. Among different physical exercise models that might help to prevent and treat COVID-19-related conditions, resistance training (RT) might be particularly relevant. Among its benefits, RT can be adapted to be performed in many different situations, even with limited space and equipment, and is easily adapted to an individual's characteristics and health status. The current narrative review aims to provide insights into how RT can be used in different scenarios to counteract the negative effects of COVID-19. By doing this, the authors expect to provide insights to help deal with the current pandemic and similar events the world may face in the future.

Prevalence of Acute Pulmonary Embolism at Autopsy in Patients With COVID-19

To date, the actual prevalence of acute pulmonary embolism (PE) in patients with SARS-CoV-2 infection remains unknown, as systematic screening for PE is cumbersome. We performed a systematic review and meta-analysis on autoptic data to estimate the prevalence of histopathologic findings of acute PE and its relevance as a cause of death on patients with COVID-19. We searched MEDLINE-PubMed and Scopus to locate all articles published in the English language, up to August 10, 2021, reporting the autoptic prevalence of acute PE and evaluating PE as the underlying cause of death in patients with COVID-19. The pooled prevalence for both outcomes was calculated using a random-effects model and presenting the related 95% confidence interval (CI). Statistical heterogeneity was measured using the Higgins I2 statistic. We analyzed autoptic data of 749 patients with COVID-19 (mean age 63.4 years) included in 14 studies. In 10 studies, based on 526 subjects (mean age 63.8 years), a random-effect model revealed that autoptic acute PE findings were present in 27.5% of cases (95% CI 15.0 to 45.0%, I2 89.9%). Conversely, in 429 COVID-19 subjects (mean age 64.0 years) enrolled in 9 studies, acute PE was the underlying cause of death in 19.9% of cases (95% CI 11.0 to 33.3%, I2 83.3%). Autoptic findings of acute PE in patients with COVID-19 are present in about 30% of subjects, whereas a venous thromboembolic event represents the underlying cause of death in about 1 of 4 patients.

Spread of COVID-19 Infection in Long-Term Care Facilities of Trieste (Italy) during the Pre-Vaccination Era, Integrating Findings of 41 Forensic Autopsies with Geriatric Comorbidity Index as a Valid Option for the Assessment of Strength of Causation

BACKGROUND

in 2020, a new form of coronavirus spread around the world starting from China. The older people were the population most affected by the virus worldwide, in particular in Italy where more than 90% of deaths were people over 65 years. In these people, the definition of the cause of death is tricky due to the presence of numerous comorbidities.

OBJECTIVE

to determine whether COVID-19 was the cause of death in a series of older adults residents of nursing care homes.

METHODS

41 autopsies were performed from May to June 2020. External examination, swabs, and macroscopic and microscopic examination were performed.

RESULTS

the case series consisted of nursing home guests; 15 men and 26 women, with a mean age of 87 years. The average number of comorbidities was 4. Based only on the autopsy results, the defined cause of death was acute respiratory failure due to diffuse alveolar damage (8%) or (31%) bronchopneumonia with one or more positive swabs for SARS-CoV-2. Acute cardiac failure with one or more positive swabs for SARS-CoV-2 was indicated as the cause of death in in symptomatic (37%) and asymptomatic (10%) patients. Few patients died for septic shock (three cases), malignant neoplastic diseases (two cases), and massive digestive bleeding (one case).

CONCLUSIONS

Data from post-mortem investigation were integrated with previously generated Geriatric Index of Comorbidity (GIC), resulting in four different degrees of probabilities: high (12%), intermediate (10%), low (59%), and none (19%), which define the level of strength of causation and the role of COVID-19 disease in determining death.

Hydrogen-oxygen therapy alleviates clinical symptoms in twelve patients hospitalized with COVID-19: A retrospective study of medical records

A global public health crisis caused by the 2019 novel coronavirus disease (COVID-19) leads to considerable morbidity and mortality, which bring great challenge to respiratory medicine. Hydrogen-oxygen therapy contributes to treat severe respiratory diseases and improve lung functions, yet there is no information to support the clinical use of this therapy in the COVID-19 pneumonia.A retrospective study of medical records was carried out in Shishou Hospital of Traditional Chinese Medicine in Hubei, China. COVID-19 patients (aged ≥ 30 years) admitted to the hospital from January 29 to March 20, 2020 were subjected to control group (n = 12) who received routine therapy and case group (n = 12) who received additional hydrogen-oxygen therapy. The clinical characteristics of COVID-19 patients were analyzed. The physiological and biochemical indexes, including immune inflammation indicators, electrolytes, myocardial enzyme profile, and functions of liver and kidney, were examined and investigated before and after hydrogen-oxygen therapy.The results showed significant decreases in the neutrophil percentage and the concentration and abnormal proportion of C-reactive protein in COVID-19 patients received additional hydrogen-oxygen therapy.This novel therapeutic may alleviate clinical symptoms of COVID-19 patients by suppressing inflammation responses.

Massive Air Embolism Following Necrotizing Pancreatitis and COVID-19 Infection-The Role of Postmortem Computed Tomography

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.

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1β, IL-6, IL-15 and TNF-α

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1β, IL-6, IL-10, IL-15, TNF-α, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1β in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-α showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes.

Long-Term Persisting SARS-CoV-2 RNA and Pathological Findings: Lessons Learnt From a Series of 35 COVID-19 Autopsies

BACKGROUND

Long-term sequelae of coronavirus disease 2019 (COVID-19), including the interaction between persisting viral-RNA and specific tissue involvement, pose a challenging issue. In this study, we addressed the chronological correlation (after first clinical diagnosis and postmortem) between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA and organ involvement.

METHODS

The presence of postmortem SARS-CoV-2 RNA from 35 complete COVID-19 autopsies was correlated with the time interval between the first diagnosis of COVID-19 and death and with its relationship to morphologic findings.

RESULTS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA can be evident up to 40 days after the first diagnosis and can persist to 94 hours after death. Postmortem SARS-CoV-2 RNA was mostly positive in lungs (70%) and trachea (69%), but all investigated organs were positive with variable frequency. Late-stage tissue damage was evident up to 65 days after initial diagnosis in several organs. Positivity for SARS-CoV-2 RNA in pulmonary swabs correlated with diffuse alveolar damage (p = 0.0009). No correlation between positive swabs and other morphologic findings was present. Cerebral (p = 0.0003) and systemic hemorrhages (p = 0.009), cardiac thrombi (p = 0.04), and ischemic events (p = 0.03) were more frequent in the first wave, whereas bacterial pneumonia (p = 0.03) was more prevalent in the second wave. No differences in biometric data, clinical comorbidities, and other autopsy findings were found.

CONCLUSIONS

Our data provide evidence not only of long-term postmortem persisting SARS-CoV-2 RNA but also of tissue damage several weeks after the first diagnosis of SARS-CoV-2 infection. Additional conditions, such as concomitant bacterial pulmonary superinfection, lung aspergillosis, thromboembolic phenomena, and hemorrhages can further worsen tissue damage.

The Impact of the COVID-19 Pandemic on the Practice of Forensic Medicine: An Overview

During the COVID-19 pandemic, forensic sciences, on the one hand, contributed to gaining knowledge about different aspects of the pandemic, while on the other hand, forensic professionals were called on to quickly adapt their activities to respond adequately to the changes imposed by the pandemic. This review aims to clarify the state of the art in forensic medicine at the time of COVID-19, discussing the following: the influence of external factors on forensic activities, the impact of autopsy practice on COVID-19 and vice-versa, the persistence of SARS-CoV-2 RNA in post-mortem samples, forensic personnel activities during the SARS-CoV-2 pandemic, the global vaccination program and forensic sciences, forensic undergraduate education during and after the imposed COVID-19 lockdown, and the medico-legal implications in medical malpractice claims during the COVID-19 pandemic. The COVID-19 pandemic has greatly influenced different aspects of human life, and, accordingly, the practical activities of forensic sciences that are defined as multidisciplinary, involving different expertise. Indeed, the activities are very different, including crime scene investigation (CSI), external examination, autopsy, and genetic and toxicological examinations of tissues and/or biological fluids. At the same time, forensic professionals may have direct contact with subjects in life, such as in the case of abuse victims (in some cases involving children), collecting biological samples from suspects, or visiting subjects in the case of physical examinations. In this scenario, forensic professionals are called on to implement methods to prevent the SARS-CoV-2 infection risk, wearing adequate PPE, and working in environments with a reduced risk of infection. Consequently, in the pandemic era, the costs involved for forensic sciences were substantially increased.

Postmortem findings in COVID-19 fatalities: A systematic review of current evidence

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the ongoing pandemic of coronavirus disease 2019 (COVID-19). Almost 17 months after the first COVID-19 case was reported, the exact pathogenesis of the virus is still open to interpretation. Postmortem studies have been relatively scarce due to the high infectivity rate of the virus. We systematically reviewed the literature available for studies that reported gross, histological, microscopic, and immunohistochemical findings in COVID-19 fatalities with the aim of reporting any recurrent findings among different demographics. PubMed and Scopus were searched up till the second of May 2021 and 46 studies with a total of 793 patients were shortlisted after the application of inclusion and exclusion criteria. The selected studies reported gross, histological, microscopic, and immunohistochemical autopsy findings in the lungs, heart, liver, gallbladder, bowels, kidney, spleen, bone marrow, lymph nodes, CNS, pancreas, endocrine/exocrine glands, and a few other miscellaneous locations. The SARS-CoV-2 virus was detected in multiple organs and so was the presence of widespread microthrombi. This finding suggests that the pathogenesis of this highly infectious virus might be linked to some form of coagulopathy. Further studies should focus on analyzing postmortem findings in a larger number of patients from different demographics in order to obtain more generalizable results.

Postmortem high-dimensional immune profiling of severe COVID-19 patients reveals distinct patterns of immunosuppression and immunoactivation

A complete diagnostic autopsy is the gold-standard to gain insight into Coronavirus disease 2019 (COVID-19) pathogenesis. To delineate the in situ immune responses to SARS-CoV-2 viral infection, here we perform comprehensive high-dimensional transcriptional and spatial immune profiling in 22 COVID-19 decedents from Wuhan, China. We find TIM-3-mediated and PD-1-mediated immunosuppression as a hallmark of severe COVID-19, particularly in men, with PD-1+ cells being proximal rather than distal to TIM-3+ cells. Concurrently, lymphocytes are distal, while activated myeloid cells are proximal, to SARS-CoV-2 viral antigens, consistent with prevalent SARS-CoV-2 infection of myeloid cells in multiple organs. Finally, viral load positively correlates with specific immunosuppression and dendritic cell markers. In summary, our data show that SARS-CoV-2 viral infection induces lymphocyte suppression yet myeloid activation in severe COVID-19, so these two cell types likely have distinct functions in severe COVID-19 disease progression, and should be targeted differently for therapy.

Survey on postmortem screening and management of COVID-19 related deaths

The COVID-19 pandemic is associated with a high case fatality rate in some countries even thought the majority of cases are asymptomatic. Scientific studies on this novel virus is limited and there is uncertainty regarding the best practices for death investigations both in terms of detection of the disease as well as autopsy safety. An online survey was conducted to identify how different institutions responded to the screening and management of dead bodies during the early phase of the pandemic from January to May. A questionnaire was developed using Google Forms and data was collected from 14 different forensic and pathological institutions in 9 countries. None of the institutions had performed any screening prior to March. Four institutions stated that screening was done routinely. In total, 322 cases had been screened using RT-PCR, out of which 40 positive cases were detected among four institutions. The commonest types of samples obtained were nasopharyngeal and oropharyngeal swabs which also had the highest rates of positivity followed by tracheal swab. Blood, swabs from cut surfaces of lung and lung tissue also gave positive results in some cases. Majority of the positive cases were > 65 years with a history suggestive of respiratory infection and were clinically suspected to have COVID-19 before death. Except for one institution which performed limited dissections, standard autopsies were conducted on all positive cases. Disposal of bodies involved the use of sealed body bags and labelling as COVID positive. Funeral rites were restricted and none of the institutions advocated cremation. There were no reports of disease transmission to those who handled COVID positive bodies.

COVID-19: Data collection and transparency among countries

This chapter discusses the importance of data collection and transparency as two important topics closely related with strong impact in the appropriate management of an epidemiological emergency like coronavirus disease 2019 pandemic. Based on the lessons learned, a centralized organization should collect few but substantial data that could be used for global and local decisions. In addition, local laws and policies related to transparency should be considered and approved by governments in order to develop trust in the public opinion.

Postmortem Biopsies of the Lung, Heart, Liver, and Spleen of COVID-19 Patients

Objective

We aimed to evaluate histopathologic alterations in the lung, heart, liver, and spleen of coronavirus disease 2019 (COVID-19) decedents through postmortem core needle biopsies.

Materials and methods

Patients who died of reverse transcription-polymerase chain reaction-proven COVID-19 were included in this postmortem case series. Postmortem percutaneous ultrasound-guided biopsies of the lungs, heart, liver, and spleen were performed using 14- and 16-gauge needles. Biopsy samples were stained with hematoxylin-eosin and examined under a light microscope. Clinicodemographic characteristics, chest computed tomography (CT) images, and COVID-19-related treatments of the patients were also collected.

Results

Seven patients were included in this study. Liver and heart tissue samples were available from all patients, and lung and spleen tissue samples were available from five and three patients, respectively. Chest CT images predominantly revealed bibasilar ground-glass opacities. Lung biopsies showed diffuse alveolar damage in all biopsy specimens. Heart findings were nonspecific and largely compatible with the underlying disease. Patchy necrosis, steatosis, and mononuclear cell infiltration were the main findings in the liver biopsies. Splenic histopathological examination showed that splenic necrosis and neutrophil infiltration were common findings in all patients.

Conclusion

Tissue acquisition was complete for the heart and liver and acceptable for the lungs. The amount of tissue was sufficient for a proper histopathologic examination. Histopathological findings were generally in accordance with previous autopsy studies. Radiological findings of the lung were also correlated with the histopathologic findings. We consider that a postmortem biopsy is a feasible alternative for histopathological examinations in COVID-19 decedents.

Minimally Invasive Tissue Sampling as an Alternative to Complete Diagnostic Autopsies in the Context of Epidemic Outbreaks and Pandemics: The Example of Coronavirus Disease 2019 (COVID-19)

Background

Infectious diseases’ outbreak investigation requires, by definition, conducting a thorough epidemiological assessment while simultaneously obtaining biological samples for an adequate screening of potential responsible pathogens. Complete autopsies remain the gold-standard approach for cause-of-death evaluation and characterization of emerging diseases. However, for highly transmissible infections with a significant associated lethality, such as COVID-19, complete autopsies are seldom performed due to biosafety challenges, especially in low-resource settings. Minimally invasive tissue sampling (MITS) is a validated new approach based on obtaining postmortem samples from key organs and body fluids, a procedure that does not require advanced biosafety measures or a special autopsy room.

Methods

We aimed to review the use of MITS or similar procedures for outbreak investigation up to 27 March 2021 and their performance for evaluating COVID-19 deaths.

Results

After a literature review, we analyzed in detail the results of 20 studies conducted at international sites, whereby 216 COVID-19–related deaths were investigated. MITS provided a general and more granular understanding of the pathophysiological changes secondary to the infection and high-quality samples where the extent and degree of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–related damage could be evaluated.

Conclusions

MITS is a useful addition in the investigation and surveillance of infections occurring in outbreaks or epidemics. Its less invasive nature makes the tool more acceptable and feasible and reduces the risk of procedure-associated contagion, using basic biosafety measures. Standardized approaches protocolizing which samples should be collected—and under which exact biosafety measures—are necessary to facilitate and expand its use globally.

An analysis of hematological, coagulation and biochemical markers in COVID-19 disease and their association with clinical severity and mortality: an Indian outlook

BACKGROUND

The "cytokine storm" (CS) in COVID-19 leads to the worst stage of illness which can be controlled only with timely intervention. There is an urgent need to identify laboratory markers of disease progression for optimum allocation of resources in developing countries like India.

METHODS

A cross-sectional study was conducted on 100 COVID-19 positive patients over two months. The cases were sub-classified based on disease severity into mild to moderate (n=61), severe (n=26) and very severe (n=13) and into survivors (n=85) and non-survivors (n=15) based on survivor status. These patients were tested for hematological parameters (total blood lymphocyte counts, NLR, PLR, platelet indices etc.), coagulation markers (D-dimer, fibrin degradation products (FDP), fibrinogen etc.) and biochemical markers (LDH, ferritin, IL-6, procalcitonin, hs-CRP).

RESULTS

Statistically significant differences were observed in hematological variables (ANC, NLR and ESR), coagulation parameters (D-dimer, FDP, fibrinogen and thrombin time) and biochemical markers (LDH, ferritin, IL-6, procalcitonin and hs-CRP) with regard to subcategories based of disease severity as well as survivor status. There was strong correlation between NLR, D-dimer, IL-6, procalcitonin and ferritin. IL-6 emerged as the single best marker of disease severity (AUC: 0.997, P=0.00), however procalcitonin, LDH, D-dimer, FDP and NLR could also predict severe disease with a good sensitivity and specificity.

CONCLUSION

To conclude, study demonstrates a plethora of biomarkers which could be utilized to accurately identify the hyperinflammation and tissue damage reminiscent of cytokine storm in COVID-19 patients so that timely, safe, and effective therapies can be administered to prevent progression and potentially reduce mortality.

Histopathological Evaluation of Deceased Persons in Lusaka, Zambia With or Without Coronavirus Disease 2019 (COVID-19) Infection: Results Obtained From Minimally Invasive Tissue Sampling

Background

Although much has been learned about the pathophysiology of coronavirus disease 2019 (COVID-19) infections, pathology data from patients who have died of COVID-19 in low- and middle-income country settings remain sparse. We integrated minimally invasive tissue sampling (MITS) into an ongoing postmortem surveillance study of COVID-19 in deceased individuals of all ages in Lusaka, Zambia.

Methods

We enrolled deceased subjects from the University Teaching Hospital Morgue in Lusaka, Zambia within 48 hours of death. We collected clinical and demographic information, a nasopharyngeal swab, and core tissue biopsies from the lung, liver, and kidneys for pathologic analysis. Individuals were considered eligible for MITS if they had a respiratory syndrome prior to death or a COVID-19+ polymerase chain reaction (PCR) nasopharyngeal swab specimen. Samples were retested using quantitative reverse transcriptase PCR.

Results

From June to September 2020 we performed MITS on 29 deceased individuals. PCR results were available for 28/29 (96.5%) cases. Three had a COVID-19+ diagnosis antemortem, and 5 more were identified postmortem using the recommended cycle threshold cut-point <40. When expanding the PCR threshold to 40 ≤ cycle threshold (Ct) ≤ 45, we identified 1 additional case. Most cases were male and occurred in the community The median age at death was 47 years (range 40–64). Human immunodeficiency virus (HIV)/AIDS, tuberculosis, and diabetes were more common among the COVID-19+ cases. Diffuse alveolar damage and interstitial pneumonitis were common among COVID-19+ cases; nonspecific findings of hepatic steatosis and acute kidney injury were also prevalent in the COVID-19+ group. Vascular thrombi were rarely detected.

Conclusions

Lung abnormalities typical of viral pneumonias were common among deceased COVID-19+ individuals, as were nonspecific findings in the liver and kidneys. Pulmonary vascular thrombi were rarely detected, which could be a limitation of the MITS technique. Nonetheless, MITS offers a valuable alternative to open autopsy for understanding pathological changes due to COVID-19.

Minimally Invasive Tissue Sampling Findings in 12 Patients With Coronavirus Disease 2019

BACKGROUND

Minimally invasive tissue sampling (MITS), a postmortem procedure that uses core needle biopsy samples and does not require opening the body, may be a valid alternative to complete autopsy (CA) in highly infectious diseases such as coronavirus disease-19 (COVID-19). This study aimed to (1) compare the performance of MITS and CA in a series of COVID-19 deaths and (2) evaluate the safety of the procedure.

METHODS

From October 2020 to February 2021, MITS was conducted in 12 adults who tested positive before death for COVID-19, in a standard, well-ventilated autopsy room, where personnel used reinforced personal protective equipment. In 9 cases, a CA was performed after MITS. A thorough histological evaluation was conducted, and the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated by real-time reverse-transcription polymerase chain reaction (RT-PCR) and immunohistochemistry.

RESULTS

The diagnoses provided by MITS and CA matched almost perfectly. In 9 patients, COVID-19 was in the chain of events leading to death, being responsible for diffuse alveolar damage and mononuclear T-cell inflammatory response in the lungs. No specific COVID-19 features were identified. Three deaths were not related to COVID-19. All personnel involved in MITS repeatedly tested negative for COVID-19. SARS-CoV-2 was identified by RT-PCR and immunohistochemistry in the MITS samples, particularly in the lungs.

CONCLUSIONS

MITS is useful for evaluating COVID-19-related deaths in settings where a CA is not feasible. The results of this simplified and safer technique are comparable to those of CA.

Autopsy Findings and Causality Relationship between Death and COVID-19 Vaccination: A Systematic Review

The current challenge worldwide is the administration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Considering that the COVID-19 vaccination represents the best possibility to resolve this pandemic, this systematic review aims to clarify the major aspects of fatal adverse effects related to COVID-19 vaccines, with the goal of advancing our knowledge, supporting decisions, or suggesting changes in policies at local, regional, and global levels. Moreover, this review aims to provide key recommendations to improve awareness of vaccine safety. All studies published up to 2 December 2021 were searched using the following keywords: “COVID-19 Vaccine”, “SARS-CoV-2 Vaccine”, “COVID-19 Vaccination”, “SARS-CoV-2 Vaccination”, and “Autopsy” or “Post-mortem”. We included 17 papers published with fatal cases with post-mortem investigations. A total of 38 cases were analyzed: 22 cases were related to ChAdOx1 nCoV-19 administration, 10 cases to BNT162b2, 4 cases to mRNA-1273, and 2 cases to Ad26.COV2.S. Based on these data, autopsy is very useful to define the main characteristics of the so-called vaccine-induced immune thrombotic thrombocytopenia (VITT) after ChAdOx1 nCoV-19 vaccination: recurrent findings were intracranial hemorrhage and diffused microthrombi located in multiple areas. Moreover, it is fundamental to provide evidence about myocarditis related to the BNT162B2 vaccine. Finally, based on the discussed data, we suggest several key recommendations to improve awareness of vaccine safety.

Cytokine-induced liver injury in coronavirus disease-2019 (COVID-19): untangling the knots

Liver dysfunction manifesting as elevated aminotransferase levels has been a common feature of coronavirus disease-2019 (COVID-19) infection. The mechanism of liver injury in COVID-19 infection is unclear. However, it has been hypothesized to be a result of direct cytopathic effects of the virus, immune dysfunction and cytokine storm-related multiorgan damage, hypoxia-reperfusion injury and idiosyncratic drug-induced liver injury due to medications used in the management of COVID-19. The favored hypothesis regarding the pathophysiology of liver injury in the setting of COVID-19 is cytokine storm, an aberrant and unabated inflammatory response leading to hyperproduction of cytokines. In the current review, we have summarized the potential pathophysiologic mechanisms of cytokine-induced liver injury based on the reported literature.

Validating a Minimally Invasive Tissue Sampling (MITS) Method in Determining Cause of Death in Stillbirths and Neonates

Complete diagnostic autopsy (CDA) remains the gold standard and a valuable technique for determining cause of death. It is a source of health statistics that can be used to measure health care services' quality, unraveling important information on disease processes, particularly in emerging and unknown diseases. It can also be a vital tool for medical education and biomedical research. However, autopsy rates have been declining globally. There is an urgent need to develop and validate alternative methods in different settings to provide reliable information on cause of death. In this study, we aimed to determine cause of death (KazCoDe) in neonates and infants using minimally invasive tissue sampling (MITS), and to compare these results with those of CDA. We conducted MITS and CDA sequentially on 24 deceased children at the Pathological Bureau of the Akimat of the city of Nur-Sultan. Clinical data of the study subjects were extracted from their clinical records. During both procedures, brain, liver and lung tissues were collected for pathological diagnosis. Fifteen (62.5%) and nine (37.5%) were stillbirths and neonates, respectively. Eight (33.3%) were females and 16 (66.7%) were males. MITS diagnosis of cause of death was concordant with CDA diagnosis in 83.3% out of the 24 cases when considering the immediate and underlying causes of death and reviewing all the clinical and laboratory test results as part of the diagnostic evaluation to arrive at a cause of death (ICD-PM). We concluded that MITS is a valuable and reliable method for cause of death diagnosis in stillbirths and neonates, which can contribute vital mortality statistics in children in the absence of CDA.

Survey on COVID-19-related mortality associated with occupational infection during the first phase of the pandemic: A systematic review

According to the Centre for Disease Control and Prevention in 2020, a cluster of pneumonia cases of unknown etiology caused by the severe acute respiratory syndrome (SARS)-coronavirus 2 was reported in Wuhan, China. The present review examined the literature to reveal the incidence of novel coronavirus-2019 disease (COVID-19) infections, underlying comorbidities, workplace infections and case fatality rates. A review was performed to identify the relevant publications available up to May 15, 2020. Since the early stages of the COVID-19 outbreak, the case fatality rate among healthcare workers (HCWs) has stood at 0.69% worldwide and 0.4% in Italy. Based on the current information, most patients have exhibited good prognoses in terms of after-effects or sequelae and low mortality rate. Patients that became critically ill were primarily in the elderly population or had chronic underlying diseases, including diabetes and hypertension. Among all working sectors, HCWs, since they are front-line caregivers for patients with COVID-19, are considered to be in the high-risk population. Increased age and a number of comorbidity factors have been associated with increased risk of mortality in patients with COVID-19. The most frequent complications of COVID-19 reported that can cause fatality in patients were SARS, cardiac arrest, secondary infections and septic shock, in addition to acute kidney failure and liver failure. Overcoming the COVID-19 pandemic is an ongoing challenge, which poses a threat to global health that requires close surveillance and prompt diagnosis, in coordination with research efforts to understand this pathogen and develop effective countermeasures.

Do We Really Need Hazard Prevention at the Expense of Safeguarding Death Dignity in COVID-19?

To date, little is known regarding the transmission risks of SARS-CoV-2 infection for subjects involved in handling, transporting, and examining deceased persons with known or suspected COVID-19 positivity at the time of death. This experimental study aims to define if and/or how long SARS-CoV-2 persists with replication capacity in the tissues of individuals who died with/from COVID-19, thereby generating infectious hazards. Sixteen patients who died with/from COVID-19 who underwent autopsy between April 2020 and April 2021 were included in this study. Based on PMI, all samples were subdivided into two groups: 'short PMI' group (eight subjects who were autopsied between 12 to 72 h after death); 'long PMI' (eight subjects who were autopsied between 24 to 78 days after death). All patients tested positive for RT-PCR at nasopharyngeal swab both before death and on samples collected during post-mortem investigation. Moreover, a lung specimen was collected and frozen at -80 °C in order to perform viral culture. The result was defined based on the cytopathic effect (subjective reading) combined with the positivity of the RT-PCR test (objective reading) in the supernatant. Only in one sample (PMI 12 h), virus vitality was demonstrated. This study, supported by a literature review, suggests that the risk of cadaveric infection in cases of a person who died from/with COVID-19 is extremely low in the first hours after death, becoming null after 12 h after death, confirming the World Health Organization (WHO) assumed in March 2020 and suggesting that the corpse of a subject who died from/with COVID-19 should be generally considered not infectious.

COVID-19's U.S. Temperature Response Profile

We estimate the U.S. temperature response profile (TRP) for COVID-19 and show it is highly sensitive to temperature variation. Replacing the erratic daily death counts U.S. states initially reported with counts based on death certificate date, we build a week-ahead statistical forecasting model that explains most of their daily variation (R2 = 0.97) and isolates COVID-19's TRP (p < 0.001). These counts, normalized at 31 °C (U.S. mid-summer average), scale up to 160% at 5 °C in the static case where the infection pool is held constant. Positive case counts are substantially more temperature sensitive. When temperatures are declining, dynamic feedback through a growing infection pool can substantially amplify these temperature effects. Our estimated TRP can be incorporated into COVID-related planning exercises and used as an input to SEIR models employed for longer run forecasting. For the former, we show how our TRP is predictive of the realized pattern of growth rates in per capita positive cases across states five months after the end of our sample period. For the latter, we show the variation in herd immunity levels implied by temperature-driven, time-varying R0 series for the Alpha and Delta variants of COVID-19 for several representative states.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10640-021-00603-8.

Body Donation, Teaching, and Research in Dissection Rooms in Spain in Times of Covid-19

The state of alarm due to Covid-19 pandemic in Spain stopped all educational and most university research activities. The Spanish Anatomical Society (SAE) Consensus Expert Group on Body Donations piloted a study based on a questionnaire to know the status of body donations and dissection activities during the lockdown, as well as the future implications of Covid-19 pandemic for body donation programs and anatomy teaching. The questionnaire results show that Spanish Universities refused body donations and stopped all dissection research and teaching. The Covid-19 expected influence on anatomy teaching was referred to the increase in teaching workforce and resources required to apply the new safety measures to future practical activities, as well as to prepare and adapt teaching material for online-only programs. The application of reinforced safety measures was expected to be perceived by the respondent's students as a gain in teaching quality, while the transformation of the anatomy courses in online-only programs will be perceived as a quality decrease. The respondent's concerns about future institutional implications of the pandemic were related to increased costs of the adaptation of the facilities and the reinforced preventive measures, as well as the eventual decrease in donations. The complete lockdown applied to dissection rooms was not justified by scientific evidence and represented a break of the confidence deposed in the institutions by the donors. A consensus is required for the adoption of a renewed, comprehensive protocol for present and future body donations including the evidence Covid-19 pandemic has contributed to create.

Histopathological findings and clinicopathologic correlation in COVID-19: a systematic review

The severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) pandemic has had devastating effects on global health and worldwide economy. Despite an initial reluctance to perform autopsies due to concerns for aerosolization of viral particles, a large number of autopsy studies published since May 2020 have shed light on the pathophysiology of Coronavirus disease 2019 (COVID-19). This review summarizes the histopathologic findings and clinicopathologic correlations from autopsies and biopsies performed in patients with COVID-19. PubMed and Medline (EBSCO and Ovid) were queried from June 4, 2020 to September 30, 2020 and histopathologic data from autopsy and biopsy studies were collected based on 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 58 studies reporting 662 patients were included. Demographic data, comorbidities at presentation, histopathologic findings, and virus detection strategies by organ system were collected. Diffuse alveolar damage, thromboembolism, and nonspecific shock injury in multiple organs were the main findings in this review. The pathologic findings emerging from autopsy and biopsy studies reviewed herein suggest that in addition to a direct viral effect in some organs, a unifying pathogenic mechanism for COVID-19 is ARDS with its known and characteristic inflammatory response, cytokine release, fever, inflammation, and generalized endothelial disturbance. This study supports the notion that autopsy studies are of utmost importance to our understanding of disease features and treatment effect to increase our knowledge of COVID-19 pathophysiology and contribute to more effective treatment strategies.

Dying "from" or "with" COVID-19 during the Pandemic: Medico-Legal Issues According to a Population Perspective

There is still a lack of knowledge concerning the pathophysiology of death among COVID-19-deceased patients, and the question of whether a patient has died with or due to COVID-19 is still very much debated. In Italy, all deaths of patients who tested positive for SARS-CoV-2 are defined as COVID-19-related, without considering pre-existing diseases that may either contribute to or even cause death. Our study included nine subjects from two different nursing homes (Cases 1–4, Group A; Cases 5–9, Group B). The latter included patients who presumably died from CO poisoning due to a heating system malfunction. All subjects tested positive for COVID-19 both ante- and post-mortem and were examined using post-mortem computed tomography prior to autopsy. COVID-19 was determined to be a contributing cause in the deaths of four out of nine subjects (death due to COVID-19; i.e., pneumonia and sudden cardiac death). In the other five cases, for which CO poisoning was identified as the cause of death, the infection presumably had no role in exitus (death with COVID-19). In our attempt to classify our patients as dying with or due to COVID-19, we found the use of complete assessments (both histological analyses and computed tomography examination) fundamental.

Why Should Clinical Autopsies Continue to Exist?

At some point in history, medicine was integrated with pathology, more precisely, with pathological anatomy [...].

Use of Food Services by Consumers in the SARS-CoV-2 Pandemic. How the Eating Habits of Consumers Changed in View of the New Disease Risk Factors?

The SARS-CoV-2 pandemic in 2020–2021 changed the eating habits of people around the world. The aim of this study is to understand the effects of COVID-19 on changing consumers’ eating habits, including their concerns about food service nutrition in case of new disease risk factors. The survey conducted using the computer-assisted web-based interviewing method on a group of 1021 adult respondents in Poland. We collected information about consumer choices and habits related to use of food services during the pandemic. This research found that COVID-19 had an impact on consumers’ use of food services, both on-site and take-away. Using cluster analysis, we identified five main groups of food service consumers. It was found that almost half of the respondent group did not change their diet during the pandemic, 20% of respondents changed their diet to a positive one, and 20% to a diet that was negative. For respondents the most important forms of protection against COVID-19 in catering establishments were hand disinfection (70.3%), table disinfection (70.4%), wearing of masks and visors by staff (68.2%), and the possibility of cashless payments (64.6%). Based on cluster analysis (eight consumer clusters), we stated that majority of respondents did not see any threats to using catering service during the pandemic. Only a small group (8.1%) of respondents were afraid of the possibility of getting sick with COVID-19. This study presented the effects of COVID-19 on consumer eating behavior in catering and their concerns with food services uses. Discovering consumer concerns can reduce risk, increase food safety and improve eating habits.

The pathogenic role of epithelial and endothelial cells in early-phase COVID-19 pneumonia: victims and partners in crime

Current understanding of the complex pathogenesis of COVID-19 interstitial pneumonia pathogenesis in the light of biopsies carried out in early/moderate phase and histology data obtained at postmortem analysis is discussed. In autopsies the most observed pattern is diffuse alveolar damage with alveolar-epithelial type-II cell hyperplasia, hyaline membranes, and frequent thromboembolic disease. However, these observations cannot explain some clinical, radiological and physiopathological features observed in SARS-CoV-2 interstitial pneumonia, including the occurrence of vascular enlargement on CT and preserved lung compliance in subjects even presenting with or developing respiratory failure. Histological investigation on early-phase pneumonia on perioperative samples and lung biopsies revealed peculiar morphological and morpho-phenotypical changes including hyper-expression of phosphorylated STAT3 and immune checkpoint molecules (PD-L1 and IDO) in alveolar-epithelial and endothelial cells. These features might explain in part these discrepancies.