Autopsy Review Research Articles

EOLP-01. PROPOSED FRAMEWORK FOR A PILOT MULTIDISCIPLINARY BEREAVEMENT FOLLOW-UP AND BRAIN AUTOPSY REVIEW FOR BEREAVED CAREGIVERS IN PEDIATRIC NEURO-ONCOLOGY

Abstract INTRODUCTION Brain tumors remain the leading cause of cancer-related death in children. The death of a child is distressing for caregivers and often associated with negative psychosocial outcomes. Bereaved caregivers frequently desire ongoing support after their child’s death. At our institution, brain autopsies with the option for tissue donation to research are offered to all families after the death of a child. Specific follow-up conducted to date and review of autopsy results have varied widely. We propose a pilot study to (1) evaluate feasibility of a comprehensive, multidisciplinary bereavement follow-up meeting with autopsy results review and grief supports for bereaved caregivers in pediatric neuro-oncology at Nationwide Children’s Hospital and (2) assess caregiver and provider perceptions regarding this follow-up meeting using mixed-methods design. METHODS/DESIGN Bereaved caregivers of children with a brain tumor who died and underwent brain autopsy through our institutional tissue donation protocol will be offered a follow-up meeting after their child’s death. The follow-up meeting will test an established PICU bereavement framework in the pediatric neuro-oncology setting with the addition of brain autopsy results review. Meetings will include caregivers and providers from neuro-oncology, palliative care, and psychosocial team (e.g., psychologist, social worker, chaplain). Caregivers will complete a Likert-scale questionnaire followed by a semi-structured interview via telephone. The goal is to conduct 7-10 meetings. Providers will participate in a focus group to provide feedback. Interviews and the focus group will be recorded, transcribed, and analyzed qualitatively. Concepts to be explored include perceived need for follow up; overall experience; satisfaction with structure, modality, and content; and perceived benefit and meaning of autopsy review. LONG-TERM GOAL To develop, evaluate, and formalize a comprehensive multidisciplinary bereavement follow-up meeting, guided by caregiver and provider feedback, that can be expanded to other institutions and become a “standard of care” for bereaved caregivers in pediatric neuro-oncology.

Prohibition of Grazing in a Decree from Herakleia An Autopsy Review of IG XII.7 509

Prohibition of Grazing in a Decree from Herakleia An Autopsy Review of <i>IG</i> XII.7 509

Unveiling challenges of maternal health in India’s tribal mothers: Insights from a case series of maternal deaths

ABSTRACT Maternal mortality remains a significant public health concern globally, with disparities often evident among marginalized populations, including tribal communities. This case series delves into the complexities surrounding maternal mortality among tribal populations in India, shedding light on the multifaceted factors contributing to this persistent public health issue. Through verbal autopsy and retrospective review of medical records, a series of maternal deaths among tribal mothers were examined. Maternal deaths have been broadly divided into two categories Bottlenecks in quality antenatal services and missed opportunities.

Monomorphic T-cell post-transplant lymphoproliferative disorder with features of HHV8-negative primary effusion lymphoma: an autopsy case and review of the literature

A 67-year-old man underwent renal transplantation in his twenties. He developed refractory pleural effusion, with many large lymphocytes with severe atypia and mitosis in the effusion, indicating malignant lymphoma. He finally died of respiratory failure. An autopsy revealed atypical lymphocytes positive for CD3, CD4, and CD30 and negative for CD8, CD20, PAX5, human herpesvirus (HHV) 8, and Epstein–Barr virus-encoded small RNAs by immunohistochemistry and in situ hybridization. Atypical lymphocytes also had T-cell receptor gene rearrangements Jβ2, Jγ2, and Jδ1 and chromosomal aberrations der(8)t(1;8)(q21;p21), add(13)(q12), add(14)(q32), and add(16)(q12-13). A few atypical lymphocytes were present at other sites. We finally diagnosed this case as monomorphic T-cell post-transplant lymphoproliferative disorder with features of HHV8-negative primary effusion lymphoma. A literature review only identified six cases (four HHV8-negative, two HHV8-positive) of effusion lymphoma of T-cell type, including the present case. Interestingly, about half of HHV8-negative and HHV8-positive cases had a history of renal transplantation in their twenties. All cases showed tumor CD30 expression, whereas CD4 and CD8 expressions were inconsistent. These findings indicated that this lymphoma may be associated with post-transplant lymphoproliferative disorder by renal transplantation at a young age, although further cases need to be analyzed.

Homelessness and Incidence and Causes of Sudden Death

Over 580 000 people in the US experience homelessness, with one of the largest concentrations residing in San Francisco, California. Unhoused individuals have a life expectancy of approximately 50 years, yet how sudden death contributes to this early mortality is unknown. To compare incidence and causes of sudden death by autopsy among housed and unhoused individuals in San Francisco County. This cohort study used data from the Postmortem Systematic Investigation of Sudden Cardiac Death (POST SCD) study, a prospective cohort of consecutive out-of-hospital cardiac arrest deaths countywide among individuals aged 18 to 90 years. Cases meeting World Health Organization criteria for presumed SCD underwent autopsy, toxicologic analysis, and medical record review. For rate calculations, all 525 incident SCDs in the initial cohort were used (February 1, 2011, to March 1, 2014). For analysis of causes, 343 SCDs (incident cases approximately every third day) were added from the extended cohort (March 1, 2014, to December 16, 2018). Data analysis was performed from July 1, 2022, to July 1, 2023. The main outcomes were incidence and causes of presumed SCD by housing status. Causes of sudden death were adjudicated as arrhythmic (potentially rescuable with implantable cardioverter-defibrillator), cardiac nonarrhythmic (eg, tamponade), or noncardiac (eg, overdose). A total of 868 presumed SCDs over 8 years were identified: 151 unhoused individuals (17.4%) and 717 housed individuals (82.6%). Unhoused individuals compared with housed individuals were younger (mean [SD] age, 56.7 [0.8] vs 61.0 [0.5] years, respectively) and more often male (132 [87.4%] vs 499 [69.6%]), with statistically significant racial differences. Paramedic response times were similar (mean [SD] time to arrival, unhoused individuals: 5.6 [0.4] minutes; housed individuals: 5.6 [0.2] minutes; P = .99), while proportion of witnessed sudden deaths was lower among unhoused individuals compared with housed individuals (27 [18.0%] vs 184 [25.7%], respectively, P = .04). Unhoused individuals had higher rates of sudden death (incidence rate ratio [IRR], 16.2; 95% CI, 5.1-51.2; P < .001) and arrhythmic death (IRR, 7.2; 95% CI, 1.3-40.1; P = .02). These associations remained statistically significant after adjustment for differences in age and sex. Noncardiac causes (96 [63.6%] vs 270 [37.7%], P < .001), including occult overdose (48 [31.8%] vs 90 [12.6%], P < .001), gastrointestinal causes (8 [5.3%] vs 15 [2.1%], P = .03), and infection (11 [7.3%] vs 20 [2.8%], P = .01), were more common among sudden deaths in unhoused individuals. A lower proportion of sudden deaths in unhoused individuals were due to arrhythmic causes (48 of 151 [31.8%] vs 420 of 717 [58.6%], P < .001), including acute and chronic coronary disease. In this cohort study among individuals who experienced sudden death in San Francisco County, homelessness was associated with greater risk of sudden death from both noncardiac causes and arrhythmic causes potentially preventable with a defibrillator.

Review of Forensic Autopsy Evidence in Proving the Crime of Murder: A Narrative Literature Review

An autopsy or post-mortem is a medical examination procedure performed on a person's body after death to find out the cause of death or other medical conditions that can be identified from the deceased's body. This literature review aimed to describe a forensic autopsy review on the crime of murder. To be able to prove that a crime has been committed a forensic autopsy is used to prove whether the crime actually occurred or not. Forensic autopsy evidence is used to facilitate judges in making decisions and to expedite the course of proceedings in court so that the truth can be proven. Forensic autopsies are performed for criminal and legal investigation purposes. This autopsy can help identify the cause of a person's death, as well as gather evidence and information needed to assist the investigation process. The specific goals of a forensic autopsy are to study the cause of death of a person, gather evidence, identify victims, assist in criminal investigations and identify signs of violence. A forensic autopsy aims to reveal a cause of death for a person and for legal/court purposes.

The surge in fatal diabetic ketoacidosis in the years of the COVID-19 pandemic: a forensic autopsy study

Abstract Introduction/Objective Although many deaths resulting from diabetic ketoacidosis (DKA) fall outside the legal jurisdiction of the medical examiner, a forensic pathologist may identify this cause of death through ancillary testing multiple times per year. We recognized a sharp increase in deaths due to DKA at a busy metropolitan medical examiner’s office in 2020 and 2021, coinciding with the COVID-19 pandemic. We hypothesize that in the majority of these cases, fatal DKA was the presenting symptom of previously undiagnosed diabetes mellitus (DM). Methods/Case Report We performed a retrospective autopsy review of all cases with a cause of death listed as “diabetic ketoacidosis” from January 1, 2018 through June 18, 2021. We compared the number of DKA deaths to all reported deaths from the same time period. Results (if a Case Study enter NA) We identified a total 34 cases of fatal DKA. In 2018, 5 cases of DKA were identified and all decedents had a known diagnosis of DM; the average age at death was 50.6 years (range: 40- 60 years) and 2 decedents were male (40%). In 2019, 5 cases of DKA were identified and 4 decedents had a known diagnosis of DM (80%); the average age at death was 51.4 years (range: 37- 61 years), and all decedents were male (100%). In 2021, 18 cases of DKA were identified and 9 decedents had a previous diagnosis of DM (50%); the average age at death was 43.5 years (range: 22- 64 years), 13 decedents were male (72%), and 1 decedent was COVID-19 positive (5.5%). In the first 6 months of 2021, 6 cases of DKA were identified and none of these decedents had a previous diagnosis of DM (0%); the average at death was 51.8 years (range: 35- 73 years), 4 decedents were male (66%), and 1 decedent was COVID-19 positive (16.6%). Reported deaths per year to our office are as follows: 2018 = 2585 deaths, 2019 = 2658 deaths, 2020 = 3091 deaths, and 2021 to date = 1482 deaths. Conclusion Coinciding with the COVID-19 pandemic, our office experienced a 16.2% increase in all reported deaths from 2019 to 2020, and a 260% increase in fatal DKA. In 2018 and 2019, 9 of the 10 decedents who died from DKA had a known diagnosis of DM (90%). However, in 2020 and the first half of 2021, DKA was the presenting symptom of previously undiagnosed DM in 15 of 24 cases of fatal DKA (62.5%). Further investigation must be done to examine the factors driving the recent surge in fatal DKA.

A Donor With Green Kidneys—To Transplant or Not to Transplant: A Case Report

A Donor With Green Kidneys—To Transplant or Not to Transplant: A Case Report

Autopsy and pre-mortem diagnostic discrepancy review in an Irish tertiary PICU.

Our study had two objectives: (1) to review ante- and post-mortem diagnoses and assign a Goldman error classification and (2) establish autopsy rates within our centre. We performed a retrospective analysis of autopsies performed on patients who died in our paediatric intensive care unit (PICU) between November 13, 2012, and October 31, 2018. Medical and autopsy data of all patients was reviewed, and Goldman classification of discrepancy between ante- and post-mortem diagnoses was assigned. Our centre is a tertiary PICU, and we included all patients that died in PICU within the designated timeframe. Our results were as follows: 396 deaths occurred in PICU from 8329 (4.75%) admissions. Ninety-nine (25%) had an autopsy, 75 required by the coroner. All were included in the study. Fifty-three were male and 46 females. Fifty-three patients were transferred from external hospitals, 46 from our centre. Forty-one were neonates, 32 were < 1 year of age, and 26 were > 1 year of age. The median length of stay was 3 days. Eighteen were post-cardiac surgery, and three post-cardiac catheter procedure. Major diagnostic errors (class I/II) were identified in 14 (14.1%), 2 (2%) class I, and 12 (12.1%) were class II errors. Class III and IV errors occurred in 28 (28.2%) patients. Complete concordance (class V) occurred in 57 (57.5%) cases.Conclusion: We conclude that the autopsy rate and the diagnostic discrepancy rate within our PICU are comparable to those previously reported. Our findings show the continuing value of autopsy in determining the cause of death and providing greater diagnostic clarity. Given their value, post-mortem examinations, where indicated, should be considered part of a physician’s duty of care to families and future patients. What is Known:• Major diagnostic discrepancies (class I/II) in PICU have been reported at 20.2%. (10)• PICU autopsy rates have varied from 36 to 67% since 1994 with most recently reported rates in 2018 being 36%. (6-9)What is New:• We report an Irish PICU major diagnostic discrepancy (class I/II) rates of 14.1% contributing further to reported discrepancy rates in PICU literature to date.• This study contributes the Irish PICU post-mortem rate in a tertiary centre which was 25% over an almost 6-year period.

Pathogenesis of COVID-19; Acute Auto-inflammatory Disease (Endotheliopathica & Leukocytoclastica COVIDicus).

The pathogenesis of the COVID19 pandemic, that has killed one million nine hundred people and infected more the 90 million until end of 2020, has been studied by many researchers. Here, we try to explain its biological behavior based on our recent autopsy information and review of literature. In this study, patients with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) result were considered eligible for enrollment. Histopathological examinations were done on 13 people who were hospitalized in Afzalipour hospital, Kerman, Iran. Clinical and laboratory data were reviewed. Tissue examination was done by light microscopy, immunohistochemistry and electron microscopy. The most frequent co-morbidity in the patients was cardiovascular disease. The common initial symptoms of COVID-19 infection were dyspnea and cough. In all cases, the number of white blood cells was higher than the normal range. Common histopathological findings were variable degrees of vasculitis as degenerative to necrotic changes of endothelium and trafficking of inflammatory cells in the vessel wall with fibrinoid necrosis. Tissue damage included interstitial acute inflammatory cells reaction with degenerative to necrotic changes of the parenchymal cells. CD34 and Factor VIII immunohistochemistry staining showed endothelial cell degeneration to necrosis at the vessel wall and infiltration by inflammatory cells. Electron microscopic features confirmed the degenerative damages in the endothelial cells. Our histopathological studies suggest that the main focus of the viral damage is the endothelial cells (endotheliopathica) in involved organs. Also, our findings suggest that degeneration of leukocytes occurs at the site of inflammation and release of cytokines (leukocytoclastica) resulting in a cytokine storm.

Two Case Reports: Utilizing Autopsy Review in Bereavement to Clarify Misconceptions and Help Families Find Meaning

Two Case Reports: Utilizing Autopsy Review in Bereavement to Clarify Misconceptions and Help Families Find Meaning

Causes of sudden death - autopsy review in a tertiary referral center

Background: The incidence of sudden death has been increasing steadily all over the worldparticularly in the urban population for the last 5 years. World health organization [WHO] hasdefined sudden death as “Death within 24 hrs from the onset of symptoms”. It can be defined asdeaths that are sudden, unexpected, clinically unexplained, or otherwise obscure even though thereneed to be no unnatural element in their causation. Materials and methods: Complete analysisand review of all autopsy/post-mortem specimens received in the Department of Pathology, KIMS,Hubballi between September 2017 to June 2019 done to find out the cause of death. Results:During the study period, a total of 153 cases of sudden death were received, age ranged from 6months to 72 years, with male preponderance. The cause of death were, 67 cases - cardiac causes[43.7%], 15 cases- respiratory causes [9.8%], 7 cases of sepsis [4.5%], 6 cases of Miliary TB[3.9%], CNS- 5 cases [3.2%], Hepatobiliary [2.6%], Renal- 2 cases [1.3%], Gastrointestinal 2cases [1.3%] Malignancy – 1 case [0.65%], Inconclusive 44 - cases [ 28.7%]. Conclusion: Thisstudy concludes that sudden death can occur at any age with the most common cause being cardiacdiseases and few among these are preventable. Therefore, creating awareness about the risk factorsand prevention of disease progression can reduce the incidence of sudden deaths.

Autopsy review of sudden natural death cases at rural government medical college in Maharashtra

Introduction: Sudden deaths in apparently healthy persons might raise doubt of foul play. Hence medico-legal autopsy in such cases is needed to satisfy the aggrieved relatives and it also gives a systemic view of various causes of deaths in such cases which ultimately improve mortality statistics. Material and Methods: Retrospective analysis of sudden natural death cases which were brought for medico-legal autopsy at Rural Govt. Medical College & Hospital during the three year period was studied. The data was compiled, tabulated and analyzed statistically. Results: The incidence of sudden natural death is 16.01%. Most common age group involved was 41-50 years followed by 31-40 years. Male predominance (77.42%) was noted. Most commonly affected system was cardiovascular system (53%) followed by respiratory system (33.64%). Among the cardiovascular system causes Coronary artery disease was accounted in 88.7% of cases. Among the respiratory system causes pneumonia was predominant with 50.69% cases. Conclusion: The incidence of sudden natural death is 16.01%. Males having age 41-50 years are most commonly affected. Cardiovascular diseases contribute to most of the sudden natural deaths of which Coronary artery disease is the leading cause. Increased awareness with regular health checkups is needed among the population at risk so as to improve quality of life. Keywords: Sudden natural deaths, Medico-legal autopsy, Cardio-vascular system

Death by cat bite: Pasteurella multocida: Autopsy findings and review of the literature

Pasteurella multocida, a gram-negative bacillus, is present in the oropharyngeal secretions of livestock, wild animals, and domesticated pets and can cause infection in humans. The most common route of entry has been shown to be via an animal bite, but a significant portion of cases of human infection lack evidence of such a wound. Review of the literature reveals that patients with a history of an animal bite tend to have a less aggressive clinical course than patients without an animal source of infection. We present a case, however, of Pasteurella multocida bacteremia which resulted in the death of an immunocompromised 80-year old woman in which the route of infection was found at autopsy to be a cat bite. This case highlights the importance of educating patients, particularly those with underlying immunocompromised conditions, of the possible lethal complications that can result from animal inflicted wounds and the importance of seeking medical assistance should a bite occur.

Homicide and concealment of the corpse. Autopsy case series and review of the literature.

The concealment of the body following a homicide undermines different moments of the forensic and medico-legal investigations. The aim of the present study is to provide an overview of the literature and the forensic casuistry of the Institute of Legal Medicine of Padova for analyzing and discussing diverse methodological approaches for the forensic pathologist dealing with covered-up homicides. A literature review, updated until September 2019, was performed, and a literature pool of forensic cases was built. In-house cases were included by conducting a retrospective analysis of the forensic caseworks of Padova of the last 20years. Data regarding epidemiology, methodology of assessment, methods of concealment, and answers to medico-legal issues were extracted for both data sets. Seventy-eight papers were included in the literature review (78.2% being case reports or case series, 17% retrospective studies, and 6% experimental studies or reviews). Literature and in-house data sets consisted of 145 and 13 cases, respectively. Death scene investigation, radiology, toxicology, and additional analyses were performed in 20-54% of literature and 62-77% of in-house cases. Cover-up by multiple methods prevailed. Death was caused by head trauma in about 40% of cases (both data sets), strangulation in 21% of literature, and 7% of in-house cases, and was undetermined in 17% of literature and 7% of in-house cases. The methodology of ascertainment should be case-specific and based on a multidisciplinary and multimodal evaluation of all data, including those gained through novel radiological and/or analytical techniques.

Will Complement Inhibition Be the New Target in Treating COVID-19-Related Systemic Thrombosis?

Will Complement Inhibition Be the New Target in Treating COVID-19-Related Systemic Thrombosis?

SIDS associated RYR2 p.Arg2267His variant may lack pathogenicity

Sudden infant death syndrome (SIDS) is the sudden death of an infant under 1 year of age that remains unexplained after death scene and medicolegal investigation, including a complete autopsy and clinical history review. The fatal event typically occurs during sleep and heart rhythm during the event is rarely documented. Large series which have utilized molecular autopsy show that long QT syndrome (LQTS) associated cardiac channel mutations contribute to between 5 and 10% of SIDS deaths. In addition, rare novel RYR2 variants have been identified in SIDS victims. Given the lack of a phenotype, the pathogenicity of these variants is inferred from in vitro studies. We report a family with 5 members (mother and 4 children) who are carriers of a rare RYR2 variant (c.6800G > A, p.Arg2267His [Exon: 45], heterozygous) which has previously been identified in a SIDS victim and shown to confer a gain-of-function CPVT phenotype in vitro. All of these 5 family members including the mother (age range 7 to 41 years) have had negative exercise stress tests, echocardiograms and Holter monitors. These findings suggest that caution should be exercised in inferring pathogenicity of rare RYR2 variants based on in vitro functional data which does not always translate to human phenotype.

Mortality patterns in patients with diabetes mellitus at a Nigerian tertiary hospital: A 10-Year autopsy study.

Diabetes mellitus (DM) is a global health problem with associated high morbidity and mortality. This study was a retrospective review of post-mortem examination findings of hospitalised patients with DM for causes of death. A retrospective, cross-sectional autopsy review of all the patients with DM in our hospital between January 2008 and December 2017 was conducted. The causes of death were classified into cardiovascular, cerebrovascular, acute diabetic emergencies, infection, cancers and unnatural deaths. The demographic data and clinicopathological parameters were extracted, and the data were analysed using the SPSS software version 23. A total of 1092 cases of autopsy were done within the study period, of which 91 cases were on patients with diabetes accounting for 8.3%. Infections with sepsis were the major cause of death, accounting for 51.6% followed by cardiovascular diseases (16.5%), cancers (14.3%), acute diabetic emergencies (6.6%) and cerebrovascular accidents (6.6%), with renal complications and road traffic accidents accounting for 2.2% each. Patients' age ranged from 31 to 84 years, with a modal age of 57 years. There was a male predominance with a male-to-female ratio of 1.5:1. Systemic hypertension co-morbidity was statistically significantly more common in patients aged 60 and above (P = 0.035). The most common lesion observed in the kidneys was benign nephrosclerosis (43.2%). This study suggests that majority of our patients with diabetes mellitus die from infections with attendant sepsis. Older patients appear to have co-morbid systemic hypertension. Patient education on infection prevention and prompt treatment might be life-saving.

An autopsy review of 78 cases of suicide by hanging in benin

Introduction: Hanging is one of the most common methods of suicide. It can also be used to conceal a crime. Thus, it is important to systematically have a forensic autopsy performed in cases of hanging. Only that examination can determine the actual forensic form of the death. At the national level, there is no epidemiological data on suicide by hanging in Benin. Aims: This study aims to describe the epidemiological and forensic features observed in the cases of suicide by hanging in Benin. Material and Methods: This is a descriptive and retrospective study of all the suicidal deaths by hanging collated in the Forensic & Legal Medicine Unit of the Faculty of Health Sciences (UML_FSS) for a period of 12 years, 2005–2017, in Benin. Result: Suicides by hanging accounted for 8.3% of the cases of suspicious deaths autopsied in the south and center of Benin. Males represented 85.9% of the corpses, and most individuals were under 40 years old (62.0%). Hangings were complete in 65.4% of the cases. The material used most often for hanging (28.7% of cases) was nylon rope. Subcutaneous hemorrhages (46.2%) and ecchymosis in the sterno-cleido-mastoid muscles (61.3%) were the most common finding at the neck dissection. Conclusion: Hanging is a common method of suicide, especially among young men. In Benin, it occurs behind closed doors and by means of tools used in everyday life. Forensic autopsies, however, remain infrequent in cases of suicides. Keywords: Hanging, Suicide, Autopsy, Benin.

Thyroid Gland as a Target of Secondary Malignancies - an Autopsy Study and Review Data

Secondary malignancies of the thyroid gland are rarely diagnosed but their incidence at autopsy is not uncommon. To investigate the clinicopathological features of patients with metastatic tumours of the thyroid gland, we reviewed autopsy records and pathological features of 36 cases with thyroidal secondary tumours from 266 cases of malignant neoplasias (excluding cases of primary thyroid cancer), over a 16-year period. There were 19 men and 17 women in the study, ranging in age from 37 to 95 years (mean 70.4 years). The incidence of metastasis in thyroid gland was 0.9% in all autopsy cases, and 13.53% of the malignant tumours. The majority were carcinomas of epithelial origin. The lung was the most common primary tumour site (33.3%), followed by the breast (8.33%) and the kidney (8.33%). The most common non-epithelial malignancy was lymphoma, followed by leukaemia (total of both 25%). As for the microscopic morphological observations, diffuse infiltration pattern of tumour cells was noted in 63.89% of the cases, the formation of nodules in 33.33% of the cases and contiguous invasion in 2.79% of the cases. There were 35.71% cases of metastases associated with multinodular goitre and 28.57% cases associated with papillary microcarcinoma. Our study indicates that thyroid secondary malignancies are not infrequent and may constitute a diagnostic problem. Lung cancer is the most common neoplasm that metastasizes to the thyroid gland in north-western Greek population.