Specialists In Pathology Research Articles

Diagnosis of Cowden Syndrome as an Example of Dentist-Physician Communication: Report of a Case

Background: The mouth is the mirror of the body and can manifest signs of underlying health issues. The oral soft and hard tissues are physically linked to the rest of the body. Therefore, the role of dentists is much greater than the dental setup. Many physicians consider dentistry as a purely practical occupation and not scientific. In recent years, the relationship between oral and systemic disease has become a leading research issue. Interventional studies focused on the relationship between dental treatment and its effect on certain systemic condition. In this regard, the aim of this study is to introduce a case of Cowden Syndrome (CS) which was first diagnosed according to their oral manifestations by a dentist. Case report: A 37-year-old woman was referred to the Department of Oral Medicine, Shahid Beheshti University of Medical Sciences complaining of aesthetic problems. Intra-oral examinations showed grooves and papillomatosis. Examination of the oral cavity showed a high- arched palate, hypoplasia of the maxilla and jaw. According to the patient’s oral presentation, we asked for a consultation with gastroenterologist, gynecologist and endocrinologist. Finally, based on clinical and paraclinical findings, the clinicians put the final diagnosis of CS. Discussion: According to the review of literature, less than 500 cases have been reported worldwide, many of which have been diagnosed by dental surgeons, or oral pathology and medicine specialists by recognition of mucocutaneous lesions. There is a close association of CS with the development of several malignant neoplasms. This point emphasizes the importance of the early recognition of these lesions, which facilitates an early diagnosis of CS. Oral lesions can be the first sign of the disease, because they develop in 90 to 99% of cases. The diagnosis of CS in this case was made based on criteria proposed by the International Cowden Syndrome Consortium. Conclusion: Since the patients can have a variety of clinical manifestations, the diagnosis can be mistaken and delayed. Therefore, it seems that there is a need for awareness of this entity in the dental community.

Legal Protection for Medical Laboratories Concerning Risk-Based Business Licensing Standards and the Fulfillment of Clinical Pathology Specialist

Medical laboratories play a crucial role in the healthcare system but often face regulatory challenges, particularly in the context of licensing. The amendment to the Ministry of Health Regulation on the Standards of Business Activities and Risk-Based Licensing in the Health Sector, which requires Clinical Pathology Specialists (DSPK) as the responsible physician, replacing general practitioners, has created difficulties for medical laboratory operators. The main issue is the uneven distribution of DSPK across Indonesia, which impacts the operation of medical laboratories. This research aims to analyze the legal protection of medical laboratories concerning the fulfillment of risk-based business licensing standards, particularly regarding the requirement for DSPK. The research employs a normative juridical method by examining relevant laws, government regulations, and judicial decisions. The results indicate that in the formulation of regulation, the legislative rationale must consider philosophical, sociological, and juridical aspects. However, the sociological aspects is not fully addressed due to the uneven distribution of DSPK, rendering the regulation ineffective at the national level. This issue hampers public access to quality laboratory services. Therefore, legal protection is needed to ensure that national health standards are achieved without creating disparities in access to healthcare services across different regions.

OGC SO19 - Management and outcomes for Barrett’s oesophagus with dysplasia in a tertiary centre

Abstract Background Barrett’s oesophagus is a premalignant condition. Development of high-grade dysplasia (HGD) formerly was an indication for oesophagectomy, but endoscopic treatment (ET) is now recommended as first-line therapy: radiofrequency ablation (RFA) or endoscopic mucosal resection (EMR). Oesophagectomy is only considered for cases where ET was unsuccessful. Previous review of our institution’s outcomes between 2014 and 2017 showed a 54% complete EMR excision rate and 20% salvage oesophagectomy (n=25). Since then, RFA has been utilised in our institution. We aimed to review our recent data to assess current outcomes. Method Retrospective analysis was performed of patients identified via registration at the Hull University Hospital Trust oesophagogastric MDT between March 2017 and December 2023. Inclusion criteria was confirmed histology of HGD on 2 occasions by 2 specialist pathologists, 6 weeks apart. EMR was performed for focal oesophageal lesions and non-nodular segments were treated by RFA. Patients were included once they had at least one surveillance endoscopy and 6 months had passed following treatment. Patients who were either unfit for ET and managed medically (n=6), and those who were subsequently proven to have more advanced disease and treated surgically (n=4) were excluded. Results 35 patients were identified: 20 underwent EMR, 15 RFA. 55% of EMR patients had successful excision, 9 required additional RFA for residual low-grade dysplasia (LGD). 66% RFA patients had successful ablation. 3 patients required further EMR for residual LGD. Overall 82% had successful ET with no HGD on surveillance. 5 patients had persistent HGD and 1 T1b disease: 4 underwent oesophagectomy, 2 managed oncologically. Barrett’s tended towards being longer in patients where ET failed to eradicate HGD (median 6cm vs 3cm MWU p=0.07). No patient in the series died because of disease-related pathology. 1 patient developed stricture post-RFA requiring dilatation. Conclusion ET for HGD is effective with a high rate of successful treatment. It can be used as a single or dual modality. Salvage oesophagectomy rates are lower than previously reported (8% vs 20%) and complications are low (3% stricture rate). Longer segment Barrett’s may be less likely be responsive to ET, although not reaching significance in our series. ET should continue to be offered as the first-line treatment for oesophageal HGD.

New model of tele-healthcare for consultation, diagnosis, and treatment of a cicatricial pemphigoid case using mobile phones for communication among the patient, the clinic dentist, and the oral pathology specialist

New model of tele-healthcare for consultation, diagnosis, and treatment of a cicatricial pemphigoid case using mobile phones for communication among the patient, the clinic dentist, and the oral pathology specialist

A decision support system for the detection of cutaneous fungal infections using artificial intelligence

Cutaneous fungal infections are one of the most common skin conditions, hence, the burden of determining fungal elements upon microscopic examination with periodic acid-Schiff (PAS) and Gomori methenamine silver (GMS) stains, is very time consuming. Despite some morphological variability posing challenges to training artificial intelligence (AI)-based solutions, these structures are favored potential targets, enabling the recruitment of promising AI-based technologies. Herein, we present a novel AI solution for identifying skin fungal infections, potentially providing a decision support system for pathologists. Skin biopsies of patients diagnosed with a cutaneous fungal infection at the Sheba Medical Center, Israel between 2014 and 2023, were used. Samples were stained with PAS and GMS and digitized by the Philips IntelliSite scanner. DeePathology® STUDIO fungal elements were annotated and deemed as ground truth data after an overall revision by two specialist pathologists. Subsequently, they were used to create an AI-based solution, which has been further validated in other regions of interests. The study participants were divided into two cohorts. In the first cohort, the overall sensitivity of the algorithm was 0.8, specificity 0.97, F1 score 0.78; in the second, the overall sensitivity of the algorithm was 0.93, specificity 0.99, F1 score 0.95. The results obtained are encouraging as proof of concept for an AI-based fungi detection algorithm. DeePathology® STUDIO can be employed as a decision support system for pathologists when diagnosing a cutaneous fungal infection using PAS and GMS stains, thereby, saving time and money.

The awareness and attitudes of oral disease specialists, pathologists, and maxillofacial surgeons in oral exfoliative cytology in Kerman, Iran

Background: The present work examines the awareness and attitudes of specialists in oral diseases, pathology, and maxillofacial surgery in 2022 regarding oral exfoliative cytology. Methods: This study was an analytical and cross-sectional research. The statistical population of the present study included Iranian oral disease specialists, pathologists, and maxillofacial surgeons. A researcher-made questionnaire was given to the specialists by a senior (final-year) student. The results were analyzed using the chi-square test and t-test using SPSS 18 software. The significance level in data analysis was P<0.05. Results: A total of 192 questionnaires were completed in the study; the study revealed that only 18 participants used the exfoliative cytology technique. Moreover, 62% of people had a positive attitude towards the application and performance of cytology. There was a significant relationship between positive attitude, field of study, graduation year, and age. The mean awareness scores in men and women were 32.38±4.21 and 34.42±3.89, respectively. The participants had a high awareness and positive attitude towards this technique. Additionally, the mean awareness scores of oral specialists, surgeons, and pathologists were 33.12±4.23, 33.65±5.12, and 33.45±5.34, respectively. Conclusion: The study revealed that only 9.4 percent of participants used the exfoliative cytology technique. However, they were highly aware of and had a positive attitude to this technique.

What is requested by the specialist in respiratory pathology

What is requested by the specialist in respiratory pathology

Attitude of Speech-Language Pathology Students and Specialists Toward People Who Stutter: Inter- and Intraregional Comparisons

Attitude of Speech-Language Pathology Students and Specialists Toward People Who Stutter: Inter- and Intraregional Comparisons

P229 Comparison of Different Histological Scoring Systems for Ulcerative Colitis [Nancy Histological Index, Robarts Histopathology Index and IBD-DCA (Inflammatory Bowel Disease-Distribution, Chronicity, Activity Score)] Among Specialists in GI Pathology and General Pathologists Pre- & Post Workshop

Abstract Background Histopathology is an emerging treatment target and an important parameter in predicting clinical outcomes of patients with ulcerative colitis (UC). Histological scoring indices Nancy Histological Index (NHI) and Robarts Histopathology Index (RHI) have been developed and validated for UC. We aim to compare the inter-observer reliability of NHI, RHI and the recently described Inflammatory Bowel Disease-Distribution, Chronicity, Activity (IBD-DCA) Score among gastrointestinal (GI) pathologists versus general pathologists pre- and post-workshop to determine the scoring system with the best reproducibility. Methods Digital whole slide images of 20 H&E-stained biopsies of ulcerative colitis (UC) cases are scored independently by 6 GI pathologists and 44 general pathologists that attended the Singhealth GI Pathology Course 2023 using NHI, RHI and IBD-DCA on the digital Pathpresenter platform. The 44 course participants performed the scoring before the course and again after attending a 3-hour IBD workshop on the assessment of histological remission using these 3 scoring systems. Data tabulation using “Free Online Surveys” platform is collated and intraclass correlation coefficient (ICC) of each component of the scoring indices is calculated. The ICC values of <0.5, 0.5–0.75, 0.75–0.9, and >0.9, indicate ‘poor’, ‘moderate’, ‘good’, and ‘excellent’ agreement, respectively. Results There is good inter-observer reliability for IBD-DCA ‘Activity’ component (ICC 0.85) and NHI (ICC 0.83) among GI pathologists while lBD-DCA ‘Distribution’ component (ICC 0.395) has the poorest agreement. Poor to moderate inter-observer reliability for all 3 scoring systems (ICC 0.4 – 0.6) is seen among the 44 participants pre-workshop with an observed post-workshop improvement, achieving best agreement for the NHI, ‘lamina propria neutrophils’ component of RHI and IBD-DCA ‘activity’ component (ICC 0.7). Conclusion GI pathologists are generally consistent in assessing disease activity in UC with good inter-observer reliability for NHI (a scoring system with an emphasis on activity grade) and only the ‘activity’ component of the IBD-DCA. Our study confirms NHI as a reliable scoring system for UC with the best reproducibility and favour its application to assess histological response in routine clinical practice to help gastroenterologists better manage patients with UC. We have also demonstrated that improvement in NHI scoring reproducibility can be achieved after training workshop for pathologists less familiar with the application of IBD histological scoring.

Perceptions of Students of the Clinical Pathology Specialist Medical Education Program towards the Learning Environment: A Multi Methodology Study

Perceptions of Students of the Clinical Pathology Specialist Medical Education Program towards the Learning Environment: A Multi Methodology Study

Dealing with specialist pathology: an unusual case of ovarian hyperstimulation syndrome managed in the emergency department with point of care ultrasound

Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of assisted reproduction. The hyperstimulated ovaries release vasoactive substances that can increase capillary permeability, resulting in volume shift to the extravascular space and leading to hypovolemia, ascites and, in complicated cases, pleural and pericardial effusions, kidney and liver failure, shock. Point Of Care UltraSound (POCUS) can help the emergency physician to detect many of these complications, as well as guide their treatment. In this case report we present a patient at low risk for OHSS who recently underwent a successful in vitro fertilization, coming to the emergency department with an unusual complication of OHSS (an isolated pleural effusion), that has been safely and promptly diagnosed and treated in the emergency room with the help of POCUS, without any unnecessary exposition to ionizing radiations.

Correlation between the Eosinophil Colonic Mucosa Density and Severity of Ulcerative Colitis

Background: The inflammatory process of ulcerative colitis (UC) involves eosinophils. Eosinophils are not only related to the severity of UC but also to clinical improvement. The role of eosinophils in colonic mucosa has not been fully understood. This study aims to determine the correlation between the density of eosinophils in the colonic mucosa and the severity of ulcerative colitis.Method: This is a prospective cross-sectional study with consecutive sampling between August 2020 and July 2021. The subjects were UC inpatients/outpatients at Dr. Sardjito Hospital who met the inclusion and exclusion criteria. The number and location of the biopsies are determined based on a colonoscopy performed by a Gastroenterology-Hepatology Consultant. An Anatomic Pathology Specialist examined the eosinophil colonic tissue. The severity of UC was classified using the Truelove Witts score. Data analysis using a computer program with a p-value 0.05 was considered statistically significant.Results: There are 3 UC severity categories according to the Truelove Witts score: 22 mild (45.8%), 9 moderate (18.8%), and 17 severe (35.4%). Seven participants (14.6%) had eosinophilia, with a median eosinophilia score of 203.33 cells/microL (0–1470 cells/microL). Five participants (10.4%) with colonic mucosal eosinophilia, with a median value of 14.13 cells/HPF (0–172 cells/HPF). The density of colonic mucosal eosinophils and the severity of UC had a moderate connection (r = 0.396; p = 0.005).Conclusion: There is a significant correlation between the density of eosinophils in the colonic mucosa and the severity of UC.

PredictONCO: a web tool supporting decision-making in precision oncology by extending the bioinformatics predictions with advanced computing and machine learning.

PredictONCO 1.0 is a unique web server that analyzes effects of mutations on proteins frequently altered in various cancer types. The server can assess the impact of mutations on the protein sequential and structural properties and apply a virtual screening to identify potential inhibitors that could be used as a highly individualized therapeutic approach, possibly based on the drug repurposing. PredictONCO integrates predictive algorithms and state-of-the-art computational tools combined with information from established databases. The user interface was carefully designed for the target specialists in precision oncology, molecular pathology, clinical genetics and clinical sciences. The tool summarizes the effect of the mutation on protein stability and function and currently covers 44 common oncological targets. The binding affinities of Food and Drug Administration/ European Medicines Agency -approved drugs with the wild-type and mutant proteins are calculated to facilitate treatment decisions. The reliability of predictions was confirmed against 108 clinically validated mutations. The server provides a fast and compact output, ideal for the often time-sensitive decision-making process in oncology. Three use cases of missense mutations, (i) K22A in cyclin-dependent kinase 4 identified in melanoma, (ii) E1197K mutation in anaplastic lymphoma kinase 4 identified in lung carcinoma and (iii) V765A mutation in epidermal growth factor receptor in a patient with congenital mismatch repair deficiency highlight how the tool can increase levels of confidence regarding the pathogenicity of the variants and identify the most effective inhibitors. The server is available at https://loschmidt.chemi.muni.cz/predictonco.

Further training to become a specialist in pathology in the GDR

Pathology in the GDR was firmly rooted in the tradition of German pathology. Further training imparted sound morphological knowledge. Until the late 1970s, it was primarily autopsy pathology. Scientific relations with the West-with centers where the discipline was developing dynamically-were severely hampered for political reasons; normal conference attendance was reserved for a few selected cadres. The inefficiency of the planned economy led to increasing material bottlenecks. GDR pathology had become a relic by the end of the GDR regime.

Anti-coagulant Treatment of Cancer-Associated Thrombosis in Frail Patients: Impact of Frailties on the Management of Drug-Drug Interactions.

Low molecular weight heparins (LMWH) and anti-Xa direct oral anti-coagulants (DOACs) are recommended for the long-term treatment of cancer-associated thrombosis (CAT) based on well-documented randomised controlled trials. Anti-Xa DOACs are viewed as a first choice for the treatment of patients with CAT. A large number of drug-drug interactions have been reported between DOACs and chemotherapy drugs, modifying circulating levels of DOAC leading to fears of increased bleeding risks or thrombotic recurrence. Progresses in anti-neoplastic therapies have improved the prognosis and the survival, thus increasing the prevalence of frail patients with cancer. However, since frailties tend to be excluded from large trials due to multiple co-morbidities, current guidelines are not fully applicable to this population. The management of these frail patients with CAT is particularly complex and requires a risk assessment on a case-by-case basis with specific focus on cancer, patient-related risk factors and drug-drug interactions. In this brief review we have identified age, co-morbidities and co-medications as key factors of frailty that require careful attention and we have developed a therapeutic decision algorithm to help clinicians optimising the use of anti-coagulants in patients with cancer with CAT, especially in case of anti-Xa DOACs concomitant medications. With the evaluation of the bleeding risk according to the type of cancer, and anticipating drug-drug interactions intensity, taking into account patient frailties allows the optimisation of the anti-coagulant choice. A systematic collaboration between oncologists, vascular pathology specialists and pharmacists is warranted to ensure an optimal patient management. Clinical studies are needed to determine the real impact of these interactions.

A-165 Test Harmonisation Is a Key Enabler of Pathology Transformation

Abstract Background In April 2021 a new joint venture was formed to deliver and transform services across South East London. Two large NHS Foundation Trusts (Guy’s and St Thomas’, and King’s College hospitals) partnered with SYNLAB who are specialist pathology providers, bringing extensive global experience and expertise in setting up, transforming and running diagnostic services. The Trusts had been working in partnership for many years but were operating in numerous areas as two separate entities. There was duplication of services and tests, with different analytical platforms and very different ways of working, which led to variations in resulting and reporting. Our aim was to establish a single consolidated service, with a harmonised test catalogue, facilitating the provision of consistent results regardless of the origin of sample, and to have a single governance framework to drive improved accountability and optimisation of resources. Our view was that test harmonisation was essential to enable the deployment of a common core Laboratory Information Management System (LIMS) from the 24 legacy systems, and that the harmonisation process should be clinically led. Method We established forums (through a series of workshops) for comprehensive engagement and dialogue to allow key clinical leads from all services to meet and agree the path forward. After extensive collaborative engagement, a new model was created with a single “Strategic Clinical Lead” with pan-site responsibility appointed for each service from the existing senior clinical staff. The Strategic Clinical Lead works with their colleagues to drive consensus, seeking wide stakeholder engagement from end service users as required. Results From an initial repertoire of circa 7100 tests, test harmonisation has resulted in a 25% reduction, and in some services such as Virology, we identified 31% duplication in tests. The establishment of the new clinical model has resulted in improved efficiency and better use of resources including staffing as well as a reduction of variation of services. Importantly, test harmonisation is essential to move samples seamlessly in a hub and spoke model. The implementation of a single common core LIMS this year will significantly improve business continuity by facilitating seamless transfer of work between sites. Conclusion Extensive clinical engagement is key to transforming pathology services. The benefits of consolidation include an overall reduction in process variation leading to improved standardisation and therefore enhanced patient safety as a result of consistency in result reporting. We established a framework and new clinical model which has resulted in improved links between staff across all sites who are working collaboratively on the new target operating model (hub and spokes) which will be live in April 2024.

The value of a specialized second-opinion pathological diagnosis for oral and maxillofacial lesions

ObjectivesAn error in the diagnosis of an oral or maxillofacial lesion could potentially be detrimental to a patient’s prognosis and management. Major discrepancies between the initial and subsequent diagnoses of head and neck pathologies range from 7 to 53%. This study determined the rate of discrepancies found in the diagnoses of oral and maxillofacial lesions after a second opinion in Saudi Arabia.MethodsA retrospective single-center study was conducted by oral and maxillofacial pathology consultants to review all cases referred for a second opinion to the oral and maxillofacial pathology laboratory between January 2015 and December 2020. If the second-opinion diagnosis matched the original diagnosis, this was described as “agreement.” If the second-opinion diagnosis did not match the original diagnosis but would not change the management or prognosis of a patient, this was classified as a “minor disagreement.” If the second-opinion diagnosis resulted in the changing of a patient’s management or prognosis, this was categorized as a “major disagreement.” Chi-square test and Fisher’s exact test were used to compare data between original and second-opinion diagnoses. A p-value of less than 0.05 was considered significant.ResultsOf 138 cases, 59 (43%) had an initial diagnosis and a second-opinion diagnosis that were in major disagreement. The most common tumor for which there was a major disagreement was squamous cell carcinoma. No single factor influenced the occurrence of major disagreements.ConclusionsOur evaluation reiterates the importance of obtaining a second opinion from a specialist in oral and maxillofacial pathology to improve the diagnostic accuracy for lesions. A formal system for this step, in addition to the obtaining of adequate clinical and radiographic information about a patient, is mandatory for the review of difficult cases.

P16 expression as a diagnostic parameter of endometrial carcinoma and endometrial hyperplasia

Background: Endometrial cancer is malignant epithelial neoplasm originating from endometrium; endometrial cancer is the sixth most common cancer in women and the fifteenth most common cancer worldwide. The aim of study is to evaluate the expression of P16 IHC in endometrial carcinoma; and its diagnostic role in different histopathological types of endometrial carcinoma. Method: Retrospective study of 70 cases with collection of paraffin embedded tissue blocks and clinical data of patients with endometrial carcinoma and endometrial hyperplasia. H&E staining of slides done to confirm the histopathological diagnosis by specialist pathologist and then stained immunohistochemically for P16 marker. Results: In the current study, the average age of women was 32 to 78 years with a mean age of 53.42. More than half of the women with endometrial carcinoma (EC) (66.6%) presented in the age group between 50 and 70 years, half of the patients with atypical hyperplasia (50%) fall in the same age group as endometrial carcinoma, and the rest of the atypical hyperplasia patients and 65% of those without atypia presented in younger ages (30-50 years’ age group). (63.3%) of patients with endometrial cancer had postmenopausal bleeding; 70% of patients with atypical endometrial hyperplasia and 75% of those without atypia had excessive monthly bleeding (HMB). Histopathology correlated with patient age and clinical presentation. P16 immune marker expression did not correlate with stage at diagnosis of endometrial cancer in TAH & BSO instances. All endometrial serous carcinoma and more than half of EEC had positive p16 IHC. Endometrial hyperplasia had no P16 IHC expression, although more than half of endometrial cancer cases did. Conclusion: All endometrial serous carcinomas expressed high P16 IHC stain. More than half of endometrioid carcinomas had p16 IHC stain, with significant expression in high-grade morphological sections (FIGO 3). Most low-grade endometrioid carcinomas are P16-negative. P16 loss in all endometrial hyperplasia. P16 immunohistochemistry marker aids endometrial carcinoma diagnosis.

EVALUATION OF ENDOMETRIAL Bcl-2 EXPRESSION AND Ki-67 PROLIFERATIVE INDEX IN INFERTILE PATIENTS WITH AND WITHOUT POLYCYSTIC OVARY SYNDROME

Objective: In women of reproductive age, polycystic ovary syndrome (PCOS) is the most prevalent cause of infertility. The purpose of this study is to compare the Bcl-2 and Ki-67 values between infertile patients with and without PCOS.
 Material and methods: The study included twenty-seven infertile patients diagnosed with PCOS and another twenty-eight infertile patients who did not meet the criteria for PCOS. Smoking, pelvic infection symptoms, endometrial polyps and submucosal myomas during a transvaginal ultrasound, pituitary insufficiency, hyperprolactinemia, congenital adrenal hyperplasia, having had adnexal surgery and having a male factor that will result in infertility are all considered exclusion criteria. All patients' data were collected, including age, the length of their infertility, body mass index (BMI), waist-to-hip ratio (WHR), hirsutism score, blood pressure, total testosterone, triglyceride, total cholesterol, LDL, and HDL values, as well as Homa-IR and Hs-CRP readings. The pathology specialist in the examples evaluated Bcl-2 and Ki-67 levels.
 Results: We found that BMI, WHR, total testosterone level, blood pressure, total cholesterol, HOMA-IR, and hs-CRP values were significantly higher in infertile cases with PCOS. We also found that the Ki-67 and Bcl-2 values were higher in endometrial cells in sterile PCOS cases than in the control group. 
 Conclusions: Ki-67 and Bcl-2 levels rise in PCOS patients, preventing apoptosis, limiting the formation of a suitable endometrial environment, and preventing embryo implantation. PCOS patients may frequently experience infertility and recurrent pregnancy losses. The cause of this problem may be the increased activity of estrogen. The primary treatment for PCOS will depend on further investigation into the variables affecting estrogen synthesis and GnRH release. The care plan should be built around this goal.

Sudden arrhythmic death and cardiomyopathy are important causes of sudden cardiac death in the UK: results from a national coronial autopsy database.

Sudden cardiac death (SCD) is defined as natural unexpected death in witnessed cases occurring < 1h and in unwitnessed cases as last seen alive < 24h. SCD due to ischaemic heart disease (IHD) is frequent in older age groups; in younger people genetic cardiac causes, including channelopathies and cardiomyopathies, are more frequent. This study aimed to present the causes of SCD from a large specialist pathology registry. Cases were examined macroscopically and microscopically by two expert cardiac pathologists. The hearts from 7214 SCD cases were examined between 1994 and 2021. Sudden arrhythmic death syndrome (SADS), a morphologically normal heart, which can be underlaid by cardiac channelopathies, is most common (3821, 53%) followed by the cardiomyopathies (1558, 22%), then IHD (670, 9%), valve disease (225, 3%), congenital heart disease (213, 3%) and myocarditis/sarcoidosis (206, 3%). Hypertensive heart disease (185, 3%), aortic disease (129, 2%), vascular disease (97, 1%) and conduction disease (40, 1%) occur in smaller proportions. To our knowledge, this is the largest SCD cohort with autopsy findings ever reported from one country. SADS and cardiomyopathies predominate. This study highlights the importance of the autopsy in SCD, which is a significant public health concern in all age groups. Knowing the true incidence in our population will improve risk stratification and develop preventative strategies for family members. There is now a national pilot study integrating molecular autopsy and family screening into the assessment of SCD victims.