Autopsy Services and Emergency Preparedness of a Tertiary Academic Hospital Mortuary for the COVID-19 Public Health Emergency: The Yale Plan.

Pathology Autopsy and Mortuary Services have been front and center in the severe acute respiratory syndrome coronavirus 2 (SARS-Co-V-2) pandemic. The sheer number of fatalities from the pandemic have been unlike any other in recent memory and needed the rapid creation of new protocols and paradigms to manage the situation. This required rapidly escalating mortuary capacity to manage the increased fatalities from the pandemic with the establishment of lines of communication and networking with governmental entities, institution of new policies for patient flow, and implementation of worker infection control and well-being plans. Autopsies also assumed a crucial role, both to provide insight into the pathomechanisms of a novel disease and to allow tissue retrieval necessary to power research directed towards finding a vaccine. We here outline the plan adopted by the Yale Autopsy and Mortuary Services, in alignment with the institutional mission of high-quality patient care, education, research and health care worker safety and well-being, as the Corona Virus Disease of 2019 (COVID-19) pandemic surged in Connecticut. In the early response phase, ensuring sufficient mortuary capacity necessarily took center stage. As we enter the recovery and plateau phase of the pandemic, setting up a process for a rapid and safe autopsy, that will meet educational and research needs while ensuring the safety of our workforce is being implemented.

COVID-19: Postmortem Diagnostic and Biosafety Considerations.

As a result of the 2019 novel human coronavirus (COVID-19) global spread, medical examiner/coroner offices will inevitably encounter increased numbers of COVID-19-infected decedents at autopsy. While in some cases a history of fever and/or respiratory distress (eg, cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with COVID-19 develop mild to no symptoms. Those dying with-but not of-COVID-19 may still be infectious, however. While multiple guidelines have been issued regarding autopsy protocol in cases of suspected COVID-19 deaths, there is some variability in the recommendations. Additionally, limited recommendations to date have been issued regarding scene investigative protocol, and there is a paucity of publications characterizing COVID-19 postmortem gross and histologic findings. A case of sudden unexpected death due to COVID-19 is presented as a means of illustrating common autopsy findings, as well as diagnostic and biosafety considerations. We also review and summarize the current COVID-19 literature in an effort to provide practical evidence-based biosafety guidance for medical examiner-coroner offices encountering COVID-19 at autopsy.

Workplace safety concerns in medico-legal death investigations related to COVID-19.

The personnel involved in the management of COVID-19 affected dead bodies, including law enforcement personnel at the scene of crime, personnel involved in transportation of the dead bodies, forensic practitioners, autopsy pathologists, mortuary personnel, as well as the family members of the dead, etc. are at risk of exposure to SARS-CoV-2 infection. Post-mortem examination is a high-risk procedure, considering that it involves aerosol generating procedures, and exposure to body fluids. The safety of the forensic practitioners and support staff in the management of suspected or confirmed COVID-19 deaths hence, is of extreme importance, especially in the absence of pre-autopsy testing for COVID-19 and due to non-availability of adequate first-hand medical history of the deceased. This communication aims to highlight the current practices and advises certain guidelines in ensuring occupational health and safety in view of these risks in medico-legal death investigations.

Nursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes.

OBJECTIVE: to develop a protocol of recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes. METHOD: a study of experts' recommendations using a structured form applied through the Delphi Technique, obtaining 100% agreement among professionals after four rounds of analysis. The population comprised six nurses members of the Scientific Department of Gerontological Nursing of the Brazilian Association of Nursing (Associação Brasileira de Enfermagem). RESULTS: the protocol was structured in a nucleus of nursing interventions to face the spread of COVID-19 in Nursing Homes, consisting of 8 actions. FINAL CONSIDERATIONS: the protocol can help nurse managers to organize assistance to face the pandemic, which can be adaptable to each reality, making training nurses and health teams easier.

Review: The safe handling of a corpse (suspected) with COVID-19.

INTRODUCTION: Countries around the world are confronted with a rising count of patients that die from COVID-19. Up to this date, there is no scientific evidence that proves that a COVID-19 corpse is still infectious. Different guidelines are being followed worldwide on how to deal with a COVID-19 positive corpse. The aim of this review is to compare different guidelines and literature on best practice for handling a COVID-19 positive corpse. RESULTS: The guidelines vary greatly in the use of PPE's and other safety measures especially during autopsy. There is great variation in the use of disinfectant and its concentration. Also recommended funeral services and contact with relatives vary greatly. CONCLUSION: In conclusion, there is very limited scientific evidence on which the researched guidelines are based. It is unclear why some guidelines propose a "business as usual" attitude and others a "code-red" attitude. More scientific evidence is needed to substantiate the handling of COVID-19 positive corpses to make an educated decision on how to safely handle a COVID-19 positive corpse.

Information on practical procedures following death.

This article outlines the procedures following a death and examines funeral arrangements, including the different types of burial and the cremation process.

[Comparative normative on sanitary practices of cadaveric preservation in Spain]. / Normativa comparada sobre prácticas sanitarias de conservación cadavérica en Españ.

In this paper the current regulations on cadaveric preservation practices required for the transfer of corpses in the different Autonomous Communities -Reglamentos de Policía Sanitaria Mortuoria- and national legislation are compared. The criteria taken into account have been: a) which sanitary practices are included in the regulations, b) which ones can be carried out in corpses posing a health risk, c) when they are compulsory to be carried out, d) when they can be carried out after death, and e) what professionals can carry them out and/or take responsibility for them. At the time of finishing the paper, a new mortuary regulation is being passed in Andalusia, as well as a decree from the Ministry of Health on technical and sanitary requirements concerning international transfer of corpses and human remains.

Se comparan las normativas vigentes sobre prácticas sanitarias de conservación cadavérica requeridas para el traslado de cadáveres, en las diferentes Comunidades autónomas y la legislación estatal. Los criterios tenidos en cuenta han sido: qué prácticas sanitarias se incluyen en la normativa, cuáles pueden llevarse a cabo en cadáveres de riesgo sanitario, cuándo se requiere su realización, en qué momento tras el fallecimiento pueden realizarse y qué profesionales las pueden llevarlas a cabo y/o responsabilizarse de las mismas. En el momento de finalizar el artículo se está tramitando la publicación del nuevo decreto de sanidad mortuoria de Andalucía, así mismo se está elaborando, por parte del Ministerio de Sanidad, Consumo y Bienestar Social, un Real Decreto sobre "Condiciones técnico sanitarias básicas en materia de traslado internacional de cadáveres, restos humanos y restos cadavéricos".

Guidelines for handling radioactively contaminated decedents.

The Centers for Disease Control and Prevention recently issued guidelines for medical examiners, coroners, and morticians in dealing with decedents after detonation of an improvised nuclear device (IND) or radiological dispersal device (RDD) (). Partners in this effort included the New York City Office of Chief Medical Examiner and the National Funeral Directors' Association. This paper describes the handling techniques required for loose surface contamination, radioactive shrapnel, and internal contamination caused by inhaling or ingesting radioactive materials from an IND or RDD, and provides suggested guidelines for medical examiners, coroners, and morticians to deal with these situations.

Mummies.

Mummies are human remains with preservation of nonbony tissue. Mummification by natural influences results in so-called natural mummies, whereas mummification induced by active (human) intervention results in so-called artificial mummies, although many cultures practiced burial rites, which to some degree involved both natural and artificial mummification. Since they are so uniquely well-preserved, mummies may give many insights into mortuary practices and burial rites. Specifically, the presence of soft tissues may expand the scope of paleopathological studies. Many recent mummy studies focus on the development and application of nondestructive methods for examining mummies, including radiography, CT-scanning with advanced three-dimensional visualizations, and endoscopic techniques, as well as minimally-destructive chemical, physical, and biological methods for, e.g., stable isotopes, trace metals, and DNA. This article discusses mummification and gives a presentation of various key mummy finds and a brief history of mummy studies. A description of the extant key technologies of natural and medical science that are applied in mummy studies is given; along with a discussion of some of the major results in terms of paleopathology. It is also shown how mummy studies have contributed much to the knowledge of the cultural habits and everyday life of past populations. Finally the impact of mummy studies on analyses of mortuary practices and cultural history is discussed.

Identification of the earliest collagen- and plant-based coatings from Neolithic artefacts (Nahal Hemar cave, Israel).

Mortuary practices in human evolution record cognitive, social changes and technological innovations. The Neolithic Revolution in the Levant was a watershed in this domain that has long fascinated the archaeological community. Plaster modelled skulls are well known at Jericho and several other Neolithic sites, and in Nahal Hemar cave (Israel, ca. 8200 -7300 cal. BC) excavations yielded six unique human skulls covered with a black organic coating applied in a net pattern evoking a headdress. This small cave was used as storage for paraphernalia in the semi-arid area of the Judean desert and the dry conditions preserved other artefacts such as baskets coated with a similar dark substance. While previous analysis had revealed the presence of amino acids consistent with a collagen signature, in the present report, specific biomarkers were characterised using combined proteomic and lipid approaches. Basket samples yielded collagen and blood proteins of bovine origin (Bos genus) and a large sequence coverage of a plant protein charybdin (Charybdis genus). The skull residue samples were dominated by benzoate and cinnamate derivatives and triterpenes consistent with a styrax-type resin (Styrax officinalis), thus providing the earliest known evidence of an odoriferous plant resin used in combination with an animal product.

A migrating pacemaker.

A deceased 79 year old man with a permanent cardiac pacemaker was due to be cremated, but the pacemaker generator was not detectable by palpation. A hand held metal detector to locate the device so that it could be extracted before cremation.

Collective secondary cremation in a pit grave: a unique funerary context in Portuguese Chalcolithic burial practices.

Perdigões is a large site with a set of ditched enclosures located at Reguengos de Monsaraz, Alentejo, South Portugal. Recently at the central area of this site burnt human remains were found in a pit (#16). This structure had inside human remains, animal bones (namely pig, sheep or goat, cattle, dog, deer and rabbit), shards, ivory idols and arrowheads. All have been subjected to fire and later deposited in that pit, resulting in a secondary disposal of human bones. The recovered fragmented human bones (4845.18 g) correspond to a minimal number of 9 individuals: 6 adults and 3 sub-adults. The aim of this work is to document and interpret this funerary context based on the study of the recovered human remains. For that purpose, observations of all alterations due to fire, such as colour change and type of bone distortion, as well as anthropological data were collected. The data obtained suggest that these human remains were probably intentionally cremated, carefully collected and finally deposited in this pit. The cremation was conducted on probably complete corpses, some of them still fairly fresh and fleshed, as some bones presented thumbnail fractures. The collective cremation of the pit 16 represents an unprecedented funerary context for Portuguese, and Iberian Peninsula, Chalcolithic burial practices. Moreover, it is an example of the increasing diversity of mortuary practices of Chalcolithic human populations described in present Portuguese territory, as well as, in the Iberian Peninsula.

Stress and resilience in military mortuary workers: care of the dead from battlefield to home.

The death of a military service member in war provokes feelings of distress and pride in mortuary workers who process the remains. To further understand their reactions, the authors interviewed 34 military and civilian personnel to learn more about their work stresses and rewards. They review stresses of anticipation, exposure, and experience in handling the dead and explore the personal, supervisory, and leadership strategies to reduce negative effects and promote personal growth. These results can be applied to many other situations requiring planning, implementing, and supervising mortuary operations involving mass death.

Nursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes / Recomendaciones para abordar la propagación de COVID-19 en Hogares para Ancianos / Recomendações para o enfrentamento da disseminação da COVID-19 em Instituições de Longa Permanência para Idosos

ABSTRACT Objective: to develop a protocol of recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes. Method: a study of experts' recommendations using a structured form applied through the Delphi Technique, obtaining 100% agreement among professionals after four rounds of analysis. The population comprised six nurses members of the Scientific Department of Gerontological Nursing of the Brazilian Association of Nursing (Associação Brasileira de Enfermagem) Results: the protocol was structured in a nucleus of nursing interventions to face the spread of COVID-19 in Nursing Homes, consisting of 8 actions. Final considerations: the protocol can help nurse managers to organize assistance to face the pandemic, which can be adaptable to each reality, making training nurses and health teams easier.

RESUMEN Objetivo: desarrollar un protocolo de recomendaciones para abordar la propagación de COVID-19 en hogares para ancianos. Método: estudio de recomendaciones de expertos utilizando una forma estructurada aplicada utilizando la técnica Delphi, obteniendo un 100% de acuerdo entre profesionales después de cuatro rondas de análisis. La población estaba compuesta por seis enfermeras que son miembros del departamento científico de enfermería gerontológica de la Asociación Brasileña de Enfermería (Associação Brasileira de Enfermagem). Resultados: el protocolo se estructuró en un núcleo de intervenciones de enfermería para enfrentar la difusión de COVID-19 en Hogares para Ancianos y consta de 8 acciones. Consideraciones finales: el protocolo puede ayudar a los gerentes de enfermería a organizar la asistencia para enfrentar la pandemia, que puede adaptarse a cada realidad, facilitando la capacitación de los equipos de enfermería y salud.

RESUMO Objetivo: elaborar um protocolo de recomendações para o enfrentamento da disseminação da COVID-19 em Instituições de Longa Permanência para Idosos. Método: estudo de recomendações de especialistas utilizando-se um formulário estruturado aplicado por meio da Técnica Delphi, obtendo-se 100% de concordância entre os profissionais após quatro rodadas de análise. A população foi constituída por seis enfermeiros membros do Departamento Científico de Enfermagem Gerontológica da Associação Brasileira de Enfermagem. Resultados: o protocolo foi estruturado em um núcleo de intervenções de enfermagem para o enfrentamento da disseminação da COVID-19 em Instituições de Longa Permanência para Idosos, consistindo em 8 ações. Considerações finais: o protocolo poderá auxiliar os enfermeiros gestores a organizar a assistência para enfrentar a pandemia, que pode ser adaptável a cada realidade, facilitando o treinamento das equipes de enfermagem e saúde.

Forensic archaeology as mortuary anthropology.

This paper argues that forensic anthropology is more than just physical anthropology, but should incorporate several subdisciplinary perspectives into a framework of mortuary anthropology. The advantage of this holistic approach is to provide context for the primary roles of physical anthropologists; identification of victims, and assessing manner of death. Mortuary anthropology provides information on processes of disposal and site formation, including the regularity, sequencing, and timing of events, which is complementary to the traditional roles of physical anthropologists. A call is made for more widespread application of this perspective.

PCDDs/DFs emissions from crematories in Japan.

Concentrations of PCDDs and PCDFs in emission gases from 10 crematories were measured. The relationship between PCDDs/DFs and several factors such as structure, equipment and operational state of the crematory is discussed. Furthermore, emission of PCDDs/DFs from all crematories in Japan is estimated. The following results are obtained: (1) total concentration of PCDDs/DFs was 2.2-290 ng/N m3, whose TEQ concentration was 0.0099-6.5 ng TEQ/N m3; (2) total concentration of PCDFs was higher than that of PCDDs; (3) T4CDFs was the highest in the homologue pattern and 2,3,7,8-T4CDF was the highest in the isomer pattern; (4) emission of PCDDs/DFs was the largest in the first 20 min of cremation; (5) concentration of PCDDs/DFs was related to the existence of a secondary combustion chamber and a dust collector, and the ratio of the numbers of main and secondary combustion chambers; (6) total emission of PCDDs/DFs from crematories in Japan was estimated to be 8.9 g TEQ/yr.

Stigma and rejection: living with AIDS in villages in southern Thailand.

The problems that face HIV/AIDS patients are now fairly well documented. These include experiences of guilt, anger, grief, fear of abandonment, and potential economic hardship and marginalization due to others' fear of infection and associated stigma. However, limited attention has been paid to the effects of AIDS-related stigma on access to, and the provision of, health services. Understanding how the stigma of AIDS affects the processes and experiences of diagnosis, treatment, prevention, and care is critical to effective public health policy and the delivery of health care programs and medical services. In this article, we examine stigma as experienced by people with HIV and AIDS, and by their families, in village Thailand. We also identify areas for improvement pertaining to people with HIV/AIDS and other stigmatizing diseases.

Post-cremation taphonomy and artifact preservation.

Contemporary commercial cremation is a reductive taphonomic process that represents one of the most extreme examples of postmortem human alteration of bone. The thorough reduction and fragmentation of cremated human remains often leaves little biological evidence of diagnostic value. Instead, non-osseous artifacts often provide the best evidence of the origin of the cremated remains, the identity of the decedent, and commingling of the remains of more than one individual. Once human remains have been cremated they are most commonly placed into a processor and reduced into small fragments and fine ash suitable for inurnment or scattering. The type of processor determines the size and utility of the particulates and artifacts available for analysis. The newest type of processors have changed the manner and degree of postmortem bone modification and altered the preservation of diagnostic bone fragments and cremation artifacts. This paper addresses the impact of the newest cremation procedures on forensic analysis of cremated remains.

The anthropometry of contemporary commercial cremation.

This study establishes baseline parameters and examines those variables thought to influence cremains weights. Data were collected during the cremation of 100 individuals. A series of measurements was taken to determine relative skeletal robusticity. The weight, stature, sex, and age of each cadaver was recorded prior to cremation. The average cremains weight for the fully developed adults (n = 91) was 2430 g and ranged from 876 g to 3784 g. Male and female means were separated by 1053 g, but there was considerable overlap in the distribution. All cremains weights above 2750 g were male and all cremains weights below 1887 g were female. Five amputees and one long bone donor produced cremains weights below the means for their respective groups, reflecting the relative contribution of the thick cortical bone of the limbs to total skeletal weight, and thus to total cremains weight. Cremains weight represented approximately 3.5% of total body weight in adults, 2.5% of total body weight in children, and approximately 1% of total body weight in fetuses. The most accurate predictor of cremains weight was cadaver stature (r = .8473; p < .01). Calculated skeletal weight was also highly correlated with cremains weight (r = .7986; p < .01). Cadaveric weight was least correlated with cremains weight (r = .5470; p < .01). Regression formulae were calculated for each of the variables.