COVID-19 in the autopsy room-requirements, safety, recommendations and pathological findings.

Modern technologies enable the exchange of information about the expansion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the continually increasing number of the coronavirus disease 2019 (COVID-19) cases almost in real time. The gravity of a current epidemiological situation is represented by the mortality rates, which are scrupulously updated daily. Performing autopsies on patients with either suspected or confirmed COVID-19 is of high importance since these might not only improve clinical management but also reduce the risk of SARS-CoV-2 infection expansion. The following paper aimed to present the most crucial aspects of SARS-CoV-2 infection from the point of view of forensic experts and pathologists, recommendations and safety precautions regarding autopsies, autopsy room requirements, possible techniques, examinations used for effective viral detection, recommendations regarding burials, and gross and microscopic pathological findings of the deceased who died due to SARS-CoV-2 infection. Autopsies remain the gold standard for determining the cause of death. Therefore, it would be beneficial to perform autopsies on patients with both suspected and confirmed COVID-19, especially those with coexisting comorbidities.

Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs.

The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."

Research Progress and Forensic Identification of Alcoholic Cardiomyopathy.

ABSTRACT: With the rapid development of the social economy in China, the incidence of diseases caused by excessive drinking is gradually increasing as well. Alcoholic cardiomyopathy refers to long-term high intake of ethanol, and has typical dilated cardiomyopathy characteristics, such as, hemodynamic changes, symptoms, signs, and morphological features. It is a kind of cardiomyopathy that excludes other causes of dilated cardiomyopathy. Due to the lack of specific pathological changes, the forensic pathological identification of alcoholic cardiomyopathy can only be based on the patient's medical history and by ruling out other causes of cardiomyopathy. This paper reviews the pathogenesis and forensic identification of alcoholic cardiomyopathy in order to provide reference for forensic pathologists and clinicians.

Evaluation of a Novel and Standardized Technique for Subcutaneous Upper Limb Dissection.

It is often necessary to dissect the subcutaneous tissues to confirm or exclude the presence of cutaneous bruising. We undertook a literature search that demonstrated that there is currently no standardized technique for subcutaneous dissection, and the specific incisions and dissections used probably vary between individual pathologists. It is our experience that dissections wider than the area of cutaneous bruising visible externally often reveal bruises not identified on external inspection. We propose a standardized technique for subcutaneous dissection of the upper limb that allows direct inspection of the subcutaneous tissues of the forearm and dorsum of the hand. We have evaluated this technique by comparing the number of bruises detected on external inspection with the number of bruises verified by subcutaneous dissection. Our study has shown a significant increase in the detection of bruises on subcutaneous dissection when compared with external inspection alone. One hundred sixteen forensic autopsies in which the technique was performed were included in our series. We recorded bruises seen on external examination alone and compared the number with additional bruises that were discovered on dissecting the upper limbs. In 49 cases (42%), the technique uncovered additional bruises that were missed on external examination alone.

Autopsy histopathology where the prosector is not a histopathologist: a proposal.

Forensic pathology is a specialty that involves death investigation while clinical forensic medicine is the application of the practice of medicine to the requests of the law in relation to the living. Around the world, there is diverse practice for these two disciplines. The forensic physician or forensic doctor (sometimes, called a forensic pathologist but not a forensic histopathologist) in parts of the world such as continental Europe, the Middle East and India, practice both clinical forensic medicine and forensic pathology. This is the specialty, for the purposes of this paper, we will call forensic medicine. The forensic doctor will usually receive training in autopsy dissection, perhaps with a short training of a few months in anatomical pathology or surgical histopathology. When undertaking autopsies (involving internal as well as external examination), if it is thought histological assessment is required, the forensic doctor will sample the organs and tissues required and refer the specimens to the hospital histopathologist for microscopic examination. This division of responsibility could compromise the quality of the autopsy unless handled correctly.Where the histological assessment of the autopsy specimen is undertaken by a pathologist other than the one who dissected the body and collected the samples, standard operating procedures need to be developed to minimize the risk to the overall quality of the autopsy. We are not aware that any such procedures have been published, hence we offer an outline of what a set of such procedures might contain.

Postmortem Body and Organ Measurements in Neonates and Infants: A Review of Reference Resources Used by Ontario Pathologists (Part 1).

It is common practice in pediatric autopsies to compare the body and organ measurements of the deceased child against the existing reference data. Although a number of resources are available, many are outdated and have significant limitations. The goal of this study was to assess the reference sources currently used by the Ontario pathologists in pediatric autopsies. A survey of 14 Ontario pathologists, who do coroners' pediatric autopsies, identified 20 publications commonly referenced for body and organ measurements. Of all the cited sources, only a few had all the features regarded by the pathologists as ideal for a reference source. These features included accessibility to the source, large sample size, defined control populations, statistical analyses, and sex distinctions. The results of this study will be used to guide the development of a new reference, based on Ontario data, that will enhance measurement standards in pediatric autopsy practice.

A Standardized Classification for Subdural Hematomas- I.

Subdural hematomas are a frequent and highly heterogeneous traumatic disorder, with significant clinical and socioeconomic consequences. In clinical and medicolegal practice, subdural hematomas are classified according to its apparent age, which significantly influences its intrinsic pathogenic behavior, forensic implications, clinical management, and outcome. Although practical, this empirical classification is somewhat arbitrary and scarcely informative, considering the remarkable heterogeneity of this entity. The current research project aims at implementing a comprehensive multifactorial classification of subdural hematomas, allowing a more standardized and coherent assessment and management of this condition. This new method of classification of subdural hematomas takes into account its intrinsic and extrinsic features, using imaging data and histopathological elements, to provide an easily apprehensible and intuitive nomenclature. The proposed classification unifies and organizes all relevant details concerning subdural hematomas, hopefully improving surgical care and forensic systematization.

[The development of nomenclature of complex medical services on specialty «pathologic anatomy¼].

The article presents definitions of concepts and analysis of classification schemes of medical services of specialty «pathologic anatomy" for last decade and directions of their development. The listing of services of such kind is to include both intravital and postmortem pathomorphologic analyses and organizational legal activity related to control and expertise of quality of medical care on the basis of collegiate clinicalpathologicoanatomic comparisons. It is appropriate to distinguish among pathologicoanatomic services the primary and secondary analyses with their reflection in statistical reports of institutions/subdivisions ofpathologicoanatomic service.

How to optimise the yield of forensic and clinical post-mortem microbiology with an adequate sampling: a proposal for standardisation.

Post-mortem microbiology (PMM) is an important tool in forensic pathology, helping to determine the cause and manner of death, especially in difficult scenarios such as sudden unexpected death (SD). Currently, there is a lack of standardization of PMM sampling throughout Europe. We present recommendations elaborated by a panel of European experts aimed to standardize microbiological sampling in the most frequent forensic and clinical post-mortem situations. A network of forensic microbiologists, pathologists and physicians from Spain, England, Belgium, Italy and Turkey shaped a flexible protocol providing minimal requirements for PMM sampling at four practical scenarios: SD, bioterrorism, tissue and cell transplantation (TCT) and paleomicrobiology. Biosafety recommendations were also included. SD was categorized into four subgroups according to the age of the deceased and circumstances at autopsy: (1) included SD in infancy and childhood (0-16 years); (2) corresponded to SD in the young (17-35 years); (3) comprised SD at any age with clinical symptoms; and (4) included traumatic/iatrogenic SD. For each subgroup, a minimum set of samples and general recommendations for microbiological analyses were established. Sampling recommendations for main bioterrorism scenarios were provided. In the TCT setting, the Belgian sampling protocol was presented as an example. Finally, regarding paleomicrobiology, the sampling selection for different types of human remains was reviewed. This proposal for standardization in the sampling constitutes the first step towards a consensus in PMM procedures. In addition, the protocol flexibility to adapt the sampling to the clinical scenario and specific forensic findings adds a cost-benefit value.

European Council of Legal Medicine (ECLM) accreditation of forensic pathology services in Europe.

Forensic experts play a major role in the legal process as they offer professional expert opinion and evidence within the criminal justice system adjudicating on the innocence or alleged guilt of an accused person. In this respect, medico-legal examination is an essential part of the investigation process, determining in a scientific way the cause(s) and manner of unexpected and/or unnatural death or bringing clinical evidence in case of physical, psychological, or sexual abuse in living people. From a legal perspective, these types of investigation must meet international standards, i.e., it should be independent, effective, and prompt. Ideally, the investigations should be conducted by board-certified experts in forensic medicine, endowed with a solid experience in this field, without any hierarchical relationship with the prosecuting authorities and having access to appropriate facilities in order to provide forensic reports of high quality. In this respect, there is a need for any private or public national or international authority including non-governmental organizations seeking experts qualified in forensic medicine to have at disposal a list of specialists working in accordance with high standards of professional performance within forensic pathology services that have been successfully submitted to an official accreditation/certification process using valid and acceptable criteria. To reach this goal, the National Association of Medical Examiners (NAME) has elaborated an accreditation/certification checklist which should be served as decision-making support to assist inspectors appointed to evaluate applicants. In the same spirit than NAME Accreditation Standards, European Council of Legal Medicine (ECLM) board decided to set up an ad hoc working group with the mission to elaborate an accreditation/certification procedure similar to the NAME's one but taking into account the realities of forensic medicine practices in Europe and restricted to post-mortem investigations. This accreditation process applies to services and not to individual practitioners by emphasizing policies and procedures rather than professional performance. In addition, the standards to be complied with should be considered as the minimum standards needed to get the recognition of performing and reliable forensic pathology service.

The development of a protocol for post-mortem management of Ebola virus disease in the setting of developed countries.

The management of the recent Ebola virus disease (EVD) epidemic continues to pose currently insuperable challenges to health care providers in the resource-deprived countries of West Africa. In an age where air travel facilitates rapid movement of people between countries and continents, there is an urgent requirement for health systems around the globe to develop management strategies and protocols in the event that EVD cases are suspected or confirmed. Departments of forensic pathology play an important, and underestimated, role in public health service delivery, particularly at times of novel infectious disease emergence. This role can include disease identification, characterization, and notification, as well as close engagement with agencies responsible for disease surveillance and treatment provision. A mass outbreak of EVD in the Western world is considered highly unlikely; however, there is clear responsibility on departments of forensic pathology to develop protocols for rapid assessment of sporadic or suspected cases while ensuring the health and safety of mortuary and pathology personnel. The Ontario Forensic Pathology Service and the Victorian Institute of Forensic Medicine have collaborated on the development of a protocol for management of EVD cases presenting at a scene or in the mortuary. It is hoped that this trans-national, inter-departmental exercise will serve as a model for future co-operative endeavors. The protocol has been distributed to forensic pathology departments around Australia and may be modified to accommodate local resource capabilities.

[Forensic medical expertise of the injurious exposure].

The objective of the present study was to develop the standardized approach to the evaluation of the character of injurious exposure with a view to objective interpretation of the conditions of injury formation and the properties of the traumatic agent. The main attention was given to such parameters of the injurious exposure as loading conditions (mass, speed, direction) and the surface properties of the traumatic agent (area, shape, hardness). It is expected that the use of the proposed system for the evaluation of the injurious exposure in the practical work of forensic medical experts will enhance the reliability of their conclusions and help to avoid mistakes.

Post-mortem computed tomography compared to forensic autopsy findings: a French experience.

OBJECTIVES: The principal aim of our study was to establish concordance between post-mortem CT (PMCT) and forensic standard autopsy (SA) in detecting lesions according to different anatomical regions. A secondary aim was to determine the efficacy of PMCT in showing lethal lesions. METHODS: PMCTs were compared with autopsies in 236 cadavers in different contexts of death. PMCT findings were assessed by two independent radiologists. RESULTS: Concordance between PMCT and autopsy was almost perfect in showing skull, basal skull and hyoid bone fractures as well as in detecting facial, vertebral or pelvic fractures. Both examinations were discordant in demonstrating some intracranial injuries, vascular or organ wounds (more findings showed by autopsy), as well in showing free air in anatomical cavities (more findings detected by PMCT). Moreover, PMCT was effective in determining lethal lesions in the context of craniofacial trauma or after a gunshot wound. Concordance between the findings of the two radiologists was almost perfect for each type of lesion. CONCLUSION: PMCT could be considered as effective as SA in determining the cause of death in certain traumatic events. It was also effective in showing lethal lesions and could be a useful tool in reducing the number of SA. KEY POINTS: • Post-mortem CT is increasingly performed as an alternative/adjunct to formal autopsy. • More modern CT systems provide greater anatomical scope. • PMCT can usually determine the cause of most deaths following trauma. • Prospective studies are still required to establish an algorithm for forensic CT.

Forensic entomology: implementing quality assurance for expertise work.

The Department of Forensic Entomology (Institut de Recherche Criminelle de la Gendarmerie Nationale, France) was accredited by the French Committee of Accreditation (Cofrac's Healthcare section) in October 2007 on the basis of NF EN ISO/CEI 17025 standard. It was the first accreditation in this specific field of forensic sciences in France and in Europe. The present paper introduces the accreditation process in forensic entomology (FE) through the experience of the Department of Forensic Entomology. Based upon the identification of necrophagous insects and the study of their biology, FE must, as any other expertise work in forensic sciences, demonstrate integrity and good working practice to satisfy both the courts and the scientific community. FE does not, strictly speaking, follow an analytical method. This could explain why, to make up for a lack of appropriate quality reference, a specific documentation was drafted and written by the staff of the Department of Forensic Entomology in order to define working methods complying with quality standards (testing methods). A quality assurance system is laborious to set up and maintain and can be perceived as complex, time-consuming and never-ending. However, a survey performed in 2011 revealed that the accreditation process in the frame of expertise work has led to new well-defined working habits, based on an effort at transparency. It also requires constant questioning and a proactive approach, both profitable for customers (magistrates, investigators) and analysts (forensic entomologists).

Toward a standardized investigation protocol in sudden unexpected deaths in infancy in South Africa: a multicenter study of medico-legal investigation procedures and outcomes.

INTRODUCTION: South Africa manifests a socio-economic dichotomy that shows features of both a developed and developing country. As a result of this, areas exist where a lack of resources and expertise prevents the implementation of a highly standardized protocol for the investigation of sudden and unexpected deaths in infants (SUDI). Although the medico-legal mortuaries attached to academic centers have the capacity to implement standardized protocols, a previous study conducted at two large medico-legal mortuaries indicated otherwise. This study also revealed that the exact number and incidence of sudden infant death syndrome (SIDS) cases was unknown. These findings prompted a multicenter study of the medico-legal investigation procedures and outcomes in five academic centers in South Africa. METHODS: A retrospective case audit was conducted for a 5-year period (2005-2009) at medico-legal laboratories attached to universities in Bloemfontein, Cape Town-Tygerberg, Durban, Johannesburg, and Pretoria. The total case load as well as the total number of infants younger than 1 year of age admitted to these mortuaries was documented. The case files on all infants younger than 1 year of age who were admitted as sudden and unexpected or unexplained deaths were included in the study population. Data collected on the target population included demographic details, the nature and scope of the post-mortem examinations, as well as the final outcome (cause of death). RESULTS: A total case load of 80,399 cases were admitted to the mortuaries over the 5 year period with a total of 3,295 (6.5 %) infants. In the infant group, 591 (0.7 %) died from non-natural causes and 2,704 (3.3 %) cases of sudden, unexpected and/or unexplained deaths in infants were admitted and included in the detailed case analysis study. One hundred and ninety-nine babies were between 0 and 7 days of age and 210 babies between 8 and 30 days. The remaining 2,295 infants were between 1 month and 12 months of age. Death scene investigation was done in a total of 14 (0.5 %) cases. Discrepancies were present in the extent of the macroscopic post-mortem examinations, as well as the type and extent of the ancillary investigations performed. The investigations were completed in 2,583 of the cases. The majority of these infants died from natural disease processes [1,976 infants (76.5 %)]. Bronchopneumonia was the leading cause of natural deaths at all the mortuaries [674 cases (26.1 %)]. SIDS was diagnosed in only 224 cases (8.7 %) and in 383 (14.8 %) cases, where a full post-mortem examination with ancillary investigations was conducted; the cause of death was recorded as "unascertained." CONCLUSIONS: This study indicated that the admission criteria (to medico-legal mortuaries) and the investigative process/protocols in cases of SUDI differ greatly among 5 of the largest academic medical institutions in South Africa. Establishing and implementing standardized admission criteria (to medico-legal mortuaries) and implementing uniform investigative and autopsy protocols would appear to be an essential prerequisite to gain better understanding of the mystery of SIDS in South Africa.

[Gunshot wounds: forensic pathology]. / Blessures par projectile d'arme à feu : aspects anatomopathologiques.

Gunshot wounds are among the most complex traumatic lesions encountered in forensic pathology. At the time of autopsy, careful scrutiny of the wounds is essential for correct interpretation of the lesions. Complementary pathological analysis has many interests: differentiation between entrance and exit wounds, estimation of firing distance, differentiation between vital and post mortem wounds and wounds dating. In case of multiple headshots, neuropathological examination can provide arguments for or against suicide. Sampling of gunshot wounds at autopsy must be systematic. Pathological data should be confronted respectively to autopsy and death scene investigation data and also ballistic studies. Forensic pathologist must be aware of the limits of optic microscopy.

[Effectiveness of histopathologic examination in a series of 400 forensic autopsies]. / Intérêt de l'analyse anatomopathologique dans une série de 400 autopsies médicolégales.

OBJECTIVES: To assess the usefulness of histopathologic examination in forensic autopsies. MATERIAL AND METHODS: All consecutive pathological reports and slides from forensic autopsies performed in our department since 2006 have been reviewed. RESULTS: Four hundred forensic necropsies were reviewed. In only 150 cases (38%), pathologists had data about manner of death and gross autopsy findings. Major diagnoses, related to death, and unsuspected by forensic pathologists, were discovered in 83 cases (21%): in 48 cases (12%) gross examination of the heart, lungs and liver showed gross diagnoses missed by the forensic pathologists, and in only 35 cases (9%) microscopic examination revealed a major unsuspected diagnosis (in brain, heart, lungs, liver, kidney and pancreas specimens). In 213 cases (53%), histopathologic examination confirmed gross autopsy findings and allowed to date some wounds. In 104 cases (26%), microscopic examination was not contributory. CONCLUSION: Microscopic examination revealed major diagnoses in less than 10% of forensic autopsies. Its effectiveness is limited for homicides and suicides. Systematic microscopic examination of numerous organs is often useless and should be limited to cases with no anatomic causes of death. Our study emphasizes the need for a better communication between forensic pathologists and histopathologists, and for a better training of some forensic pathologists for gross examination.

Role of forensic pathologists in mass disasters.

The forensic pathologist has always had a central role in the identification of the dead in every day practice, in accidents, and in disasters involving hundreds or thousands of victims. This role has changed in recent years, as advances in forensic odontology, genetics and anthropology have improved the chances of identifying victims beyond recognition. According to the Interpol DVI Guide, fingerprints, dental examination and DNA are the primary identifiers, and this has given new emphasis to the role of the forensic pathologist as the leader of a multidisciplinary team of experts in a disaster situation, based on his or her qualifications and the experience gained from doing the same work in the everyday situation of an institute of forensic medicine.

Evaluation of autopsy and police reports in the investigation of sudden unexplained death in the young.

To evaluate police and autopsy reports in sudden unexplained deaths in 0-40 year olds. A structured, blind review of police and autopsy reports send to a cardiac genetic service from before (February 2006-December 2007) and after (January-December 2009) new best practice guidelines were introduced in Australia and New Zealand was performed. The reviews focused on reporting on: (1) presentation and clinical history, (2) cardiac autopsy, (3) histological tests and toxicology, and (4) detailed examination of coronary arteries. 110 reports were evaluated against the guidelines. 100 % reported location, 95 % activity at time of death, and 84 % some clinical history. Less than 25 % reported on family history, presence/absence of illicit drugs or alcohol, recorded a possible arrhythmic trigger, or history of fits/faints or collapses. Over 95 % listed heart weight, valvular examinations, pulmonary and some myocardial histology. Less than 50 % commented on septal, LV (left ventricle) and RV (right ventricle) wall thickness. Less than 50 % mentioned site of histology samples, or gave specific description of LV or RV histology or conduction system. Toxicology was not mentioned in a third. Histology of coronary arteries was described in only 18 %. Post guidelines reporting increased in some areas, e.g. in 1-40 year olds: antecedent symptoms (22-61 %), number and location of histology samples (0-47 %), and histology of coronary arteries (6-50 %). Most police and autopsy reports fall short of best practice guidelines. They have improved somewhat after the new guidelines were introduced, but need to be more consistent and particularly need to include significant negative findings.