Consideraciones de bioseguridad en la realización de la autopsia de casos positivos de COVID-19 / Biosafety considerations in the autopsy of positive COVID-19 cases

Fundamento: la autopsia permitirá dilucidar la patogenia y la correlación clínico-patológica de la infección por SARS-Cov-2, si bien su realización presenta riesgos de contagio, estos pueden ser minimizados al aplicar medidas de bioseguridad recomendadas por instituciones con gran experiencia en el manejo de enfermedades infecciosas. Objetivo: contribuir a la organización de la evidencia sobre la realización de autopsias de casos COVID-19 bajo niveles óptimos de bioseguridad. Métodos: se realizó una búsqueda en MEDLINE/PUBMED, se utilizaron las palabras: COVID-19, SARS-Cov-2, autopsia y bioseguridad. Se incluyeron guías y resoluciones de instituciones, series y presentaciones de casos con descripción de los procederes de autopsia. Los criterios de elegibilidad fueron: el país, número de autopsias realizadas, tipo de autopsia (completa o mínimamente invasiva), descripción de las medidas personales de bioseguridad y características del espacio físico de la morgue. Resultados: se obtuvieron 27 artículos que describen los procedimientos, equipos empleados y condiciones de infraestructura para garantizar la bioseguridad. De ellos, 13 describen la realización de la autopsia en una sala con presión negativa, y en 11 se describe la técnica y las medidas de bioseguridad a utilizar, con el uso de los equipos de protección personal. Se hallaron un total de cuatro documentos normativos o recomendaciones oficiales sobre los procedimientos a seguir para la realización de la autopsia con el mínimo de riesgos. Además de dos artículos que resumen dichas normativas. Conclusiones: los exámenes post mortem de casos COVID-19 se pueden realizar de manera segura con la aplicación de los equipos de protección personal adecuados (AU)

Background: the autopsy will allow elucidating the pathogenesis and the clinical-pathological correlation of the infection by SARS-Cov-2, although its performance presents risks of contagion, these can be minimized by applying bio-safety measures recommended by institutions with great experience in the management infectious diseases. Objective: to contribute to the organization of the evidence on the performance of autopsies of COVID-19 cases under optimal levels of bio-safety. Methods: a MEDLINE / PUBMED search was performed, using the words: COVID-19, SARS-Cov-2, autopsy and bio-safety. Guidelines and resolutions from institutions, series and case presentations were included with a description of the autopsy procedures. The eligibility criteria were: country, number of autopsies performed, type of autopsy (complete or minimally invasive), description of personal bio-safety measures, and characteristics of the physical space of the morgue. Results: 27 articles were obtained that describe the procedures, equipment used and infrastructure conditions to guarantee bio-security. Of these, 13 describe the autopsy in a room with negative pressure, and 11 describe the technique and bio-safety measures to be used, using personal protective equipment. A total of four normative documents or official recommendations were found on the procedures to follow to carry out the autopsy with the minimum of risks. In addition to 2 articles that summarize these regulations. Conclusions: post-mortem examinations of COVID-19 cases can be performed safely with the application of appropriate personal protective equipment (AU)

Does peer consultation between forensic physicians reduce inter-doctor variation when issuing medical death certifications?

INTRODUCTION: Because earlier research showed that inaccuracies were observed in the interpretation and handling of deaths by forensic physicians, peer consultation among forensic physicians was introduced before advice was given to treating physicians calling for advice. In addition, peer consultation was introduced as a means to improve the correctness of conclusions concerning the manner of death when performing external post-mortem examinations. METHOD: In the period of November 2017 until April 2018 all reports of external postmortem examinations (n = 498) and all telephonic consultations between treating physicians with forensic physicians, concerning postmortem examinations (n = 167), were analyzed retrospectively. RESULTS: Peer consultation among forensic physicians took place in 70% of the 167 telephonic consultations initiated by treating physicians. In 92% of all cases of telephonic consultation, the accurateness of advice to treating physicians was deemed accurate. In 67% (n = 498) of all external postmortem examinations in the study period, peer consultation between forensic physicians took place. The conclusion regarding the manner of death after external postmortem examination was accurate in 99% of all cases (n = 491 out of 498). CONCLUSION: The advices given by forensic physicians to treating physicians have improved after the introduction of peer consultation among forensic physicians. Peer consultation therefore should be recommended as a means for quality assurance.

AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE.

OBJECTIVE: Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU). METHODS: This is a cross-sectional, retrospective study on 31patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria. RESULTS: Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. Therewas a 67% decrease in the number of autopsies over the last 10years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). Therewas greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Sevenpatients were admitted in critical health conditions and died within the first 24 hours of hospitalization. CONCLUSIONS: Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

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.

Autopsy examination in sudden cardiac death: a current perspective on behalf of the Association for European Cardiovascular Pathology.

In sudden cardiac death, an autopsy is an essential step in establishing a diagnosis of inherited cardiac disease and identifying families that require cardiac screening. To evaluate aspects of post-mortem practice in Europe, a questionnaire was designed and circulated to both clinical and forensic pathologists. There was a 48% response rate and information was obtained from 17 countries. The results showed a wide variety in the management of sudden cardiac death, with a general tendency towards a lack of thorough investigation. In up to 40% of cases, autopsies were not performed in subjects less than 50 years who may have died from cardiac disease. Reasons for this were lack of finance and lack of interest from police, legal authorities, and doctors. Only 50% of pathologists seem to follow a standard protocol for autopsy examination, apparently due to lack of expertise and/or training. When autopsies were performed, histology and toxicology were almost always taken, genetic studies were generally available and retention of the heart for specialist study was usually permitted. Our results suggest that although the standard of practice is appropriate in many centres, many more cases should have autopsies, especially in sudden deaths in subjects less than 50 years.

COVID-19 autopsies: Procedure, technical aspects and cause of fatal course. Experiences from a single-center.

Autopsies on COVID-19 have provided deep insights into a novel disease with unpredictable and potentially fatal outcome. A standardized autopsy procedure preferably with an in-situ technique and systematic tissue processing is important. Strict safety measures include personal protective equipment with a standardized protocol for dressing and undressing, usage of FFP-3 masks and minimization of aerosol production. The use of an airborne infection isolation (AIIR) room is preferred. Viral RNA analysis using swabs from throat, both lungs and other organs provides information on cross-organ viral dynamics. To correctly determine the full extent of pathological organ changes an adequate processing procedure is of the utmost importance. Systematic dissection and processing of the lungs revealed pulmonary infarction caused by thrombosis and thromboembolism and bacterial bronchopneumonia as the most frequent cause of death. Fungal pneumonia (aspergillus) was found in one case. The quality of the tissue was sufficient for histopathological and immunohistochemistry analyses in all cases. Viral RNA from throat or lung swabs was detectable post mortem in 89 % of the cases and could also be detected from paraffin-embedded tissue by real-time PCR. Complete COVID-19 autopsies including extensive histopathological studies and viral RNA analysis require approximately three times more human and technical resources and time compared to standard non-COVID autopsies. Autopsies on COVID-19 are feasible, present a manageable risk, while following a strict protocol, and provide novel insights into disease pathogenesis and the clinician with important feedback.

Cutoff value for hypertrophic heart weight in the Japanese population.

BACKGROUND: Cardiac hypertrophy is a clinical risk factor for cardiovascular death (CVD) frequently recorded in autopsy reports, but the diagnostic criteria for the condition have not been clearly-established for autopsy. This study aimed to estimate the cutoff value for hypertrophic heart weight that can efficiently assist the postmortem diagnosis of CVD. METHODS: We analyzed accumulated autopsy data from 3534 individuals aged 0-101 years. RESULTS: We found that heart weight increased linearly with a person's age until 20 years, after which it remained stable. The mean heart weight in CVD cases was 473 g in men and 379 g in women. The mean heart weight in non-CVD cases was 385 g in men and 320 g in women. Receiver operating characteristic curve analysis for CVD assessment revealed that the cutoff value of heart weight was 407 g (odds ratio of 4.2) in men and 327 g (2.6) in women, and that of heart weight/body height was 2.38 g/cm (4.0) in men and 2.15 g/cm (2.6) in women, respectively. Overall, heart weight was a more useful predictor of CVD in men than in women. In logistic regression analysis, the predictive power of heart weight for CVD was higher than that of body mass index in both sexes. CONCLUSION: Thus, the criteria for hypertrophic heart weight are practical and useful for autopsy recordings, and it can be helpful for postmortem diagnosis of CVD. Our report is the first to reveal the cutoff value for hypertrophic heart weight in the Japanese population.

Agreement between clinical and anatomopathological diagnoses in pediatric intensive care / Avaliação da concordância entre diagnósticos clínicos e anatomopatológicos em terapia intensiva pediátrica

ABSTRACT Objective: Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU). Methods: This is a cross-sectional, retrospective study on 31patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria. Results: Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. Therewas a 67% decrease in the number of autopsies over the last 10years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). Therewas greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Sevenpatients were admitted in critical health conditions and died within the first 24 hours of hospitalization. Conclusions: Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

RESUMO Objetivo: Embora a necropsia seja considerada o exame padrão-ouro de diagnóstico, observa-se declínio em sua realização, enquanto cresce o número de eventos adversos na saúde, dos quais 17% são erros diagnósticos. O estudo objetivou estimar a prevalência do erro de diagnóstico, com base no diagnóstico anatomopatológico, em uma Unidade de Terapia Intensiva Pediátrica (UTIP). Métodos: Estudo de corte transversal, retrospectivo, de 31pacientes que foram a óbito entre 2004 e 2014. Os diagnósticos foram comparados para verificar se houve concordância de diagnóstico principal (CDP) e diagnóstico da causa da morte (DCM), classificados de acordo com os critérios de Goldman. Resultados: De 3.117 pacientes, 263 foram a óbito. Em 38 casos foi realizada autopsia (14,4%) e 31 foram incluídos no estudo. Observou-se decréscimo de 67% no número de autopsias em dez anos. Concordância absoluta entre os diagnósticos (classe V) foi observada em 18 casos (58,0%) e discordância (classe I), em 11 (35,4%). Observou-se maior dificuldade no diagnóstico de doenças agudas e de evolução fatal rápida, como as miocardites. Sete pacientes foram admitidos em estado geral grave, indo a óbito nas primeiras 24 horas de internação. Conclusões: A necropsia não só permite a identificação de erros diagnósticos, como também a oportunidade de se aprender com o erro. Os resultados enfatizam a importância desse exame para a elucidação diagnóstica e a construção de uma base de informações sobre os principais diagnósticos envolvidos em pacientes que evoluem rapidamente para o óbito em UTIP, aumentando o grau de suspeição pela equipe da Unidade.

WHO guidelines for plague management: revised recommendations for the use of rapid diagnostic tests, fluoroquinolones for case management and personal protective equipment for prevention of post-mortem transmission

Plague has killed millions of people during the past 25 centuries, and the disease reappeared in several countries during the 1990s. Consequently, plague was categorized as a re-emerging disease. Human plague outbreaks continue to be reported, including an outbreak of pneumonic plague in Madagascar in 2017. Plague is an acute bacterial infection caused by Yersinia pestis. Although effective antimicrobials are available, plague still has high mortality because most outbreaks take place in remote places, where proper diagnosis and treatment remain challenging. Early identification of the disease is crucial to ensure prompt treatment and better outcomes. Pneumonic plague is highly contagious and of particular concern because of the high risk of triggering epidemics. Thus, plague is both a medical and a public health emergency. These guidelines were developed in accordance with the WHO handbook for guideline development. A WHO Steering Group, led by the responsible technical officer, developed the draft scope of the guidelines and the key questions to be addressed. The Steering Group selected the members of the Guideline Development Group (GDG) to ensure diverse areas of expertise were represented, including clinicians, microbiologists, public health professionals, researchers and an anthropologist. The Steering Group also commissioned technical advisers to lead the Evidence Review Team and provide methodological support. The GDG assisted with developing the final scope of the guideline and defining the key areas to be addressed, and also formulated the recommendations. Three key areas were selected to be addressed: (i) the use of rapid diagnostic tests (RDTs) for diagnosing plague in different contexts; (ii) the choice of antimicrobials for treating the different forms of plague, including whether fluoroquinolones should be introduced as a first-line medicine of choice; and (iii) the use of personal protective equipment in case of exposure to the dead body of a person who was infected with plague. The Evidence Review Team conducted systematic reviews to address each of the three key areas. At a meeting in Antananarivo, Madagascar, on 20­21 September 2019, the GDG interpreted the main findings of the systematic reviews as they applied to each key question and formulated evidence-based recommendations following the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. For each key question, there was discussion about the certainty of the evidence, desirable and undesirable effects, values and preferences, cost, acceptability, equity, feasibility and barriers to implementation. The GRADE evidence-to-decision tables were used to facilitate consensus and record the decision of the GDG. The GDG developed final recommendations where possible and graded each of them as strong or conditional. The final guidelines were written by the Evidence Review Team.

COVID-19 instigates resurgence of 'needless autopsies' issue in India.

COVID-19 has swamped the entire world and turned into a pandemic. Its high contagiousness compelled authorities to categorize all autopsies as 'high risk' considering the risk of exposure to the healthcare workers. In India, the Criminal Procedure Code authorizes investigating police officer to hold an inquest into suspicious deaths. The present article draw attention towards the 'needless autopsies' in times of COVID-19 and emphasizes on causes and recommendations.

Case Report: Adrenal Pathology Findings in Severe COVID-19: An Autopsy Study.

Although high mortality has been reported in many COVID-19 studies, very limited postmortem information from complete autopsies is available. We report the findings in the adrenal glands in 28 autopsies with confirmed SARS-CoV-2 infection. Microscopic lesions were identified in the adrenal glands in 12/28 patients (46%). Seven cases showed necrosis, generally ischemic; four showed cortical lipid degeneration; two showed hemorrhage; and one unspecific focal adrenalitis. Vascular thrombosis in one patient and focal inflammation in association with other findings in three patients were observed. No case presented adrenal insufficiency. In conclusion, adrenal lesions are frequent in patients with severe COVID-19. The lesions are mild but could contribute to the lethal outcome.

[Deaths that seem natural]. / Sterfgevallen die natuurlijk lijken.

Every dead body is examined by a doctor to establish the manner of death. In the Netherlands, however, both the quality of post-mortem examinations and the number of autopsies carried out in a clinical or forensic setting are low. Not all causes of death can be determined by post mortem examination alone; the law should, therefore, be changed to allow a forensic physician to legally request additional investigations, such as a toxicological or radiological report, to ensure the detection of crimes such as murder. Additional investigation could increase the quality of post-mortem examinations, and might bridge the quality gap between full autopsy and a simple post mortem. The information obtained could, for instance, be informative for relatives in the context of hereditary research. Finally, to improve the quality of post-mortem examination and identify all cases of murder, it is of the utmost importance that there is sufficient focus on post mortem examination of the cadaver during medical specialist training.

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.

Precautions in postmortem examinations in Covid-19 - Related deaths: Recommendations from Germany.

The Covid-19 pandemic is also a considerable risk for forensic workers, among other healthcare providers. The risk of contamination is serious in post-mortem procedures. SARS-CoV2 is a microorganism classified as Hazard Group 3. However, the lack of adequate scientific work on Covid-19 should prompt us to be even more cautious when handling potentially infected persons or materials. Before starting the post-mortem investigation a risk assessment should be carried out and the suitability of facilities, personnel and equipment should be evaluated. An autopsy room conforming to BSL 3 standards would be ideal but is not mandatory. For suspicious or approved cases however a number of procedural changes must be made concerning the body's removal, storage and inspection procedures. Facilities, equipment and training issues need to be revised against existing and potential risks of infection. In addition to proper ventilation and insulation, personal protective equipment, aerosol reduction measures and disinfection applications are required. As of yet it is still unclear how long this public health issue, which has grown to become a pandemic, will last. This article highlights preventive measures to be taken into consideration in post-mortem processes when a Covid-19 infection is suspected or confirmed. It should be noted that there is no standard guide yet in this regard. A guide should be created according to international standards and revised according to changing conditions.

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.

Nota Técnica 18/2020/SES/GASEC [Biossegurança para Manejo de cadáveres suspeitos ou confirmados por Covid-19] / Technical Note 18/2020 / SES / GASEC [Biosafety for Handling Suspected or Confirmed Corpses by Covid-19]

Traz orientações de Biossegurança para o manejo de cadáveres suspeitos ou confirmados por Covid-19 pelos serviços de somatoconservação, funerárias, cemitérios, crematórios, serviço de verificação de óbito, autópsia, transladação de cadáveres e velórios no Estado do Tocantins.

It provides Biosafety guidelines for the management of suspected or confirmed corpses by Covid-19 by somatoconservation, funeral services, cemeteries, crematoriums, death verification service, autopsy, transfer of corpses and funerals in the State of Tocantins.

Traz orientações de Biossegurança para o manejo de cadáveres suspeitos ou confirmados por Covid-19 pelos serviços de somatoconservação, funerárias, cemitérios, crematórios, serviço de verificação de óbito, autópsia, transladação de cadáveres e velórios en Estado do Tocantins.