The radioactive autopsy: safe working practices

Autopsy cases involving individuals retaining radioactive substances are fortunately rare, but when they occur they can impose significant radiation safety and legal requirements. This review aims to improve the understanding of these issues so that appropriate precautions are implemented when necessary. This review describes the properties of ionizing radiations, natural and man-made sources of ionizing radiation and its use in healthcare. It identifies the most likely circumstances leading to radioactive substances being present during autopsy and sources of information, including radiation protection advice. It discusses precautions that may need to be implemented prior to, during and following autopsy. Despite the issue of appropriate information to patients and next of kin, it is inevitable that some cases will be identified only at autopsy and it is important that robust local procedures are maintained. Information must be communicated to assist safe management of the body and liaison between relevant professional groups may be needed to standardize methods of communication. Provided that appropriate precautions are implemented, determined through consultation with a qualified expert in radiation protection and by completion of risk assessment, the radioactive autopsy can be undertaken safely and in compliance with relevant legislative requirements.     

Introduction of autopsy imaging redefines the concept of autopsy: 37 cases of clinical experience

A new autopsy imaging (AI) system was introduced at the Research Center Hospital for Charged Particle Therapy (RCCPT) in January 2000. Autopsy imaging is a postmortem and preautopsy diagnostic procedure using magnetic resonance imaging (MRI). Scanning is performed with a 1.5 Tesla MRI system before autopsy. The AI results are reported to the pathologist and, in light of this information, autopsy is performed with minute precision. Autopsy imaging was performed on 37 cancer cases. In seven cases, AI was less informative than the autopsy, but in 30 cases, more precise reports on the final diagnosis were available with the combined application of autopsy and AI than autopsy alone, particularly in eight limited autopsy cases. Thus, AI provides critical and supplementary information for autopsy; furthermore, AI itself is a unique imaging system of great importance.     

Research issues in forensic pathology: a survey of academic institutions employing forensic pathologists

In an effort to characterize research efforts in forensic pathology, a questionnaire was sent to a representative of each of the 14 academic medical centers that employ full-time faculty forensic pathologists. Responses were received from all 14 (100%) of the institutions queried, representing a total of 39 forensic pathology faculty positions; 21 positions were tenure track and 18 positions were clinical or other tracks. Of the 39 positions, 25 positions (64%) at 10 institutions required some degree of research or scholarly output. Of the 25 forensic pathologists with a research imperative, only 3 (12%) were principal investigators or co-investigators on funded forensic pathology-based projects. The major limitation cited by respondents on the performance of forensic pathology research was the lack of protected time from service responsibilities. Fellowship training in forensic pathology was available at 6 of the 14 respondent institutions. Of these institutions, 4 (67%) had a research requirement for trainees, and 4 (67%) provided research training. In conclusion, very few US medical schools currently employ full-time faculty forensic pathologists. Of these, only a small number of institutions prioritize research by these faculty members. Scant federal funds are available to support research in forensic pathology. Few forensic pathology fellowship programs provide research training. To achieve a robust research agenda in forensic pathology that is sufficient to support the needs of the criminal justice and public health systems will require a paradigm shift in the medicolegal death investigative system and investment by federal agencies.     

Daily application of post-mortem computed tomography digital autopsy in a public mortuary

The digital autopsy has gained increasing attention in the past decade as post mortem computed tomography has become more widely available. Whether conducted with, or without, radiographic contrast, digital autopsies have been shown to be a valuable adjunct to invasive examinations in the investigation of natural and unnatural deaths. This radiology investigation has the potential to reduce the number of full invasive autopsies performed, allowing for more targeted, or limited, invasive examinations. In certain deaths, the digital autopsy may obviate the need for an invasive examination entirely. This article considers the daily use of post mortem computed tomography in routine coronial autopsy practice in a busy public mortuary in England. The integration of the digital autopsy into the investigation of natural deaths (including decomposing and embalmed bodies) is first considered before dealing with commonly encountered unnatural deaths after surgery, industrial disease, trauma, drug overdose and suicides.     

Adrenal lipomas: incidental autopsy findings

Two rare cases of lipomas of the adrenal gland are reported. In both cases the tumor was found incidentally at autopsy, in the course of the medicolegal investigation of death. The first case involved a small tumor of the left adrenal gland in a 70-year-old man who died by drowning. In the second case, a previously healthy 45-year-old man died suddenly. At autopsy a lipoma of the right adrenal gland was associated with a pheochromocytoma in the contralateral gland.     

General practitioner''s knowledge of when to refer deaths to a coroner.

BACKGROUND--In 1992 about 179,000 deaths were reported to coroners in England and Wales and these represented 32% of the total number of registered deaths. Many of these cases were referred to coroners by general practitioners who certify the vast majority of deaths which occur outside hospitals. The safeguards to society which are provided by the coroner system in England and Wales are undermined if doctors fail to recognize those deaths which should be reported for further investigation. AIM--A study was undertaken to assess the ability of general practitioners to recognize deaths which require referral to a coroner. METHOD-A postal questionnaire consisting of 12 fictitious case histories was sent to all 323 general practitioners in Sheffield and the senior staff of the local coroner's office (two coroner's officers and two deputy coroners). Ten of the case histories contained a clear indication for referral to the coroner. RESULTS--A total fo 196 general practitioners (61%) and all the coroner's office staff returned the questionnaire. General practitioners correctly identified whether or not referral was indicated, with reasons, in a mean of 8.5 cases (range 4-12). Only six general practitioners (3%) were correct in all 12 cases. All of the coroner's staff were correct in all cases. CONCLUSION--General practitioners may be failing to bring certain categories of cases to the attention of coroners because of misconceptions of ignorance of their medico-legal responsibilities. General practitioner education in this area, and a closer working relationship between general practitioners and coroners may improve the situation.     

The Johanson-Blizzard syndrome: A second report of full autopsy findings

We report on a second patient with Johanson-Blizzard syndrome with full autopsy. The findings are similar to those of the one other available case, but gross or fine CNS maldevelopment was not present; although small by weight, the brain showed no cytoarchitectural disturbance. Normal intellecutal development does occur in this syndrome and may relate to the variable effects of the deleterious gene on the developing CNS.     

心源性猝死33例尸检临床病理分析

目的 分析心源性猝死的临床特点以及尸检病理学特征.方法 收集与医疗纠纷有关的不明原因死亡的87例尸体解剖资料进行病理组织学检查.结果 心源性猝死33例,其中,冠心病20例(占64%),主动脉夹层动脉瘤破裂4例,心肌炎5例,肥厚性心肌病2例,冠状动脉炎和肺动脉脂肪栓塞各1例.结论 正确、系统地进行尸体解剖,可以明确猝死原因,提高医疗质量,并为医疗纠纷鉴定提供可靠的鉴定依据.     

先天性腹壁缺损36例尸体解剖和组织学观察

目的：探讨腹壁缺损的病理形态学变化,方法：对36例腹壁缺损进行尸体解剖,按照Hartwig方法分型,并对24例不同组织和胎盘进行组织学观察。结果：36例腹壁缺损多伴有其它畸形,包括肢体,颜面,神经管,泌尿生殖及消化和心血管系统,腹壁缺损皮肤－膜移行区为复层扁平上皮逐渐向意志层上皮过渡,间质由丰富胶原纤维变为疏松的结缔组织,证实了羊膜外胚层过渡带的存在。5例肾脏和1例脑组织中发策钙化病灶,胎盘表现绒毛发育不同步,绒毛间质水肿或纤维化,有血管增生,血栓形成等变化。部分病例提示有绒毛炎,13例孕母曾有TORCH感染,11例胎儿脏器TORCH PCR－DNA扩增检测阳性,结论：在胚胎腹壁形成期,如果受到某些致畸因素的干扰,除发生腹壁缺损外,还将出现多种复杂畸形,腹壁缺损的致畸因素不能除外TORCH如巨细胞病毒等感染的可能。     

Special considerations when conducting forensic psychological evaluations for immigration court

Immigrants are more likely to experience mental health symptoms due to the trauma and persecution they often experience before arrival, and the stress of migration. In addition, as immigration policies have become more restricted in the United States, larger numbers of immigrants are facing deportation, proceedings, and/or detention. This has increased the demand for psychologists who are needed to conduct forensic psychological evaluations in immigration courts. Psychologists can aid immigration courts in a number of ways, including by providing evidence of trauma in asylum seekers or in victims of human trafficking, or by assessing competency to participate in immigration proceedings, or risk for violence. Through a case sample, this paper highlights special considerations when conducting cross-cultural forensic assessments in immigration court and illustrates some ways in which clinical psychologists can apply their knowledge to immigration proceedings by developing expertise in the areas of multicultural psychology and forensic assessment.     

Diffuse pulmonary ossification: an uncommon incidental autopsy finding

AIM: To determine the incidence of diffuse pulmonary ossification (DPO) and its subtypes at autopsy and correlation with clinical and histological features. METHODS: Autopsy reports from our institution over a 64-month period were reviewed for findings of DPO. The pattern of ossification, demographics and clinical data were obtained from both paraffin sections and final autopsy reports. In a selected case, chest radiograph and wet tissue were obtained. RESULTS: Seventeen histologically confirmed cases of DPO were found in 10,426 autopsy cases, representing an incidence of 1.63 cases/1000 autopsies. There was a predilection in males (88%) and underlying pulmonary disease (88%). In contrast to published studies, dendriform DPO was more common than the nodular type in our cohort (11 and 6 cases, respectively). The dendriform type was more commonly associated with marrow elements. CONCLUSIONS: Diffuse pulmonary ossification is uncommon and rarely diagnosed during life, but can easily be identified when sectioning the lungs at autopsy. There is recent renewed interest in diagnosing and determining the significance of DPO using high resolution computed tomography and thoracoscopic biopsy.     

Primary amebic meningoencephalitis due to Naegleria fowleri: An autopsy case in Japan

Free-living amebas represented by Naegleria fowleri, Acanthamoeba and Balamutia have been known to cause fatal meningoencephalitis since Fowler and Carter (1965) reported the first four human cases. An autopsy case of a 25-year-old female with primary amebic meningoencephalitis (PAM) due to Naegleria fowleri is described. Headache, lethargy and coma developed in this patient, and her condition progressed to death 8 days after the onset of clinical symptoms. Cerebral spinal fluid examination confirmed clusters of amebas, which were grown in culture and identified as Naegleria fowleri. At autopsy, lesions were seen in the central nervous system (CNS) and the ethmoid sinus. The CNS had severe, suppurative meningoencephalitis with amebic trophozoites mingled with macrophages. This case is the first report of PAM due to Naegleria fowleri in Japan.     

Primary pleural angiosarcoma associated with pneumoconiosis: An autopsy case

We report a case of pleural angiosarcoma in an adult male patient confirmed by autopsy and possibly associated with pneumoconiosis. The lesion was characterized by thickened pleura of both lungs with nodular tumors. Histologically, the tumor was composed of spindle‐to‐polygonal epithelioid cells that were positive for CD31, CD34, vimentin, and cytokeratin on immunohistochemical staining but were negative for calretinin. Further examination revealed mix‐dust pathological findings consistent with the existence of pneumoconiosis; dystrophic ossification, anthracosis, and fractal small dust particles were observed in the lung parenchyma and a hilar lymph node. The current case suggests that pneumoconiosis‐associated pathologies may be risk factors for the development of angiosarcoma in the pleura.     

The forensic examination of the infant and young child

This article describes the approach to the post-mortem examination of an infant or young child where the possibility of unnatural causation and assault, in particular, has not been excluded. The authors describe the methodology in detail with justification for the extent of the examination. They also describe the problem areas with respect to interpretation and conclusions.     

以皮肌炎样表现为特征的血行播散性结核--附3例尸检

目的：为了避免临床误诊,对结核病的肌肉病变特点进行探讨。方法：复习２５例经尸检证实为急／亚急性血播散性结核的病例,其中３例临床上主要表现为皮肤和肌肉损害,分别在患者生前诊断为皮肌炎（２例）和多发性硬化症（１例）。对其骨骼肌进行详细的镜下观察。结果：四肢肌、膈肌、食道和喉的横纹肌均有程度不同的变性、坏死和淋巴细胞浸润,表现为：（１）肥大或萎缩;（２）嗜酸性、玻璃样和絮状变性;（３）溶解和凝固性坏死;     

Imported malaria in a Japanese male: An autopsy report

Fatal cases of malaria are rare in Japan. We report a case of a 47-year-old Japanese man with Plasmodium falciparum malaria. The patient was examined because of fever and headache after a trip to Africa. He was diagnosed with malaria. Chemotherapy begun on day three decreased the percentage of infected red blood cells (RBC) from 25% to 2%, but the patient fell into coma on the same day. The patient was considered brain dead for 3 days before he died, and he was autopsied on day nine. Brain hemispheres were preserved and swollen with meningeal congestion. The ventral area of the pons and medulla oblongata were softened, and the tonsils of the cerebellum were softened and herniated. The spleen was blackish, enlarged and showed a small infarction. The liver was yellowish and enlarged. Many infected RBC were seen in the capillaries of the brain and malaria pigments were seen in the spleen and liver. DNA of P. falciparum was detected by polymerase chain reaction from paraffin-embedded brain materials, however, the DNA could not be detected in other organs. Besides malaria, the patient had latent primary thyroid cancer, which was a small and invasive papillary carcinoma.     

Invasive fungal disease in university hospital: a PCR-based study of autopsy cases

Invasive fungal disease (IFD) has high mortality rate, especially in the growing population of immunocompromised patients. In spite of introduction of novel diagnostic approaches, the intravital recognition of IFD is challenging. Autopsy studies remain a key tool for assessment of epidemiology of visceral mycoses. We aimed to determine species distribution and trends of IFD over the last 10 years in unselected autopsy series from a large university hospital. Forty-five cases of visceral mycoses, confirmed by histopathology and panfungal PCR, were found in 587 consecutive autopsies. Major underlying diseases were diabetes mellitus (20%), hematologic malignancies (15.6%) and systemic lupus erythematosus (15.6%). There was a high risk for disseminated IFD in immunocompromised patients stayed in the hospital over 1 month with a fever longer than 3 weeks. The most common fungi were Aspergillus spp. (58%), Candida spp. (16%), Mucorales (14%) and Fusarium spp. (10%). We found significant increase in Aspergillus flavus (P = 0.04) and Mucorales (P < 0.01) infections over the last 5 years. Concordance rate between histopathology and panfungal PCR was 89.5% to the genus level. All 6 cases of fusariomycosis were misinterpreted as aspergillosis by histology alone. The precise species identification, necessary for targeted antifungal treatment, was rendered only by the molecular technique. Panfungal PCR showed high performance on formalin-fixed paraffin-embedded specimens, providing important epidemiological data in retrospective autopsy series. Rapid detection of fungi by panfungal PCR assay has high potential for intravital diagnostics of IFD in surgical and biopsy specimens.     

Aortic squamous metaplasia in a patient with aortoesophageal fistula secondary to thoracic aortic aneurysm: An autopsy case

Aortoesophageal fistula (AEF) is highly lethal. A 74‐year‐old man presented with hematemesis and consciousness loss. He had a long‐term history of hypertension and gout. Computed tomography revealed an aneurysm of the distal descending thoracic aorta, which was treated by insertion of an aortic stent graft. After 24 days of stenting, endoscopic examination revealed an AEF. After 6 months of stenting, he died owing to mediastinitis. On autopsy, macroscopically, we found a 4 × 2.5‐cm, oval, well‐circumscribed AEF. We identified squamous epithelium in the area surrounding the AEF that covered the thoracic aorta inner cavity. Immunohistochemical analysis revealed that the squamous epithelium in the thoracic aorta was positive for p63 and 34βE12. In conclusion, we encountered a long‐term AEF case with aortic squamous metaplasia. To the best of our knowledge, human aortic metaplasia has never been reported. In the present case, aortic squamous metaplasia retained continuity with the esophageal squamous epithelium; therefore, the migration of the squamous epithelium through the AEF may have been induced by aortic erosion.