Effect of minimally invasive autopsy and ethnic background on acceptance of clinical postmortem investigation in adults

Objectives Autopsy rates worldwide have dropped significantly over the last five decades. Imaging based autopsies are increasingly used as alternatives to conventional autopsy (CA). The aim of this study was to investigate the effect of the introduction of minimally invasive autopsy, consisting of CT, MRI and tissue biopsies on the overall autopsy rate (of CA and minimally invasive autopsy) and the autopsy rate among different ethnicities. Methods We performed a prospective single center before-after study. The intervention was the introduction of m

Hospital implementation of minimally invasive autopsy: A prospective cohort study of clinical performance and costs

Objectives Autopsy rates worldwide have dropped significantly over the last decades and imaging-based autopsies are increasingly used as an alternative to conventional autopsy. Our aim was to evaluate the clinical performance and cost of minimally invasive autopsy. Methods This study was part of a prospective cohort study evaluating a newly implemented minimally invasive autopsy consisting of MRI, CT, and biopsies. We calculated diagnostic yield and clinical utility—defined as the percentage successfully answered clinical questions—of minimally invasive autopsy. We performed minimally invasive autopsy in 46 deceased (30 men, 16 women; mean age 62.9±17.5, min-max: 18–91). Results Ninety-six major diagnoses were found with the minimally invasive autopsy of which 47/96 (49.0%) were new diagnoses. CT found 65/96 (67.7%) major diagnoses and MRI found 82/ 96 (85.4%) major diagnoses. Eighty-four clinical questions were asked in all cases. Seventy-one (84.5%) of these questions could be answered with minimally invasive autopsy. CT successfully answered 34/84 (40.5%) clinical questions; in 23/84 (27.4%) without the need for biopsies, and in 11/84 (13.0%) a biopsy was required. MRI successfully answered 60/84 (71.4%) clinical questions, in 27/84 (32.1%) without the need for biopsies, and in 33/ 84 (39.8%) a biopsy was required. The mean cost of a minimally invasive autopsy was €1296 including brain biopsies and €1087 without brain biopsies. Mean cost of CT was €187 and of MRI €284. Conclusions A minimally invasive autopsy, consisting of CT, MRI and CT-guided biopsies, performs well in answering clinical questions and detecting major diagnoses. However, the diagnostic yield and clinical utility were quite low for postmortem CT and MRI as standalone modalities

DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative Treatment. A MULTICENTER RANDOMISED CLINICAL TRIAL

Background: Persisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses. Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management. We, therefore, constructed a randomised clinical trial comparing these two treatment strategies. Methods/design: The DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used. The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-u

Non-invasive or minimally invasive autopsy compared to conventional autopsy of suspected natural deaths in adults: a systematic review

Objectives: Autopsies are used for healthcare quality control and improving medical knowledge. Because autopsy rates are declining worldwide, various non-invasive or minimally invasive autopsy methods are now being developed. To investigate whether these might replace the invasive autopsies conventionally performed in naturally deceased adults, we systematically reviewed original prospective validation studies. Materials and methods: We searched six databases. Two reviewers independently selected articles and extracted data. Methods and patient groups were too heterogeneous for meaningful meta-analysis of outcomes. Results: Sixteen of 1538 articles met our inclusion criteria. Eight studies used a blinded comparison; ten included less than 30 appropriate cases. Thirteen studies used radiological imaging (seven dealt solely with non-invasive procedures), two thoracoscopy and laparoscopy, and one sampling without imaging. Combining CT and MR was the best non-invasive method (agreement for cause of death: 70 %, 95%CI: 62.6; 76.4), but minimally invasive methods surpassed non-invasive methods. The highest sensitivity for cause of death (90.9 %, 95%CI: 74.5; 97.6, suspected duplicates excluded) was achieved in recent studies combining CT, CT-angiography and biopsies. Conclusion: Minimally invasive autopsies including biopsies performed best. To establish a feasible alternative to conventional autopsy and to increase consent to post-mortem investigations, further research in larger study groups is needed. Key points: • Health care quality control benefits from clinical feedback provided by (alternative) autopsies. • So far, sixteen studies investigated alternative autopsy methods for naturally deceased adults. • Thirteen studies used radiological imaging modalities, eight tissue biopsies, and three CT-angiography. • Combined CT, CT-angiography and biopsies were most sensitive diagnosing cause of death

Intervju: akademik Jakša Barbić

Over the past 20 years evidence has accumulated confirming the immunomodulatory role of the appendix in ulcerative colitis (UC). This led to the idea that appendectomy might alter the clinical course of established UC. The objective of this body of research is to evaluate the short-term and medium-term efficacy of appendectomy to maintain remission in patients with UC, and to establish the acceptability and cost-effectiveness of the intervention compared to standard treatment. These paired phase III multicenter prospective randomised studies will include patients over 18 years of age with an established diagnosis of ulcerative colitis and a disease relapse within 12 months prior to randomisation. Patients need to have been medically treated until complete clinical (Mayo score <3) and endoscopic (Mayo score 0 or 1) remission. Patients will then be randomised 1:1 to a control group (maintenance 5-ASA treatment, no appendectomy) or elective laparoscopic appendectomy plus maintenance treatment. The primary outcome measure is the one year cumulative UC relapse rate - defined both clinically and endoscopically as a total Mayo-score ≥5 with endoscopic subscore of 2 or 3. Secondary outcomes that will be assessed include the number of relapses per patient at 12 months, the time to first relapse, health related quality of life and treatment costs, and number of colectomies in each arm. The ACCURE and ACCURE-UK trials will provide evidence on the role and acceptability of appendectomy in the treatment of ulcerative colitis and the effects of appendectomy on the disease course. NTR2883 ; ISRCTN5652301

Frequencies of postmortem PMCT and PMMR features of the brain.

<p>Frequencies of postmortem PMCT and PMMR features of the brain.</p

Postmortem imaging features of the brain.

<p>(A) PMCT: Symmetrical hyperdense cerebral arteries (arrowheads). (B) PMCT: Hyperdensity in the dependent cerebral veins and sagittal sinus (arrowheads). (C) T1w PMMR: High signal of the basal nuclei of the brain (arrowheads). (D) T1w PMMR: Sulcal effacement (arrowheads). (E/F) PMCT (E) and antemortem CT (F) of the same patient. The antemortem CT scan shows normal grey-white matter differentiation (arrowhead). PMCT shows complete loss of grey-white matter differentiation (arrowhead).</p

Internal livores of the liver and spleen.

<p>(A/C) T1w (A) and T2w fs (C) PMMR. Internal livores. In the liver 3 distinct layers (arrowheads) of different T1 signal can be seen and in the spleen 2 layers (arrows). A low T1 signal layer on top, relatively intermediate-to high signal layer in the middle and a low T1 signal layer in the dependent part of the liver. On T2w fs internal livores are not clearly seen. (B/D) T1w (B) and T2w fs (D) PMMR. The spleen shows 2 layers of different T2 signal (arrowheads). T1w show no clear livores in this patient. (E) HE, x100 original magnification. Centrilobular area of the liver with wide sinuses extended by blood (asterisks). (F) HE, x200 original magnification. Congested spleen with lakes of blood (asterisks).</p

Postmortem imaging features of the heart and large vessels.

<p>(A) T2w PMMR: Sedimentation of blood in the heart chambers (arrowhead). T2 signal decay from subepicardial to subendocardial myocardium (arrows). (B) T2w PMMR: Postmortem clotting in the right atrium (arrowhead). Additional finding: a mediastinal herniation of the stomach (asterisk). (C/D) PMCT: Extensive air in the right and left ventricle (arrowheads) and coronary veins (arrows). (E) PMCT: Collapsed ascending aorta (arrowhead). (F) T2w PMMR: Sedimentation of the blood (arrowheads), the plasma layer becomes hyperintense and the dependent layer becomes hypointense. (G) PMCT: Relatively hyperdense aortic wall (arrow) as a result of sedimentation. This is best seen in the ascending aorta. The descending aorta shows a sedimentation level with a hyperdense aspect of the anterior vessel wall (arrowhead). (H) PMCT: Complete collapse of the abdominal aorta (arrowhead) and vena cava inferior (arrow).</p