virtual autopsies

[scienceguy19]

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http://abcnews.go.com/Health/virtual-autopsies-provide-insights-death/story?id=18134544#.UOnH2-TWKIV

Can you see this taking off? I'm wondering if virtual autopsies would be done by radiologists or pathologists, and whether they would require a fellowship.

 

[Substance]

They'll go nowhere because the payment is also virtual. No rad in his right mind would do a free autopsy. Plenty of paths would but they don't have the experience or training to interpret cross-sectional imaging.

 

[KCShaw]

This has been around for a while now, but as pointed out, there is little to no money in it -- especially as a replacement for day-to-day autopsies -- and the hardware, maintenance, power supply, digital storage, radiographer, etc. are expensive before one even gets to the professional interpretation of them. Right now I believe most of them in the U.S. are still being done either alongside a traditional autopsy, or as a tool to document significant injury when that hasn't already been done in hospital (mainly MVC's and the like), and almost all of them are being done in large population centers where there is either research money or an incentive to minimize the number of autopsies because they can't afford another pathologist. In those cases significant injury is pretty obvious even to a non-radiologist -- just as they can be on plain x-ray, which is sometimes used in similar circumstances without a radiologist read.

Where it gets really neat is in the 3D reconstructions, which can be excellent images to go alongside of or instead of a typical photograph, to help a pathologist explain in court what was found at autopsy.

Where it isn't really ready is as a replacement for autopsy in a typical forensic case where the possibility of legal action exists. It isn't great for some soft tissue injuries, it isn't great for some skin surface injuries (patterned abrasions, contusions, etc.), it doesn't always show small vessels like coronaries that well, not so good with re-approximated subluxations and ligamentous injuries, and as most of you know there are a lot of false positives and false negatives even on living patients with a formal radiologist read. Frankly, by the time one does a CT & MRI, waits for reconstruction, and gets a formal read, many experienced forensic pathologists would be done with the case.

So, like x-ray, it's a useful tool where one can afford or justify it, and there may be a tiny market to get paid for private/non-forensic cases, but I don't see it as the next coming.

 

[deleted314957]

THE military (office of chief m.e. of armed forces) has done them on all iran and afghanistan deaths.

 

[Enkidu]

http://abcnews.go.com/Health/virtual-autopsies-provide-insights-death/story?id=18134544#.UOnH2-TWKIV

Can you see this taking off? I'm wondering if virtual autopsies would be done by radiologists or pathologists, and whether they would require a fellowship.

What's the point of doing this again? Autopsies don't really need to be non-invasive, and the examples they gave weren't very compelling. The CT detected a burst aneurysm and a knife wound?

 

[KCShaw]

I believe they're doing them on every case that goes through the Dover office, and have been for some years -- maybe since around 2004? -- but they also get autopsies. I'm not aware of them doing -only- CT. A lot has been learned from their experience, but they have a somewhat unique case population. They also have somewhat unique resources. A very few other offices have added or were reportedly adding the capability internally, among the more recent I know of being Maryland/Baltimore's new office.

 

[KCShaw]

What's the point of doing this again? Autopsies don't really need to be non-invasive, and the examples they gave weren't very compelling. The CT detected a burst aneurysm and a knife wound?

The real-world use in the forensic setting is probably in averting an autopsy in certain suicides, MVA's, and select other accidents where the cause and manner of death are..generally..pretty self evident following review of scene and circumstances and the point of the autopsy is mainly to document injury, and in non-suspicious possible accidental vs natural deaths (fall with question of significant head trauma/subdural/hip or pelvic fracture) where if they had had a CT scan in hospital prior to death they might never have been brought in and the death certificate signed based on the medical records. In small offices the volume vs cost doesn't work out these days. In very busy offices, however, that could be half a dozen cases every single day, or the workload of 1-2 busy pathologists. Of course the trade off is in occasionally misinterpreting or missing something else or "possibly" having misinterpreted or missed something else being argued in court 2 years later, and it's not entirely clear yet whether the accrediting bodies (really only one right now) will be OK with that kind of use in the long run. But you have to remember that these kinds of cases already get signed out all the time without autopsy (moreso in certain jurisdictions, less so in others) IF reasonable(sufficient in the mind of the FP) medical investigation and diagnosis already took place, such as premortem CT. I think that may depend on the results of studies published over the next 5-10 years now that we have high volume MEO's with this capability and the motivation to look at this exact issue.

Still there's only limited things that a CT can do that x-ray &/or meticulous autopsy can't as far as the basic mandate of determining cause and manner of death, and identifying materials of evidentiary value such as projectiles or other penetrating fragments. But it is a nice tool, and it does look at a few compartments or show some things (posterior soft tissues, posterior aspect of the vertebrae, extremities, gas in places it shouldn't be, etc.) which the average autopsy doesn't or might more easily miss.

I think some of the radiologists would like to see it "replace" hospital autopsy..but be reimbursed like a typical CT. The articles in typical news media seem to flail somewhere in between, showing the cool factor and mixing up cases that need to have an autopsy with hospital cases where family objections matter and talking about declining autopsy rates -- which as far as I can tell is only in the hospital setting. Every ME office I know has been trending upward in their numbers, though my n is very small. If it could be paid for I doubt very many people would object to hospital postmortem CT without autopsy on non-forensic cases since the alternative might be to do nothing at all, except perhaps some academic places that still need numbers for their path residents, though one has to realize CT != autposy in terms of what the results tell you. But if radiology was getting paid for it (really paid for, case by case, not stolen from the hospital general coffers to be "rolled into your salary as a hospital -ologist") then that's more than many pathologists have gotten in many years.

 

[Enkidu]

The articles in typical news media seem to flail somewhere in between, showing the cool factor and mixing up cases that need to have an autopsy with hospital cases where family objections matter and talking about declining autopsy rates -- which as far as I can tell is only in the hospital setting. Every ME office I know has been trending upward in their numbers, though my n is very small.

The news media is all about the "cool factor". This article struggled to convey an actual benefit, except relating family objections. But it anecdotally suggested that CT produced a better result.

Is forensic autopsy rate going up in part because of public interest in forensic science in general? Maybe relating to those television shows?

one has to realize CT != autposy in terms of what the results tell you.

Frankly, it appears to be strictly worse in most ways. Even if it's better at certain compartments, as you mentioned - don't most radiological findings just produce a differential that would lead to pathologic diagnosis?

 

[mlw03]

I'm not going to write long thing here, but short answer is, no, I don't see this taking off to a large extent in our lifetime for numerous reasons. Two easy ones. CTs are expensive, both up front and to maintain. Also, rads make significantly more than us. There are lots of others. At best, CT will be an adjunct in large offices. But I have zero fear of losing my job during my time in practice because of this. And I did my training at one of two civilian offices in the US that have a CT (Baltimore and Albuquerque); Toronto is building a new office that I think will have a CT. KC is right about Dover (the AFME office). UNM is interesting because they have both CT and MRI. Their faculty will get papers for years to come out of this stuff, but my opinion is this is an academic curiosity, not something that will be of use to the majority of forensic pathologists in the next 30 years.

 

[KCShaw]

..snip..

Is forensic autopsy rate going up in part because of public interest in forensic science in general? Maybe relating to those television shows?

Frankly, it appears to be strictly worse in most ways. Even if it's better at certain compartments, as you mentioned - don't most radiological findings just produce a differential that would lead to pathologic diagnosis?

I don't think public interest has much effect on forensic autopsy rates, because the public doesn't have much say in what cases fall under ME/C jurisdiction or which of those are autopsied. And it's rare that ME/C budgets become a public/political issue until way way after it's too late. Maybe it has had an effect on some of the lay coroners, I don't know. It's probably worth a proper review of the numbers against some likely variables, but I suspect it's a combination of raw population increases, cheap fast cars (how many of you got a car at 16? how many of your parents? how many of -their- parents?), longer commutes, more drugs being available and abused in more ways along with that being more of a culture (especially prescription drugs), aging population which means more deaths among those who don't have a physician even if nothing else, more people moving away from family supports, etc.

As for radiologic findings, well, I can't speak for the radiologists. Some pathologic evaluations really only narrow the differential too. There's a lot of forensic use for radiology when evaluating bones, and this is one of the things CT is generally very good at. Simple x-ray of ribs, skull and spine can have false negatives because it can be difficult to get sufficient penetration/orientation -- on the other hand if it's a real concern then a focused dissection isn't all that difficult and certainly ribs & skull are pretty well visualized at a typical autopsy. In contrast to bone, interpreting soft tissue findings are more difficult and generally less sensitive or specific, but CT is still generally better than x-ray and worse than autopsy except for those areas a typical autopsy doesn't cover and a few things like the presence and location of gas. There's no comparison of a written report to a high quality 3D reconstruction of a CT when trying to explain certain things, though -- picture being worth 1000 words and all that. We could go on, but we're basically talking about niche issues. In a lot of ways it's "better" than simple x-ray or autopsy *alone*, but that may be the same kind of "better" a full size Hummer is versus an old 4-cyl Chevy S10 -- they both get you back and forth to work but one is a lot sexier.

But yeah, there are a *few* things that CT is "better" than autopsy at in direct comparison, at least as far as we currently know, though they do exist. I concur with mlw that this isn't going to be stealing any FP jobs anytime soon. It might slow a couple of big offices from adding a position once or twice, maybe, but that doesn't even touch the FP shortage issues across the country. It's more likely that improved x-ray systems will become more prevalent, and those systems will eventually morph into pseudo-CT capabilities, with the FP in the trenches still doing almost all of the reads and performing autopsies alongside at least most of those scans.