Virtual Autopsy

Autopsy, or postmortem examination, is often the stuff of crime thrillers these days, limited in use to circumstances of suspicious death. Popular depictions of the procedure in the media often feature cold, forbidding tile-bound rooms with stainless steel tables and a multitude of refrigerated cadaver bays, more often than not presided over by a white-coated, gloved pathologist who slips out to the loading dock to smoke a surreptitious cigarette even while confronted with abundant evidence of mortality.  Hmmmm.  Small wonder then that most family members decline a postmortem examination for their loved one.  Yet as Rick and I discuss on PodMed this week, as revealed in Annals of Internal Medicine, a new technique that isn't invasive or destructive seems poised to revive the procedure, with likely benefits for all.

Virtual autopsy with multiphase postmortem computed tomographic angiography, known by the much more friendly acronym PMCT angiography is a technique combining CT with injection of blood vessels with contrast medium after death. This study employed the technique in fifty hospitalized patients who died unexpectedly or within 48 hours following an event requiring cardiopulmonary resuscitation. Both PMCT angiography and traditional autopsy were performed in each patient.  Of the 336 diagnoses gleaned from medical records prior to the patient's death, virtual autopsy confirmed 93%, compared with 80% confirmation using medical autopsy. Additionally, 16 new major diagnoses and 238 new minor diagnoses were identified using both techniques, with 32 cases of coronary artery stenosis identified by the CT method. Additional unique findings were also found with virtual autopsy but not with medical autopsy.

Okay, so the PMCT angiography seems to be superior in terms of finding new causes or contributory factors to a patient's death, but what's the point of that?  The authors cite the estimate that about 15% of diagnoses are routinely missed by clinicians, and correctly establishing these diagnoses is likely to result in a more educated clinician at least, and hopefully one poised to utilize additional information that may prolong life for some.  Why have autopsies fallen so far out of favor? Physicians may be reluctant to ask, family members often decline, everyone seems to have greater faith in modern diagnostic techniques, and clinical workflow may preclude a window of opportunity to conduct such an examination.  Who will pay for PMCT angiography? And what happens if data reveals that a clinician missed a diagnosis?  While all of these are considerations, the fact remains that autopsy provides a valuable opportunity to add to the body of information relative to diseases and conditions, and routine employment of the technique could spot trends or upticks in disease incidence earlier than they may be seen otherwise.  The virtual technique also avoids what some family members may view as desecration of their loved one's body.  Clearly, Rick and I are in favor of increased employment of PMCT angiography as a means to provide information to aid the living.

Other topics this week include fibrinolysis for pulmonary embolism in NEJM, chemotherapy and peripheral neuropathy in the Journal of Clinical Oncology, and trying to decrease use of benzodiazepines in the elderly in JAMA.  Until next week, y'all live well.

On an entirely different note, Rick and I would like to extend our thanks to Alejandro Delgado and colleagues at Albert Einstein Medical Center in Philadelphia, for hosting us recently to give Grand Rounds. It was a great pleasure to talk about one of our favorite subjects, PodMed, to such a welcoming and enthusiastic audience.  We're thankful they didn't ask us any questions that stumped us; this group has recently chalked up victory in the ACC Jeopardy competition.  Thanks again!

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