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.

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.

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.

Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.

CONTEXT.­: The novel coronavirus disease 2019 (COVID-19) pandemic is significantly changing methodologic approaches in all branches of the health system. From a forensic point of view, this event is partly changing the manner in which forensic pathologists and all those who work in autopsy services operate, but above all, it is changing the patterns established for years by which cadavers are analyzed postmortem. OBJECTIVE.­: To present a review of the literature and a proposal for COVID-19 autopsy protocols. To contain the infection risk, a revision of all the protocols that until now have been applied to the examination of bodies that require autopsy services is required. DATA SOURCES.­: Currently, the diagnosis and postmortem analysis of positive or suspected COVID-19 cases plays a crucial role in scientific research. A review of the main recommendations proposed by international scientific societies regarding the risk of infection during autopsy was carried out. Scientific papers currently available via the PubMed NCBI search engine on COVID-19 postmortem diagnosis were also examined. CONCLUSIONS.­: Throughout the history of medicine, autopsy has been fundamental to the understanding of multiple pathogenic processes that are investigated postmortem. The purpose of the study is to propose an operating protocol that can be useful for all clinical and forensic autopsies, with particular reference to the correct methods to be applied to the examination of positive or suspected COVID-19 cases, regarding both the autopsy procedure and the collection and analysis of biological samples.

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.

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.

COVID-19: Postmortem Diagnostic and Biosafety Considerations.

As a result of the 2019 novel human coronavirus (COVID-19) global spread, medical examiner/coroner offices will inevitably encounter increased numbers of COVID-19-infected decedents at autopsy. While in some cases a history of fever and/or respiratory distress (eg, cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with COVID-19 develop mild to no symptoms. Those dying with-but not of-COVID-19 may still be infectious, however. While multiple guidelines have been issued regarding autopsy protocol in cases of suspected COVID-19 deaths, there is some variability in the recommendations. Additionally, limited recommendations to date have been issued regarding scene investigative protocol, and there is a paucity of publications characterizing COVID-19 postmortem gross and histologic findings. A case of sudden unexpected death due to COVID-19 is presented as a means of illustrating common autopsy findings, as well as diagnostic and biosafety considerations. We also review and summarize the current COVID-19 literature in an effort to provide practical evidence-based biosafety guidance for medical examiner-coroner offices encountering COVID-19 at autopsy.

[Provisional guidelines on autopsy practice for deaths associated with COVID-19].

COVID-19 has been included in Category B infectious diseases and is prevented and controlled according to Category A infectious diseases. In order to establish a diagnosis or conduct further research, a post-mortem examination may be desired on a possible COVID-19 death. To guide the personnel engaged in the autopsy to carry out the correct operation, and ensure the safety of the pathologists and disease control staffs during the epidemic, the Chinese Pathological Society, the Chinese Pathologist Association and the Pathology and Pathophysiology national key discipline at Shantou University Medical College, formulated this guidance for the autopsy for deaths associated with COVID-19 during the prevention and control period of COVID-19 in China.