Ownership and uses of human tissue: what are the opinions of surgical in-patients?

AIMS: To investigate whether patient opinion about the uses of tissue removed at therapeutic operations has changed since the adverse publicity surrounding the Alder Hey and Bristol Royal Infirmary Inquiries, and to see whether it aligns with the Human Tissue Act 2004. METHODS: A questionnaire was given to 220 postoperative patients in a teaching hospital during an 11 week period. Aggregated responses to each question were ranked in frequency order. Unweighted centroid linkage hierarchical clustering analysis was performed with dendrogram display for the main data on tissue usage. RESULTS: 203 completed questionnaires were collected (compliance rate 92.3%). 96.3% of patients indicated that they would not object to their tissue being used in research, significantly higher than in the 1996 study (89.1%) with no overlap of the 95% CIs. 29.1% of patients believed that the hospital had ownership of tissue once it has been removed during surgery, 23.2% believed they had ownership, 19.7% believed that the pathology laboratory had ownership, and 15.3% believed that nobody had ownership rights in the case of tissue samples. CONCLUSIONS: This new survey indicates that despite a turbulent decade for those involved in human tissue retention in the UK, public support for a wide range of human tissue based activities, especially biomedical research, has not diminished and that patient opinion aligns well with the Human Tissue Act 2004.

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.

The use of digital imaging, video conferencing, and telepathology in histopathology: a national survey.

AIMS: To undertake a large scale survey of histopathologists in the UK to determine the current infrastructure, training, and attitudes to digital pathology. METHODS: A postal questionnaire was sent to 500 consultant histopathologists randomly selected from the membership of the Royal College of Pathologists in the UK. RESULTS: There was a response rate of 47%. Sixty four per cent of respondents had a digital camera mounted on their microscope, but only 12% had any sort of telepathology equipment. Thirty per cent used digital images in electronic presentations at meetings at least once a year and only 24% had ever used telepathology in a diagnostic situation. Fifty nine per cent had received no training in digital imaging. Fifty eight per cent felt that the medicolegal implications of duty of care were a barrier to its use. A large proportion of pathologists (69%) were interested in using video conferencing for remote attendance at multidisciplinary team meetings. CONCLUSIONS: There is a reasonable level of equipment and communications infrastructure among histopathologists in the UK but a very low level of training. There is resistance to the use of telepathology in the diagnostic context but enthusiasm for the use of video conferencing in multidisciplinary team meetings.

Telepathology: current status and future prospects in diagnostic histopathology.

Telepathology is the process of diagnostic histopathology performed on digital images viewed on a display screen rather than by conventional glass slide light microscopy. The technology of telepathology has radically improved over the past 5 years so that it is no longer the limiting factor in the diagnostic process. This review looks at the resources needed for dynamic and static telepathology, including image quality, computers and software interfaces, means of transmission and human resources. It critically analyses 32 published trials of telepathology, including some large prospective studies, in all areas of diagnostic histopathology including intraoperative frozen sections, routine and referral cases. New developments, including internet solutions and virtual microscopy, are described and there is analysis of the economics of telepathology within health care systems. The review concludes that all the necessary technology for telepathology is available, there is strong published evidence for a diagnostic accuracy comparable with glass slide diagnosis, in many contexts there is a clear-cut economic argument in favour of telepathology, and that the technique should now be integrated into mainstream diagnostic histopathology.

Offline telepathology diagnosis of colorectal polyps: a study of interobserver agreement and comparison with glass slide diagnoses.

BACKGROUND/AIMS: Technological advances have produced telepathology systems with high quality colour images and reasonable transmission times. Most applications of telepathology have centred on the remote diagnosis of frozen sections or remote real time expert opinions. This study investigates the reproducibility and accuracy of offline telepathology as a primary diagnostic medium for routine histopathology specimens. METHODS: One hundred colorectal polyps (50 hyperplastic, 50 adenomatous) were presented in a randomised order to five histopathologists as offline images on a telepathology workstation. Six images of each case were used: the slide label, a low power scan of all material on the slide, and four higher magnification views. The times taken to prepare the images, and to make the diagnoses, were recorded. Interobserver agreement was measured with kappa statistics and compared with the glass slide diagnoses. RESULTS: The kappa statistics for the interobserver agreement on the telepathology images lay in the range of 0.90-1.00, which is interpreted as excellent agreement, and were significantly higher than those for the glass slide diagnoses (range, 0.84-0.98; p = 0.001). The median time taken to capture the images for a case was 210 seconds. The median time taken to make a diagnosis from the telepathology images was five seconds, which was significantly shorter than for the glass slide diagnoses (median, 13 seconds; p < 0.0005). CONCLUSIONS: Offline telepathology has the potential to be a primary diagnostic medium for routine histopathology with a high degree of reproducibility and short diagnosis times. Further studies are required to validate offline telepathology for different types of specimens and different operators of the image capture system.

ACP Best Practice No 164: Necropsy techniques in ophthalmic pathology.

Much important information can be obtained at necropsy by the pathological examination of the eye and its adnexal structures in adults and children. This information may be related to the cause of death (for example, violent shaking trauma in physical child abuse), or may pertain to disease processes affecting the eye, the orbit, and surrounding structures outside the orbit. This article reviews the technical methods used to remove the following: the vitreous (for example, for biochemistry); the eye itself (anterior approach); the eye and orbital contents (posterior approach); the eye, orbit and orbital walls; and the eye, orbital walls, and surrounding structures. The removal of the eye and adnexal ocular structures must be recognised as a "culturally sensitive" issue, which must be approached cautiously. It should only be undertaken for sound scientific reasons, with the fully informed consent of the relatives and/or the coroner (or equivalent authority), and with properly agreed procedures for the eventual retention or disposal of the ocular tissues. For this reason, this article reviews not only the scientific indications and methods for the removal of such tissues, but also the legal and ethical issues that must underpin this pathology "best practice".

The effects of crossing porcine renal artery ostia with various endovascular stents.

OBJECTIVES: To compare the effects of crossing renal artery ostia with various stents. METHODS: The renal artery ostia of 24 large white pigs were covered with a Wallstent (nine ostia), a Palmaz stent (nine ostia) and a Memotherm stent (13 ostia). After an interval of 6-15 weeks, aortography, renal pressure and blood samples were performed and the pigs then sacrificed for histological examination. RESULTS: Histological examination revealed an organised collagen matrix with endothelial cells covering the struts in contact with the aorta. This occurred with all stents but was most organised with the Wallstent. This matrix did not involve the renal artery ostia crossed by Wallstents, but in one Palmaz stent and in 12/13 Memotherm stents, a disorganised acellular matrix caused partial ostial occlusion. There was no mean fall in renal artery pressure but traces were damped in 8/13 cases of partial occlusion. There was a rise in serum creatinine in two cases using the Palmaz stent. CONCLUSIONS: Covering renal arteries with the Wallstent appears to be safe in the short-term. Placement of stents with larger struts across renal arteries will require imaging methods, such as intravascular ultrasound (IVUS) to ensure that the ostia are not obstructed.

Acp. Best practice no 155. Pathological investigation of deaths following surgery, anaesthesia, and medical procedures.

The pathological investigation of deaths following surgery, anaesthesia, and medical procedures is discussed. The definition of "postoperative death" is examined and the classification of deaths following procedures detailed. The review of individual cases is described and the overall approach to necropsy and interpretation considered. There are specific sections dealing with the cardiovascular system (including air embolism, perioperative myocardial infarction, cardiac pacemakers, central venous catheters, cardiac surgery, heart valve replacement, angioplasty, and vascular surgery); respiratory system (postoperative pneumonia, pulmonary embolism, pneumothorax); central nervous system (dissection of cervical spinal cord), hepatobiliary and gastrointestinal system; musculoskeletal system; and head and neck region. Deaths associated with anaesthesia are classified and the specific problems of epidural anaesthesia and malignant hyperthermia discussed. The article concludes with a section on the recording of necropsy findings and their communication to clinicians and medicolegal authorities.

A prospective audit of pacemaker function, implant lifetime, and cause of death in the patient.

AIM: To audit prospectively the reasons for pacemaker implantation, the duration of the pacemaker use, the cause of death, and pacemaker function after removal from the patient. METHODS: Pacemakers were removed at necropsy, or from the bodies of patients awaiting cremation, in three hospitals over a three year period. The cause of death was taken from the results of the necropsy or from the certified cause of death. Demographic data, including the time of implant and reasons for implantation, were checked. The pacemakers were analysed in terms of battery status, program, and output under a standard 470 ohm load. RESULTS: 69 patients were studied. Average age at death was 78 and 80 years for men and women, respectively. The average duration since pacemaker implantation was 46 months. Eleven patients had necropsies, showing that three died from ischaemic heart disease, six from cardiomyopathy, one from an aortic aneurysm, and one from disseminated neoplasia. From the necropsy results and death certificates, the distribution of causes of death in the group as a whole were ischaemic heart disease (21), cardiomyopathy (8), cerebrovascular disease (11), neoplasia (11), chest infection/chronic obstructive airways disease (8), and other causes (10). In all cases the pacemaker box function was within normal limits. CONCLUSIONS: Neither primary nor secondary pacemaker dysfunction was found. The study highlights the impact of arrhythmias in cardiomyopathy, and raises questions about the true role of ischaemic heart disease in these pacemaker requiring patients. The relatively short gap between pacemaker implantation and death requires further study.

Skin appendage involvement in anal intraepithelial neoplasia.

BACKGROUND: High-grade anal intraepithelial neoplasia (AIN III) may be premalignant. Surgical excision of large areas of anal epithelium carries significant morbidity. Ablation treatments may carry less morbidity; however, the depth of ablation is uncertain and failure to ablate dysplasia in hair shafts and other skin appendages may lead to early recurrence. METHODS: This study assesses morphometric aspects of skin appendages in perianal skin and anal canal mucosa in tissues from 30 patients with AIN III. Both normal and dysplastic epithelium was assessed in each patient. The depth to which AIN III involved skin appendages was measured using computerized image analysis. RESULTS: Both the perianal epidermis and anal canal mucosa affected by AIN III were significantly thicker than normal. Nineteen of 30 patients with AIN III had skin appendage involvement. Some 57 per cent of hair follicles (79 of 138), 16 per cent of sebaceous glands (11 of 69) and 25 per cent of sweat glands (24 of 96) observed beneath an abnormal epithelium had evidence of AIN. The median depth of AIN involvement of the hair follicle was 1.14 (range 0.44-1.67) mm, sebaceous glands 1.44 (range 0.96-1.90) mm, and sweat glands 0.94 (range 0.50-2.20) mm. These figures do not take into account tissue shrinkage due to histological processing. CONCLUSION: AIN III involvement of epithelial appendages is a significant problem. For disease eradication, tissue destruction or removal to a depth of at least 2.2 mm below the adjacent basement membrane is required. Surgical excision of high-grade AIN remains the treatment of choice.

Does funeral preference influence clinical necropsy request outcome?

Attitudes towards necropsy have been shown to be more favourable amongst those relatives preferring cremation as a method of disposal compared to those with a preference for burial. In a two-year retrospective study, no significant relationship was found between funeral preferences (burial or cremation) and clinical necropsy request outcome when age, sex and religion were taken into account. Potential religious objections to necropsy were infrequent and cremation was found to have become the most popular method of disposing of the dead during a period when local clinical necropsy rates have continued to decline. Funeral preference is unlikely to have been a significant factor in the decline in clinical necropsy rates.

Ownership and uses of human tissue: does the Nuffield bioethics report accord with opinion of surgical inpatients?

OBJECTIVE: To compare opinion of surgical inpatients with the conclusions of the report of the Nuffield Council on Bioethics regarding the ownership and uses of human tissue. DESIGN: Survey of results of questionnaires completed by patients. SETTING: Large teaching hospital. SUBJECTS: 384 postoperative adult surgical patients. RESULTS: There was strong support among patients for the use of tissues in medical education, research, and science with the exception of those tissues which may transmit disease to others. Few patients (39; 10%) believed that they retained ownership of tissue removed at surgery. Most believed that the tissue belonged to the hospital (103; 27%), to nobody (103; 27%), or to the laboratory (77; 20%). Most patients had not been given any information about the possible uses of their tissues after removal. CONCLUSIONS: Surgical inpatients seem to endorse the conclusions of the Nuffield report regarding the ownership and uses of human tissue. The recommendations regarding patient information and consent procedures should be implemented at the earliest opportunity.

Clinician beliefs underlying autopsy requests.

The aim of the study was to use psychological theory to identify and evaluate factors influencing clinical autopsy requests. A series of pilot interviews were conducted with 20 clinicians to identify beliefs about the benefits and drawbacks, social groups and circumstances influential in the decision to make an autopsy request. The most common beliefs, together with measures of intention to request autopsies, were incorporated into a questionnaire which was distributed among all appropriate clinicians in four hospitals. Statistical analyses identified which beliefs had the most influence on clinicians' intentions to request autopsies. A total of 145 clinicians returned the questionnaire, a response rate of 42%. Clinicians were significantly more likely to request autopsy the more they thought that the outcome of requesting would be of educational value, would confirm clinical diagnoses, would not distress relatives, would not be time-consuming and that the request itself would receive support from their consultant. An autopsy request was unlikely in circumstances where clinicians felt uncomfortable when requesting relatives' permission and when the patients were elderly. The fear of causing distress to relatives and the degree of support from the clinician's consultant were found to be the strongest predictors of intention to request autopsies. These are two areas in which intervention could help to increase autopsy request rates.