What would you learn from heart path slides though? Presumably for mechanism you'll need in vitro/animal studies with live virus. Seems like most path findings would be non-specific leukocytic infiltration, unless I am missing something.Originally Posted by YVK
edit: actually, it could be useful to see if there is any truth to this coagulopathy/ischemic injury hypothesis that is floating around
Direct viral injury vs vascular injury. If direct, type of cellular and immune response and whether immuno suppression should be considered, given relatively low reported incidence of bacterial superinfection and high incidence of CV death in sicker patients. If vascular injury, how much thrombosis, what kind, and whether antiplatelet or anticoagulation treatment might be in order. Any pre-existing pathologic predictors of poor CV outcome and whether anything can be done to modulate that (remember the ACEI concern 150 pages ago, is it that, or maybe LVH etc). Is injury resulting in significant necrosis and fibrosis or not (long term implications for survivors), and their patterns.
In general, the demise of a clinical postmortem exam in this country is a very sad thing. I come from a place and era where every patient who died in the hospital had a mandatory postmort exam. Every single person, and it had to be attended by at least one doc from a treating clinical team. In three years I worked there I went to dozens of those, and I learned a lot.
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The PPE saga continues.
Last Friday, FDA published guidelines on what goods from CN can be imported and what certs/provenance would be required. Much clarity from FDA. A good thing.
The CN government has taken a ton of incoming fire regarding non-performing product and outright fake certifications. They're taking steps to stop it. Also good.
What steps does an authoritarian government take to accomplish this? Exert control, of course.
Starting next week, PPE exporters will need to have a government permit to export. Not only will they need a permit, which apparently will be a 2-week process to obtain, they will also need to provide batch-level data and be subject to inspection. Again... good news but the opposite of fast.
"No free man shall ever be debarred the use of arms." - Thomas Jefferson, Virginia Constitution, Draft 1, 1776
So, yes autopsy pathology is tremendous for assisting researchers in mechanisms of injury and understanding the underlying respiratory, cardiac, renal, heme/coag and neuro changes. Remember, as part of the autopsy we can obtain fresh and fixed tissue for later staining and ultrastructural analysis as well as directly visualizing mechanisms of injury and death.
The great misconception abut autopsy pathology is that imaging is "just as good". The imaging has increased at an unbelievable rate, and the hospital diagnosis discordance rate compared to autopsy has not changed a bit since the 70's. Autopsy is the ultimate hospital QC/QA. However, autopsies cost money, and since the 70s, the financial incentive to do an autopsy has been progressively reduced until it is no longer a priority in any medical facility. Which is why you see so few autopsy pathologists, except in really big teaching institutions or as part of medicolegal death investigation. And within MDI circles, the number of forensic pathologists is critically low. There's less than 500 of us in the US (and only a handful in Canada). Again, all financially driven, forensic path salary at 1/2 to 1/3 of what private practice makes.
With respect to the role of autopsy within the current pandemic. Death investigation is handled at a state level, so each state has different reporting guidelines and different criteria for case jurisdiction and autopsy. So there is a bit of a patchwork with respect to whether these cases are part of the MDI system and if so, whether they are autopsied. Also, there are significant differences in facility capability. For example, I have a building built in 1978 with the absolute best technology available from 1963. So, I have no capability to isolate the case, nor an air handling system capable of introducing negative pressure to my autopsy room. I also can't clean the room effectively, because it is all porous surfaces. In my state, Public Health Emergency is not part of my criteria for accepting a case. So we are not accepting deaths that happen to admitted patients from the hospital, and not autopsying cases that we know are positive. We're swabbing high risk cases and testing before we examine them. And most of that is done outside, in a tent. Yay.
But other states are very aggressive about doing Covid autopsies and are collecting lots of data and tissue for CDC.
Burial/cremation. Embalming kills anything but is a procedure than can aerosolize blood and fluids. Most funeral homes are late adopters of PPE. So they have an inadequate supply. Funerals spread disease. One funeral in this state is responsible for a tremendous number of deaths. So, funeral homes are having to limit the numbers of people present. Direct burial and direct cremation are becoming more popular. The funeral homes are working on best practices, but as always, we don't know enough to understand what those best practices should be.
Yes, I saw that too story from NYC, from what looked like a credible source. And I've heard of similar instances in other counties. If these reports are correct, there's a number of folks who die from COVID-19 related issues, but are never hospitalized or tested. And aren't included in the official numbers.
They eventually get recorded, just not in the twice daily updates.
We've got our hands full. We just don't make or want press about it.
I understood very little of that but found it riveting nevertheless.
“Remember, being healthy is basically just dying as slowly as possible,” Ricky Gervais
Me too.
Doesn't read posts longer than two paragraphs.
Just got my results back. Got my annual bronchitis last week with a low grade fever. Knocked me down for two days, so it was milder than most episodes. Waited 24 hours after my fever subsided to go back to work. Coworkers shit themselves. Sent home and could not return until I got tested. Did the drive through test. Swab got shoved so far into my nasopharanx that I thought it would trigger a siezure. When I swallowed my soft palate was moving around the swab, I do not recommend taking this test if you don't have to.
Took 30 hours to get negative results.
pat
So, back to this question. Presume we're using COVID+ cadavers in order to better elucidate the pathophys of the virus (AKI, myocardial injury etc). A couple thoughts:
1. Presumably we'd also need a reasonable sample size, correct? Obviously most COVID patients do not die or even end up in the ICU, and it seems like the symptomatology is very heterogenous, so getting myocardium/renal parenchyma/other tissues of interest from a single patient would not be sufficient to draw a conclusion.
2. Is there any reason these tissue samples couldn't be taken endovascularly, to reduce exposure to viral particles? Seems like obvious limitations would be : A. safety/consent/enrollment issues for patients who would be of interest as they would all be seemingly intubated, sedated, and very sick; B. seems like it would be a hard sell for providers who would have to go in, use PPE and risk exposure, and C. Doesn't seem like endovascular approach would work terribly well on a cadaver. That said, would this be a better approach than traditional autopsy? Or at least some other percutaneous Bx approach?
3. Assume we can use cadavers to better understand some of the more basic, "gross" mechanisms of injury (inflammatory vs thromboembolic, etc). Presumably to leverage this into improved therapies we would still need to bring this into some sort of basic research model, no? Most of the specific therapies we might apply (broadly, antivirals and antinflammatory/immunosuppressive meds eg. toculizumab) would still have to be selected and trialed based on their putative molecular targets, which I assume we wouldn't be able to identify via cadaver sections alone. Certainly the antivirals, at the very least.
It seems like it would be helpful to know if this creates a hypersensitivy rxn, if this causes a coagulopathy/microvascular disease, etc etc, but ultimately it seems like it would not much juice/a lot of squeeze at this particular point in time. Let me know if you think there is something I am missing here.
I don't really have the perspective to understand the decline of anatomical pathology services and how this has affected practice, but I definitely understand the concerns. Certainly from my point of view one movement that concerns me is the move away from cadaver lab-based anatomy teaching in MS1/2, which is gaining momentum nationwide. We had a very traditional, 10 week intensive anatomy course in a very nice cadaver lab. I can't say I remember the insertion/origin/action of all of the extensors and flexors of the forearm, but I also can't imagine going through medical school without that experience.
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