- Email: [email protected]
First virtual autopsy in Saudi Arabia: A case report with literature review
Journal of Forensic Radiology and Imaging 3 (2015) 76–79
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
First virtual autopsy in Saudi Arabia: A case report with literature review Khaldoon Aljerian, Abdulrahman Alhawas, Sakher Alqahtani, Bartolomeu Golding, Theeb Alkahtani n King Saud University, Riyadh, Saudi Arabia
art ic l e i nf o
a b s t r a c t
Article history: Received 12 September 2014 Received in revised form 1 November 2014 Accepted 7 November 2014 Available online 18 November 2014
In this paper we document the first reported use of virtual autopsy tools in Saudi Received Arabia. The subject was a female stillbirth who was subjected to a multi-detector CT Accepted scan, revealing radiological findings consistent with the diagnosis of Available Online autosomal recessive polycystic kidney disease (ARPKD). This was later refuted by manual autopsy that diagnosed MCDK. More studies are required before a conclusion on the validity of virtual autopsy can be reached. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Virtual autopsy First case Saudi Arabia Islamic fatwa Multicystic dysplastic kidney disease (MCDK)
1. Introduction Post-mortem examination (PME) is a procedure performed on a cadaver, usually as a means of determining cause of death [1], but also as a way of ensuring accurate record keeping of mortality statistics [2], quality assurance in critical care units [3–5] and as an assessment of medical diagnostics and care [6–8]. In Saudi Arabia, the importance of PME is escalated as the majority of death certificates are not accurate [9] and the rate of consanguinity is very high [10–12] which has genetic implications for offspring including birth defects [13–17]. In Islam, it is a religious requirement to bury the body immediately after death [18]. This is why Muslims consider that immediate burial is essential to comfort the deceased and many times do not allow autopsy. As the Holy Qur'an and the Hadith have not directly addressed the issue of autopsy [19], help was sought of a fatwa which is a ruling on a point of Islamic law given by a recognized authority [20] issued by the Islamic Committee to know the indications of performing hospital or medico legal autopsy. The fatwa decreed that autopsies were allowed if the following conditions were observed: ▪ When it is requested by a judge during criminal proceedings to determine the cause of death of a victim when the latter is deemed ambiguous or unclear.
n
Corresponding author.
http://dx.doi.org/10.1016/j.jofri.2014.11.002 2212-4780/& 2014 Elsevier Ltd. All rights reserved.
▪ To confirm the presence of infectious diseases that, if confirmed, may require preventative or containment measures to avoid public health concerns. ▪ For teaching purposes in certified institutions such as Universities and colleges of medicine. The other clauses of the fatwa narrate the ethical and moral values of Islam, which are mandatory while dealing with human dead bodies. Nonetheless, this fatwa clarifies the Islamic perspective of PME and recommends such an examination where needed. In current days, Islam no longer conflicts with autopsy, but social aspects matter more to the public view than religious facts [20]. But, even though hospital autopsy services are urgently required, they are, as of yet, scarce in both private and government healthcare institutions. However, current health concerns, such as the MERS epidemic, have served to increase the demand of such services due to the severe number of fatalities in a short period of time. Faced with these issues, the medical community has been compelled to question the reasons for the lack of availability of PME and instigated the implementation of practical alternative. Virtual autopsy PME by multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) [29], is an innovative technique in forensic medicine that may be used as a part of PME [21] or as an alternative tool to the classic forensic autopsy. However, its use as an alternative to autopsy is yet in its nascent phases [30] although several institutions worldwide have implemented it in their medico-legal workflow [22]. Virtual autopsy is expected not only to increase the rate of PMEs, but also to serve an effective alternative to the classic autopsy in countries like Saudi
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
Arabia, which lack highly specialized pathologists and have sociocultural and religious barriers. In this study, the first ever implementation, in Saudi Arabia, of virtual autopsy tools for the diagnosis of cause of death is documented and compared with a manual autopsy to confirm the results. The objective was to help support virtual autopsy as an accurate alternative for manual practices and thus a way to bypass the barriers that exist in modern society.
77
numerous cysts [42]. Multicystic dysplastic kidney disease (MCDK) was considered as there was also evidence parenchymal destruction [23]. However, as the condition was bilateral which is very uncommon in MCDK, the suggestion was discarded. Following this, a forensic pathologist, using standard dissection and tissue analysis, conducted a manual autopsy with biopsy of kidney tissue for laboratory analysis. The diagnosis was multicystic dysplastic kidney disease (MCDK) as there was evidence of renal dysplasia, which is not found in ARPKD [24], and large irregular cyst masses (Fig. 2).
2. Case description The deceased was a female stillbirth. Unfortunately, due to a hospital misfiling, parental and pre-natal information could not be obtained. Virtual autopsy was conducted to determine cause of death after consent was obtained from the subject's parents. The postmortem scan was performed by a General Electrical (GE) light speed 16 multi-detector computerized tomography scan (MDCT), manufactured by GE Healthcare (Milwaukee, WI, USA). The PMCT specifications were 180 mAs, 120 kVp and a measured FOV of 50 cm. This was reconstructed to images of 0.625 mm slice thickness at 1.375:1 Pitch. All images were exported to a dedicated review workstation (Advantage workstation, version 4.5; GE Healthcare, Milwaukee, WI) for further assessment. A qualified radiologist then reviewed the findings. Needle biopsy was not performed due to a lack of proper equipment. When viewed by a qualified radiologist, the CT images revealed significant enlargement of both kidneys with numerous bilateral cystic hypodense lesions, mainly in peripheral areas, causing destruction of normal renal parenchyma. The renal pelvis was under-developed and there was also mild flank distention (Fig. 1). These findings suggested the diagnosis of Autosomal Recessive Polycystic kidney disease (ARPKD) which is characterized by presenting bilaterally enlarged, diffusely hypodense kidneys with
Fig. 2. Images showing the (a) gross kidney structure with bilateral presentation and (b) a histological section showing dysplastic ducts, immature tubules, abortive glomeruli and disorganized nephrons, all of which are consistent with MCDK.
Fig. 1. (a) Coronal and (b) axial mid-abdomen crosssectional CT image showing enlargement of both kidneys (indicated) with diffuse hypodensity. Numerous cysts in addition to an under-developed pelvicalyceal system are also in evidence.
Fig. 3. Image of the right side of the subjects face depicting the characteristic deformities of Potter's facies. A frontal image could not be obtained.
78
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
There was also evidence of Potter facies, with the fetus exhibiting characteristic deformed facial features such as flattened nose and low set ears, caused by insufficient renal function during gestation, leading to reduced amniotic fluid (Fig. 3) [25].
procedures (biopsies). However, the degree of invasiveness is small and therefore still acceptable under cultural limitations. Further studies would need to be conducted to determine if this is indeed the case or simply the result of a very uncommon and misleading condition.
3. Discussion
4.1. Recommendation
Postmortem macroscopical and histological examination is the most accurate method of determining cause of death and auditing accuracy of clinical diagnosis, diagnostic tests and death certification [26]. Nevertheless, there has been a decline in the rate of autopsy worldwide for decades, a fact that has been widely documented [27–30,31–35]. Studies have shown that the declining rate of non-coroner autopsies is caused by the creation of bioethics laws [36], patients views on the practice which makes it difficult to obtain consent from relatives; advances in modern diagnostic techniques [37,38], delay in obtaining autopsy reports [39], concerns about disfigurement and other cultural [40,41] or religious reasons. There is also a lack of satisfactory knowledge about autopsies in relatives and clinicians [42,43]. We believe that using virtual autopsy can solve most of these issues. Our findings show that virtual autopsies can serve as a practical means to counter this problem. Its execution was fast, taking no more than 20 min to complete the scan, and required little in technical expertise to accomplish. This would help to avoid the need for prolonged preservation of the body, which can be expensive and difficult in hot countries. Furthermore, there was no physical tampering with the body or treatment with any chemical that could mare its appearance. This should serve to make it more acceptable in the public eye and not causes any religious outcry on grounds of desecration or disrespect of a loved-ones remains. Furthermore, the resulting scans, being in digital form, did not require any immediate attention and could be seen by a trained radiologist as time allowed. This would help to ameliorate the problem of short supply of medical professionals, as it would only require a fraction of the time to analyze the results rather than conduct extensive manual testing. We are well aware that performing a biopsy simultaneously to a virtual autopsy is advisable [44,45] and could have provided the physical evidence required to make the accurate diagnoses between MCDK and ARKP but, being a relatively new procedure in SA, the equipment necessary was lacking. Considering this and the fact that bilateral MCDK is rare, the misdiagnosis of ARPKD is under stable. This highlights the problem of using a virtual autopsy without taking a biopsy or performing a manual autopsy. The lack of physical data or samples could result in physicians misdiagnosing a condition as they would draw conclusions based on past experience or what they believe to be the most likely disease by descriptions provided. This raises the question of how much of an alternative a virtual autopsy is if it requires an invasive procedure to be performed to be accurate, the very thing that needed to be avoided.
Recommendations are divided into two sections, those pertaining to the Saudi Arabia clinicians and those pertaining to any generalized public. Those directed at clinicians include:
4. Conclusion There is a requirement for concerted effort on the part of clinicians, pathologists, the public, and the government to resuscitate and sustain the practice of autopsy in Saudi Arabia and virtual autopsy can attain high public acceptability. The procedure shows a relatively good degree of accuracy but it may fail to stand on its own without the aid of minimal invasive
Comprehensive internal examination to reach the histological
diagnosis should be performed and its findings should be compared with the diagnosis of virtual autopsy. We recommend that more studies be conducted before any conclusions on the validity of a virtual autopsy as an alternative tool for manual autopsies can be reached. Virtual autopsy should be made essential in medical care, education and research and, if warranted minimal invasive procedures such as fine needle biopsy of suspected organ or tissue may be subsequently performed to reach the cause of death. Recommendations for general audiences are
Awareness of virtual autopsy alternatives should be promoted
to the public and training and encouragement to radiologists, pathologists and other healthcare professional should be provided across Saudi Arabia. A unit of forensic radiology should be established at King Saud University to flourish the scope of Victory in the country and to broaden its role in medical education, clinical research and healthcare quality assurance.
Acknowledgments We would like to thank the College of Medicine of King Saud University, Riyadh, for allowing us to use their facilities and equipment for the present study. We would also like to thank the department's staff for their help in running the equipment and preparing the resulting imagery. References [1] OxfordDictionaries. Post-mortem-definition [Online]. Available at: 〈http:// www.oxforddictionaries.com/definition/english/post-mortem〉, 2014 (accessed 16.05.14). [2] T. Kircher, et al., The autopsy as a measure of accuracy of the death certificate, N. Engl. J. Med. 313 (1985) 1263–1269. [3] P. Fernandez-Segoviano, et al., Autopsy as quality assurance in the intensive care unit, Crit. Care Med. 16 (1988) 683–685. [4] J. Hasson, H. Gross, The autopsy and quality assessment of medical care, Am. J. Med. 56 (1974) 137–140. [5] B. Hill, R. Anderson, An autopsy-based quality assessment program for improvement of diagnostic accuracy, Int. J. Qual. Health Care 5 (1993) 351–359. [6] O. Castellanos, et al., The evaluation of autopsy in the pediatric intensive unit, An. Esp. Pediatr. 46 (1997) 224–228. [7] G. Ferreira, M. Montenegro, Autopsy: quality assurance in the ICU, Intensive Care Med. 25 (1999) 360–363. [8] R. Anderson, et al., A model for the autopsy-based quality assessment of medical diagnostics, Hum. Pathol. 21 (1990) 174–181. [9] A. BinSaeed, et al., Assessment of the accuracy of death certification at two referral hospitals, J. Fam. Community Med. 15 (2008) 43. [10] M. El-Hazmi, et al., Consanguinity among the Saudi Arabian population, J. Med. Genet. 32 (1995) 623–626. [11] M. El-Mouzan, et al., Regional variations in the prevalence of consanguinity in Saudi Arabia, Saudi Med. J. 28 (2007) 1881–1884.
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
[12] G. Seifeddin, et al., Consanguineous marriage in an urban area of Saudi Arabia: rates and adverse health effects on the offspring, J. Community Health 23 (1998) 75–83. [13] S. Becker, et al., Consanguinity and congenital heart disease in Saudi Arabia, Am. J. Med. Genet. 99 (2001) 8–13. [14] S. Naderi, Congenital abnormalities in newborns of consanguineous and nonconsanguineous parents, Obstet. Gynecol. 53 (1979) 195–199. [15] A. Gatrad, et al., Consanguinity and complex cardiac anomalies with situsambiguus, Arch. Dis. Child. 59 (1984) 242–245. [16] L. Jaber, et al., Marked parental consanguinity as a cause for increased major malformations in an Israeli Arab community, Am. J. Med. Genet. 44 (1992) 1–6. [17] C. Stoltenberg, et al., Birth defects and parental consanguinity in Norway, Am. J. Epidemiol. 145 (1997) 439–448. [18] R. Charlton, Autopsy and medical education: a review, J. R. Soc. Med. 87 (1994) 232–236. [19] H. McHaffie, et al., Consent to autopsy for neonates, Arch. Dis. Child—Fetal Neonatal Ed. 85 (2001) F4–F7. [20] M. Thali, et al., New horizons in forensic radiology: the 60-second digital autopsy—full-body examination of a gunshot victim by multislice computed tomography, Am. J. Forensic Med. Pathol. 24 (2003) 22–27. [21] M. Loughrey, et al., The declining autopsy rate and clinicians' attitudes, Ulst. Med. J. 69 (2000) 83. [22] K. Kamlesh, Referral for autopsies: analysis of 651 consecutive deaths in one general practice, Postgrad. Med. J. 76 (2000) 415–416. [23] R. Lahti, et al., Exploitation of autopsy in determining natural cause of death: trends in Finland with special reference to the diagnostics of ischemic heart diseases and cerebrovascular disease in middle-aged male 1974–1993 91 (2) (1998) 109–121Forensic Sci. Int. 91 (2) (1998) 109–121. [24] O. Mansoor, et al., Long-term risk of chronic kidney disease in unilateral multicystic dysplastic kidney, Pediatr. Neprhol. 26 (2011) 597–603. [25] Multicystic dysplastic kidney. [26] A. Lugli, et al., Effect of simple interventions on necropsy rate when active informed consent is required, Lancet 354 (1999) 1391. [27] W. Sweeney, E. Avner, Polycystic Kidney Disease, Autosomal Recessive. Gene Reviews [Online]. Available from: 〈http://www.ncbi.nlm.nih.gov/books/ NBK1326/〉, 2014 (accessed October). [28] J. Wiener (2013). Multicystic Dysplastic Kidney Imaging. Medscape [Online]. Available at: 〈http://emedicine.medscape.com/article/411365-overview〉, 2014 (accessed October). [29] S. Shastry, et al., Potter's sequence, Clin. Neonatol. 1 (2012) 157–159.
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[30] H. Harcke, et al., Autopsy radiography: digital radiographs (DR) vsmultidetector computed tomography (MDCT) in high-velocity gunshot-wound victims, Am. J. Forensic Med. Pathol. 28 (2007) 13–19. [31] R. Gatrad, A. Sheikh, Palliative care for Muslims and issues after death, Int. J. Palliat. Nurs. 8 (2002) 594–597. [32] OxfordDictionaries. Fatwa-definition [Online]. Available at: 〈http://www. oxforddictionaries.com/definition/english/fatwa〉, 2014 (accessed 16.05.14). [33] M. Mohammed, A. Magdy, Autopsy in Islam and current practice in Arab Muslim countries, J. Forensic Leg. Med. 23 (2014) 80–83. [34] J. Thali, et al., Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)—a feasibility study, J. Forensic Sci. 48 (2003) 386–403. [35] D. Wichmann, et al., Virtual autopsy as an alternative to traditional medical autopsy in the intensive care unit a prospective cohort study, Ann. Intern. Med. 156 (2012) 123–130. [36] M. Thali, et al., Virtopsy–the Swiss virtual autopsy approach, Leg. Med. 9 (2007) 100–104. [37] J. Roulson, et al., Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review, Histopathology 47 (2005) 551–559. [38] E. Campion, et al., Age and the declining rate of autopsy, J. Am. Geriatr. Soc. 34 (1986) 865–868. [39] K. Zhu, S. Zhang, Analysis of autopsy cases in 50 years, Chin. J. Intern. Med. 43 (2004) 128–130. [40] P. Chariot, et al., Declining autopsy rate in a French hospital: physicians' attitudes to the autopsy and use of autopsy material in research publications, Arch. Pathol. Lab. Med. 124 (2000) 739–745. [41] P. Bradley, et al., A head and neck cancer patient dies! Why perform an autopsy: for the relatives, for the clinicians or for the pathologists? Acta Otolaryngol. 123 (2003) 348–354. [42] P. Lindström, et al., Declining autopsy rate in Sweden: a study of causes and consequences in Malmö, Sweden, J. Int. Med. 242 (1997) 157–165. [43] A. Leibovitz, et al., Postmortem examinations in patients of a geriatric hospital, Aging 13 (2001) 406–409. [44] O. Oluwasola, et al., The autopsy: knowledge, attitude, and perceptions of doctors and relatives of the deceased, Arch. Pathol. Lab. Med. 133 (2009) 78–82. [45] L. Filograna, et al., Diagnosis of fatal pulmonary fat embolism with minimally invasive virtual autopsy and post-mortem biopsy, Leg. Med. 12 (2010) 233–237.
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case report
First virtual autopsy in Saudi Arabia: A case report with literature review Khaldoon Aljerian, Abdulrahman Alhawas, Sakher Alqahtani, Bartolomeu Golding, Theeb Alkahtani n King Saud University, Riyadh, Saudi Arabia
art ic l e i nf o
a b s t r a c t
Article history: Received 12 September 2014 Received in revised form 1 November 2014 Accepted 7 November 2014 Available online 18 November 2014
In this paper we document the first reported use of virtual autopsy tools in Saudi Received Arabia. The subject was a female stillbirth who was subjected to a multi-detector CT Accepted scan, revealing radiological findings consistent with the diagnosis of Available Online autosomal recessive polycystic kidney disease (ARPKD). This was later refuted by manual autopsy that diagnosed MCDK. More studies are required before a conclusion on the validity of virtual autopsy can be reached. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Virtual autopsy First case Saudi Arabia Islamic fatwa Multicystic dysplastic kidney disease (MCDK)
1. Introduction Post-mortem examination (PME) is a procedure performed on a cadaver, usually as a means of determining cause of death [1], but also as a way of ensuring accurate record keeping of mortality statistics [2], quality assurance in critical care units [3–5] and as an assessment of medical diagnostics and care [6–8]. In Saudi Arabia, the importance of PME is escalated as the majority of death certificates are not accurate [9] and the rate of consanguinity is very high [10–12] which has genetic implications for offspring including birth defects [13–17]. In Islam, it is a religious requirement to bury the body immediately after death [18]. This is why Muslims consider that immediate burial is essential to comfort the deceased and many times do not allow autopsy. As the Holy Qur'an and the Hadith have not directly addressed the issue of autopsy [19], help was sought of a fatwa which is a ruling on a point of Islamic law given by a recognized authority [20] issued by the Islamic Committee to know the indications of performing hospital or medico legal autopsy. The fatwa decreed that autopsies were allowed if the following conditions were observed: ▪ When it is requested by a judge during criminal proceedings to determine the cause of death of a victim when the latter is deemed ambiguous or unclear.
n
Corresponding author.
http://dx.doi.org/10.1016/j.jofri.2014.11.002 2212-4780/& 2014 Elsevier Ltd. All rights reserved.
▪ To confirm the presence of infectious diseases that, if confirmed, may require preventative or containment measures to avoid public health concerns. ▪ For teaching purposes in certified institutions such as Universities and colleges of medicine. The other clauses of the fatwa narrate the ethical and moral values of Islam, which are mandatory while dealing with human dead bodies. Nonetheless, this fatwa clarifies the Islamic perspective of PME and recommends such an examination where needed. In current days, Islam no longer conflicts with autopsy, but social aspects matter more to the public view than religious facts [20]. But, even though hospital autopsy services are urgently required, they are, as of yet, scarce in both private and government healthcare institutions. However, current health concerns, such as the MERS epidemic, have served to increase the demand of such services due to the severe number of fatalities in a short period of time. Faced with these issues, the medical community has been compelled to question the reasons for the lack of availability of PME and instigated the implementation of practical alternative. Virtual autopsy PME by multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) [29], is an innovative technique in forensic medicine that may be used as a part of PME [21] or as an alternative tool to the classic forensic autopsy. However, its use as an alternative to autopsy is yet in its nascent phases [30] although several institutions worldwide have implemented it in their medico-legal workflow [22]. Virtual autopsy is expected not only to increase the rate of PMEs, but also to serve an effective alternative to the classic autopsy in countries like Saudi
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
Arabia, which lack highly specialized pathologists and have sociocultural and religious barriers. In this study, the first ever implementation, in Saudi Arabia, of virtual autopsy tools for the diagnosis of cause of death is documented and compared with a manual autopsy to confirm the results. The objective was to help support virtual autopsy as an accurate alternative for manual practices and thus a way to bypass the barriers that exist in modern society.
77
numerous cysts [42]. Multicystic dysplastic kidney disease (MCDK) was considered as there was also evidence parenchymal destruction [23]. However, as the condition was bilateral which is very uncommon in MCDK, the suggestion was discarded. Following this, a forensic pathologist, using standard dissection and tissue analysis, conducted a manual autopsy with biopsy of kidney tissue for laboratory analysis. The diagnosis was multicystic dysplastic kidney disease (MCDK) as there was evidence of renal dysplasia, which is not found in ARPKD [24], and large irregular cyst masses (Fig. 2).
2. Case description The deceased was a female stillbirth. Unfortunately, due to a hospital misfiling, parental and pre-natal information could not be obtained. Virtual autopsy was conducted to determine cause of death after consent was obtained from the subject's parents. The postmortem scan was performed by a General Electrical (GE) light speed 16 multi-detector computerized tomography scan (MDCT), manufactured by GE Healthcare (Milwaukee, WI, USA). The PMCT specifications were 180 mAs, 120 kVp and a measured FOV of 50 cm. This was reconstructed to images of 0.625 mm slice thickness at 1.375:1 Pitch. All images were exported to a dedicated review workstation (Advantage workstation, version 4.5; GE Healthcare, Milwaukee, WI) for further assessment. A qualified radiologist then reviewed the findings. Needle biopsy was not performed due to a lack of proper equipment. When viewed by a qualified radiologist, the CT images revealed significant enlargement of both kidneys with numerous bilateral cystic hypodense lesions, mainly in peripheral areas, causing destruction of normal renal parenchyma. The renal pelvis was under-developed and there was also mild flank distention (Fig. 1). These findings suggested the diagnosis of Autosomal Recessive Polycystic kidney disease (ARPKD) which is characterized by presenting bilaterally enlarged, diffusely hypodense kidneys with
Fig. 2. Images showing the (a) gross kidney structure with bilateral presentation and (b) a histological section showing dysplastic ducts, immature tubules, abortive glomeruli and disorganized nephrons, all of which are consistent with MCDK.
Fig. 1. (a) Coronal and (b) axial mid-abdomen crosssectional CT image showing enlargement of both kidneys (indicated) with diffuse hypodensity. Numerous cysts in addition to an under-developed pelvicalyceal system are also in evidence.
Fig. 3. Image of the right side of the subjects face depicting the characteristic deformities of Potter's facies. A frontal image could not be obtained.
78
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
There was also evidence of Potter facies, with the fetus exhibiting characteristic deformed facial features such as flattened nose and low set ears, caused by insufficient renal function during gestation, leading to reduced amniotic fluid (Fig. 3) [25].
procedures (biopsies). However, the degree of invasiveness is small and therefore still acceptable under cultural limitations. Further studies would need to be conducted to determine if this is indeed the case or simply the result of a very uncommon and misleading condition.
3. Discussion
4.1. Recommendation
Postmortem macroscopical and histological examination is the most accurate method of determining cause of death and auditing accuracy of clinical diagnosis, diagnostic tests and death certification [26]. Nevertheless, there has been a decline in the rate of autopsy worldwide for decades, a fact that has been widely documented [27–30,31–35]. Studies have shown that the declining rate of non-coroner autopsies is caused by the creation of bioethics laws [36], patients views on the practice which makes it difficult to obtain consent from relatives; advances in modern diagnostic techniques [37,38], delay in obtaining autopsy reports [39], concerns about disfigurement and other cultural [40,41] or religious reasons. There is also a lack of satisfactory knowledge about autopsies in relatives and clinicians [42,43]. We believe that using virtual autopsy can solve most of these issues. Our findings show that virtual autopsies can serve as a practical means to counter this problem. Its execution was fast, taking no more than 20 min to complete the scan, and required little in technical expertise to accomplish. This would help to avoid the need for prolonged preservation of the body, which can be expensive and difficult in hot countries. Furthermore, there was no physical tampering with the body or treatment with any chemical that could mare its appearance. This should serve to make it more acceptable in the public eye and not causes any religious outcry on grounds of desecration or disrespect of a loved-ones remains. Furthermore, the resulting scans, being in digital form, did not require any immediate attention and could be seen by a trained radiologist as time allowed. This would help to ameliorate the problem of short supply of medical professionals, as it would only require a fraction of the time to analyze the results rather than conduct extensive manual testing. We are well aware that performing a biopsy simultaneously to a virtual autopsy is advisable [44,45] and could have provided the physical evidence required to make the accurate diagnoses between MCDK and ARKP but, being a relatively new procedure in SA, the equipment necessary was lacking. Considering this and the fact that bilateral MCDK is rare, the misdiagnosis of ARPKD is under stable. This highlights the problem of using a virtual autopsy without taking a biopsy or performing a manual autopsy. The lack of physical data or samples could result in physicians misdiagnosing a condition as they would draw conclusions based on past experience or what they believe to be the most likely disease by descriptions provided. This raises the question of how much of an alternative a virtual autopsy is if it requires an invasive procedure to be performed to be accurate, the very thing that needed to be avoided.
Recommendations are divided into two sections, those pertaining to the Saudi Arabia clinicians and those pertaining to any generalized public. Those directed at clinicians include:
4. Conclusion There is a requirement for concerted effort on the part of clinicians, pathologists, the public, and the government to resuscitate and sustain the practice of autopsy in Saudi Arabia and virtual autopsy can attain high public acceptability. The procedure shows a relatively good degree of accuracy but it may fail to stand on its own without the aid of minimal invasive
Comprehensive internal examination to reach the histological
diagnosis should be performed and its findings should be compared with the diagnosis of virtual autopsy. We recommend that more studies be conducted before any conclusions on the validity of a virtual autopsy as an alternative tool for manual autopsies can be reached. Virtual autopsy should be made essential in medical care, education and research and, if warranted minimal invasive procedures such as fine needle biopsy of suspected organ or tissue may be subsequently performed to reach the cause of death. Recommendations for general audiences are
Awareness of virtual autopsy alternatives should be promoted
to the public and training and encouragement to radiologists, pathologists and other healthcare professional should be provided across Saudi Arabia. A unit of forensic radiology should be established at King Saud University to flourish the scope of Victory in the country and to broaden its role in medical education, clinical research and healthcare quality assurance.
Acknowledgments We would like to thank the College of Medicine of King Saud University, Riyadh, for allowing us to use their facilities and equipment for the present study. We would also like to thank the department's staff for their help in running the equipment and preparing the resulting imagery. References [1] OxfordDictionaries. Post-mortem-definition [Online]. Available at: 〈http:// www.oxforddictionaries.com/definition/english/post-mortem〉, 2014 (accessed 16.05.14). [2] T. Kircher, et al., The autopsy as a measure of accuracy of the death certificate, N. Engl. J. Med. 313 (1985) 1263–1269. [3] P. Fernandez-Segoviano, et al., Autopsy as quality assurance in the intensive care unit, Crit. Care Med. 16 (1988) 683–685. [4] J. Hasson, H. Gross, The autopsy and quality assessment of medical care, Am. J. Med. 56 (1974) 137–140. [5] B. Hill, R. Anderson, An autopsy-based quality assessment program for improvement of diagnostic accuracy, Int. J. Qual. Health Care 5 (1993) 351–359. [6] O. Castellanos, et al., The evaluation of autopsy in the pediatric intensive unit, An. Esp. Pediatr. 46 (1997) 224–228. [7] G. Ferreira, M. Montenegro, Autopsy: quality assurance in the ICU, Intensive Care Med. 25 (1999) 360–363. [8] R. Anderson, et al., A model for the autopsy-based quality assessment of medical diagnostics, Hum. Pathol. 21 (1990) 174–181. [9] A. BinSaeed, et al., Assessment of the accuracy of death certification at two referral hospitals, J. Fam. Community Med. 15 (2008) 43. [10] M. El-Hazmi, et al., Consanguinity among the Saudi Arabian population, J. Med. Genet. 32 (1995) 623–626. [11] M. El-Mouzan, et al., Regional variations in the prevalence of consanguinity in Saudi Arabia, Saudi Med. J. 28 (2007) 1881–1884.
K. Aljerian et al. / Journal of Forensic Radiology and Imaging 3 (2015) 76–79
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