{"id":124925,"date":"2013-07-22T17:06:28","date_gmt":"2013-07-22T20:06:28","guid":{"rendered":"http:\/\/revistapesquisa.fapesp.br\/?p=124925"},"modified":"2016-02-11T18:09:32","modified_gmt":"2016-02-11T20:09:32","slug":"digital-autopsy","status":"publish","type":"post","link":"https:\/\/revistapesquisa.fapesp.br\/en\/digital-autopsy\/","title":{"rendered":"Digital Autopsy"},"content":{"rendered":"
\"Full-body

School of Medicine\/USP<\/span>Full-body colored CT images of cadaversSchool of Medicine\/USP<\/span><\/p><\/div>\n

The most celebrated portrayal\u00a0of a human dissection is a 1632\u00a0oil painting by the Dutch artist\u00a0Rembrandt. Known as The Anatomy Lesson of Dr. Nicolaes Tulp<\/em>, the\u00a0picture shows seven earnest medical\u00a0students looking at the body of a criminal\u00a0stretched out on a table, with one\u00a0of his arms sliced open and the inside\u00a0exposed. Over the centuries, medicine\u00a0has relied on the type of procedure that\u00a0Rembrandt depicted not only as part of\u00a0medical training\u2014so that future doctors\u00a0could learn about the workings of\u00a0the human body and its diseases\u2014but\u00a0also as a means of determining cause\u00a0of death when necessary. The current\u00a0trend worldwide is to use standard\u00a0medical equipment such as CT scans\u00a0and MRIs to \u201csee\u201d the cause of death\u00a0without needing to cut open the body\u00a0of the deceased. However, the scientific\u00a0foundations of these approaches are still\u00a0limited. One of the most ambitious studies\u00a0in this realm is being conducted in\u00a0S\u00e3o Paulo at the University of S\u00e3o Paulo\u00a0School of Medicine (FMUSP). There,\u00a0under the coordination of Prof. Paulo\u00a0Saldiva, head of the Department of Pathology,\u00a0a group of researchers is testing\u00a0ways to conduct an autopsy using images\u00a0obtained using tomography equipment.\u00a0Working in conjunction with the\u00a0company Braile Biom\u00e9dica, located in\u00a0S\u00e3o Jos\u00e9 do Rio Preto, state of S\u00e3o Paulo,\u00a0the group has developed an injection\u00a0pump that introduces contrast through\u00a0an artery in the groin of a corpse; from\u00a0there, the agent spreads through the\u00a0body, producing high-quality images.<\/p>\n

The researchers expect to take a large\u00a0step forward in their studies in 2014,\u00a0following delivery of a high-field magnetic\u00a0resonance scanner \u2014 the first in\u00a0the Southern Hemisphere \u2014 purchased\u00a0with funds totaling US$7 million from\u00a0three sources: FAPESP, the S\u00e3o Paulo\u00a0State Department of Health, and USP.\u00a0\u201cAs medicine has evolved and as methods\u00a0have been adopted from biochemistry\u00a0and cell and molecular biology, along\u00a0with imaging techniques, autopsies have\u00a0become a thing of the past, even in the\u00a0specialization of doctors,\u201d says Saldiva. \u201cAutopsies are a lot of work; they can take up to three days to do, and they pay poorly.\u201d\u00a0He reports that medical autopsies\u00a0have decreased worldwide in the case\u00a0of death by natural causes. The situation\u00a0is different in forensic medicine, which\u00a0addresses violent deaths, such as those\u00a0resulting from gunshots and stabbings. In\u00a0these cases, a body must be processed at\u00a0the Instituto M\u00e9dico Legal (IML), where\u00a0a forensic physician, who generally has\u00a0police academy training as well as a degree\u00a0in medicine, prepares reports for\u00a0criminal investigations and legal processes.\u00a0\u201cMedical autopsies are for cases\u00a0where people are found dead at home\u00a0or in a public place, or who arrive at an\u00a0emergency department DOA, for example,\u00a0and the doctors don\u2019t know what\u00a0cause to put on the\u00a0death certificate,\u201d\u00a0Saldiva explains.<\/p>\n

These ambitious\u00a0studies on digital\u00a0autopsies are made\u00a0possible by new\u00a0equipment at the\u00a0School of Medicine.\u00a0They are important\u00a0because USP is responsible for the Death\u00a0Certification Service of the city of S\u00e3o\u00a0Paulo (Svoc), which has been attached to the university since its creation by a\u00a0state-level decree in 1939. The service\u00a0processes all cases in the municipality\u00a0of S\u00e3o Paulo that require medical autopsies.\u00a0\u201cThis is the largest medical autopsy\u00a0service in the world,\u201d Saldiva said. \u201cNo other has ties to a university; the Svoc is\u00a0an agency like the Paulista Museum or\u00a0the Institute of Tropical Medicine, attached\u00a0to USP. Anyone who dies in S\u00e3o\u00a0Paulo and doesn\u2019t have a death certificate\u00a0is brought here.\u201d More than 13,000 autopsies a year are performed at the\u00a0Svoc, and many studies are conducted\u00a0there as well, always with the approval of\u00a0family members. Unclaimed bodies\u2014for\u00a0example, of indigents\u2014are not autopsied.\u00a0In 2012, there were 194 such cases. \u201cWe\u00a0have all of these autopsies on hand, and\u00a0with them we can further our research\u00a0and develop new knowledge, in addition\u00a0to relying on the collaboration of\u00a0all departments in the School of Medicine.\u00a0Today there are questions about\u00a0the role of the autopsy as a source of\u00a0scientific knowledge. We want to prove\u00a0that an autopsy can be extremely useful\u00a0when it incorporates new technology,\u201d\u00a0Saldiva says.<\/p>\n

\"Three-dimensional

School of Medicine\/USP<\/span><\/a> Three-dimensional\u00a0reconstruction\u00a0based on a CT scan.\u00a0Organs are shown\u00a0in red. Bones and\u00a0the contrast inside\u00a0blood vessels\u00a0are shown in white\u00a0to gray tonesSchool of Medicine\/USP<\/span><\/p><\/div>\n

Discovering discrepancies<\/strong>
\nIn a scientific article published in the\u00a0journal The Lancet<\/em> in 2012, a group of\u00a0researchers from Oxford University\u00a0presented a study that analyzed 182\u00a0deaths, using CT scanning and MRIs\u00a0alone, without any biopsies. \u201cWith the\u00a0support of the Svoc, we are able to perform\u00a01,000 autopsies a year using images\u00a0and biopsies,\u201d Saldiva explain. \u201cWe\u00a0can do a minimally invasive autopsy\u00a0and a conventional autopsy on the same\u00a0body. We believe a minimally invasive\u00a0autopsy is better than the conventional\u00a0in some situations but not in others. We\u00a0will be able to define these cases and figure\u00a0out where the new technique works\u00a0and where it doesn\u2019t.\u201d<\/p>\n

The scientific bases for using imaging\u00a0studies have been established only in\u00a0the case of violent death. Post-mortem\u00a0imaging was developed in the sphere of\u00a0legal medicine, with Switzerland leading\u00a0the way. \u201cYou can see lesions, bruising, fractures, and where the bullet entered\u00a0and what its trajectory was, without\u00a0cutting open the body and then displaying\u00a0the images before a judge and jury,\u201d\u00a0Saldiva says.<\/p>\n

A medical autopsy, according to Saldiva,\u00a0first serves to determine a person\u2019s\u00a0primary cause of death. It is then possible\u00a0to identify an underlying illness that may\u00a0have contributed to the death. It is also\u00a0possible to ascertain whether any treatment that had been given was appropriate\u00a0and if there were any complications stemming\u00a0from it. \u201cThere\u2019s room here for quality\u00a0control at hospitals,\u201d he says. Saldiva\u00a0remembers a study conducted at Massachusetts\u00a0General Hospital, which performed\u00a0a comparative analysis of autopsy\u00a0results over a 30-year period and found\u00a0that serious mistakes had been made in\u00a010% of cases, mistakes that would have\u00a0altered the stated cause of death. \u201cAt the\u00a0hospital connected to Harvard University, 11% of the autopsies presented errors,\u00a0while a rate of 15% was found at Hospital\u00a0das Cl\u00ednicas in S\u00e3o Paulo. Of course, there\u00a0is a bias towards selecting more complicated\u00a0cases for autopsy, and this might\u00a0lead to the discovery of more mistakes than usual,\u201d he says.<\/p>\n

\u201cFrom a research perspective,\u201d Saldiva adds, \u201cautopsies have an unimaginable contribution to make. When it comes to analyzing brains in the case of age-related diseases such as Alzheimer\u2019s, they\u2019re\u00a0an extremely important tool because there\u2019s no way you can do a biopsy on\u00a0a living person.\u201d He believes that MRIs\u00a0and other new imaging tools will help in\u00a0the selection and analysis of brain tissue\u00a0for the brain bank now being assembled\u00a0at USP. However, he wants to go further by identifying and correlating deaths in\u00a0each region of the city of S\u00e3o Paulo. \u201cIf\u00a0there\u2019s a concentration of young women\u00a0with breast cancer in a certain region of\u00a0the city, we can detect it. It\u2019s a way of assessing\u00a0the relationship between genome and environment,\u201d he says. He dreams of\u00a0collecting the data on the 13,000 autopsies\u00a0performed at the Svoc annually and\u00a0studying each person\u2019s habits\u2014for example,\u00a0determining their diet\u2014and then\u00a0mapping out diseases, especially those linked to air pollution.<\/p>\n

In practical terms, the quality of research\u00a0at the School of Medicine has\u00a0been enhanced by the injection pump,\u00a0which introduces contrast composed\u00a0of iodine and polyethylene glycol, a viscous\u00a0solution. \u201cWe\u2019d been told about a\u00a0device in Switzerland that cost \u20ac100,000,\u00a0but the contrast was very expensive and\u00a0would have to be imported. So we spoke\u00a0to Domingo Braile [a surgeon and one\u00a0of the owners of Braile Biom\u00e9dica; see\u00a0Pesquisa FAPESP<\/em> Issue No. 176<\/a>], and he\u00a0offered us access to his team,\u201d says Saldiva.\u00a0\u201cWe adapted the heart-lung machine\u00a0that we use in cardiac or lung surgery so\u00a0that it can inject the contrast. We added\u00a0some controls, especially in relation to\u00a0the flow of the liquid, which has to be\u00a0well monitored so that no blood vessel\u00a0is accidentally ruptured,\u201d says Marcos\u00a0Vinicius, an electronic engineer and the\u00a0superintendent of testing at Braile.<\/p>\n

\"Images

School of Medicine\/USP<\/span><\/a> Images of the heartSchool of Medicine\/USP<\/span><\/p><\/div>\n

Special shielding<\/strong>
\nThe injected contrast not only yields\u00a0better images but also makes it apparent\u00a0whether a vein or artery has broken\u00a0open. \u201cThe equipment is very capable\u00a0and flexible in developing the functionalities\u00a0that our projects demand,\u201d says\u00a0Prof. Luiz Fernando Ferraz da Silva, a\u00a0member of Saldiva\u2019s group. Brazilian\u00a0technology offers another advantage: the\u00a0design of software tailored specifically\u00a0to this research. Together, the company\u00a0and USP are analyzing the possibility of\u00a0applying for a patent on the equipment,\u00a0which should ultimately cost US$ 43,800\u00a0\u2013 US$ 65,600.<\/p>\n

The injection pump is also being designed\u00a0to work with the MRI machine\u00a0that will be installed in a suite of rooms on\u00a0the lower level of the School of Medicine.\u00a0Oversight of the installation of the rooms\u00a0and equipment is in the hands of Prof.\u00a0Silva, who explains that heavy shielding\u00a0around the room \u2014 made from 400 metric\u00a0tons of iron \u2014 is needed to contain the\u00a0emissions from the strong magnetic field.\u00a0Without this shielding, people who have\u00a0metal prostheses or pacemakers could\u00a0have problems if they were too close to\u00a0the equipment. The MRI has a magnetic\u00a0field of 7 teslas (T). \u201cClinical machines,\u00a0like those used in hospitals, for example,\u00a0have 3 teslas,\u201d Silva notes. \u201cWe were going\u00a0to purchase a 3-T, but at the request\u00a0of the staff in radiology, we bought one\u00a0that is more appropriate for research purposes,\u201d\u00a0says Saldiva. \u201cOnly Germany, the\u00a0United States, England, Japan, Switzerland,\u00a0and France have this type of MRI,\u00a0which has not been approved for use in\u00a0clinical tests yet.\u201d<\/p>\n

Project<\/strong>
\nImage platform in the autopsy room (N\u00ba. 2009\/54323-0<\/a>); Grant Mechanism<\/strong> Multi-user Equipment\u00a0Program (EMU); Coordinator<\/strong> Paulo Hil\u00e1rio Nascimento\u00a0Saldiva – USP; Investment<\/strong> R$ 3,000,000.00 (FAPESP),\u00a0R$ 3,000,000.00 (USP), R$ 1,500,000.00 (School of Medicine\u00a0Foundation), and R$ 3,000,000.00 (USP).<\/p>\n","protected":false},"excerpt":{"rendered":"New equipments help ascertain causes of death","protected":false},"author":10,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[169],"tags":[247],"coauthors":[97],"class_list":["post-124925","post","type-post","status-publish","format-standard","hentry","category-technology","tag-medicine"],"acf":[],"_links":{"self":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/124925","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/users\/10"}],"replies":[{"embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/comments?post=124925"}],"version-history":[{"count":0,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/posts\/124925\/revisions"}],"wp:attachment":[{"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/media?parent=124925"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/categories?post=124925"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/tags?post=124925"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/revistapesquisa.fapesp.br\/en\/wp-json\/wp\/v2\/coauthors?post=124925"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}