Novel Applications and Refinements of Current Imaging Techniques in Perinatal and Childhood Death Investigation

背景：据估计，在英国，每80个怀孕中就有1个会因胎儿畸形而导致流产或死产。尸检可以提供死亡原因的信息，并有助于改变未来怀孕的管理(1)，然而许多父母拒绝这种检查，因为他们觉得自己的孩子已经遭受了足够的痛苦。这意味着他们错过了宝贵的信息，比如他们的孩子为什么会死，未来的孩子是否会遭受类似的命运。我们的机构开创了使用成像来调查死亡原因的“微创”方法，并表明通过使用磁共振成像（MRI）和“钥匙孔”手术方法来获取组织样本，我们在90%(2)的病例中得到与尸检相同的答案。然而，这种方法很昂贵，而且不幸的是没有广泛使用。我们相信，我们可以通过使用超声成像和针活检来改进这项技术，这种方法会在皮肤上留下更少、更小的痕迹，如果它能达到与全面尸检相似的精度水平，就会更容易在全国推广。目的：本研究将测试超声引导下的针组织活检与尸检相比效果如何。我们还将研究不同的成像检查单独使用和与组织取样结合使用时的效果。方法：同意进行儿童尸检的父母将获得一系列成像检查和侵入性较小的针活检。然后，我们将这些结果与我们目前的尸检结果进行比较，并测试发现的任何差异。应用和好处：父母告诉我们，他们希望在这个非常困难和情绪化的时刻，用“最低限度的必要”方法来进行尸检。通过展示一种侵入性更小、以成像为主导的技术是可以实现的，并且可以给出准确的结果，我们打算为父母提供一种发现孩子死亡原因的替代方法。这意味着不仅要提供针活检，还要了解什么时候仅靠成像就能诊断。通过使用另一种更可接受的调查方法收集的信息，可以帮助父母结束悲痛，了解孩子死亡背后的原因，并有助于了解未来的孩子患类似疾病的风险是否会增加。提高这项调查的接受率也可能意味着我们可以更好地理解和探索儿童死亡背后的原因。这有助于为改善孕产妇和儿童健康的公共卫生政策和举措提供信息。目前，并非英国所有的中心都能提供一种侵入性较小的调查方法。如果这项研究可以为更好的实践提供证据，我们希望这将为新的NHS尸检服务奠定基础。(1) Lawn JE, Cousens S, Zupan J. 400万新生儿死亡：何时发生？在哪里?为什么?《柳叶刀》2005年;[2]张建军，张建军，张建军，等。磁共振成像在胎儿和儿童尸检中的应用。《柳叶刀》2013年;382: 223 - 233

Background:It is estimated that 1 in 80 pregnancies in the UK will result in a termination or stillbirth due to an abnormality of the baby. An autopsy can provide information on the cause of death and help change management in future pregnancies (1), however many parents refuse this examination as they feel their child has suffered through enough. This means they miss out on valuable information about why their child died and whether future children will suffer a similar fate.'Less invasive' ways for investigating the cause of death using imaging have been pioneered at our institution and shown that by using magnetic resonance imaging (MRI) together with 'key-hole' surgery methods to obtain tissue samples, we get the same answer as autopsy in >90% (2) cases. This method is however expensive and unfortunately not widely available. We believe we can improve on this technique by using ultrasound imaging with needle biopsies which makes fewer and smaller marks to the skin and would be easier to roll-out nationally if it can achieve a similar level of accuracy as a full autopsy.Aims:This study will test how good ultrasound guided needle tissue biopsies are compared to autopsy. We will also investigate how good different imaging tests are when used alone and in combination with tissue samplingMethods:Parents who consent for childhood autopsy will be offered a series of imaging tests and less invasive needle biopsies. We will then compare these results with our current autopsy results and test for any differences in findings. Applications and benefits:Parents tell us that they want the 'minimum necessary' approach to autopsy during this very difficult and emotional time for them. By showing that a less invasive, imaging-led technique is achievable and can give accurate results, we intend to offer parents an alternative method for discovering the cause for their child's death. This means not only offering needle biopsies, but also understanding when imaging alone would be sufficient in coming to a diagnosis.The information gathered by using an alternative, more acceptable method of investigation may help parents in their grieving process by providing closure and understanding for reasons behind their child's death, and help to understand whether future children are at increased risk of similar diseases.Increasing the rate of uptake of this investigation may also mean we can better understand and explore reasons behind why children die. This can help inform public health policies and initiatives in improving maternal and child health. At present not all centres in the UK can offer a less invasive method of investigation. If this research can provide evidence for better practice, we hope this will set the foundations of a new NHS autopsy service. (1) Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365:891-900(2) Thayyil S, Sebire NJ, Chitty LS et al Post-mortem MRI versus conventional autopsy in fetuses and children: a prospective validation study. Lancet 2013; 382: 223-233