What value does an X-ray add to autopsy findings?

James Egans

Joe probably doesn't recall his golden moment in politics when he whispered something naughty in Obama's ear. A word most common in use but whose origin remains a mystery got a new lease of life in the Amy Winehouse song "Me and Mr Jones". But Amy merely borrowed the word from everyday Jamaican, where it's pronounced "fuck-ree" and means irritating, bothersome, out of order, and, more importantly, oppression, the inherent corruption of a dominant society. Indeed, because the inherent domination in medicine is the endless "Fck-ree" of consultants who, for the most part, are pretty poorly educated.

Sandie Bohin thinks one can buffer an acid with another acid; Sally Kinsey doesn't know the difference between air and nitrogen. Not many people challenge these idiots; they carry on propagating their stupidity from generation to generation, safe in this knowledge, and when they get caught out, they simply make shit up, which is Doughy's speciality. If you really want to know what many of these people think of you, here's a taster. Remember who's got two thumbs and doesn't give a crap?

Owen Arthurs, that's who. He's a radiologist, a "technician" more than a "physician".

Owen thinks he can see air with his X-ray machine, but like the pink in the mottling and the harmonics in the screams, his world is largely a world of illusion.

X-rays are also electromagnetic radiation with a narrow range of wavelengths ranging from about 0.01 to 10 nanometers (nm), corresponding to frequencies in the range of 30 petahertz to 30 exahertz (3x10^16 Hz to 3x10^19 Hz). So-called "hard" x-rays, commonly used in medical radiography and imaging, have wavelengths between 0.2-0.1 nm (energies between 5-10 keV). Soft X-rays, less desirable for medical diagnostics, have longer wavelengths and lower energies and are more readily absorbed by the body.[

- The specific wavelength of x-rays used in clinical settings depends on the application, with higher energy (shorter wavelength) x-rays used for imaging denser tissues and lower energy (longer wavelength) x-rays used for softer tissues.

There are no nada, zero, zilch medical studies into using X-rays to diagnose air embolism. In fact, when I put the question to Google, I got this answer:

"One of the search results mentions that a forensic scientist noted "striking evidence" from an abdominal x-ray in a case involving Lucy Letby. This suggests that X-rays may provide helpful information in some post-mortem investigations.

Professor Owens can also project himself into the past:

Consultant paediatric radiologist Owen Arthurs is first up in the witness box this morning. In this case, (Baby I) is giving expert evidence on CT scans, X-rays and other images. ( Except there were no CT scans or other images)

Dr Arthurs has said there is evidence of Pneumatosis (gas within the wall of the small or large intestine) on an X-ray from 30 September of Child I

Dr Arthurs has said Child I had a 'normal' bowl, as per her X-ray on 18 October and into 20 October. Looking at an X-ray from 23, there is a 'massive' dilatation of the stomach.

Dr Arthurs says it is 'quite unusual to see babies with this degree of dilatation of the stomach'; he says it can cause 'splits in the diaphragm' and that can lead to 'respiratory complications.'

Asked how much air it would take to generate such images, Dr Arthurs said: 'We don't know, I don't think anybody really knows. Those experiments can't really be carried out, we can't experiment on babies giving them 50 or 100mls of air and taking x-rays.'

He adds, 'I would guess more than 20mls of air".

'When asked, in the absence of another explanation, whether 'someone has deliberately injected air,' Dr Arthurs says, 'I think that stands to reason.'

Except there is another explanation. The real one is that Pneumatosis in a neonatal abdominal X-ray refers to the presence of gas within the walls of the small or large intestine.

Pneumatosis intestinalis is a virtually pathognomonic (diagnostic) radiographic sign of necrotizing enterocolitis (NEC) in neonates. Pneumatosis appears as a "bubbly" or "soap bubble" appearance in the bowel wall on the abdominal X-ray due to the presence of submucosal gas "blebs" or curvilinear lucencies in the subserosal location. The incidence of Pneumatosis in cases of NEC can range from 19% to 98%, though its presence does not always correlate with the clinical severity of the disease. Pneumatosis can also be seen in other conditions like volvulus, ischemic bowel necrosis, and neutropenic colitis, so it is not entirely specific to NEC. Correct identification of Pneumatosis on abdominal X-rays is critical for the early diagnosis and management of NEC in neonates, as it is one of the key radiographic signs of this serious gastrointestinal condition. Therefore, Pneumatosis on a neonatal abdominal X-ray refers to the presence of gas within the intestinal wall, which is a hallmark radiographic finding associated with necrotizing enterocolitis, though it can also occur in other abdominal pathologies.

That's how 99.999% of all known doctors would see it. They wouldn't feel the need to make up numbers for things without empirical data. In fact, doing so is a grave ethical offence.

Guessing correct diagnoses without proper diagnostic reasoning is unethical, as it can lead to improper treatment and harm to the patient. The search results indicate that even when medical students guessed the correct diagnosis, 7% of the time, their reasoning was incorrect.

The proper answer to this question was that Pneumatosis was a finding of common pathology and that the notion of passing 20 ml into a gut over four metres long is plain stupid.

The non-invasive autopsy typically involves CT scanning of the body rather than a traditional invasive autopsy. A small amount of dye is introduced into the coronary arteries through two small incisions to allow scanning of the blood vessels. The CT scan images are then examined by a specialist NHS Consultant Radiologist, who considers the scan results along with any other available information to determine the cause of death. If the CT scan can reveal a clear medical cause of death, an invasive autopsy can usually be avoided. However, in up to 10% of cases, the radiologist may be unable to determine the cause of death from the CT scan alone. In these instances, the coroner may request a limited or complete invasive autopsy by a pathologist. Pathologists can still assist with complex cases by providing additional evidence to supplement the CT scan findings. The non-invasive autopsy is typically performed within 48 hours of death or sooner if there are particular reasons to expedite the process. NHS staff carry out the entire process, including body preparation, scanning, and reporting.

The evidence for the use of this type of autopsy in children is not good.

Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate?

A systematic review of diagnostic test accuracy.

Abstract:

Objectives: To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age.

Design This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO.

Participants: Deaths from conception to one adjusted year of age.

Search methods MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021.

Diagnostic tests Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy.

Data collection and analysis Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.

Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect.

Main outcome measures Direction of effect was expressed as percentage of patients per study.

Findings: We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against a virtual autopsy. For the remaining tests, the direction of effect was inconclusive.

A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.

Seven trial registrations were included but yielded no results.

Conclusions Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.

If there is insufficient evidence to make firm conclusions using an entire protocol, there is zero evidence for drawing cartoon conclusions from a few dodgy X-rays.

The British public should be grateful that these people don't sell second-hand cars