autopsy room. s. cross, r. start and d. cotton. harwood academic publishers. cd-rom

neurobiology before describing how transplantation exper-iments can elucidate mechanisms of CNS disease. Transplan-tation techniques can now restore specific functions to patientswith Parkinson’s disease and neural grafting for Huntington’sdisease is also being investigated. This chapter is perhapscurrently of more theoretical than practical interest. There aretwo colour illustrations as well as several in black and white.

The authorship of this volume is mostly European. The styleand the referencing are variable and the lack of suitablephotomicrographs in some chapters limits the value of thework as a diagnostic aid. However, it does provide a compactsource of useful information for those not regularly involved intransplant pathology.

I would recommend this book as an interesting updateon the clinical transplantation of various organs and tissues,but the practising transplant pathologist may wish to refer tomore detailed publications on specific diagnostic problems.It is more likely to be a departmental than an individualpathologist’s purchase.

C. M. HDepartment of Pathology,

Queen’s University,Belfast

Autopsy Room.S. C, R. S D. C. Harwood Academic

Publishers. CD-ROM.

Autopsy Room is a CD-ROM produced by Simon Cross,Roger Start, and Dennis Cotton from the Department ofPathology in Sheffield, using an array of multimedia tech-niques (sound excluded). This CD-ROM offers the user theability to investigate circumstances pertaining to the death of30 individuals; the running titles include ‘retired widow’,‘hospice man’, ‘young boy’, ‘bronchial man’, ‘hypertensiveman’ and more intriguing labels such as ‘Mr Vice’ and NicoTine’. Thus, at the point of entry to the cases, the enquiringmind should already be asking questions relevant to the finalpathology. Entry to the cases is by looking at a large refrig-erator cabinet with 30 doors and choosing an appropriate case.On selection, the door opens to reveal, somewhat tastelessly, apair of feet lying on a tray with a label attached, presumablyrepresenting the cadaver in question. The scene changes toreveal the same pair of feet lying on a trolley at the end ofwhich is a clipboard allowing access to the clinical history. Tothe edges of this screen are five cantilever boards which allowaccess to details of pre-mortem investigations, the autopsy,cause of death, MCQs, and return to the other 29 cases.

The case history given is in most instances a simple vignetteof some five to ten lines of brief but relatively succinct data,unsullied by the plethora of detail that most career pathol-ogists see in their normal practice. The pre-mortem investiga-tion box allows access to a range of laboratory investigationsincluding haematology, microbiology, and biochemistry. Alsoincluded in this area are details of cytopathology and surgicalpathology, if relevant to the case.

The next section of interest is the autopsy itself, beginningwith external examination and working through all of themajor organ systems of the body. Information is given either inthe form of brief written descriptions, photographs of organsseen at post-mortem, or photomicrographs of relevant pathol-ogy. Taking, for example, the cardiovascular system, the menuoffered includes chest cavity, pericardium, heart, coronaryarteries, aorta and other arteries, and finally the venoussystem. In some instances, there may be up to three or fourpictures of gross pathology or photomicrography from aparticularly relevant diseased organ in the autopsy being

examined. A ‘hint’ box can be opened to help inform theviewer (?Player, about which more later!)

Having studied the history, pre-mortem investigations, andvarious autopsy findings, one is then invited to enter the causeof death. This area is divided into two halves. The first, Part A,is labelled ‘immediate cause of death’, and the second, Part B,is labelled ‘antecedent cause of death’. One is able to scrollthrough a wide variety of disease entities in each of theseseparate menus and once selected, a response button can beactivated which will show whether the chosen immediate andantecedent causes of death are correct. Assuming correctanswers have been given, one can move on to run through aseries of MCQ questions relevant to the disease process andwhen this is complete, return to the original menu of 30 casesto start the procedure again, if desired, or, or course, exit.

In this day of the computer game, the score is everything!Therefore added into this clinico-pathological investigation isa system of scoring. If, for example, the hint box is looked atwhen a photograph of gross or microscopic pathology is onscreen, a description of pathology is delivered by the machine.This attracts a penalty of 1 point. The more hints asked for, themore penalties accrued. This is taken further when it comes togiving the cause of death. For example, coming up with thewrong answer attracts penalty points. A partially wronganswer in which, for example, Part A (immediate) or Part B(antecedent) cause of death is given incorrectly attracts a lessernumber of penalty points than does a completely incorrectanswer; if, however, one becomes frustrated and cannot wait todecide on the correct cause of death and forces the machine topresent the cause of death, then a major penalty of 25 points isthe result. Thus, scores can be obtained for the individualsusing the CD-ROM during particular sessions. Of course, theoriginal entry into the CD-ROM is based on entering the nameof the individual or group which is recorded for futurereference. Ultimately a ‘Hall of Fame’ is formed of all thosewho have ‘played the game’.

The entire system can be managed by a person labelled the‘administrator’ and this facility can no doubt be used to allowindividuals or groups to compare scores with each other, andallow the administrator to see how individuals and groupshave scored in the ‘game’.

At which group is this product aimed? Medical students,junior house officers faced with their first death certificationfor real, specialist registrars, pathologists in training, generalpractitioners, others? The documentation included with theCD-ROM states that ‘all doctors will issue death certificates atsome point in their career. It is crucial to establish the cause ofdeath accurately to avoid medico-legal problems, undue dis-tress for the relatives, and embarrassment for the doctor.’ Itwould seem, therefore, that this CD-ROM is directed at thosedoctors involved in death certification and for whom theautopsy is part of the knowledge base which they may use toestablish the cause of death accurately. This would suggest thatthose most likely to obtain benefit are the ranks of juniorhospital doctors, who, for many years and by long tradition,are left by their seniors with the job of death certification.Medical students, especially in their later clinical years, con-templating imminent qualification would also benefit from thisCD-ROM. It certainly works, it is reasonably friendly to use,most of the material is fairly straightforward, and it is not toodifficult to get something out of a session with the CD-ROM.

However, all is not as straightforward as it may seem. Weare all aware that the death certificate invites the doctor to givethe immediate cause of death in format 1a due to 1b due to 1cand under item 2 the doctor is further invited to add details ofdiseases, which may have contributed to, but not directlycaused death. In the format used in this CD-ROM, in whichone is invited to indicate only the immediate and antecedent

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Copyright ? 1999 John Wiley & Sons, Ltd. J. Pathol. 189: 294–296 (1999)

cause of death, one is not really going much further than the 1aand 1b of the ‘real’ death certificate. This is probably done tosimplify matters, but then is life or death always simple?

I did find some mistakes. For example, in the MCQ relatedto a case of infective endocarditis, the statement was made thatdrug addicts injecting drugs intravenously introduced organ-isms into the left side of the heart. An interesting view ofanatomy! More serious, perhaps, was to find that gross photo-graphs of three separate brains had been used for no less thanseven of the cases. Cases 2 and 8, for example, shared the samephotograph of a brain stated as weighing 1210 g in case 2 and1270 g in case 8. In another instance, the same photographof brain was shared between three cases, the weights allbeing different. This concerns me. Case-based education is verymuch the flavour of our times. Case-based education can bemade up quickly out of the head of the teacher (or should I usethe term ‘facilitator’!). A series of questions can be made up

about the case and suitable archival material may be drawnfrom a number of different sources and be brought together toproduce what is claimed to be a single case. We all do this! Ihave done it! However, I feel uneasy when I see a fudge of thistype in a product such as this, in which material produced bypathologists and obviously directed for the use of eitherdoctors in training or medical students is so obviously ‘artifi-cially constructed’. Maybe as a boring old pathologist, Ihaven’t adjusted to the concept that ‘virtual reality’ does notneed to be real.

M. D. O’HSenior Lecturer/Consultant Pathologist,

Institute of Pathology,Royal Hospitals Trust,

Queen’s University of Belfast,Belfast BT12 6BL

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Copyright ? 1999 John Wiley & Sons, Ltd. J. Pathol. 189: 294–296 (1999)