Women's health in migrant populations: a qualitative study in France.

BACKGROUND: In 2019, there are 6.5 million migrants living in France. Numerous quantitative studies show inequalities in access and quality of care, in particular in women's health. This study aimed to explore migrant women's experience of gynaecological care. METHODS: We conducted 17 semi-structured in-depth interviews with migrant women in Toulouse (France). We used a Grounded Theory approach to perform the analysis. RESULTS: Although migrant women were generally satisfied with the gynaecological care received, they also reported dysfunctions. Positive elements were the French health insurance system, the human qualities of the healthcare providers and the performance of the health system. Although reassuring, the structured framework was perceived to have little flexibility. This was sometimes felt as oppressive, paternalistic or discriminatory. These obstacles, amplified by the women's lifestyle instability and precariousness, the language barrier and the difficulty to understand a totally new healthcare system, made women's health care and, especially, preventive care, a difficult-to-achieve and low-priority objective for the women. CONCLUSIONS: Migrant women's overall satisfaction with the healthcare system contrasted with the known health inequalities in these populations. This is a good example of the concept of acculturation. Healthcare professionals need to make an introspective effort to prevent the emergence of stereotypes and of discriminatory and paternalistic behaviours. A better understanding and respect of the other person's culture is an indispensable condition for intercultural medicine, and thus for reducing the health inequalities that migrant women experience.

Age estimation at death using pubic bone analysis of a virtual reference sample.

Age at death estimation is a major part of forensic anthropology, but is often poor in the latter decades of life and should benefit from specific population standards. The aim of this study was to test a virtual reference sample with a uniform age distribution in order to improve the accuracy of age estimation for individuals over 40 years of age. We retrospectively built a random virtual reference sample of pubic symphyses from 1100 clinical cases using computed tomography at two French hospitals; this was compared with a test sample (pubic symphyses from 75 corpses undergoing post-mortem computed tomography at a French forensic department) and with the sample originally used in the Suchey-Brooks (SB) system. Inaccuracy and bias were calculated and the proportions of cases in which the real age fell within the estimated age ± 1 standard deviation were calculated. Compared to using the SB sample, using our French sample resulted in a lower inaccuracy for males over 55 years and bias showed that that for males aged 56 to 70 years were less underestimated. Compared to using the SB sample, using our French sample resulted in a lower inaccuracy for females over 70 years and bias showed that that for females aged 56 and older were less underestimated. This study presents a large data set of pubic symphyseal phases from a French virtual sample that allows for improving age estimation accuracy at death, particularly for individuals over 40 years. This kind of material can be useful to improve the age estimation accuracy in a specific region. However, the reliability remains poor and the variability of pubic symphysis morphology related to bone degeneration seems to be an unavoidable limit of the method.

Virtual anthropology: useful radiological tools for age assessment in clinical forensic medicine and thanatology.

Virtual anthropology consists of the introduction of modern slice imaging to biological and forensic anthropology. Thanks to this non-invasive scientific revolution, some classifications and staging systems, first based on dry bone analysis, can be applied to cadavers with no need for specific preparation, as well as to living persons. Estimation of bone and dental age is one of the possibilities offered by radiology. Biological age can be estimated in clinical forensic medicine as well as in living persons. Virtual anthropology may also help the forensic pathologist to estimate a deceased person's age at death, which together with sex, geographical origin and stature, is one of the important features determining a biological profile used in reconstructive identification. For this forensic purpose, the radiological tools used are multislice computed tomography and, more recently, X-ray free imaging techniques such as magnetic resonance imaging and ultrasound investigations. We present and discuss the value of these investigations for age estimation in anthropology.

Evaluation of an automatic method for forensic age estimation by magnetic resonance imaging of the distal tibial epiphysis--a preliminary study focusing on the 18-year threshold.

The contribution of magnetic resonance imaging to forensic age estimation of living individuals is a subject of ongoing research. Several studies have focused on the wrist, clavicle, knee, and foot, and shown interesting results regarding the 18-year threshold. Authors have developed various staging systems for epiphyseal growth plate maturation. However, the procedure is observer-dependent and requires experience and a certain time-learning process. To reduce these pitfalls, we have developed an automatic method based on the analysis of variations of gray levels within the epiphyseal-metaphyseal junction. This method was tested on 160 MRI scans of the distal tibial epiphysis in a sample of individuals aged from 8 to 25 years old, after intensity non-uniformity correction of all images. Results showed that in our sample, 97.4 % of males and 93.9 % of females aged 18 years or more would be correctly classified using this method. To our knowledge, automatic methods for MRI analysis have not been used in the field of age estimation yet. Further studies should be performed to assess the validity of this procedure.

Fetal age estimation using MSCT scans of the mandible.

The purpose of this study was to examine a documented fetal collection, to carry out morphometric analysis of femoral length and of the mandible, and to develop diagnostic standards for estimating fetal age at death based on multislice computed tomography (MSCT) reconstructions. The sample was composed of 81 fetuses, whose ages were recorded in weeks of amenorrhea (WA) between 20 to 40 WA. The measurements made were femoral length (FL) and six distances and four angles of the mandible. Femoral length was measured in 81 fetuses (39 females and 42 males). Morphometric study of the mandible was carried out in 65 fetuses (31 females and 34 males), as the mandible was missing in 16 fetuses. R software was used for statistical analyses. Coefficient correlation (R(2)) and linear regression formulas were calculated. Intra-observer and inter-observer variabilities were very satisfactory (intra-class correlation coefficient ≥0.95). Our method appears to be reliable and reproducible. Femoral length was most strongly correlated with age (R(2) = 0.9). The measurement of six distances and four mandible angles from four landmark positions showed a correlation similar to the femoral length correlation (R(2) ≥ 0.72). The results of this study agreed with those of the literature. We conclude that the mandible is a reliable indicator for estimating fetal age at death. Moreover, MSCT has been shown to be an innovative and reliable technology for this purpose.

Fetal age estimation using MSCT scans of deciduous tooth germs.

Evaluation of fetal age is an essential element in many fields such as anthropology, odontology, paleopathology, and forensic sciences. This study examines the correlation between fetal age, femoral diaphyseal length (considered as the gold standard), and deciduous tooth germs of fetuses aged 22 to 40 weeks amenorrhea (WA) based on computed tomography (MSCT) reconstructions. Qualitative and quantitative studies of femoral and deciduous tooth germ lengths were performed on 81 fetuses (39 females and 42 males). R software was used for statistical analyses. Intra-observer and inter-observer variabilities and the interclass correlation coefficient (ICC) were calculated. Correlation coefficients (R (2)) and linear regression equations were calculated. Intra- and inter-observer variabilities were very satisfactory (intra-observer ICC ≥ 0.96, inter-observer ICC ≥ 0.95). Femoral length was significantly correlated with age (R (2) = 0.9). The correlation coefficient between age and height, width, and dental volume was R (2) ≥ 0.73. Tooth germs were good indicators of fetal age. Our method appears to be reliable and reproducible, and the results of this study agreed with those of the literature. The dental formula provided a precise estimation of fetal age between 25 and 32 WA. Tooth germs were reliable indicators of fetal age, and multislice computed tomography was shown to be an innovative and reliable technology for this purpose.

Modeling and determination of directionality of the kerf in epifluorescence sharp bone trauma analysis.

Characteristics of sharp bone trauma can be extremely useful to determine the origin of cut marks and to provide information regarding the context of death. Using human ribs and clavicle bones, this study analyzes the characteristics of bone kerfs made by different bladed implements, thanks to epifluorescence macroscopy. This technique, which is a nondestructive tool that uses autofluorescence of bones, documents bone damage precisely with high resolution. Both qualitative and quantitative criteria are analyzed. Our results identify unique class characteristics on bone lesions, allowing modeling kerf depending on the weapon, regardless of the type of bone that is wounded. Moreover, we demonstrate for the first time microscopic criteria of directionality, using fluorescence excitation. Orientation of cracks, flakes, and lateral pushing back especially helps in determining the tip and the end of the lesion, leading to the position of the aggressor. Kerf wall characteristics and striation location are also very useful. Epifluorescence macroscopy could be a new tool of choice in anthropology through cut mark analysis in establishing how the blade was used and providing details about the blow.

Age estimation by magnetic resonance imaging of the distal tibial epiphysis and the calcaneum.

Age estimation of living individuals is of critical importance in forensic practice, especially because of the increased migration in developed countries. Recently, the contribution of magnetic resonance imaging (MRI) to age evaluation has been studied, as it seems to be an efficient technique to analyze growth plate maturation and epiphyseal fusion. We developed an MRI staging system for the distal tibial epiphysis and the calcaneal epiphysis and evaluated its reliability on 180 MRI scans of the ankle and foot in a sample of individuals aged from 8 to 25 years old. For both bones, the degree of union between the metaphysis and epiphysis was classified in three stages. Intra- and inter-observer variabilities were good, showing the validity and reproducibility of the method. Our results were consistent with data in the literature indicating that both epiphyses mature earlier in females than in males. Bayesian predictive probabilities were used to assess the validity of our method in estimating the age of an individual in relation to the 18-year threshold. MRI of the ankle and foot can be used in association with other methods to estimate age in living individuals.

[Forensic scientist's implication regarding medical autopsies: experience in a French university hospital (CHU Toulouse)]. / Implication des médecins légistes dans l'autopsie médicale : l'expérience toulousaine.

UNLABELLED: Despite its progressive decline, clinical autopsy remains a useful diagnostic tool. In the French Toulouse University Hospital, a pathologist in collaboration with a forensic scientist performs theses autopsies since macroscopic time. AIM: Our purpose is to present a retrospective study of theses autopsies since the beginning of this collaboration. PATIENTS AND METHOD: We reviewed the demands of medical autopsies between January 2006 and June 2010. We have then analyzed different data such as epidemiological data, gross and microscopic findings and the different causes of death. RESULTS: Thirty-eight medical autopsies were performed during this period. The average age of patients was 45.7 years and the sex ratio M/F 1.5. We distinguished two different populations in this sample: hospitalized patients with numerous associated diseases and non-hospitalized patients who died in a context of sudden unexpected death. A diagnosis was established in 73.7% of the observations. Most of them suffered from infections. Discrepancies between clinical and autopsy diagnoses reached 50% of all cases. Histological examination allowed to establish a complete diagnosis in 47.3% of cases. Histological analysis has a major impact on necropsy diagnosis especially in the lungs, heart or brain. CONCLUSION: Medical autopsy is still the most accurate method of determining the cause of death. Gross and microscopic examinations are fundamental to achieve this aim. Two experts, one pathologist and one forensic scientist, perform these autopsies in Toulouse, in order to improve both experiences and performance in the diagnosis of death.

Prescribed drugs and violence: a case/noncase study in the French PharmacoVigilance Database.

AIM: Our aim was to identify prescribed drugs associated with violent behaviours using the French PharmacoVigilance Database (FPVD). METHODS: All reports of adverse drug reactions (ADR) recorded in the FPVD between 1 January 1985 and 31 July 2008 and including the terms aggressiveness or violence were selected. We compared proportion of exposure to different drugs between cases (reports with violence) and noncases (other reports in the database). RESULTS: Among 537 cases, 56 were included (48 men, mean age 46 years). Misuse was observed in ten cases (18%). In 25 cases (44.6%), a previous psychiatric history was documented. Main drugs involved were nervous system (63.6%) followed by respiratory (7.8%), alimentary tract and metabolism (7.8%), dermatological (5.2%) and anti-infective (5.2%) agents. Case/noncase analysis found an association with dopaminergic agonists (pergolide, pramipexole, bromocriptine, piribedil), benzodiazepines (alprazolam, bromazepam) and serotoninergic antidepressants (taken as a whole), but not antipsychotics or antiepileptics. Association was also found with varenicline, isotretinoin, interferon alpha-2b, rimonabant, benfluorex, topiramate and antiviral drugs (ribavirin, efavirenz). CONCLUSION: Dopaminergic agonists, benzodiazepines and serotoninergic antidepressants are the main pharmacological classes able to induce aggressive behaviour. This study also emphasises the putative role of other drugs less known to be involved in such ADR.

Appraisal by Year Six French medical students of the teaching of forensic medicine and health law.

Legal medicine is a cross-sectional specialty in which medico-legal situations very frequently combine with routine medical practice. A total of 132 students in the last year of the second cycle of medical studies (Year 6) replied anonymously and voluntarily to a questionnaire corresponding to the topics in the curriculum for the national ranking examination: law relating to death and the dying, examination of assault victims, medical malpractice liability rules, writing death certificates, respect of medical confidentiality and the principles of medical deontology. The most frequently cited activities of the forensic physician were autopsy (87.9%), writing certificates (75.8%) and consultations with victims of violence (60.6%). Students did not often come into contact with a medico-legal situation during Years 2-6 of medical studies. Assiduity in attending lectures was low. Students preferred the standard textbooks available in specialized bookshops. They were severe in their appraisal of their own competence at the end of the second cycle, and did not feel ready to examine a corpse (95.5%) or to examine victims of assault (92.4%). Knowledge of the law and of the risks of medical practice was felt to be inadequate by 60.5% of students, and of the writing of a medical certificate by 56.8%. Training medical students in this field is a major challenge in view of the limited number of teaching hours and the need to acquire increasingly specialized knowledge. Complementary initiatives appear to be necessary, such as partnership with other clinical specialties which are frequently confronted with medico-legal situations.

Mitral valve prolapse and out-of-hospital sudden death: a case report and literature review.

The emergency medical services were called to the workplace of a 25-year-old woman who appeared to be dead. The alarm was raised by employees who had found her unconscious at her desk. There was no semi-automatic defibrillator on the premises and no member of staff had received specific training in management of cardiac arrest. External cardiac massage was immediately started as advised by telephone by the emergency physician and ventricular fibrillation was diagnosed on arrival of the medical team. Despite continuous resuscitation, the victim did not revive. The death certificate was signed with a medicolegal objection to burial, leading to an inquiry. Several causes were suggested by the emergency physician who had been called to the patient, and who was unable to account for the death. Autopsy established the diagnosis of mitral valve prolapse. The authors stress that autopsy is imperative and detail the implications of such a procedure.

Acute copper sulphate poisoning: a case report and literature review.

Voluntary copper poisoning is a rare mode of suicide. We report a case of copper sulphate poisoning in a patient presenting delusions with mystic demands for purification. The initial gastrointestinal symptoms were followed by intravascular haemolysis and renal failure. The course was favourable after symptomatic treatment and specific copper chelation therapy. However, the pathogenesis is not fully understood and with the present state of knowledge, no one treatment can be said to be superior to another. The authors discuss the various treatments of this rare poisoning through a review of the available literature.

Application of the Iscan method to two- and three-dimensional imaging of the sternal end of the right fourth rib.

Age determination is a major field of interest in physical and forensic anthropology. Among the different methods based on macroscopic skeletal study, the Iscan method, which analyzes the sternal end of the right fourth rib, is one of the most reliable. We applied the Iscan method to two- and three-dimensional multislice computed tomography (MSCT) reconstructions of the sternal end of the right fourth rib on 39 ribs. The intra-observer variability on MSCT reconstructions was good (gamma coefficient equal to 0.86; value of the Krippendorff's alpha reliability equal to 0.79); inter-observer variability on MSCT reconstructions was also good (gamma coefficient ranging from 0.82 to 0.88; value of the Krippendorff's alpha reliability ranging from 0.78 to 0.86). We demonstrated excellent agreement between the results of analysis of bone samples and those of the two- and three-dimensional images, in particular regarding bone projections, morphology of the pit and of its rim. The accuracy of age estimation did not significantly differ between the Iscan method applied to dry bones and the same method applied to MSCT images. Determination of the Krippendorff's alpha reliability coefficient for the inter-error method confirmed the agreement between phase estimations obtained with the two methods (ranging from 0.55 to 0.71). The real civil age was comprised in 21 cases out of 36 for assessment performed on dry bones and in 23 cases out of 36 on MSCT reconstructions, which represented 58.3% and 63.9%, respectively. Use of MSCT reconstructions in forensic anthropology offers many advantages: no bone preparation, no damage to bone material, and the possibility of application to living individuals.

Virtual autopsy and forensic anthropology of a mummified fetus: a report of one case.

A jar containing the mummified body of a fetus was found in a bush near a building. Full-body multislice computed tomography (MSCT) was performed prior to autopsy to study the bones and internal organs. Age was estimated by measuring femoral and tibial lengths and examining the temporal and occipital bones. The results were then compared with the autopsy and histopathological findings. MSCT was superior to autopsy for examination of the bones and internal organs. Autopsy was difficult because of the fragility of the dried corpse. MSCT determined the gestational age of the fetus and excluded skeletal abnormalities. Estimated age was similar with the two methods used. However, the major advantage of MSCT was rapid measurement of bones or anatomical regions which are difficult to examine during autopsy and which required specific preparation for further anthropological study. This case report illustrates the possibilities offered by MSCT for studying mummified bodies, even fetuses.

Professional indemnity insurance and the practice of medicine during bullfights in France.

Bullfighting can provoke strong reactions, for fans and laymen alike. Risks to the health of participants are inseparable from the spectacle. Organisers call on a medical team whose main task is to treat the bullfighter's injuries. Despite the special features of this medical practice doctors are not exempt from the possibility of the question of their liability being raised in the event of medical malpractice and large financial damages for the bullfighter if he is harmed. The doctor's public liability and professional indemnity insurance contract is therefore all the more important, in fact, this insurance covers damages for harm caused by the policy holder from the moment he is declared liable. In the statute of 4th March 2002, the French legislature brought in compulsory insurance for health professionals with the aim of achieving the best possible compensation for harm. While public liability and professional indemnity insurance is compulsory for doctors, the purpose of making this insurance compulsory is to cover compensation for harm suffered by the victim. In the case of bullfights, faced with insufficient legal regulation and the fact that more often than not the medicine practised in this field is on a voluntary basis, it might be interesting to offer some thoughts on the special features of the insurance contract that ought to be adapted to these extreme working conditions.

Virtual autopsy and forensic identification-practical application: a report of one case.

The body of an unidentified elderly woman was found trapped in a floodgate. Prior to autopsy, full-body multislice computed tomography (MSCT) was performed for study of bone lesions and cause of death. Age was estimated by analysis of the sternal end of the fourth rib and of the pubic symphyseal medial articular surfaces. The results were then compared with the autopsy findings. MSCT was superior to autopsy in diagnosis of traumatic bone lesions and also revealed dental anomalies and signs of drowning. Age estimation gave a similar result for both methods. This case report illustrates the potential value of MSCT for medico-legal investigations of death: diagnosis of injuries, possibility of determining the cause of death, and anthropological study in order to estimate age or to visualize features likely to enable identification of a corpse.

Emergency suicide care in France: the psychiatrist's liability as seen in case law.

In France, in general emergency departments, psychiatric consultations are on the increase and suicidal behavior represents a frequent reason for consultation. Psychiatrists treat patients whose behavior may be impulsive and irrational, and whose critical judgment is impaired. In emergency units, the reception and initial assessment of the patient determines his or her future pathway through the healthcare system. By its very nature, emergency medicine deals with inherently unstable situations, which may lead to the risk of medical malpractice. The aim of this article is to provide a summary of the initial management of suicidal patients by general emergency units and to comment on the medical malpractice that may expose the practitioner to risk of liability. An analysis of case history has shown that in suicide cases, malpractice due to inadequate supervision is the most frequent ruling.

[Vasectomy and vas deferens contraceptive surgery: legal and technical aspects]. / Vasectomie et chirurgies contraceptives déférentielles: aspects légaux et techniques.

OBJECTIVES: To analyse technical innovations, their results and the changing legislation in France concerning sterilizing or contraceptive vas deferens surgery. MATERIAL AND METHODS: A review of the literature was performed using the key words: male/contraception/vas deferens. From the 332 research articles obtained from PUBMED, we selected 54 articles for their methodological quality and the importance of their results. RESULTS: Vasectomy remains the only validated vas deferens surgical technique. Although microsurgical reconstructive techniques have improved the vas deferens restoration rate, vasectomy must be considered to be a definitive method of sterilization. The other contraceptive (reversible) vas deferens surgical techniques have not demonstrated sufficient efficacy to be used outside of the context of clinical trials. However the encouraging results ofsome ofthese studies could allow their development in the intermediate term. From a legal point of view, since the reform of sterilizing surgery in Article L2123-1 of the French Public Health Act, vasectomy is now authorized in a regulatory framework. CONCLUSION: The urology community must take into account progress in the field of contraceptive vas deferens surgical techniques.

Post-traumatic venous and systemic air embolism associated with spinal epidural emphysema: multi-slice computed tomography diagnosis.

A 30-year-old man was admitted with chest trauma after a road traffic accident. The patient was paraplegic and suffered from transient monoparesia of the left arm. The chest X-ray revealed a severe right tension pneumothorax and thoracic spine fractures. Emergency right thoracic drainage was carried out followed by angiography. Unfortunately the patient died and an autopsy was not permitted. Consequently post-mortem multi-slice computed tomography (MSCT) was performed, revealing presence of air inside the right cerebral arteries, bilateral pneumothorax accompanied by a severe right tension pneumothorax, bilateral haematic pleural effusion, pneumomediastinum and bilateral lung contusions. Air was also observed within the right coronary artery, ascending aorta and right ventricle. Thoracic and cervical spinal epidural emphysema were diagnosed. Venous air embolism followed by arterial air embolism producing paradoxical embolism was diagnosed. To the best of our knowledge, this is the first case illustrating by post-mortem MSCT such simultaneous complications after chest trauma as spinal epidural emphysema and cerebral and coronary air embolism.