Forensic criteria, clinical and theoretical issues of the indication of court-ordered treatment: A comparative survey among experts in forensic psychiatry and sentencing judges in France.

Following the French law n° 98-468 of 17 June 1998 relative to the prevention of sexual offenses and the protection of minors, social and judicial follow-up and court-ordered treatment were introduced with the aim of reinforcing the prevention of recidivism. Court-ordered treatment is one of the possible obligatory measures provided for by social and judicial follow-up. However, there is no consensus between the different professionals concerning the criteria of indication and the final purpose of this measure. Most of the few available studies are retrospective. Only rare studies have assessed the influence of criminological factors on the indication of court-ordered treatment. We carried out a nation-wide qualitative comparative study in two populations, psychiatric experts and sentencing judges, by means of e-mail questionnaires. The aim was to determine the criteria for court-ordered treatment according to psychiatric experts and to sentencing judges, to identify the criteria that gave rise to differences in appreciation between these professionals, and to attempt to explain these differences. The secondary aim of the study was to determine the methods and tools used in expert practice to evaluate dangerousness and risk of recidivism. We obtained 20 responses in each of the two populations. The great majority of psychiatric experts and sentencing judges considered that court-ordered treatment was appropriate when the offender presented with psychiatric dangerousness, and so with an underlying mental disorder. When a subject had no identified mental disorder, the psychiatrists were divided in their opinion, whereas the majority of sentencing judges were in favor of court-ordered treatment. Opinions differed particularly significantly between the two populations in four circumstances: a subject with an antisocial/psychopathic personality disorder, a subject who denied the alleged acts, the influence of precarious social circumstances and the influence of instability in intimate relationships. The majority of experts used international classifications (DSM-5 and ICD-10) as a basis for their psychiatric diagnosis. Just under half of those surveyed used structured or semi-structured interview guides and only a few stated that they used standardized actuarial tools to assess risk of recidivism. The concepts of care, dangerousness and mental disorder are associated with multiple representations that certainly play a part in the disagreements between the different professionals. It is of prime importance to define these concepts more clearly in order to encourage the use of a common language and to clarify the indications and purpose of court-ordered treatment. We also hypothesize that disagreements between professionals regarding the criteria for court-ordered treatment may be related to certain difficulties raised by the management of the convicted person. The development of guidelines that could be used by all professionals would help to reduce some of these difficulties. Psychiatric experts remain attached to clinical evaluation. Their limited use of assessment tools may relate to the material constraints and time constraints involved. The issue at stake in court-ordered treatment and social and judicial follow-up is to promote cooperation between the various professionals by creating a space for exchange of ideas where the fundamental questions raised by these measures can be discussed, fears shared and knowledge pooled.

Psychiatric disorders and management of sexual offenders in the prison psychiatric consultation unit of Marseille.

Since 2017, complaints of sexual violence have increased in France. At the same time, the management of sexual offenders has been at the center of international public health policies. The prevalence of mental disorders among sexual offenders is an essential field of research. There are some published studies on the prevalence of psychiatric disorders in sexual offenders in detention, but there are few recent published studies among French individuals who were detained. Our objectives were to determine the prevalence of psychiatric disorders among persons detained for sexual offenses and the level of care received according to their diagnosis. For this purpose, we carried out a retrospective observational study from January 2017 to October 2021 of all adult sexual offenders, whether accused or convicted, who were seen in the psychiatric consultation unit of Les Baumettes prison, Marseille, France. The primary outcome measure was the psychiatric diagnosis entered in the medical records. One hundred forty-two patients were included in analysis. All patients were men, and the majority (n = 97, 68.3%) of these patients presented with at least one psychiatric disorder, principally a personality disorder (31.7%). 10.6% presented with a schizophrenic disorder, 4.9% a bipolar disorder, 3.5% a depressive disorder, 5.6% pedophilic paraphilia, and 25.4% an addictive disorder. Their management and comorbid addictions were analyzed in subgroups for each psychiatric disorder. Patients appeared to receive an appropriate level of care for their diagnosed disorder. It seems important to develop structured assessment of recidivism risk for better management of sexual offenders.

Cervical Dysplasia and Treatments Barrier in Jail: A Study in Marseille's Detention Center-Les Baumettes, France.

Introduction: The main objective was to estimate the prevalence of cervical dysplasia among incarcerated women. The secondary objective was to identify obstacles to the possible management of a cervical dysplasia in detention by assessing their knowledge of screening for cervical cancer (CC), the existence of vaccination, and the management of precancerous lesions. Materials and Methods: The first part of the study was descriptive and retrospective, studying pap-smear results in women's correctional facility at the Baumettes prison center (PC) in Marseille, France. The second part of the study was qualitative and prospective and took place at the Baumettes PC. Voluntary and French-speaking inmates aged 25-65 years answered an short-form 12 quality-of-life questionnaire and a more targeted questionnaire on CC screening and cervical dysplasia treatments. Results: In total, 201 pap-smear tests were assessed, 135 were normal (66.8%) and 33 unsatisfactory (16.3%). There were 33 abnormal pap-smear tests (16%). The patients were 38.9 years (±9.5 years), had 4.05 pregnancies (±2.7), and 2.29 children (±1.85). Seventy-five percent were smokers. Psychiatric disorders were found in 52.2% inmates. In the second part of the study, among the 35 inmates questioned, the SF-12 questionnaire's analysis shows that the physical health component score was on average 43.6 and the mental health component score (MCS) was 36.5. Analysis demonstrated that the uncertainty of the exact day of hospitalization is an obstacle to treatment for 15 patients presenting significantly a lower MCS score (p = 0.047). Conclusion: Prevalence of pathological pap-smear tests is higher within a prison population, screening is accepted and the inmates are receptive to information about CC prevention, delivered during individual interviews. Mental health's management and care system's reorganization in detention are essentials factors for care acceptance.

[Loss of chance in compensation for non-accidental bodily injury: inventory]. / Perte de chance en réparation du préjudice corporel hors accident : état des lieux.

Loss of chance in compensation for non-accidental bodily injury: inventory The main problem with this notion is the hypothetical nature of the loss of chance, insofar as it is impossible to take for sure if the hoped-for event would actually haved occurred. This this is the main difficulty encountered when estimating a loss of chance. The aim of this work is to identify a number of tools that will serve as a basis for the assessment of loss of chance damage. The contribution of data from the literature, the use of abacuses depending on the terrain and the pathology and the contribution of sapients will be described. The calculation methodology will also be discussed in the context of the cumulative loss of chances suffered by the patient.

Perte de chance en réparation du préjudice corporel hors accident : état des lieux La problématique de la notion de perte de chance est son caractère hypothétique, dans la mesure où il est impossible de savoir avec certitude si le fait espéré se serait réellement réalisé. C'est là toute la difficulté qui incombe au calcul de la perte de chance. Il est cependant possible de distinguer ou d'envisager un certain nombre de moyens permettant d'évaluer le préjudice de perte de chance. Les données de la littérature, les abaques, en fonction du terrain et de la pathologie, et les experts y contribuent. La méthodologie de calcul, dans le cadre du cumul de pertes de chances subies par le patient, mérite aussi d'être discutée.

Sudden unexpected infant death characteristics in the French region of West Provence-Alpes-Côte d'Azur.

Background: Although the incidence of sudden unexpected infant death (SUID) has decreased since the 'Back to Sleep' campaign in English-speaking countries and other preventive campaigns, the circumstances of such deaths remain unclear. Aim: To analyse infant deaths recorded at the referral centre for sudden infant death of the West Provence-Alpes-Côte d'Azur region of France (West PACA) and the forensic medicine department of Marseille University Hospital. Methods: Information on all SUID cases from 2000 to 2017 was extracted from the referral centre for sudden infant deaths in West PACA and the forensic medicine department of Marseille. Results: The study included 130 infants over the 17 years with a very similar distribution. There was a marked male preponderance, with 61.6% of boys whatever the age at death (sex ratio 1.6). Half of the deaths occurred in the first 6 months of life and the majority (61%) of infants died during autumn and winter. Nearly one-third (33.2%) had presented with minor infections and 21% had been seen by a doctor or had been admitted to hospital. Most deaths (86.4%) occurred during sleep (night or day). Nearly half of the infants (47.7%) were discovered in a prone position. A large majority of parents (90.7%) agreed to a post-mortem examination. Only 6.2% of deaths led to legal proceedings. Nearly 16.9% remained unexplained after compiling all the data included in the protocol and 9.2% remained unexplained because of incomplete investigation, including refusal of post-mortem examination. Abuse was involved in 2.3% of cases. Conclusions: Asymptomatic infectious conditions were associated with a high proportion of SUID cases. Non-supine sleep positions were still practised. There is a need to increase SUID prevention campaigns. Abbreviations: HAS, Haute Autorité de Santé: French National Health Authority; NICHD, National Institute of Child Health and Human Development; PACA, Provence-Alpes-Côte d'Azur region of France; SUID, sudden unexpected infant death; SIDS, sudden infant death syndrome; CépiDc, Centre d'Epidémiologie sur les Causes Médicales de Décès/Center for Epidemiology on the Medical Causes of Death.

Repeated attempted homicide by administration of drugs documented by hair analysis.

Attempted murder by repeated poisoning is quite rare. The authors describe the case of a 62-year-old man who was admitted to an intensive care unit (ICU) for neurological disturbances complicated by inhalation pneumopathy. He presented a loss of consciousness while his wife was visiting him at the ICU (H0). Forty-eight hours later (H48), police officers apprehended the patient's wife pouring a liquid into his fruit salad at the hospital. Toxicological analyses of a blood sample and the infusion equipment (H0), as well as the fruit salad and its container (H48), confirmed the attempted poisoning with cyamemazine (H0) and hydrochloric acid (H48). In order to evaluate the anteriority of poisonings, hair analysis was requested and the medical records of the 6 previous months were also examined. Two 6-cm brown hair strands were sampled and the victim's medical record was seized in order to determine the treatments he had been given during the previous six months. Segmental hair testing on two 6-cm brown hair was conducted by GC-MS, LC-DAD and LC-MS/MS (0-2/2-4/4-6 cm; pg/mg). Haloperidol (9200/1391/227), amitriptyline (7450/1850/3260), venlafaxine (332/560/260), that had never been part of the victim's treatment were detected, as well as some benzodiazepines (alprazolam, bromazepam, nordazepam); cyamemazine was also detected in all the segments (9960/1610/2367) though only a single dose administration was reported in the medical records. The toxicological analyses performed at H0 and H48 confirmed the homicide attempts in the ICU. In addition, comparison of the results in hair analysis with the medical records confirmed repeated poisoning attempts over the previous six months, and thus explain the origin of the disorders presented by the victim. This case serves to remind us that repeated attempted murder can be difficult to diagnose and that hair analysis can be an effective way to detect such attempts.

Concerns About Lung Cancer Among Prisoners.

BACKGROUND: Few studies have looked at lung cancer in prisoners, despite this population is possibly at increased risk of malignancy. In a previous study, we found an early onset of lung cancer in prisoners. Thus, the present CARCAN study was aimed at assessing the epidemiological characteristics, management, prognosis, and incidence of lung cancer in prisoners compared to a sample of non-prisoner patients. METHOD: We performed a multi-center observational case-control study. Cases were prisoners diagnosed with lung cancer from 2005 to 2013. Controls were non-prisoner lung cancer patients selected from hospital databases and randomly matched to cases (targeted case-control ratio: 1:3). Incidence rates in both groups were calculated using national statistics. RESULTS: Seventy-two cases and 170 controls met inclusion criteria. Cases were mainly men (99%). Mean age at diagnosis was 52.9 (± 11.0) in cases and 64.3 (± 10.1) in controls (p < 0.0001). More case patients were current smokers compared to control patients (83% vs 53%; p < 0.0001). We found no significant differences between the two groups as concerns histologic types, TNM stages at diagnosis, initially-employed treatments, times to management or survival. Incidence rates (2008-2012) in male prisoners were higher than those in the general population in all concerned age groups. CONCLUSION: There is a shift of lung cancer toward young people in prisons. However, the presentation, management, and prognosis of lung cancer are similar between prisoners and non-prisoners. These finding could justify a specific screening policy for the incarcerated populations.

Suicide by Medication Overdose in Prison: A Study of Three Cases.

Suicide is one of the principal causes of mortality in a prison environment. Although suicide by medication overdose is less frequent than suicide by hanging, self-strangulation, or vein cutting, it raises questions as to how the medications are obtained, particularly in view of the specific organization of the medication circuit in prisons. We present three cases of suicide by medication overdose involving different therapeutic classes with different distribution circuits and review the regulatory requirements and the measures that could be taken to prevent such suicides.

Death by self-mutilation after oral cannabis consumption.

Major self-mutilation (amputation, castration, self-inflicted eye injuries) is frequently associated with psychiatric disorders and/or substance abuse. A 35-year-old man presented with behavioral disturbances of sudden onset after oral cannabis consumption and major self-mutilation (attempted amputation of the right arm, self-enucleation of both eyes and impalement) which resulted in death. During the enquiry, four fragments of a substance resembling cannabis resin were seized at the victim's home. Autopsy confirmed that death was related to hemorrhage following the mutilations. Toxicological findings showed cannabinoids in femoral blood (tetrahydrocannabinol (THC) 13.5 ng/mL, 11-hydroxy-tetrahydrocannabinol (11-OH-THC) 4.1 ng/mL, 11-nor-9-carboxy-THC (THC-COOH) 14.7 ng/mL, cannabidiol (CBD) 1.3 ng/mL, cannabinol (CBN) 0.7 ng/mL). Cannabinoid concentrations in hair (1.5 cm brown hair strand/1 segment) were consistent with concentrations measured in chronic users (THC 137 pg/mg, 11-OH-THC 1 pg/mg, CBD 9 pg/mg, CBN 94 pg/mg). Analysis of the fragments seized confirmed that this was cannabis resin with high levels of THC (31-35%). We discuss the implications of oral consumption of cannabis with a very high THC content.

Successful Treatment of Pulmonary and Cerebral Toxoplasmosis Associated with Pneumocystis Pneumonia in an HIV Patient.

In both the post and pre combination antiretroviral therapy (cART) era, Pneumocystis jirovecii and Toxoplasma gondii remain common opportunistic infectious agents. The common manifestations are pneumonia for P. jirovecii and brain abscess for T. gondii. Nevertheless, co-infection remains rare, and pulmonary toxoplasmosis is scarce, or may be underestimated because of its similarity with Pneumocystis jirovecii pneumonia. We reported an uncommon case of an AIDS patient (6 CD4 + T cells/mm³) with both pulmonary and cerebral toxoplasmosis associated with pneumocystis pneumonia. The patient presented with general weakness, fever and dyspnea. Pulmonary toxoplasmosis and pneumocystis were confirmed by microscopic examination and DNA detection in the bronchoalveolar lavage. Computed tomography imaging of the brain revealed a single characteristic cerebral toxoplasmosis lesion of the left capsular area. He was successful treated by trimethoprim/sulfamethoxaxole in conjunction with an early reintroduction of cART, and without IRIS development. During a 3-year follow-up, HIV viral load remained undetectable, and the patient did not relapse for toxoplasmosis or Pneumocystis pneumonia.

Post Mortem Redistribution of Drugs: Current State of Knowledge.

BACKGROUND: Drug concentrations obtained from post mortem samples do not necessarily reflect the concentrations at the time of death, and variations of concentration may be observed between different sites and/or different sampling times. These phenomena, collectively termed post mortem redistribution, concern numerous molecules (medications, drugs of abuse, gases, etc.) and can complicate the interpretation of toxicological analyses. METHODS: Literature review. RESULTS: The mechanisms that cause these phenomena are complex and often intricate. Certain organs, which concentrate the molecules before death, may release them very early in the vascular sector. The gastrointestinal tract, liver, lungs and myocardium are mainly concerned. Cell autolysis also plays a part in drug release. Furthermore, micro-organisms (mainly bacteria and yeasts) which colonize the organism during putrefaction may cause neoformation and/or the degradation of certain molecules. Lastly, it appears that the physicochemical and pharmacokinetic profile of xenobiotics, notably their lipophilic nature, their ionization state and their volume of distribution may be factors likely to influence redistribution phenomena. Some recommendations concerning anatomic sampling sites, sampling methods and sample storage make it possible to limit these phenomena.

Coexistence of Subdural Hematoma and a Rare Cardiopathy in an Infant: Etiological and French Medicolegal Discussion.

During legal proceedings following the unexpected death of an infant, the magistrate calls on an expert to clarify the causes of death and to decide on the course to be taken. A report was made following the death of a 7-month-old baby girl after recovery from cardiac arrest when investigations of the cause revealed a subdural hematoma (SDH). We discuss the interconnection of these two entities and their role in the lethal process. In this infant, two distinct lesions with medicolegal implications were simultaneously present: on the one hand histiocytoid cardiopathy, and on the other hand SDH, which could result from ill-treatment. The case of this infant reminds us that the role of the pediatrician is to report the suspicion, whereas the role of the medical expert is to inform the magistrate as to the reality of abuse and its implication in the lethal process.

A ten-year experience of physical Intimate partner violence (IPV) in a French forensic unit.

Forensic units have a central role to play in healthy public policy, by the collection and management of violence. This study aims to describe the characteristics of physical Intimate Partner Violence (IPV) against men reported over 10 years in the forensic unit of Toulouse (France) and to compare them with the characteristics of physical IPV against women over the same period. All the medico-legal reports of male victims over 18 years of age between 2005 and 2014 were analyzed. Female victims over 18 years of age in the same period were randomized by year in order to study a similar number of individuals. We analyzed 712 forensic reports of male victims and 865 forensic reports of female victims. Repeated consultation concerned 20.5% of women and 7.5% of men (p < 0.001). More male victims than female victims consulted in an emergency unit (p < 0.001). The most frequently alleged manner of attack was punching for male victims (34.1%) and grabbing or pushing for female victims (86.7%). There were fewer wounds and vascular or visceral injuries for female victims (p = 0.001). There were more reports of no injury for female victims (p < 0.001) and fewer reports with at least two injuries (p = 0.002). The most common injuries were superficial skin injuries (abrasion, bruise or hematoma) for both groups. On the one hand, physical IPV against women was more frequent than against men, while physical IPV against men seemed to be more severe than against women. The distribution of alleged manners of attack and injuries were consistent with previous studies. However, the mechanisms of the origin of the process of violence are difficult to apprehend in such a dyadic context. The findings should be interpreted with caution, but they provide original and substantial material, which can be useful in recognizing victims and in developing preventive strategies. With this aim, forensic units have a central role to play in the collection of violence and in individualized management. In France, this subject has not been extensively studied and future research is needed to emphasize the characteristics of IPV in order to better understand the phenomenon and to create and assess public policies in order to prevent it.

Medicolegal Implications of Nosocomial Infections: A Case Report of Aspergillus Contamination during Cardiac Surgery.

Nosocomial infections have become a major issue of public health and lead to an increasing number of suits for damages. We present a rare case of Aspergillus contamination during cardiac surgery, describe the medicolegal investigation, and present the new system for compensation of bodily injury after nosocomial infection in France, based on the law of March 4, 2002 on patient rights and quality in the health system. This case demonstrates the limits of compensation for nosocomial infections on the grounds of national solidarity. The expert report requested by the regional commission for conciliation and compensation is of fundamental importance in enabling the commission to decide between fault and inherent risk of treatment.

Medico-legal analysis of legal complaints in bariatric surgery: a 15-year retrospective study.

BACKGROUND: Bariatric surgery for severe obesity has become an effective and accepted treatment for sustained weight loss. OBJECTIVES: The aim of our study was to analyze the complications and issues raised by the experts on which jury or judges' decisions were made for the different types of bariatric surgery. SETTING: University Hospital, France. MATERIALS AND METHODS: We have carried out a retrospective study of 59 expert review dossiers over a period of 15 years (1999-2014) on the different types of bariatric surgery (laparoscopic adjustable gastric band [LAGB], sleeve gastrectomy [SG], Roux-en-Y gastric bypass [RYGB], vertical banded gastroplasty [VBG], and gastric plication [GP]). RESULTS: Of the cases, 81% were women and the average age was 39 years old (range 19 to 68 years). Among the procedures giving rise to the complaints, 40% were for LAGB, 28% for RYGB, and 23% for SG. The most common initial complications were perforations (30%), fistulae (27%), bowel obstruction (14%), vascular injuries (9.5%), and infections (peritonitis, pleurisy, abscesses, and so forth) (8%). Revision surgery was required in 78% of patients, and perioperative complications accounted for 28.5% of dossiers. The experts concluded that fault had occurred in 40% of case. Negligence arising from an error deemed to be an act of negligence was found in 30% of cases, 67% of which were because of delayed diagnosis. Major long-term complications accounted for 8% of dossiers and minor long-term complications for 22%. Forty-seven percent of patients completely recovered. CONCLUSION: Delayed diagnosis was the main error established by the experts. Surgeons should remain vigilant postoperatively after every bariatric surgical procedure.

Death from Hypothermia during a Training Course under "Extreme Conditions": Related to Two Cases.

Death from hypothermia following exhaustion or from various complicated pathologies is no longer a frequent cause of death among combat troops. During a training course under "extreme conditions" in the French Alps, two young African officers died. Confronted with these two clinically confirmed cases of hypothermia, the unknown anatomopathological and biological specificities associated with death from hypothermia were highlighted. In these typical and clinically confirmed cases of death from subacute exhaustion hypothermia, none of the signs revealed by the autopsy were specific. Although some recent publications have addressed the utility of postmortem biochemical markers when establishing a diagnosis, with no anamnesis, with no knowledge or analysis of the circumstances of death, and without an in situ examination of the body, it appears difficult, if not impossible, to confirm that death was caused by hypothermia.

The impact of medication-focused workshops in a diabetes educational program in jail: a pilot study.

BACKGROUND: Correctional institutions have unique circumstances offering care and the opportunity to adopt healthy behaviours for populations suffering from chronic diseases such as diabetes. In view of their expertise on medication, pharmacists can contribute to multidisciplinary educational health programmes in prisons. OBJECTIVE: To assess the effectiveness of a pharmacist led diabetes medication-related workshops. METHOD: Pharmacists led workshops about patients' empowerment in their treatment within the educational program. On a prospective observational study basis, the impact was assessed in terms of relevance, learning outcomes and achievement transfer using the Kirkpatrick training assessment method. Hb1Ac was measured as glycemic control outcome. RESULTS: Fifteen patients involved in the workshops showed a significant decrease in HbA1c compared to the control group (-1.18 ± 0.52 vs. +0.26 ± 0.28 %; p < 0.001). RELEVANCE: All participants were satisfied and ready to join other sessions. LEARNING OUTCOMES: (LO) Postworkshop scores were significantly improved (LO1: 4.2 ± 0.9 vs. 2.2 ± 1.4; LO2: 4.5 ± 0.9 vs. 2.6 ± 1.3; p < 0.05). Decrease in HbA1c was correlated to increase in LO2's scores. (Y = 0.946 - 1.134X; R = -0.692; p < 0.05). ACHIEVEMENT TRANSFER: Key points from all LOs were reported. In case studies, 70 % of participants adopted healthy strategies (LO3). CONCLUSION: These results highlight the positive impact of the workshops and the additive value of pharmacists' involvement within the educational program in jail.