[General medical care in French psychiatric units for inmates: A national survey]. / Soins médicaux généraux en unité hospitalière spécialement aménagée : une enquête nationale.

OBJECTIVES: The UHSA (UHSA) are French psychiatric units for inmates which admit detainees suffering from a psychiatric disorder requiring full-time hospital care. Non-psychiatric pathologies are overrepresented in patients with psychiatric disorders but also in detainees. As a result, patients hospitalized in UHSA are largely exposed to non-psychiatric conditions, and exploring the organization of general medical care for these patients appears very relevant. The aim of this study is to review the general medical care in all French UHSA. METHODS: A descriptive study was carried out through a survey of the nine facilities. RESULTS: All UHSA benefit from the intervention of a general practitioner. The physical clinical examination, the biological assessment and the electrocardiogram are systematically performed at the patient's admission in 7, 5 and 9 establishments, respectively. However, the offer of general medical care in UHSA seems disparate and sometimes insufficient. Specialized consultations are regularly requested during hospitalizations, but no establishment benefits from a telemedicine system or specialized consultations on site. The extraction of the patient to the general hospital is therefore systematic when such a consultation is needed. But the number of penitentiary escorts per day is limited. In 6 UHSA, medical extractions are thus regularly canceled by the penitentiary administration, sometimes without a medical opinion. Finally, the patient's regular physician is only contacted in 3 UHSA during hospitalizations. CONCLUSION: Based on these results, ways of improving the organization of general medical care in UHSA are proposed through four main axes: the structure and general organization; the general medical care; the link with the healthcare partners and the articulation with the penitentiary administration.

[First trends of change in mortality by suicide in Nord-Pas-de-Calais since VigilanS]. / « Premières analyses de mortalité par suicide en Nord-Pas-de-Calais depuis l'implantation de VigilanS ¼.

INTRODUCTION: In terms of suicide prevention, population-based prevention devices often struggle to demonstrate an effect in terms of reducing suicidal acts of suicide, often focusing on the evolution of the number of suicide attempts, on time too short to statistically interpret changes in mortality. The consolidated figures for mortality in France are provided by the CepiDC with a delay of approximately three years. We therefore had to try to work with an approximation of the phenomenon, and we tested the proxy value of the enumeration of corpses, body examinations and medico-legal autopsies for suicide by the forensic doctors of the Nord-Pas-de-Calais region in France. In parallel, we conducted a comprehensive mortality study for 2016 in the VigilanS cohort. METHOD: By measuring the evolution of the number of body lifts for suicide by the Department of Forensic Medicine of the region, for the 3 years before VigilanS (2012-2014) compared to the 3 years since VigilanS (2015-2017). The deaths of patients of the VigilanS cohort were identified by calling the city halls of birth and domicile of all patients integrating the device in 2016. The cause of death was then characterized by contact of the attending physician. RESULTS: We observe an average decrease in suicide mortality of 9.9% (-12% for men, +0.3% for women). The exhaustive analysis of suicide mortality in the VigilanS cohort in 2016 found 19 deaths, of which 14 by suicide, or 0.4% of patients. This observed mortality rate in the VigilanS cohort in 2016 is significantly below the expected threshold in the literature (1 to 2% in the year following TS). CONCLUSION: It seems possible to reach the 2020 target for a 10% decrease in suicidal behavior in industrialized countries by 2020. The VigilanS device could therefore be protective in terms of suicide mortality.

An experimental investigation into the colonization of concealed cadavers by necrophagous blowflies.

We used seven baited boxes with different combinations of access holes and odor diffusion surfaces to study the arrival of necrophagous flies. During laboratory experiments, 30 gravid Lucilia sericata females were kept in a chamber with one of the boxes. The box with the largest odor diffusion surface (99 cm(2)) combined with the lowest accessibility (one 1 cm(2) entrance hole) was entered least (5 ± 3.7 flies per run). In contrast, the most frequently entered box (one 9 cm(2) entrance hole with no additional odor diffusion surface) caught a mean of 24.6 ± 3.4 flies per run. These results indicate that 1) L. sericata entered nearly inaccessible places and 2) both odor diffusion and accessibility impacted the number of flies caught. During field experiments, the seven boxes were placed together outdoors. The box with the most entrances (ten 9-cm(2) holes) caught the most flies (55.6-99.4% of the total). Only a few flies entered the other boxes. Access to the less accessible boxes (poor odor diffusion and small entrances) was also delayed. The major conclusions of the field experiments are that 1) boxes with low accessibility took longer to be accessed; 2) larger odor diffusion surfaces were more attractive to flies; and 3) flies accessed boxes more readily through larger holes than through an equivalent surface area made up of smaller holes. With these conclusions in mind, attempts to quantify the preappearance interval or to interpret the number of flies observed in indoor forensic entomology cases should be approached with caution.

[Asthma and scuba diving: Creation and evaluation of a website (For doctors, asthmatics and diving instructors)]. / Asthme et plongée sous-marine : création et évaluation d'un site internet (à destination des médecins, plongeurs asthmatiques et moniteurs de plongée).

INTRODUCTION: Scuba diving has long been strictly contraindicated for asthmatics; this contraindication has been questioned in recent years. Our objective was to provide a website, evaluated by its users, for doctors, diving instructors and asthmatics. MATERIALS AND METHODS: Creation of the site Asthme-Plongee.com based on a peer-reviewed literature review, then distribution of a questionnaire in summer 2018 to diving clubs, general practitioner groups, pulmonologists and FFESSM federal offices, and via social networks. RESULTS: Our sample consisted of 413 assessors, including 264 health professionals (63.9%), 74 asthmatics (17.9%) and 92 diving instructors (22.3%), spread over the entire territory of France. The structure of the website, the clarity of the information written and its relevance were generally appreciated by the entire population with a median score of 8/10. The site was found useful: 72.9% of respondents thought they would visit it later. CONCLUSION: Faced with a growing number of amateur divers, it seems essential to raise awareness of current recommendations and good diving practices.

Vehicle-assisted ligature decapitation: A case report and a review of the literature.

Decapitation resulting by vehicle-assisted ligature strangulation is a suicide method rarely described in the literature. The lesions observed at autopsy have a common morphology with to those found in post-hanging decapitation. They depend on the force applied by the acceleration of the vehicle, the slope of the road and the characteristics of the link used. They can also mimic a stabbing homicide. We report the case of a 43-year-old man who used a long steel rope, attached between his neck and a streetlight, and started his vehicle, causing a complete decapitation. The results of the autopsy provided information on the morphology of the cervical lesions, but also on the causes of death. In spite of decapitation, the histological examination of the organs confirmed the presence of asphyxiation process by a mechanical origin that occurred before decapitation.

Medical liabilities of the French physician passenger during a commercial air flight.

Nearly two billion passengers travel each year on commercial air flights. More elderly people and/or people with a pre-existing condition are taking to the air and with the anticipated growth of air travel, in-flight illnesses and injuries are expected to increase as well. Even if in-flight medical events and deaths are still uncommon, physician passengers are occasionally called upon to render assistance. Although no case law exists as yet in France, physicians who often travel on commercial flights should be aware of the risks they run if they do not respond to the well-known call, 'Is there a doctor on board?', or if they assist a sick passenger. This paper describes in-flight resources available to a physician who is called upon to treat an ill or injured passenger. Two questions concerning the French physician passenger are discussed: What are the liabilities of the physician who does not respond to the call of a medical event aboard an aircraft? What are the liabilities of the physician providing assistance to a sick passenger? The different liabilities and also the legal status of the French physician passenger are examined.

Forensic features of a fatal Datura poisoning case during a robbery.

Datura poisonings have been previously described but remain rare in forensic practice. Here, we present a homicide case involving Datura poisoning, which occurred during a robbery. Toxicological results were obtained by second autopsy performed after one previous autopsy and full body embalmment. A 35-year-old man presented with severe stomach and digestive pain, became unconscious and ultimately died during a trip in Asia. A first autopsy conducted in Asia revealed no trauma, intoxication or pathology. The corpse was embalmed with methanol/formalin. A second autopsy was performed in France, and toxicology samples were collected. Scopolamine, atropine, and hyoscyamine were found in the vitreous humor, in addition to methanol. Police investigators questioned the local travel guide, who admitted to having added Datura to a drink to stun and rob his victim. The victim's death was attributed to disordered heart rhythm due to severe anticholinergic syndrome following fatal Datura intoxication. This is a recent case of a rare homicide involving Datura that highlights general information on Datura and discusses forensic interpretation after a previous autopsy and body embalmment.

Necrophilous insect succession on rabbit carrion in sand dune habitats in northern France.

Six freshly killed rabbit carcasses were exposed in different habitats in the coastal dune massif of Ambleteuse (northern France) during the spring seasons of 1996 and 1997. In total, 66 arthropod species were collected during the decomposition of these carcasses, and particular attention was paid to taxa of necrophilic significance. The pattern of insect activity was recorded and is discussed in relation to meteorological conditions. One significant feature in this study was the delay in initial oviposition by flies during 1996, which demonstrates the need for caution in estimation of postmortem interval by entomological techniques in early spring. Although daily temperatures may be favorable for adult fly activity, flies may be absent because of small population size and low nocturnal temperatures during this period.

Immunoassay of digoxin in hair.

Digoxin analysis in blood is an essential tool for therapeutic drug monitoring in cardiology because compliance with the treatment is a critical issue for the patient. Unfortunately, in postmortem cases blood digoxin concentration is of poor quality because there is a possible drug redistribution in the corpse and because of digoxin-like factors present in some people's blood. On the other hand, no biological fluid can be obtained at the autopsy. The aim of the present study was to evaluate the ability of an immunological method to determine digoxin in hair, in order to confirm that hair analysis can provide information on digoxin use before death. We studied 35 elderly patients who had been taking digoxin (60-250 micrograms/day) for 1-5 years. Two decontamination procedures were tested: washing by dichloromethane or by water and methanol. Three extraction procedures were compared: crushing in a ball mill and chloroform/acetone: crushing and methanol; enzymatic digestion. Immunoassays were performed by a microparticulate enzyme immunoassay. Serum digoxin levels were also assayed when sampling hair. The best results were obtained after decontamination with water and methanol followed by enzymatic digestion. Hair digoxin concentrations range from 3.6 to 11.4 pg/mg. Those very low concentrations are probably due to low and narrow range serum digoxin levels (0.3-1.4 ng/ml). No correlation was found between hair and blood digoxin. A forensic case is presented with 5 pg/mg digoxin in hair.

Morphine extraction in necrophagous insects remains for determining ante-mortem opiate intoxication.

To study the potential use of insects remains as toxicological indicators, we measured morphine in desiccated entomological materials using a radioimmunoassay method (Coat-A-Count Serum Morphine, Dade Behring, France) following enzymatic hydrolysis.First, enzymatic cuticle extraction of morphine (pronase digestion preceded by a 2h incubation with a dithiothreitol solution) was performed on various substrates (Calliphoridae puparial cases and desiccated adults, and desiccated pupae of Dermestidae) which were then tested to identify possible interferences with the radioimmunoassay procedure. This same procedure was performed on puparial cases and desiccated adults of Lucilia sericata (Diptera, Calliphoridae) previously reared on minced meat containing various morphine concentrations. Morphine was detected only in cuticle powder from insects reared on meats containing 100 and 1000mg/kg. Higher concentrations were measured in puparial cases. Rearings on psoas from eight heroin overdose victims confirmed previous experimental results. Remains of necrophagous insects, particularly puparial cases, are often preserved for a long time, and consequently can serve as late alternative specimens for toxicological analysis when suitable tissues are not available.

A case of fatal salt water intoxication following an exorcism session.

In response to a recent article published in this review, we present in this paper, an unusual case of fatal salt water intoxication. In this case, we point out three special features, the type of water ingested, the physiopathologic consequences of the ingestion and the very strange context of occurrence. This complex case allows us to point out complications due to salt poisoning and others caused by water intoxication.

Determination of drug levels in two species of necrophagous Coleoptera reared on substrates containing morphine.

Two species of necrophagous Coleoptera: Dermestes frischi (Dermestidae) and Thanatophilus sinuatus (Silphidae), were reared on substrates containing different amounts of morphine. Colonies of D. frischi were reared on rabbit carcasses which had been given 10, 20, and 40 mg/h of morphine hydrochloride via ear artery perfusion over a 3 h period prior to death. A fourth rabbit served as a control. T. sinuatus was reared on minced beef spiked with morphine hydrochloride to give concentrations of 1,000, 2,500, 5,000, and 10,000 ng/g and one control colony. These dosages were calculated to create tissue concentrations of morphine similar to those encountered in human deaths due to morphine overdose. Larvae. pupae, and adults (except for T. sinuatus) were analyzed for morphine content. All developmental stages of D. frischi were positive for morphine and concentrations correlated with cadaveric tissue concentrations during larval stages and to a lesser extent in the adult stage. For T. sinuatus, the best correlations were found in 2nd and 3rd instar larvae. This study demonstrates the potential for use of necrophagous Coleoptera, as well as Diptera larvae, as alternate specimens for toxicological analyses.

Determination of drug levels in larvae of Protophormia terraenovae and Calliphora vicina (Diptera: Calliphoridae) reared on rabbit carcasses containing morphine.

Two species of blow flies (Diptera: Calliphoridae) were reared on tissues from rabbits administered different dosages of morphine. These species, Protophormia terraenovae and Calliphora vicina are among the first wave of insects colonizing a dead body. Two series of 3 rabbits were given dosages of 10, 20, and 40 mg/h of morphine over a 3 h period via ear artery perfusion. A morphine blood level plateau was attained after 1 h of perfusion. Two other rabbits were used as controls. Samples of tissues collected from rabbits using a coelioscopic technique were determined to have morphine concentrations similar to those encountered in human overdoses and were correlated with dosages of morphine administered. All samples from control rabbits were negative for morphine. Larvae and puparia of both species were regularly collected from each rabbit for toxicological analysis. Concentrations of morphine in larvae reared on rabbit carcasses containing morphine were significantly lower than concentrations found in the tissues. There was a decrease in concentration in morphine observed in transition from feeding 3rd instar larva to puparium. A correlation between larval concentration and tissue concentration was found only in feeding 3rd instar larvae.

Immunohistochemical contribution to the study of morphine metabolism in Calliphoridae larvae and implications in forensic entomotoxicology.

Morphine was detected by immunohistochemistry on sections of third stage larvae of Calliphora vomitoria (Diptera, Calliphoridae) reared on minced beef meat previously treated with morphine hydrochloride. The detection was performed with an avidin-biotin-peroxidase-complex method. Positive specimens showed specific staining of the haemolymph and a more intense immunoreaction in an area located at the limit between exocuticle and endocuticle. These results constitute an evidence of morphine accumulation inside the cuticle of Diptera larvae during their development. During the pupariation, the larval cuticle is transformed into the sclerotized puparium. This study consequently points out the possibilities of analyzing empty pupariae when suitable tissues or living necrophagous insects are absent.

Morphine perfused rabbits: a tool for experiments in forensic entomotoxicology.

In order to establish an animal model for entomotoxicological studies, the kinetics of morphine elimination from blood after a single intravenous injection of morphine and the concentration of morphine in tissues following a continuous perfusion were studied. The aim of these experiments was to obtain controlled morphine tissue concentrations similar to those encountered in fatal human heroin overdoses. These tissues can be used as a food source for developing fly larvae in entomotoxicological studies. In the single injection experiment, seven rabbits were administered 1 or 2 mg/kg body weight of morphine chlorhydrate via the main ear artery. Blood samples of 200 microL were removed regularly via a catheter. Morphine concentration was determined using RIA techniques. Morphine was found to be first rapidly distributed and then slowly eliminated, following a two-exponential equation. Elimination of morphine from blood can be described as a two-compartment model. Constants of the equation were determined using the Kaleidagraph program. Using those constants, the main pharmacokinetics parameters were calculated. Results of these parameters showed the following: clearance from 13.3 to 16.2 L.h.1, half-life of the distribution phase from 0.6 to 0.9 min, and half-life of the elimination phase from 21 to 26 min. These results were used to calculate the rate of perfusion of morphine for rabbits to obtain desired, controlled, and constant concentrations of morphine in tissues. In the second experiment, three rabbits received a perfusion of morphine intravascularly at a rate of 2 mg/kg/h for a period of 3 h. These rabbits were sacrificed and analyses performed on several abdominal and thoracic organs. Results showed that the concentrations of morphine differed according to the organ analyzed, but were reproducible for organs between animals. These concentrations were similar to those normally encountered in cases of human death due to heroin overdoses.

Determination of drug levels in larvae of Lucilia sericata (Diptera: Calliphoridae) reared on rabbit carcasses containing morphine.

This study concerns the determination of morphine concentrations in fly larvae reared on rabbits administered different concentrations of morphine and a correlation between concentrations of the drug in larvae and tissues. Three rabbits (R1, R2 and R3) were given dosages of 12.5, 25.0 and 50.0 mg/h of morphine over a 3 h period via continuous ear artery perfusion. These dosages and time of perfusion were calculated to create tissue concentrations of morphine similar to those encountered in human death due to overdose. Morphine blood level plateau was attained after 1 h of perfusion. A fourth rabbit was used as a control. To evaluate drug concentrations, tissues were sampled using a coelioscopic technique. Approximately 400 eggs of Lucilia sericata, all of the same age category, were placed in eyes, nostrils and mouth of each rabbit carcass. Larvae and puparia were regularly collected from each rabbit for toxicological analysis. The concentrations of the drug in the tissues sampled were determined to be similar to those normally encountered in human overdoses and were correlated with the dosage of morphine that had been administered. Morphine was detected in all larvae and pupae fed on tissues from carcasses administered morphine, except for puparia from the colony fed on the R1 animal which received 12.5 mg/h dosage of morphine. All samples from the control rabbit were negative for morphine. Concentrations of morphine in larvae reared on rabbit carcasses containing morphine were 30 to 100 times lower than the concentrations found in the tissues. A correlation between the tissue concentrations and larval concentrations was found in only 3rd instar larvae (80 to 140 h following hatching). No correlations were found between administered dosages, tissue concentrations and younger larvae, prepuparial larvae or puparia.

Effects of morphine in decomposing bodies on the development of Lucilia sericata (Diptera: Calliphoridae).

This study concerns the effects of morphine in tissues on the rate of development of Lucilia sericata (Diptera: Calliphoridae) using those tissues as a food source. Lucilia sericata is a species of fly commonly found on human corpses in Europe during the early stages of decomposition and thus of forensic interest. Three rabbits were administered 12.5, 25.0 and 50.0 mg/h of morphine chlorhydrate via ear perfusion over a period of 3 h. These dosages and duration of perfusion were calculated to give tissue concentrations of morphine similar to those encountered in fatal human overdoses. A fourth rabbit was used as a control. Following administration of the drug, rabbits were sacrificed and 400 eggs of Lucilia sericata, all of the same age, were placed in the eyes, nostrils and mouth of each rabbit. Developing larvae were sampled daily to determine growth rate and weight. Puparia and emerging adult flies were also sampled. Data were analyzed using analysis of variance (ANOVA) and Student's T-test. Results of this study show that an underestimation of the postmortem interval of 24 h is possible if the presence of morphine in tissues is not considered. This study demonstrates again the necessity of considering the possible effects of drugs in tissues on insect growth rates when estimating the postmortem interval using entomological techniques.

[Infection with hepatitis C virus in a prison environment. A prospective study in Loos-lez-Lille, France]. / Infection par le virus de l'hépatite C en milieu carcéral. Etude prospective réalisée à Loos-lez-Lille.

OBJECTIVES: The aim of this study was to assess the prevalence of hepatitis C virus (HCV) markers, and risk factors of contamination in a prison population. PATIENTS AND METHODS: Eight hundred and six prisoners were prospectively included, at the moment of their imprisonment, between December 1st 1995 and May 31st 1996. Each prisoner was included in a group "drug abusers" or "non drug abusers" based on a clinical examination. Serum anti-HCV antibodies were tested in each group. Other risk factors were also analysed (type of drug abuse, share of syringes and needles, blood transfusion, haemodialysis, and hemophilia). RESULTS: Among the 806 prisoners, 30.3% were anti-HCV positive. Four hundred and thirty nine prisoners (54.4%) were placed in the "drug abuser" group and 367 (45.5%) in the "non drug abuser" group. In the first group, 55.6% were anti-HCV positive (80% of the prisoners who were intravenous drug users and 10.8% for the others) and 4.2% were anti-HCV positive in the second group. CONCLUSIONS: Half of the prisoners entering our center were drug abusers and half were anti-HCV antibody positive. HCV infection is a major public health problem in prison.

Medical responsibility and air transport.

When a medical emergency occurs during a flight operated by a commercial airline, the assistance of a physician-passenger fortuitously present aboard may be requested. This physician becomes bound by both his professional and civil responsibilities. However, in the case of a serious problem, he would usually ignore the question of the jurisprudence of the country where the emergency occurs. In discussing this issue, this paper analyses different situations and risks that the physician may incur and points out various defects in the law not currently covered by existing international conventions.

A safe, free and efficient way to control Nasonia vitripennis, a common pest in forensic entomology laboratories.

Nasonia vitripennis Walker (Hymenoptera: Pteromalidae) is a parasitoid of necrophagous blowflies. Its presence in a forensic entomology laboratory can be extremely damaging to samples and can compromise the PMI estimation. We describe for the first time a simple, safe and efficient trap to control N. vitripennis infestations. Adhesive tape is placed horizontally on windows to create an obstacle. Wasps go underneath until they reach the adhesive side of the tape and become stuck by their wings. This method is highly selective, costless and has been successfully used in our laboratory for years.