Hospitalization for physical child abuse: Associated medical factors and medical history since birth.

BACKGROUND: Physical abuse often begins at a very young age and sometimes results in serious or fatal injuries. It is crucial to diagnose physical abuse as early as possible to protect this vulnerable population. OBJECTIVE: To study the factors associated with the first hospitalization for physical abuse from birth to the infant's first birthday in France. PARTICIPANTS AND SETTING: We included all singleton children born in a hospital setting in France between 2009 and 2013, who were identified from the French national information system database (SNDS). METHODS: To study factors associated with the first hospitalization for physical abuse during the first year after birth, we used the Fine and Gray regression model. Factors included in the multivariate model were the infant's sex, prematurity, neonatal conditions, the number of hospitalizations (at least two), medical consultations and complementary universal health insurance (proxy for family precariousness and socio-economic vulnerability). RESULTS: Over the 2009-2013 period, among 3,432,921 newborn singletons, 903 (0.026 %) were hospitalized for physical abuse in the year following birth. Among the factors associated with physical abuse, such as prematurity (aHR = 2.2[1.8-2.7]), male sex (aHR = 1.3[1.2-1.5]), or having had at least two hospitalizations (aHR = 1.7[1.4-2.1]), we found that complementary universal health insurance coverage was the factor most associated (aHR = 4.1[3.5-4.7]) with being hospitalized for physical abuse. CONCLUSION: These findings could help introduce preventative measures for infant protection in certain groups, such as parents of infants born prematurely, especially if they are in a precarious situation. This study also suggests that particular attention should be paid to infants who have been hospitalized at least two times in the first year of life, whatever the reason.

Suicide of an adolescent girl with sodium nitrite ordered on the internet.

Nitrites are commonly used in the chemical, pharmaceutical, and food industries. Recently, they have been identified in cases of voluntary intoxication. We report the case of a 13-year-old girl who was found lifeless on her bed next to a glass containing a white powder and a bottle containing a white powder with a moistened appearance. External examination and autopsy revealed a nonspecific asphyxia syndrome, which was confirmed by the pathological analysis. Analysis of the samples revealed metoclopramide in the peripheral blood at a concentration of 0.402 mg/L (LC-HRMS). An analysis of the gastric contents was carried out after sodium nitrite was detected in the powders found near the body (Raman spectrometry). Nitrites were found in the gastric fluid at a concentration of 30.9 mg/L. Death occurred secondary to anoxia, following ingestion of nitrites; suicide kits are available on the web and nitrites are relatively easy to source and inexpensive. Nitrites are delivered in powder form to be dissolved in liquid, which may then be consumed with metoclopramide (or an alternative anti-emetic drug) to maximize absorption and reduce emesis. The toxic effect of nitrites lies in their oxidizing power, causing the transformation of hemoglobin into methemoglobin, which, when it accumulates, induces tissue anoxia resulting in death. There has been an alarming increase in the number of cases linked to suicide using nitrites or a nitrite suicide kit. The fact that nitrites are readily available online underscores the importance of establishing effective preventive measures such as limiting the access and use of this chemical.

[Child maltreatment and Covid-19: A crisis within a crisis]. / Maltraitance envers les enfants et Covid-19 - Une crise dans la crise.

The fight against the SARS-CoV-2 pandemic was carried out through strong restrictive measures, including general population lockdown, which allowed the convergence of risk factors for child abuse. During this period, the French national hotline for children in danger recorded a 56% increase in calls. Calls followed by an alert to departmental child protection services increased by 30%. Through an algorithm created by our team, we showed a 50% increase in the relative frequency of hospitalizations for physical abuse in children aged 0-5 years during the lockdown. This has fueled thinking about subsequent health measures to protect the youngest children. Our goal is now to use this algorithm for epidemiological purposes as a barometer of abuse or in daily practice to help the diagnosis of physical abuse in young children.

Title: Maltraitance envers les enfants et Covid-19 - Une crise dans la crise. Abstract: En France, au début de l'année 2020, environ 690 000 vies ont pu être épargnées grâce au confinement général de la population et aux mesures restrictives de lutte contre la Covid-19. Conséquence inattendue, ces mesures ont eu un impact sur une autre frange vulnérable de la population : celle des jeunes enfants, pour lesquels il a été démontré une augmentation des maltraitances subies à cette période. À partir de données de la littérature et de l'apport de nos travaux de recherche dans le domaine, nous proposons une documentation de cette crise des violences intra-familiales, intriquée dans la crise sanitaire de la Covid-19.

"Clandestine" home delivery with mifepristone.

Denial of pregnancy is a rare psychic process associated with an increased risk of infant death. Forensic examinations to determine viability at birth can heavily influence the legal proceedings in cases of clandestine deliveries that result in the death of the infant. A 32-year-old woman who experienced a denial of pregnancy up to 30 weeks of amenorrhea reported giving birth at home at an estimated term of 35 weeks of amenorrhea. No one witnessed the delivery. She claimed the infant was stillborn. Forensic examinations revealed characteristic features of a live born infant. The mother tested positive for mifepristone. Mifepristone is an anti-progestin drug used for early abortion and to induce labor in cases of in-utero fetal death in later pregnancy. Even if mifepristone crosses the placenta, it has no direct toxic effect on the fetus. Our observations suggest premature live birth caused by mifepristone, followed by asphyxia due to meconium inhalation syndrome associated with lung immaturity especially since the birth occurred at home and no medical care was provided after the birth. The tragic outcome of this clinical case calls for vigilance and global management, including the psychiatric care of parturients in the context of late discovery of pregnancy. In France, this situation showed a legal gap between the consideration of the fetus and laws concerning abortion. To our knowledge, in France, this case has allowed the court to set a legal precedent as a similar case had never been reported elsewhere.

Mental Health Support for Hospital Staff during the COVID-19 Pandemic: Characteristics of the Services and Feedback from the Providers.

French authorities created mental health support services to accompany HCWs during the pandemic. We aimed to obtain feedback from staff providing these mental health support services within French hospitals to identify positive and negative features and avenues for improvement. A mixed-methods study was performed between 1 April and 30 June 2020. We contacted 77 centres to identify those providing mental health support services. We developed a questionnaire containing questions about the staff providing the service (quantitative part), with open questions to enable feedback from service providers (qualitative part). Of the 77 centres, 36 had mental health support services; 77.8% were created specifically for the epidemic. Services were staffed principally by psychologists, mainly used a telephone platform, and had a median opening time of 8 h/day. Thirty-seven professionals provided feedback, most aged 35-49 years. For 86.5%, it was their first time providing such support. Median self-reported comfort level was 8 (interquartiles 3-10), and 95% would do it again. Respondents reported (i) difficulties with work organisation, clinical situations, and lack of recognition and (ii) a desire for training. This study suggests that mental health support needs to be adapted to the needs of HCWs, both in terms of the content of the service and the timing of delivery.

Physical abuse of young children during the COVID-19 pandemic: Alarming increase in the relative frequency of hospitalizations during the lockdown period.

BACKGROUND: In France, the COVID-19 pandemic led to a general lockdown from mid-March to mid-May 2020, forcing families to remain confined. We hypothesized that children may have been victims of more physical abuse during the lockdown, involving an increase in the relative frequency of hospitalization. METHODS: Using the national administrative database on all admissions to public and private hospitals (PMSI), we selected all children aged 0-5 years hospitalized and identified physically abused children based on ICD-10 codes. We included 844,227 children hospitalized in March-April 2017-2020, of whom 476 (0.056%) were admitted for physical abuse. Relative frequency of hospitalization for physical abuse observed in March to April 2020 were compared with those from the same months in the three previous years (2017-2019). FINDINGS: Even if absolute number of children exposed to physical abuse did not fluctuate significantly, we found a significant increase in the relative frequency of young children hospitalized for physical abuse from 2017 (0.053%) to 2020 (0.073%). Compared with the 2017-2019 period, and considering the observed decrease in the number of overall hospital admissions during the first lockdown, the number of children exposed to physical violence was 40% superior to what would be expected. INTERPRETATION: The sharp increase in the relative frequency of hospitalizations for physical abuse in children aged 0-5 years in France is alarming. As only the most severe cases were brought to the hospital for treatment during the lockdown, our figures probably only represent the tip of the iceberg of a general increase of violence against young children.

Sudden Death by Spontaneous Epiglottic Hematoma Secondary to High Blood Levels of Warfarin.

A 67-year-old man was found dead, at his home. On external examination, we found a voluminous purplish black ecchymosis of the anterior neck area. On internal examination, we found a voluminous epiglottis hematoma completely obstructing the upper airway. It was associated with other sites of intra-abdominal hemorrhage. Toxicological studies revealed the presence of warfarin at a concentration of 8.4 mg/L in peripheral blood, which supposes an INR well above 4.5. To conclude, we supposed death was due to asphyxia secondary to a spontaneous epiglottic hematoma caused by a high blood concentration of warfarin. Hemorrhage in the epiglottis is very rare. To our knowledge, our patient is the only case of "sudden death" reported with spontaneous epiglottic hematoma due to high blood concentration of warfarin. In forensic practice, an anterior neck ecchymosis, without trauma, may suggest hemorrhage into soft airway tissues. Pathology findings make it possible to exclude exogenous trauma.

Patients' views on pay for performance in France: a qualitative study in primary care.

BACKGROUND: Pay for performance was implemented in 2009 in France. The system was optional at first and then became widespread. Since 2012, it has been standard for most GPs. Several studies have attempted to investigate its efficiency and the GP's opinion of the system, but few studies have yet to examine the patient's view. AIM: To gain an understanding of the views of French family practice patients about pay for performance. DESIGN AND SETTING: Forty patients were interviewed between March and July 2013 in the Île-de-France region, of France. METHOD: A qualitative study using semi-structured individual interviews, in primary care. RESULTS: Most of the patients did not know what pay for performance was and stated that they had not noticed any change in care since the system began. Some patients noted the possible benefits in the quality of care, such as an improvement in follow-up and prevention, better information provided by the GP, and a decrease in the volume of prescriptions and therefore health costs. Other patients were concerned about potential downsides, such as an overprescription of unnecessary medical treatments, an increase in health costs, patient selection, and standardised consultations that do not necessarily take into account the patient's individual concerns. CONCLUSION: Since implementation of pay for performance, patients had not noticed any modification in their medical care. They could understand the need for change in the remuneration policy and expressed their agreement about performance-based remuneration if, and only if, it is not the cause of depersonalised health care.

[General practitioners' representations and perceptions about the medical practice standards they are facing]. / Représentations et ressentis des médecins généralistes sur les normes de pratiques médicales auxquelles ils sont confrontés.

BACKGROUND: Since the early 1990s, national health institutions including the national health insurance increase the incentives for physicians to comply with standards of good practice dedicating these standards in medical practices. The objective of this study was to explore GP's on standards of medical practice in a context of standardization. METHOD: Individual semi-structured qualitative interviews with 16 GPs in Île-de-France. RESULTS: Thematic analysis of 16 interviews has highlighted that doctors had the impression of being confronted with multiple medical practice guidelines from various sources. They said they consider these standards as indicative benchmarks and not as imperatives to comply. Strict standardization of practices did not seem compatible with their profession given the singular and complex nature of each situation and the necessary comprehensive care to their patients. They opposed ethical arguments insistent standardization. Mandatory standards appeared detrimental to their quality of care. Doctors have said it better accept scientific guidelines than standards of health insurance that seemed directed to them by economic considerations. They said also to experience a significant normative pressure from health insurance. DISCUSSION: GPs had spotted increasing standards governing their practices. They were not opposed to the fact that they may be indicative targets provided they are not mandatory.

Why did most French GPs choose not to join the voluntary national pay-for-performance program?

BACKGROUND: In 2009, a voluntary pay for performance (P4P) scheme for primary care physicians was introduced in France through the 'Contract for Improving Individual Practice' (CAPI). Although the contract could be interrupted at any time and without any penalty, two-thirds of French general practitioners chose not to participate. We studied what factors motivated general practitioners not to subscribe to the P4P contract, and particularly their perception of the ethical risks that may be associated with adhering to a CAPI. METHOD: A cross-sectional survey among French general practitioners using an online questionnaire based on focus group discussion results. Descriptive and multivariate statistical analyses with logistic regression. RESULTS: A sample of 1,016 respondents, representative of French GPs. The variables that were associated with the probability of not signing a CAPI were "discomfort that patients were not informed of the signing of a P4P contract by their doctors" (OR = 8.24, 95% CI = 4.61-14.71), "the risk of conflicts of interest" (OR = 4.50, 95% CI = 2.42-8.35), "perceptions by patients that doctors may risk breaching professional ethics" (OR = 4. 35, 95% CI = 2.43-7.80) and "the risk of excluding the poorest patients" (OR = 2.66, 95% CI = 1.53-4.63). CONCLUSION: The perception of ethical risks associated with P4P may have hampered its success. Although the CAPI was extended to all GPs in 2012, our results question the relevance of the program itself by shedding light on potential adverse effects.

[Evaluating the total incapacity to work: implementing French National Authority for Health guidelines in clinical practice]. / Détermination de l'incapacité totale de travail au sens du Code pénal: mise en œuvre des recommandations de la Haute Autorité de santé en pratique clinique.

Total incapacity to work (TIW) is a legal concept that allows magistrates to assess the severity of violence against persons. The TIW is the duration of the victims' inability to fulfil their usual activities and is determined by physicians. Professional guidelines from the French National Authority for Health indicate that TIW applies both to physical and psychological problems. The law of 9 July 2010 makes explicit reference to TIW in cases of psychological violence and intimate partner harassment. Prosecutors base criminal penalties on the duration of TIW in cases of assault and battery. Whatever the physician, they should describe the mental state of the victim and identify the signs that may indicate the mental impact of reported assaults. Identifying combinations of symptoms can be useful in deciding whether the duration of TIW should be increased because of the psychic state. In case of stalking, assessment of TIW can allow prosecutors to link the reported facts to a criminal offence. In complex situations, the physician may be unable to assess a duration of TIW and can suggest expert assessment. In all cases, the duration of TIW needs to be based on functional criteria. The extent of harm to the life of relationships results from suffered violence, from the victim's reaction, and from the perception of their family and friends. In this area, we suggest to limit the first assessment of TIW to a few days and to reassess it later, according to real information reported by the victims, to careful observation of their behaviour, and to results of a questioning that should be as little suggestive as possible. At either end of the age scale and in case of preexisting functional impairment, assessment of TIW should take into account the actual and global capacity of the person before the assault.