Pictorial review of the postmortem computed tomography in neonaticide cases.

Neonaticide is defined by the deliberate killing or homicide of a child within 24 h of its birth. In this context, three fundamental questions are generally asked of the forensic pathologist: what is the cause of death of the neonate? Was the child viable (i.e., what is the gestational age of the neonate)? Finally, was the neonate stillborn or liveborn?Postmortem imaging can help answer these questions by conducting (1) a complete lesional analysis of the body and the placenta, (2) an estimation of the gestational age by measuring the lengths of the diaphyseal long bones, and (3) an analysis of the aeration of the lungs and intestines. Using the details of 18 cases, we illustrate aspects of neonaticide cases in postmortem computed tomography (PMCT), offering detailed examples of notable postmortem changes and abnormalities, especially in the analysis of the pulmonary parenchyma. This article presents a useful iconography for the radiologist confronted with this rare yet complex forensic situation.

Lung density measurement in postmortem computed tomography: a new tool to assess immediate neonatal breath in suspected neonaticides.

INTRO: Evidence of breath after birth is one of the main forensic issues in suspected neonaticide. Hydrostatic test (HT) and pathological examination are currently used to assess it, but they are not entirely reliable or immediately available. OBJECTIVE: To determine the performance of postmortem computed tomography (PMCT) to assess neonatal breath in suspected neonaticide, by comparing lung CT attenuation values between live birth and stillbirth cases, in correlation with HT and pathology. METHOD: Cases of suspected neonaticides who underwent a PMCT and complete forensic autopsy with an HT were retrospectively selected from the databases of four French Forensic Medicine Departments. The diagnosis of vitality (i.e., stillbirth or live birth) was based on the pathological examination and/or a combination of arguments, including HT result. Lung density on CT was measured in Hounsfield units (HU) by ROIs drawn in both pulmonary parenchymas. RESULTS: Eleven patients were included, six live birth and five stillbirth cases. The result of HT was concordant with pathological examination when available (seven cases). Mean lung densities in live birth cases (- 173 HU [- 255; - 91 CI 95%]) were significantly lower than in stillbirth cases (40 HU [28; 52 CI 95%]) (p < 0.05), with a very high degree of interobserver reproducibility (ICC = 0.998 (CI 95% 0.991-0.999; p < 0.001). CONCLUSION: PMCT and especially lung CT attenuation measurement is a reliable and easy-to-use method for assessing neonatal breath in suspected neonaticides.

Complete post-mortem data in a fatal case of COVID-19: clinical, radiological and pathological correlations.

A 75-year-old man presented to a French hospital with a 4-day fever after returning from a coronavirus disease-19 (COVID-19) cluster region. A reverse-transcription polymerase chain reaction test was positive for severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) using a nasopharyngeal swab sample. After he returned home and a telephone follow-up, he was found deceased 9 days after first showing symptoms. Whole-body, non-enhanced, post-mortem computed tomography (PMCT) and a forensic autopsy were performed approximately 48 h after death, with sanitary precautions. The PMCT showed bilateral and diffuse crazy-paving lung opacities, with bilateral pleural effusions. Post-mortem virology studies detected the presence of SARS-CoV-2 (B.1 lineage) in the nasopharynx, plasma, lung biopsies, pleural effusion and faeces confirming the persistence of viral ribonucleic acid 48 h after death. Microscopic examination showed that severe lung damage was responsible for his death. The main abnormality was diffuse alveolar damage, associated with different stages of inflammation and fibrosis. This case is one of the first to describe complete post-mortem data for a COVID-19 death and highlights the ability of PMCT to detect severe involvement of the lungs before autopsy in an apparently natural death. The present pathology results are concordant with previously reported findings and reinforce the disease pathogenesis hypothesis of combined viral replication with an inappropriate immune response.

[Difficulties to GPs in determining the medical time of personal incapacity in daily life]. / Difficultés rencontrées par les médecins généralistes sur la détermination de l'incapacité totale de travail.

OBJECTIVE: Identifying the principal difficulties to general physicians in the administrative region of Loire-Atlantique to determining the medical time of personal incapacity in daily life named ITT in French legislation linked to wounds. METHODS: A study was performed by an anonym self-assessment questionnaire including 200 GPs. The study was divided in five sections (doctor's profile, self evaluation of establishing medical description of violence and evaluating ITT, questions about theoretical knowledge of ITT, medical difficulties during the assessment of wounds, and free medical comments). RESULTS: The answer rate was 50,5% of included GPs. 90,4% of medical doctor drafted medical certificate for assault victims. Only 55% of GPs fixed ITT systematically. They were influenced by the importance of assault. They express difficulties about the psychological troubles following assault. These two results were the most medical difficulties during their evaluation. DISCUSSION: The legal consequences of while incapacity is not sufficiency mastered. The psychological troubles resulting of assault is difficult to estimating for a lot of GPs. The medical doctors collect the patient pressure to increase time of personal incapacity in daily life. Lack of academic training and absence of legal ITT references are reproached by GPs. CONCLUSION: Medical certificate of stoppage work is now known as different as the time of personal incapacity for GPs. This way, we think that the evaluation of the ITT has to remain an act of GPs. if difficulties are reported by GPs, the medical testifying will be improved by references and tables which do not exist this day on the subject.

The Ogival Palate: A New Risk Marker of Sudden Unexpected Death in Infancy?

Objective: Ogival palate (i.e., a narrow and high-arched palate) is usually described in obstructive breath disorder but has been found in infants unexpectedly deceased. We studied the association between ogival palate and sudden unexpected death in infancy (SUDI) on the basis of a computed tomography (CT) evaluation. Methods: We conducted a monocentric case-control study of children under 2 years of age who died of SUDI, for which a head CT scan and an autopsy were performed between 2011 and 2018. Each case was matched by sex and age (± 30 days) to two controls selected among living children in the same center who benefited from a cranio-encephalic CT scan. Four parameters of the hard palate were measured by CT: height, width, length, and sagittal angle; the height/width ratio was calculated. The presence of an ogival palate was also subjectively evaluated by the radiologists, independently from the measurements. Standardized odds ratios (OR) were calculated using conditional logistic regression models, all expressed for +1 standard deviation (SD). Results: Thirty-two deceased children were matched to 64 living control children. Mean ages were 5.0 and 5.3 months, respectively. Twenty-eight cases were considered to have died as a result of SIDS. The mean heights of the hard palate were significantly higher in the deceased children [4.1 (± 0.7) millimeters (mm)] than in the living children [3.2 (± 0.6) mm], with OR (+1SD) = 4.30 (95% confidence interval [CI], 2.04-9.06, P = 0.0001). The mean widths of the hard palate were 21.0 (± 1.9) mm and 23.2 (± 2.1) mm, respectively, with OR = 0.15 (95% CI, 0.06-0.40, P = 0.0001). The mean sagittal angles were significantly more acute in deceased children [134.5° (± 9.3)] than in living children [142.9° (± 8.1)], with OR = 0.28 (95% CI, 0.14-0.56, P = 0.0003). The mean height/width ratios were 19.8 (± 3.7) and 14.1 (± 3.3), respectively, with OR = 6.10 (95% CI, 2.50-14.9, P = 0.0001). The hard palate was subjectively considered as ogival in 59.4% (19/32) of the cases versus 12.5% (8/64) of the controls. Conclusion: Radiological features of the ogival palate were strongly associated with SUDI. This observation still needs to be confirmed and the corresponding clinical features must be identified.

Petechiae in hanging: a retrospective study of contributing variables.

Petechiae, one of the classic signs of asphyxia, are thought to be more frequently observed in cases of hanging where part of the body is supporting the victim's weight, ie, cases of incomplete hanging. However, there is very little evidence-based medicine to support this claim. The present study is intended to evaluate the relationship between petechiae and the type of hanging (complete vs. incomplete). Furthermore, several other variables were analyzed to determine if they contribute significantly to the presence of petechiae. An 8.5-year retrospective study of 206 cases of death by hanging reviewed autopsy reports for the presence of petechiae. For each case, the following information was also compiled: gender and age, height and weight, body mass index, the type of hanging (complete or incomplete suspension), the type of ligature used (narrow or wide), and whether or not the victim had received cardiopulmonary resuscitation maneuvers. Statistical analysis revealed that the incidence was higher among incomplete hanging victims compared with cases of complete suspension and that the incidence of petechiae varied inversely with the height of the victims. The other factors were not shown to contribute significantly to the presence of petechiae.

Asylum seekers alleging torture in their countries: Evaluation of a French center.

MATERIALS AND METHODS: Over a 6-year period, 570 survivors gave consent to this study and were examined by forensic medical doctors in academic French hospital. They evaluated with the aim of cataloguing the physical evidence of torture. Sociological data, declared violence (single physical altercation, repeated physical violence less than one year or more than one year, incarceration not more than one week or more than 1 week), and method of violence (blows by blunt object, crushing, burns, electrical shocks, attempted drowning, smothering, incision, or gunshot) were studied. An association between victims' statements and physical evidence of torture was determined. RESULTS: 70% were male with an average age of 31.9 years and ages between 1 and 70 years old. Dagestan, Guinea-Conakry and Guinea-Bissau were the countries most represented among asylum seekers. Beatings were reported by 27.89%, confinement was reported by 40.22%, and repeated violence by 30.16% of refugees. The average time interval between the first assault and forensic evaluation was 53 months. Forms of torture reported included: blunt force trauma (82.51%) truncheon blows (27.50%), arm incision (30%), and burns (16.3%). Statistically, truncheon blows were experienced more often by males in confinement due to political conflict. The use of crushing methods and electrical shocks also were experienced more often by males during confinement. Victims who had received incision wounds were significantly younger. Gunshots were statistically associated with male survivors of political conflict. Men experienced drowning and electrical shocks while in confinement in the Balkans, Asia, and Russia. Electrical shocks were reported by males during confinement and in northern Caucasus countries. The association was significant between assertions of burns and the presence of cutaneous scars (p = 0.0105); similarly, assertions of incision wounds were significantly corroborated by evidence of scars (p = 0.0009). DISCUSSION: Asylum seekers assessed were usually young men. Beatings with blunt objects were the most often reported form of torture used during episodes of repeated violence and during confinement. Assertions of burns were not associated with any particular circumstances. Electrical shocks were reported during confinement and most often in countries of the northern Caucasus. Attempted drowning, smothering, and shocking were noted, but these methods typically do not leave physical evidence. Wounds resulting from burns and incisions usually leave scars that corroborate refugee statements. Torture by crushing and gunshot were reported by asylum seekers for the first time. CONCLUSION: Investigation of the types of torture and circumstances under which torture occurs is critical for efficient forensic evaluation of claims of torture experienced by asylum seekers.

Evaluation of problematic psychoactive substances use in people placed in police custody.

INTRODUCTION AND AIMS: In France, the law states that any person held in custody could be examined by a doctor. The main objective of the medical examination is to give medical evidence of health compatibility with custody. This review identifies health risks such as addictive behaviour. We wanted to know which psychoactive substances are used in this particular population, and how problematic these uses are. DESIGN AND METHODS: A prospective, monocentric, open-ended study conducted via a structured questionnaire was carried out on detainees who reported having taken drugs or illegal substances. Practitioners investigated desired effects for each substance, and characteristics of use, by means of the dependence criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994). Problematic use was assessed when at least 3 items of the DSM IV were positive. RESULTS: 604 questionnaires were examined. 90.7% of questionnaires reported tobacco use, 76.2% cannabis, 57.3% alcohol, 12.5% psychostimulants, 10.0% opiates and 0.7% benzodiazepines or Z-drugs. The frequency of problematic use was 74.6% for opiates, 44.9% for cocaine and 25.3% for cannabis. Compared to non-problematic users, problematic users were older, more likely to be jobless without financial means, more likely to have a medical history, including a greater likelihood of mental illness, and more chance of undergoing prescribed medical treatment. They included more women and more homeless people. DISCUSSION AND CONCLUSIONS: These results show characteristics of psychoactive substance use in a sample of people in custody. Psychoactive substances mentioned by respondents are not different from those observed in the general population, but for certain users, the desired effects are far from the pharmacologically expected ones. For some, taking substances seems to be part of their way of life, for others it is a means to compensate for an underlying feeling of uneasiness. Furthermore, problematic users present severity criteria which seem to be greater than in psychoactive substance users in the general population.

Sarcoidosis diagnosed in elderly subjects: retrospective study of 30 cases.

STUDY OBJECTIVE: This study investigated the clinical features and disease course of sarcoidosis diagnosed in patients > 70 years of age. METHODS: A retrospective analysis was made of cases treated at the University Hospital in Nantes, France, between 1986 and 2000. The diagnosis of sarcoidosis was confirmed histopathologically. Cases involving progressive cancer and active tuberculosis were excluded. RESULTS: Thirty white patients with sarcoidosis diagnosed after age 70 years (mean, 74 years) were included. An alteration of general health (asthenia and/or anorexia and/or weight loss) was frequent (53%) and characteristic of the systemic form of the disease. Dyspnea was a fairly common sign (23%). The intrathoracic form of sarcoidosis was most frequent (43.3%). Diagnosis was difficult and lengthy, and symptomatology was atypical. Accessory salivary gland biopsy was an important contributing factor to diagnosis (70.6% were positive). Oral corticosteroid therapy was often required (60.7%). The disease course was satisfactory overall (81.8% of cases), but only for 50% of patients in intrathoracic stage IV. CONCLUSIONS: The clinical presentation of sarcoidosis in elderly subjects is mainly characterized by an alteration of general health. Diagnosis is difficult and should include accessory salivary gland biopsy. Therapy frequently involves corticosteroids. Overall prognosis is similar to that for young subjects.

Fatal anoxia due to rachacha consumption: Two cases reported.

Deaths due to ingesting rachacha, which is a homemade paste obtained by decocting poppy heads, are very rare. No fatalities have been recorded in scientific publications. This product is not considered to be very dangerous by its users. We are reporting the first deaths (a 30-year-old man and a 28-year-old woman), after ingesting rachacha balls and alcohol consumption during an evening with a friend. Signs compatible with acute anoxia were observed during autopsy. Toxicological analyses highlighted the presence of morphine and codeine in the blood, urine and bile, with an absence of 6-acetylmorphine. Concomitant consumption of alcohol certainly played a role in the occurrence of death. The black paste found at the scene was identified as rachacha. The mean of consumption (orally) was confirmed by the presence of morphine and codeine in the gastric contents of both victims. The analysis of hair samples was performed to reveal the substance consumption history. Therefore, a possibility of contamination by sweat and/or putrefactive liquids in the post-mortem period must be considered for the interpretation of the results. These two cases show that taking rachacha can be dangerous, especially when combined with the consumption of substances which could potentiate respiratory depression induced by morphine.

A case of atypical chronic subdural hematoma: a spontaneous rupture of dural lymphoma nodule.

In forensic medicine, a chronic subdural hematoma (SDH) usually results from trauma, sometimes minimal for elderly people. The case reported here is a forensic medical description of an atypical chronic subdural hematoma. A woman aged of 40-year-old died following a coma. The autopsy and histological analyses revealed the hemorrhagic disintegration of a lymphoid nodule, a metastasis from generalized lymphoma. The combination of chronic symptomatic SDH and a tumor of the dura mater have been described, but are very rare. The possibility of trauma, even minimal, has never been excluded in these cases. In fact, the clinical picture of these patients suggested a significant movement of the brain within the cranial cavity due to the physiological decrease in brain volume. In the reported case, this particular process was excluded since the spontaneous hemorrhagic effusion produced by the meningeal lymphoid nodule was the cause of the chronic SDH. This pathophysiological explanation was possible because the entire brain and meninges were removed for histological analysis. Trauma, even minimal trauma, is not always involved in the formation of a chronic SDH.

Medical, social, and law characteristics of intoxicant's users medically examined in police custody.

INTRODUCTION: There are no studies on medically examined persons in custody which specifically focus on identifying dependence profiles among users of intoxicants. Nonetheless, the characterisation of dependence profiles for intoxicants such as alcohol, cannabis, cocaine, heroin, amphetamines and their by-products is a medical necessity in this setting. MATERIALS AND METHODS: A prospective, monocentric, open-ended study conducted by structured questionnaire was carried out on detainees who admitted to having taken an intoxicant/s (tobacco, alcohol, drugs or illegal substances). Social, legal and medical data were collected. The aim of the study was to explore characteristics of these persons in police custody. RESULTS: 817 questionnaires were examined. More than one-third have a dependence on at least one substance. 37.7% were dependant of tobacco, 86.5% of drinkers, 24.7% of cannabis users. Of these, 90.1% were from men with a mean age of 29.4 years, 40% from individuals living alone, 25.7% from persons with no financial means and 19.6% from homeless persons. 10% were believed to be suffering from mental illness, 7.2% were thought to be asthmatic, 3% to have a chronic infection, and 2.9% to have epilepsy. 36.2% reportedly received treatment, 37.5% of which included benzodiazepine and 20.3% opiate substitution therapy. Incidence of psychological and psychiatric disorders is close to 10% of intoxicant detainees. DISCUSSION: In this study, some of the stated pathologies occur in ratios similar to those in other published results. But, there is a high, and probably underestimated, prevalence of psychological and psychiatric disorders in this population of detainees reporting exposure to intoxicant or illegal substances.

Fracture of the neck structures in suicidal hangings: a retrospective study on contributing variables.

INTRODUCTION: Several factors may play a role in the development of fractures of the neck structures in hanging. It has been repetitively demonstrated that the incidence of fractures increases with age. The role of other variables is less clear, different studies presenting contradictory results on the role of gender, the type of suspension, or the type of ligature. However, most of these studies evaluated these factors independently of the age of the victims. Considering that age is probably the most important factor in the development of neck structure fractures, all other contributing factors should be studied in relation to age. The aim of the present study is to evaluate the role of contributing factors to the development of neck structure fractures, taking age categories into account. MATERIALS AND METHODS: A total of 206 cases were analysed for the presence and localization of thyroid fracture. For each case, the following information was also compiled: the presence and localization of other neck structure fractures, gender and age, height and weight, body mass index (BMI) type of suspension (complete or incomplete), type of ligature used (rope, wire, clothes, sheet or lace) and localization of the knot (anterior, right, left or posterior). RESULTS: The incidence of neck structure fractures increased with age (χ(2)=21.85; p<.001) and is significantly higher in male victims (31.4%) compared to female victims (11.8%) (χ(2)=5.41; p=.02). The incidence of fractures varied significantly with the height (t=2.19; p=.031; D=.33), weight (t=4.38; p<.001; D=.89) and BMI (t=3.84; p<.001; D=.60). The incidence of fractures did not vary significantly with the type of suspension (i.e. complete hanging with feet off the ground or incomplete hanging with body parts partially supporting the weight of the body) (χ(2)=3.12; p=.077; Phi=.077) and the type of ligature (i.e. narrow vs wide) (χ(2)=.05; p=.828; Phi=.015). However, when taking the age of the victims into account, a different picture was revealed: in individuals aged 40 years or more, victims with complete suspension of the body presented with a significantly higher incidence of fractures (63.2%) compared to victims with incomplete suspension (31.0%) (χ(2)=6.79; p=.009; Phi=.318). CONCLUSION: Several variables contribute to the development of neck structure fractures in hanging. Age is probably the most important one. Other contributing factors are gender, height, weight, BMI and the type of suspension.

Mechanism of death in hanging: a historical review of the evolution of pathophysiological hypotheses.

In cases of hanging, the exact mechanism leading to death has yet to be elucidated. Most of our contemporary knowledge is still based on writings from the end of the 19th and the beginning of the 20th century. This article reviews the historic experiments that shaped our current theories. Medico-legal textbooks written in English and French from 1870 to 1930 were reviewed. Various animals, such as rabbits, mice, and dogs, have been used to develop animal models of hanging. Limited human studies on cadavers and judicial hangings have provided some additional insight into the pathophysiology of death by hanging. The main pathophysiological theories described were respiratory asphyxia, interruption to cerebral blood flow because of occlusion of vessels in the neck, and cardiac inhibition secondary to nerve stimulation. The relative contributions of each of these theories to death in cases of hanging is still debated today.

Respiratory, circulatory, and neurological responses to hanging: a review of animal models.

The pathophysiology of hanging is still poorly understood. This article presents a review of eight animal models: four models of isolated occlusion of the vessels of the neck (group 1), one model of combined tracheal and vessel occlusion (group 2), and three models of true animal hanging (group 3). Occlusion of the airway passages in group 2 did not accelerate respiratory arrest compared to group 1. Cessation of cerebral blood flow, rather than airway obstruction, seems to be the main cause of respiratory decline. In general, muscular movements ceased after 1-3.5 min and early generalized tonic-clonic convulsions were described. Complete circulatory collapse seems to occur between 4 and 8.5 min. These observations from animal models of hanging are compared with the data collected from filmed human hangings. Avenues to improve animal models are discussed.

[Roles and missions of the reliable person at the hospital: Insufficiently known by the patients]. / Rôles et missions de la personne de confiance à l'hôpital : insuffisamment connus par les malades Enquête semi-directive chez 95 patients du CHU de Nantes.

INTRODUCTION: The law of March 4th, 2002 allows the patient hospitalized to appoint a reliable person who can support him, help him and represent him throughout his disease. This possibility must be necessarily proposed by hospitals. The roles and the missions entrusted to this reliable person do not stop becoming more marked since. OBJECTIVE: A study was realized to know if the hospitalized patients knew that is a reliable person and if yes how had they learnt him? The study tried to know who is or would then be appointed and who are or would be and would be the roles and missions which appear to him important? METHOD: By one question semi-directive distributed to the patients hospitalized in units of pointed care, following care and the long-term care of Nantes (France), these estimated the roles and the missions awarded to the reliable person by the legal texts. RESULTS: A meadow of a patient on two does not know who is a reliable person. A direct relative (parent children, spouse and not the regular doctor) is or would be indicated. The reliable person is a help considered very important by the patients. More than 8 patients on 10 estimate him very precious audience in the accompaniment during the hospitalization and in the respect for their last wills more than in the direct support. The patients of more than 65 years old and retired know less well this reliable person. The information delivered to the reliable person has to be the object for the patient of a real partnership with the teams of care. DISCUSSION: The information and the knowledge by the patients and the nursing of the roles and the missions of the reliable person are clearly insufficient. Establishments in other did not take all the measure of this obligation to propose his name. An initial and continuous training nursing on its subject would be necessary. CONCLUSION: The patients grant a big importance for this reliable person and this study shows that the patients would tune him a lot of importance if hospital departments answered their obligations.

Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France.

BACKGROUND: In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. The aim of this study was to analyse the practices of some French nephrologists, 17 of whom (in six nephrology units) were interviewed for this study. METHODS: A questionnaire was formulated on the basis of a bibliographical search of the topic. A series of questions, initially open and then more targeted, regarding scientific and non-scientific factors influencing the decision to discontinue or refuse haemodialysis in elderly patients, were put to nephrologists. RESULTS: Psychological and physical deterioration emerged as the principal factors governing decisions to refuse or discontinue treatment. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. Although the main reasons for refusing dialysis were cognitive disorders, severe dementia and irreversible neurological conditions, none of these factors where actually found to be in and of themselves decisive. CONCLUSIONS: This study has shown that refusing or discontinuing dialysis are practices accepted by the vast majority of nephrologists in one region of France. Patient refusal is not a basis for denial or discontinuation of dialysis in elderly patients. Our investigation has demonstrated a consensus regarding decisions to refuse or discontinue dialysis.