Fetal facial bone growth: Post-mortem CT analysis.

OBJECTIVE: To describe and model the normal growth of fetal facial bones and angles. MATERIAL AND METHODS: A total of 118 fetal CT scans obtained at 19 to 41 weeks gestation after in utero fetal death or late miscarriage were analyzed. CT scan was followed by autopsy and pathological examination and only fetuses free from brain disease or abnormal craniofacial development were included. The measurements were taken using software for frontal, sagittal and 3D reconstruction from native axial sections. The optimal plane for bone analysis was chosen and the measurements made by multiplanar reconstruction. RESULTS: There was a statistically significant increase (P<0.001) in all measurements regardless of gestational age (GA) except those of the mandibulo-fronto-maxillary angle (P=0.412), the naso-mandibulo-maxillary angle (P=0.828) and mandibular width (P=0.86). There was no significant difference according to fetal sex. Based on these results, the corresponding growth curves were created. The anteroposterior mandibular diameter (APD) was very strongly correlated with GA (R=0.926, P<0.001). The following equation: GA=(8.187×APD)+4.257 can be used to estimate GA with a confidence interval (CI) of±2.42. The same applies to maxillary width (MW) (R=0.922; P<0.001). The equation GA=(11.059×MW)+7.571 can be used to estimate GA with a CI of 2.17. CONCLUSION: The growth of the mandible, maxilla, zygomatic bone and orbits was measured and the corresponding growth curves were established. Several measurements were strongly correlated with gestational age.

Sudden death after facial impacts: Is the brainstem involved?

Three deaths following facial impacts in the presence of witnesses and resulting in brain lesions that were visualized only on pathological examination were studied at the forensic medicine institute of Marseille. Craniofacial impacts, even of low intensity, received during brawls may be associated with brain lesions ranging from a simple knock-out to fatal injuries. In criminal cases that are brought to court, even by autopsy it is still difficult to establish a direct link between the violence of the impact and the injuries that resulted in death. During a facial impact, the head undergoes a movement of violent forced hyperextension. Death may thus be secondary to the transmission of forces to the brain, either by a mechanism involving nerve conduction that may be termed a reflex mechanism (for example by vagal hyperstimulation) or by injury to the central nervous system (axonal damage). In such situations, autopsy does not make it possible to determine the cause of death, but only to suspect it in a context of voluntary violence in the presence of witnesses, with or without violent injury observed on external examination or on superficial incisions to determine the extent of bruises or hematoma. Systemic and comprehensive investigation involving pathology and toxicology is essential in any medicolegal case for positive interpretation and discrimination of other causes of death.

Judicial handling of cases of non-accidental head trauma in infants: Review and analysis of expert assessments.

INTRODUCTION: Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI. METHOD: A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis. RESULTS: In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases. CONCLUSION: Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

Study of the growth and shape of the brain and cranial base during the first two years of life.

Ontogeny of the cranial base and the brain integrates data on growth, maturation and ontogenetic allometry of these two systems in the course of development. The aim of our work was to study the ontogeny of the cranial base and the brain in order to understand their growth dynamic and shape changes using a traditional morphometric approach in individuals with normal (non-pathological) development. MATERIEL AND METHOD: Forty-seven infants having been included in the unexpected infant death french protocol were analyzed. Medical imaging (CT and MRI) exams, followed by an autopsy and pathology examination allowed us to include only infants free from brain disease or pathology affecting growth. RESULTS: Testing of measurement reliability validated 12 distances and 3 angles as well as the positioning of the landmarks that had been used to obtain the distances and the angles. No correlation between sex and the various variables studied was found. However, a correlation was observed between these variables and age, making it possible to propose a growth curve. A medium to strong correlation was found between brain variables and the bone variables of the cranial base, underlining the parallel development of the two systems. CONCLUSION: Our study, carried out in a rigorously selected population of infants, presents a fundamental approach to the study of ontogenesis.

Biomechanical study of the thyroid cartilage: A model of bi-digital strangulation.

The presence of fracture on neck elements is an indication of violence. Both the hyoid bone and the larynx can be damaged by a strangulation mechanism. Thyroid cartilage, more specifically, may present lesions in response to this mechanical stress. These lesions result in fractures at the bases of the horns of the thyroid cartilage. This study focuses on the thyroid cartilage behavior in cases of bi-digital strangulation, using an anthropometric and biomechanical approach. To develop a biomechanical model, we performed an anthropometric study taking into account 14 distances measurements as well as 3 measurements of angles. These measures allowed us to determine a significant sexual dimorphism between individuals. Then, we define 6 morphologies models, composed of 3 females and 3 males individuals. In order to visualize the ossification of the cartilage, each model has been tested with bone properties. Strangulation cases were simulated by applying an imposed velocity of 0.4m/s then 1m/s. We observed different behaviors of the thyroid cartilage according to the sex and the morphology.

Folie à deux and homicide: Literature review and study of a complex clinical case.

Folie à deux is a psychiatric illness involved in homicides. OBJECTIVE: To study the mechanisms leading to homicide and determine homicide risk factors in folie à deux patients through a literature review and the study of a complex clinical case. MATERIALS AND METHODS: We included articles available on PubMed, ScienceDirect or Cairn that address the forensic implications of folie à deux. Then, we analyzed the criminal psychiatric assessments of two murderers (husband and wife) of a child in a case of folie à deux. RESULTS: Seventeen articles were included. In the cases examined, homicides were committed with great violence, usually against a victim in the family circle, and were sometimes followed by suicide. The main risk factor for homicide was the combination of mystical and persecutory delusions. The homicides occurred in response to destabilization of the delusional dyads. Concerning the clinical case, we described the circumstances surrounding the killing and analyzed the four expert reports that permit us to infer the occurrence of induced psychosis, which is a form of folie à deux. DISCUSSION: Psychiatrists must attain a better knowledge of folie à deux to allow early identification of risk situations and to improve their assessments.

Is the French criminal psychiatric assessment in crisis?

The criminal psychiatric assessment in France seems to be facing growing criticism related to disagreements between experts and, on the other hand, a lack of interest of psychiatrists for the assessment. We start by explaining the current framework of the criminal psychiatric assessment in France, which differs from the assessment used in English-speaking countries, where Roman law applies. Then, we will describe the disagreements through a literature review and two clinical vignettes. Finally, we will try to understand the causes of discrepancies between experts and the reasons for a supposed lack of interest of the psychiatrists for the expertise. For this, we conducted a survey among the psychiatric experts. We individually questioned experts on the discrepancies and on their awareness of the expertise. We found that 75% of the experts we surveyed had already faced the divergent opinion of a colleague. In addition, the experts were divided on their conclusions related to the fictional scenario we gave them for an a priori assessment (a person with schizophrenia who was accused of murder), particularly in the specific contexts that we submitted to them. The main cause of disagreement between experts was the various schools of thought that influence the psychiatric experts in the forensic discussion and, therefore, the conclusions of a case. Moreover, the experts believed that the decrease in the number of psychiatric experts could be attributed to the adverse financial situation of the assessment, the considerable workload required, and the extensive responsibility that falls on the expert. Calling on a team of forensic experts to perform assessments seems to be the first solution to this crisis. Furthermore, if the experts were better compensated for the assessments, more people would want to undertake this work.

Anatomical basis of the coordination between smooth and striated urethral and anal sphincters: loops of regulation between inferior hypogastric plexus and pudendal nerve. Immuno-histological study with 3D reconstruction.

PURPOSE: (1) Describe both nervous pathways to the sphincters, and highlight the anatomical support of their coordination. (2) Obtain a 3D representation of this complex innervation system. METHODS: A computer-assisted anatomical dissection technique was used. Serial histological sections were cut in the pelvis of four female human foetuses (aged 19-32 weeks of gestation). The sections were treated with conventional staining, and with seven different immunostainings. The sections were digitalized and, finally, a 3D representation was built from the corresponding images. RESULTS: Myelinated and sensory fibres were detected at the inferior hypogastric plexus (IHP) level. Our analysis showed that most of the afferent sensory fibres come from the urinary and anal sphincters through the anterior and posterior branches of the IHP respectively. A highly positive nitrergic (anti-NOS1) and sensitive (anti-CGRP) labelling was found in the external layer of the urethral sphincter. The 3D representation allowed describing the two components of the innervation system. A sensory-motor regulation loop was found for both sphincters. CONCLUSION: A 3D description of the components of both nervous pathways to the sphincters has been established. Our findings on the innervation of the sphincters tend to question the classical infra/supra levatorian muscle description. The coordinated work of the internal and external layers of the anal and urethral sphincter is probably mediated by multiple roles regulation.

[Differences in psychiatric expertise of responsibility for schizophrenic persons accused of murder: Study with experts of the Court of Appeal of Aix-en-Provence]. / Divergences dans l'expertise de responsabilité des personnes schizophrènes accusées d'homicide volontaire : enquête auprès des experts de la cour d'appel d'Aix-en-Provence.

INTRODUCTION: In France, forensic psychiatric assessment plays a central role in the relationship between psychiatry and justice. The psychiatric expert is commissioned to determine whether or not the accused has a mental disorder and to specify whether or not it affected discernment at the time of offense. Nowadays, psychiatric expertise is coming under more and more criticism, particularly regarding divergences between experts. OBJECTIVES: Our objectives were to find points of divergence between experts, try to understand causes and suggest ways to try to reduce them. METHODS: For this we conducted a study, between July 2012 and January 2013, with psychiatric experts of the Court of Appeal of Aix-en-Provence through semi-structured interviews. We focused on a limited context: psychiatric expertise of responsibility for schizophrenic persons accused of murder. We questioned the experts about the issue of criminal liability of a person with schizophrenia in general but also in clinical situations we thought particularly involved in disagreements. RESULTS: We recruited a population of 17 psychiatrists, mostly males of average age of 58 years, working mostly in the department of adult psychiatry of a hospital. We highlighted the differences between the experts, first with regards to the issue of liability in general. Experts divided seemed to keep in majority (52.9 %) the alternative between abolition and alteration of discernment when faced with a schizophrenic person accused of murder. The differences were even more pronounced in specific contexts. Thus, the fact that the person had suffered from delirium at the time of the offense led half of the experts (47.1 %) to conclude a systematic abolition of discernment, while the other half made such a conclusion when the delirium was directly linked to the facts. Discontinuation of neuroleptic treatment, drug abuse or existence of premeditation changed the conclusions of the experts in half the cases, more in the sense of an increased accountability in the cases of drug abuse or premeditation, and in the direction of a reduction of liability in case of cessation of treatment. The denial of facts by the accused caused fewer disagreements between experts. Among experts, 76.5 % had already observed differences, which, according to them, were based primarily on schools of thought, or personal views (64.7 %), which could distort clinical evaluation and especially forensic interpretation of the relationship between pathology and facts. The experts thought it was possible and desirable to reduce differences and proposed different solutions for this, especially the return to dual expertise and colleges of experts. DISCUSSION: Our results were consistent with those in the literature. Based on proposals from experts and data from the literature, we identified five perspectives likely to reduce differences: first it would be useful to put in place a better specific training in forensic psychiatry and expertise, not only theoretical but also in terms of practical training through tutoring. We would identify a jurisprudence in forensic psychiatric assessment and identify consensual points. It would be good to allow experts to acquire sufficient experience not just through tutorials but also by statutory changes. Moments of exchange between experts - including a return to dual expertise and the organization of work meeting - could also reduce differences. Finally, we propose legislative changes: not only to rewrite the paragraph 2 of Article 122-1 of the French Penal Code, but also to give priority to the expertise of responsibility on the expertise of dangerousness. CONCLUSION: We showed that there were differences between the experts mainly concerned with the forensic interpretation, and that they seemed linked to schools of thought or to personal views of each expert. To reduce the differences, we discussed five perspectives.

[Post-mortem perinatal imaging: State of the art and perspectives, with an emphasis on ultrasound]. / Imagerie post-mortem périnatale : état des lieux, point de vue et perspectives, échographiques en particulier.

The fields of application of post-mortem imaging have been exponentially growing for 10 years. Its potential to identify the cause of death in trauma and ballistic cases is now properly documented. In pediatric and perinatal practice, large significant series are less available, except for MRI and central nervous system analysis where scientific evidence is now robust. After a short historical and state-of-the-art review, we will try to depict the way we see the future of this sub-specialty of post-mortem imaging, especially in specific perinatal situations.

[Differences in psychiatric expertise of responsibility: Assessment and initial hypotheses through a review of literature]. / Divergences dans l'expertise psychiatrique de responsabilité : bilan et premières hypothèses à travers une revue de la littérature.

INTRODUCTION: Forensic psychiatric assessment regarding liability ensures a balance between justice and psychiatry. In France, criminal assessment is not contradictory. The psychiatric expert is commissioned by judges to determine whether or not the accused has a mental disorder and specify whether it affects discernment and control of actions at the time of offense. Its mission focuses on the mental element required to constitute an offense, and is structured around Article 122-1 of the Criminal Code. This article, composed of two paragraphs, distinguishes the framework of the abolition of discernment ­ a cause of non-imputability and therefore of a statement of lack of criminal responsibility due to mental disorder ­ and the framework of the alteration of discernment. Nowadays expertise seems to meet discomfort, with criticism focusing on possible differences among psychiatric experts, without specific studies having been conducted to confirm it. OBJECTIVES: Our objective was to identify the main points of disagreement between psychiatric experts and to propose explicative hypotheses. MATERIALS AND METHODS: For this, we carried out a literature review on PubMed, Science Direct and Cairn, and studied the report of the 2007 public hearing on forensic psychiatric assessment with contributions from different authors. The keywords were: forensic psychiatry, psychiatric court report, psychiatric expertise, differences among experts, legal responsibility, and discernment. We defined differences as disagreements between experts, or as a mismatch in conclusions and approaches of experts. RESULTS: The differences among experts concerned mainly forensic interpretation, i.e. the discussion of the relationship between pathology and offense, particularly in contexts that involve a larger forensic discussion, including interruption of medication, use of drugs, association with antisocial personality, premeditation, denial of facts, especially when the accused suffers from a mental illness (especially schizophrenia). For a finding of abolition of discernment, an expert must consider two requirements, one temporal (the mental disease must be active during offense) and the other causal that involves seeking a direct and exclusive relationship between the offence and the mental state, according to expert jurisprudence. Some experts do not comply with these two requirements or this jurisprudence, whence differences. There were also diagnostic differences and disputes relating to the concept of "alteration of discernment". Disagreements appeared to be related primarily to personal ideologies or different schools of thought that influenced interpretations and conclusions of experts, e.g. accountability as a therapeutic response for the psychotic person. Then, the lack of clarity of expert mission regarding necessary causal relationship ­ between any disease and crime ­ to demonstrate to conclude an abolition of discernment, could also contribute to differences. Moreover, time available to achieve the mission is too short and the expert would not devote enough time to an expert examination, which could lead to less good expertise and differences; especially as observed clinical examination in expertise is sometimes difficult, misleading, due to pathological reticence of accused mentally ill but also sometimes due to possible simulations. Finally, the low quality of some expert reports ­ due in part to the less well-trained experts, but also the particular conditions of achievement of expertise, especially in prisons ­ were mentioned by some authors as causes of differences. DISCUSSION: It appears from this review of literature that differences mainly concern forensic interpretation and are mainly explained by ideologies. This synthesis is a preliminary work prior to a study among psychiatric experts.

[Vulvar lichen sclerosus in children misdiagnosed as sexual abuse]. / Lichen scléro-arophique vulvaire chez l'enfant : diagnostic différentiel d'abus sexuel.

INTRODUCTION: With the frequency of lawsuits for sexual abuse increasing, high-quality care for victims is of utmost importance. Genital examination is difficult to perform, especially on children, but is a key item for diagnosis. A case report is presented herein to illustrate this issue. CASE PRESENTATION: A sexual assault was suspected on 2.5-year-old female twins. Clinical examination primarily detected vulvar micro-hematoma and hypopigmentation, discreetly sclerosing, as well as atrophic labia and a beginning of lichenification on one of them. The other twin showed an unspecific and erythematous lesion. Elimination of the supposedly dangerous environment and a remote consultation brought out a paradoxical development to the story and confirmed the diagnosis of vulvar lichen sclerosus. DISCUSSION: Traumatic lesions caused by sexual abuse are uncommon. Coexisting allegations and lesions in the genital area lend support to the hypothesis of sexual abuse. However, genital-anal tropism dermatosis can mimic traumatic injuries. Lichen sclerosus is an example of a differential diagnosis of vulvar traumatic lesions, which is quite often unknown to physicians, including pediatricians. This case report shows that taking the appropriate time in multidisciplinary councils can suggest a differential diagnosis. Nonetheless, it should be remembered that identifying the pathology behind the lesions cannot allow the physician to negate the child's story about potentially sexual acts, although the truth of this story and the perpetrator must still be proven by a court of law.

Liability under post-tonsillectomy lethal bleeding of the tonsillar artery: a report of two cases.

Post-operative haemorrhage is a frequent complication of tonsillectomy: a primary haemorrhage occurring in the first hours is rapidly dealt with by the surgical team. A secondary haemorrhage, which commonly occurs once the child has returned home, can be fatal if it is not dealt with quickly. We present two cases of a lethal outcome in children following a secondary post-tonsillectomy haemorrhage, for which the parents filed legal proceedings. Medical liability can be exercised during all stages of health care. Performing an autopsy associated with histological analyses is found to be indispensable for the identification of the causes of bleeding, as well as its mechanism.

[Responsibility for prescribing and monitoring an act transfusion and safety blood transfusion]. / La responsabilité en matière de prescription et surveillance d'un acte transfusionnel et sécurité des produits sanguins.

The act to transfuse is a prescription following basic rules similar to drug prescriptions. If harm happens, potentially linked with this prescription, the harm's responsibility is borne by the physician, the paramedics, the care organization but by the supplier laboratory too. The setting of good practice rules consistent with science data at the time when the act is performed, the respect of the patient's rights and the quality of supplied products will be assessed during the expertise. Under restorative responsibility, it is necessary to previously establish a direct and certain causation between the litigious act and the harm to enforce the vicarious liability. Nowadays, legal precedents grant a larger protection to more and more numerous victims, enhancing the field of the fault with the appeal to assumption of fault. At the same time, the lawmaker himself promulgated objective conditions of compensation for many categories of victims of medical risk from which transfused people are part. The law of March the 4th of 2002 went one step closer devoting a new foundation of compensation: national solidarity.

[Prescribing medication in 2013: legal aspects]. / Prescrire un médicament en 2013: aspects légaux.

AIM: To describe the legal framework of medicine prescription in France in 2013. METHODS: With the assistance of lawyer and forensic pathologist, consultation (legifrance.gouv.fr), analysis, summary of French laws and rules surrounding drugs prescriptions to humans for medical purpose. RESULTS: Free medicine prescription is an essential feature of a doctor's action. To prescribe involve his responsibility at 3 levels: deontological, civilian and penal. Aim of the rules of medicine prescription is to preserve patient's safety and health. Doctors are encouraged to refer to recommendations and peer-reviewed publication every time the prescriptions go out of the case planned by law. CONCLUSION: Knowledge and respect of medicine prescription legal rules is essential for a good quality practice. Medical societies have a major role to improve medicine use among practitioners.

[Fatal hemorrhage in postpartum by rupture of a splenic artery aneurysm]. / Hémorragie létale dans le post-partum par rupture d'un anévrisme de l'artère splénique.

The maternal mortality is rare and when it arises, the family often puts the medical profession in guilty's position. We present the case of a 38-year-old woman, died in the post-partum in a context of intense back pains. The autopsy found an incidental hemorrhagic syndrome to a two-stage rupture of the splenic artery. We shall discuss the aetiology. The autopsy and the anatomopathological examination are practiced only in hardly more than a quarter of the cases while they will be important in proceedings and will allow the family to go into mourning.

Medical liability in surgery for morbid obesity by adjustable gastric band: nine case reviews.

Adjustable gastric banding is recognized for its effectiveness in obtaining long-term weight loss with low morbidity-mortality for patients with morbid obesity. However, life-threatening complications can sometimes occur, and surgeons may end up in court. We analyzed complications, some of them lethal, arising from gastric banding surgery in nine patients and the main issues identified by the experts, contributing to the judge's decision. Gastric banding is considered a benign operation, but, of the nine cases examined herein, five resulted in death while the other four had serious consequences with several damages, especially aesthetic and psychological suffering. Perforations of the oesophagus or stomach remain the leading causes of complications; the experts identified several issues from the records that helped the judge to render a decision and condemn seven of the nine surgeons. Three types of faults were considered the responsibility of the doctors: the lack of patient information or incomplete medical records, a clumsy mistake or delay of appropriate treatment due to underestimation of clinical symptoms, and finally, failure to observe the proper indications. Expert opinion focused most often on criticism of postoperative behaviour and failure to make decisions according to the state of the art.