[After the COVID crisis, what solutions for the future nursing home?] / Rapport 22-02. Après la crise COVID, quelles solutions pour l'EHPAD de demain ?

The ageing of the population induces situations of large vulnerability and dependence. Home care usually remains the best response to comply with the person's wish, the family's desire, and the civil society's interest. However, there are circumstances where patient management in a nursing home (EHPAD) is the only solution. The present pandemic of coronavirus COVID-19 has highlighted the issue of EHPAD and their limitations to provide high quality care. To analyze the current position of EHPAD into the care chain and to understand difficulties to their functioning, it seems essential to seek out accelerated changes in the EHPAD since their establishment in 1999 and then in the light of the current crisis, propose possible solutions with a positive view of the role which each EHPAD will have to ensure for future.

Hypofractionated stereotactic radiotherapy for challenging brain metastases using 36 Gy in six fractions.

PURPOSE: Stereotactic radiosurgery and hypofractionated stereotactic radiotherapy are standard treatments for brain metastases when they are small in size (at the most 3cm in diameter) and limited in number, in patients with controlled extracerebral disease and a good performance status. Large inoperable brain metastases usually undergo hypofractionated stereotactic radiotherapy while haemorrhagic brain metastases have often been contraindicated for both stereotactic radiosurgery or hypofractionated stereotactic radiotherapy. The objective of this retrospective study was to assess a six 6Gy-fractions hypofractionated stereotactic radiotherapy scheme in use at our institution for haemorrhagic brain metastases, large brain metastases (size greater than 15cm3) or brain metastases located next to critical structures. MATERIAL AND METHODS: Patients with brain metastases treated with the 6×6Gy scheme since 2012 to 2016 were included. Haemorrhagic brain metastases were defined by usual criteria on CT scan and MRI. Efficacy, acute and late toxicity were evaluated. RESULTS: Sixty-two patients presenting 92 brain metastases were included (32 haemorrhagic brain metastases). Median follow up was 10.1 months. One-year local control rate for haemorrhagic brain metastases, large brain metastases, or brain metastases next to critical structures were 90.7%, 73% and 86.7% respectively. Corresponding overall survival rates were 61.2%, 32% and 37.8%, respectively. Haemorrhagic complications occurred in 5.3% of patients (N=5), including two cases of brain metastases with pretreatment haemorrhagic signal. Tolerance was good with only one grade 3 acute toxicity. CONCLUSION: The 6×6Gy hypofractionated stereotactic radiotherapy scheme seems to yield quite good results in patients with haemorrhagic brain metastases, which must be confirmed in a prospective way.

Energy valorization of industrial biomass: using a batch frying process for sewage sludge.

This paper studies the energy valorization of sewage sludge using a batch fry-drying process. Drying processes was carried out by emerging the cylindrical samples of the sewage sludge in the preheated recycled cooking oil. Experimental frying curves for different conditions were determined. Calorific values for the fried sewage sludge were hence determined to be around 24 MJ kg(-1), showing the auto-combustion potential of the fried sludge. A one-dimensional model allowing for the prediction of the water removal during frying was developed. Another water replacement model for oil intake in the fried sewage sludge was also developed. Typical frying curves were obtained and validated against the experimental data.

Preparation and characterization of activated carbon from sewage sludge: carbonization step.

Sewage sludges produced from wastewater treatment plants continue to create environmental problems in terms of volume and method of valorization. Thermal treatment of sewage sludge is considered as an attractive method in reducing sludge volume which at the same time produces reusable by-products. This paper deals with the first step of activated carbon production from sewage sludge, the carbonization step. Experiments are carried out on viscous liquid sludge and limed sludge by varying carbonization temperature and heating rate. The results show that carbonized residue properties are interesting for activated carbon production.

Age and gender effects on cardiomyocyte apoptosis in the normal human heart.

BACKGROUND: Animal studies have suggested that apoptosis could play a significant role in the myocardial aging process. Although no information is available in humans, the paradigm that cardiomyocyte apoptosis is increased in the aged human heart has been widely propagated. Moreover, it is unknown whether gender differences may influence cardiomyocyte apoptosis. METHODS: Cardiomyocyte apoptosis was compared between subjects ranging in age from 21 to 93 years (22 men and 19 women), free of any cardiovascular disease, who died of either violent or natural causes. Strict inclusion and exclusion criteria were used to ensure that the selected hearts accurately represented normal aging. RESULTS: Apoptosis was detected using the TdT-mediated dUTP digoxigenin nick end labeling (TUNEL) technique (controls for TUNEL included negative staining for splicing factor SC-35 and for Ki-67 antigen). The percentage of cardiomyocyte death ranged from 0% to 0.0437%, with no correlation with the age of the subject (p =.85). However, the percentage of apoptosis was threefold higher in men than in women (0.0133% +/- 0.0030% vs 0.0042% +/- 0.0008%, respectively; p <.01). CONCLUSIONS: Our results in humans do not support the hypothesis that aging influences the percentage of cardiomyocyte apoptosis. However, gender appears to be an important determinant of the occurrence of apoptosis.

[Sudden death and physical activity and sports]. / Mort subite et activité physique et sportive.

A growing number of people are involved in recreational physical activity. We examined the clinical and cardiac pathological patterns in 29 persons who died suddenly during a sport activity and were autopsied at the Institute of Forensic Medicine of Paris, 1990-1999. Twenty-seven males ranging in age from 13 to 57 years, mean 30.5, and two females, 8 and 60 years old, died suddenly during a sport activity. The sports included running, 11 cases; cycling, 4; soccer, 3; swimming, 2; basket-ball, 2; rugby, 1, gymnastic exercises, 2; tennis, 1; gockart, 1; skiing, 1; hand-ball, 1 case. The causes of deaths were as follows; coronary artery disease, 9 cases; congenital anatomic anomaly of a coronary artery, 1; hypertrophic cardiomyopathy, 5; right ventricular dysplasia, 3; myocarditis, 2; endomyocardial fibrosis, 1; bridging of the left anterior descending coronary artery, 2; stroke, 2; rupture of aortic aneurysm, 4. Despite severity of lesions, only 4 victims had a known cardiovascular disease. Efforts should be continued to improve sensitivity and specificity of diagnostic tools and screening strategies. Therefore, medico-legal autopsies should be systematically performed for a better knowledge of sport-related mortality.

[The body packer syndrome]. / Le syndrome du "body packer".

BACKGROUND: Ingestion of illicit drug packages is a well known method for transportation. These packages are prone to rupture causing overdose. The body packer syndrome may be overlooked in medical practice as illustrated by the following case report. CASE REPORT: A 19-year old male had convulsions followed by cardiac arrest during a flight. He was resuscitated in the plane, but he died a few hours after admission in intensive care unit. Chest and abdominal X-rays were considered normal. Cocaïne métabolites were found in his urine. The death was considered suspicious. X-rays performed before medicolegal autopsy showed numerous packages in his digestive tract. Thirty-six packages were found in the stomach and intestine. Two were ruptured in the stomach. The cause of death was cocaïne overdose caused by package rupture. DISCUSSION: The packages are usually visible on an standard abdomen X-ray. The drug is often wrapped in latex membranes or condoms. The air is trapped between the condoms by the nodes, forming two crescents visible on the X-ray. Surgery is preferred to laxatives when the packages are fragile with a high risk of rupture.

[Sudden cardiac death in adults. Epidemiology]. / La mort subite d'origine cardiaque chez l'adulte. Epidémiologie.

Epidemiology studies indicates that in populations sudden death is a prominent and lethal feature of coronary heart disease. Estimations show that 20-25 per cent of cardiac mortality die suddenly. The temporal definitions of sudden death range within 1 hour of the acute onset of symptoms in a subject who has been well. The usual risk factors of coronary heart disease are also predictive of sudden death but family history is a independent factors.

Suicide among youth and young adults, 15 through 24 years of age. A report of 392 cases from Paris, 1989-1996.

The aims of our study were (1) to examine the socio-demographic, clinical characteristics, autopsy and toxicological findings in 392 youth suicides in Paris, between 1989 through 1996, and (2) to analyze the psychodynamic determinants leading up to the onset of the suicide. During the eight-year study period 392 suicides involving young people were investigated at the Institute of Forensic Medicine of Paris. Two hundred and sixty victims (66%) were males. The mean age was 22 years in both sexes. Fifteen percent of the victims were below 20 years. Ninety-two percent of the subjects were single. Forty percent of the victims were students, 35% were unemployed. One third of the victims had previously attempted suicide. Thirty-five percent of the subjects used to take psychoactive prescription drugs and some of them had been under the care of a mental health professional at the time of the suicide. In 40% of the cases a suicide note was found near the body. Depression (70% of victims), schizophrenia, (10%), affective disorders, parent-child relational problems, partner relational problems, adolescent antisocial behavior, and borderline personality were found to be the most frequent diseases and stressors involved in the suicides. The suicide was rarely an accidental reaction to stress. It was constantly preceded by situational distress, which led to suicidal ideas if the adolescent failed to cope with problems. Ten percent were known as heroin users. In more than 40% of the cases, the victim's parents were divorced or separated. The most frequent method of suicide was poisoning followed by jumping from a height, gunshot, subway death, and hanging/asphyxia. Among firearms, a handgun was more likely to be used than rifles (85/15%). Tranquilizers were the most frequent psychoactive drugs used for suicide followed by antipsychotic drugs, antidepressants, and barbiturates (10%).

Homicide followed by suicide: Paris and its suburbs, 1991-1996.

Homicide-suicides (HS) are relatively infrequent events. Yet, they are of great concern because they often result in the death of family members, young children, and cause additional morbidity, family disruption and childhood psychological trauma. The aims of our study were (a) to examine the sociodemographic, clinical, and autopsy characteristics of HS in Paris and its suburbs from 1991 through 1996, and (b) to analyze the psychodynamic determinants leading up to the onset of HS. Our findings are compared with those obtained in other international studies. For the purpose of the present study. HS was defined as a violent event in which an individual committed homicide and subsequently committed suicide within a few hours. The main results are as follows. During the six-year study period, 56 HS involving 133 victims were investigated at the Institute of Forensic Medicine of Paris. Seventeen events occurred in Paris and 39 in its suburbs. Paris has a population of approximately 2,200,000 while its suburbs are home to another 8,5000,000. Of the 56 offenders, 48 (85%) were males. The mean age of offenders was 51 years in males (range, 24 to 83) and 40.5 years in females (range, 33 to 56). In 45 events (80%), the offenders used a gun for both the homicide and suicide. A knife was used in only 4 murders, strangulation in 4 other cases, with poisoning, arson, or beating occurring in one case each. In 9 cases, the offender used a different weapon for homicide and suicide. Among firearms, handguns were more likely to be used (26 cases) than shotguns (6 cases) or rifles (13 cases). In 40 cases the offender killed one victim, in 11 cases 2 victims, and in 5 cases 3 victims. The homicide victims consisted of 34 children (21 boys), mean age 8 years (range, 1 to 16), 29 spouses (26 females), 2 girlfriends, 10 strangers, and 2 relatives. Five pets were killed. HS were most likely to be committed in the home. A suicide note was found near the victims in 29 cases (50% of events). In 42 cases the offender was found to be severely depressed. Familial HS were the most frequent events followed by suicidal pacts. When male sexual proprietariness and amorous jealousy were involved, the HS perpetrators acted often impulsively in carrying out the HS. There had been a chronically chaotic relationship and frequent physical violence and verbal threats. The triggering event was often the female withdrawal or estrangement. Only in a few cases, other motivations such as occupational or money problems were involved. Chronic alcoholism was found in 16 cases. In conclusion, the offender was more likely to be a male, severely depressed, violent and jealous who killed his spouse, and often his children, with impulsiveness, but after numerous threats. Our findings suggest that HS differ from both homicide and suicide and thus occupy a distinct epidemiological domain requiring specific prevention programs.

Diagnosis of drowning by combined computer-assisted histomorphometry of lungs with blood strontium determination.

The aim of our study was to examine the combined contribution of computer-assisted histomorphometry of lungs with blood strontium (BS) measurement to the diagnosis of drowning in cadavers recovered from fresh water. The study population comprised 116 drowned subjects. The results for this group were compared with those obtained for three non-drowned groups: 22 subjects who died from causes other than asphyxia, 13 subjects who died of asphyxia (strangulation or hanging); and 23 healthy living subjects in whom normal BS level was measured. Samples of water where the bodies had been found were analyzed in order to establish a relation with the BS concentration of the drowned subjects. Histologically, each type of pulmonary lesion (congestion, edema, alveolar macrophages, alveolar hemorrhage, and emphysema aquosum) was evaluated semiquantitatively using a score according to the severity of the pathology. Then, a quantitative histomorphometric study was performed using a computer-assisted image analyzer to measure the length and thickness of the alveolar walls, and the area and density of the alveolar cavities. The mean values of the BS levels in the 116 drowned subjects and of the water strontium concentrations were found to be much higher than in the living individuals. Although the ranges were wide, we found no overlap between values found in drowned subjects and those in non-drowned subjects. Emphysema aquosum and to a lesser extent alveolar hemorrhage were found to be the most significant histologic changes in the drowned and asphyxia groups compared with the nonasphyxia control groups.

Pathology of arrhythmogenic right ventricular cardiomyopathy/dysplasia--an autopsy study of 20 forensic cases.

Arrhythmogenic right ventricular dysplasia/ cardiomyopathy (ARVC) is characterized histologically by massive infiltration of the right ventricular wall by fat tissue, with surviving strands of cardiomyocytes bordered by or embedded in fibrosis. ARVC has been recognized as a cause of sudden death, especially in the young. The purpose of our autopsy study was to examine the clinical characteristics and the pathological patterns in the hearts of 20 people who died suddenly of ARVC. In view of our findings and the literature, we discussed the possible causes and pathogenesis of ARVC, as well as the mechanisms by which sudden death occurs in this disease. During the 7-year study period, 20 hearts from 9 men and 11 women fulfilled the criteria for ARVC. The mean age was 41 years (range, 17 to 80). The disease was unknown prior to death in all cases. Fourteen persons died at rest, and six on effort. In 9 of the 20 cases, the trigger of sudden death was an acute emotional stress, sometimes associated with a moderate physical activity. The mean heart weight was 380 g (range, 280 to 520). Both ventricles were involved in 40% of the cases. Inflammatory infiltrates consisting of lymphocytes were present in 60% of the cases, but myocyte necrosis was found in only one case. ARVC is more likely to result from a degenerative process than a congenital disorder. Genetic factors, viral or autoimmune inflammation or both, and apoptosis are also involved in the degenerative disorder.

[Prone sleeping position and other risk factors in sudden infant death syndrome: a prevalence study in Geneva]. / Position ventrale de sommeil et autres facteurs de risque du syndrome de mort subite du nourrisson: une étude de prévalence à Genève.

A survey by telephone interviews has been carried out in 1993 in the canton of Geneva, in order to measure the prevalence of 3 risk factors for the sudden infant death syndrome (SIDS) and to evaluate the potential for SIDS prevention based on these factors: prone sleeping position, tobacco smoking by the parents during pregnancy, and no complete breast-feeding at 8 days of age. 278 families participated to the study, of 320 families who could be contacted by telephone in Geneva, from a random sample of 550 families having had a child in Geneva in the preceding 12 months. 40% of the infants had been put to bed in the prone position on the preceding evening 18% of the mothers had smoked during pregnancy. Prevalence of low birth weight was 4.9% for 0 to 4 cigarettes per day during pregnancy, 17.2% for 5 cigarettes and more. At one week, 16.5% of children were not exclusively breast-fed. On the basis of these results, it can be estimated that an effective prevention programme, centered on prone sleeping position could decrease the incidence of SIDS by 50% or more. An even greater fraction of cases, up to 80%, could be avoided by the prevention of the 3 studied factors. These estimates show the need to develop a mother and child health programme in Switzerland.

[Cardiac sudden death in adults]. / La mort subite d'origine cardiaque chez l'adulte.

Sudden death is becoming a matter for concern as this type of accident represents an increasing proportion of deaths from cardio-vascular causes. A campaign is being launched aimed at promoting early diagnosis and appropriate action at the time of the event itself. At the same time it is necessary to get to know the target population better, especially with regard to the specific anatomical conditions which are the cause of death. For the last seven years we have been carrying out a descriptive pathological research study. The first stage took form of a three year retrospective study (1989-1991) involving 365 subjects victims of sudden death. The second part was a prospective study carried out in 1994. Heart disease emerged as the principal cause of death, something which is already well known. More interesting was the discovery that 72.3% of the subjects were completely asymptomatic despite the fact that in 85% of cases they had bi-truncal or tri-truncal lesions. The same findings emerged from the study of a subgroup of persons who had died suddenly as a result of acute stress. The data obtained are extremely homogeneous. When compared to the findings obtained from a control group of the same age who had died as the result of violence, the difference between the two populations is highly significant. Finally we should like to draw attention to the lack of epidemiological data on sudden death available in France at the present time, and this despite the fact that it is undoubtedly a public health priority. There is a need to promote both education and action in relation to this somewhat disturbing subject.

Homicide among youth and young adults, 15 through 29 years of age. A report of 138 cases from Paris and its suburbs, 1991-1993.

Recent surveys of some metropolitan areas in the United States have shown an increasing death rate as a result of violence among adolescents and young adults. In France, there has been no systematic research into the characteristics of homicide among youth and young adults. We have attempted from autopsy and police records to determine the incidence and the circumstances of homicides in the 15 to 29 age group, in Paris and its suburbs, during the past 3 years.

Beta AP deposition and head trauma.

Head trauma is considered to be a risk factor for Alzheimer's disease, because a high prevalence of beta AP deposits has repeatedly been reported in patients who died within a few days following head injury. To evaluate this statement, we undertook two studies using immunohistochemistry for beta AP and found a surprisingly low prevalence of beta AP diffuse deposits. We first selected 23 patients aged 17-63 years, who died 0-76 days after head trauma. Using beta AP antibody at the usual dilution (1:100), we did not find any deposits. With a high concentration of antibody (dilution 1:2) we found beta AP diffuse deposits in one 46-year-old case. In a second study, 17 patients aged 60-79 years old, who died 1-35 days after head injury, were compared to a control group. We did not find any significant difference in the density of beta AP diffuse deposits between cases and controls using usual dilutions of beta AP antibody. The density of beta AP diffuse deposits was linked only to aging and the presence of senile plaques.

Stressful events as a trigger of sudden death: a study of 43 medico-legal autopsy cases.

The reports relating emotional stress to sudden death are largely anecdotal. In addition to experimental and electrophysiological studies, an opportunity for a better understanding of possible stress-related sudden death (SSD) may be provided by medicolegal autopsies. The goal of our autopsy study was to analyze cardiovascular pathologic findings in cases of SSD and if possible identify mechanisms by which the stressful event (SE) could be the cause. Forty three cases were studied (29 males and 14 females). In all cases, the SE and the death were witnessed. The age range was 22 to 90 years in males (mean, 52) and 30 to 92 years in females (mean, 64). Death occurred in all cases without premonitory symptoms. In 20 cases, death occurred during the SE and in the other 23 cases occurred within 2 h of the event. SE included fear, 15 cases; altercation, 21 cases; sexual activity, 3 cases; police questioning or arrest, 4 cases. According to police reports, in 40 cases (90%), the victims had no previous clinical history of cardiovascular disease. At autopsy, the heart weight in males ranged from 255 to 1000 g with a mean of 517 g and in females the range was 250-700 g with a mean of 417 g. In only 3 cases, gross and microscopic examination of the heart was normal. In 2 of the remaining 40 cases the subjects died of subarachnoid hemorrhage. In 38 cases, a cardiac cause of death was found as follows: coronary heart disease, 27 cases; cardiomyopathy, 6 cases; aortic valvular stenosis, 2 cases and right ventricular dysplasia, 3 cases. A coronary artery thrombosis was found in 8 cases of sudden coronary death. Post myocardial infarction fibrosis was present in 25 cases (92%) of sudden coronary death. In conclusion, it appears from our autopsy study that SSD occurs primarily in those individuals with severe heart disease, especially coronary heart disease.

[Death due to drug addiction in Ile-de-France]. / Décès par toxicomanie en Ile-de-France.

The aim of a cooperative study, carried out by the Paris Forensic Medicine Institute and the French National Institute of Health and Medical Research (INSERM SC8) was to assess the number of drug addiction-related deaths occurring in the Paris region in 1990. There were 253 deaths including 92 in Paris and 161 in Paris suburbs. A large percentage of these deaths were not recorded in the National death statistics registry (only 36% of all the deaths and only 24% of the Paris deaths had been registered). The overall drug addiction mortality in the Paris region is 29.4 per million inhabitants and is highest among the 25-29 year age group. Rates decrease rapidly after 30 years of age and are extremely low after 40. Mortality is highest in unmarried men and in the inactive population with a wide variability according to site of residence. Rates are much higher in Paris than in the suburbs. For the 20-29 year population in Paris, drug addiction has an important impact on the mortality figures for the general population, causing 12% of all deaths. It is the third cause of death after AIDS and suicide.

Childhood homicide in Paris, 1990-1993: a report of 81 cases.

Homicide represents the most dramatic and heart breaking cause of death in children. Yet, in France, the true incidence and medicolegal data (modes, circumstances of deaths, and perpetrators) have been previously unknown. The goal of our study was to analyze the epidemiological and autopsy data in homicides in children in Paris and its suburbs during the past four years. We have included children from a few days after birth to 14 years of age. We report on 81 cases during the following period (17 in 1990; 14 in 1991; 16 in 1992; and 34 in 1993). Of those, 47 were boys and 34 girls. The mean age in boys was 6 years and in girls, 5 years. Fifteen homicides took place in Paris. The other 66 cases were from its suburbs. Twenty-nine of the murdered children were siblings. Seventy children (86%) were killed in their own homes; the father being responsible in 28 cases, and the mother in 17. In 20 instances, the murderer was unknown initially to the police. In 22 cases, the children were killed by gunshot, by stabbing in 14 cases, by battering in 22 cases. Four children died from drug poisoning, 13 from strangulation, and 6 from drowning. A prior history of child abuse was documented in 82% of fatal batterings.