The monthly incidence of abusive head trauma, inflicted skeletal trauma, and unexplained skin lesion in children in six French university hospitals during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic was a stressful period. Lockdowns may have added to parental difficulty leading to an increase in violence. This study aimed to compare the monthly incidence of high suspicion of child physical abuse before and during the COVID-19 pandemic. MATERIAL: We have retrospectively reviewed imaging examinations of children having a skeletal X-ray examination in six university hospitals with high suspicion of abusive head traumatism (AHT), inflicted skeletal trauma (IST) and unexplained skin lesions (USL) between March 2020 and June 2021 and compared with the similar period from 2018 to 2019. The monthly incidence of the different physical maltreatment was analyzed using a QuasiPoisson regression model. RESULTS: We included 178 children (n = 127 boys, 71.3 %), 110 during the pandemic period, median age 5 months. AHT was diagnosed in 91 children, 55 had inflicted skeletal trauma (IST) and 46 had unexplained skin lesions (USL). Among the 91 patients with AHT, 86 had a subdural hematoma (95.6 %) and 40 had bridging veins thrombosis (44 %). The ophthalmological examination performed on 89 children (97.9 %) revealed retinal hemorrhages in 57 children (89.8 %). The incidence of AHT doubled during the months of COVID-19 lockdowns (rate ratio = 2; 95 % CI [1.1; 3.6], p = 0.03). No difference in monthly incidence was observed for IST and USL groups. CONCLUSION: A significant increase in AHT was observed during the months with lockdowns and curfews during the COVID-19 pandemic. This highlights the need for developing a national strategy to prevent physical abuse in children in this context.

Forensic cardiac device analysis at the Los Angeles County Department of the Coroner: A 20-year experience.

Cardiac implantable electronic devices (CIEDs) store information continuously; however, the log of these devices is rarely analyzed in forensic practice. We retrospectively reviewed all cases referred for CIED interrogation by the Los Angeles County Department of Medical Examiner-Coroner between 2001 and 2020. According to the Department's practice, CIED interrogation may be requested for decedents in which details or cause of death are not clear from autopsy and clinical history. The CIED analysis was considered informative for the coroner's investigation either if it detected an arrhythmia or malfunction likely related to decedent's terminal event or if it was essential to determine time of death or identity of decedent. A total of 57 CIEDs were evaluated during the 20-year period. In almost half of cases (26/57: 45.6%), device analysis was informative for coroner's investigation. Arrhythmias likely related to terminal event were commonly detected (21/57: 36.8%). Device malfunction was identified as the likely cause of death in almost 10% of decedents (5/57: 8.8%), including three cases of battery depletion (3/57: 5.3%), one case of misclassification of ventricular tachycardia as supraventricular tachycardia with failure to deliver therapy (1/57: 1.7%), and one case of lead failure due to a broken pacing wire (1/57: 1.7%). Not infrequently, CIED interrogation was essential for determination of time of death (9/57: 15.8%), and there was one case (1/57: 1.7%) in which interrogation was essential for identifying the decedent. Our study shows that postmortem CIED interrogation can provide unique information regarding mechanism and time of death, and decedent's identity.

Age estimation based on computed tomography exploration: a combined method.

Despite an extensive number of existing methods, age estimation of human remains is still an unsolved matter in the field of forensic anthropology, especially when it comes to mature adults. The specific aim of this work was to propose a combined method for age estimation, for forensic purposes, by coupling the Suchey-Brooks method and the measure of the pubic bone density. For this purpose, we used an independent test sample comprising 339 CT scans of living individuals aged 15 to 99 years old. Measurement of bone density and staging according to the Suchey-Brooks phases were performed, followed by estimation of ages based on a combined method and an existing virtual reference sample. Results highlighted a significant negative correlation between bone density and age. Good accuracy was obtained for the measurement of pubic bone density for age estimation of men and women, especially concerning mature adults, with an absolute error ranging from 9 to 16 years for all individuals. The authors propose a practical combined method consisting of, first, allocating phases according to the scannographic approach of the Suchey-Brooks method. For phases I to IV, the age estimation is given using the Suchey-Brooks method. For phases V to VI, the pubic bone density measurement is used. Further study will be needed to assess the reproducibility of these results on cadavers and dry bones, as the post-mortem process could interfere with the measurement of mineral bone density.

[Compensation of damage in cancerology]. / Réparation du dommage en cancérologie.

In a few situations, the consequences secondary to a carcinological pathology require an assessment of damages for compensatory purposes. This is particularly the case when liable parties have been found to be at cause of the disease: occupational pathologies in the case of inexcusable employer's fault, exposure to a radioactive risk, for example in the context of full compensation for damages suffered by the victims of nuclear experiments performed by France, or lastly, in the after-effects of late diagnosis. This article does not discuss the imputability of cancer pathologies to an event, but it proposes an adaptation of methods for assessing damages, in an attempt to provide full compensation for damages.

Aberrant intrinsic connectivity in women victims of sexual assault.

This study aims to determine if resting-state functional connectivity may represent a marker for the progression of posttraumatic stress disorder (PTSD) in women victims of sexual assault. Participants were 25 adult women recruited three weeks following exposure to sexual assault (T1) and 19 age-matched healthy, non trauma-exposed controls (HC). Among the victims, 10 participants met (PTSD) and 15 did not meet (trauma-exposed controls, TEC) DSM-IV criteria for PTSD six months post-trauma (T2). At both visits, patterns of intrinsic connectivity, a measure of network centrality at each voxel of the brain, were derived from resting-state functional magnetic resonance imaging. Compared to both the HC and TEC groups, victims who developed PTSD at T2 showed higher centrality in the right middle/superior occipital gyrus at T1, while reduced centrality of the posterior cingulate cortex (PCC)/precuneus at T1 was found for the TEC group, compared to the HC group only. There were no differences in intrinsic connectivity at T1 between the TEC and PTSD groups. There were no significant between-group differences in intrinsic connectivity at T2, and no significant group-by-time interaction. This study indicates that increased occipital centrality three weeks post-trauma exposure may represent a marker of the later development of PTSD. On the other hand, reduced centrality of the PCC/precuneus may represent a marker of resilience to trauma exposure.

Technical note: age estimation by using pubic bone densitometry according to a twofold mode of CT measurement.

In forensic anthropology, age estimation is a major element in the determination of a biological profile and the identification of individuals. Thus, many anatomical structures have been studied, such as the pubic symphysis, which is a source of major interest due to its late maturation. One of the most well-known methods of assessment is the Suchey-Brooks (SB) system based on the morphological characteristics of the pubic symphysis. The aim of this study was to propose linear regression formulae in order to deduce chronological age from bone density, using both Hounsfield unit (HU), and mean bone density (mBD) values of the pubic symphysis. Moreover, we intended to test the reliability and then to explore the feasibility of using HU instead of mBD values for age estimation. We built retrospectively a reference sample of 400 pubic symphyses using computed tomography at a French hospital and a test sample of 120 pubic symphyses. Equations were created to establish linear regression models for age estimation. Inaccuracy and bias were calculated for individuals aged more or less than 40 years. We highlighted homogeneous mean absolute errors for both HU and mBD values, most of them being less than 10 years. Moreover, we reported a moderate overestimation for younger individuals and a very small underestimation for older individuals. This study proposes a correlation between the bone density and age of individuals with a valuable level of reliability. Finally, HU measurements seem to be suitable for linking bone density with the age of individuals in forensic practice.

Cameriere's third molar maturity index in assessing age of majority: a study of a French sample.

Forensic age estimation is a challenging field in forensic sciences because of the increase of migratory flows. Medicolegal age assessment is a key point because it has many implications for authorities. Dental age estimation is an essential part of the global age assessment. The aim of this study was to evaluate and test the accuracy of Cameriere's cutoff values of the third molar maturity index (I3M) in assessing legal adult age of 18 years in a French population. The sample was constituted of 431 orthopantomograms performed between January 2014 and August 2017 on patients aged between 14 and 22 years. The reproducibility and repeatability of the method were high. Age distribution gradually decreases as I3M increases in both sexes. 0.08 seemed to be the best I3M cutoff. For females, the sensitivity and specificity of the test were 74.51% and 88.23%, respectively. The sensitivity and specificity for males were 92.19% and 88.35%, respectively. The accuracies were 80.74% for female, 90.57% for male. Estimated post-test probabilities were 0.879 for female and 0.899 for male. To conclude, the specific cutoff value of I3M ˂ 0.08 may be a useful additional tool in discriminating adults and minors in French population.

[Thanatobiochemistry: its contribution to the diagnosis of hypothermia fatalities]. / Biochimie thanatologique : ses apports au diagnostic de décès par hypothermie.

Hypothermia is a potentially lethal pathology whose in vivo diagnosis is relatively easy, based on the observation of a body temperature below 35̊C. However, its post mortem diagnosis is much more complex because of a thermal decrease occurring systematically after the death, which renders most often uninterpretable the body temperature as a diagnostic argument for hypothermia. Moreover, none of the macroscopic or microscopic autopsy elements described as suspicious of hypothermia are pathognomonic of a hypothermic death. Currently, this diagnosis arises in the light of an association of concordant arguments including these autopsic and histological elements but also some biomarkers. The aim of this article is to illustrate by a practical case the diagnostic complexity of a death by hypothermia through the evocative elements currently described, by emphasizing the reflection on some biomarkers confirmed or under study.

Correlation between pubic bone mineral density and age from a computed tomography sample.

In forensic anthropology, the estimation of age at death is mainly required to establish a biological profile and facilitate individual identification. The Suchey-Brooks (SB) system represents one of the most commonly used and tested methods of assessment based on the morphological characteristics of the pubic symphysis. However, this method has certain drawbacks, including frequently inaccurate estimation for older individuals. The aim of this work was to test the evolution of pubic bone mineral density (BMD) according to age, especially for individuals over 40 years old. We retrospectively studied pubic bones from males (n = 88) and females (n = 113) over 40 years of age undergoing clinical multi-slice computed tomography (MSCT) in a French hospital between November 2017 and April 2018. The results revealed a significant negative correlation between BMD and age for males (R = -0.62) and females (R = -0.55). The intra- and inter-observer reliabilities of the phase allocation were moderate for males (kappa values at 0.72 and 0.65) and strong for females (kappa values at 0.93 and 0.86). Moreover, a significant difference in BMD between stages 6-1 and 6-2 for males was observed. We hypothesize that BMD might help improve the reliability of the SB system for older individuals. In addition to the pubic bone, numerous other anatomical regions such as the area of Ward could represent interesting areas of study in order to relate bone density to age.

Contribution of third molar eruption to the estimation of the forensic age of living individuals.

Forensic age estimation of a living individual is frequently performed in clinical forensic medicine. Medicolegal physicians are usually called upon by the authorities to estimate the age of a living person requesting asylum or to determine whether a suspected offender is subject to juvenile or adult criminal law. Dental age is one of the parameters studied to estimate biological age. Several methods are used, and among these, analysis of the eruption of the third molar (M3) on an orthopantomogram (OPG) is one of the common methods. The objective of the study was to analyse the contribution of M3 eruption to age estimation, in particular with regard to the threshold of 18 years of age, in a sample of individuals examined in a French university hospital. The stage of wisdom tooth eruption of all individuals aged between 15 and 24 years, who had an OPG performed between 1 January 2013 and 31 December 2015, was interpreted using a three-stage scoring system. In total, 557 OPGs (340 males and 217 females) were included. None of the stage scores allowed a distinction between minors and majors, for either sex. Overall, 85% of females and 98% of males with four M3s in stage 3 (complete emergence in the occlusal plane) were majors.

Neurocognitive, emotional and neuroendocrine correlates of exposure to sexual assault in women.

BACKGROUND: Survivors of sexual assault are vulnerable to long-term negative psychological and physical health outcomes, but few studies have investigated changes in cognition, emotional processing and brain function in the early stages after sexual assault. We used a multimodal approach to identify the cognitive and emotional correlates associated with sexual assault in women. METHODS: Twenty-seven female survivors of sexual assault were included within 4 weeks of the traumatic event, and they were compared with 20 age-matched controls. Participants underwent functional MRI while performing cognitive/emotional tasks (n-back, emotional go/no-go, mental imagery). We also measured diurnal salivary cortisol and conducted neuropsychological assessments of attention and memory abilities. RESULTS: Relative to the control group, the survivor group had lower levels of morning cortisol and showed attentional deficits. We observed no between-group differences in brain activation during the n-back or mental imagery tasks. During the emotional go/no-go task, however, the survivor group showed a lack of deactivation in the dorsal anterior cingulate cortex when processing emotional material, relative to neutral material. Exploratory analyses in the survivor group indicated that symptom severity was negatively associated with cerebellar activation when positive emotional (happy) content interfered with response inhibition, and positively associated with cerebellar activation when thinking of positive (happy) memories. LIMITATIONS: The small sample size was the main limitation of this study. CONCLUSION: Dysfunctions in the dorsal anterior cingulate cortex and the cerebellum may represent early functional brain modifications that alter higher cognitive processes when emotional material is involved.

Forensic age estimation using computed tomography of the medial clavicular epiphysis: a systematic review.

Medicolegal physicians are increasingly called upon to aid in determining the administrative age group affiliation of refugees with questionable unaccompanied minor claims. According to guidelines for forensic age assessment, age differentiation along the 18-year-old cut-off relies on clavicular ossification. The thin-slice computed tomography scan (TSCTs) of the medial clavicular epiphysis (MCE) is one of the methods contributing to this assessment, though it is not yet universally accepted. The aim of this systematic review was to identify scientific papers where age was assessed using TSCTs of the MCE and to observe whether this examination was reproducible and reliable in estimating a person's age relative to the 18-year-old threshold. A search algorithm was applied to several databases to identify articles in accordance with the PRISMA (Preferred Reporting Items for Systematic-Reviews and Meta-Analyses) statement. One boxplot per article was constructed, separating by stage of maturation and sex. The 13 articles selected represented a sample of 5605 individuals (3396 males, 2209 females) aged 10 to 35 years. All individuals classified as stages 4 and 5 were aged 18 years or older. The same result was obtained concerning stage 3c, except in one article. The results thus appear reliable and reproducible, in particular, with respect to the 18-year-old threshold; medicolegal physicians should be able to estimate that all individuals in stages 4 and 5 are at least 18 years old. Additional studies applied to several other populations in the world should complement the selected studies.

Neurocognitive, emotional and neuroendocrine correlates of exposure to sexual assault in women.

BACKGROUND: Survivors of sexual assault are vulnerable to long-term negative psychological and physical health outcomes, but few studies have investigated changes in cognition, emotional processing and brain function in the early stages after sexual assault. We used a multimodal approach to identify the cognitive and emotional correlates associated with sexual assault in women. METHODS: Twenty-seven female survivors of sexual assault were included within 4 weeks of the traumatic event, and they were compared with 20 age-matched controls. Participants underwent functional MRI while performing cognitive/emotional tasks (n-back, emotional go/no-go, mental imagery). We also measured diurnal salivary cortisol and conducted neuropsychological assessments of attention and memory abilities. RESULTS: Relative to the control group, the survivors group had lower levels of morning cortisol and showed attentional deficits. We observed no between-group differences in brain activation during the n-back or mental imagery tasks. During the emotional go/no-go task, however, the survivors group showed a lack of deactivation in the dorsal anterior cingulate cortex when processing emotional material, relative to neutral material. Exploratory analyses in the survivors group indicated that symptom severity was negatively associated with cerebellar activation when positive emotional (happy) content interfered with response inhibition, and positively associated with cerebellar activation when thinking of positive (happy) memories. LIMITATIONS: The small sample size was the main limitation of this study. CONCLUSION: Dysfunctions in the dorsal anterior cingulate cortex and the cerebellum may represent early functional brain modifications that alter higher cognitive processes when emotional material is involved.

Age estimation at death using pubic bone analysis of a virtual reference sample.

Age at death estimation is a major part of forensic anthropology, but is often poor in the latter decades of life and should benefit from specific population standards. The aim of this study was to test a virtual reference sample with a uniform age distribution in order to improve the accuracy of age estimation for individuals over 40 years of age. We retrospectively built a random virtual reference sample of pubic symphyses from 1100 clinical cases using computed tomography at two French hospitals; this was compared with a test sample (pubic symphyses from 75 corpses undergoing post-mortem computed tomography at a French forensic department) and with the sample originally used in the Suchey-Brooks (SB) system. Inaccuracy and bias were calculated and the proportions of cases in which the real age fell within the estimated age ± 1 standard deviation were calculated. Compared to using the SB sample, using our French sample resulted in a lower inaccuracy for males over 55 years and bias showed that that for males aged 56 to 70 years were less underestimated. Compared to using the SB sample, using our French sample resulted in a lower inaccuracy for females over 70 years and bias showed that that for females aged 56 and older were less underestimated. This study presents a large data set of pubic symphyseal phases from a French virtual sample that allows for improving age estimation accuracy at death, particularly for individuals over 40 years. This kind of material can be useful to improve the age estimation accuracy in a specific region. However, the reliability remains poor and the variability of pubic symphysis morphology related to bone degeneration seems to be an unavoidable limit of the method.

Twenty-five years of French jurisprudence in criminal medical liability.

We report on a comprehensive 25-year study on criminal medical liability in France, undertaken to establish trends in the number of cases being brought before the criminal courts. We did this by interrogating the database on the Légifrance website using a Boolean equation (' pénal' (criminal) AND ' médecin' (physician) OR ' docteur' (doctor)). In total 539 cases were selected, in which the status of the physician either influenced the punishment imposed, or was a prerequisite for the commission of the offence. The results of the search produced two outcomes: offences and the dates of the most recent criminal judgements (which had been left blank). Further data were also collected: references to court cases, hearing dates, offence dates, procedural time limits, numbers of accused parties, types of punishments and physician characteristics. The number of court hearings increased from the 1980s until the late 1990s. Since then, it has remained stable at around 25 cases per year. Of the defendants appearing before the courts, 39.2% have been found guilty. On average, 10 to 13 physicians every year - that is, one per month - are punished. Those most often punished are obstetrician-gynaecologists (13%), followed by intensive care anaesthetists (11%) and then by general practitioners (6.7%). The offences most frequently occurring are manslaughter (36.5%), illegal profits (12%), unintentional injuries (11.5%) and sexual offences (10.1%). The results are most reassuring in terms of the risks posed by the practice of medicine in France. Such a risk does indeed exist; however, it is at a low level and stable.

Reliability of the Suchey-Brooks method for a French contemporary population.

The Suchey-Brooks method is commonly used for pubic symphyseal aging in forensic cases. However, inter-population variability is a problem affected by several factors such as geographical location and secular trends. The aim of our study was to test the reliability of the Suchey-Brooks method on a virtual sample of contemporary French males. We carried out a retrospective study of 680 pubic symphysis from adult males undergoing clinical Multislice Computed Tomography in two hospitals between January 2013 and July 2014 (Toulouse and Tours, France). The reliability of the Suchey-Brooks method was tested by the calculation of inaccuracy and bias between real and estimated ages, and the mean age for each stage and the mean stage for each 10-years age interval were compared. The degree of inaccuracy and bias increased with age and inaccuracy exceeded 20 years for individuals over 65 years of age. The results are consistent with an overestimation of the real age for stages I and II and an underestimation of the real age for stages IV, V and VI. Furthermore, the mean stages of the reference sample were significantly lower for the 14-25 age group and significantly higher for individuals over 35 years old. Age estimation is potentially limited by differential inter-population error rates between geographical locations. Furthermore, the effects of secular trends are also supported by research in European countries showing a reduction in the age of attainment of indicators of biological maturity during the past few decades. The results suggest that the Suchey-Brooks method should be used with caution in France. Our study supports previous findings and in the future, the Suchey-Brooks method could benefit from re-evaluation of the aging standards by the establishment of new virtual reference samples.

Sudden Death Due to Undiagnosed Rheumatic Heart Disease in a Child.

We report the case of a 5-year-old boy who died from complications of rheumatic heart disease with atypical presentation. He was hospitalized for recent inflammatory and neurological symptoms. He was diagnosed with viral encephalitis. He died the day after he was discharged. The macroscopic autopsy findings were unremarkable. Histology revealed typical rheumatic heart disease. Neuropathology showed cerebral infarction due to an embolic event linked with the rheumatic valvulitis. The cause of death was determined as heart failure due to rheumatic heart disease secondary to an undiagnosed acute rheumatic fever. It is related to an autoimmune response to infection with group A streptococcus. It mainly affects children in developing countries. In our case, viral encephalitis was consistent with the medical history and the proper diagnosis was made on histological analysis. Forensic pathologists should consider this diagnosis facing a sudden unexpected death in childhood, even in industrialized countries.

Contribution of magnetic resonance imaging of the wrist and hand to forensic age assessment.

Forensic age estimation of living individuals is a controversial subject because of the imprecision of the available methods which leads to errors. Moreover, young persons are exposed to radiation, without diagnostic or therapeutic advantage. Recently, non-invasive imaging techniques such as magnetic resonance imaging (MRI) have been studied in this context. The aim of this work was to study if the analysis of wrist/hand MRI enabled determination of whether a subject was 18 years old. Two observers retrospectively analyzed metaphyseal-epiphyseal fusion of the distal epiphysis of the radius and the ulna and the base of the first metacarpus in wrist/hand MRI of living people between 9 and 25 years of age. A three-stage scoring system was applied to all epiphyses. Intra- and inter-observer variability was excellent. Staging of the distal radial epiphysis allowed the subjects to be correctly evaluated with regard to the 18-year-old threshold in more than 85 % of cases. Analysis of the radius alone was as good as the analysis of the three epiphyses together. Evaluation of the metaphyseal-epiphyseal fusion of the distal radius in wrist MRI gave good results in forensic age estimation. Wrist MRI could meet ethical expectations with regard to the link between the benefit and risk of practicing radiologic examination on individuals in this context.