Validation of a post-mortem computed tomography method for age estimation based on the 4th rib in a French population.

Age estimation is a key factor for identification procedure in forensic context. Based on anthropological findings, degenerative changes of the sternal extremity of the 4th rib are currently used for age estimation. These have been adapted to post-mortem computed tomography (PMCT). The aim of this study was to validate a post-mortem computed tomography method based on a revision of the Iscan's method on a French sample. A total of 250 PMCT (aged from 18-98 years (IQR 36-68 years, median 51 years); 68 (27%) females) from the Medicolegal Institute of Paris (MLIP) were analyzed by two radiologists. The sternal extremity of 4th right rib was scored using method adapted from Iscan et al. Weighted κ was used to evaluate intra- and inter-observer reliability and Spearman correlation was performed to evaluate relationship between age and score. Confidence intervals for individual prediction of age based on 4th rib score and sex were computed with bootstrapping. The intra-observer reliability and inter-observer reliability were almost perfect (weighted κ = 0.85 [95%CI: 0.78-0.93] and 0.82 [95%CI 0.70-0.96] respectively). We confirmed a high correlation between the 4th rib score and subject age (rho = 0.72, p < 0.001), although the confidence intervals for individual age prediction were large, spanning over several decades. This study confirms the high reliability of Iscan method applied to PMCT for age estimation, although future multimodal age prediction techniques may help reducing the span of confidence intervals for individual age estimation.Trial registration: INDS 0,509,211,020, October 2020, retrospectively registered.

An overview of forensic operations performed following the terrorist attacks on November 13, 2015, in Paris.

On the evening of November 13, 2015, the city of Paris and its surroundings was hit by a series of attacks committed by terrorist groups, using firearms and explosives. The final toll was 140 people deceased (130 victims and 10 terrorists or their relatives) and more than 413 injured, making these attacks the worst mass killings ever recorded in Paris in peacetime. This article presents the forensic operations carried out at the Medicolegal Institute of Paris (MLIP) following these attacks. A total of 68 autopsies of bodies or body fragments and 83 external examinations were performed within 7 days, and the overall forensic operations (including formal identification of the latest victims) were completed 10 days after the attacks. Over this period, 156 body presentations (some bodies were presented several times) were provided to families or relatives. Regarding the 130 civilian casualties, 129 died from firearm wounds and one died from blast injuries after an explosion. Of the 10 terrorists or their relatives who were killed, eight died from suicide bombing, one was shot by police and one died from crush injuries due to partial collapse of a building following the police raid against a terrorist's hideout after the attacks. All mass shootings were perpetrated with AK-47 or Zastava M70 assault rifles using 7.62 mm × 39 mm cartridges. In the case of ballistic injuries, death was most often obviously caused by craniocerebral injuries, extensive organ lacerations and/or massive haemorrhage. Among the terrorists killed by bombing, the lesion patterns were body transection, multiple amputations, extreme organ lacerations and the presence of foreign bodies owing to the shrapnel load (steel nuts, glass fragments) or the explosive charge fastening system of the devices. This discussion highlights the particular difficulties of interpretation encountered within the framework of ballistic injuries, a conclusion that should lead to a modest and realistic approach in these exceptional situations where forensic operations involve a very large number of victims in a constrained time.

Angioedema Related to Angiotensin-Converting Enzyme Inhibitors: Attack Severity, Treatment, and Hospital Admission in a Prospective Multicenter Study.

The number of cases of acquired angioedema related to angiotensin converting enzyme inhibitors induced (ACEI-AAE) is on the increase, with a potential concomitant increase in life-threatening attacks of laryngeal edema. Our objective was to determine the main characteristics of ACEI-AAE attacks and, in doing so, the factors associated with likelihood of hospital admission from the emergency department (ED) after a visit for an attack.A prospective, multicenter, observational study (April 2012-December 2014) was conducted in EDs of 4 French hospitals in collaboration with emergency services (SAMU 93) and a reference center for bradykinin-mediated angioedema. For each patient presenting with an attack, emergency physicians collected demographic and clinical presentation data, treatments, and clinical course. They recorded time intervals from symptom onset to ED arrival and to treatment decision, from ED arrival to specific treatment with plasma-derived C1-inhibitor (C1-INH) or icatibant, and from specific treatment to onset of symptom relief. Attacks requiring hospital admission were compared with those not requiring admission.Sixty-two eligible patients with ACEI-AAE (56% men, median age 63 years) were included. Symptom relief occurred significantly earlier in patients receiving specific treatment than in untreated patients (0.5 [0.5-1.0] versus 3.9 [2.5-7.0] hours; P < 0.0001). Even though icatibant was injected more promptly than plasma-derived C1-INH, there, however, was no significant difference in median time to onset of symptom relief between the 2 drugs (0.5 [0.5-1.3] versus 0.5 [0.4-1.0] hours for C1-INH and icatibant, respectively, P = 0.49). Of the 62 patients, 27 (44%) were admitted to hospital from the ED. In multivariate analysis, laryngeal involvement and progressive swelling at ED arrival were independently associated with admission (Odds ratio [95% confidence interval] = 6.2 [1.3-28.2] and 5.9 [1.3-26.5], respectively). A favorable course was observed in all patients. Three patients (5%) experienced a recurrence after angiotensin-converting enzyme inhibitor discontinuation after a median follow-up of 18 (11-30) months.Two severity criteria-laryngeal edema and the progression of the edema-were independent factors associated with likelihood of hospital admission. Appropriate specific treatments (plasma-derived C1-INH or icatibant) should be available in EDs to prevent possibly life-threatening complications.

Detection and follow-up, after partial liver resection, of the urinary paracetamol metabolites by proton NMR spectroscopy.

BACKGROUND: Combination drug therapy is often used to achieve optimal analgesia in surgery. Paracetamol can be used as one component of an analgesic regime following hepatic resection. OBJECTIVE: This study was designed to investigate paracetamol and its metabolites by proton NMR spectroscopy in patient urine and to assess whether N-acetyl-p-benzoquinone imine (NAPQI, a hepatotoxic metabolite) formation is increased after liver resection. METHOD: We studied the excretion of acetaminophen and its metabolites by 5 patients who were operated on for partial liver resection by proton NMR spectroscopy. As an intravenous infusion 1 g of paracetamol was given over 15 min every 6 h during 48 h. The first injection was given in the operating theatre after liver resection was completed. Urine samples were collected before injection (T1) and 24 and 48 h after the first injection (T2 and T3); the samples were frozen and kept at -20°C up to the analysis by NMR spectroscopy. RESULTS: Metabolites of the paracetamol were detected for all patients. Among the discerned metabolites, 4 were identified as metabolites of paracetamol: paracetamol glucuronide, paracetamol sulfate, N-acetyl-L-cysteinyl paracetamol (metabolite of NAPQI) and paracetamol. Their ratios, respectively, were: 46-82.9, 12.6-30.0, 0.5-5.5 and 1.43-3.54%. CONCLUSION: This study showed that there was no increase in the formation of toxic metabolite (NAPQI) after treatment with paracetamol in these few cases of liver resections. A larger study is necessary to confirm these results.

Are daily routine chest radiographs useful in critically ill, mechanically ventilated patients? A randomized study.

OBJECTIVE: Whether chest radiographs (CXRs) in mechanically ventilated patients should be routinely obtained or only when an abnormality is anticipated remains debated. We aimed to compare the diagnostic, therapeutic and outcome efficacy of a restrictive prescription of CXRs with that of a routine prescription, focusing on delayed diagnoses and treatments potentially related to the restrictive prescription. DESIGN: Randomized controlled trial. SETTING: Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. PATIENTS AND PARTICIPANTS: All consecutive patients mechanically ventilated for > or = 48h between January and June 2006. INTERVENTIONS: Patients were randomly assigned to have daily routine CXRs (routine prescription group) or clinically indicated CXRs (restrictive prescription group). MEASUREMENTS AND RESULTS: For each CXR, a questionnaire was completed addressing the reason for the CXR, the new findings, and any subsequent therapeutic intervention. The endpoints were the rates of new findings, the rates of new findings that prompted therapeutic intervention, the rate of delayed diagnoses, and mortality. Eighty-four patients were included in the routine prescription group and 81 in the restrictive prescription group. The rates of new findings and the rates of new findings that prompted therapeutic intervention in the restrictive prescription group and in the routine prescription group were 66% vs. 7.2% (p < 0.0001), and 56.4% vs. 5.5% (p < 0.0001) respectively. The rate of delayed diagnoses in the restrictive prescription group was 0.7%. Mortality was similar. CONCLUSIONS: Restrictive use of CXRs in mechanically ventilated patients was associated with better diagnostic and therapeutic efficacies without impairing outcome.

Agreement between quantitative cultures of postintubation tracheal aspiration and plugged telescoping catheter, protected specimen brush, or BAL for the diagnosis of nosocomial pneumonia.

BACKGROUND: The diagnosis of ventilator-associated pneumonia relies on protected specimen brush (PSB), BAL, and plugged telescoping catheter (PTC) procedures. In the particular setting of nosocomial pneumonia (NP) occurring in non-mechanically ventilated patients, no consensus exists on their use. When mechanical ventilation (MV) becomes mandatory, postintubation tracheal aspiration (PITA) could be a simple, fast, and cheap diagnostic tool. Our aim was to compare the diagnostic accuracy of PITA to that of PSB, BAL, or PTC in patients requiring MV for suspected NP. METHODS: Patients with a prior hospital stay of > or = 48 h who required MV for suspicion of NP were prospectively enrolled in the study. PITA was performed by sterile suction. Within 2 h, pulmonary samples were obtained by PSB, BAL, or blinded PTC, which are referred to hereafter as "reference methods" (RMs). The definite diagnosis of NP was made using a composite item of clinical, radiologic, and bacteriologic (ie, blood or pleural fluid cultures) patterns. The agreement between the quantitative microbiological results obtained with PITA and those of the RMs was assessed by the kappa-statistic. The sensitivity, specificity, and positive and negative likelihood ratios of PITA and RMs were calculated taking the definite diagnosis of NP as the reference. RESULTS: There were 44 cases (63.8%) of confirmed NP. The kappa-statistic was 0.71. The sensitivity, specificity, and positive and negative likelihood ratios were 77%, 84%, 4.80, and 0.27, respectively, for PITA, and 75%, 88%, 6.25, and 0.28, respectively, for RMs. CONCLUSIONS: PITA may be a reliable alternative to RMs in the particular setting of NP in newly mechanically ventilated patients.

Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock.

OBJECTIVE: To assess whether different diagnostic and prognostic cutoff values of procalcitonin should be considered in surgical and in medical patients with septic shock. DESIGN: Prospective observational study. SETTING: Intensive care unit of the Avicenne teaching hospital, France. PATIENTS: All patients with septic shock or noninfectious systemic inflammatory response syndrome within 48 hrs after admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were allocated to one of the following groups: group 1 (surgical patients with septic shock), group 2 (surgical patients with noninfectious systemic inflammatory response syndrome), group 3 (medical patients with septic shock), and group 4 (medical patients with noninfectious systemic inflammatory response syndrome). Procalcitonin at study entry was compared between group 1 and group 2 and between group 3 and group 4 to determine the diagnostic cutoff value in surgical and in medical patients, respectively. Procalcitonin was compared between survivors and nonsurvivors from group 1 and group 3 to determine its prognostic cutoff value. One hundred forty-three patients were included: 31 in group 1, 36 in group 2, 36 in group 3, and 40 in group 4. Median procalcitonin levels (ng/mL [interquartile range]) were higher in group 1 than in group 3 (34.00 [7.10-76.00] vs. 8.40 [3.63-24.70], p = .01). In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL, with 91.7% sensitivity and 74.2% specificity. In medical patients, the best diagnostic cutoff value was 1.00 ng/mL, with 80% sensitivity and 94% specificity. Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. A cutoff value of 6.00 ng/mL had 76% sensitivity and 72.7% specificity for separating survivors from nonsurvivors. CONCLUSIONS: The diagnostic cutoff value of procalcitonin was higher in surgical than in medical patients. Early procalcitonin was of prognostic interest in medical patients.