[Asthma and scuba diving: Creation and evaluation of a website (For doctors, asthmatics and diving instructors)]. / Asthme et plongée sous-marine : création et évaluation d'un site internet (à destination des médecins, plongeurs asthmatiques et moniteurs de plongée).

INTRODUCTION: Scuba diving has long been strictly contraindicated for asthmatics; this contraindication has been questioned in recent years. Our objective was to provide a website, evaluated by its users, for doctors, diving instructors and asthmatics. MATERIALS AND METHODS: Creation of the site Asthme-Plongee.com based on a peer-reviewed literature review, then distribution of a questionnaire in summer 2018 to diving clubs, general practitioner groups, pulmonologists and FFESSM federal offices, and via social networks. RESULTS: Our sample consisted of 413 assessors, including 264 health professionals (63.9%), 74 asthmatics (17.9%) and 92 diving instructors (22.3%), spread over the entire territory of France. The structure of the website, the clarity of the information written and its relevance were generally appreciated by the entire population with a median score of 8/10. The site was found useful: 72.9% of respondents thought they would visit it later. CONCLUSION: Faced with a growing number of amateur divers, it seems essential to raise awareness of current recommendations and good diving practices.

Vehicle-assisted ligature decapitation: A case report and a review of the literature.

Decapitation resulting by vehicle-assisted ligature strangulation is a suicide method rarely described in the literature. The lesions observed at autopsy have a common morphology with to those found in post-hanging decapitation. They depend on the force applied by the acceleration of the vehicle, the slope of the road and the characteristics of the link used. They can also mimic a stabbing homicide. We report the case of a 43-year-old man who used a long steel rope, attached between his neck and a streetlight, and started his vehicle, causing a complete decapitation. The results of the autopsy provided information on the morphology of the cervical lesions, but also on the causes of death. In spite of decapitation, the histological examination of the organs confirmed the presence of asphyxiation process by a mechanical origin that occurred before decapitation.

[General medical care in French psychiatric units for inmates: A national survey]. / Soins médicaux généraux en unité hospitalière spécialement aménagée : une enquête nationale.

OBJECTIVES: The UHSA (UHSA) are French psychiatric units for inmates which admit detainees suffering from a psychiatric disorder requiring full-time hospital care. Non-psychiatric pathologies are overrepresented in patients with psychiatric disorders but also in detainees. As a result, patients hospitalized in UHSA are largely exposed to non-psychiatric conditions, and exploring the organization of general medical care for these patients appears very relevant. The aim of this study is to review the general medical care in all French UHSA. METHODS: A descriptive study was carried out through a survey of the nine facilities. RESULTS: All UHSA benefit from the intervention of a general practitioner. The physical clinical examination, the biological assessment and the electrocardiogram are systematically performed at the patient's admission in 7, 5 and 9 establishments, respectively. However, the offer of general medical care in UHSA seems disparate and sometimes insufficient. Specialized consultations are regularly requested during hospitalizations, but no establishment benefits from a telemedicine system or specialized consultations on site. The extraction of the patient to the general hospital is therefore systematic when such a consultation is needed. But the number of penitentiary escorts per day is limited. In 6 UHSA, medical extractions are thus regularly canceled by the penitentiary administration, sometimes without a medical opinion. Finally, the patient's regular physician is only contacted in 3 UHSA during hospitalizations. CONCLUSION: Based on these results, ways of improving the organization of general medical care in UHSA are proposed through four main axes: the structure and general organization; the general medical care; the link with the healthcare partners and the articulation with the penitentiary administration.

[First trends of change in mortality by suicide in Nord-Pas-de-Calais since VigilanS]. / « Premières analyses de mortalité par suicide en Nord-Pas-de-Calais depuis l'implantation de VigilanS ¼.

INTRODUCTION: In terms of suicide prevention, population-based prevention devices often struggle to demonstrate an effect in terms of reducing suicidal acts of suicide, often focusing on the evolution of the number of suicide attempts, on time too short to statistically interpret changes in mortality. The consolidated figures for mortality in France are provided by the CepiDC with a delay of approximately three years. We therefore had to try to work with an approximation of the phenomenon, and we tested the proxy value of the enumeration of corpses, body examinations and medico-legal autopsies for suicide by the forensic doctors of the Nord-Pas-de-Calais region in France. In parallel, we conducted a comprehensive mortality study for 2016 in the VigilanS cohort. METHOD: By measuring the evolution of the number of body lifts for suicide by the Department of Forensic Medicine of the region, for the 3 years before VigilanS (2012-2014) compared to the 3 years since VigilanS (2015-2017). The deaths of patients of the VigilanS cohort were identified by calling the city halls of birth and domicile of all patients integrating the device in 2016. The cause of death was then characterized by contact of the attending physician. RESULTS: We observe an average decrease in suicide mortality of 9.9% (-12% for men, +0.3% for women). The exhaustive analysis of suicide mortality in the VigilanS cohort in 2016 found 19 deaths, of which 14 by suicide, or 0.4% of patients. This observed mortality rate in the VigilanS cohort in 2016 is significantly below the expected threshold in the literature (1 to 2% in the year following TS). CONCLUSION: It seems possible to reach the 2020 target for a 10% decrease in suicidal behavior in industrialized countries by 2020. The VigilanS device could therefore be protective in terms of suicide mortality.

Forensic features of a fatal Datura poisoning case during a robbery.

Datura poisonings have been previously described but remain rare in forensic practice. Here, we present a homicide case involving Datura poisoning, which occurred during a robbery. Toxicological results were obtained by second autopsy performed after one previous autopsy and full body embalmment. A 35-year-old man presented with severe stomach and digestive pain, became unconscious and ultimately died during a trip in Asia. A first autopsy conducted in Asia revealed no trauma, intoxication or pathology. The corpse was embalmed with methanol/formalin. A second autopsy was performed in France, and toxicology samples were collected. Scopolamine, atropine, and hyoscyamine were found in the vitreous humor, in addition to methanol. Police investigators questioned the local travel guide, who admitted to having added Datura to a drink to stun and rob his victim. The victim's death was attributed to disordered heart rhythm due to severe anticholinergic syndrome following fatal Datura intoxication. This is a recent case of a rare homicide involving Datura that highlights general information on Datura and discusses forensic interpretation after a previous autopsy and body embalmment.

An experimental investigation into the colonization of concealed cadavers by necrophagous blowflies.

We used seven baited boxes with different combinations of access holes and odor diffusion surfaces to study the arrival of necrophagous flies. During laboratory experiments, 30 gravid Lucilia sericata females were kept in a chamber with one of the boxes. The box with the largest odor diffusion surface (99 cm(2)) combined with the lowest accessibility (one 1 cm(2) entrance hole) was entered least (5 ± 3.7 flies per run). In contrast, the most frequently entered box (one 9 cm(2) entrance hole with no additional odor diffusion surface) caught a mean of 24.6 ± 3.4 flies per run. These results indicate that 1) L. sericata entered nearly inaccessible places and 2) both odor diffusion and accessibility impacted the number of flies caught. During field experiments, the seven boxes were placed together outdoors. The box with the most entrances (ten 9-cm(2) holes) caught the most flies (55.6-99.4% of the total). Only a few flies entered the other boxes. Access to the less accessible boxes (poor odor diffusion and small entrances) was also delayed. The major conclusions of the field experiments are that 1) boxes with low accessibility took longer to be accessed; 2) larger odor diffusion surfaces were more attractive to flies; and 3) flies accessed boxes more readily through larger holes than through an equivalent surface area made up of smaller holes. With these conclusions in mind, attempts to quantify the preappearance interval or to interpret the number of flies observed in indoor forensic entomology cases should be approached with caution.

A safe, free and efficient way to control Nasonia vitripennis, a common pest in forensic entomology laboratories.

Nasonia vitripennis Walker (Hymenoptera: Pteromalidae) is a parasitoid of necrophagous blowflies. Its presence in a forensic entomology laboratory can be extremely damaging to samples and can compromise the PMI estimation. We describe for the first time a simple, safe and efficient trap to control N. vitripennis infestations. Adhesive tape is placed horizontally on windows to create an obstacle. Wasps go underneath until they reach the adhesive side of the tape and become stuck by their wings. This method is highly selective, costless and has been successfully used in our laboratory for years.

[Clinical forensic valuation of school violence]. / Violences en milieu scolaire : 20 ans d'observations médico-légales en région Nord Pas-de-Calais.

AIM: In recent years, the National Education in France has developed tools to identify acts of violence in schools. This has allowed adjusting government policies for the care of victims. School violence can also be measured from the perspective of clinical forensic medicine, a special discipline for observing a society's violence. PATIENTS AND METHODS: This study summarized and compared three similar single-center, prospective, and descriptive studies conducted in 1992, 2002, and 2012 in the Department of Forensic Medicine, University Hospital of Lille, via an evaluation form completed during consultations requested by victims in cases of school violence. The purpose was to identify the characteristics of victims, those of their perpetrators, the circumstances and reasons for school assaults, as well as their medical and administrative consequences. RESULTS: Each study had identified about 160 such attacks annually. The victims were younger, especially boys (the average age decreased from 14.8 to 13.6). The gender distribution showed an increase in female victims (the sex ratio decreased from 2.9/1 to 2.3/1). The location of attacks changed, with a marked increase of attacks on the way to school (from 10% to 27%). Recurrence of attacks also rose: victims with a previous history of attacks increased from 18.5% to 32.2% with a high proportion of violence resulting in a strong psychological impact, increasingly requiring psychological support (from 9 to 16%). The duration of school cases rose sharply, from 20 to 53% in 2012. The grade level of the perpetrator showed a significant increase in cases of violence at junior high school (from 40 to 67%), with a relative stability of violence in elementary and high schools. The parameters measured to characterize the aggressors remained stable: they were known to their victims in approximately 80% of cases and these attacks were for the most part related to previous disagreements. DISCUSSION: Since the 1990s, government policies for the prevention, measurement, and punishment of violence in schools have not ceased to grow, but this violence has not attenuated. It is identified annually by the government and the data from the present study show comparable trends to national data. CONCLUSION: The progression of school violence over the past 20 years shows trends brought out through a forensic medicine framework. This discipline is indeed an observatory of violence and it has an important role to play in the detection of fragile psychological situations. This violence is increasing and compromises pupils' privacy. In the future, different forms of violence with a strong psychological impact should be emphasized, including the influence on academic achievement and child development.

Use of larder beetles (Coleoptera: Dermestidae) to deflesh human jaws.

We describe new experimental data for the defleshing of human bones using larder beetles (Dermestes haemorrhoidalis) (Küster, 1852). Although the ability of larder beetles to feed on vertebrate remains has been, and still is, used by taxidermists to deflesh skulls and bones, this method has never been documented from a quantitative perspective and has over time become ignored in most forensic anthropology or odontology laboratories. To promote the rational and efficient use of this method, we performed experiments to estimate the quantity of food consumed by larvae. From the 2nd instar to nymphosis, each larva consumed a mean of 0.13±0.03 g of dry beef muscle. We then used 100±50 D. haemorrhoidalis adults and 100±50 larvae to deflesh human maxillae and mandibles sampled within a forensic context (victim identification). Each sample was weighed and photographed before, during and after the experiment. According to our experiments, 20-25 days were sufficient to completely deflesh all of the samples. We concluded that a small number of larder beetles can be used to efficiently deflesh human jaws. According to this result, the use of larder beetles appears to be an inexpensive, simple and efficient way to clean mandibles and maxillae. Furthermore, this method is DNA-safe (compared to usual maceration techniques) and thus allows the samples to be used for subsequent DNA and drug analyses.

3D-MSCT imaging of bullet trajectory in 3D crime scene reconstruction: two case reports.

Postmortem investigations are increasingly assisted by three-dimensional multi-slice computed tomography (3D-MSCT) and have become more available to forensic pathologists over the past 20years. In cases of ballistic wounds, 3D-MSCT can provide an accurate description of the bullet location, bone fractures and, more interestingly, a clear visual of the intracorporeal trajectory (bullet track). These forensic medical examinations can be combined with tridimensional bullet trajectory reconstructions created by forensic ballistic experts. These case reports present the implementation of tridimensional methods and the results of 3D crime scene reconstruction in two cases. The authors highlight the value of collaborations between police forensic experts and forensic medicine institutes through the incorporation of 3D-MSCT data in a crime scene reconstruction, which is of great interest in forensic science as a clear visual communication tool between experts and the court.

Philemon and Baucis syndrome: three additional cases of double deaths of married couples.

The simultaneous death of two people is immediately considered as a suspect. However, this feeling is reinforced when the individuals are spouses. In these situations, criminal and forensic investigations are required to establish whether or not the deaths were homicidal in nature. Despite many descriptions of simultaneous deaths being present in the literature, the simultaneous death of two spouses from natural causes is poorly described with Ciesiolka et al., Department of Legal Medicine in Gießen (Germany), being the only ones to have reviewed two case reports involving these circumstances. The scarcity of this type of information in the literature renders the task of claiming natural simultaneous death as the final outcome of an investigation difficult. We would like to report three additional cases with the aim of better describing this type of event. In all three cases, the bodies were those of a married couple in their 80s. The bodies were discovered in the same room. In each case, the death of one of the spouses could be attributed to natural cause; however the death of the other spouse could not be determined with certainty, and shared several similarities in all cases: simultaneity in death; a pre existing cardiovascular disease/disorder; a certain degree of fragility and dependence on the other spouse whose death could lead to acute psychological stress. Intense psychological disorder could trigger acute coronary or rhythmic disorders. The mechanisms by which brain activity influences cardiac electrophysiology are now known to take place via the autonomic nervous system mediation. This brain activity could provide an explanation for the death of the individuals with pre-existing heart conditions, who underwent significant stress upon occurrence of the death of their partners. The death of these individuals, which took place at the same place and time as their deceased spouses, can be attributed to natural causes: the Philemon and Baucis syndrome.

Typical external skull beveling wound unlinked with a gunshot.

Lesions of the cranial vault resulting from firearms are traditionally described in forensic medical literature with many reports illustrating atypical bone lesions carried out to the skull by gunshot wounds. The authors present this report which illustrates an external beveled skull wound, associated with internal beveling damage, caused by a stabbing injury. A partially buried human skeleton was found in a forest. The examining of the skull revealed a hole resembling the exit wound caused by a bullet and two other smaller stab wounds. No typical entering bullet wound and no other bone lesions were found. During the course of the investigation, one of the perpetrators admitted to hitting the victim, using a sickle, and to hiding the body. For this purpose, he dragged the corpse with the sickle still implanted in the skull, using it as a hook. Upon retrieving the sickle, a piece of cranial vault was removed, thus creating an external beveled wound. In order to identify the mechanism which brought about this kind of lesion, experimental work was carried out on a human skull. In this particular case, the tip of the sickle penetrated into the bone, creating a lesion that would typically be produced with a stabbing instrument when applied with vertical force. When the body was dragged, using the sickle as a hook, this was a hand-produced vertical force, which was applied in the opposite direction. It caused the tearing of a piece of bone and the creation of an outer bevel. This atypical lesion should be made known to medical examiners and pathologists in order to help investigating and understanding of the circumstances of injuries.

[Organ procurement in forensic deaths]. / Prélèvements d'organes et décès médico-légaux.

OBJECTIVE: There is a chronic shortage of transplants. There are many obstacles on organ procurement and some are related to forensics aspects of deaths. In these situations in France, the judge decides whether or not to perform the organ recovery. These refusals are about 40 donors per year, representing a loss of more than 120 potential transplants. STUDY DESIGN: Retrospective study of 9 years (2003-2011) aimed to study the expectations of judges in comparing them with forensics issues. PATIENTS AND METHODS: Sixty-two cases of organ recovery with judicial proceedings have been treated in collaboration between the Agency of Biomedicine (Northeast) and the Medico-Legal Institute of Lille (northern France). RESULTS: When there is a judicial opposition to an organ procurement, it is mostly upon criminal circumstances (57%). The main reason is the need to perform an autopsy (38%), raising fears of a loss of evidence because of resuscitation and surgery for the judges. However, autopsies rule out these problems if strict protocols are followed. CONCLUSIONS: In case of forensic death, French law provides that a forensic examination to take place prior to surgical procedures. The law also provides for collaboration between caregivers and medical examiners. Nevertheless, judicial oppositions persist and appear to belong to a lack of communication between actors (judges/medical examiners/organ procurement organization). Better collaboration through protocols must be thought to satisfy the demands of justice and public health.

Mechanisms of hyoid bone fracture after modelling: evaluation of anthropological criteria defining two relevant models.

Several studies have attempted to describe the morphology of the hyoid bone, while other authors have focused on discovering the role of this bone in the occurrence of fractures. Hyoid fractures are known to be dependent on the force applied against the bone, or on the location at which the force is applied. We wished to assess the value of defining one or more models of the hyoid bone by analyzing variations in the size and angle of the various component parts of the bone relative to the sex and morphology of an individual (height and weight) in a sample of 72 bones obtained during forensic autopsy at our institution. Statistical analyses were developed using SAS software (Statistical Analysis System, version 9.2). We observed that the length of the hyoid bone and the angle between the greater horns differed significantly between men and women. Length was significantly greater in men (38.20 ± 4.67 mm) than in women (30.49 ± 7.90 mm) and the angle between the greater horns of the hyoid bone was larger in women (36.46 ± 13.77°) than in men (27.56 ± 13.02°). There was also a statistically significant correlation between the body mass index of an individual and the length of the hyoid bone. As weight increased, the hyoid bone was found to be longer. The weight of an individual was also significantly correlated with the angle of the hyoid bone, with lower weight resulting in larger angles of the bone. Furthermore, hierarchical classification enabled the hyoid bone to be differentiated into two groups or clusters according to anthropometric measurements. ROC curves were used to determine threshold values of length, width and angle to classify the hyoid bones in these two clusters: the first was composed of individuals with longer hyoid bones, and the second of individuals with greater hyoid bone widths and wider angles. Logistic regression showed male gender was more frequently associated with the first group. The morphology of the hyoid bone can be differentiated according to the gender and corpulence of an individual because these parameters are correlated. These findings are crucial in establishing a protocol for modelling the mechanism of fracture of the hyoid bone in strangulation. Two models of the hyoid bone appear to be needed to meet the practical requirements that are the purpose of these biomechanical studies.

Medical liabilities of the French physician passenger during a commercial air flight.

Nearly two billion passengers travel each year on commercial air flights. More elderly people and/or people with a pre-existing condition are taking to the air and with the anticipated growth of air travel, in-flight illnesses and injuries are expected to increase as well. Even if in-flight medical events and deaths are still uncommon, physician passengers are occasionally called upon to render assistance. Although no case law exists as yet in France, physicians who often travel on commercial flights should be aware of the risks they run if they do not respond to the well-known call, 'Is there a doctor on board?', or if they assist a sick passenger. This paper describes in-flight resources available to a physician who is called upon to treat an ill or injured passenger. Two questions concerning the French physician passenger are discussed: What are the liabilities of the physician who does not respond to the call of a medical event aboard an aircraft? What are the liabilities of the physician providing assistance to a sick passenger? The different liabilities and also the legal status of the French physician passenger are examined.

Child barbarity and torture: a case report.

Penile strangulation with a strand of hair, acting as a tourniquet, and perforation of the eyes with a knife are uncommon accidental injuries in children. In such a situation, a mistreatment must be evoked. We present a case of barbarity and torture involving a young boy 3 years old. He was a victim of penis strangulation and perforation of the eyes, performed on previous surgical and infectious lesions. The mistreatment was performed by his mother's boyfriend. The perpetrator used the previous lesions to hide his misdeed. This amazing case of mistreatment points out the violence of the wounds and their being performed on previous lesions.

High-performance liquid chromatographic method to screen and quantitate seven selective serotonin reuptake inhibitors in human serum.

A high-performance liquid chromatographic screening method (HPLC) is described for the determination of seven selective serotonin reuptake inhibitors (SSRIs) (fluvoxamine, milnacipran, paroxetine, sertraline, fluoxetine, citalopram, venlafaxine) and for three pharmacologically active N-demethylated metabolites (desmethylcitalopram, didesmethylcitalopram and norfluoxetine). A tricyclic antidepressant, clomipramine, was used as an internal standard. The method consists of liquid extraction of serum after alcalinisation at pH 9.50, followed by chromatography on a Beckman C18 reversed-phase column. Compounds were detected at 200.4 nm. The standard curves were linear over a working range of 50-1,000 ng/ml for fluvoxamine, 15-1,000 ng/ml for fluoxetine, 25-500 ng/ml for norfluoxetine, 50-500 ng/ml for sertraline, 20-500 ng/ml for paroxetine, 25-550 ng/ml for citalopram, 25-750 ng/ml for desmethylcitalopram, 25-800 ng/ml for didesmethylcitalopram, 25-650 ng/ml for milnacipran, and 25-500 ng/ml for venlafaxine. The quantitation limits of the method were 15 ng/ml for fluoxetine, 20 ng/ml for paroxetine, 25 ng/ml for venlafaxine, norfluoxetine and citalopram, and its metabolites, 40 ng/ml for sertraline and 50 ng/ml for fluvoxamine. No interferences were noted with this sensitive and specific method which can be used for therapeutic drug monitoring.

Morphine extraction in necrophagous insects remains for determining ante-mortem opiate intoxication.

To study the potential use of insects remains as toxicological indicators, we measured morphine in desiccated entomological materials using a radioimmunoassay method (Coat-A-Count Serum Morphine, Dade Behring, France) following enzymatic hydrolysis.First, enzymatic cuticle extraction of morphine (pronase digestion preceded by a 2h incubation with a dithiothreitol solution) was performed on various substrates (Calliphoridae puparial cases and desiccated adults, and desiccated pupae of Dermestidae) which were then tested to identify possible interferences with the radioimmunoassay procedure. This same procedure was performed on puparial cases and desiccated adults of Lucilia sericata (Diptera, Calliphoridae) previously reared on minced meat containing various morphine concentrations. Morphine was detected only in cuticle powder from insects reared on meats containing 100 and 1000mg/kg. Higher concentrations were measured in puparial cases. Rearings on psoas from eight heroin overdose victims confirmed previous experimental results. Remains of necrophagous insects, particularly puparial cases, are often preserved for a long time, and consequently can serve as late alternative specimens for toxicological analysis when suitable tissues are not available.

Complete autoerotic asphyxiation: suicide or accident?

A case of a typical form of sexual asphyxiation is described, involving a young man hanging, in a context of autoerotic asphyxia. Multiple and different parameters are included in the definition.