An unusual case of attempted suicide by a depressive woman: self-inflicted intracranial stabbing.

Self-inflicted stab injury to the skull, particularly in the neurocranium, is a rare method used to commit suicide. Herein is presented a case of a 26-year old woman with a temporal wound found by her partner in their home. No weapon was found in the approximate environment and the victim said that she fell. A CT scan performed at admission to the emergency room was interpreted as being compatible with injury from falls. A second CT scan in a neurosurgical unit suggested a cranio-cerebral injury from a sharp object; aggression was suspected. The discording elements led to an interview with a psychiatrist and diagnosis of attempted suicide through the action of a knife in the context of severe depression. This is a rare case that implicates a depressive woman and stabbing directly to the neurocranium.

[Hymenal examination of under age children with a context of sexual assault]. / Examen de l'hymen chez les mineures dans un contexte d'agression sexuelle.

The hymeneal examination is often considered as the key of the gyneacological examination of a young girl victim of sexual assault, mainly because the concept of penetration is important under the French criminal code. However, the amount medical literature related to this topic is poor. The hymen examination must be conducted under strict conditions, by qualified personnel and as soon as possible after the alleged assault.The only kind of anomaly that can confirm a penetration is an injury to the posterior hymen extending up its base. The sensitivity of this sign is, however, low and its absence does not suggest that of penetration. A vaginal penetration does not always break the hymen, especially among adolescents. Moreover, the hymen can heal and thus it makes the examination difficult when it occurs a long time after the facts. Examination of the hymen is rarely the decisive factor in the forensic assessment of a young victim of sexual assault.

[Evolution and follow-up of hunger strikers: experience from an interregional hospital secured unit]. / Évolution et surveillance des patients grévistes de la faim : expérience d'une unité hospitalière sécurisée interrégionale.

PURPOSE: A hunger strike is a voluntary fast, performed to protest publicly against an issue deemed unfair. In the case of French prisoners, hospitalization in an interregional hospital secured units (UHSI) may be necessary. METHODS: A retrospective epidemiological study based on one UHSI medical records was performed on the period of May, 2006 to December, 2008, and focused on symptoms, outcomes and ethical problems encountered. RESULTS: Seven men and one woman with a mean age of 32.6 years were hospitalized in an UHSI, with nine episodes of hunger strike of a median duration of 57 days. Clinical symptoms began after two weeks of voluntary deprivation in the form of dizziness, weakness, muscle pain and headache. Laboratory tests showed hypoglycemia (<0.4g/L) on admission, 16.3% decrease of albumin after 40.5 days, and dehydration in case of thirst strike. The clinical tolerance was good and no patient presented Wernicke's encephalopathy. A diabetic patient developed acidocetosis during two hunger strikes. All hunger strikes were respected by medical staff, and treatment was based upon surveillance of symptoms, vitamin B and sweetened drinks administration and explanations of the clinical hazards on a daily basis. CONCLUSION: The special problem encountered in the medical management of these strikers was to convince them to accept treatments in order to avoid a coercive life-saving treatment as requested by French law.

[Compensation for vaccination accidents]. / L'indemnisation des accidents de vaccination.

The compensation of the inoculation accidents evolved after the law of August 9th, 2004 which stated the conditions of a complete repair of the attributable damages in a compulsory inoculation in conformance with the National Solidarity. The Office National d'Indemnisation des Accidents Médicaux, des Affections Iatrogènes et des Infections Nosocomiales (ONIAM) ensures this repair. For the not compulsory inoculations, the medical responsibility can be called only in conformance with a fault committed by the doctor. In spite of the absence of link scientifically established as in the inoculation of the hepatitis B and the induction of a multiple sclerosis at the end of 2008, the jurisprudence in vaccinal accidents varies according to the civil, social, administrative jurisdictions. The appreciation of the link of causality between the inoculation and its consequences is more rigorous in front of the civil jurisdictions than in front of the administrative or social jurisdictions.

[Intoxications specific to the Aquitaine region]. / Les intoxications particulières de la région aquitaine.

Some intoxications are more specifically linked to the Aquitaine region than to other regions of France, due to environmental circumstances (fauna, flora, climate) or traditional activities (gastronomy). Three types of intoxications are particular in this area. Pine processionary caterpillar envenomations (Thaumetopoea pityocampa), a Southern Europe pinewood parasite, are frequently encountered in the Landes' forest. They are responsible of ocular and/or skin lesions with urticaria or contact dermatitis, seldom associated with immediate IgE hypersensitivity. According to the south Atlantic coastal region geology and the marine streams, venomous marine animals are mainly located in Charente-Maritime for jellyfish, in Gironde and in Landes for weeverfish and in Atlantic Pyrenees for sea anemone. Usually not dangerous, first-aid workers treat most cases of these envenomations. Some endemic mushrooms (Tricholoma auratum) which grow on the dunes of the Atlantic coastal region, are usually considered as very good comestibles, but were recently responsible for serious intoxications: T.auratum was responsible of several cases of rhabdomyolysis, without neurological involvement, nor renal or hepatic lesion. Three deaths were notified. Animal studies confirmed the responsibility of the mushrooms.

[Medical liability: new obligations concerning information of patients on infectious risks]. / Responsabilité médicale: les nouvelles obligations en matière d'information sur les risques infectieux.

Nosocomial infections have always been considered as "unbearable" by patients and public opinion. Court decisions progressively evolved to a greater compensation until the 4 March 2002 law, "relative to the rights of patients and to the healthcare system quality" which set up a very specific protocol for liability and access to compensation, whether care is given in public or private practice. Furthermore, this law has determined new obligations concerning information of patients, especially concerning nosocomial infections which must be acknowledged by physicians.

Postmortem findings in 22 victims due to two grain silo explosions in France.

In 1982 and 1997 there were explosions of barley-containing silos in France, one in Metz (1982) and the other in Blaye (1997). There were a total of 25 victims, including 23 fatalities (12 in Metz and 11 in Blaye). In each case there was one survivor. This report is a retrospective study of 22 victims (11 at each site); all of them had multiple lesions due to the explosion and the immediate aftermath. The lesions demonstrated direct involvement of the blast effect associated with silo destruction, the heat from the explosion, the effects of toxic gases and asphyxia. The forensic pathologist is an important member of the emergency response team. This team has the responsibility for initially assessing the damage and for identifying the victims. The role of the forensic pathologist is therefore essential and they should be included in emergency planning to facilitate the initial assessment, shorten the time taken to identify the victims and improve safety procedures. Although dust explosions in agro-business plants are occurring more frequently, postmortem data are rare.

Hair analysis of seven bodybuilders for anabolic steroids, ephedrine, and clenbuterol.

Several bodybuilders, all winners of international competitions, were arrested for trafficking of a number of doping agents including anabolic steroids, ephedrine, beta-adrenergics, human chorionic gonadotropin, antidepressants, and diuretics. In accordance with the recent French law against doping, the judge asked to test seven bodybuilders to identify doping practices. Hair and urine specimens were collected for analysis. After decontamination, a 100 mg hair strand was pulverized in a ball mill, hydrolyzed, extracted, and derivatized to be tested by GC/MS for anabolic steroids, beta-adrenergic compounds, ephedrine, and other doping agents. Urine was analyzed for anabolic steroids and metabolites, beta-adrenergic compounds, ephedrine, and human chorionic gonadotropin, in addition to a broad spectrum screening with GC/MS. The following compounds were detected in urine: ephedrine (29 and 36 ng/mL, n = 2), clenbuterol (0.2 to 0.3 ng/mL, n = 3), norandrosterone (4.7 to 100.7 ng/mL, n = 7), norethiocholanolone (0.9 to 161.8 ng/mL, n = 6), stanozolol (1 to 25.8 ng/mL, n = 4), methenolone (2.5 to 29.7 ng/mL, n = 4), testosterone (3 to 59.6 ng/mL, n = 7), epitestosterone (1 to 20.4 ng/mL, n = 7) and ratio testosterone/epitestosterone >6 for four subjects (18.5 to 59.6). The following drugs were detected in hair: ephedrine (0.67 and 10.70 ng/mg, n = 2), salbutamol (15 to 31 pg/mg, n = 3), clenbuterol (15 to 122 pg/mg, n = 6), nandrolone (1 to 7.5 pg/mg, n = 3), stanozolol (2 to 84 pg/mg, n = 4), methenolone (17 and 34 ng/ml, n = 2), testosterone enanthate (0.6 to 18.8 ng/mg, n = 5), and testosterone cypionate (3.3 to 4.8 ng/mg, n = 2). These results document the doping practice and demonstrate repetitive exposure to anabolic compounds and confirm the value of hair analysis as a complement to urinalysis in the control of doping practice.

Last performance with VIAGRA: post-mortem identification of sildenafil and its metabolites in biological specimens including hair sample.

A 43-year-old man was found dead in a hotel room during a sexual relation with a colleague.He was treated both for cardiovascular disease and for erectile dysfunction with VIAGRA. A pillbox was found in the room with several tablets of verapamil (Isoptine), trimetazidine (Vastarel), yohimbine and bromazepam (Lexomil). A box of VIAGRA 25mg was found in his raincoat and two tablets were missing. His wife declared during the investigation that he was also treated by trinitrine. Autopsy revealed severe coronary artery sclerosis as well as signs of previous myocardial infarctions. Blood, urine, bile, gastric content and hair and representative tissues for histology were collected for toxicological analysis. Sildenafil and yohimbine were screened with liquid chromatography/mass spectrometry (LC/MS) and trinitrine with headspace injection (HS)/GC/MS. Verapamil and trimetazidine were identified and quantified with LC/diode array detection (DAD). Sildenafil was identified in blood, urine, bile and gastric content at 105, 246, 1206 and 754ng/ml, respectively. Hair concentration was 177pg/mg. The desmethyl metabolite was quantified in urine at 143ng/ml. Blood concentrations of verapamil and trimetazidine were measured at 659 and 2133ng/ml, respectively and were above therapeutic ranges. Trinitrine and yohimbine were not identified. These results confirm the absorption of sildenafil, verapamil and trimetazidine before the death and hair analysis indicates the chronic use of sildenafil. To the author's knowledge, this is the first report of a fatal sildenafil-verapamil association, probably by hypotension and cardiac dysrhythmia.

Obsessive compulsive disorder secondary to head injury.

Obsessive-compulsive disorder (OCD) is a rare sequel of head injury. There are few reports on the subject. This article presents the case of a young patient who developed OCD several years after head injury. In the light of the present state of knowledge, the authors discuss the relationship between OCDS and the brain lesions observed, their localizations and their physiopathological mechanisms, which may explain the occurrence of the disorder.

[Drug prescriptions outside the marketing product license and its responsibilities]. / Prescription de médicaments hors AMM et responsabilités.

In France, drugs are commercialized after obtaining marketing approval. There are some situations however in which clinicians are authorized to prescribe drugs outside the limits set by the approval document. Clinicians must comply with certain number of regulations. Compliance with prescription modalities, particularly precautions concerning prescription writing or the patient's informed consent, is mandatory. Although patients cannot be reimbursed for drugs prescribed outside the approval limitations, they may nevertheless benefit from special dispositions: temporary approval for use and experimentation within the framework of the Huriet law. We analyze here the question of liability in case of drug prescriptions outside approval limitations, discussing the issues of civil and penal law and patient reimbursement.

The contribution of statistics in the forensic appraisal of post-transfusion contamination by hepatitis C virus.

Many patients were contaminated by blood products in the 1980s and early 1990s, a period during which there was no means of detecting hepatitis C virus (HCV) and measures of vigilance in French blood transfusion centers were lacking in rigor, and it has become a real public health issue by now. The blood transfusion centers which produce and distribute the products are liable for such contamination, as long as the expert appraisal has established a link of causality between the transfusion and the contamination. When the viral serologic status (i.e. the contaminating potential) of the donors is not known, experts often resort to indirect evidence, including use of probability estimates calculated according to the following method. The probability (P) that there was at least one contaminating donor among those having provided the blood given to a patient, is calculated using the following formula:P=1.(1.pHCV)(N)where pHCV is the prevalence of subjects who have tested positive for anti-C virus antibodies in a population of blood donors, and N is the number of donors having contributed to the transfusion in question. Although the polymerase chain reaction (PCR) is very sensitive, its threshold, below which weak replication is undetectable, varies depending on the technique used. One study has demonstrated that below a dilution of 10(-4), RNA is no longer detected by the majority of laboratories. The specificity of PCR is not flawless either, since false-positive results are found, probably resulting from contamination of the samples. Considering that 0.10% is a reasonable approximation of the prevalence of subjects who had anti-HCV antibodies that were detectable by recombinant immunoblot assay during that period, one can calculate the probability that there is a contaminating donor among the blood donors who contributed to the product that was administered and determine a curve.

Spontaneous human combustion: a sometimes incomprehensible phenomenon.

Several cases of human combustion, the cause of which was not evident, have been described over the last few centuries. There are three intriguing elements to such cases. Firstly, although the body is destroyed, the immediate surroundings are left almost intact. Secondly, there is often no visible source of heat that might have started the fire. Thirdly, sometimes bodies are not completely destroyed, certain parts being perfectly preserved, adjacent to others that are reduced to a state of ashes.

Review of factors susceptible of influencing post-mortem carbohydrate-deficient transferrin.

Seric carbohydrate-deficient transferrin (CDT) is a biochemical marker of chronic alcohol abuse. Assessment of the influence of factors likely to modify CDT concentration is necessary to justify its use in the analysis of post-mortem blood samples. Hemolysis, site of collection and storage were tested. Hemolysed samples showed decreased CDT concentration. Statistical analysis of CDT concentration in cardiac blood versus femoral blood revealed no significant differences. Storage for fifteen days at +4 degrees C or +20 degrees C did not affect CDT concentration but repeated freezing and thawing resulted in decreased levels of CDT.

[Medico-legal dimension of informed consent in medicine]. / La dimension médicolégale du consentement éclairé en médecine.

The practice of the medical arts is more and more becoming framed by laws and regulations. Concurrently, the civil liability in the medical field has also been deeply changed, in particular by reversing the charge of proof of the information given to the patient. After having been reminded of the place in the juridical arsenal of informed consent to a medical procedure, its value is discussed regarding the explanations given by the physicians. Guidelines for a forensic appraisal, with the aim of evaluating and appreciating the information received by the patient, are proposed. Recent judiciary decisions about refusal of care, especially blood transfusions, are discussed.

An unusual case of sexual assault on an infant: an intraperitoneal candle in a 20-month-old girl.

The recent publication of cases of sexual abuse and child prostitution networks may have the harmful effect of arousing latent desires or causing sexual delinquents to act out their impulses. The authors report a recent case in which a wax candle was introduced into the vagina of a 20-month-old baby. The forensic description is given and provisional conclusions are drawn.

Ethics and law in the field of medical care for the elderly in France.

The authors discuss law and ethics when medical decisions are to be taken by patients who are unable in any valid sense to express their own wishes. The main problem in legal terms is to protect an individual's free will as far as possible and ensure that his or her wishes, if known, are respected. If a patient's independent wishes cannot be known, then we must at least ensure that nothing is imposed which is not in his interest. Legal measures, however, are far from adequate in resolving all the concrete problems that emerge. The field of ethics does bring some better adapted solutions, but none is laid down in law. One such approach, involving a multidisciplinary advisory group in a department of geriatrics, is discussed.

Judicial problems related to transsexualism in France.

The French courts have recently changed their juridical position about transsexualism. The new decisions have, among other things, asserted the necessity for preliminary judicial expertise, an ordinary medical report not being satisfactory as a legal basis. The authors present a summary of the juridical evolution, an expert analysis of transsexualism and the key concepts that the experts will have to debate.

Sperm conservation and HIV infection.

In the course of preparing a medico-legal report in civil proceedings instituted by a couple contaminated by HIV, the case of Mr B. was brought to our attention. At the end of 1984 Mr B. had a serious accident in consequence of which he received a number of blood transfusions. The post-transfusion inquiry established blood contamination. Several years later (in 1990), and for reasons closely related to the above accident, Mr B. and his wife were having difficulty in having a child. They decided to resort to intraconjugal artificial insemination (IAI) first through a private laboratory and then through a CSCOS (Centre for the Study and Conservation of Human Ova and Sperm). In 1992 Mr B. and his wife were both found to be HIV positive; the infection was ascribed to the IAI, as the most plausible cause. In the face of such dramatic events, we wondered why neither the laboratory nor the CSCOS had checked whether the couple were HIV positive. Reflecting on this led us: (a) to make an inventory of the different organizations and facilities empowered to manipulate sperm for medically assisted procreation (MAP); (b) to investigate their obligation in terms of the prevention and control of specific diseases.