[Population of people placed in police custody, hidden barometer of diverted medicines]. / La population des personnes placées en garde à vue à Paris, baromètre du détournement invisible des médicaments.

PURPOSE OF THE STUDY: The population of people in police custody is a sentinel niche that is poorly represented in the "usual panels" of public health studies. The aim is to make an overview of their diversion of drugs. PATIENTS AND METHODS: A retrospective study based on cases of misuse in a sample of people in custody examined between 2015 and 2016 at the forensic medicine unit of the hospital Hôtel-Dieu-Paris. RESULTS: Of the 5149 medical examinations, 302 were for substance use disorder or drug misuse. In 2016, the number of notifications for misuse of clonazepam increased (n=65); the user population appears to be getting younger (average age=23.5 years) and to be supplied mainly by deal (63%). Regarding opioid substitution treatments, the indicators of abuse and diversion are confirmed, while morphine sulfate stands out with a strong deal (>75%), IV injection (62%) and polydrug use, including methadone, cocaine (62%). CONCLUSION: From our results, national surveys in general population and studies carried out in the context of deprivation of liberty, people in police custody constitute a real barometer of the parallel market for street drugs. Clinical impacts can be major; a better monitoring is needed. For caregivers, it is also a matter of better identification of misuse, substance use disorder for a future orientation of the patient.

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.

Terrorist attacks: cutaneous patterns of gunshot and secondary blast injuries.

Terrorist attacks have been on the rise. During the recent terrorist attacks in France, terrorists perpetrated their acts using weapons of war, as well as explosive charges. These two modes of action, when combined, can create skin lesions with similar macroscopic appearances, which can sometimes go unnoticed because of body fragmentation. A total of 68 autopsies, 83 external examinations, 140 standard radiographic examinations, and 49 computed tomography (CT) scans were performed over 7 days during the 2015 terrorist attacks in France. Bodies were injured by firearms and shrapnel-like projectiles. We analysed the clinical findings for the secondary blast cutaneous lesions from the explosive devices and compared these lesions with ballistic-related lesions to highlight that patterns can be macroscopically similar on external examination. Secondary blast injuries are characterised by penetrating trauma associated with materials added to explosive systems that are propelled by explosive air movement. These injuries are caused most often by small, shrapnel-like metallic objects, such as nails and bolts. Propulsion causes ballistic-type injuries that must be recognised and distinguished from those caused by firearm projectiles. Differentiating between these lesions is very difficult when using conventional criteria (size, shape, number and distribution on the body) with only external examination of corpses. This is why the particularities of these lesions must be further illustrated and then confirmed by complete autopsies and radiological and anatomopathological examinations.Key pointsWhen occurring simultaneously in terrorist attacks, injuries caused by secondary blasts appear as cutaneous wound patterns that can be macroscopically very similar to those caused by firearm projectiles.The criteria usually found in the literature for distinguishing these two types of projectiles may be difficult to use.It is important in these difficult situations to benefit from systematic postmortem imaging.Systematic autopsy and then anatomopathological analyses of the orifices also help determine the cause of the wounds.

Pregnancy, cesarean, and pheochromocytoma: a case report and literature review.

A 43-year-old full-term pregnant woman (gravida 2, para 1, medical history of gestational diabetes mellitus) developed a sudden and malignant hypertension with hemoptysis, sweat, and tachycardia during a scheduled C-section. A dead newborn was delivered and was successfully resuscitated. The mother died after resistant cardiac arrest. Autopsy and pathological analyses revealed an acute pulmonary edema and a necrotic and hemorrhagic voluminous tumor of the left adrenal gland, which was a pheochromocytoma. Pheochromocytoma is a rare tumor of the adrenal glands which secretes catecholamines. In pregnant women, its symptoms can mimic gestational hypertension, preeclampsia or eclampsia, and gestational diabetes mellitus. The gestational diabetes mellitus was presumed to be a symptom of the pheochromocytoma, and cardiopulmonary failure the result from the necrosis of the tumor provoked by gravid uterus compression. From a medico-legal point of view, the tumor could not have been suspected during the pregnancy.

[What should a physician do facing drug facilitated crimes?]. / Conduite à tenir devant une suspicion de soumission chimique.

Chemical submission is the administration, for criminal purposes, of psychoactive substances to an individual without their knowledge. It is clear that general practitioners remain helpless against such a phenomenon. Most of the time, diagnosis is negatively affected by delayed management, due to omitted diagnosis or inappropriate samples. The purpose of our paper is therefore to provide a few simple recommendations. A victim suspecting of being drugged without knowing should be adequately interviewed, examined and informed about the possibility of pressing charges. A quick referral to an emergency unit or a forensic medicine unit is necessary to collect biological samples for toxicological testing as promptly as possible. In the event of a prosecution, these samples will be submitted for toxicological analysis, a critical step in identifying the psychoactive substance used.

[Misuse of psychotropic medications in a population of subjects held for custody in the city of Paris]. / Mésusage de médicaments psychotropes au sein d'une population de gardés à vue à Paris.

OBJECTIVE: Identify which psychotropic medications are misused and peddled in a population of subjects held for custody in the city of Paris. METHODS: Subjects held for custody in the Medico-Legal Emergency Unit of the Paris Hôtel-Dieu hospital were examined and interrogated between March 2006 and March 2007 in order to assess their consumption of psychotropic medications. RESULTS: Sixty one of the 659 subjects (9.2%) interrogated were included in the study. Their main source of psychotropic medications was street dealers. The most frequently misused psychotropic agent was clonazepam (42.6%), followed by buprenorphine (30.65%) and methadone (21.3%). Clonazepam appears to have replaced flunitrazepam which now only comes in fifth position (11.4%). The finding that methadone is the third most misused drug should lead us to query this medication's dispensing method. CONCLUSIONS: Practitioners should remain vigilant regarding the potential misuse of psychotropic medications, particularly since they may induce severe undesirable events (addiction, neurological disorders, possibly lethal overdosage).

[Drug-facilitated crimes: prospective data collection in a forensic unit in Paris]. / Soumission chimique: administration de psychotropes à l'insu d'une victime à des fins d'agression Etude prospective de 52 cas au sein d'une unité médico-judiciaire.

INTRODUCTION: Little is known about the rate of crimes that are facilitated by the administration of psychoactive products without the victim's knowledge. This study analyzes the cases collected over a two-year period in a forensic unit in Paris. MATERIAL AND METHODS: The study covers the period from January 1, 2005 and December /31, 2006. It includes crime victims who consulted for toxicological testing in the forensic unit of the Hôtel Dieu in Paris, after filing a criminal complaint describing symptoms suggestive of chemical submission (amnesia, impaired vigilance or behavior) and whose toxicological tests indicated the presence of a psychoactive product that they had not been aware of taking. The tests used chromatographic techniques on blood, urine, hair, and food or drink residue. RESULTS: Toxicological testing identified 52 cases of drug-facilitated crimes, primarily for theft and sexual abuse (including rape). The psychoactive products were most often incorporated in drinks, half of them alcoholic beverages. Benzodiazepines accounted for 77% of the cases. Other substances, found more rarely, included antihistamines, neuroleptics, and GHB. CONCLUSION: Appropriate samples must be taken from victims rapidly to enable toxicological analysis. Chromatographic analysis must supplement immunological analysis, which is not sufficiently specific or sensitive. The collection of this information must continue in order to quantify the phenomenon and monitor the emergence of new products.