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Summary Focal cortical dysplasia (FCD) is the third leading cause of pharmacoresistant epilepsy diagnosed by epilepsy surgery and is a common malformation of cerebral cortical development. It is marked by abnormalities of cortical lamination, neuronal differentiation, and neuronal maturation. These epileptogenic lesions have proven anatomical and clinical correlations. Only one case of incidental FCD had been described. Incidental findings highlight infrequent lesions that go unnoticed when a person is alive. It can be an important finding for pathologists as well as for the forensic expert. The difficulty of the expertise will be in cases where these incidental lesions are known to cause symptoms that may be the cause of death. We wish to argue if they can be used in a medico-legal procedure. We report two cases demonstrating discrepancies between anatomical and clinical features, which should encourage the medical expert to use caution when interpreting neuropathological reports.

International audience; We report the case of an infant aged 8 and a half months, who had an apparent life-threatening event and died despite optimal resuscitation management. The medical history was marked by mild symptoms, mainly feeding difficulties and progressively settling skin lesions. Parents were related (first cousins) and the patient had two healthy older sisters. Autopsy showed growth delay, symmetrical erythematous and ulcerated periorificial lesions associated with punctiform erythematous lesions of the face and alopecia. Microscopic examination revealed deep bronchial inhalation with the onset of infectious pneumopathy, major inflammatory ulceration of the gastrointestinal tract, hepatic steatosis, brain stem and pancreas abnormalities. We conclude that the cause of death was a multi-visceral failure with inhalation pneumopathy, in a context of very early onset inflammatory bowel disease (VEO-IBD). Genetic consultation, into a rare disease reference center, allowed to orient the analysis, to identify a homozygous pathogenic variant in the IL10RA gene, confirming the diagnostic of an autosomal recessive very early onset inflammatory bowel disease (inflammatory bowel disease 28, early-onset, autosomal recessive, #613148).; Nous rapportons le cas d’un nourrisson âgé de 8 mois et demi, ayant fait un malaise grave du nourrisson et décédé malgré une prise en charge optimale en réanimation. L’histoire de la maladie est marquée par des symptômes frustes, principalement des difficultés alimentaires et des lésions cutanées d’installation progressive. Parmi les antécédents, on note que les parents étaient apparentés et qu’il y avait deux sœurs aînées en bonne santé. L’autopsie a montré, outre un retard staturo-pondéral, des lésions péri-orificielles érythémateuses et ulcérées, symétriques, associées à des lésions érythémateuses punctiformes du visage et à une alopécie. L’examen microscopique a mis en évidence une inhalation bronchique profonde avec début de pneumopathie infectieuse, des ulcérations inflammatoires majeures du tube digestif, une stéatose hépatique et des anomalies du tronc cérébral et du pancréas. Ce tableau clinique nous a permis d’évoquer une défaillance multi-viscérale avec pneumopathie d’inhalation, dans un contexte de maladie inflammatoire de l’intestin à début précoce. Un avis génétique, au sein d’un centre de référence maladie rare, a permis d’orienter les analyses, d’identifier un variant pathogène homozygote dans le gène IL10RA et de poser le diagnostic de maladie inflammatoire de l’intestin à début précoce, de transmission autosomique récessive (inflammatory bowel disease 28, early onset, autosomal recessive, #613148).

Resume Introduction Les medecins sont souvent confrontes a des situations sociales complexes necessitant les competences d’une assistante socio-educative (ASE). L’objectif de ce travail est d’identifier la place des ASE au sein d’un service d’unite medico-judiciaire (UMJ). Materiels et methodes Il s’agit d’une etude retrospective, descriptive faite a partir des donnees recueillies lors des entretiens sociaux a l’UMJ de l’hopital de la Timone a Marseille. L’objectif est d’identifier le role de l’ASE, a partir d’une etude epidemiologique descriptive sur sept ans, et d’une analyse des demarches realisees pour chacune des victimes recues par les ASE. Resultats Chaque annee, pres d’un quart des victimes recues a l’UMJ, sont egalement prises en charge par les ASE. La majorite des victimes sont de sexe feminin et majeurs. Plus d’un tiers des victimes sont mineurs. L’accueil des personnes victimes de violences conjugales (25 %), scolaires, de maltraitance (18 %) et d’agressions sexuelles (7 %) reste privilegie aupres des ASE. Les missions specifiques des ASE d’UMJ resident dans la prise en charge des personnes victimes au cours des situations d’urgences, notamment pour la protection des personnes par la recherche d’hebergement d’urgence. L’orientation vers des associations pour un accompagnement psychosocial, le suivi juridique et la prise en charge specifique des mineurs sont egalement des missions caracteristiques des ASE d’UMJ. Conclusion Ce travail souligne l’importance d’une prise en charge globale des victimes au sein d’une UMJ. De par leur role determinant dans le cadre des violences intrafamiliales notamment les violences conjugales et les violences sur mineurs, les ASE jouent un role crucial dans les UMJ.

Loss of chance in compensation for non-accidental bodily injury: inventory The main problem with this notion is the hypothetical nature of the loss of chance, insofar as it is impossible to take for sure if the hoped-for event would actually haved occurred. This this is the main difficulty encountered when estimating a loss of chance. The aim of this work is to identify a number of tools that will serve as a basis for the assessment of loss of chance damage. The contribution of data from the literature, the use of abacuses depending on the terrain and the pathology and the contribution of sapients will be described. The calculation methodology will also be discussed in the context of the cumulative loss of chances suffered by the patient.Perte de chance en réparation du préjudice corporel hors accident : état des lieux La problématique de la notion de perte de chance est son caractère hypothétique, dans la mesure où il est impossible de savoir avec certitude si le fait espéré se serait réellement réalisé. C’est là toute la difficulté qui incombe au calcul de la perte de chance. Il est cependant possible de distinguer ou d’envisager un certain nombre de moyens permettant d’évaluer le préjudice de perte de chance. Les données de la littérature, les abaques, en fonction du terrain et de la pathologie, et les experts y contribuent. La méthodologie de calcul, dans le cadre du cumul de pertes de chances subies par le patient, mérite aussi d’être discutée.

Introduction Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI. Method A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis. Results In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases. Conclusion Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

Summary Three deaths following facial impacts in the presence of witnesses and resulting in brain lesions that were visualized only on pathological examination were studied at the forensic medicine institute of Marseille. Craniofacial impacts, even of low intensity, received during brawls may be associated with brain lesions ranging from a simple knock-out to fatal injuries. In criminal cases that are brought to court, even by autopsy it is still difficult to establish a direct link between the violence of the impact and the injuries that resulted in death. During a facial impact, the head undergoes a movement of violent forced hyperextension. Death may thus be secondary to the transmission of forces to the brain, either by a mechanism involving nerve conduction that may be termed a reflex mechanism (for example by vagal hyperstimulation) or by injury to the central nervous system (axonal damage). In such situations, autopsy does not make it possible to determine the cause of death, but only to suspect it in a context of voluntary violence in the presence of witnesses, with or without violent injury observed on external examination or on superficial incisions to determine the extent of bruises or hematoma. Systemic and comprehensive investigation involving pathology and toxicology is essential in any medicolegal case for positive interpretation and discrimination of other causes of death.

International audience; The regions of Provence-Alpes-Côte d'Azur and Corsica in southeast France are regularly affected by firearm deaths, and a large amount of data has been collected by our forensic institute. We carried out a single-center retrospective descriptive study of the records of our institute between January 1, 2011, and 31 December, 2018, relating to firearm deaths (homicides and suicides). There were 302 cases (218 homicides and 84 suicides). The anatomic locations most frequently involved were the thorax, abdomen and head, in that order, in homicides and the head in suicides. More than 80% of the homicides in our series had more than one wound complex and nearly one in four homicides had more than 7. The weapon most frequently used in suicides was a hunting smooth bore gun, followed by the 9mm Luger and then by the .22 Long Rifle. In homicides, the caliber most frequently used was the 7.62 × 39 (29.6%), followed by the 9mm Luger (29%) and lastly by hunting calibers (27%). More than 10% of cases involved two weapons of two different calibers. Our study, which used a dual forensic and ballistic approach, was carried out in one of the most heavily populated regions of metropolitan France. We observed very few similarities with the literature regarding type of caliber and wound complexes. This may be explained, among other factors, by differences in political, societal or cultural contexts.

Post-mortem imaging has become more frequently used in forensic procedures, notably in a ballistic context. Despite many advances in this field, the interpretation of computed tomography (CT) can be a very complex matter. Our case illustrates the difficulties of interpretation after quasi-tangential cranial ballistic impact and keyhole wounds. These wounds are difficult to visualize on CT and are among the factors complicating the precise determination of ballistics. These sources of error remind us that CT findings must be interpreted in close comparison with autopsy findings.

Resume Le syndrome de la mort inattendue du nourrisson (MIN) est defini selon la Haute Autorite de sante (HAS) comme « une mort survenant brutalement chez un nourrisson alors que rien, dans ses antecedents connus, ne pouvait le laisser prevoir ». Il s’agit d’un diagnostic d’exclusion. Il existe de grandes disparites interregionales tant d’un point de vue epidemiologique que dans la prise en charge des MIN malgre les recommandations professionnelles etablies par la HAS en fevrier 2007. Pour l’examen de l’encephale, les consignes de la HAS sont peu adaptees a la pratique courante et de recherche. Le role du pathologiste, comme tout intervenant dans le cadre des MIN, est d’eliminer un traumatisme en particulier en lien avec une maltraitance et de determiner la cause du deces. Les lesions neuropathologiques majeures par definition n’existent pas. Les lesions d’hypoxie/ischemie sont les plus frequentes et sont peu specifiques. L’accessibilite de l’immunomarquage anti-APP a permis de souligner le role de l’anoxie dans l’apparition des lesions axonales diffuses. De nombreuses etudes recherchent un substratum neurologique de la MIN (neuropathologiques et/ou neurobiochimiques). Cet article a pour objectif de definir un protocole de prelevement detaille a partir de consensus etrangers et des donnees actuelles de la science afin d’aider les anatomopathologistes et de favoriser une banque de donnees homogenes en France.

Resume Lors de deces par balle, les experts en medecine legale et balistique sont tenus de soumettre des informations precises et clairement comprehensibles aux autorites judiciaires, dont le personnel doit etre considere comme novice dans le domaine. En quelques annees, la tomodensitometrie (TDM) post-mortem pre-autopsique est devenue non seulement la technique de choix pour la localisation multiplanaire de la balle, mais aussi pour etablir les aspects dynamiques de la blessure, sans modification de l’etat du corps qui peut donc etre reconstruit en trois dimensions (Thali et al., 2003, 2005 ; Yen et al., 2004 ; Campana et al., 2016 ; Ebert et al., 2014).

Resume Environ 40 000 cas de mort subite sont enregistres en France chaque annee, le plus frequemment d’origine cardiaque. Si les cardiopathies ischemiques en constituent l’etiologie la plus frequente au-dela de 35 ans, les cardiomyopathies constitutives et les canalopathies sont responsables d’un nombre important de deces chez le sujet jeune. Certaines pathologies acquises peuvent egalement entrainer des morts subites cardiaques. Nous rapportons ici l’observation d’un jeune homme de 17 ans victime d’une mort subite au decours d’une activite sportive. L’autopsie et l’etude anatomopathologique retrouvaient un cœur pathologique siege d’anevrysmes coronariens geants remanies et thromboses associes a des foyers fibreux myocardiques cicatriciels d’episodes ischemiques, l’ensemble etant en faveur de sequelles d’une maladie de Kawasaki. La maladie de Kawasaki constitue une etiologie rare, mais non exceptionnelle de mort subite d’origine cardiaque chez le sujet jeune. En l’absence d’antecedent connu, certains aspects morphologiques, bien que non specifiques, peuvent faire evoquer ce diagnostic. Meme face a une bonne tolerance clinique apparente de ces sequelles, un suivi cardiaque est indispensable devant le risque non negligeable de mort subite.

The presence of fracture on neck elements is an indication of violence. Both the hyoid bone and the larynx can be damaged by a strangulation mechanism. Thyroid cartilage, more specifically, may present lesions in response to this mechanical stress. These lesions result in fractures at the bases of the horns of the thyroid cartilage. This study focuses on the thyroid cartilage behavior in cases of bi-digital strangulation, using an anthropometric and biomechanical approach. To develop a biomechanical model, we performed an anthropometric study taking into account 14 distances measurements as well as 3 measurements of angles. These measures allowed us to determine a significant sexual dimorphism between individuals. Then, we define 6 morphologies models, composed of 3 females and 3 males individuals. In order to visualize the ossification of the cartilage, each model has been tested with bone properties. Strangulation cases were simulated by applying an imposed velocity of 0.4m/s then 1m/s. We observed different behaviors of the thyroid cartilage according to the sex and the morphology.

Brain and cervical injuries are often described after major facial impacts but rarely after low-intensity mandibular impacts. Force transmission to the brain and spinal cord from a mandibular impact such as a punch was evaluated by the creation and validation of a complete finite element model of the head and neck. Anteroposterior uppercut impacts on the jaw were associated with considerable extension and strong stresses at the junction of the brainstem and spinal cord. Hook punch impacts transmitted forces directly to the brainstem and the spinal cord without extension of the spinal cord. Deaths after this type of blow with no observed histological lesions may be related to excessive stressing of the brainstem, through which pass the sensory-motor pathways and the vagus nerve and which is the regulatory center of the major vegetative functions. Biological parameters are different in each individual, and by using digital modeling they can be modulated at will (jaw shape, dentition…) for a realistic approach to forensic applications.

Nosocomial infections have become a major issue of public health and lead to an increasing number of suits for damages. We present a rare case of Aspergillus contamination during cardiac surgery, describe the medicolegal investigation, and present the new system for compensation of bodily injury after nosocomial infection in France, based on the law of March 4, 2002 on patient rights and quality in the health system. This case demonstrates the limits of compensation for nosocomial infections on the grounds of national solidarity. The expert report requested by the regional commission for conciliation and compensation is of fundamental importance in enabling the commission to decide between fault and inherent risk of treatment.

Background Bariatric surgery for severe obesity has become an effective and accepted treatment for sustained weight loss. Objectives The aim of our study was to analyze the complications and issues raised by the experts on which jury or judges' decisions were made for the different types of bariatric surgery. Setting University Hospital, France. Materials and Methods We have carried out a retrospective study of 59 expert review dossiers over a period of 15 years (1999–2014) on the different types of bariatric surgery (laparoscopic adjustable gastric band [LAGB], sleeve gastrectomy [SG], Roux-en-Y gastric bypass [RYGB], vertical banded gastroplasty [VBG], and gastric plication [GP]). Results Of the cases, 81% were women and the average age was 39 years old (range 19 to 68 years). Among the procedures giving rise to the complaints, 40% were for LAGB, 28% for RYGB, and 23% for SG. The most common initial complications were perforations (30%), fistulae (27%), bowel obstruction (14%), vascular injuries (9.5%), and infections (peritonitis, pleurisy, abscesses, and so forth) (8%). Revision surgery was required in 78% of patients, and perioperative complications accounted for 28.5% of dossiers. The experts concluded that fault had occurred in 40% of case. Negligence arising from an error deemed to be an act of negligence was found in 30% of cases, 67% of which were because of delayed diagnosis. Major long-term complications accounted for 8% of dossiers and minor long-term complications for 22%. Forty-seven percent of patients completely recovered. Conclusion Delayed diagnosis was the main error established by the experts. Surgeons should remain vigilant postoperatively after every bariatric surgical procedure.

Background: Although the incidence of sudden unexpected infant death (SUID) has decreased since the ‘Back to Sleep’ campaign in English-speaking countries and other preventive campaigns, the circum...

Resume Les champs d’application de l’imagerie post-mortem sont en croissance exponentielle depuis 10 ans. Son potentiel pour identifier la cause du deces dans des situations traumatiques et balistiques est maintenant correctement documente. Dans la pratique pediatrique et perinatale, des grandes series sont moins nombreuses, sauf pour l’IRM et en particulier l’analyse du systeme nerveux central ou les preuves scientifiques sont maintenant robustes. Apres un bref rappel historique et l’analyse de l’etat de l’art, nous allons essayer de decrire les defis actuels et la facon dont nous voyons l’avenir de cette sur-specialite de l’imagerie en coupe post-mortem, en particulier dans les situations specifiques a la perinatalite.

Resume Introduction Face a la frequence croissante des plaintes pour agression sexuelle, la prise en charge des victimes doit etre de qualite. L’examen genital est de realisation difficile en particulier chez l’enfant, cependant c’est un element cle du diagnostic. Observation Des attouchements sexuels ont ete suspectes sur des jumelles de deux ans et demi. Les examens realises initialement sur l’une d’elles avaient identifie des micro-hematomes vulvaires, des lesions de depigmentation, des levres discretement sclereuses et atrophiques et un debut de lichenification. L’autre jumelle presentait une lesion erythemateuse aspecifique de la grande levre. L’eviction du milieu suppose dangereux et une consultation a distance ont permis de montrer une evolution infirmant l’hypothese initiale et l’etablissement du diagnostic de lichen sclereux atrophique vulvaire. Discussion La coexistence d’allegations et de lesions des regions genitales tend a soutenir l’hypothese de violences physiques a caractere sexuel. Cependant, des dermatoses a tropisme genito-anal peuvent mimer des lesions traumatiques. Un exemple est le lichen sclereux, souvent meconnu des praticiens. Ce cas clinique montre que la temporisation et la pluridisciplinarite des avis peuvent permettre de proposer un diagnostic differentiel. Il faut toutefois rappeler que l’identification d’une affection expliquant les lesions ne permet pas de rejeter les dires d’enfants concernant des gestes a caractere potentiellement sexuel dont l’etablissement de la realite et l’identification de l’auteur restent du ressort de la justice.

Purpose To study the feasibility of perinatal post-mortem computed tomography angiography (PMCTA) and to evaluate the informations provided. Material and methods From January to March 2014, we included all fetuses referred to our fetopathology unit for intra-uterine fetal death or termination (IUFD) or pregnancy (TOP). We noted sex, gestational age in weeks׳ gestation (WG) at referral, and reason for TOP. All bodies were scanned with the same CT device using the same protocol, before and after contrast injection. We analyzed the success rate of the injection, the quality of vascular filling and the informations provided compared to prenatal data and confirmed by standard autopsy for all patients. Results We prospectively included 17 consecutive attempts of PMCTA in fetuses aged 16–37 WG (mean 28), 9 were male and 8 were female, originating from intra-uterine fetal death ( n =4, 23.5%) or termination of pregnancy ( n =13, 76.5%). Injection failed in 4 cases (23%). In the 13 successful others (77%), injection was quoted sub-optimal in 2 cases (15%). Overall, additional informations were provided by PMCTA in 5 cases (29%), meaning 38% of cases when injection was successful. Conclusion Perinatal PMCTA is feasible and provides additional data compared to prenatal imaging. We strongly believe it is a very promising technique, especially in association with ultrasound, more or less dedicated brain MRI.

International audience; The ready availability of butane makes butane abuse frequent. Fatalities are rare. This study presents two cases of death by butane overdose. The postmortem analyses were carried out using headspace gas chromatography-mass spectrometry. It revealed femoral blood butane concentrations of 18 and 22 mg/L, respectively, as well as specific combinations of adjuvants in each victim. In one of the victims, brain and fatty tissue also contained butane, pointing to chronic consumption. The originality of this study is to show that the identification of specific combinations of adjuvants can be helpful for identifying the brand of deodorant used. Also, sampling the skin and mucosa can help identify the method of drug delivery. The histological examination documented both the direct toxic effect of the gas on the respiratory mucosa and signs of chronic abuse. Volatile substance intoxications should be systematically considered in case of sudden death in a teenager.

International audience; During legal proceedings following the unexpected death of an infant, the magistrate calls on an expert to clarify the causes of death and to decide on the course to be taken. A report was made following the death of a 7-month-old baby girl after recovery from cardiac arrest when investigations of the cause revealed a subdural hematoma (SDH). We discuss the interconnection of these two entities and their role in the lethal process. In this infant, two distinct lesions with medicolegal implications were simultaneously present: on the one hand histiocytoid cardiopathy, and on the other hand SDH, which could result from ill-treatment. The case of this infant reminds us that the role of the pediatrician is to report the suspicion, whereas the role of the medical expert is to inform the magistrate as to the reality of abuse and its implication in the lethal process.

Forensic medicine has always used radiographic techniques, and interested readers may also want to consult the “Autopsy and Histological Findings” chapter for more about the post-mortem context. For over a decade now, forensic medicine has been taking advantage of the new cross-sectional imaging modalities (ultrasound and especially CT and MRI). In virtual autopsy, one or more of these imaging techniques is performed prior to autopsy to prepare, guide, and facilitate the work of medical examiners in determining the cause of death. Post-mortem imaging is playing an increasingly important role, particularly in the field of suspected or confirmed abuse. However, familiarity with normal post-mortem changes on imaging—which can be diagnostically misleading—is essential.

According to the French High Authority for Health, sudden unexpected death in infants (SUDI) is defined as "a sudden death that occurs in an infant, whereas nothing in its known history could have predicted it". This is an exclusion diagnosis. There are great interregional disparities despite the professional recommendations established in February 2007. For the examination of the brain, instructions are not adapted to current and research practice. The role of the pathologist, like anyone involved in SUDI, is to eliminate an abuse head trauma and to determine the cause of death. Major neuropathological lesions by definition do not exist. Lesions of hypoxia/ischemia are the most frequent but not specific. The accessibility of anti-APP immunoblotting has highlighted the role of anoxia in the development of axonal diffuse damages. Many studies are looking for a neurological substratum of the SUDI (neuropathological and/or neurobiochinic). This article aims to define a detailed sampling protocol based on foreign consensus and current data of science in order to assist pathologists and to promote a homogeneous data bank in France.

The aim of postmortem medicolegal examination in pediatric death is primarily to establish the circumstances and causes of death and to exclude child abuse. In France, pediatric death is systematically documented by medicolegal or medical autopsy. In case of medicolegal autopsy, the complementary examinations, requested and financed by justice, are rarely limited to a histopathological examination. However in medical autopsies other tools are available to the pathologist as toxicology, biochemistry and molecular biology. The purpose of this article is to evaluate the efficacy of forensic histopathology in pediatric forensic autopsies. We analyze the main causes of pediatric death in a forensic context. Between 2004 and 2015, 157 infant deaths were identified in Marseille university hospital. The forensic histopathology and autopsy reports of all 157 cases were available for systematic review. Medical or surgical causes represented 41,3% of deaths in our center, accidental causes 8.1% and child abuse 28,8%. The definitive diagnosis was made at autopsy in 30% of cases and at histopathological examination in 70% highlighting that forensic histopathology is an indispensable tool in pediatric medicolegal autopsies. Significant histological abnormalities may be detected in selected organs such as the brain, lungs, heart, liver, adrenal glands and kidneys in spite of macroscopically normal appearances. This justifies systematic sampling of all organs. Despite the implementation of the French sudden infant death protocol which recommends medical autopsies, too many pediatric autopsies are carried out in a medicolegal context. 30% of the cases remain without diagnosis at the end of the autopsy and histological examination. This number could be reduced by the contribution of others laboratory investigation.

The act to transfuse is a prescription following basic rules similar to drug prescriptions. If harm happens, potentially linked with this prescription, the harm's responsibility is borne by the physician, the paramedics, the care organization but by the supplier laboratory too. The setting of good practice rules consistent with science data at the time when the act is performed, the respect of the patient's rights and the quality of supplied products will be assessed during the expertise. Under restorative responsibility, it is necessary to previously establish a direct and certain causation between the litigious act and the harm to enforce the vicarious liability. Nowadays, legal precedents grant a larger protection to more and more numerous victims, enhancing the field of the fault with the appeal to assumption of fault. At the same time, the lawmaker himself promulgated objective conditions of compensation for many categories of victims of medical risk from which transfused people are part. The law of March the 4th of 2002 went one step closer devoting a new foundation of compensation: national solidarity.

OBJECTIVE. The purpose of our study was to define the postmortem CT semiology of gas collections linked to putrefaction, postmortem "off-gassing," and decompression illness after fatal diving accidents and to establish postmortem CT diagnostic criteria to distinguish the different causes of death in diving. SUBJECTS AND METHODS. A 4-year prospective study was conducted including cases of death during diving. A hyperbaric physician analyzed the circumstances of death and the dive profile, and an autopsy was performed. Subjects were divided into three groups according to the analysis from their dive profile: decompression illness, death after decompression dive without decompression illness, and death after nondecompression dive without decompression illness. Full-body postmortem CT was performed before autopsy. RESULTS. The presence of intraarterial gas associated with death by decompression illness had a negative predictive value (NPV) of 100%, but the positive predictive value (PPV) was only 54% because of postmortem off-gassing. The PPV reached 70% when considering pneumatization of the supraaortic trunks. Pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not specific for decompression illness. CONCLUSION. This study is the first to show that pneumothorax, subcutaneous emphysema, and intraarterial gas, all of which are classic criteria for decompression illness diagnosis, are not specific for decompression illness. Complete pneumatization of supraaortic trunks is the best postmortem CT criteria to detect a fatal decompression illness when CT is performed within 24 hours after death.

Resume Fixer une duree d’incapacite totale de travail est un acte medico-legal auquel tout medecin doit pouvoir repondre. Compte tenu de l’importance des consequences juridiques de cette evaluation, il parait souhaitable que cette pratique soit parfaitement maitrisee par tous les praticiens. Cependant, dans la pratique quotidienne des unites medico-legales, une disparite est souvent relevee entre les evaluations des medecins legistes et les evaluations fournies par d’autres praticiens. Pour evaluer cette difference d’evaluation, nous avons realise une etude retrospective, sur 4 annees d’archives, de dossiers de victimes du service de medecine legale de Marseille (CHU Timone), et mis en evidence une disparite entre les evaluations des medecins legistes, des medecins generalistes et des urgentistes. Que ce soit pour les comparaisons d’evaluation entre les medecins legistes versus les medecins generalistes (n = 367) ou celles des medecins legistes versus les medecins urgentistes (n = 511) on retrouve dans un tiers des cas une requalification medico-legale. Pour les evaluations des medecins generalistes la majorite (80 %) de ces evaluations etaient determinees a plus de 8 jours initialement et ont ete reevaluees sous cette limite par un medecin legiste. Cette tendance s’inverse pour la majorite des cas (61 %) de requalification des evaluations d’urgentistes (evaluation a plus de 8 jours par les medecins legistes. Cette etude, prouvant un fait longtemps suspecte, souleve de nombreux questionnement quant a ces disparites d’evaluation que nous avons discutees.

Resume L’examen de personnes se declarant victime d’une agression sexuelle est une situation frequemment rencontree dans les unites medico-judiciaires. Cette etude se basait sur 592 examens de victimes de viol acceptant un examen complet, entre 2003 et 2013 a l’unite medico-judiciaire de Marseille. Les victimes etaient examinees sur requisition judiciaire par des medecins legistes formes a l’examen des victimes de viol. Plus de 90 % des cas concernaient des victimes feminines. L’âge moyen des victimes de viol etait de 25,8 ans avec une mediane a 22 ans (ecart-type = 12,93). Concernant les 44 victimes masculines l’âge moyen etait de 17,9 ans avec une mediane a 14,5 (ecart-type = 12,35). Des antecedents d’agression sexuelle etaient retrouves chez 2 % des victimes. La presence d’une pathologie psychiatrique (« etat vulnerable ») etait retrouvee chez 7,6 % des victimes. Le viol etait le fait d’un seul individu dans 84 % des cas et d’un proche de la victime (famille, conjoint ou ex-conjoint) dans 28 % des cas. Dans 7 % des cas ( n = 43), l’agresseur etait un membre de la famille. Chez les victimes feminines, le type de viol le plus frequemment retrouve etait la penetration penio-vaginale avec 64,9 % des cas. La penetration penio-anale et la penetration penio-buccale etaient decrites dans respectivement 26 % et 23,9 % des cas. L’utilisation d’une arme etait evoquee dans 9 % des cas. Une augmentation croissante des cas de viol apres une rencontre via Internet etait notable. La majorite des victimes ne presentait pas de lesion, cependant dans 1 cas sur 5, des lesions de la sphere genito-anale etaient retrouvees. Chez les femmes, pour la region genitale, ces lesions concernaient preferentiellement l’hymen suivi de la fourchette vulvaire posterieure puis les petites levres. L’etude des lesions extra-genitales mettait en evidence une predominance des lesions du visage et de l’extremite des membres superieurs mais egalement des violences plus importantes au niveau de la poitrine. Le lien statistique entre les lesions gyneco-anales et les lesions sur le reste du corps n’a pas ete demontre. Aucun resultat statistiquement significatif n’a ete demontre entre l’absence de lesion et le nombre d’agresseur ou entre la presence de lesion et le statut de l’agresseur (proche ou inconnu). Seule la presence d’une arme lors de l’agression etait statistiquement associee a la presence de lesions extra-genitale. Notre etude apporte un interet epidemiologique et clinique. Elle permet de confirmer certaines donnees statistiques et d’en inclure de nouvelles grâce a des donnees epidemiologiques trop peu utilisees que constituent les donnees recueillies lors des actes medico-legaux.

Resume En France, en cas de coups et blessures volontaires ou involontaires, il est demande au medecin d’evaluer les consequences de ces agressions en estimant l’Incapacite Totale de Travail (ITT) liee a celles-ci et de rediger un certificat medical descriptif. L’objectif de notre etude residait dans l’analyse des attentes de la justice en matiere d’evaluation de la duree d’ITT. Materiel et methode Des entretiens individuels ont ete conduits au cours de l’annee 2013 aupres de magistrats, officiers de police judiciaire et avocats penalistes acceptant de participer a notre etude. Ils ont ete guides par un questionnaire standardise repondant a trois categories : la qualification medicale du professionnel redigeant le certificat, la redaction et l’interpretation de ce certificat, et enfin l’utilite reelle pour la justice de cet outil d’evaluation. Resultats Quatre-vingt-deux personnes ont repondu a nos questions : 31 magistrats, 46 enqueteurs et 15 avocats. L’ensemble des participants s’accordait sur le fait que l’ITT devait etre fixee par un medecin titulaire d’un diplome de medecine legale. L’estimation de l’ITT est jugee comme un exercice difficile qui implique legalement son auteur. Ce qui d’apres les reponses ne semble pas etre assez pris en compte par les medecins. Les elements devant etre mentionnes dans le certificat sont discordants selon les participants. Les magistrats rappellent que le medecin doit decrire uniquement les lesions constatees et fixer l’ITT le plus precisement possible. L’ITT est jugee comme un outil peu adapte mais empirique. Conclusion Cette etude a mis en evidence les attentes differentes et les utilisations particulieres du certificat medical, par chaque profession impliquee.

A 58-year-old man died suddenly in Madagascar and poisoning was suspected. The body was embalmed after death and the general state of preservation was good. We found a major aortic dissection with a large false lumen from the aortic root to the common iliac arteries and a hemopericardium with formalinized blood clot. The intimal tear was on the ascending aorta, and an intramural hemorrhage was noted at the right coronary artery, attesting to a retrograde dissection. Microscopic studies confirmed aortic dissection with extensive intramural hemorrhage and also confirmed the retrograde dissection to the right coronary artery with a reduction of 90% of the true lumen. Classically, aortic dissection occurs in individuals with hypertension and individuals with genetic disorders of collagen formation. The diagnosis is often first established at the postmortem examination. Aortic dissection is therefore dealt with largely in necropsy studies. The usual cause of death is rupture into the pericardial sac. One case of bloodless dissection has been reported but the sudden death was explained by acute myocardial ischemia secondary to dissection of the left coronary artery. In our case, we found major hemopericardium and also intramural hemorrhage at the right coronary artery. We were able to make the diagnosis of aortic dissection and exclude the suspicion of homicide 15 days after death and after embalming.

Resume La mise en evidence de lesions cutaneo-muqueuses, causees par un agent traumatique sur une personne identifiee comme victime, constitue pour le magistrat un argument en faveur de la realite d’une agression. Le but de cette etude est faciliter la visualisation des lesions de l’epithelium humain sur le vivant et en post mortem grâce a une application de fluoresceine et observation sous eclairage ultra-violet (UV). Cette technique est deja employee en medecine veterinaire pour detecter des lesions traumatiques sur des poissons par immersion de ces derniers dans des bains contenant jusqu’a 0,20 mg de fluoresceine par millilitre. La fluoresceine, produit couramment employe en ophtalmologie pour la mise en evidence des lesions de cornee, trouve ici une application certes voisine mais inedite sur les lesions cutaneo-muqueuses peut visible a l’œil nu chez les victimes de viol ainsi que sur l’observation de lesion sur les corps en autopsie. Du fait de l’accessibilite de la fluoresceine en milieu hospitalier et de son faible cout ce produit offre un confort d’emploi non negligeable pour tout intervenant lors d’une expertise medico-legale de violence sexuelle ou lors d’une autopsie. De plus, les proprietes physico-chimiques de la fluoresceine permettent une utilisation sans risque pour le patient examine et une innocuite sur les differents prelevements en vue d’une analyse ADN.

ObjectivesThis study sought to analyze whether the plasmatic level of leukocyte-derived microparticles (LMP) is associated with unstable plaques in patients with high-grade carotid stenosis.BackgroundPreventive carotid surgery in asymptomatic patients is currently debated given the improvement of medical therapy. Therefore, noninvasive biomarkers that can predict plaque instability are needed. The LMPs, originating from activated or apoptotic leukocytes, are the major microparticle (MP) subset in human carotid plaque extracts.MethodsForty-two patients with >70% carotid stenosis were enrolled. Using a new standardized high-sensitivity flow cytometry assay, LMPs were measured before thromboendarterectomy. The removed plaques were characterized as stable or unstable using histological analysis according to the American Heart Association criteria. The LMP levels were analyzed according to the plaque morphology.ResultsThe median LMP levels were significantly higher in patients with unstable plaque (n = 28; CD11bCD66b+ MP/μl 240 [25th to 75th percentile: 147 to 394], and CD15+ MP/μl 147 [60 to 335]) compared to patients with stable plaque (16 [0 to 234] and 55 [36 to 157]; p < 0.001 and p < 0.01, respectively). The increase in LMP levels was also significant when considering only the group of asymptomatic patients with unstable plaque (n = 10; CD11bCD66b+ MP/μl 199 [153 to 410] and CD15+ MP/μl 78 [56 to 258] compared with patients with stable plaque (n = 14; 20 [0 to 251] and 55 [34 to 102]; p < 0.05 and p < 0.05, respectively). After logistic regression, the neurologic symptoms (odds ratio: 48.7, 95% confidence interval: 3.0 to 788, p < 0.01) and the level of CD11bCD66b+ MPs (odds ratio: 24.4, 95% confidence interval: 2.4 to 245, p < 0.01) independently predicted plaque instability.ConclusionsLMP constitute a promising biomarker associated with plaque vulnerability in patients with high-grade carotid stenosis. These data provide clues for identifying asymptomatic subjects that are most at risk of neurologic events.

Hydrogen sulfide (H(2)S) poisonings are classically reported in occupational settings. We describe an unusual domestic case of fatal acute poisoning by H(2)S inhalation. A mother and her infant daughter were found dead in the kitchen of their home. The emergency medical team described a strong smell of rotten eggs, suggesting acute H(2)S poisoning. Autopsies revealed only multiorgan congestion. H(2) S was measured in blood and lung tissue samples by gas chromatography/mass spectrometry. Body fluids were negative, but H(2) S was found in the lungs of both the mother and the child at concentrations of 1.46 and 1.92 mg/kg, respectively, concentrations described in the literature as potentially lethal. Expert surveys of the premises suggested a complex mechanism involving both defective maintenance of the pipes and drains of the building and faulty assembly of the sink siphon, which led to stagnation of waste water and formation of a pocket of H(2)S.

Resume Nous rapportons le cas d’une jeune femme sans antecedent, d’origine senegalaise, decedee brutalement devant temoin et dont l’autopsie permit de reveler une thrombose aigue du tronc brachio-cephalique sur reduction luminale d’amont, conduisant a une defaillance cardiovasculaire. L’analyse histologique des differents organes a permis de mettre en evidence une granulomatose inflammatoire pan-parietale subclaviere bilaterale et des granulomes epithelio-giganto-cellulaires sur le foie et les poumons, permettant de retenir le diagnostic de sarcoidose. L’atteinte vasculaire d’une sarcoidose est exceptionnellement decrite dans la litterature et son lien avec une vascularite de Takayasu est discute. Cette observation exceptionnelle rappelle l’interet de dissequer entierement l’arc aortique, notamment les branches subclavieres et c’est une nouvelle fois l’occasion de souligner l’apport de l’autopsie dans la comprehension de la pathogenie de certaines affections.

Objective To test plasma levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) in patients with high-grade carotid stenosis according to plaque histology. Methods This cross-sectional single-centre study included patients with ≥70% North American Symptomatic Carotid Endarterectomy Trial (NASCET) carotid stenosis, who were treated surgically. Serum Lp-PLA2 and high-sensitivity C-reactive protein (hs-CRP) were determined on the day of surgery. Histopathological analysis classified carotid plaque as stable or unstable, according to AHA classification. Results Of the 42 patients (mean age 70.4 ± 10.5 years; 67% men), neurological symptoms were present in 16 (38%). Unstable plaques were found in 23 (55%). Median plasma level of Lp-PLA2 was significantly higher in patients with unstable plaque compared to those with stable plaque (222.4 (174.9–437.5) interquartile range (IQR) 63.5 vs. 211.1 (174.9–270.6) IQR 37.2 ng ml−1; p = 0.02). Moreover, median Lp-PLA2 level were higher in asymptomatic patients with unstable plaque (226.8 ng ml−1 (174.9–437.5) IQR 76.8) vs. stable plaque (206.9 ng ml−1 (174.9–270.6) IQR 33.7; p = 0.16). Logistic regression showed that only the neurological symptoms (OR = 30.9 (3.7–244.6); p

A 39-year-old woman was found dead at home. She was single, foreign national, chronic alcoholic, and had given shelter to a compatriot for three days. This man found the deceased in her bed, after a night of heavy drinking. The emergency medical team observed numerous recent blue ecchymoses of the upper limbs. Because of the unclear circumstances, a medicolegal autopsy was ordered by the public prosecutor. Massive hemoperitoneum was diagnosed with no visible internal traumatic injury. Autopsy revealed hepatic and pancreatic abnormalities secondary to chronic alcoholism, which were confirmed by pathological study. The source of the hemoperitoneum was not identified despite careful visceral and vascular examination. The authors concluded that death was secondary to idiopathic spontaneous hemoperitoneum or abdominal apoplexy. The forensic literature on unexpected death due to massive nontraumatic intra-abdominal hemorrhage in association with liver cirrhosis is sparse, with only five cases reported, including the present case.

Resume La cardiomyopathie histiocytoide est une affection rare. L’affection atteint classiquement les nourrissons de sexe feminin. Nous rapportons deux observations concernant deux nourrissons âges de 11 et 15 mois presentant respectivement une tachycardie ventriculaire decouverte dans les suites d’une perte de connaissance et une fibrillation ventriculaire dans les suites d’un arret cardiorespiratoire brutal sans prodrome, avec lesions cerebrales anoxo-ischemiques graves. Le bilan etiologique ne revelait qu’une cardiomegalie moderee et seuls l’autopsie couplee a l’examen microscopique ont permis de porter le diagnostic. De plus dans la premiere observation, une agenesie du corps calleux etait decouverte.

Resume La pancreatite aigue (PA) post-traumatique est classiquement decrite dans des contextes de traumatismes abdominaux fermes responsables de lacerations ou de section complete de la glande sur le billot rachidien. Cette complication n’est pas habituelle dans le cadre de lesion abdominale penetrante par arme blanche. Nous rapportons le cas d’un homme de 46 ans decede suite a une pancreatite aigue necrotico-hemorragique post-traumatique, consecutive a un traumatisme abdominal penetrant par un coup de hache. Lors de l’exploration chirurgicale initiale, seule une lesion de la veine mesenterique superieure par dilaceration etait retrouvee avec un aspect normal du pancreas. L’evolution vers la PA s’est faite des le second jour entrainant le deces du patient au 20 e jour post-traumatique dans un tableau de defaillance multiviscerale. L’autopsie medicolegale retrouvait d’importantes lesions de PA necrotico-hemorragique, confirmees par l’examen anatomopathologique. Il n’existait, par ailleurs, aucune lesion pouvant faire evoquer un etat anterieur de pathologie pancreatique. En conclusion, cette observation montre que les traumatismes abdominaux penetrants par arme blanche peuvent s’accompagner, a l’image des traumatismes fermes, d’un mecanisme d’impact brutal du pancreas sur le billot rachidien, lie a la force de l’agresseur et au poids de l’arme, et etre responsables de lesions pancreatiques letales.

The success of high-dose buprenorphine (HDB) as substitution therapy for major opioid dependence is related to its partial agonist effect on opioid receptors, which in theory makes it very safe to use. However, numerous deaths directly attributable to buprenorphine have been described in the literature. These deaths are generally related to misuse of HDB with intravenous administration and/or concomitant use of benzodiazepines, and they usually occur in patients on HDB substitution therapy for opioid dependence. We present three deaths attributed to HDB which arose from uncommon mechanisms and led to unusual forensic situations. The first death was that of a patient admitted to hospital after simultaneous prescription of HDB, clonazepam, oxazepam, and cyamemazine. The second death followed forcible administration of a very low dose of HDB to a patient with post-hepatitis C cirrhosis and heart failure. The third death was subsequent to an HDB overdose, probably with suicidal intent, in a young woman who had not been prescribed the drug as opiate substitute. Such deaths raise the question of the mechanisms involved and draw attention to the resulting unusual forensic situations.

Objectifs : Les auteurs rapportent un cas inhabituel d’intoxication aigue par inhalation d’hydrogene sulfure (H2 S) en milieu domestique. Patients et methodes : Une mere et sa fille de 9 mois sont retrouvees mortes dans la cuisine de leur domicile, pres de l’evier au bord duquel se trouve une ventouse. Les temoins et les pompiers decrivent une forte odeur d’œuf pourri qui oriente rapidement les recherches vers une intoxication aigue par l’H2 S. Les autopsies ne revelent qu’une congestion polyviscerale. L’H2 S est recherche dans les echantillons de sang et de poumon par chromatographie en phase gazeuse couplee a un spectrometre de masse avec introduction par espace de tete. Resultats : La recherche est negative dans les liquides biologiques, mais l’H2 S est mis en evidence dans les poumons de la mere et de l’enfant a des concentrations respectives de 1,46 et 1,92 mg/kg, soit des concentrations decrites dans la litterature comme potentiellement letales. Conclusion : Ce cas demontre que l’H2 S peut etre implique dans des intoxications domestiques et que le dosage de l’H2 S dans le tissu pulmonaire s’avere utile lorsque les concentrations sanguines sont dans les limites de la normale.