Search

To describe and model the normal growth of fetal facial bones and angles.A total of 118 fetal CT scans obtained at 19 to 41 weeks gestation after in utero fetal death or late miscarriage were analyzed. CT scan was followed by autopsy and pathological examination and only fetuses free from brain disease or abnormal craniofacial development were included. The measurements were taken using software for frontal, sagittal and 3D reconstruction from native axial sections. The optimal plane for bone analysis was chosen and the measurements made by multiplanar reconstruction.There was a statistically significant increase (P0.001) in all measurements regardless of gestational age (GA) except those of the mandibulo-fronto-maxillary angle (P=0.412), the naso-mandibulo-maxillary angle (P=0.828) and mandibular width (P=0.86). There was no significant difference according to fetal sex. Based on these results, the corresponding growth curves were created. The anteroposterior mandibular diameter (APD) was very strongly correlated with GA (R=0.926, P0.001). The following equation: GA=(8.187×APD)+4.257 can be used to estimate GA with a confidence interval (CI) of±2.42. The same applies to maxillary width (MW) (R=0.922; P0.001). The equation GA=(11.059×MW)+7.571 can be used to estimate GA with a CI of 2.17.The growth of the mandible, maxilla, zygomatic bone and orbits was measured and the corresponding growth curves were established. Several measurements were strongly correlated with gestational age.

The criminal psychiatric assessment in France seems to be facing growing criticism related to disagreements between experts and, on the other hand, a lack of interest of psychiatrists for the assessment. We start by explaining the current framework of the criminal psychiatric assessment in France, which differs from the assessment used in English-speaking countries, where Roman law applies. Then, we will describe the disagreements through a literature review and two clinical vignettes. Finally, we will try to understand the causes of discrepancies between experts and the reasons for a supposed lack of interest of the psychiatrists for the expertise. For this, we conducted a survey among the psychiatric experts. We individually questioned experts on the discrepancies and on their awareness of the expertise. We found that 75% of the experts we surveyed had already faced the divergent opinion of a colleague. In addition, the experts were divided on their conclusions related to the fictional scenario we gave them for an a priori assessment (a person with schizophrenia who was accused of murder), particularly in the specific contexts that we submitted to them. The main cause of disagreement between experts was the various schools of thought that influence the psychiatric experts in the forensic discussion and, therefore, the conclusions of a case. Moreover, the experts believed that the decrease in the number of psychiatric experts could be attributed to the adverse financial situation of the assessment, the considerable workload required, and the extensive responsibility that falls on the expert. Calling on a team of forensic experts to perform assessments seems to be the first solution to this crisis. Furthermore, if the experts were better compensated for the assessments, more people would want to undertake this work.

Resume L’expertise psychiatrique penale semble aujourd’hui en France connaitre un malaise, avec des critiques de plus en plus nombreuses, portant plus particulierement sur l’existence de divergences entre les experts. Notre objectif etait de rechercher les points de divergences entre les experts, d’essayer d’en comprendre l’origine et de proposer des pistes pour essayer de les reduire. Pour cela, nous avons realise une enquete aupres des experts psychiatres de la cour d’appel d’Aix-en-Provence, a l’aide d’entretiens semi-directifs, portant sur un cadre restreint, l’expertise psychiatrique pre-sententielle des personnes schizophrenes accusees d’homicide volontaire. Nous avons mis en evidence d’importantes divergences entre les experts concernant la question de la responsabilite penale des personnes schizophrenes – pour laquelle les professionnels semblaient plutot retenir l’alternative entre abolition et alteration du discernement –, plus particulierement dans des contextes plus specifiques, comme l’arret du traitement ou la prise de toxiques au moment des faits. Les desaccords etaient lies a des ecoles de pensee differentes ou a des conceptions personnelles qui pouvaient fausser l’evaluation clinique et surtout l’interpretation medicolegale du lien entre la pathologie et les faits. Nous avons degage cinq perspectives pour reduire les divergences.

Folie a deux is a psychiatric illness involved in homicides. Objective To study the mechanisms leading to homicide and determine homicide risk factors in folie a deux patients through a literature review and the study of a complex clinical case. Materials and methods We included articles available on PubMed, ScienceDirect or Cairn that address the forensic implications of folie a deux. Then, we analyzed the criminal psychiatric assessments of two murderers (husband and wife) of a child in a case of folie a deux. Results Seventeen articles were included. In the cases examined, homicides were committed with great violence, usually against a victim in the family circle, and were sometimes followed by suicide. The main risk factor for homicide was the combination of mystical and persecutory delusions. The homicides occurred in response to destabilization of the delusional dyads. Concerning the clinical case, we described the circumstances surrounding the killing and analyzed the four expert reports that permit us to infer the occurrence of induced psychosis, which is a form of folie a deux. Discussion Psychiatrists must attain a better knowledge of folie a deux to allow early identification of risk situations and to improve their assessments

Resume Introduction L’expertise psychiatrique penale de responsabilite permet d’assurer un equilibre entre la psychiatrie et la justice. Aujourd’hui elle semble connaitre un malaise, avec des critiques de plus en plus nombreuses portant particulierement sur l’existence de divergences entre les experts, sans que des etudes specifiques n’aient ete menees pour le confirmer. Objectif Notre objectif etait de proposer une revue de la litterature sur ce sujet pour degager les principaux points de divergences et proposer des pistes explicatives. Materiel et methodes Pour cela, nous avons etudie le rapport de la commission d’audition de 2007 sur l’expertise psychiatrique penale ainsi que les contributions des differents auteurs et avons realise une recherche bibliographique sur PubMed, Cairn et Science Direct. Resultats Les divergences concernaient surtout l’interpretation medicolegale, la discussion de la relation entre la pathologie et l’infraction, plus particulierement dans des contextes qui impliquent une discussion medicolegale plus poussee, notamment l’arret des traitements medicamenteux, la prise de toxiques ou encore la negation des faits par un accuse souffrant de troubles mentaux. Il existait egalement des divergences diagnostiques et des divergences liees au concept meme d’alteration du discernement. Discussion Les desaccords semblaient lies avant tout a des conceptions personnelles ou a des courants de pensee differents qui influencaient l’interpretation et les conclusions des experts.

Resume La chirurgie de l’obesite par anneau gastrique ajustable est reconnue pour son efficacite a long terme sur la perte de poids et son faible taux de morbi-mortalite. Seulement, de graves complications peuvent parfois survenir, amenant les chirurgiens devant les tribunaux. A partir de neuf observations de complications graves souvent letales survenues sur une periode de cinq ans, nous analysons les complications et les points releves par les experts permettant la decision du juge. Cette chirurgie est consideree, a defaut, comme une intervention « benigne » ; seulement, sur les neuf cas expertises apres pose d’un anneau gastrique, cinq ont abouti au deces et quatre ont eu des consequences graves avec de nombreux prejudices, notamment de souffrances endurees, esthetiques et psychologiques. Si la perforation œsophagienne ou gastrique reste la cause principale de complications, les differents experts relevaient plusieurs points dans les dossiers qui ont permis au juge de prendre sa decision et de condamner sept chirurgiens sur neuf. Trois types de fautes ont engage la responsabilite des medecins : le defaut d’information ou des dossiers medicaux incomplets, une faute par maladresse ou suite a un retard de prise en charge secondaire a une sous-estimation des signes cliniques, et enfin le non-respect des indications. La discussion expertale est en fait le plus souvent centree par la critique du comportement dans les suites postoperatoires immediates par defaut decisionnel non conforme aux regles de l’art.

Resume Objectif Decrire le cadre juridique de la prescription des medicaments en France en 2013. Methode Avec l’aide d’experts juriste et medecins legiste enseignant en droit de la sante, consultation des textes legaux (legifrance.gouv.fr), analyse et resume de ceux-ci. Resultats La liberte de prescription du medecin est essentielle a son action, elle est encadree par la loi. Prescrire engage la responsabilite du medecin au plan deontologique, civil et penal. La prescription obeit a des regles stricte dont l’objectif principal est de preserver la securite des patients. Ce cadre legal laisse une marge de decision au medecin en insistant sur la reference aux donnees scientifiques publiees et aux recommandations des societes savantes. Conclusion Connaitre et respecter le cadre legal de la prescription des medicaments est essentiel a une pratique de qualite. Les societes savantes ont un role essentiel pour maintenir et ameliorer l’usage des medicaments.

The fields of application of post-mortem imaging have been exponentially growing for 10 years. Its potential to identify the cause of death in trauma and ballistic cases is now properly documented. In pediatric and perinatal practice, large significant series are less available, except for MRI and central nervous system analysis where scientific evidence is now robust. After a short historical and state-of-the-art review, we will try to depict the way we see the future of this sub-specialty of post-mortem imaging, especially in specific perinatal situations.

The aim of this study was to assess the value of fetal skeletal radiographs in determining the etiology of fetal death. A total of 1193 post-mortem fetal skeletal radiographs were analysed. Fetuses were classified into one of three groups (group I: abnormality diagnosed during pregnancy; group II: maternal pathology; group III: spontaneous abortion of pregnancy, IIIa before 26 weeks of gestation (WG), IIIb after 26 weeks of gestation). Face, supine and lateral skeletal views were performed. Skeletal abnormalities were detected in 33.9% of the fetuses, including 22.7% with minor abnormalities (abnormal rib number, no nasal bone ossification, amesophalangia or P2 hypoplasia of the fifth digit) and 14.5% with major abnormalities (other skeletal abnormalities). Among the fetuses with major abnormalities, 98.8% came from group I, 2.9% came from group II, 2.3% came from group IIIa and none came from group IIIb. Fetal skeletal radiographs are not useful in fetuses arising from spontaneous abortion of pregnancy without abnormality on ultrasound screening, abnormality clinical examination or in fetuses with prenatal diagnosis of chromosomal abnormality. This practice is valuable only if there is a multidisciplinary team, with all the participants (pathologists, radiologists, geneticists) knowledgeable about fetal pathology. In the absence of this multidisciplinary approach, it is easier to X-ray all fetuses to avoid misdiagnosis and the important consequences for genetic counselling.

Objectif Classiquement attribues a une depression respiratoire, les deces secondaires a une prise de methadone peuvent egalement resulter d’un trouble du rythme cardiaque. Les auteurs presentent un cas de deces chez une adolescente consommant regulierement de la methadone, pour lequel l’etude genetique a objective un polymorphisme dans le gene KCNH2 , precedemment decrit comme implique dans le syndrome du QT long chez des patients sous methadone [1] . Description Une adolescente de 14 ans, de corpulence adulte, sans antecedent notable, consomme de la methadone au cours d’une soiree. Retrouvee inconsciente dans la nuit, elle decede malgre les tentatives de reanimation entreprises par les secours. L’autopsie effectuee 48 heures plus tard revele un œdeme pulmonaire massif. Des prelevements a visees anatomopathologique et toxicologique ont ete effectues. Une meche de cheveux noire de 12 cm a ete prelevee en vertex posterieur. Methodes Les analyses ont ete effectuees dans le sang cardiaque (sang peripherique absent) et l’urine par GC-MS et LC-MS/MS. L’analyse capillaire segmentaire (4 × 3 cm) a ete realisee par LC-MS/MS. Les genes CYP2B6 , KCNE1 , KCNE2 , KCNQ1 et KCNH2 ont ete sequences. Resultats Les analyses realisees dans le sang revelent la presence de methadone a 324 μg/L et d’EDDP a 92 μg/L, soit des concentrations compatibles avec une prise therapeutique [2] . On note egalement la presence de THC (1 ng/mL), de THC-COOH (18 ng/mL), de BZE (8,6 ng/mL), d’EME (3,6 ng/mL) en faveur d’une consommation de cannabis et de cocaine dans les heures precedant le deces. L’analyse capillaire revele la presence de methadone (M) et d’EDDP (E) dans les 4 segments analyses (ng/mg) ( Tableau 1 ). De faibles concentrations de marqueurs du cannabis et de la cocaine, en faveur d’un usage occasionnel de ces produits, ont egalement ete mises en evidence dans tous les segments de cheveux. L’examen anatomopathologique a revele la presence d’une dysplasie ventriculaire arythmogene. Aucune mutation deletere n’a ete mise evidence par le sequencage des 5 genes analyses. Seul le polymorphisme rs1805123 (Lys 897 Thr) a ete identifie dans le gene KCNH2 . Conclusion L’analyse capillaire documentant des prises repetees de methadone pendant les 12 mois ayant precede le deces n’est pas en faveur de l’hypothese initiale d’une depression respiratoire secondaire a une prise de methadone chez un sujet naif. Par contre, le genotypage, en objectivant la presence du polymorphisme Lys 897 Thr dans KCNH2 , a permis de soulever l’hypothese d’un deces par trouble du rythme cardiaque provoque par la methadone. Une contribution eventuelle de la cocaine et du cannabis ne peut etre exclue. L’examen anatomopathologique, en revelant une dysplasie arythmogene du ventricule droit, a conforte cette hypothese.

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.

In France, forensic psychiatric assessment plays a central role in the relationship between psychiatry and justice. The psychiatric expert is commissioned to determine whether or not the accused has a mental disorder and to specify whether or not it affected discernment at the time of offense. Nowadays, psychiatric expertise is coming under more and more criticism, particularly regarding divergences between experts.Our objectives were to find points of divergence between experts, try to understand causes and suggest ways to try to reduce them.For this we conducted a study, between July 2012 and January 2013, with psychiatric experts of the Court of Appeal of Aix-en-Provence through semi-structured interviews. We focused on a limited context: psychiatric expertise of responsibility for schizophrenic persons accused of murder. We questioned the experts about the issue of criminal liability of a person with schizophrenia in general but also in clinical situations we thought particularly involved in disagreements.We recruited a population of 17 psychiatrists, mostly males of average age of 58 years, working mostly in the department of adult psychiatry of a hospital. We highlighted the differences between the experts, first with regards to the issue of liability in general. Experts divided seemed to keep in majority (52.9 %) the alternative between abolition and alteration of discernment when faced with a schizophrenic person accused of murder. The differences were even more pronounced in specific contexts. Thus, the fact that the person had suffered from delirium at the time of the offense led half of the experts (47.1 %) to conclude a systematic abolition of discernment, while the other half made such a conclusion when the delirium was directly linked to the facts. Discontinuation of neuroleptic treatment, drug abuse or existence of premeditation changed the conclusions of the experts in half the cases, more in the sense of an increased accountability in the cases of drug abuse or premeditation, and in the direction of a reduction of liability in case of cessation of treatment. The denial of facts by the accused caused fewer disagreements between experts. Among experts, 76.5 % had already observed differences, which, according to them, were based primarily on schools of thought, or personal views (64.7 %), which could distort clinical evaluation and especially forensic interpretation of the relationship between pathology and facts. The experts thought it was possible and desirable to reduce differences and proposed different solutions for this, especially the return to dual expertise and colleges of experts.Our results were consistent with those in the literature. Based on proposals from experts and data from the literature, we identified five perspectives likely to reduce differences: first it would be useful to put in place a better specific training in forensic psychiatry and expertise, not only theoretical but also in terms of practical training through tutoring. We would identify a jurisprudence in forensic psychiatric assessment and identify consensual points. It would be good to allow experts to acquire sufficient experience not just through tutorials but also by statutory changes. Moments of exchange between experts - including a return to dual expertise and the organization of work meeting - could also reduce differences. Finally, we propose legislative changes: not only to rewrite the paragraph 2 of Article 122-1 of the French Penal Code, but also to give priority to the expertise of responsibility on the expertise of dangerousness.We showed that there were differences between the experts mainly concerned with the forensic interpretation, and that they seemed linked to schools of thought or to personal views of each expert. To reduce the differences, we discussed five perspectives.

Forensic psychiatric assessment regarding liability ensures a balance between justice and psychiatry. In France, criminal assessment is not contradictory. The psychiatric expert is commissioned by judges to determine whether or not the accused has a mental disorder and specify whether it affects discernment and control of actions at the time of offense. Its mission focuses on the mental element required to constitute an offense, and is structured around Article 122-1 of the Criminal Code. This article, composed of two paragraphs, distinguishes the framework of the abolition of discernment — a cause of non-imputability and therefore of a statement of lack of criminal responsibility due to mental disorder — and the framework of the alteration of discernment. Nowadays expertise seems to meet discomfort, with criticism focusing on possible differences among psychiatric experts, without specific studies having been conducted to confirm it.Our objective was to identify the main points of disagreement between psychiatric experts and to propose explicative hypotheses.For this, we carried out a literature review on PubMed, Science Direct and Cairn, and studied the report of the 2007 public hearing on forensic psychiatric assessment with contributions from different authors. The keywords were: forensic psychiatry, psychiatric court report, psychiatric expertise, differences among experts, legal responsibility, and discernment. We defined differences as disagreements between experts, or as a mismatch in conclusions and approaches of experts.The differences among experts concerned mainly forensic interpretation, i.e. the discussion of the relationship between pathology and offense, particularly in contexts that involve a larger forensic discussion, including interruption of medication, use of drugs, association with antisocial personality, premeditation, denial of facts, especially when the accused suffers from a mental illness (especially schizophrenia). For a finding of abolition of discernment, an expert must consider two requirements, one temporal (the mental disease must be active during offense) and the other causal that involves seeking a direct and exclusive relationship between the offence and the mental state, according to expert jurisprudence. Some experts do not comply with these two requirements or this jurisprudence, whence differences. There were also diagnostic differences and disputes relating to the concept of "alteration of discernment". Disagreements appeared to be related primarily to personal ideologies or different schools of thought that influenced interpretations and conclusions of experts, e.g. accountability as a therapeutic response for the psychotic person. Then, the lack of clarity of expert mission regarding necessary causal relationship — between any disease and crime — to demonstrate to conclude an abolition of discernment, could also contribute to differences. Moreover, time available to achieve the mission is too short and the expert would not devote enough time to an expert examination, which could lead to less good expertise and differences; especially as observed clinical examination in expertise is sometimes difficult, misleading, due to pathological reticence of accused mentally ill but also sometimes due to possible simulations. Finally, the low quality of some expert reports — due in part to the less well-trained experts, but also the particular conditions of achievement of expertise, especially in prisons — were mentioned by some authors as causes of differences.It appears from this review of literature that differences mainly concern forensic interpretation and are mainly explained by ideologies. This synthesis is a preliminary work prior to a study among psychiatric experts.

Resume Introduction.– La relation entre les cancers digestifs et la maladie de Crohn est controversee mais plusieurs cas d’adenocarcinome ileocolique ont ete rapportes ces dix dernieres annees. Exegese.– Nous rapportons deux cas d’adenocarcinome ileal chez des adultes jeunes. Ces patients etaient asymptomatiques pendant les 15 annees suivant le diagnostic de maladie de Crohn et presentaient un syndrome occlusif brutal. Une tumeur infiltrant la sereuse etait observee sur les pieces operatoires et l’examen anatomopathologique montrait des foyers de dysplasie adjacents a la proliferation. Malgre la resection chirurgicale, les deces survinrent rapidement. Conclusion. – Le caractere quiescent de la maladie, son evolution longue et la presence d’une stenose doivent faire evoquer la possibilite d’un carcinome. La surveillance endoscopique reste illusoire dans cette localisation en raison de la difficulte d’acces, de la presence frequente d’une stenose inflammatoire et de l’invisibilite de la tumeur due a son caractere infiltrant. Il est donc important d’etre vigilant dans ce mode de presentation clinique.

With the frequency of lawsuits for sexual abuse increasing, high-quality care for victims is of utmost importance. Genital examination is difficult to perform, especially on children, but is a key item for diagnosis. A case report is presented herein to illustrate this issue.A sexual assault was suspected on 2.5-year-old female twins. Clinical examination primarily detected vulvar micro-hematoma and hypopigmentation, discreetly sclerosing, as well as atrophic labia and a beginning of lichenification on one of them. The other twin showed an unspecific and erythematous lesion. Elimination of the supposedly dangerous environment and a remote consultation brought out a paradoxical development to the story and confirmed the diagnosis of vulvar lichen sclerosus.Traumatic lesions caused by sexual abuse are uncommon. Coexisting allegations and lesions in the genital area lend support to the hypothesis of sexual abuse. However, genital-anal tropism dermatosis can mimic traumatic injuries. Lichen sclerosus is an example of a differential diagnosis of vulvar traumatic lesions, which is quite often unknown to physicians, including pediatricians. This case report shows that taking the appropriate time in multidisciplinary councils can suggest a differential diagnosis. Nonetheless, it should be remembered that identifying the pathology behind the lesions cannot allow the physician to negate the child's story about potentially sexual acts, although the truth of this story and the perpetrator must still be proven by a court of law.

To describe the legal framework of medicine prescription in France in 2013.With the assistance of lawyer and forensic pathologist, consultation (legifrance.gouv.fr), analysis, summary of French laws and rules surrounding drugs prescriptions to humans for medical purpose.Free medicine prescription is an essential feature of a doctor's action. To prescribe involve his responsibility at 3 levels: deontological, civilian and penal. Aim of the rules of medicine prescription is to preserve patient's safety and health. Doctors are encouraged to refer to recommendations and peer-reviewed publication every time the prescriptions go out of the case planned by law.Knowledge and respect of medicine prescription legal rules is essential for a good quality practice. Medical societies have a major role to improve medicine use among practitioners.

Summary Adjustable gastric banding is recognized for its effectiveness in obtaining long-term weight loss with low morbidity-mortality for patients with morbid obesity. However, life-threatening complications can sometimes occur, and surgeons may end up in court. We analyzed complications, some of them lethal, arising from gastric banding surgery in nine patients and the main issues identified by the experts, contributing to the judge's decision. Gastric banding is considered a benign operation, but, of the nine cases examined herein, five resulted in death while the other four had serious consequences with several damages, especially aesthetic and psychological suffering. Perforations of the oesophagus or stomach remain the leading causes of complications; the experts identified several issues from the records that helped the judge to render a decision and condemn seven of the nine surgeons. Three types of faults were considered the responsibility of the doctors: the lack of patient information or incomplete medical records, a clumsy mistake or delay of appropriate treatment due to underestimation of clinical symptoms, and finally, failure to observe the proper indications. Expert opinion focused most often on criticism of postoperative behaviour and failure to make decisions according to the state of the art.

The maternal mortality is rare and when it arises, the family often puts the medical profession in guilty's position. We present the case of a 38-year-old woman, died in the post-partum in a context of intense back pains. The autopsy found an incidental hemorrhagic syndrome to a two-stage rupture of the splenic artery. We shall discuss the aetiology. The autopsy and the anatomopathological examination are practiced only in hardly more than a quarter of the cases while they will be important in proceedings and will allow the family to go into mourning.

Aims The use of cannabis has been linked to an increased risk for acute psychosis, especially delirious episodes or schizophrenicspectrum disorders. Self-mutilation and dissociative disorders are rare (Bergua A et al. Ophthalmologica 2002;216:269–71). On the contrary, according to some authors, cannabis resin consumption would reduce these disorders (Passie T et al. Drug Test Anal. 2012;4:649-59). We report on original case of death by automutilation in a patient with cortical dysplasia following consumption of a highly concentrated resin cannabis. Case report Mr. B., 36 years-old, presents on the public roads a major state of agitation with self-mutilation and bilateral enucleation. Despite the intervention of emergency services, he impales on the fence and dies in an array of cataclysmic hemorrhage. According to statements of two witnesses who have spent the day with the victim, he would have presented a state of major agitation after spending few minutes in his apartment. They also indicate that the victim was a regular cannabis user and had presented unlabeled psychiatric disorders few years earlier. Four fragments of a brown substance resembling cannabis resin were seized at the home of the victim. Methods The autopsy was performed 12 hours later. Toxicological samples (cardiac blood, peripheral blood, pleural fluid, gastric content, vitreous humor and hair) were taken. Blood screening for major drugs and narcotics was done by LC-MS/MS. Dosages of amphetamines, opiates and cocaine were done by GC-MS, quantification of cannabinoids by GC-MS/MS. Identification and dosage of hallucinogens, new synthetic drugs, and synthetic cannabinoids were performed by LC-MS and LC-MS/MS. The composition of the four brown fragments seized at the home of the victim was determined by GC-MS and GC-FID. A pathological expertise was also performed. Results Toxicological analysis of the biological fluids and hair revealed the presence of different markers of cannabis consumption: THC 11-OH-THC THC-COOH Cannabinol Cannabidiol Cardiac blood (ng/mL) 25 3.2 13 0.6 0.3 Femoral blood (ng/mL) 13.5 4.1 14.7 1.3 0.7 Gastric content (ng/mL) 868 0.8 26 – 22 Hair (1,5 cm) (pg/mg) 137 1 ns* 9 94 These results indicate a recent cannabis consumption and the high gastric concentrations are in favor of an orally absorption. Hair analysis confirms regular consumption. A postmortem redistribution between the blood compartments can be observed. The analysis of fragments (F1 to F4) confirmed that it was cannabis resin with following composition (%): THC Cannabinol Cannabidiol F1- F3 31.1 5.5 1 F2 34.8 6 1.1 F4 35.4 6 1 The 4 pieces of cannabis resin highlights similar qualitative and quantitative composition with very high levels of active compounds. The pathological expertise reveals brain cortical dysplasia and lung lesions alveolitis type with pigmented macrophages related to regular toxic inhalation. Discussion and conclusion cortical dysplasia induces seizures and hallucinations. In this particular case, the absorption of a large dose of an highly concentrated cannabis extract may have caused hallucinations and dissociative disorders.

Compensation for victims of medical accidents identified as no-fault medical accidents (NFMA) will be financed by national solidarity: this is a major and innovative feature of the Law of March 4, 2002 relative to Patients' Rights. In this review, we analyse the decisions of the regional commission on compensation of medical accidents in the Provence-Alpes-Côtes d'Azur (PACA) region of France in 2004 and 2005, and we attempt to identify the prevalence of certain surgical procedures liable to result in NFMA and to define the concept of "unintended consequences" in the context of state of health of the patient and the predictable course of the malady. We hope to improve the medical information given to the patient and thereby the overall quality of management. NFMA was acknowledged in 57 claims, about 10% of all those received by the commission during this period. Nearly half of the claims were within the competence of the commission because of the existence of serious sequelae (Permanent Partial Disability) in 47%. No typical profile of age or gender emerged in the patients with NFMA. The majority of cases occurred after surgical procedures, in particular gastrointestinal surgery and orthopaedic surgery; 91% were planned procedures. We did not identify increased risk related to any given type of surgery, particular disease condition, or precise anatomic region. Complications were those usually observed such as neurological complications in vascular surgery or perforations in gastrointestinal surgery. The interpretation of NFMA has undergone an evolution during this two-year period. In 2004, previous poor health status precluded acknowledgment of a medical accident, the argument being that there was a predisposition to the complication which occurred. In 2005, compensation was based on a reduced Partial Permanent Disability score compared to the patient's previous health status. This became a means of measuring the impact of the medical complication on an already predictably unfavorable clinical course without medical intervention, and the legal aspect of the "ineluctable nature" of this course.

On a first anatomical series of 52 hearts of trisomic 21 fetuses, published in June 2002, we described a new minor cardiac anomaly, belonging to the atrioventricular septal defect, with a linear insertion of the atrioventricular valves without defect. We want to confirm these data, on a larger series of 213 new hearts of trisomic 21 fetuses by adding a complementary section to the standard examination; 100% of controls have shown a normal insertion with an offsetting of the atrioventricular valves. On 113 out of these 213 hearts of trisomic 21 fetuses, with a so called "normal" heart at the standard examination showing no defect, the complementary section has shown that only 37.2% of these hearts have a normal insertion, whereas 62.83% show a linear insertion, without offsetting and without any septal defect. This linear insertion has been observed in all the different types of atrioventricular septal defect as a good hallmark for trisomy 21; but, since then, they have always been described associated with a septal defect, atrial or ventricular. Our hypothesis is that the linear insertion of the atrioventricular valves without defect is the minor form of the atrioventricular septal defect spectrum, taking place between the prior described partial types of atrioventricular septal defect, in which there is always a defect (ostium primum type atrial septal defect or inflow type ventricular septal defect), and the real normal heart. A precise description of the level of the complementary section and of the anatomic peculiarities of the linear insertion of the atrioventricular valves without defect would help its screening in fetal ultrasonography.

The authors report the results of prenatal diagnosis of the hypoplastic left heart syndrome since 1998 in the University Hospitals of Marseille and Montpellier. Twenty-four prenatal diagnoses of this condition were made in mothers with a mean age of 29 (18 to 40 years) and after a mean term of 22 (18.5 to 33) weeks of amenorrhea. Seventeen therapeutic abortions were carried out and 7 neonates born after a mean term of 39 (28 to 40) weeks, were admitted to the paediatric intensive care unit. Two patients required ventilatory assistance with one early death. The other patients were stable after surgery. A Norwood (first stage) procedure was carried out in 6 neonates at a mean age of 5 (1 to 6) days. There was only one survivor (17%). Prenatal diagnosis of the hypoplastic left heart syndrome allows cardiac and extracardiac evaluation of foetuses with this condition. Therapeutic abortions may be proposed and was the commonest choice of the parents in this study. On the other hand, despite better management of neonates with this prenatal diagnosis, the poor prognosis of the Norwood first stage procedure is unchanged. A systematic search for a restriction of the foramen ovale on foetal echocardiography could optimise neonatal management of this problem.

The relationship between digestive neoplasia and Crohn's disease remains debated but several cases of carcinoma have been reported in the past 10 years.We report two cases of intestinal adenocarcinoma found in young people. Patients were asymptomatic during 15 years after the diagnosis of inflammatory bowel disease and presented a sudden occlusive syndrome. Carcinoma was observed incidentally at gross examination, and histopathological study showed dysplasia adjacent to neoplasia. Despite adequate surgical resection, death occurred quickly.Crohn's carcinoma should be suspected in patients with long-standing disease, poor symptomatology, and stenosis. Intestinoscopy surveillance remains illusory because inflammatory stenosis is often present and infiltrative neoplasia is invisible. Thus, it is important to be vigilant in this clinical presentation.

Before the first 12 hours, diagnosis of early myocardial infarctions is always difficult for forensic pathologists. We tested complement C9 expression in 121 formalin-fixed and paraffin-embedded heart samples by an immunohistochemical procedure. The heart specimens were separated into four groups: 33 cases in group 1 with typical ischemic damages histologically located, 20 cases in group 2 with death related to myocardial infarction on the basis of ischemic presentation on electrocardiogram but no obvious histological ischemic damage, 35 cases in group 3 with severe coronary disease without cause of death found at the autopsy, and 33 cases in group 4 without sign of myocardial infarction and without coronary disease. In the first group, all 33 heart samples showed a well-defined C9 expression in the necrotic areas. The second group in 17 of 20 cases showed positive areas for C9 expression. In the other three heart specimens, only few stained cells were observed whereas the painful symptoms had begun less than 1 h before death. The third group showed C9 immunopositive areas in six of 35 cases, few stained cells in 8 cases, and no C9 deposition in the 21 other cases. The last group showed no staining area. To avoid nonspecific C9 staining due to tissue autolysis, we studied C9 expression during a controlled putrefactive process in four cases included in group 1; staining was found only in infarcted myocardial areas, and was observed up to ten days. Specificity of C9 expression was evaluated to be 100% [89.4 to 100%] and sensitivity to be 85% [62.11 to 96.79%]. In conclusion, evaluation of immunohistochemical expression of C9 appears to be a highly sensitive and specific marker of early myocardial infarction, useful in forensic medicine if survival is more than 1 h after the beginning of myocyte damage.

This study was performed on 18 police officers, in order to evaluate relations between behavior and the activity of the main hormonal systems implicated in stress management. All subjects were male volunteers with more than 2 years on the job, a type A psychological profile according to Friedman and Rosenman, suffering from no mental or physical illness. The experimental setting used to study the role of different stress factors consisted of a series of tests that re-created stressful situations that the subject might encounter in his job. The study showed that during stressful states, not only did peripheral secretion of catecholamines increase, but that the ratio of epinephrine to norepinephrine was a determinant factor. Epinephrine secretion which was elevated at the beginning, decreased when the stressful situation was clarified or controlled, whereas norepinephrine secretion remained elevated as long as the subject had to remain alert. Cortisol secretion seemed to depend upon anticipation of the stressful event more than its actual happenning.