Pro-active drug-facilitated crimes (DFC): a study in the Department of Forensic Medicine of Paris, France

INTRODUCTION

Proactive drug facilitated crime (DFC) is the administration of psychoactive substances (PAS) for criminal purposes without the victim's knowledge or by force. In Paris, France, patients who report suspected proactive DFC to the police are examined at the Department of Forensic Medicine (DFM) of the Hôtel-Dieu Hospital. Preventively blood and urine samples are collected but not systematically analyzed by the judicial authority. We aimed to assess the proportion of probable proactive DFC in patients examined at the Hôtel-Dieu DFM following a police report for suspected proactive DFC.

METHOD

Blood and urine samples were collected from 100 patients. Toxicological analyses were performed by the toxicology laboratory of the Lariboisière Hospital. The results were correlated with the clinical data collected at the initial and follow-up consultations.

RESULTS

At least one PAS was detected in 86% of the cases (voluntary or involuntary intake). After correlation with clinical data, 32% of the cases were classified as probable proactive DFC. In these cases, 49% of the substances identified were illicit substances (amphetamines, MDMA, etc.); 16% were benzodiazepines and related substances; 16% were antihistamines and sedatives; 14% were opioids; and 5% were antidepressants and anti-epileptics. In 90% of the cases, patients reported a voluntary ethanol consumption in the hours prior to the suspected proactive DFC.

CONCLUSION

Toxicological analyses revealed a high proportion of both probable proactive DFC and probable opportunistic DFC. Our results indicate the need to perform systematical toxicological analysis in cases of suspected DFC.

Trends in adverse drug reactions related to oral weak opioid analgesics in therapeutic use in adults: A 10-year French vigilances retrospective study

AIM

To describe the symptoms, patient demographics, and trends over time of adverse drug reactions (ADRs) related to weak opioid analgesics reported to the French vigilance networks.

METHODS

Retrospective study of data from French Poison Control Centers and Pharmacovigilance Centers databases of weak opioid analgesics-related ADRs cases, with high causality score, in adults, in therapeutic analgesic use, without co-exposure, between 2011 and 2020.

RESULTS

The number of cases was 388 in the Poisonings database and 155 in the Pharmacovigilance database; ratio of the number of these cases to all reported cases during the study period was 0.02% and 0.03%, respectively. Tramadol was most often involved (74% and 56.1%, respectively), followed by codeine (26% and 38.7%, respectively). There was no significant variation in the number of cases reported. Cases most often involved young adults (median age: 40 years) and mostly women (76%). Gastrointestinal symptoms were mostly reported (80% and 65%, respectively) as described in the Summary of Products Characteristics. Patterns of ADRs were comparable in both databases, except for codeine-associated acute pancreatitis and anaphylaxis that were reported in the Pharmacovigilance database. No fatality was observed. Severity was more often observed in the Pharmacovigilance database (30%) than in the Poisonings database (moderate toxicity: 7%).

CONCLUSION

ADRs mostly occurred among young women using tramadol, without significant variation in the number of reported cases over time. Serious ADRs were more frequently reported to the Pharmacovigilance database, particularly for codeine. Women seemed to be at greater risk of ADRs.

Short message service as a tool for mass follow-up of patients requesting a poison centre: a retrospective comparative study in France

INTRODUCTION

The short message service is an alternative to telephone follow-up of exposure cases reported to poison centres. The aim of this study was to compare the proportion of exposure cases successfully followed up and the respective cost of telephone and short message service follow-up between two poison centres, one using both methods of follow-up (Paris centre) and the other using telephone follow-up only (Nancy centre).

METHODS

In 2021, we included cases eligible for short message service follow-up at both centres. Eligibility criteria were calls from the public reporting non-toxic or minor toxic exposure not requiring medical consultation. We collected the follow-up type (telephone/short message service) and outcome (success/failure). The cost of each type of follow-up was estimated.

RESULTS

In 2021, 16,867 and 11,107 exposure cases were eligible for short message service follow-up at the Paris and Nancy centres, respectively. The Paris centre followed up 86.2 per cent of cases by short message service, and the remainder by telephone, while the Nancy centre followed up all cases by telephone. The Paris centre had a greater follow-up rate compared to the Nancy centre (93.0 per cent versus 43.6 per cent; P < 0.0001). Overall, the success rates were similar between the two centres (P = 0.06), with short message service and telephone follow-up showing comparable success rates (88.1 per cent versus 88.7 per cent; P = 0.25). On average, telephone follow-up took almost twice as long (1.51 min versus 0.85 min) and cost 1.3 times more (0.59 euros versus 0.45 euros) than short message service follow-up.

DISCUSSION

Short message service follow-up allows more patients to be successfully followed up at a lower cost compared to telephone-only follow-up, albeit with potential differences in information quality.

CONCLUSIONS

Short message service follow-up is a promising tool for poison centres to follow up with patients. Further studies are needed to assess the quality of the data collected and caller satisfaction.

[Prevalence, consequences of female genital mutilation among asylum seekers in Ile-de-France and socio-demographic characteristics]

INTRODUCTION

Female Genital Mutilation (FGM) is an intervention on the female genital organs for non-medical reasons. In France, asylum is possible for girls at risk of FGM in their country of origin. The procedure includes a forensic examination of the child.

PURPOSE OF RESEARCH

To describe the prevalence of FGM and the sociodemographic characteristics of girls and their mothers examined at the Department of Forensic Medicine of Paris.

RESULTS

Between 2018 and 2021, 2422 family interviews were conducted. The mothers were mainly from Côte d’Ivoire, Mali, and Guinea Conakry. A FGM was found in 84.4% of the 1838 women examined, mostly of type IIb. The mothers reported immediate complications (21.2%: hemorrhage, pain) and long-term complications (31.8%: sexual disorders, obstetrical complications) due to these FGM. The families often included several children, and 3307 girls were examined. They were mostly born in France (72.0%). An FGM was identified in 61 of these girls (1.8%, mostly type IIb); it was already known by the family in half of the cases. Three of these girls were born in Europe.

CONCLUSIONS

FGM is a public health problem on a global scale, but also in France due to migratory pathways. This descriptive study carried out an initial medical assessment of FSM in female asylum seekers examined at the Department of Forensic Medicine of Paris, and difficulties in the diagnosis of FSM. Other studies are useful to corroborate and compare our results.

Risk of occupational infection in forensic workers: a review

The occupational risk of infection in forensic workers is a cause for concern, furthermore in the current context of the coronavirus disease-19 (COVID-19) pandemic. In order to characterize this risk, we performed an extended review of the literature on occupational infections occurring in forensic workers. Seventeen articles were included. Direct contamination by aerosolization was the main mode of transmission reported, with 17 cases of tuberculosis. Indirect contamination was described as the mode of transmission in 10 cases (five cases of blastomycosis, two cases of tuberculosis, two Streptococcus pyogenes, and one case of human immunodeficiency virus). In all the other included cases, the mode of transmission was unknown. For two of them, the information provided was sufficient to link them to occupational exposure (one case of toxoplasmosis, one case of tuberculosis). For the remaining 10 cases, the link was uncertain (six cases of tuberculosis, three of hepatitis B, and one of COVID-19). Even if there is probably significant under-declaration, the number of infections linked to an occupational risk in forensic workers is not alarming, thanks to effective preventive measures.

Male Victims of Rape: An Observational Study over Four Years in Paris, France

Sexual violence is a common and under-reported form of violence that affects all categories of individuals. We sought to provide epidemiological data on men aged 15 years and over, victims of rape or suspecting a rape, and who reported it to the police. We conducted a retrospective study at the Department of Forensic Medicine of Hôtel-Dieu, Paris, France, between 2018 and 2021. Two-hundred men were included in the study, with an average age of 28.8 years. A vulnerability was mentioned for 17.5% of them. Most of the patients reported anal penetration, committed by a single male assailant, whom they met on the day of the assault. More than 60% of the patients reported the voluntary consumption of alcohol and/or illicit substances prior to the assault. Most patients were examined shortly after the assault (median 1 day). Anal lesions were found on examination in 37.0% of patients reporting anal penetration regardless of the time frame. The presence of anal lesions was statistically higher when patients were examined within 48 h. Our results reinforce the data in the literature on the risk factors associated with sexual violence among men, notably the consumption of alcohol and illicit substances, and psychological, economic, and social vulnerability.

Possible impact of the COVID-19 pandemic on the recreational use of nitrous oxide in the Paris area, France

INTRODUCTION

Recreational use of nitrous oxide (N₂O) is increasing in Western countries, including France. During the COVID-19 pandemic, some authors warned that recreational N₂O use could increase further as the supply of illicit drugs was impacted by various containment measures.

METHODS

We retrospectively analyzed N₂O exposures reported to the Paris Poison Control Center (France) from 2010/01/01 to 2021/04/15. The Poison Severity Score was used to grade severity.

RESULTS

During the study period, 93 cases of N₂O recreational exposures were reported (male/female ratio: 1.1; median age: 20.9 years range: [14.8-49.0]). The first case was reported in 2012, 84/93 (90%) and 65/93 (70%) were reported since 2019 and March 17^th 2020 (first lockdown in France) respectively. Most of the patients were symptomatic (88/93; 95%) and developed neurological symptoms (78/93; 84%). Among the fourteen patients who developed moderate to severe symptoms, eleven were reported after March 2020.

CONCLUSION

Despite a marked increase in recreational N₂O exposures during the COVID-19 pandemic, the exact impact of COVID-19 on this increase remains to be determined as it was observed from 2019.

Usefulness of lead isotopes analysis in a pediatric case of chronic lead poisoning

Identifying the source of lead is a key measure in the management of childhood lead poisoning. In cases with multiple potential sources or with unusual circumstances, this identification can be complex. By comparing the lead isotopic ratios (IRs) between the potential sources and the blood sample from the patient, it is possible to identify which source caused the poisoning. We report here the case of a 13-years-old girl, screened for lead poisoning as she was known to eat paint chips from two walls in her apartment. Her blood lead level was 395 µg/L, and the environmental investigation came back negative. X-ray fluorescence found lead concentration in paints to be below the regulatory threshold of 1 mg/cm². As there was no other potential source of lead exposure in this case, a comparative analysis of the IRs of lead between the child's blood and two presumed sources (bathroom and kitchen paints) was performed. This analysis confirmed the source of lead intoxication to be the paints in the apartment, mostly from the bathroom wall.

Loss of Consciousness and Visual Hallucinations Related to 5-MeO-DALT Intake, a Case Report Confirmed by Toxicological Analyses

5-MeO-DALT or 5-methoxy-N,N-diallyltryptamine is a derivative of tryptamines, consumed for its hallucinogenic and entheogenic effects. We report the case of a 46-year-old-man, presenting with a brief loss of consciousness and visual hallucinations, after the consumption of three 5-MeO-DALT tablets bought online. Liquid chromatography coupled to tandem mass spectrometry method (LC-MS/MS) was performed, and 5-Meo-DALT was quantified in both the tablets (32,5 mg per tablet, 11% of purity) and the patient's plasma (7 ng/ml - 8 hours between the consumption and the blood sample). 5-MeO-DALT poisonings are rarely described. Given the broad availability of these products, it is important that emergency department physicians and clinical toxicologists do not overlook the possibility of the ingestion of recreational tryptamines, especially since they are not detected by most routine toxicological screening.

Exposure to immediate-release tramadol in children 6 years and under - a nationwide French poison control center study

INTRODUCTION

Data regarding immediate-release (IR)-tramadol exposures in children remain sparse. We aimed to investigate the incidence of IR-tramadol exposures in ≤6-year-old children, to describe the characteristics and resulting outcome of ingestions involving IR-tramadol alone, and to estimate a clinically relevant toxic dose in this population.

METHODS

Retrospective analysis of IR-tramadol exposures in ≤6-year-old children, collected by the French Poison Control Centers (PCCs) in 2003-2019. The incidence was estimated using IR-tramadol prescription data from the Health Improvement Network database (the French version of THIN). The Poison severity score (PSS) was used to grade severity.

RESULTS

We found 1260 IR-tramadol exposures in ≤6-year-old children. The number of cases per 100,000 IR-tramadol-treated patients increased over time (p < .0001). One hundred forty-five cases involving IR-tramadol alone were analyzed. The median age was 3.0 years (IQR: 1.9, 4.0), the M/F ratio was 1.5 and the median dose was 5.0 mg/kg (IQR 3.3-11.1). Half of the children (49.7%) remained asymptomatic (PSS0) while 29.6% and 14.5% developed minor (PSS1) or moderate-to-severe (PSS2-PSS3) neurological symptoms, respectively. Twelve children developed respiratory depression. No seizures and no fatality were reported. All symptomatic children recovered within 24 h. The ingested IR-tramadol dose was positively correlated with the PSS (p < .0001). Using a receiver operating characteristic (ROC) curve approach (area under the curve, 0.92; p < .001), ingestion of ≥7.4 mg/kg IR-tramadol was appropriate to recommend hospital referral (sensitivity, 100% [95% confidence interval (CI), 85-100]; specificity, 73% [95% CI, 64-80]; predictive positive value, 39% [95% CI, 35-57]; negative predictive value, 100% [95% CI, 96-100]). Children who ingested <7.4 mg/kg IR-tramadol developed no (n = 68) or minor (n = 22) neurological symptoms.

CONCLUSIONS

Despite increasing tramadol prescriptions in adults during the study period in France, oral exposure to IR-tramadol in ≤6-year-old children was rare but possibly responsible for severe toxicity. Children with no underlying disease and concomitant medication ingesting <7.4 mg/kg IR-tramadol alone could be observed at home. However, given the observed variability in the onset of seizures after tramadol ingestion, which can occur at ingested tramadol doses below 7.4 mg and even at therapeutic doses, parents or guardians should be specifically warned about the risk of seizures.

Bowel obstruction following ingestion of superabsorbent polymers beads: literature review

RATIONALE

Superabsorbent polymers are marketed as toys, and cases of ingestion in children are increasingly reported. Even if these cases are usually considered benign, bowel obstruction has been reported.

OBJECTIVE

To investigate the exposure characteristics, clinical presentation, management, and outcome of patients who developed bowel obstruction following ingestion of superabsorbent polymer-made products.

METHODS

Databases were searched (no start date - 2020/01/31) using the following keywords: ("superabsorbent" OR "polymer" OR "hydrogel" OR "crystal" OR "jelly" OR "Orbeez" OR "beads") AND ("ingestion" OR "obstruction" OR "perforation") AND ("intestinal" OR "bowel"). All cases of bowel obstruction following superabsorbent polymer-made product ingestion were included.

RESULTS

Report selection: We found 25 reports reporting 43 cases of bowel obstruction following superabsorbent polymer-made product ingestion. All the reports were retrospective, including 20 case reports and 4 case series. Patient characteristics and clinical presentation: Age ranged from 6 to 36 months, and the female/male sex ratio was 1.3. The median delay between the ingestion of the product and the onset of the first symptoms (available in only four reports) was 1.0 [0.7;1.8] day (from 15 h to 2 days). The median delay between the onset of gastrointestinal symptoms and hospital admission, available for all but 15 patients, was 3 [2;4] days (from 15 h to 30 days). The reported symptoms were persistent vomiting in all cases, associated with constipation (11/43), diarrhea (1/43), abdominal pain (1/43), and clinically assessed dehydration (14/43). Abdominal palpation found abdominal tenderness or distension in 11/43 and 28/43 patients, respectively. An abdominal mass was palpated in 3/43 patients. Two patients presented with fever, and three patients developed seizures. Characteristics of exposure: Ingestion of superabsorbent polymer-made products was reported by relatives on hospital admission in only 10/43 cases. Based on imaging and/or surgically/endoscopically removed products, all were bead-shaped objects. The median number of beads removed (available in 27/43) was 1 [1-2] (range from 1 to 6). Their median diameter (available in 21/43 patients) at the time of the diagnosis of bowel obstruction - i.e., at hydrated state - was 30 [30;36] mm (range from 25 to 65 mm). Imaging findings: Abdominal radiography, performed in 31/43 patients, never showed evidence of foreign body ingestion Abdominal computed tomography scanning, performed in 10/43 patients, visualized an intraluminal mass in 5/10 cases. Abdominal ultrasound performed in 34/43 patients allowed visualization of a rounded intraluminal image that corresponded to a bead in 28/34 patients but led to a correct diagnosis of foreign body-induced bowel obstruction in only 15/34 cases. One case reported the contributory use of abdominal MRI. Beads were always located in the small bowel (from the duodenum to the terminal ileum). Removal of beads: Bead removal required endoscopy in 2/43 cases and surgery in 41/43 cases (enterotomy or resection in 36/43 and 5/43 cases, respectively). In 3/36 cases, additional enterotomy was performed to remove beads that had not been found during the first surgery. The delay between the onset of gastrointestinal symptoms and removal procedures ranged from 1 to 7 days. Outcome: Except for two fatal cases, the outcome was favorable.

CONCLUSIONS

Ingestion of superabsorbent polymer-made beads can be responsible for fatal bowel obstruction in children related to the increase in bead size within the intestinal tract. Diagnosis is made difficult by the radiolucent properties of the beads. The management of bowel obstruction probably most often requires endoscopic or surgical procedures. Children under 4 years of age are probably the most at risk of developing bowel obstruction.

Aortic dissection in a body packer: Did cocaine play a part?

Body packing is defined as the ingestion of drug packets, to conceal them during transportation. We report the case of a 63-year-old cocaine body packer, who died from an aortic dissection. He was arrested in Paris as he disembarked from a flight from Cayenne (French Guinea) and custom officers found cocaine in his suitcase. The patient admitted the ingestion of cocaine packets. He was transferred to the hospital where an initial computerized tomography scan showed hyperdense, uniformly shaped packets located in the colon. On admission, his blood pressure was elevated but he did not exhibit any other signs of adrenergic syndrome. The diagnosis of chronic hypertension unrelated to the cocaine body packing was retained. During hospitalization, 40 h after the ingestion of the cocaine packets, the patient showed acute agitation, sweat and a high blood pressure. Given the context, an emergency thoraco-abdominal-pelvic CT-scan was carried out to rule out a cocaine leakage. None of the packets showed evidence of leakage but the CT-scan assessed an aortic dissection extending to the entire descending aorta. Despite intensive care, the patient passed away on the fifth day. This aortic dissection could have appeared spontaneously in a patient with significant atherosclerosis lesions of the aortic network. Nevertheless, we believe that cocaine impregnation causing high blood pressure might have played a role in the aortic dissection, even without a cocaine leakage from the packets. This case highlights the need to achieve an effective control of the blood pressure in cocaine body packers.

Management of the COVID-19 epidemic in a French immigration detention center

PURPOSE

The purpose of this paper is to give an overview of management of the COVID-19 epidemic in a French immigration detention center.

DESIGN/METHODOLOGY/APPROACH

During containment in France because of COVID-19, the judicial authorities had to deal with the risk of contamination within immigration detention centers (IDC). In the Paris IDC, which can usually receive up to 240 individuals, measures have been taken to limit the risk of contamination by releasing individuals without prior judicial conviction and testing the others by a nasal swab.

FINDINGS

The test was done for all the present individuals (48), except two who refused. Eight tests (17.4%) were positive and only one was symptomatic. Individuals testing positive for COVID-19 were transferred into COVID-centers specially created during this health crisis.

ORIGINALITY/VALUE

Management of the COVID-19 epidemic in this French IDC illustrates the necessity of good cooperation between judicial authorities and medical teams in charge of those centers and the difficulty of balancing public health actions with state security.

Emerging issues related to the management of patients in custody during the COVID-19 outbreak in France

PURPOSE

This paper aims to give an overview of emerging issues relating to the management of patients in custody during the COVID-19 outbreak in France.

DESIGN/METHODOLOGY/APPROACH

During custody in France, a medical consultation is provided for any patient who requests it. In the Paris area, this consultation is carried out by a practitioner in forensic medicine, based in a general hospital. Usually, most medical consultations for patients in custody take place directly in police stations. With the COVID-19 outbreak, the authors chose to suspend this activity, asking law enforcement to bring patients directly to their hospitals. Patients presenting with severe infections or indicative symptoms of the severe acute respiratory syndrome Coronavirus 2 infection and a comorbidity are tested for COVID-19. Such patients remain hospitalized until results of the test are received. If the result is positive, they are hospitalized for the length of their custody. If sent to prison, they are transferred to a medical facility in detention.

FINDINGS

From the onset of the outbreak, the authors observed increased pressure from law enforcement to obtain medical information. According to the French Code of Medical Ethics, no medical information should be disclosed regarding the authors' patients' medical situations. The authors are also concerned about sending a potentially infected patient back to a police station, to prison or to his/her home.

ORIGINALITY/VALUE

This paper provides a snapshot of issues relating to the management of patients in custody during the COVID-19 outbreak in France. Unfortunately, the current situation in France does not permit a wider range of testing for the specified population in this paper.

Envenomation by Centruroides pococki scorpion with neuromuscular toxicity

Cases of human envenomation by Centruroides pococki are exceptionally reported in human. We report a Class III human envenomation by C. pococki in Guadeloupe, French West Indies, with neuromuscular toxicity that has never been described before. Symptoms resolved within a few hours, without the need for intravenous scorpion-specific antivenom.

Acute occupational exposure to holothurians (Cucumaria frondosa) resulting in irritating symptoms: About three cases

Holothurians are marine invertebrates also known as sea cucumbers. They are used in fresh or dried forms in various cuisines around the world and have alleged medicinal properties. Consequently, sea cucumbers, notably the orange-footed sea cucumber (Cucumaria frondosa)are increasingly harvested from the environment or farmed via aquaculture. We report three cases of unusual occupational exposure to C. frondosa resulting in cutaneous, respiratory and ocular irritating symptoms. These symptoms occurred as sea cucumbers were cut on half and eviscerated manually, following a machine breakdown in a sea cucumber processing factory. Given the composition of holothurians, these symptoms probably resulted from the aerosolization of various holothurins, saponins secreted by sea cucumbers as mean of defense. Treatment was solely symptomatic and included decontamination of the skin and the eyes, inhaled glucocorticoids, anticholinergic agents and oral glucocorticoids. As the exposure resulted from a machine breakdown, no specific protective equipment was put in place. Employees were advised not to handle manuallythe sea cucumbers in case such a breakdown was to happen again.

Unintentional exposure to pregabalin in ≤6-year-old children: a nationwide French Poison Control Center study

INTRODUCTION

In France, pregabalin is widely prescribed in adults but still not approved for children. We aimed to investigate the incidence of pregabalin exposure in ≤6-year-old children, to describe the characteristics and outcome of ingestions involving pregabalin alone, and to estimate a clinically relevant toxic dose in this population.

METHODS

Retrospective analysis of pregabalin exposures in ≤6-year-old children, collected by the French Poison Control Centers in 2004-2019. The incidence was estimated using pregabalin prescription data from the Health Improvement Network database (the French version of THIN). The poison severity score (PSS) was used to grade severity.

RESULTS

We found 313 unintentional immediate-release pregabalin ingestions in ≤6-year-old children. The number of cases per 100,000 pregabalin-treated adults increased over time (p < 0.001). One hundred twenty-six cases involving pregabalin alone (age, 2 years [1.6-3.0] (median [25th-75th percentiles]); median ingested dose 6.4 mg/kg [3.6-10.9]) were analyzed. No child presented an underlying neurological/cardiac disease and/or took concomitant medications. Most of the children (77%) remained asymptomatic (PSS0) while 21% and 2% developed minor (PSS1) or moderate (PSS2) neurological symptoms, respectively. No severe complications/fatalities were reported. All symptomatic children recovered within 24 h. The ingested pregabalin dose was positively correlated with PSS (p < 0.0001). Using a ROC curve approach (area under the curve, 0.85; p < 0.001), ingestion of ≥19.4 mg/kg pregabalin was appropriate to recommend hospital referral (sensitivity, 39% [95% confidence interval (95% CI), 24-56], specificity, 100% [95% CI, 96-100], predictive positive value, 100% [95% CI, 64-100], and negative predictive value, 85% [95% CI, 82-89]). Symptomatic children who ingested <19.4 mg/kg pregabalin developed minor symptoms.

CONCLUSION

Despite increasing prescriptions in adults in France, unintentional pregabalin ingestions in ≤6-year-old children remain rare and cause minimal toxicity. Children with no underlying neurological/cardiac disease and concomitant medication ingesting <19.4 mg/kg immediate-release pregabalin alone can be safely observed at home.

[Medical certificates, determination of the total work incapacity, and elementary traumatic injuries]

Medical certificates, determination of the total work incapacity, and elementary traumatic injuries. The drafting of medical certificates is an essential act in the practice of every doctor. Its importance on the medico- legal level obliges us to write these certificates in an applied and rigorous way. In the case of assault and battery, the doctor must issue an initial medical certificate describing all the medical findings. The judicial authority will require a forensic doctor from a Forensic Unit to determine the total incapacity to work, a period during which the patient is unable to carry out all the gestures of daily life independently.

The attack on November 13, 2015: organisation of the medico-judicial unit of the Hôtel-Dieu Hospital in Paris

The main aims of a medico-judicial unit are to ensure the examination of assault victims or persons in custody and to perform sampling necessary for investigations. Forensic examination is essential to describe the wounds and to evaluate the consequences of an assault by determining days of total incapacity for work (ITT). After the Paris attack on November 13, 2015, 121 victims were examined at the medico-judicial units of Paris. An initial forensic certificate was issued by forensic physicians with an assessment of physical ITT. A consultation with a forensic psychiatrist was systematically scheduled on the same day to obtain a forensic certificate for the psychological ITT. The average age of the victims was (33 ± 7) years and the sex ratio was 1.26. Most victims were in the Bataclan concert hall (78/121 or 64.5%). Of the 121 victims, 73 (60.3%) had projectile lesions (bullets, bolts and nuts, metal fragments, etc.) and 48 (39.7%) had non-projectile lesions (bruises, hematomas, etc.). The average physical ITT was 27 days (0; 190). The evaluation of the number of days of physical ITT was often complicated as some patients were still in medical care at the time of the initial examination. This experience enabled the Paris medico-judicial unit to anticipate the management required should any future event of this magnitude occur. It also reinforced cooperation between the medico-judicial unit and other departments, mostly emergency services and the forensic psychiatric unit. The Paris medico-judicial unit was thus able to offer a unique place of care by providing both physical and psychological examinations.

Death of an apprentice bodybuilder following 2,4-dinitrophenol and clenbuterol intake

We present the case of a 17-year-old man, who died after 2,4-dinitrophenol (DNP) and clenbuterol consumption, which he likely took for physical enhancement. Forensic post-mortem examination revealed a yellowish skin colour and nonspecific signs of asphyxia. Analytical confirmation of the intoxication was obtained in blood and urine, with high levels of DNP and clenbuterol. Both of these substances are used by bodybuilders as DNP enhance lipolysis and clenbuterol has anabolic properties, but their toxicity is underestimated. DNP uncouples oxidative phosphorylation, leading to thermogenesis and even relatively small doses can cause fatal hyperthermia. Clenbuterol is a β2 agonist that causes electrolyte disturbances (hypokalemia and hyperglycemia mostly) and death have been described through coronary vasospasm. Given the circumstances in which the body was found and toxicological results, we believe the cause of death to be fatal hyperthermia from DNP intake. These substances are illegal in many countries, but easily bought online. Through this availability, the last decades have seen an increase of fatal intoxications. Websites selling them are regularly closed by French public authorities and Interpol, but unfortunately it seems insufficient.

[Outbreak of carbon monoxide poisoning in the Ile-de-France region during the spring 2016 Seine flooding]

INTRODUCTION

Heavy rainfall in May 2016 caused large-scale flooding of the Seine and its tributaries. Analysis of this unusual event showed that it could recur on an even larger scale. The sanitary consequences were less frequently assessed in this analysis, particularly the risk of accidental collective carbon monoxide (CO) poisoning caused by the use of combustion engine drainage pumps.

METHODS

We retrospectively reviewed all cases of acute accidental carbon monoxide exposure observed in the Ile-de-France region, related to the use of drainage pumps in spring and summer 2016 and notified to the Ile-de-France CO poisoning surveillance network.

RESULTS

Five events were identified, including 45 people exposed to carbon monoxide. Thirty-four of these people were poisoned, 5 were not poisoned and insufficient data were available for 6 people. Three people showed signs of severity and 2 were treated by hyperbaric oxygen therapy. The other poisoned individuals were managed in hospital and treated by oxygen therapy. All were cured.

DISCUSSION

Collective CO poisonings are common sanitary events during flooding and can be potentially severe. They can occur during the event or over the following days. Preventive measures may help to reduce the risk of CO poisoning, such as increased awareness among professionals, better information of individuals who rent these types of devices or even the use of CO detectors during their use.