Applicability of Cameriere's third molar maturity index on orthopantomograms and computed tomography scans from a French population

Cameriere developed a method on orthopantomograms (OPG) to assess adult age of 18 years based on the relationship between age and the third molar maturity index I3M. The aim of this study was to evaluate whether Cameriere's method could be applied to computed-tomography scans (CT-scans) from a population of French juveniles and young adults and compare the results obtained from OPG of the same individuals. Our sample comprised 200 examinations that had been performed at the radiological department of a French University hospital between 2007 and 2020. Each patient had received an OPG and a cranial CT scan for medical purposes, and we used a similar adaptation of I3M based on OPG to determine the I3M based on CT scans. Due to exclusion criteria, our final sample comprised 71 OPGs and 63 CT scans. Based on the 71 OPGs, there was concordance between chronological age and estimated age, with a sensitivity of 78.57%, a specificity of 89.47%, and a misclassified rate of 18.03% based on tooth 38, and a sensitivity of 78.79%, a specificity of 91.67%, and a misclassified rate of 17.78% based on tooth 48. Our results based on CT scans presented concordance between chronological age and estimated age for tooth 38 described by a sensitivity of 77.78%, a specificity of 94.12%, and a misclassified rate of 16.98%. The concordance between chronological age and estimated age based on 48 had a sensitivity of 75.00%, a specificity of 93.75%, and a misclassified rate of 19.23%. The > 90% ICC indicate an excellent similarity between measurements of teeth 38 and 48 based on OPGs and CT scans. This study has revealed the applicability of the Cameriere's method to calculate the I3M based on CT scans from a French population. The results based on CT scans are similar to results based on OPGs from the same individuals.

Prevalence of abnormalities seen on orthopantomograms performed for forensic age estimation in unaccompanied minor asylum seekers

OBJECTIVES

Evaluate the prevalence of radiological anomalies on orthopantomograms (OPT) performed as part of forensic age estimation in unaccompanied minors.

METHODS

This is a retrospective study conducted on 208 OPT examinations requested by a magistrate. These OPTs were interpreted independently by two readers to establish the number of missing teeth (MT), presence of dental fillings (DF), and dental anomalies (DA). The presence of radiolucent (RL), radiopaque, and mixed lesions was also assessed.

RESULTS

Most radiologic anomalies were RL, detected on 41% and 39% of the subjects evaluated for R1 and R2, respectively, with a mean of 1.3 ± 2.4 (1-16) and 1.1 ± 2 (1-13) RL lesions per subject. Among the RL identified, the majority were dental (70% for R1 and 65% for R2), all of which had a suspected infectious origin. Among readers, 43% and 41% of the subjects evaluated presented MT, 21% and 15% presented DF, and 22% and 20% presented DA for R1 and R2, respectively. The inter- and intra-observer reproducibility for OPT classification was considered excellent (Kappa = 0.84, 95% CI 0.78-0.90, and Kappa = 0, 95, 95% CI 0.86-0.99).

DISCUSSION

There was a non-negligible prevalence of radiological anomalies in OPT studies performed for forensic age estimation. Most of these lesions were suspected to be infectious in origin, potentially requiring medical care. This constitutes an ethical dilemma inherent in the judicial expertise injunction requiring a limited specific response.

CLINICAL RELEVANCE STATEMENT

This study highlights a non-negligible prevalence of supposedly infectious radiological abnormalities. The restricted possibility for the legal expert to declare these abnormalities raises ethical and medical questions.

KEY POINTS

• Orthopantomograms can be performed as part of forensic age estimation. • Results indicate the majority of radiological anomalies detected on OPTs were of suspected infectious origin. • These findings give rise to ethical and medical questions about the way in which these forensic examinations are carried out.

Technical note: Interest of focused fields in post-mortem computed tomography using photorealistic images for age at death estimation from the pubic symphysis

INTRODUCTION

The morphological assessment of the pubic symphysis using the Suchey-Brooks method is considered a reliable age at death indicator. Age at death estimation methods can be adapted to the images obtained from post-mortem computed tomography (PMCT). The aim of this study is to evaluate the utility of pubic symphysis photorealistic images obtained through Global illumination rendering (GIR) for age at death estimation from whole-body PMCT and from focused PMCT on the pubic bone.

MATERIALS AND METHODS

We performed virtual age at death estimation using the Suchey Brooks method from both the whole-body field of view (Large Field of View: LFOV) and the pubis-focused field of view (Small and Field of View: SFOV) of 100 PMCT. The 3D photorealistic images were evaluated by three forensic anthropologists and the results were statistically evaluated for accuracy of the two applied PMCT methods and the intra- and inter-observer errors.

RESULTS

When comparing the two acquisitions of PMCT, the accuracy rate reaches 98.5% when using a pubic-focused window (SFOV) compared to 86% with a whole-body window (LFOV). Additionally, the intra- and inter-observer variability has demonstrated that the focused window provides better repeatability and reproducibility.

CONCLUSION

Adding a pubic-focused field of view to standard PMCT and processing it with GIR appears to be an applicable technique that increases the accuracy rate for age at death estimation from the pubic symphysis.

The Prevalence and Characteristics of Intrafamilial Child and Adolescent Homicides in Greece over 11 Years (2010-2020)

Intrafamilial child/adolescent homicide is the murder of a child/adolescent by one or more family members. This study delves into the medical and sociological consequences of child homicide, shedding light on the broader impact beyond individual families, which extends into the local community. Two Internet search engines and the search engines of major national news websites were surveyed to identify the number of intrafamilial child/adolescent homicide cases that occurred in Greece from January 2010 to December 2020. Over the study period, 34 victims of intrafamilial child/adolescent homicides were identified. The above deaths reflect an intrafamilial child/adolescent homicide rate of 0.15 homicides per year per 100,000 inhabitants. Most of the perpetrators (51.4%) were male, and the victims were equally divided into males and females. The ages of the perpetrators ranged from 13 to 61 years, and the ages of the victims ranged between 0 and 17 years. Most perpetrators (54.5%) had a previous psychiatric history and in many cases, they committed (33.3%) or attempted (15.2%) suicide after the homicide. The most common method of homicide was strangulation (usually combined with suffocation) (25%), followed by abandonment (15.6%). The most commonly reported motives were spousal revenge (26.5%) and psychotic disorders (26.5%). Raising awareness for intrafamilial child and adolescent homicide is of the utmost importance for the prevention of this dreadful phenomenon.

Teledentistry and Forensic Odontology: Qualitative Study on the Capacity of Implementation

The postmortem identification of people without an identity is performed either by using DNA, dental charts, or fingerprints (until advanced decomposition prevents their study). The lack of forensic dentists who can conduct identifications lead us to reflect on the use of digital technology in this area. The aim of this study was to validate the organizational capacity of using teledentistry for the identification of bodies in a forensic medicine department. A mixed observational study was conducted on 55 cases between July 2020 and February 2021 in the Forensic Medicine and Thanatology Department of Montpellier University Hospital. The protocol was structured in five steps: an initial interview with the agent (a forensic autopsy technician/caregiver specialized in forensic medicine), regarding the idea they had in terms of using telemedicine in their daily practice; agent training in the telemedicine system; realization of a clinical examination using an intra-oral camera by the agent; data analysis by a dental surgeon; final interview with the agent. The study was conducted on 55 subjects. The average age was 54 years old, with more than two-thirds of the patients being male (69%). The videos had an average duration of 29 min. There was an increase in visit duration when rigidity was high; this was also the case when there were many dental specificities in the oral cavity. The quality of the videos was either good or excellent. This study showed that remote identification could be considered as a new non-invasive identification tool. Many features were analyzed to create a training guide for forensic institutes.

Procalcitonin is associated with sudden unexpected death in infancy due to infection

Infection is an important cause of death during infancy worldwide and is a frequent etiology of sudden unexpected death in infancy (SUDI). Procalcitonin (PCT) is a useful marker to diagnose infection in patients, and several studies report the stability of PCT after death. The added value of a biological marker, such as the PCT level in the blood, remains controversial in investigating SUDI. The aim of this study was to determine if PCT can help clinicians determine whether infection caused SUDI. We conducted a retrospective, multicenter study with the French SUDI registry (Observatoire National des Morts Inattendues du Nourrisson; OMIN). We collected data from this registry on children who died between May 2015 and June 2021. The levels of PCT in the blood of 540 SUDI patients were measured. We compared PCT and other biological tests performed in terms of infection status, autopsy results, and cause of death using clinical and biological data compiled by pediatricians at the SUDI referral center. PCT levels were significantly higher in the children who died from infection than in those who did not (0.12 µg/L vs. 0.08 µg/L, p < 0.001). A PCT blood level exceeding 0.2 µg/L was more frequently observed when infection was present than in the absence of infection (44.3% vs. 15.4%, p < 0.001). The same data were obtained with a 0.5 µg/L cut-off (36.1% with infection vs. 9.2% without, p < 0.001).  Conclusions: PCT is a sensitive biomarker for detecting infections postmortem; thus, additional samples may be necessary during autopsy. What is known: • PCT is a stable marker postmortem and increases earlier than CRP, i.e., 2-4 h after the beginning of an infection vs. 6 h. • PCT can be measured up to 140 h after death. What is new: • PCT is a sensitive marker for detecting infection in SUDI patients postmortem. • This test can reveal an infection from non-standardized samples obtained during autopsy if such an infection was not determined before death.

Age Estimation in 0-8-Year-Old Children in France: Comparison of One Skeletal and Five Dental Methods

Age estimation in juveniles is a critical procedure in judicial cases for verification of imputability or for civil reasons when adopting children. Several methods based both on skeletal and dental growth have been performed and applied on different populations; nevertheless, few articles have compared different methods in order to test their reliability in different conditions and age ranges, and this is a clear obstacle in the creation of common guidelines for age estimation in the living. A comparison of five dental methods (Anderson, Ubelaker, Schour and Massler, Gustafson and Koch, Demirjian) and one skeletal method (Greulich a Pyle atlas) was performed on a population of 94 children aged between 0 and 8 years. Results showed that, whereas under 2 years all the methods have the same inaccuracy, over 2 years the diagram methods, such as Schour and Massler and Ubelaker's revised one, have a lower error range than the most frequently used Greulich and Pyle atlas and Demirjian method. Schour and Massler, Gustafson and Koch, and Ubelaker methods showed, respectively, a mean error amounting to 0.40, 0.53, and 0.56 years versus the 0.74 and 0.88 years given by Demirjian and the Greulich and Pyle atlas. An in-depth analysis of the potential of several methods is necessary in order to reach a higher adherence of age estimation with the complexity of growth dynamics.

Discrimination between falls and blows from the localization and the number of fractures on computed tomography scans of the skull and the trunk

The distinction between falls and blows is a common and difficult task in forensic sciences. One of the most often used criteria to address this issue is the hat brim line (HBL) rule, which states that fall-related injuries do not lie above the HBL. Some studies, however, have found that the use of HBL rule is not so relevant. This study assesses the aetiologies, the number of fractures, and their location on the skull and the trunk in a sample of 400 individuals aged 20-49 years, which were CT scanned after traumas. This may facilitate the interpretation of such injuries in skeletonized or heavily decomposed bodies in which soft tissues are no longer available. Our aim is to improve the distinction rate between falls and blows by combining several criteria and assessing their predictability. Skeletal lesions were analysed using retrospective CT scans. Cases selected comprise 235 falls and 165 blows. We registered the presence and the number of fractures in 14 skeletal anatomical regions related to the two different aetiologies. We showed that the HBL rule should be used with caution, but there is nevertheless a possibility of discussing the aetiology of blunt fractures. Possibly, parameters like the anatomical location and the number of fractures by region can be used to distinguish falls and blows.

Myeloperoxydase and CD15 With Glycophorin C Double Staining in the Evaluation of Skin Wound Vitality in Forensic Practice

Background

The determination of skin wound vitality based on tissue sections is a challenge for the forensic pathologist. Histology is still the gold standard, despite its low sensitivity. Immunohistochemistry could allow to obtain a higher sensitivity. Upon the candidate markers, CD15 and myeloperoxidase (MPO) may allow to early detect polymorphonuclear neutrophils (PMN). The aim of this study was to evaluate the sensitivity and the specificity of CD15 and MPO, with glycophorin C co-staining, compared to standard histology, in a series of medicolegal autopsies, and in a human model of recent wounds.

Methods

Twenty-four deceased individuals with at least one recent open skin wound were included. For each corpse, a post-mortem wound was performed in an uninjured skin area. At autopsy, a skin sample from the margins of each wound and skin controls were collected (n = 72). Additionally, the cutaneous surgical margins of abdominoplasty specimens were sampled as a model of early intravital stab wound injury (scalpel blade), associated with post-devascularization wounds (n = 39). MPO/glycophorin C and CD15/glycophorin C immunohistochemical double staining was performed. The number of MPO and CD15 positive cells per 10 high power fields (HPF) was evaluated, excluding glycophorin C—positive areas.

Results

With a threshold of at least 4 PMN/10 high power fields, the sensitivity and specificity of the PMN count for the diagnostic of vitality were 16 and 100%, respectively. With MPO/glycophorin C as well as CD15/glycophorin C IHC, the number of positive cells was significantly higher in vital than in non-vital wounds (p < 0.001). With a threshold of at least 4 positive cells/10 HPF, the sensitivity and specificity of CD15 immunohistochemistry were 53 and 100%, respectively; with the same threshold, MPO sensitivity and specificity were 28 and 95%.

Conclusion

We showed that combined MPO or CD15/glycophorin C double staining is an interesting and original method to detect early vital reaction. CD15 allowed to obtain a higher, albeit still limited, sensitivity, with a high specificity. Confirmation studies in independent and larger cohorts are still needed to confirm its accuracy in forensic pathology.

[Two experimental models for wound vitality evaluation in forensic pathology: A clinical prospective non-interventional study and an animal model]

AIM OF THE STUDY

In forensic pathology, wound age evaluation allows to determine if a wound was inflicted before or after death, and to date wounds of different ages. This dating is performed in conventional histopathology by observing inflammatory cells and hemorrhage at the wound site. However, these criteria seem to show low sensitivity and/or specificity. The aim of our study was to compare two models of wound vitality evaluation: a human surgical model, and a porcine experimental model; using these histological criteria.

PATIENTS AND METHOD

In the two human (n=38) and porcine (n=11) models, three wounds were performed at regular time-lapse before devascularization/sacrifice, and a control wound after devascularization/sacrifice. The main evaluation criteria were the presence of interstitial hemorrhage and the number of interstitial polymorphonuclear neutrophils at 10 high power fields.

RESULTS

In the two models, the number of polymorphonuclears neutrophils was significantly higher in vital wounds compared to the post-devascularization/sacrifice wounds (P<0.001), with a very low sensitivity (human model: 4.3%; porcine: 47%). Hemorrhagic infiltration was more frequent in vital wounds (human: P<0.001; porcine: P=0.01), with a low specificity (human: 48%; porcine: 54%).

DISCUSSION AND CONCLUSION

This first study confirms, in the two models, the limitations of conventional histopathology in wound vitality evaluation. The next step will be testing several immunohistochemical markers in the two models.

[Prospective forensic study on the characterization of genital examination in women with consented sexual activity]

OBJECTIVE

The number of women victims of sexual assault remains high, despite prevention and information campaigns. These victims can be adolescent girls, women of childbearing age or postmenopausal women. As part of examinations of victims of sexual assault, the morpho-anatomical diversity of the female genitalia requires knowledge of the physiological variations existing by the practitioners caring for these victims. Our work aimed to describe and characterize the genital examination of women with consented sexual activity.

METHOD

Our cohort consisted of 196 women aged 14 to 81, examined in the context of medical gynecology consultations in two French maternity hospitals.

RESULTS

Recent genital traumatic injuries were found in 12.8% of women whose last sexual intercourse was less than 5 days old. Intact hymens, free from traumatic tearing despite regular sexual activity, were present in 10.7% of these women.

CONCLUSION

Thus, in many cases, genital examination alone cannot confirm or deny the existence of prior sexual intercourse, whether or not it was consented to. The development of work on data on female genital anatomy would make it possible to optimize the medico legal care of victims of sexual assault.

Teledentistry and forensic odontology: Cross-sectional observational comparative pilot study

Forensic dentistry is the branch of forensic science concerned with the study of teeth and jaws. To facilitate the work of experts, new comparative identification tools are emerging, with digital techniques such as the intra-oral camera, which are revolutionising current techniques in forensic dentistry.

OBJECTIVE

The aim of this study is to evaluate the diagnostic quality of the post-mortem odontogram carried out remotely via a video of the oral cavity using an intra-oral camera. The gold standard is the post-mortem odontogram obtained via the standard identification technique during the clinical examination.

MATERIALS AND METHODS

25 deceased patients were included in the study and the data were collected in the Forensic Medicine and Thanatology Department at the University Hospital of Montpellier. The protocol was divided into three stages: the gold standard consultation, the recording of videos with the Soprocare® camera, and the remote analysis of the images obtained. The gold standard consultation and the remote analysis were carried out by two separate dental surgeons responsible for completing a clinical file, used to establish the odontogram of the deceased patient.

RESULTS

The study was carried out on 25 deceased subjects, between 13 May and 12 June 2019. Our sample was composed of 68% men and 32% women. A sensitivity threshold of 0.97 was observed for the performance of the odontogram, i.e., for all the teeth actually present in the mouth for all subjects in the study, 97% of them were identified with the videos taken using the intraoral camera. The examination with the intra-oral camera demonstrated a good diagnostic performance in the detection of missing teeth with a PPV of 97.9% and a NPV of 98.2%. Practitioner became more skilled at recording the videos with the intra-oral camera. One can therefore note an ease in the handling of this digital tool, which gradually improved with the number of subjects included in the study CONCLUSIONS: The Soprocare® intraoral camera has an acceptable diagnostic validity in establishing the odontogram of the deceased. It enables fundamental elements to be detected with optimal efficiency. However, several points still need to be improved, in order to make the use of the camera during data collection as easy and efficient as possible.

Case study: Lesions due to forced ritual scarification in Cameroon - A warning from cultural anthropology to forensic medicine

Asylum seekers and refugees are constantly increasing worldwide because of human rights' violations and political-related abuses. As a result, some of them show scars due to torture and other forms of maltreatments. In addition, they may also present scars due to ethnical practices, namely ritual scarifications. This case study presents a victim who did not give consent to perform such ethnical practices on her body. The authors aim to enlighten the difficulty to understand the origin and the purpose of these specific injuries and the importance to know how to distinguish them from other forms of abuse. Indeed, it appears that such lesions follow a cultural path, meaning that the lesions are performed methodically and may show macroscopic differences compared to others. The story narrated by the victim can be helpful for the experts' assessment, regardless, they may present memory-loss issues. This represents the value of a correct injuries' diagnosis and the importance of cultural anthropology-related analyses. The cultural and social background are relevant since the injuries have their own signification because of their symbolism. Therefore, a multidisciplinary approach with a cultural anthropologist may have the possibility to help the forensic experts in understanding and interpreting such stories fostering their ability to better assess asylum seekers stories and their reliability.

Age estimation from the biometric information of hand bones: Development of new formulas

INTRODUCTION

In the judicial context of the age estimation of living individuals, a new method was recently proposed, based on the collection of biometric information on hand bones radiographs. The aim of this study was to apply this method to a large French sample to provide new tools for age estimation MATERIALS AND METHODS: The study sample consisted of metacarpals and proximal phalanges measurements of 1003 individuals aged less than 21 years. This sample was divided into two subgroups 1-12 and 13-21 years as the age of 13 is a relevant legal threshold for most European countries. A quadratic discriminant analysis was performed to identify the group to which an individual was most likely to belong. Age estimation formulas were also constructed from linear models: for each subgroup and the total sample.

RESULTS

The belonging of an individual to the 1-12 or 13-21 subgroup was determined with a correct classification rate of 89.8%. Age estimation formulas became less precise with age, with a mean absolute error ranging between 11 and 21 months.

CONCLUSION

We proposed a two-step procedure for age estimation: firstly, the identification of the age group to which the individual is most likely to belong, and secondly, the age estimation of this individual by applying the appropriate formula.

The potential of bone disease for personal identification: a case of tuberculosis

In the forensic anthropology practice, bone diseases are rarely considered for personal identification. In this paper, we present a forensic skeletonized case with tuberculous bone lesions, for which bone pathology may provide an indicator for positive personal identification. Antemortem hospital records were available. Postmortem CT scans of the pathologically affected bones were performed, and 3D reconstructions with Global Illumination Reconstruction software (GIR) were realized, in order to confront antemortem and postmortem data. As a result, the juxtaposition and superimposition of antemortem and postmortem images evidenced several points of correspondence in the position, anatomical contour, character, and morphological characteristics of the bone lesions, thus demonstrating through a concrete case study the potential of morphological features of bone lesions for the personal identification of unknown deceased.

Using histomorphometry for human and nonhuman distinction: A test of four methods on fresh and archaeological fragmented bones

Positive identification of human remains is the very first step in anthropological analysis, and the task may be particularly difficult in the case of fragmented bones. Histomorphometry methods have been developed to discriminate human from nonhuman bones, based on differences in the size and shape of Haversian systems between the two groups. Those methods all focus on a very specific type of bone, section, and zone. Therefore, the objective of this study was to test the efficiency of four histomorphometric methods on a sample of fragmented bones. The sample is composed of 37 archaeological and fresh specimens, 25 nonhumans (Bos taurus, Equus caballus, Sus scrofa, Capreolus, Canis familiaris, Cervus elaphus, Ovis, and Capra) and 12 humans (Homo sapiens). Eight histomorphometric criteria were collected from all intact osteons visible on each fragment and then inserted into the corresponding discriminate function of each method. The results were compared with the real origin to establish rates of correct classification for each method. The methods of Martiniaková et al. (2006) and Crescimanno and Stout (2012) obtained very low percentages of good classification (32 % and 67 %). Those of Cattaneo et al. (1999) obtained 94 % correct classification, but only after a correction of the units of measurement for Haversian canal area in their formula. The methods of Dominguez and Crowder (2012) obtained an 86 % rate for well-classified specimens. Some of the methods tested here contain errors in the original publication that make them unusable in their current state. Plus, it seems that histomorphometric methods developed from specific areas are more difficult to apply to fragments. A reduced number of intact osteons analyzed may partially affect the reliability of the method by being unrepresentative of the entire microstructure. Therefore, this study demonstrates that one should be cautious with the use of histomorphometric methods to distinguish human and nonhuman fragmented bone until further research can refine these methods to achieve greater reliability.

Automatic rib unfolding in postmortem computed tomography: diagnostic evaluation of the OpenRib software compared with the autopsy in the detection of rib fractures

OBJECTIVES

The main objective of this study was to evaluate the diagnostic performance of the OpenRib software against the gold standard of autopsy in the detection of rib fractures. The secondary objective was to measure inter-rater agreement between each radiological reader.

MATERIALS AND METHODS

Thirty-six subjects who underwent postmortem CT and autopsy were included in this study. Rib fractures were first assessed during the autopsy by carefully dissecting and examining each rib. They were also independently evaluated by three readers using OpenRib software. This software produces from postmortem CT images a reformat of the rib cage and a display of all ribs in a single plane. Each reader was asked to determine if the rib was fractured and, if so, whether the fracture was single or multiple.

RESULTS

After exclusions, 649 ribs were included in the statistical analysis. The two readers with a similar level of experience showed a satisfactory inter-rater agreement and a sensitivity of 0.73 and 0.83 with a specificity of 0.95 and 0.91. However, the experienced reader diagnosed significantly more fractures than the autopsy and the other two readers (p < 0.001).

CONCLUSION

The use of automatic rib unfolding software in postmortem CT allows an efficient and accurate assessment of rib fractures and enables the diagnosis of fractures that cannot be detected during a standard autopsy. For now, this method seems to be the simplest that can be routinely performed; however, it requires training time in order to be sufficiently effective.

Fatal left coronary artery dissection due to blunt chest trauma: A case report and literature review

Blunt chest traumas can cause cardiac injuries and contusions. However, post-traumatic coronary artery dissections are quite uncommon. Here, we report the case of a 58-year-old woman who died suddenly 14 hours after a car accident. The macroscopic anomalies observed during the autopsy could not explain the death. However, microscopic examination revealed an acute left anterior descending coronary dissection, with a cleavage of the external layers of the media. The infiltration of polymorphonuclear neutrophils in the adventitia was a sign of the pre-mortem occurrence of this lesion and was compatible with the chronology of the accident. It was the only pathological finding that could explain the death, which was probably caused by a cardiac rhythm disorder triggered by acute ischaemia. We did not observe specific histological signs of cardiac necrosis, and we observed no significant atheroma, vasculitis or dysplasia in the left anterior descending coronary artery. We concluded that the dissection was secondary to the blunt chest trauma. Eleven case reports of lethal post-traumatic coronary dissection have been reported in the literature. Most of them involved male subjects aged <60 years old following a traffic accident, and were localised to the left coronary artery or one of its branches. Histological specific signs of myocardial ischaemia were present in only 33% of the cases. In this case, only microscopic examination could identify the dissection. This pathology may be underdiagnosed, and it highlights the necessity to undertake rigorous examination of the heart and coronary arteries following blunt chest trauma.

Estimating the time of death with infrared tympanic thermometer: a new prospective study in France

Very few studies are available on the use of infrared tympanic thermometer to estimate the postmortem interval. The purpose is to observe the decrease of the infrared tympanic temperature according to the postmortem interval under standardized conditions and to compare with the gold standard (rectal temperature). One hundred seventeen cadavers are included at the mortuary of the University Hospital of Nancy from 1 June 2015 to 1 June 2016. The infrared tympanic temperature is measured twice in each ear for each cadaver with a control of these measurements and the taking of rectal temperature for the part of them. In our experiments, the reproducibility of the measurements was excellent between both the ears of one body [intra class coefficient correlation [ICC] = 0.952], the right ear and the left ear with a same observer [ICC = 0.853] and the different observers [ICC = 0.830]. The postmortem interval is correlated with the infrared tympanic temperature (rho = - 0.483; p < 0.0001) with an average of 3.79 h ± 2.38 h. A calculation method is developed (postmortem interval = 16.14 - 0.39 × infrared tympanic temperature). Even if the correlation with the gold standard was correct (rho = 0.505), it is not associated with the postmortem interval (p = 0.0702) due to weakness of the sample. Despite early and only time point postmortem measurements, these results are promising and might impact the forensic science community by drawing the attention of researchers to the estimation of the time period since death and by developing a simple and non-invasive method, even for non-medical investigators at the scene.

[Child sexual abuse: Description of a French population having consulted in a forensic medical service between 2011 and 2015]

BACKGROUND

When child sexual abuse (CSA) is suspected, the detection of anogenital anomalies is rare. In France, since 2011, most clinical examinations of children for whom CSA is suspected take place in the forensic medical service (FMS).

OBJECTIVES

To describe a population of children examined for suspected CSA in the FMS of the Nancy Regional University Hospital Center.

PATIENTS AND METHODS

Children under the age of 18 who consulted for suspected CSA in the Nancy FMS between 2011 and 2015 were included. Demographic data as well as data from questioning, the physical examination, any further examination, and the medical conclusions were collected.

RESULTS

Three hundred and twenty-five girls and 79 boys were enrolled. The average age at the time the abuse was committed was 118.9 months. Two hundred sixty-nine (66.6%) children alleged fondling and 59 (14.6%) fellatio. Two hundred twelve victims (52.5%) described a penetration, 163 (76.9%) in the vagina and 73 (34.4%) in the anus. Significant bruises were found at the examination of 13 children, accounting for 2.5% of all victims. Thirty-four (11.7%) girls had lesions in the external genitalia and 28 (9.8%) lesions of the virginal membrane. One boy (1.3%) had a nonspecific lesion of the external genitalia. Six (8.2%) children alleging anal penetrations showed injury. The examiner concluded that clinical examinations were compatible with alleged facts for 253 (62.6%) victims. It was impossible to conclude for 116 (28.7%) children.

CONCLUSION

In the case of suspected CSA, the clinical examination is frequently normal. This examination must be performed by physicians trained in child abuse, under appropriate conditions. It is important not to jump to conclusions about the reality of the alleged facts. A multidisciplinary approach, with the cooperation of the medical, social, and forensics sector is necessary.

Cardiothoracic injuries after CardioPump CPR: a report of two cases and review of the literature

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

[Forensic examination of sexual assault victims: Medical aspects and associations with the legal outcomes]

OBJECTIVES

To describe the medical and legal characteristics of sexual assault victims and to highlight which aspects of the medical examination may be associated with a conviction of the alleged offender.

METHODS

This study included all women who consulted to the center for the victims of sexual assault in Nancy between 2008 and 2012 and who filed a complaint. Associations were evaluated with a logistic regression trying to explain the presence of a conviction at the end of the legal proceeding.

RESULTS

Three hundred seventy-six victims were included. Following aspects were associated with a reduced probability of conviction: the use of psychoactive substances, the prescription of an antiretroviral therapy and the presence of more than one assailant. The prescription of pain killers were contrarily related to the conviction of an assailant.

CONCLUSION

A detailed description, an interpretation of the physical injuries and the prescription of toxicological tests if needed are decisive in the outcome of the legal proceedings of victims of sexual assault. The education of populations at risk and the accompanying of the victims can reduce the delay of care and optimize the collection of evidence.

Skin wounds vitality markers in forensic pathology: An updated review

Wound age evaluation is one of the most challenging issues in forensic pathology. In the first minutes or hours, standard histological examination may not determine whether the wound was inflicted in the pre- or post-mortem period. While red blood cell infiltration is classically considered as a sign of vital reaction, several studies have shown that extravasation of blood cells may also occur after death and cannot be used as a reliable marker in the diagnosis of wound vitality. Numerous studies about wound vitality are available in the literature. They have evaluated markers involved in coagulation or inflammation, using various methods such as enzymology, molecular biology or immunohistochemistry. In this update, we first introduce some methodological principles. Then, we review the main studies available in the literature. Immunohistochemistry seems to be the most valuable method, given its easy application and the possibility to analyse the localization of the molecules of interest. Some markers are promising, such as CD15, TNFα, IL-6, IL-1β, TGFα or TGFβ1. Prior to their application in daily practice, these early results need to be confirmed with other studies, conducted by independent teams and integrating multiple controls. Most notably, the antibodies have to be tested in numerous post-mortem wounds. Indeed, a critical risk of overexpression in post-mortem wounds is present. Some promising markers have been later invalidated because of post-mortem false positivity. Finally, optimal sensitivity and specificity values could probably be reached by combining several markers, validated by large groups of pre- and post-mortem wounds.

Precise survival time and physical activity after fatal left ventricle injury from sharp pointed weapon: a case report and a review of the literature

Survival time and physical activity following fatal injury are especially important during investigation of homicide cases and the estimation of a victim's survival time and physical activity following a fatal injury from a sharp weapon is a commonly raised issue, particularly at trial. According to the literature, survival time and physical activity after cardiac damage are short-term estimates without high accuracy. We report the homicide case of a young man who died as a result of a left ventricle injury caused by a sharp pointed weapon. This case is based on evidence from a video surveillance camera that recorded the whole scene after the fatal injury: The victim showed an adapted physical activity for 38 s, although the left ventricle incision measured 2 cm. Despite several cases in the literature, it is not possible to correlate precisely the size of the wounds and the acting capability.

Biological and psychological predictors of posttraumatic stress disorder onset and chronicity. A one-year prospective study

BACKGROUND

Few studies have prospectively examined risk factors for posttraumatic stress disorder (PTSD) in the aftermath of a traumatic exposure. The aim of this study is to identify the concurrent influence of psychological and biological diatheses on PTSD onset and maintenance, taking into account socio-demographic factors and psychiatric antecedents.

METHODS

A total of 123 civilians (61.8% of women) recruited in emergency units, were assessed using validated instruments during the first week and then at 1, 4, and 12 months post-trauma. Baseline assessment included evaluation of the psychological diathesis (i.e. psychiatric history and peritraumatic distress and dissociation), and the biological diathesis [i.e. cortisol, norepinephrine, epinephrine, c-reactive protein, total cholesterol, HDL cholesterol, glycosylated haemoglobin, waist-to-hip ratio (WHR), body mass index, diastolic and systolic blood pressure (SBP), and heart rate].

RESULTS

Multivariate logistic regression analyses demonstrated both psychological and biological diatheses to be independent risk factors for PTSD. Peritraumatic distress and dissociation predicted onset (1-month) and mid-term PTSD (4-months), respectively. PTSD risk was associated positively with SBP and negatively with WHR, throughout the follow-up. In addition, a higher level of 12 h-overnight urinary norepinephrine independently predicted mid-term PTSD (4-months).

CONCLUSIONS

This prospective study shows that peritraumatic psychological and biological markers are independent predictors of PTSD onset with specificities according to the stage of PTSD development; the psychological diathesis, i.e. peritraumatic distress and dissociation, being a better predictor of short-term dysfunction whereas biological diathesis was also predictive of development and maintenance of PTSD.

Technical note: The two step procedure (TSP) for the determination of age at death of adult human remains in forensic cases

This paper presents the principles and results of TSP (the two step procedure), a comprehensive (combined) method of age estimation in mature human skeletal remains. The first step consists of the examination of the pubic symphysis using the Suchey-Brooks system for a "pre-choice". Then for SBS phases I, II, III, (young adults up to about 40) the age estimate is given using the chronological interval corresponding to each phase. For SBS phase is IV, V or VI (mature adults, about 40 to 60), then (second step) the dental method of Lamendin (using single rooted tooth) will be applied alone. Both methods are fast, easy to learn and to use (requiring no preparation except cleaning soft tissues from the pubic bone) and are not expensive, making TSP usable by all pathologists or anthropologists in any Forensic unit. It is also of great practical use in mass disaster and mass grave situation. After 15 years of use, a literature review and four evaluation studies we confirm that TSP is more accurate than any single method for aging adults and at least as good as more complicated combined methods. Despite its advantages TSP is, like all other aging methods, not efficient in adults over 65 years of age.

FVIIIra, CD15, and tryptase performance in the diagnosis of skin stab wound vitality in forensic pathology

The timing of skin wounds is one of the most challenging problems in forensic pathology. In the first minutes or hours after infliction, histological examination fails to determine whether a wound was sustained before or after death. The aim of this study was to evaluate the use of three immunohistochemical markers (FVIIIra, CD15, and tryptase) for the interpretation of the timing of cutaneous stab wounds. We evaluated these markers in intravital wounds from autopsy cases (n = 12) and surgical specimens (n = 58). As controls, we used normal skin samples from autopsies (n = 8) and an original ex vivo surgical human model of recent postmortem wounds (n = 24). We found overexpression of FVIIIra in 100 % of vital wounds, but also in 53 % of the controls. The number of CD15-positive cells was higher in wound margins than in internal controls (p < 0.0001) and was significantly correlated with the time interval between incision and devascularization (p = 0.0005; minimal time for positivity, 9 min). Using the anti-tryptase antibody, we found that the mast cell degranulation rate was higher in wound margins (p < 0.0001) and correlated with the time interval (minimal time, 1 min). The sensitivity and specificity for the diagnosis of vitality were respectively 100 and 47 % for FVIIIra, 47 and 100 % for CD15, and 60 and 100 % for tryptase. The inter-observer agreement coefficients were 0.68 for FVIIIra, 0.90 for CD15, and 0.46 for tryptase. Finally, we demonstrated that these markers were not reliable in putrefied or desiccated specimens. In conclusion, CD15 and tryptase, but not FVIIIra, may be useful markers for differentiating recent antemortem from postmortem injuries.

[Post-rape pregnancy]

A rape is a traumatizing circumstance for the victim. This aggression often has, regrettably, immediate repercussions, and then medium and long-term ones. Its complications are psychological, but also sometimes somatic, like pregnancy. Through an international literature review, and the study of the national legislation, we will summarize the main essential elements of the medical and forensic care of a pregnancy arising after a rape.

Organ volume measurements: comparison between MRI and autopsy findings in infants following sudden unexpected death

OBJECTIVE

To assess the accuracy of a semiautomated 3D volume reconstruction method for organ volume measurement by postmortem MRI.

METHODS

This prospective study was approved by the institutional review board and the infants' parents gave their consent. Postmortem MRI was performed in 16 infants (1 month to 1 year of age) at 1.5 T within 48 h of their sudden death. Virtual organ volumes were estimated using the Myrian software. Real volumes were recorded at autopsy by water displacement. The agreement between virtual and real volumes was quantified following the Bland and Altman's method.

RESULTS

There was a good agreement between virtual and real volumes for brain (mean difference: -0.03% (-13.6 to +7.1)), liver (+8.3% (-9.6 to +26.2)) and lungs (+5.5% (-26.6 to +37.6)). For kidneys, spleen and thymus, the MRI/autopsy volume ratio was close to 1 (kidney: 0.87±0.1; spleen: 0.99±0.17; thymus: 0.94±0.25), but with a less good agreement. For heart, the MRI/real volume ratio was 1.29±0.76, possibly due to the presence of residual blood within the heart. The virtual volumes of adrenal glands were significantly underestimated (p=0.04), possibly due to their very small size during the first year of life. The percentage of interobserver and intraobserver variation was lower or equal to 10%, but for thymus (15.9% and 12.6%, respectively) and adrenal glands (69% and 25.9%).

CONCLUSIONS

Virtual volumetry may provide significant information concerning the macroscopic features of the main organs and help pathologists in sampling organs that are more likely to yield histological findings.

Sudden infant death syndrome (SIDS): characteristics of deaths since the fall in SIDS in the French region of Languedoc-Roussillon

The characteristics of sudden infant death syndrome (SIDS) in the French region of Languedoc-Roussillon from 2003-2008 were examined in a retrospective study of two groups classified as unexplained sudden unexpected death in infancy (SUDI) (SIDS, n = 27) or explained SUDI (n = 22). The interval between the time the baby was last observed alive (time of last feed) and the discovery of death was evaluated. In SIDS, 67% (18/27) of deaths were discovered during the day (09:00-21:00 h) mostly within 4 h after feeding (66%). In explained SUDI, 68.2% of deaths were discovered at night and time intervals between the last feed and discovery of death were longer (mean 7.1 h, p<0.01). Most SIDS deaths were discovered during the day and explained SUDI discovered at night. Variations in time between the last feed and discovery of death in the two groups may result from differences in parental attentiveness during the day and at night.

Age at death estimation in adults by computer-assisted histomorphometry of decalcified femur cortex

In 1965, Kerley pioneered histomorphometry of bone as an aging method. The technique has been modified by several authors, and some have used computer-assisted image analysis. Undecalcified bone sections used in these methods are obtained with a diamond wafer saw or by grinding the sections manually or automatically with abrasive paper. In the present study, we examined the application of histomorphometry to decalcified bone sections, routinely obtained in every pathology lab, from paraffin blocks cut with a standard microtome. This study was divided into two parts: in the first, we tested different decalcifying methods to determine the most appropriate for femoral bone; in the second part, we used computer-assisted histomorphometry to estimate age at death in 29 samples of femoral bone. We measured intact osteon density (N.On), fragmented osteon density (N.On.Fg) and percentage of lamellar bone surface per unit area (Lm.B.Ar) in the cortex of the femoral midshaft, on four or 20 fields per section. We found that 20% nitric acid solution at room temperature proved to be the best decalcifying method, with a mean decalcification duration of 1 week. Fragmented osteon density was found to be the morphometric feature most closely correlated with age, followed by intact osteon density; Lm.B.Ar. did not increase accuracy. The best accuracy (4.1 +/- 3.5 years) was obtained for individuals under the age of 70 when measurements of 20 fields were used for the analysis. For all individuals, the inaccuracy was 6.1 +/- 6.2 years and 8.1 +/- 8 years, with 20 and four fields respectively. The present study shows that decalcification of bone sections can be used for age estimation at death. This procedure is particularly useful in case of mass disaster as it is easily done in any pathology department.

Infrared tympanic thermography as a substitute for a probe in the evaluation of ear temperature for post-mortem interval determination: a pilot study

Reported methods which have been used to measure tympanic temperatures on cadavers up to now are quite invasive. They involve the use of a probe which can perforate the tympanic membrane and frequently causes bleeding from the ear. For this reason a non traumatic method for estimating tympanic temperature should be applied. Infrared tympanic thermometry seems to be a plausible option. Reliability of infrared tympanic thermometry (ITT) has been largely assessed on living individuals but only one author up to now has assessed its applicability for post-mortem interval determination. Thus the authors set out to test the difference between ear temperatures taken with a probe vs. ITT, differences between left and right ear and reproducibility of measurements of ITT. The aim of the study was to verify whether ITT could be a plausible option for measuring ear temperature for PMI estimation. Ear temperatures were taken on 25 cadavers (15 males, 10 females). Temperatures were taken alternately by similarly trained personnel by two technical methods (Checktemp 1 thermocouple probe and First Temp Genius infrared thermometer) for a total of 93 measurements. Statistical analysis of the data was performed using SAS statistical software. The range of temperature measured was from 20 to 28 degrees C, statistical analysis revealed no differences within the two technical methods, both for right and left ear (ITT: 22.33+/-0.35 vs. probe: 23.08+/-0.25; P=0.087). The study shows the ITT method can be considered as a possible alternative to the probe for measuring ear temperative and further studies should be considered.

Cooling rates of the ear and brain in pig heads submerged in water: implications for postmortem interval estimation of cadavers found in still water

The state of the art for determining postmortem interval in submerged bodies reflects a serious lack of studies. The objectives of the present study were therefore to study cerebral and tympanic cooling in water and its relation to cooling in air, in a pig model. First of all, cerebral and tympanic cooling on a single head and on an entire body were compared and proven to be very similar in air and in water. Nine pairs of heads were then exposed to 9 temperature intervals from 0 degrees C to 20 degrees C. For every set temperature, one head was placed in water, the other in "ambient" air in a thermostatic chamber. Ear and brain temperature were simultaneously measured every 10 minutes during 8 hours. Results showed that both in air and in water, cooling curves were almost exponential, regardless of the site (ear or brain) or the environmental temperature. Cooling was always more rapid in water than in air. Cerebral and tympanic cooling always had a correlation coefficient of 0.98-0.99. Assuming that these cooling patterns are applicable to man, this research may provide a starting point for postmortem interval estimation in submerged cadavers.