R. Torrents

Manual strangulation: experimental approach to the genesis of hyoid bone fractures.

Discovery of a fracture of the hyoid bone during forensic autopsy is a feature that raises suspicions of constriction of the neck. Studies have shown the influence of gender and build of the individual on the morphology of this bone. Our aims were to confirm these findings and to develop an experimental protocol for simulating manual strangulation in order to determine the force required to fracture the hyoid bone and the influence of anthropometric parameters on this force. A total of 77 intact hyoid bones were obtained, scanned, modeled, measured and embedded in resin. Using a hydraulic press, we applied force to the distal extremity of the greater horn. The relationships between the parameters of sex, weight and height of the subject, anteroposterior length of the hyoid, width between the greater horns, angle, fusion of the greater horns and force applied were analyzed. Our study confirmed sexual dimorphism, shown by greater length in males (>37.8 mm) than in females, and a larger angle in females (a shorter bone with a width>43.7 mm and an angle>31°01). The study confirmed the positive correlation between the length of the hyoid and the weight and height of the subject (p<0.05). Sixty-seven of the 77 hyoid bones fractured during the experiment (87% fracture rate). Of the fractures, 48% occurred at the junction between the body and the greater horns, 49% in the greater horns (mean distance from the distal extremity of the horn 17.33±4.37 mm), and 3% in the median part of the body. No significant association was found between gender and type of fracture, or between fusion or non-fusion of the horn (p>0.05). Fused bones were not more susceptible to fracture than non-fused bones. Fracture occurred at a mean force of 30.55 N (±18.189). Multiple linear regression showed a significant negative correlation between force required for fracture and age, weight and height of the subject, anteroposterior length and angle. The younger the individual, the slighter their build, the longer the bone and the smaller the angle, the greater the force required to fracture the hyoid bone.

Child poisonings with methadone in France: A 6-year prospective national survey since the availability of capsules in 2008.

Abstract Background. Methadone for opiate substitution was available only in syrup formulation prior to 2008. In 2007, the French Health Authorities made solid forms available. A national survey was performed in order to evaluate the modification of child poisonings induced by such a new pharmaceutical formulation. Methods. A prospective study was set up (April 15, 2008 to April 15, 2014) with the analysis of cases of unintentional ingestion of methadone by patients under 18 years old and managed by the 10 French poison control centers at the national level. As soon as a new pediatric exposure was recorded in the informatics data bank of the Poison Centers, a telephone survey was performed by the Marseilles’ Poison Center to obtain the evolution and all the necessary details. Results. 87 cases of child poisonings with the 2 forms were reviewed (syrup, 56 patients; capsules, 31 patients). Comparison shows that patients were similar for both formulations (no significant difference concerning age [median 2 years], sex ratio [M/F 0.85], previous history, and ingested quantities of methadone). There was a similar severity profile with both formulations proving that methadone can lead to lethal child intoxications (1 death with capsules and 4 with syrup). The relative risk of pediatric accidents is also the same with 2 formulations, leading the health authorities, in collaboration with laboratories, to design and distribute flyers. The aim was to inform patients who are also parents about the high danger risk of their treatment for children, whatever the formulation of methadone present in the house. Discussion. The results of this survey were similar to those of another national study by the French Poison Centers concerning adult suicide attempts with methadone. Both prospective studies led to the conclusion that methadone must be considered as a dangerous molecule for patients and their families. The recent availability of a solid formulation in France did not change the profile of poisonings with this opiate substitute treatment.

Transmission of force to the hyoid bone during manual strangulation: Simulation using finite element numerical models

INTRODUCTION Strangulation is a medicolegal form of mechanical asphyxia, and can be difficult to identify if cutaneous damage to the neck is limited. We began by creating a numerical model of a hyoid bone with adjustable anthropometric parameters and then subjected our model to compression simulating a precision grip on the neck from the front. MATERIALS AND METHODS We selected six bones from the 77 hyoid bones contained in the database we created during a previous study led by our laboratory, in which we demonstrated the sexual dimorphism of this bone and identified the minimal force required for fracture. The anthropometric characteristics of these six bones (angle, length and width) corresponded to those of the 10th, 50th and 90th percentiles from cluster 1 (male individuals) and cluster 2 (female individuals), respectively. After enhancing, developing and meshing the selected 3D models, we analysed and reproduced simulation conditions that were as close as possible to the in vivo conditions of neck strangulation from the front (area of pressure on the bone, tissue environment, and biological variability of this bone). RESULTS We modelled the six numerical hyoid bone models using the finite element method. For all models, the simulation of mechanical pressure applied to simulate anterior strangulation resulted in fractures. The forces required to produce these fractures matched the results obtained in the experimental testing of dissected hyoid bones. CONCLUSION Six finite element numerical models were created, covering the anthropometric morphological variability of the hyoid bone. These six models enabled numerical simulation of the in vivo behaviour of a hyoid bone subjected to one-handed strangulation.

Adverse consequences of low-dose methotrexate medication errors: data from French poison control and pharmacovigilance centers

OBJECTIVE The objectives of this study are to carefully describe the context of methotrexate medication errors, to details medical consequences and management approaches, and to determine the rate of fatal outcome. METHODS Data on methotrexate medication errors were obtained from the French network of poison control and pharmacovigilance centres, which collected and documented reported drug-induced adverse effects. Cases were included if the intake was more than 2-fold the intended weekly dose or a weekly cumulative dose ≥ 30 mg and a follow-up of at least 4 days after the last dose. Data were analysed for demographics, treatment indication, prescribed dose, drug interactions, clinical complications and medical outcomes. RESULTS Seventy four patients were included. The causes of methotrexate errors resulted from an erroneous prescription renewal (23.3%), incomprehensiveness of the weekly schedule by patients or at-home caregivers (56.2%) and administration of a wrong dose by a health care professional (20.5%). Of the 70 patients who took methotrexate daily, the mean daily dose received over the whole duration of the error was 9.6 ± 4.1 mg (range 2.5-22.5) with a mean duration of the error of 11.7 ± 12.2 days (range 2 to 90). Thirteen (18%) patients remained asymptomatic and 61 (82%) developed complications of which 46 (62.2%) were severe. Nine (14.8%) patients died within 11 to 45 days after the first dosing error. Compared to patients with no or mild symptoms, those with severe symptoms were more likely to be older (75.6 ± 10.8 vs. 69.5 ± 12.9 years) and to be exposed to a higher cumulative dose (94.8 ± 46.2 vs. 68.0 ± 45.7 mg). CONCLUSIONS This study confirms that dosing errors with methotrexate can be lethal and persisted despite several warnings from drug agencies. Further measures are awaited from the European Medicine Agency.

Suicide Attempt by Ingestion of Rotenone-Containing Plant Extracts in French Polynesia: A Case Report

Figure. Derris trifoliata. Developing seedpods. Photograph by: Vengolis. Creative Commons Attribution-Share Alike 3.0. To the Editor: Several species of the Fabaceae family contain ichthyotoxic rotenoids, which are traditionally used for fishing in numerous tropical regions. These plants are collected, crushed up, and spread into small rivers to sedate fish downstream within 10 to 20 minutes. The stunned fish can then be easily harvested by the fishermen and safely eaten. Rotenone is also toxic to arthropods, and as a consequence, was widely used as an insecticide in the early 20th century. Human ingestion of rotenone and rotenoids at low concentration is relatively nontoxic, causing mild gastrointestinal symptoms, whereas high concentrations can result in neurotoxicity observed as seizures, coma, and respiratory failure. We report the case of a man who attempted to commit suicide by drinking an extract of rotenone-containing plants. To our knowledge, this is the first reported case of poisoning with this plant in scientific literature from French Polynesia. (Figure.) On the Nuku Hiva Island (one of the Marquesas Islands in Northern French Polynesia), a 63-year-old man with no significant past medical history attempted to commit suicide by ingesting an extract made from 10 leaves of a plant identified as Derris trifoliata (family Fabaceae), which was confirmed by a digital picture sent to the regional poison control center. Twelve hours later, he again drank a similar dose of the extract. Two hours following this second ingestion, the patient presented to the emergency department with generalized seizure activity and a Glasgow Coma Scale of 3. No acute intracranial abnormalities were noted on the computerized tomography (CT) scan of the brain. Liver function tests were carried out and results were consistent with mild hepatotoxicity, with enzyme levels of 92 UI/L for aspartate aminotransferase (AST), and 108 UI/L for alanine aminotransferase (ALT). The patient was stabilized, orally intubated, ventilated, treated with benzodiazepines, and transferred by helicopter to the closest tertiary care unit in Papeete Hospital. To prevent further liver toxicity, a 24-hour treatment regimen of N-acetylcysteine (intravenous injection of 100 mg/kg) was administrated for hepatic protection. On day 2, the liver function tests improved, there were no further neurological symptoms, and the patient began to breathe spontaneously. In medical literature, several self-poisonings have been reported after ingestion of concentrated forms of rotenone used commercially as an insecticide. We are aware of only 2 published cases in China and French Guiana describing ingestion of rotenone-containing plants. The typical clinical presentation is characterized by gastrointestinal symptoms (abdominal pain, vomiting, diarrhea), followed by dizziness, loss of consciousness, and respiratory failure. Some patients also experience liver toxicity associated with metabolic acidosis. Although our patient suffered from mild hepatotoxicity, there were no sign of metabolic acidosis. In our report, the patient showed classic signs of rotenone poisoning, which included coma, respiratory failure, and hepatotoxicity after ingesting an extract of Derris trifoliata. Self-limited seizure activity was unique to our patient. When patients survive this poisoning, they typically recover quickly. The therapeutic protocols are primarily based on symptomatic treatment including endotracheal intubation and ventilatory support. As a conclusion, travelers and health care providers in French Polynesia, as well as the South Pacific Islands should be aware of this plant and its potential toxicity.

A rarely described use of neostigmine in a case of acute anticholinergic poisoning

La Presse Medicale - In Press.Proof corrected by the author Available online since samedi 5 novembre 2016

Envenomation by caterpillars of the genus Megalopyge in French Guiana with an atypical clinical presentation, based on three observations

Summary of 3 cases of Megalopyge caterpillar bite collected in French Guiana.Case Age (years) Envenomation areaClinical and biological features Treatment Evolution1 51 Dorsal side of the 4th finger of the right handInstant and intense pain with finger mobility limitationVagal faintness Localized and facial swellingAnalgesics Corticosteroids AntihistaminesHealing without sequelae in few hours2 19 Right hand and arm Instant and intense pain with finger mobility limitationAnalgesics Corticoster-oids Local anesthetic InjectionHealing without sequelae in few hours3 31 Righ thigh and wrist Intense pain, CPK at 10 N Analgesics Corticosteroids Antihistamines Local anesthetic InjectionHealing without sequelae in few hours Fig. 1. Pictures of the genus Megalopyge caterpillar involved in case 3 (colour version of this figure can be found in the online Clinical Toxicology Downloaded from informahealthcare.com by Hopital Salvator on 08/31/15 version at www.informahealthcare.com/ctx).For personal use only.