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Introduction: Several studies have suggested a circadian and septadian pattern of incidence of sudden cardiac death with a morning peak and a Monday peak., Objective: To analyze the circadian and septadian pattern of occurrence of sudden cardiac death in the eight northern Tunisian governorates., Methods: We prospectively collected epidemiological and autopsy data of sudden cardiac death victims occurring in the northern region of Tunisia between January 2013 and December 2019., Results: The population included 1834 men (79.6%) and 468 women (20.4%) with a mean age of 56.5 ± 14 years. Smoking (53.9%) was the most prevalent cardiovascular risk factor. One-fifth (20.9%) of victims had known heart disease, and 3% had a family history of sudden death. ischemic heart disease was the leading cause of sudden death (46.8% of cases). One- fourth (25.7%) of autopsies were negative. Analysis of the circadian pattern of occurrence of sudden cardiac death identified a peak (36.1%, p < 0.001) between midnight and 6 am. This nocturnal excess mortality was significant (p < 0.001) and independent of sex (34.1 % in men and 43.8 % in women) and cause of death (39.3 % of cases of sudden ischemic death and 33.3 % of cases of nonischemic death). Moreover, there was a significant septadian variability in the occurrence of sudden death (p: 0.0015), with a peak on Friday (15.8 %, p: 0.042)., Conclusion: This study showed a peak of sudden death between midnight and 6 am, and on Fridays, confirming the modification of the classic circadian and septadian pattern of sudden death occurrence. These results may help optimize the deployment of emergency mobile teams and structures during the most vulnerable periods., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Initial medical certificate is a descriptive medical and legal document whose purpose is to prove the existence of a damage and to enable the victim to access his or her right. The purpose of our study was to study the content and to evaluate the writing quality of initial medical certificates. We conducted a retrospective and descriptive study over an 18-month period, from January 2017 to June 2018. We collected data from 450 initial medical certificates at the Forensic Medicine Department of the Charles Nicolle University Hospital in Tunis. The quality of the initial medical certificates was assessed using a template that allowed to assign them a score out of 30. A mean score was mainly assigned to initial medical certificates Template scores ranged between 9.5 and 27.5/30 with an mean of 18.59/30. General practitioners and specialist physicians, such as ophthalmologists, neurosurgeons and doctors using the support provided by the Ministry of Health wrote better certificates. Similarly, we noted better quality of writing when certificates dealt with intentional assaults and injuries. Our study shows that the majority of initial medical certificates does not conform to editorial guidelines. These shortcomings are probably related to the fact that doctors have never received adequate medical-legal training., Competing Interests: Les auteurs ne déclarent aucun conflit d'intérêts., (Copyright: Chahnez Makni et al.)

Background: Sudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death., Methods: We prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed., Results: The study population included 1834 men and 468 women with a mean age of 56.5±14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P<0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P<0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P<0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P<0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P<0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes., Conclusions: Women had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objectives: Bacteriospermia may result in male hypofertlity. Indeed, 60% of patients treated by Assisted Reproductive Techniques had a local infection or inflammation of genital tract. However, direct effects of bacteriospermia on semen parameters remain controversial. The aim of our work was to explore the effect of bacteriospermia on sperm parameters among patients consulting for hypofertility., Methods: A retrospective comparative study of two groups: a group of 70 patients with bacteriospermia (group 1) and a control group of 70 patients without bacteriospermia (group 2). For these groups, we studied the standard semen parameters (seminal volume and viscosity and spermatozoa count, initial and secondary mobility, vitality and morphology). Comparison of these parameters was made by the Chi 2 test and the Fisher test., Results: The mean age of our population was 40.4±6.7 years. There was no significant difference between ejaculate average volume in the 2 groups (group B: 2.78mL versus group A: 2.92mL with P=0.2). Similarly, for the viscosity no difference was noted (P=0,68). The altered parameters in the presence of bacteriospermia were mean concentration and sperm motility (P=0.001 and P=0.049 respectively). The prevalence of secondary asthenospermia was higher in the presence of bacterospermia (P=0.006). No statistically significant differences were observed for morphology and vitality of spermatozoa (P=0.276 and P=0.075 respectively). The leucospermia was associated with bacteriospermia in 10% patients. Ureaplasma urealyticum was the germ most found (45.7%) followed by Streptococcus and Staphylococcacae (20.3% for each), Gram negative rods accounted for 12.9%, while Corynebacterium spp was isolated only in 4,3% patients. U. urealyticum was associated with hypospermia in 33% of cases (P=0.031). Spermatozoa motility was significatively decreased not only in the presence of this bacteria (FT=0.002) but also when cultures were positive for Streptococcus (0.04) and Corynebacterium (P<0.001). Morphological abnormalities were also noticed with Streptococcus with index of teratozoospermia of 46% versus 19% in the 2nd group (P=0.046)., Conclusion: Bacteriospermia may impair sperm parameters. The treatment of this affection seems to improve sperm fertilizing potential. In addition, it could prevent contamination of culture media., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Several studies have suggested a relationship between weather parameters and the occurrence of sudden cardiac death., Aim: The aim of this work was to study the impact of changes in temperature and humidity level on the occurrence of sudden cardiac death in the north of Tunisia., Methods: it's an autopsic study that included all victims of sudden cardiac death occurring in northern Tunisia between October 2010 and September 2012. The minimum, maximum and average of daily temperatures and humidity during the study period were recorded and compared with the monthly variation in the occurrence of sudden death., Results: The study population included 392 men and 108 women with a mean age of 52.2 + / - 15.8 years.The highest rate of sudden death (37%) was observed at ambient temperatures below 15 degrees and only 4.2% of deaths occurred at temperatures above 30 degrees ambient temperatures (p <0.001). Among the population aged over 60 years, the highest mortality rate (47.3%) were recorded at temperatures below 15 degrees, while 35.5% of young patients under 40 years died during periods with temperatures between 20 and 30 degrees and 56.8% of deaths occurred in the humidity levels between 60 and 78% ., Conclusion: In the north of Tunisia where the climate is temperate, a temperature drop below 15 degrees was significantly associated with a sudden cardiac death. This excess winter cardiac mortality was more pronounced in the elderly.

Background: The sudden cardiac death remains a major public health problem. Several studies have reported weekly variation of this dramatic event., Aim: The aim of this work is to determine the day-of-week variability in sudden cardiac death in northen Tunisia., Methods: We prospectively collected clinical, socio demographic and autopsic data of victims of sudden cardiac death occurring in the northern Tunisia between october 1 st ,2010 and september 30,2012., Results: The study population included 392 men and 108 women with a mean age of 52.27 + / - 15.8 years. Three quarters of the victims was sedentary, 57.9% were smoker and a family history of sudden death was identified in 9.8% of cases. The vast majority of deaths had occurred either in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the leading cause of death with 267 cases (53.4%); however a negative autopsy was found in 13.9% of victims. The highest sudden death occurrence was on Sundays (17.8%) and the lowest on Mondays (11.4% p: 0.01).The same weekly variation was noted among both men and women , and also in victims > 60 years, a minimum of events occurred on Mondays (11.6%) and a maximum on Sundays (21.9%). In addition, we found the same peak of mortality on Sunday (18.8%) in young adults and the nadir on Monday (10.3%)., Conclusions: The present study demonstrates marked variation in the occurrence of sudden cardiac death in the northern Tunisia with peak on Sundays and nadir on Mondays. No age or gender- related differences were found in weekly variation of sudden death.

Background: Several studies have reported a circadian variation in the occurrence of sudden cardiac death., Aim: To analyze the circadian, weekly and seasonal variations of sudden cardiac death occurring in northern Tunisia., Methods: We prospectively collected epidemiological and autopsic data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between October 2010 and September 2012., Results: The study population included 392 men and 108 women with a mean age of 52.3±15.8 years. Physical inactivity and smoking were the most common risk factors, they accounted for 76.4% and 57.9% respectively. Family history of sudden death was identified in 9.8% of victims. The vast majority of deaths occurred in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the most frequent causes of death (269 cases). Sudden cardiac death was homogeneously distributed over the day. A maximum of events occurred on Sundays (17.8%) and a minimum on Mondays (11.4%), we also recorded an excess cardiac mortality in winter with a peak in December and a nadir in September (13% vs. 4.4% P=0.0001)., Conclusions: In northern Tunisia, under Mediterranean climate, a winter excess cardiac mortality was found. Sudden cardiac death was homogeneously distributed over the day, however, an excess of mortality was recorded over the weekend with a nadir on Monday., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Purpose: To develop profile of the victims and to study circumstances, causes of death and autopsy findings., Methods: Retrospective study of cases of sudden death in sport activity whose autopsy was performed in forensic department of Tunis, between January 2005 and December 2009., Results: During study period, 32 cases of SD in sport activity were recorded. These are amateur athletes predominantly male (84% of cases). Victims are aged between 15 and 79 years with an average age of about 33.16 years. Young subjects whose age is less than 35 years representing 68.7% of cases. 9.3% of victims had a family history of SD and 18.7% of cases had a known cardiac history. The sports most involved are running (40.6% of cases), football (31.3% of cases) and dance (12.5% of cases). Sixty-nine percent of victims died during sports activities. Presence of witnesses was noted in all cases; however, none of these witnesses has begun resuscitation. Cause of death was cardiac in 84.4% of cases. In young athletes, hypertrophic cardiomyopathy is the leading cause (nine cases), followed by arrhythmogenic right ventricular dysplasia (three cases). Among other causes, there is the myocardial bridge, congenital anomalies of the coronary arteries, aortic dissection and dilated cardiomyopathy. Beyond 35 years, coronary artery diseases represent the cause of death (nine cases). Only case of death secondary to non-cardiac disease occurred after a severe asthma attack. In four cases (12.5%), no cause of death was identified after a complete autopsy accompanied by further investigations. The cause of the death was imputed to a rhythmic pathology., Conclusion: This is the first study dealing with autopsy in SD in sport have provided a specific profile of victims. Other studies on larger samples and using standardized autopsy protocols are needed., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Carpal tunnel syndrome is the most frequent of tunnel syndromes in the field of the professional sphere. It is related to repetitive movements of flexion-extension of the wrist and fingers or to a support on the heel of the hands., Aim: To determine the posts in a risk and to specify the modalities of guaranteed reimbursement of professional carpal tunnel syndrome., Methods: A retrospective and descriptive study of 27 medical files of employees indemnified for professional carpal tunnel syndrome registered in the medical control services of the social security office in charge of medical insurance of Tunis and Sousse during a period of 10 years (1995-2004)., Results: There were 24 women and 3 men with the average age of 40 years all occupying posts in a risk. Their average time of service is 15 years. Tow-thirds of them work in the clothing and textile industry. The attack is bilateral in 13 cases. Nightly acroparaesthesia rules the clinical rate (44.44% of cases). Motor disorders are noted in the quarter of cases. The electromyogram had confirmed diagnosis in all of cases. The previous state study put in evidence the antecedent of carpal tunnel syndrome in 5 cases and diabetes in one case. Twenty-one patients had profit of permanent partial incapacity with a rate varying from 3 to 25%. Five had got a transfer of working place and one stayed in the same post with a half-time work., Conclusion: The professional origin of carpal tunnel syndrome must be called up in front of an activity in a risk. The reparation is done according to picture 82 of occupational diseases.

We report the case of a collective intoxication by ingestion of a mushroom "Lepiota brunneoincarnata" at the origin of the death of four members of the same family aged between 3 and 15 year old. We discuss the physiopathology and the prognosis factors of such intoxications through these four observations which highlight the clinical signs, biological disturbances due to the intoxication, autopsy and histology findings. The first observation concerns a six year old girl. She presented an abdominal pain with vomiting and aqueous diarrhea. She died during the early phase of the intoxication (seven hour after the ingestion of the mushroom), death was secondary to an acute dehydration. The three other observations concern children aged between three and fifteen year old. They presented typical phalloïdian syndrome symptoms evolution with first gastro-intestinal and then hepatic signs. They died after a period varying between three and eleven days without being able to profit from a hepatic transplantation. The autopsy findings showed the presence of an important cerebral edema and hemorrhagic zones of the liver in all the cases, the presence of hemorrhagic complications in two cases. Histology investigations showed the presence of a diffuse centrilobular and periportals necrosis.

Background: Community-acquired pneumonia due to Panton-Valentine producing S.aureus is a serious infection recently described. Many cases have been reported worldwide., Aim: We report here the first case in Tunisia., Observation: Our patient is a previously healthy fourteen-year-old girl hospitalized for bilateral hypoxemic pneumonia. The clinical course had violently deteriorated two hours later, marked by massive hemoptysis that lead to rapid degradation of her hemodynamic state and death. Toxicologic research and bloodcultures were negatives. A post-mortem pleural specimen culture yielded a meticillin-resistant Staphylococcus aureus strain that carried the Panton-Valentine leucocidin genes., Conclusion: Community-acquired pneumonia due to Panton-Valentine producing Staphylococcus aureus is a serious affection unrecognized in our country. Thus, this pathogen must imperatively be included in the spectrum of those responsibles for pulmonary infections in children and young adults

Objective: The aim of our work was to study cardiac sequelae of penetrating cardiac injuries., Material and Methods: It is a retrospective study including nine patients (eight men and one woman with an average age of 26.6 +/- 7.4 years) hospitalised between January 1st, 1988 and December 31, 2002 in cardiovascular surgery department of Tunis Rabta hospital for heart wounds., Results: It was stab wounds in all patients. Heart lesions concerned primarily the right ventricle. In admission, two patients had cardiac tamponade and seven were in shock. Beating heart surgery without cardiopulmonary bypass in all patients performed surgical repair and it consisted in simple suture. Functional symptoms were observed in five patients at late outcome. Five patients had heart sequelae. It consisted of conduction abnormalities (right bundle branch block) in five patients. One patient had a small ventricular septal defect. Finally, partial permanent disability rates were less than 10%., Conclusion: Cardiac sequelae of penetrating cardiac wounds have good prognosis with the exception of a small partial permanent disability rate. Their prevention must be based on the fight against the urban violence and on the good initial management.

Background: In Tunisia, cardiovascular diseases are the leading causes of death (30%) and a few studies conducted in the population have demonstrated that the level of their risk factors is increasing. For policy makers, the health system impact of these diseases is currently a crucial issue. The National Public Health Institute has identified the implementation of a morbidity register as a priority., Methods: A CVD morbidity register is implemented since 2001, in 3 different geographical populations having contrasted levels of health status (Tunis, Ariana and Ben Arous). The 3 regions are covering about 2 millions inhabitants which is the fifth of the overall Tunisian population. All coronary heart events occurring among adults 25 years old and above in the 3 populations are recorded. The diagnosis of events, case fatality and classification are defined according to MONICA criteria. The data are recorded from public and private hospitals, death certificates and autopsies., Results: During the year 2001, the total number of myocardial infarction events was estimated at 942: in men, the age-standardized rates were 163.8/100000 in Tunis population vs. 161.9 in Ariana and 170.5 in Ben Arous. In women, the rates were respectively 43.4, 61.1 and 44.6. Medical causes of death registration was the most crucial problem in spite of the implementation of the death certificate designed according to WHO model. Specific surveys for clinical assessment and surveillance of risk factors were conducted in the register populations., Conclusion: It is the first time that data on coronary heart disease incidence and fatality are available in Tunisia through this experience which highlights the practical difficulties experienced in registering and coding coronary events in a developing country. The data source quality should be improved and the register should be integrated in the local health system.