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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.)

Background: Sudden cardiac death (SCD) represents a frequent etiology of sudden death. It represents a major public health issue. Few data about SCD in women are available from the Arab world. Our work aimed to analyze the risk factors of sudden cardiac death in Tunisian women in comparison with men., Methods: A cross-sectional retrospective study including all sudden cardiac death cases, conducted in the Forensic Medicine Department of the main teaching hospital of Tunis, between January 2010 and December 2019., Results: We counted 417 cases of sudden cardiac death in women representing 17.5% of the total number of sudden cardiac deaths recorded during the study period. The average age was 60.03 ± 15.01 years with a predominance of urban married women. The most frequent cardiac risk factors were high blood pressure (50%), diabetes (36.2%), and cardiac disease history (34.2%). Predominately married women with a history of High blood pressure and diabetes, had a high predictive of sudden cardiac death., Conclusion: Cardiac sudden death is no longer a male focused issue. As a matter of facts Rates of SCD in women are rising with a different pattern. We will highlight the importance of adopting specific preventive measures of SCD in female., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Sharp force injuries represent a major constituent of physical assaults and homicidal fatalities, especially in countries with strict firearm legislations. In forensic investigations, the examination of homicidal sharp force cases remains a challenge for both determining the cause and manner of a death. The aim of this study is to analyze the patterns of homicidal sharp force cases in Northern Tunisia. We perform a descriptive study with a retrospective data collection over an 11-year period (January 2007-December 2017). During the study period, 405 cases of homicidal sharp force casualties were observed. The mean age was 33.9 years, with a range of 2 months-89 years. We note a male predominance (male to female ratio of 4.7), most of who were single (91.2%). The casualties lived mainly in urban areas (68.4%) and were unemployed or daily workers in 61% of cases. Assaults occurred mainly during summer (52.4%) at weekends (38%) in a public place (62.4%) with essentially one perpetrator (68.6%) who was an acquaintance of the deceased in 32.6% of cases. The injuries were primarily located in the thorax (75%) and were associated with defensive wounds in the upper limbs. The most frequent cause of death observed was hemorrhage (82.9%). The analysis of patterns in homicidal sharp force cases allows us to construct specific preventive measures that target young males. Lesion analysis aids forensic specialists in following a thorough autopsy to determine the causes of death., (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: The aim of our study was to analyze the epidemiological characteristics for suicide methods and factors over a 12-year period among child suicides in Northern Tunisia and to compare juvenile and adolescent suicides., Study Design: This is a cross-sectional study., Methods: We included all child and adolescent suicide cases that took place in the North of Tunisia over a 12 year period (2005-2016). Data were collected from medical records and judicial inquiries and were classified into three sections: sociodemographic data, the circumstances of suicide, and the autopsy findings. Data were then compared between the 'juvenile suicide group' and 'the adolescent suicide group', according to the WHO definition., Results: Casualties were equally males and females, mostly adolescents (74.5%), aged 15 years old on average. Hanging was the most frequent suicidal method. A peak of frequency was observed in 2014., Conclusion: Our results suggested to focus, among other preventive measures, on the role of media coverage of child suicides., (Copyright © 2021 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Coronary ectasia is a rare vessel defect that represents a pathological and incidental finding in routine coronary angiography performed for other coronary syndromes. This defect exposes to the risk of intra-coronary thrombosis by blood stasis due to the turbulent blood flow in those dilated areas that can lead to sudden death. We report an autopsy case of a male subject suddenly deceased. A medico-legal autopsy concluded an ischemic heart failure due to a vascular thrombosis by a blood clot in a coronary ectasia. Our case report aimed to discuss the mechanisms of sudden death attributed to coronary artery ectasia., (Copyright © 2021 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

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.)

Objective: The aim of our study was to discuss the epidemiological features of self-poisoning suicide in Northern Tunisia., Methods: We conducted a retrospective, descriptive and cross-sectional study, including all the cases of fatal self-poisoning suicide occurring between January 2005 and December 2015., Results: In the study period, 204 cases of self-poisoning suicide occurred in northern Tunisia, with a prevalence of 0.44 cases/100 000 inhabitants/year. Among these cases, 59% were females (the sex ratio was 0.69). The mean age was 34 ± 15.3 years-old. The most common age group of the victims (28.4%) was between 20 and 29 years old. Victims were unemployed in 45% of cases and single at the time of suicide in 52%. None of the victims left a suicide note. Self-poisonings were due to the ingestion of drugs (52.5%), pesticides (42.6%), caustic products (5.5%) and Butane gas (1 case)., Conclusions: Fatal casualties of self-poisoning in Tunisia are frequently young, single, unemployed women. This pattern would allow planning of targeted preventive measures., (Copyright © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objective: To analyze the victims profile related to death among homeless people., Study Design: A descriptive, retrospective, and cross-sectional study., Methods: We included all deaths among homeless people that occurred during a 10-year period (2005-2014) that were autopsied in the Department of Legal Medicine of the Charles Nicolle Hospital of Tunis. Causes of death were classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision. Data were classified in three sections: sociodemographic data, circumstances of death, and autopsy findings. A univariate data analysis was performed., Results: The sex ratio (M/F) was of 7.45. The average age was of 59 years. The majority of deaths (80.9%) occurred in the metropolis of Tunis with a significant occurrence of cases in other governorates after the 2011 revolution (P = 0.002). Deaths occurred more often during winter (34.8%). The bodies were frequently discovered in public places (36.0%) and private locations (34.0%). The deaths of 55.3% of cases were attributed to natural causes, significantly affecting the elderly, whereas the accidental causes (25.7%) were more frequent before the age of 49 years, followed by suicides (3.9%) and homicides (3.3%)., Conclusions: Our study highlighted a phenomenon not yet studied in Tunisia. Our results highlight an urgent need for preventive measures focused on the improvement of healthcare measures among homeless people., (Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Introduction: In Tunisia, the phenomenon of self-immolation has increased dramatically since the self-burn of Mohamed Bouazizi which occurred on 17 December 2010. The aim of our study was to compare the casualties' profile of suicide by self-immolation before and after the Tunisian Revolution over a period of 10 years (2006-2015)., Methods: We conducted a retrospective review including all the cases of self-immolation suicides that occurred in Northern Tunisia five years before and five years after the January 2011 Revolution. We excluded cases of self-immolations committed in governorates other than the north of Tunisia as well as casualties of accidental or criminal burns and those where the context could evoke suicidal immolation but the self-inflicted nature has not been confirmed. The study sample was subdivided in two groups according to the Revolution date: before the Revolution (2006-2010) and after the Revolution (2011-2015). We compared for each group data related to the age, gender, marital status, employment, mental disease history, previous suicide attempts and threats, place of suicide and its motive, the type of fire accelerator, the hospitalization and the average body surface area burned., Results: The number (n=48/24.5% before 2011) of suicide by self-immolation has tripled during the post-revolution period (2011-2015) with a stable trend. The average age (35.6±13.4) has not changed. The male remained predominant before and after the Revolution (sex ratio of respectively 1.67 and 3.23). Marital status (victims being single in n=81 cases/41.3%) and the employment (unemployed in n=128/65.3%) of the casualties have not changed either after 2011. Fewer cases with psychiatric history were reported (n=21/43.7% before against n=52/35.1% after). Self-immolation increased in public places (n=9/18.7% before against n=50/33.8% after) and in an administration (n=2/4.2% before against n=19/12.8% after). More suicides after 2011 were due to financial problems (n=2/4.2% before against n=30/20.3% after) or due to a conflict with a state representative (n=2/4.2% before against n=18/12.2% after) with fewer cases due to a decompensation of mental illness (n=18/37.5% before against n=22/26.4% after)., Conclusion: Our study highlighted modifications of the casualties' profile of self-immolation after the Tunisian Revolution represented essentially by less psychiatric history and more suicides occurring in public places and in front of public administrations as well as suicides motivated by financial problems or conflicts with a state representative. Specific preventive measures should target young unemployed males., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: In Tunisia, few data are available about self-immolation epidemiology especially in the absence of official statistics on suicides. The aim of our study was to analyze the trends of suicide by self-immolation over a period of ten years (2005-2014)., Methods: We conducted a descriptive, retrospective study including all the cases of self-immolation suicides that occurred over a period of 10 years (2005-2014) and autopsied in the Department of Legal Medicine of the Charles Nicolle Hospital of Tunis, including self-immolation occurring in Northern Tunisia as well as those committed in remaining governorates and transferred before death to the central intensive care unit of burnt in Tunis receiving patients from all over Tunisia (about 80% of cases occurring in Tunisia)., Results: 235 cases of self-immolation were collected. The average age at death was 34.1±12.43 years (range 14-83 years). Gender ratio was of 3.27. Psychiatric history was mentioned in 32.8% of cases, represented by schizophrenia in 17.9% and depression in 12.3% of cases. 12.3% had a history of suicide attempts, and 7.3% presented a history of suicidal threats. The number of casualties of suicide by self-immolation tripled after 2011 with a rising trend during the next three years and slight drop in 2014. The most reported reason in our study was decompensation of a psychiatric illness (24.7%). Self-immolation occurred most frequently in a private home (34.5%) or a public place (30.2)., Conclusion: Our study showed that self-immolation affects essentially, young men, who are unemployed and mostly having mental diseases., (Copyright © 2016 Elsevier Ltd and ISBI. 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.)

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.