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Purpose: This study aims to analyze the pattern of deaths in detention in Northern Tunisia as well as the causes of death., Design/methodology/approach: The authors conducted a cross-sectional retrospective study including all the casualties of death in detention examined in the legal medicine Department in the main teaching hospital from 2005 to 2019. The department covers 10 out of the 11 governorates of Northern Tunisia and 13 prisons., Findings: Of a total of 197 casualties, only 2 were females. The mean age was 45.39 ± 14.43 years. A known medical history was reported in 63.5%, mainly cardiovascular disease, mental health disorders and diabetes. Half of the deaths occurred at the hospital. A total of 53 victims spent less than one year in custody before their death. Most deaths occurred due to disease-related causes (78.7%; n = 155); among these, 69 victims died from cardiovascular disease. Suicide accounted for 3.6% of the casualties and homicides for four cases., Research Limitations/implications: Several missing data regarding the details of the detention circumstances as well as the absence in some cases of the toxicological and histopathology analysis results, which could bias the study findings., Practical Implications: Death in detention in Northern Tunisia involved mainly males between their 30s and their 50s who died mainly from cardiovascular or pulmonary disease. These results underscore the importance of empowering the penitentiary health system., Originality/value: To the best of the authors' knowledge, this study is one of largest studies with regard to the number of decedents and the number of prisons from the Arab countries allowing to draw a pattern of casualties of death in prison., (© Emerald Publishing Limited.)

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.)

Cerebral sinus thrombosis (CST) is an uncommon condition in children with a variable clinical presentation which has rarely been described in the setting of diabetic ketoacidosis. We present the case of 14-year-old child in whom lateral sinus thrombosis was caused by dehydration complicating ketoacidosis in a previously undiagnosed type 1 diabetes. The diagnosis of the CST was established during the autopsy due to the rapidity of the neurological deterioration. The cause of death was tonsillar herniation due to diffuse cerebral edema secondary to CST. This is the first published report of a CST in association with new onset type 1 diabetes in a child diagnosed at the postmortem examination., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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.)

Objective: The aim of this study was to compare follicular liquid levels of IL6 and AMH in women with and without endometriosis and to evaluate their potential impact on ICSI outcomes., Materials and Methods: It is a prospective case-control study conducted on 25 women with proven endometriosis and 50 patients diagnosed with other causes of infertility. All these patients were candidates for ICSI cycles. Their follicular fluid was collected at the time of oocyte retrieval and used to evaluate IL-6 and AMH titers by electro-chemiluminescent immunoassay (Cobas e411-Roche)., Results: The IL-6 levels in follicular fluid were higher in the endometriosis group than in the control group (152.3 vs. 19.9 pg/mL; p = 0.02). The median level for AMH was 2.2 ± 1.88 ng/mL with no statistical difference between the two groups (2.2 vs. 2.7 ng/mL, p = 0.41). No significant correlation between the follicular IL6 and AMH levels was observed., Conclusions: The oocyte quality seems to be preserved in patients with endometriosis with the adequate response to ovarian stimulation. High levels of follicular IL6 are in accordance with the inflammatory phenomenon of the disease; however, this increase has no impact on ICSI outcomes.

Ntroduction: Writing medical certificates is part of the doctor's daily practice., Aim: To analyze the complaints related to medical certificates filed to the Regional Council of the Order of Doctors (RCOD) of Tunis and to identify the predictive factors of disciplinary sanctions., Methods: We collected the complaints filed to the RCOD of Tunis between 01/01/2017 and 31/12/2017, in relation to a problem with the establishment and/or the issuance of medical certificates by registered certifying doctors at RCOD, Tunis., Results: We collected 32 complaints, the reason for which was a certificate of convenience in 88% of cases, a drafting error in 9% of cases and a fee problem in 3% of cases. The decision of the RCOD was a closing of the file in 56% of cases, a call to order in 28% of cases and a temporary ban on practicing medicine in 16% of cases.The multivariate analysis with logistic regression identified one independent predictor of a call to order or a sanction from the RCOD, namely the fact that the doctor did not bring the file of the patient(s) having been the subject of the complaint, at the time of his invitation to RCOD Tunis (p=0.037, OR=22.66)., Conclusion: The doctor must always keep a medical form or a patient file, which will allow him to justify himself in the event of a complaint against him, for the reason of a certificate of convenience.

Background: Actually, no data on the prevalence of plasmid colistin resistance in Tunisia are available among clinical bacteria., Objectives: This study aimed to investigate the current epidemiology of colistin resistance and the spread of the mcr gene in clinical Gram-negative bacteria (GNB) isolated from six Tunisian university hospitals., Methods: A total of 836 GNB strains were inoculated on COL-R agar plates with selective screening agar for the isolation of GNB resistant to colistin. For the selected isolates, mcr genes, beta-lactamases associated-resistance genes and molecular characterisation were screened by PCRs and sequencing., Results: Colistin-resistance was detected in 5.02% (42/836) of the isolates and colistin-resistant isolates harboured an ESBL ( bla CTX-M-15 ) and/or a carbapenemase ( bla OXA-48 , bla VIM ) encoding gene in 45.2% of the cases. The mcr -1 gene was detected in four E. coli isolates (0.59%) causing urinary tract infections and all these isolates also contained the bla TEM-1 gene. The bla CTX-M-15 gene was detected in three isolates that also carried the IncY and IncFIB replicons. The genetic environment surrounding the mcr -carrying plasmid indicated the presence of pap-2 gene upstream mcr -1 resistance marker with unusual missing of ISApl1 insertion sequence., The Conclusions: This study reports the first description of the mcr -1 gene among clinical E. coli isolates in Tunisia and provides an incentive to conduct routine colistin susceptibility testing in GNB clinical isolates.

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.)

Purpose: Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations., Methods: Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV)., Results: The average length of the LAV was 21 mm its mean width was 5 mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8 mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found., Conclusions: The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Sudden gastrointestinal (GI) death is an unexpected death due to digestive system causes mainly found after autopsy. The literature is rich in articles that studied sudden death due to cardiac causes while sudden GI deaths remain less well-documented. We retrospectively investigated all cases of gastrointestinal death at the Department of Forensic Medicine in Tunis, over 13 years (January 1, 2006 to December 31, 2018). Two hundred and eight cases were collected. The mean age of our series was 51.06 ± 20.99 years. No history of digestive disorders was reported in 78.4%, and no family history of sudden death was found in any cases. A male predominance was found in most epidemiological characteristics of the sample with a significant statistical rate in some features. Non-specific abdominal pain was the most described symptom (n = 92). Perforation of GI tract was the common mechanism involved in the death of 55 cases, of which 44 were related to ulcer perforation. These ulcer perforations were statistically more reported in smokers and people suffering from schizophrenia. Intestinal obstruction was the second commonest cause of death, mainly found in the elderly. Sudden death in children was most frequently caused by acute intussusception. This study highlights that systematic study of sudden death due to GI causes might provide opportunities to identify avenues for overall health improvement., (© 2021 American Academy of Forensic Sciences.)

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.)

Purpose: Partial nephrectomy is gaining, nowadays, more interest in oncologic kidney surgery. This type of surgery requires the good knowledge of vascular renal anatomy to make it safe and to guarantee good functional and oncological outcomes. This paper exposes the clinical implication of the arterial renal anatomy in nephron-sparing surgery., Methods: This is a cadaveric study of 71 human kidneys performed at Charles Nicolle mortuary. The right and left kidneys with surrounding tissues were removed en bloc with the adjacent part of the aorta and inferior vena cava, cleared and studied. Colored resin was injected in each artery, vein, and urinary ducts, with a specific color code for each structure. Corrosion technique was used to eliminate the surrounding tissue, leaving only the colored resin matrix. The Ternon anatomic classification of the inferior polar artery, based on its emergence point was used., Results: Multiple renal arteries were noted in 9.85% of casts. Anterior and posterior division of main renal artery was found in 95.7% of cases. Posterior segmental artery crossed posteriorly the upper caliceal infundibulum and the renal pelvis in 93% of cases. The upper renal pole was vascularized by an apical segmental artery in 16.9% of cases and a superior polar artery in one case (1.4%). The mid pole of the kidney was supplied by a unique anterior branch and a single posterior branch in 40% of cases. Inferior polar artery was found in 52 casts (73.23%). Type I of Ternon was found in 6 casts (11.53%), Type II in 25 cases (48.07%), Type III in 19 cases (36.53%), Type IV in 2 cases (3.84%), and type V in 13 casts (25%)., Conclusion: Renal vascular anatomy presents large variations. Good knowledge of the segmental arterial anatomy of the kidney is a primordial to a safe partial nephrectomy. Good preoperative vascular mapping can be of great help for the surgeon., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Intramyocardial cartilage has never been reported in the human heart before. In the literature, the only reported localizations of cartilage in the heart were in the central fibrous body and the valves. We report a case of an unusual presence of cartilage tissue within the myocardial wall of the left ventricle in a 10-year-old boy who died unexpectedly. This case presents an interesting, unusual and apparently asymptomatic sudden cardiac death related to a cartilaginous myocardial tumor. Conducting system disturbance secondary to the myocardial tumor is the probable cause of death. This case is relevant not only for its singularity and originality, but also for the diverse and controversial hypotheses related to the onset of cartilaginous tissue in the myocardial wall. Early detection of this tumor by modern thoracic imaging may have prevented a fatal unexpected outcome.

Data about homicidal burns remain scarce. Intentional burns are a challenging situation in the case of an individual found dead in a fire zone with no witness of the fatal act. This study aimed to analyze the victim profiles of homicidal burns in Northern Tunisia. It was a descriptive cross-sectional study with a retrospective data collection over 15 years (January 2005-December 2019). In total, 60 cases of homicidal burns were collected. The mean age was 40.22 ± 18.1 years (range 4-82 years). We noted a male predominance (sex ratio M/F = 1.3). Most of the victims were married (48.3%), unemployed (40%), and living in an urban area (63.3%). Homicidal burns occurred most frequently in private homes for female victims (80.8%) and in public places for male victims (31.4%) (p < 0.001). The reported motive varied according to the victim's sex; males were mostly assaulted by an acquaintance in an interpersonal conflict (47.1%), and females were mostly assaulted by an intimate partner while in a dispute (42.3%; p = 0.001). The median total body surface area (TBSA) that was burned was 60.4%, and burn injuries were observed mainly in the anterior part of the body. In 19 cases, the burns were associated with another type of trauma, from which the most common association was burning and stab wounds (12 cases). The identified pattern of homicidal burn casualties was similar to the reported data in Western countries and to homicides in general in Tunisia, suggesting that prevention measures should address those of intentional interpersonal violence., (© 2021 American Academy of Forensic Sciences.)

Background: Progress in oncology has improved patient survival. However, cancer chemotherapy can be gonadotoxic and affect their fertility. Recourse to fertility preservation before starting these treatments is therefore necessary in order to allow a better life quality after survival. The aim of this work was to study the impact of chemotherapy on ovarian reserve by AMH measurement., Methods: This is a descriptive and longitudinal study from 2015 to 2018 carried out at Aziza Othmana hospital ART center in Tunis on patient aged less than 41 years who were candidates for fertility preservation. Patients included had AMH measurement prior to cancer treatment. We called them back to follow up the AMH level after chemotherapy. The AMH assay was performed by electrochemilumiescence technique. At the end, only 66 patients met the inclusion criteria., Results: The most frequent pathologies were Hodgkin's lymphoma and breast cancer. The mean age of patients was 26.7 ± 6.8. The most used chemotherapy protocols were BEACOPP, ABVD or the combination of both in lymphoma and FEC + TXT for breast cancer treatment. A significant difference between AMH before and after chemotherapy was found for BEACOPP and FEC + TXT protocols (p < 10 3). The patient's age was correlated with the AMH decrease after chemotherapy (r = 0.577, p < 10 3)., Conclusion: Our results showed that the high risk gonadotoxicity protocols were BEACOPP for lymphoma treatment and FEC + TXT for breast cancer treatment. However, studies with a larger sample and more time extended monitoring are necessary for a better gonadotoxicity understanding of the cancer treatments available today., Competing Interests: Declarations of Competing Interest None., (Copyright © 2020 Elsevier Masson SAS. 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.)

Introduction: Community-acquired urinary tract infection is one of the most common reasons for consultation in everyday practice; it represents a major source of antibiotic consumption. Escherichia coli ( E. coli ) is the main pathogen incriminated., Objective: The aim of this study was to evaluate antimicrobial susceptibility patterns of community-acquired uropathogenic E coli throughout a 7-year period., Methodology: All strains of E. coli isolated from urine samples between January 1st 2012 and December 31st 2018 were included. Presence of ≥ 10 3 CFU/ml in urine culture media was considered as significant for urinary tract infection. The identification of E. coli strains was realized using standard laboratory techniques. Antibiotic susceptibility testing was performed using the disk diffusion method according to the CA-SFM/ EUCAST criteria., Results: A total of 1,335 E. coli strains were isolated. Overall susceptibility rates to antimicrobial agents were as follows: ampicillin 39.1%, amoxicillin-clavulanic acid 64.9%, cefotaxime 94.9%, trimethoprim/sulfamethox-azole 67.6%, ciprofloxacin 89.2%, ofloxacin 86.9%, amikacin 98.6%, gentamicin 93.9%, nitrofurantoin 97.6% and fosfomycin 99.3%. All isolates were susceptible to carbapenems. The frequency of extended spectrum beta-lactamases-producing E. coli strains was 4.7%. Susceptibility rates of E. coli for ampicillin, trimethoprim/sulfamethoxazole and amikacin remained relatively stable over the study period, whereas susceptibility to amoxicillin-clavulanic acid, cefotaxime and fluoroquinolones showed a 2-phase pattern. As for gentamicin, a continuous decrease in susceptibility rates was observed., Conclusion: Antimicrobial susceptibility profiles of uropathogenic E. coli are constantly changing, due to modifications in the antibiogram interpretation criteria and antibiotic prescription habits. Rigorous surveillance of resistance rate is necessary to determine appropriate empirical treatment and limit the spread of multiresistant strains., (Copyright © 2020 by S. Karger AG, Basel.)

Neck paragangliomas are relatively rare neuroendocrine nonsecretory tumors. They are mainly observed among adults and are often asymptomatic, causing a frequent delay in diagnosis. In pediatric cases, neck paragangliomas can be associated with adrenergic symptoms that may lead to complications.A report of a sudden death due to a carotid paraganglioma in a young girl is reported. Autopsy revealed a thoracic arotic dissection and a 4-cm jugulocarotidian mass in the absence of traumatic injuries. Histology showed no evidence of underlying aortic disease, including signs of Marfan syndrome, and a paraganglioma. Postmortem biochemistry analysis showed blood metanephrines levels 100 times higher than normal range. The cause of death was an aortic dissection complicating a neck paraganglioma. The manner of death was concluded as natural.Our case highlighted the importance for forensic pathologist to consider the diagnosis of paraganglioma in case of sudden hypertensive complications, especially among young people.

Background: Death in workplaces remains a public health issue. However, data regarding workplace homicides are scarce in most of regions, especially in the Arab world. The aim of our study was to analyze the epidemiological features of workplace homicides in northern Tunisia., Materials and Methods: This is a descriptive study with retrospective data collection over a 15-year period (January 2003 to December 2017)., Results: We recorded 50 workplace homicide cases. Sex ratio was 49:1 (male/female). The mean age was 41.6 ± 15.13 years. Occupations the most at risk were security guards (odds ratio, 8.25; 95% confidence interval, 4.28-15.91; P < 0.0001) and taxi drivers (odds ratio, 5.61; 95% confidence interval, 2.39-13.18; P < 0.00001). The motive of the aggression was either interpersonal conflict or robbery (47.9% and 43.8%, respectively). Victims working as security guards or taxi drivers were most frequently assaulted by an unknown perpetrator, the motive being robbery. Death was most frequently secondary to blunt trauma (n = 20) or stab wounds (n = 15)., Conclusions: Workplace homicides represent a substantial phenomenon in Tunisia. The application of prevention measures is required based on improving environmental measures targeting, in priority, security guards and taxi drivers.

Background: The Tunisian Penal Code defines infanticide as the murder committed by the mother on her child at birth or immediately after. There is a dearth of studies and official statistics on infanticide in the Arab region and North Africa., Objective: to analyze the infanticide trends in northern Tunisia between 1977 and 2016., Participants and Setting: we included all cases of infanticides autopsied at the Legal Medicine Department of Charles Nicolle Hospital in Tunis, over a period of 40 years (1977-2016)., Methods: A descriptive retrospective study., Results: We collected a total of 513 cases of infanticide over the study period. The general prevalence of infanticide was 0.42 per 100,000 live births per year. Infanticide often occurred during the week, in winter (31.5%) and in spring (30.9%). The newborn was often found on public roads (40.9%) and in urban areas (81.4%). The newborn was often full-term (73.6%), mature, without any congenital malformation, found completely naked (75.2%) and with an empty stomach (93.7%). The umbilical cord was often cut (71.5%), not ligated (82%) with an irregular edge (64%). There was often no putrefaction (54.4%). The hydrostatic test (81.8%) and histological examination (81.1%) showed that infants had breathed. Neglect was the most common cause of death (49.9%)., Conclusion: Northern Tunisia has a low prevalence of infanticide compared to most of the previous European and American studies. A better understanding of infanticide would allow us to adapt measures of prevention., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Workplace accidents represented a Global public health problem with about two millions persons dying from accidents at work or occupational diseases. In Tunisia, data on fatal traumatic workplace accidents remain scarce. Work-related accidents accounted for 0.4% of the employed population in 2014, with a prevalence of fatal accidents between 4 and 25 per 100,000 workers depending on the region and the field., Aim: To describe the victim's profile of workplace traumatic accidents in Northern Tunisia., Methods: It was a retrospective cross-sectional study, including all cases of accidental workplace traumatic accidents autopsied at the Department of Forensic Medicine, Charles Nicolle Hospital in Tunis over a period of 12 years (2003- 2014)., Results: We collected 741 cases, including 724 men. The median age was 38.5 years. Construction sector represented 70% and the industrial sector represented 12.6% of cases. Victims were workers in 91.4%. Falls from height was the most frequent accident type (43.5%), followed by objects falling (26.5%) and electrocutions (18.5%). Death occurred at the place of accidents in 58% cases., Conclusion: Our study highlighted the need to reinforce and to adapt the prevention measures toward workers in the construction sector, in order to reduce the mortality from traumatic workplace accidents.

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.)

The existing knowledge on anatomy of segmental branches of left portal vein (LPV) is limited. This study aims to describe the surgical anatomy and variations of LPV and its segmental branching pattern. Forty fresh cadaveric liver dissections were performed. The dissection of LPV was carried out from its emergence at the level of the portal vein bifurcation to its segmental branches penetrating the left hemiliver. LPV characteristics, the number, and situation of its segmental branches were recorded. LPV comprises two portions: a 28 ± 6.7 mm-long transverse portion (TPLPV) and a 34.9 ± 4.4 mm-long umbilical portion (UPLPV). Mean number of LPV branches to segments I, II, III, and IV was 2 ± 1 (1-6), 2 ± 1 (1-4), 2 ± 1 (1-5), and 8 ± 2 (4-14), respectively. A single large vein supplied segment II in 90% of the cases. Segment III constantly had one vein arising from the left horn of UPLPV with mean diameter of 5.9 ± 1.6 mm. Most of the veins to segment IV took origin from the right horn of UPLPV with a mean number of 5 ± 2 (2-8). Segmental veins arising from UPLPV and TPLPV and supplying segment IV were present in 90 and 45% of the cases respectively. Segmental veins arising from LPV are often multiple and variable in position. Detailed knowledge of these veins is mandatory in order successfully perform anatomical liver resections or monosegment graft harvest for pediatric liver transplantation. Clin. Anat. 31: 1122-1128, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

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.)

It is widely accepted that the estimation of biological attributes in the human skeleton is more accurate when population-specific standards are applied. With the shortage of such data for contemporary North African populations, it is duly required to establish population-specific standards. We present here the first craniometric standards for sex determination of a contemporary Tunisian population. The aim of this study was to analyze the correlation between sex and metric parameters of the skull in this population using CT scan analysis and to generate proper reliable standards for sex determination of a complete or fragmented skull. The study sample comprised cranial multislice computed tomography scans of 510 individuals equally distributed by sex. ASIR TM software in a General Electric TM workstation was used to position 37 landmarks along the volume-rendered images and the multiplanar slices, defining 27 inter-landmark distances. Frontal and parietal bone thickness was also measured for each case. The data were analyzed using basic descriptive statistics and logistic regression with cross-validation of classification results. All of the measurements were sexually dimorphic with male values being higher than female values. A nine-variable model achieved the maximum classification accuracy of 90% with -2.9% sex bias and a six-variable model yielded 85.9% sexing accuracy with -0.97% sex bias. We conclude that the skull is highly dimorphic and represents a reliable bone for sex determination in contemporary Tunisian individuals.

Background: In Tunisia and in the Arab world, few data are available about homicide patterns. The aim of our study was to analyse the victims' profiles and the general pattern., Methods: 636 homicide victims were autopsied at the Legal Medicine Department of Charles Nicolle Hospital in Tunis, over a period of 10 years (2005-2014)., Results: Victims were males in 79.7% with a male-to-female ratio of 3.93 and the average age was 37.7 years. The victim was generally from an urban area (66.7%), single (55.7%) and semiskilled (50.2%). The most common methods of homicide were sharp force (51.7%) and blunt trauma (24.8%)., Conclusions: This study suggests applying urgent preventive measures targeting essentially young males and the importance of a national 'Violence Repository'., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Acute myeloid leukaemia (AML) often presents with non-specific symptoms such as fatigue, anaemia or infection. Pulmonary involvement is uncommon in AML during the course of the disease and is usually caused by infection, haemorrhage, leukaemic pulmonary infiltrates and leukostasis. Lung localization of AML is very uncommon and potentially life threatening if not diagnosed and treated rapidly. The authors describe the sudden death of an asymptomatic five-month-infant because of a misdiagnosed lung localization of AML. Autopsy examination followed by histopathological studies showed an extensive leukostasis and extramedullary leukaemic infiltrating the lungs. Special stains and immunohistochemical studies revealed findings consistent with acute myelogenous leukaemia. This case suggests that underlying acute leukaemia should be considered as a cause of flu-like symptoms in infants. Medical personnel are urged to be alert to fever, sore throat, weakness and dyspnea that may be characteristic of serious systemic diseases.

Background: Job satisfaction is a key element in managing human resources despite the scope of practice. It is intimately linked to motivation but acts independently., Aim: To evaluate the degree of job satisfaction of the teaching physicians practicing in the hospitals of Tunis., Methods: It was a descriptive study including a sample of 75 teaching physicians practicing in Tunis hospitals, selected randomly and anonymously with a 1:20 scale with a matching based on the grade and the speciality. The evaluation was carried out by the Saphora-Job satisfaction questionnaire., Results: The 75 physicians who participated had a sex ratio (M / F) of 0.42. The Median seniority was of seven years. The majority of physicians who participated in the study had a professional experience of less than 10 years (72%) and were mostly Assistant Professors (57.3%). The overall job satisfaction rating of participants in the study was 3.13 ± 1.2. Indicators that were related to relatively high satisfaction were represented by the relationship between colleagues, the nature of work and the adequacy of work and personal life. Indicators that were linked to the lowest satisfaction were represented by knowledge and access to regulation, remuneration and knowledge of the organization of the institution., Conclusion: Our study suggested the need for serious discussions between the different stakeholders about teaching physicians' salary ranges and opportunities for personal development as well as reward system for hospital-based physicians.

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.)

Objective: Assess Death Certificates accuracy (DCs) issued by a teaching emergency department in Tunis., Methods: It is a descriptive study. We included all death certificates issued in the Emergency Department of a teaching Hospital in Tunis over 17 months period (October 2013 - March 2014). Twenty-one errors have been predefined and classified as "Editing errors" or "Medical analysis error" then as major or minor errors., Results: 757 certificates were studied; all DCs had at least three errors with an average number of errors of 6.92±1.55.      The mechanism of death was inadequate in 20% of the DCs.  The cause of death was "unacceptable" in 21% of the DCs., Conclusion: The results are similar to those reported in international literature. Therefore, it is urgent to start working on further and regular training on how to fulfil a death certificate for undergraduate and postgraduate medical students.

The role of the pathologist has been highlighted by the medias since the recent years and the Tunisian law system suffers from a huge and there are no rules or jury verdicts concerning the e responsability  of the doctors in general with emphasis on pathologists. One might think that the lack of laws benefits to the pathologist, on the other hand, we can consider this as dangerous either for the patients or the pathologists. This lack of laws makes the judge dependant on the expert view. Other countries like European ones and the United States, has available data furnished by the insurance bodies that enrich the jury verdicts and the different laws that are available. Our aim was to help the pathologists understand their legal responsibilities and the law system. The latter may seem as complex for the pathologist as a pathologic report for a judge.

Drug-induced eosinophilic myocarditis is uncommon with few cases reported in the literature. It is a rare but potentially life-threatening disease.We report the case of an 11-year-old girl without medical history who developed an acute malaise and chills, followed by severe shortness of breath and a cardiopulmonary arrest 1 hour after an intramuscular injection of penicillin.At autopsy, we observed in the external examination nonspecific asphyxia signs, an injection mark, and the absence of traumatic signs. The organs examination showed a heart with a normal shape and a transmural, diffuse, tannish discoloration of the myocardium. The lungs were severely congested with a diffuse edema. Histological examination of the ventricular walls and septum revealed suggestive signs of eosinophilic myocarditis. Immunohistochemical analysis for the phenotypic characterization of the inflammatory cells revealed the positivity of the CD3 antibody without any stain for CD20.The diagnosis of fulminant myocarditis with an eosinophilic infiltrate was established as the cause of death. The manner of death was stated as natural.

We present two cases of occult gastric carcinoma associated to a large pulmonary tumors thrombosis microangiopathy (PTTM). The first case is a 28 years-old man. He was dead due to a respiratory failure. Autopsy showed a whitish indurated mass invading the stomach wall. Histological findings showed a primary "signet ring" gastric adenocarcinoma with pulmonary carcinomatosis and multiple PTTM and a heart metastasis. The second case is a 24 years-old pregnant woman. The main symptoms were nausea and stomach discomfort and they were seen as pregnancy signs. She was dead because of respiratory failure, 10 hours after a vaginal delivery. Autopsy showed the absence of any cause of death related to the delivery and the presence of a whitish indurated mass in the stomach. Histological findings showed a primary "signet ring" gastric adenocarcinoma, with pulmonary carcinomatosis and multiple PTTM., (© Copyright Società Italiana di Anatomia Patologica e Citopatologia Diagnostica, Divisione Italiana della International Academy of Pathology.)

Objectives: To analyze the impact of the Tunisian Revolution on suicide and homicide patterns in Tunisia., Methods: It is a retrospective, cross-sectional study, including all the cases of homicides and suicides that occurred during an 8-year period (2007-2014) in Northern Tunisia. We compared data before and after the revolution., Results: After the revolution, the number of suicides rose 1.7 times, with a prevalence rising from 1.8 to 3.12 suicides per 100,000 persons per year. Homicides rose 1.3 times after the revolution. For both manner of death, victims were mostly males, aged between 20 and 39 years, living in urban areas. Hanging and self-immolation rose, respectively, 1.8 and 3 times after 2011. We observed suicide cases most frequently occurred in public places and in front of public administration after 2011. Homicide victims' profile and circumstances showed a single variation which is an increase in number of cases happening in rural areas., Conclusions: Our results proved a short-term impact of the transition period on homicides and suicides. Urgent preventive measures are needed especially to decrease the suicide rates.

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.)

Background: A better understanding of the anatomy of the renal vein and its relationship with the arterial and excretory systems can prevent intra operative complications., Methods: Three-dimensional endocasts of intrarenal vessels and renal collecting systems were obtained from fresh cadavers, by injecting a polyester resin coloured with different pigments. A total of 71 endocasts were studied: 37 right kidneys and 34 left kidneys., Results: Renal vein was unique in 88% of cases and double in 11% of cases. It was formed in 52% of cases by 3 trunks. Intrarenal veins anastomosed together to form 2 levels of arcades in 28% of cases and 3 levels in 71% of cases. The venous drainage of the upper pole was provided by two anterior and posterior plexus in 38% of cases, and by a single anterior plexus in 61% of cases. In 22% of cases, the venous drainage of the lower pole was provided by both an anterior and a posterior plexus, and in 77% of cases, there was only an anterior plexus. Renal artery was posterior to the vein in 66% of cases. It was anterior to the vein in 29% of cases, and located directly above it in 4% of cases. In 60% of cases, we noted a close relationship between the anterior surface of the ureteropelvic junction and the lower branch of the renal vein., Conclusion: Venous vascularisation of the kidney appears to be variable and its relationship with the arterial and the excretory systems may be complex.

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.