Ordinal disciplinary responsibility of the certifying physician.

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.

Fatal cerebral sinus thrombosis associated with diabetic ketoacidosis in a child.

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.

Risk factors of sudden cardiac death in women: A 10 years study in Tunisia.

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.

A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein.

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.

Homicidal sharp force cases: An 11-year autopsy-based study.

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.

Sudden death related to the gastrointestinal system in Tunisia: A 13 year autopsy study.

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.

Cadaveric study of arterial renal anatomy and its surgical implications in partial nephrectomy.

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.

Fatal coronary ectasia: An autopsy case report and review of literature.

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.

Pattern of homicidal burns in Northern Tunisia: An autopsy-based study over 15 years (2005-2019).

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.

Unexpected fatal intramyocardial cartilaginous tumor: pathophysiology, mechanism of death and review of the literature.

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.

[Forensic evaluation of initial medical certificates within health facilities in Northern Tunisia]. / Evaluation médico-légale des certificats médicaux initiaux au sein des structures sanitaires du Nord de la Tunisie.

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.

Sudden Death Due to Neck Paraganglioma: A Pediatric Case Report and Review of the Literature.

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.

Workplace traumatic accidental death in Northen Tunisia.

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.

Workplace Homicides in Northern Tunisia: A 15-Year Study (2003-2017).

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.

Trends of infanticides in northern Tunisia: A 40 years study (1977-2016).

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.

Pattern of suicide by self-poisoning in Northern Tunisia: An eleven-year study (2005-2015).

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 ±â€¯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.

Sex determination of a Tunisian population by CT scan analysis of the skull.

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. ASIRTM software in a General ElectricTM 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.

Patterns of homicide in North Tunisia: a 10-year study (2005-2014).

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'.