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.

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.

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.

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.

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 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.

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'.

Segmental branching pattern of the left portal vein: Anatomical characteristics and clinical implications.

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.

Penicillin-Induced Fulminant Myocarditis: A Case Report and Review of the Literature.

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.

Legal responsibility of the pathologist in Tunisia.

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.

Evaluation of the work satisfaction of the teaching physicians practicing in the hospitals of Tunis.

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.

Death certificate accuracy in a Tunisian Emergency Department.

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.

Anatomical variations of renal venous vascularisation. A study of 71 three-dimensional kidney endocasts.

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.

Notch signaling is involved in human articular chondrocytes de-differentiation during osteoarthritis.

CONTEXT: During osteoarthritis (OA), chondrocytes undergo de-differentiation, resulting in the acquisition of a fibroblast-like morphology, decreased expression of collagen type II (colII) and aggrecan, and increased expression of collagen type I (colI), metalloproteinase 13 (MMP13) and nitric oxide synthase (eNOS). Notch signaling plays a crucial role during embryogenesis. Several studies showed that Notch is expressed in adulthood. OBJECTIVE: The aim of our study was to confirm the involvement of Notch signaling in human OA at in vitro and ex vivo levels. MATERIALS AND METHODS: Normal human articular chondrocytes were cultured during four passages either treated or not with a Notch inhibitor: DAPT. Human OA cartilage was cultured with DAPT for five days. Chondrocytes secreted markers and some Notch pathway components were analyzed using Western blotting and qPCR. RESULTS: Passaging chondrocytes induced a decrease in the cartilage markers: colII and aggrecan. DAPT-treated chondrocytes and OA cartilage showed a significant increase in healthy cartilage markers. De-differentiation markers, colI, MMP13 and eNOS, were significantly reduced in DAPT-treated chondrocytes and OA cartilage. Notch1 expression was proportional to colI, MMP13 and eNOS expression and inversely proportional to colII and aggrecan expression in nontreated cultured chondrocytes. Notch ligand: Jagged1 increased in chondrocytes culture. DAPT treatment resulted in reduced Jagged1 expression. Notch target gene HES1 increased during chondrocyte culture and was reduced when treated with DAPT. CONCLUSION: Targeting Notch signaling during OA might lead to the restitution of the typical chondrocyte phenotype and even to chondrocyte redifferentiation during the pathology.

[Relation entre la température ambiante, l'humidité et la mort subite cardiaque au nord de la Tunisie]. / Relationship between ambient temperature, humidity and sudden cardiac death in northern Tunisia.

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.

[Weekly variation of sudden cardiac death in northen Tunisia]. / La variation hebdomadaire de la survenue de mort subite cardiaque au nord de la Tunisie.

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

Sudden death due to pulmonary embolism in north Tunisia: 37 cases study.

AIM: To determine frequency of pulmonary embolism as the cause of sudden death and to study clinical, epidemiological characteristics and risk factors. METHODS: Prospective study of cases of sudden death secondary to pulmonary embolism, whose autopsy was performed in the forensic department of Tunis, between October 2009 and of September, 2011. RESULTS: During study period, 37 cases of pulmonary embolism were recorded. They represented 6.8 % of all cases of sudden cardiovascular deaths. Victims were male in most cases (65 %). Victims were aged between 21 and 87 years with an average age of about 52 years. Pathological histories were noted in 9 cases: three cases of recent surgery, four cases of pelvic trauma, a case of ovarian tumor and a case of which the PE arose in post-partum. Concerning other risk factors of pulmonary embolism, confinement to bed was noted in 24 cases (64.8 %), obesity in 12 cases (32.4 %), an arterial high blood pressure in 4 cases. Histories of psychiatric pathology were noted in 5 cases (13.5 %). Symptomatology preceding death was dominated by sudden death (35 %) followed by dyspnoea (30 %) and thoracic pains (16 %). In 8 cases , victims consulted emergencies within 48 hours preceding death, for a varied symptomatology without diagnosis of pulmonary embolism is suspected. At autopsy, in 30 cases embolism was massive. In 29 % of the cases, a deep venous thrombosis was revealing in particular at the primitive iliac veins. CONCLUSION: Pulmonary embolism is an affection that still kills a lot. It can benefit from prevention and from an effective treatment. This testifies the major importance of clinical diagnosis of pulmonary embolism as well as the technical means for the diagnosis.