Anatomy and anatomical variations of adrenal veins and its application to adrenal venous sampling.

PURPOSE: Our aim was to study the anatomy of the left and right main adrenal veins (LAV and RAV) and to identify their anatomical variations in order to see the practical application of these findings to adrenal venous sampling (AVS). METHODS: Our work is based on dissection of 80 adrenal glands from fresh corpses in the forensic medicine department. We studied the number, the drainage, the direction and the level of termination of the main adrenal veins. RESULTS: The average length of the LAV was 21 mm. It ended in 100% of cases at the upper edge of the left renal vein with a mean connection angle of 70° and after an anastomosis with the lower phrenic vein in 36 cases(90%). The average length of the RAV was 9 mm. It ended in 100% of cases at the level of the retro hepatic inferior vena cava (IVC) mainly on its posterior face in 21 cases (53%) and on its right lateral border in 18 cases (45%). The mean angle of the RAV in relation to the vertical axis of the IVC was 40°, with extremes ranging from 15° to 90°. CONCLUSIONS: AVS seems to be easier on the left than on the right side because of the greater length of the adrenal vein (21 mm vs. 9 mm) and a greater angle of connection (70° with the left renal vein vs. 40° with the IVC), which explains the lower success rate of cannulation and the more frequent occurrence of blood sample contamination on the right side.

A cadaveric anatomical study of the adrenals: vascular relationship.

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

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.

Management of blunt renal trauma on pre-existing diseased kidneys: a cross-sectional study.

Pathological kidney trauma is a special entity. Congenital or acquired lesions may interfere with clinical presentation, radiological imaging, and the therapeutic approach. Objective: Our objective was to determine the clinical, radiological, and therapeutic features of this entity. Materials and methods: The medical records of 37 observations were retrospectively collected from January 1992 to February 2022. All cases were explored by a kidney ultrasound and/or a computed tomography scan, and classified according to the American Association of Surgery of Trauma. Pre-existing renal abnormalities were found in 37 patients among 203 (18.2%). The most common underlying lesion were urolithiasis (37.8%) followed by pyelo-ureteral junction syndrome (32.4%). Surgical abstention was decided in 11 cases, four nephrectomies were performed as a matter of urgency, and seven nephrectomies were performed remotely. The cure of uropathy was performed after an average delay of 3 months. Conclusion: Kidneys with underlying pathology are habitually more susceptible to trauma. Contusions are often benign contrasting with a high nephrectomy rate.

A comparative study of the injury pattern between suicidal and accidental falls from height in Northern Tunisia.

BACKGROUND: Falls from height are a common cause of marbidity and mortality. The aim of this study is to examine the characteristics of the victims, the circumstances of the fall and distribution of the injuries of accidental and suicidal falls from height. MATERIALS AND METHODS: It was a retrospective cross-sectional study, based on autopsies performed over 16 years (January 2005 to December 2020). The recorded variables included demographic data of the victim, height of fall, death scene findings, length of hospital stay, autopsy findings, and toxicological results. RESULTS: Of the 753 victims of fall from height, 607 were fallers and 146 were jumpers. We found that male victims were predominant in the accidental group (86.8% vs. 69.2%). The mean age at death was 43.6 ± 17.9 years. Suicidal falls occurred in a private house in the majority of cases (70.5%), while accidental falls occurred most frequently at workplace (43.8%). Suicidal falls were higher than accidental falls (10.4 ± 7.3 m vs. 7.1 ± 5.7 m). Injuries in the thorax, abdomen, pelvis, upper and lower extremities were more frequentl in the suicidal falls group. Pelvic fractures were 2.1 times more likely to occur in the suicidal falls. Head injuries were more frequent in the accidental falls group. The survival delay was shorter in the suicidal falls group. CONCLUSIONS: our study highlights the differences in the profile of the victims and in the pattern of injuries caused by falls from height, depending on the victim's intention to fall.

Ecotoxicity of chrysene and phenanthrene on meiobenthic nematodes with a case study of Terschellingia longicaudata: Taxonomics, toxicokinetics, and molecular interactions modelling.

Polycyclic aromatic hydrocarbons (PAHs) are toxic for humans and marine fauna alike. The current study assessed the impact of PAHs on the migratory behaviour of meiobenthic nematodes collected from the Bizerte lagoon, Tunisia. The experiment lasted for 15 days and was carried in open microcosms, which comprised a lower, contaminated and an upper, uncontaminated compartment. Three treatments were used, for each of them an untreated control was set up: sediment contaminated with chrysene (116 ng g-1 dry weight (DW), with phenanthrene (116 ng g-1 DW) and a mixture of both. The results showed a significant decrease in diversty and abundance in the lower, contaminated compartments compared to the upper zones. The results also highlighted that under an increased stress some species progressively increased in number, these were considered PAH-tolerant species such as Odontophora villoti, some others had an occasionally increased in number were considered as opportunistic species, such as Paracomesoma dubium and the species that showed a progressive decreased in number, such as Metoncholaimus pristiurus and Steineria sp., Terschellingia. longicaudata, and Oncholaimellus sp. were classified as PAH-sensitive. Moreover, an increase in the activity of biochemical biomarkers was observed following the exposure of males and gravid females of T. longicaudata to 29, 58 and 87 ng g-1 DW of chrysene and phenanthrene paralleled by a higher vulnerability of the latter demographic category. Besides, a significant decrease in fertility of females and an increase in pharyngeal sucking power were observed for both types of PAHs considered. The sex ratio was also significantly imbalanced in the favor of males, which suggest that chrysene and phenanthrene affect also the hormone system of T. longicaudata. The high affinities of these PAHs and their molecular interactions with both germ line development protein 3 (GLD-3) and sex-determining protein (SDP) may justify these results and explain the toxicokinetic attributes.

Patterns of Unnatural Deaths Among Children and Adolescents: Autopsy Study (2011-2018).

BACKGROUND AND AIMS: The problem of unnatural death in children is still relevant because of their vulnerability. This work aimed to describe the epidemiological profile and patterns of these medicolegal deaths in children and adolescents in northern Tunisia. METHODS: We conducted a retrospective study from January 2011 to December 2018, within the Forensic Department of Charles Nicolle Hospital in Tunis. All children who died of unnatural causes were included (767 cases). RESULTS: An overall male predominance was observed (sex ratio = 2.4). Accidental deaths represent the most common manner of death (81.4%) involving most frequently domestic accidents occurring in children aged between 1 and 4 years. In cases of suicide, the highest risk profile was a female child aged between 15 and 18 years. The suicide occurred most often in the victim's home with hanging representing the common means of suicide. For the criminal form, the most common means in those cases were stabbing and blunt injuries. CONCLUSION: Our study delivered a broad picture of unnatural deaths among children in Tunisia. These deaths, largely absent from child survival initiatives presently on the global agenda, can be prevented if they are addressed strategically, as their injury prevention strategies differ from adults.

The response of meiobenthinc sediment-dwelling nematodes to pyrene: Results from open microcosms, toxicokinetics and in silico molecular interactions.

An experiment conducted with 'open microcosm' made by connected sedimentary compartments with different qualities was for 30 days to evaluate the migratory behaviour of nematodes as induced by exposure to pyrene. The nematofauna was collected along with sediment from a reference site in Bizerte lagoon. Following one week acclimatization period, the populated sediments were topped with azoic sediments, with a pyrene concentration of 150 µg kg-1. The concentration of pyrene from sediments was measured on a weekly basis. A stable status of nematode assemblages was reached between the upper and lower compartments in each microcosm, whatever the treatment type. An upward exploratory phase was observed during the first two weeks within the assemblages, possibly induced by the repellent chemodetection of pyrene. This observation was confirmed by the toxicokinetic properties and molecular interactions of pyrene with the germ-line development Protein 3 and sex-determining protein of Caenorhabditis elegans as nematode model.

Lichtenberg Figures: How a Cutaneous Sign Can Solve Suspicious Death Cases.

Lightning is a natural weather phenomenon that occurs most commonly during the summer months in the afternoon or early evening. Lightning strikes can cause accidental deaths. In developed countries, lightning fatalities occur almost exclusively outdoors. Deaths from lightning may be in remote places with no witnesses. Forensic pathologists may not be able to reach the scene of death because it is too hazardous or inaccessible. Bodies may have neither evidence of skin burns nor torn areas on their clothes. The presumption of accidental death may be difficult to prove. We present 3 cases in which neither the examination of the death scene nor the examination of the bodies by those who attested to the death were performed. The bodies were transported to the morgue for a forensic autopsy because the deaths were considered suspicious. Physicians who attest to death in open spaces during weather that could produce lightning should actively search for Lichtenberg figures, which are considered irrefutable proof of fatal lightning in such settings. They should also photograph them and submit them as evidence. Nevertheless, physicians should keep in mind that Lichtenberg figures are not considered pathognomonic of lightning because some skin manifestations may mimic them.

A 13-Year Study of Fatal Falls From Height in Northern Tunisia.

INTRODUCTION: Falls from height are a major cause of unintentional injury death, resulting in high disability and mortality. We investigated the characteristics of fatal falls and their relationship with intentionality, injury patterns, and death on impact. MATERIALS AND METHODS: In this retrospective study, we examined 545 cases of fatal falls from height that underwent autopsy in the forensic department of the Charles Nicolle hospital of Tunis (Tunisia) between January 2008 and December 2020. Cases were reviewed in terms of demographics, fall characteristics, and autopsy findings. RESULTS: The population was predominately male (86.6%). Four hundred twenty-one (77.3%) originated from accidents, 120 (22%) were found to be suicidal, with 4 homicide cases. A notable decline in cases was noticed following the Jasmine revolution, 2011 (R squared = 0.8). The mean height of falls was 8 m. Higher falls were associated with a set of organ-specific injuries. Organ injury pattern did not differ based on intentionality. Female victims were 2.4 times more likely to sustain pelvic injuries than males. The majority of victims deceased before reaching health care structures. Death on impact was strongly associated with higher falls, cranial impact, and organ-specific injuries, including cardiac, pulmonary, and skull injuries.Falls from height are in many cases preventable. A clearly defined fall safety policy, strict implementation of evidence-based interventions, efficient allocation of resources, and raising safety awareness must to be urgently implemented. CONCLUSION: Understanding patterns of injury and the factors that influence death on impact may be of further interest in the prevention and management of survivors in the acute period.

Sudden death due to a massive hydatid pulmonary embolism secondary to a cardiac cyst rupture.

Cardiac echinococcosis is rare, and its clinical evolution is slow and asymptomatic until complications occur such as sudden death. Although more frequent in endemic countries, hydatid disease should be known by forensic specialists with regard to the migration flows of people from zones with high endemicity and who are likely to die from infection. We report an autopsy case of a 33-year-old male without any medical history who presented to the emergency room with shortness of breath, chest tightness, tingling all over the body and faintness without fever. He died suddenly before the medical examination. Autopsy showed no traumatic injuries or signs of violence. A cardiac 7 cm multivesicular hydatid cyst situated on the interventricular septum and the interatrial septum was observed. The cyst was ruptured with a massive hydatid pulmonary embolism. Hydatid cysts were also observed in the lungs. No signs of anaphylactic shock were found. The diagnosis of hydatid cyst was confirmed by histopathological examinations. Our case report highlights the mechanisms of occurrence of cardiac echinococcosis and hydatid pulmonary embolism as a complication, as well as the autopsy findings and the precautions needed by the forensic doctor.

Molecular autopsy and clinical family screening in a case of sudden cardiac death reveals ACTN2 mutation related to hypertrophic/dilated cardiomyopathy and a novel LZTR1 variant associated with Noonan syndrome.

BACKGROUND: Genetic cardiac diseases are the main trigger of sudden cardiac death (SCD) in young adults. Hypertrophic cardiomyopathy (HCM) is the most prevalent cardiomyopathy and accounts for 0.5 to 1% of SCD cases per year. METHODS: Herein, we report a family with a marked history of SCD focusing on one SCD young adult case and one pediatric case with HCM. RESULTS: For the deceased young adult, postmortem whole-exome sequencing (WES) revealed a missense variant in the ACTN2 gene: c.355G > A; p.(Ala119Thr) confirming the mixed hypertrophic/dilated cardiomyopathy phenotype detected in the autopsy. For the pediatric case, WES allowed us the identification of a novel frameshift variant in the LZTR1 gene: c.1745delT; p.(Val582Glyfs*10) which confirms a clinical suspicion of HCM related to Noonan syndrome. CONCLUSION: The present study adds further evidence on the pathogenicity of ACTN2: p. Ala119Thr variant in SCD and expands the mutational spectrum of the LZTR1 gene related to Noonan syndrome.

The exposure to polyvinyl chloride microplastics and chrysene induces multiple changes in the structure and functionality of marine meiobenthic communities.

The effects of microplastics and sorbed polycyclic aromatic hydrocarbons at community levels were rarely assessed in laboratory experiments, despite their obvious advantage in reflecting better the natural conditions compared to traditionally single species-focused toxicological experiments. In the current study, the multifaceted effects of polyvinyl chloride and chrysene, acting alone or combined, on general marine meiobenthos, but with a special focus on free-living marine nematode communities were tested in a laboratory experiment carried in microcosms. The meiobenthos was exposed to two polyvinyl chloride (5 and 10 mg.kg-1 Dry Weight 'DW') and chrysene (37.5 and 75 ng.g-1 DW) concentrations, respectively, as well as to a mixture of both compounds, for 30 days. The results highlighted a significant decrease in the abundance of all meiobenthic generic groups, including nematodes, directly with increasing dosages of these compounds when added alone. The addition of chrysene adheres to microplastics, making the sediment matrix glueyer, hence inducing greater mortality among generic meiobenthic groups. Moreover, the nematofauna went through a strong restructuring phase following the exposure to both compounds when added alone, leading to the disappearance of sensitive nematodes and their replacement with tolerant taxa. However, the similarity in nematofauna composition between control and polyvinyl chloride and chrysene mixtures suggests that the toxicity of the latter could be attenuated by its physical bonding to the former pollutant. Other changes in the functional traits within the nematode communities were a decline in the fertility of females and an increase of the pharyngeal pumping power following exposure to both pollutants for the dominant species. The latter results were also supported by additional toxicokinetics analyses and in silico modeling.

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.

Molecular interactions of polyvinyl chloride microplastics and beta-blockers (Diltiazem and Bisoprolol) and their effects on marine meiofauna: Combined in vivo and modeling study.

The ecotoxicological effects of beta-blockers (i.e. Diltiazem and Bisoprolol) and their interactions with the microplastic polyvinyl chloride on marine meiofauna were tested in laboratory microcosms. An experimental factorial design was applied, using meiobenthic fauna collected from the Old Harbor of Bizerte (NE Tunisia), but with a main focus on the nematode communities. The meiobenthic invertebrates were exposed to two concentrations of Diltiazem and Bisoprolol, of 1.8 µg.L-1 and 1.8 mg.L-1, respectively, and one concentration of polyvinyl chloride (i.e. 20 mg.kg-1), separately and mixed. The overall meiofauna abundance was significantly reduced in all treatments, mainly that of polychaetes and amphipods. Moreover, the juveniles-gravid female ratios of the nematode communities were the lowest in the 1.8 µg.L-1 Bisoprolol treatment and for the 1.8 mg.L-1 mixture of Diltiazem and microplastics, suggesting that different dosages influence the maturity status of the examined species. The demographic results were also supported by in silico approach. The simulation of molecular interactions revealed acceptable binding affinities (up to -8.1 kcal/mol) and interactions with key residues in the germ line development protein 3 and sex-determining protein from Coenorhabditis elegans. Overall, the experimental outcome strongly indicates synergistic interactions among the beta-blockers Diltiazem and Bisoprolol and the microplastic polyvinyl chloride on marine nematode communities.

Effects of the antidepressant paroxetine on migratory behaviour of meiobenthic nematodes: Computational and open experimental microcosm approach.

An open experimental setup was established in order to explore the toxic effects of the antidepressant paroxetine on meiobenthic nematodes. Three types of microcosms made from polyvinyl chloride tubes, each comprising two sediments compartments (upper and lower), were used in a laboratory experiment for 15 days. The experimental setup targeted the migratory behaviour of the nematofauna from the above compartments, which were exposed to paroxetine (0.4 and 40 µg.l-1), towards below compartments. The univariate indices significantly decrease in the contaminated compartments compared to controls. Multivariate analyses revealed also significant taxonomic dissimilarities between contaminated and uncontaminated compartments. Furthermore, SIMPER functional outcomes highlighted a significant decrease in 2A feeding groups, 'co' tail shape, 1-2 mm interval length, 'cr' amphid shape, and c-p2 life history in contaminated compartments. Computational approach showed that paroxetine bound GLD-3 and SDP with high affinities, which together with molecular interactions and toxicokinetics satisfactorily explain the experimental results.

Diuron environmental levels effects on marine nematodes: Assessment of ecological indices, taxonomic diversity, and functional traits.

Coastal marine systems are the most sensitive zones to emerging pollutants. The present study aims to investigate the effect of Diuron on the meiofaunal assemblages, collected from the Bizerte channel (Tunisia). Microcosm experiments were set up using four increasing Diuron concentrations [D1 (10 ng g-1 dry weight (DW)), D2 (50 ng g-1 DW), D3 (250 ng g-1 DW) and (1250 ng g-1 DW)] compared to non-contaminated sediments (controls) and all plots were incubated for 30 days. Our results show that Diuron-supplemented sediments provoked the significant decrease of meiofaunal abundance as well as a change in nematodes' diversity and structure composition. All univariate indices, as well as the cumulative k-dominance, were lower in the Diuron than the control plot. Additionally, the ordination of treatments according to the two-dimensional nMDS plots analysis showed a clear structural separation of the Diuron treated replicates from the controls based on the functional groups lists. These current data emphasize the utility of the use of biological traits in the detection of disturbances in the aquatic biotope.

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.