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.

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.

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 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.

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.

[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.

A fatal case of cannabis body-packing: About an autopsy case report.

The body packing represents an illegal drug trafficking practice across the borders of certain countries. It has experienced enormous growth in recent years. The medical literature is rich in publications interested in body packaging of cocaine or heroin with sometimes lethal consequences. However, reported cases of cannabis body packing appear to be rare, sometimes underestimated, despite the notoriety of cannabis in the illegal drug market and its wide consumption around the world. We report in this work a forensic case of a cannabis body packer deceased due toa stercoral peritonitis secondary to a double perforation of thesigmoid and rectal colon.

Medico-legal aspects related to Telemedicine in Tunisia in the context of the covid-19 pandemic.

Telemedicine has become a privileged mode of medical practice providing medical care while reducing the transmission of Covid-19 among patients, families, and clinicians. The law established in 2018 settled a legal framework for telemedicine in Tunisia. However, thelatterremains not sufficient in itself, as legal issues remain especially delimiting the precise conditions for this exercise and to expose the limits of responsibility of each party involved among its organizers, its health service providers, and its users. Several medico-legal issues may be generated by the practice of telemedicine in Tunisia. Our paper aimed to discuss these medico-legal issues relating to telemedicine in anticipation of its legislation.

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.

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.

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'.

Suicide by self-immolation in Tunisia: A 10 year study (2005-2014).

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.

Impact of the Tunisian Revolution on homicide and suicide rates in Tunisia.

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.