Death in detention in the Northern part of Tunisia: a 15-year study (2005-2019).

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

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.

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'.

A comparison of suicidal behavior by burns five years before and five years after the 2011 Tunisian Revolution.

INTRODUCTION: In Tunisia, the phenomenon of self-immolation has increased dramatically since the self-burn of Mohamed Bouazizi which occurred on 17 December 2010. The aim of our study was to compare the casualties' profile of suicide by self-immolation before and after the Tunisian Revolution over a period of 10 years (2006-2015). METHODS: We conducted a retrospective review including all the cases of self-immolation suicides that occurred in Northern Tunisia five years before and five years after the January 2011 Revolution. We excluded cases of self-immolations committed in governorates other than the north of Tunisia as well as casualties of accidental or criminal burns and those where the context could evoke suicidal immolation but the self-inflicted nature has not been confirmed. The study sample was subdivided in two groups according to the Revolution date: before the Revolution (2006-2010) and after the Revolution (2011-2015). We compared for each group data related to the age, gender, marital status, employment, mental disease history, previous suicide attempts and threats, place of suicide and its motive, the type of fire accelerator, the hospitalization and the average body surface area burned. RESULTS: The number (n=48/24.5% before 2011) of suicide by self-immolation has tripled during the post-revolution period (2011-2015) with a stable trend. The average age (35.6±13.4) has not changed. The male remained predominant before and after the Revolution (sex ratio of respectively 1.67 and 3.23). Marital status (victims being single in n=81 cases/41.3%) and the employment (unemployed in n=128/65.3%) of the casualties have not changed either after 2011. Fewer cases with psychiatric history were reported (n=21/43.7% before against n=52/35.1% after). Self-immolation increased in public places (n=9/18.7% before against n=50/33.8% after) and in an administration (n=2/4.2% before against n=19/12.8% after). More suicides after 2011 were due to financial problems (n=2/4.2% before against n=30/20.3% after) or due to a conflict with a state representative (n=2/4.2% before against n=18/12.2% after) with fewer cases due to a decompensation of mental illness (n=18/37.5% before against n=22/26.4% after). CONCLUSION: Our study highlighted modifications of the casualties' profile of self-immolation after the Tunisian Revolution represented essentially by less psychiatric history and more suicides occurring in public places and in front of public administrations as well as suicides motivated by financial problems or conflicts with a state representative. Specific preventive measures should target young unemployed males.

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.

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.

PSMA-PSA clones controlled by full Akt phosphorylation (T308+,S473+) recapitulate molecular features of human prostate cancer.

BACKGROUND: (PSMA+,PSA+) and (PSMA+,PSA-) are the two most individual clones that we have previously identified during prostate cancer (PC) progression. However, molecular signatures associated with these distinct PSMA-PSA prostate clones and their specific correlation with disease outcome is yet to be defined. AIM: Since Akt is a major pathway involved in the critical activating events that leads to malignant form of the disease, we studied the involvement of full Akt activation (T308+,S473+) connected with serum PSA levels, tissue PSMA expression and angiogenic activity on the emergence of (PSMA+,PSA+) and (PSMA+,PSA-) PC clones. METHODS: The study was carried out in 6 normal prostate, 25 benign prostate hyperplasia (BPH) and 23 (PC). Immunohistochemical analysis was performed to study the expression of PSMA, PSA, pAkt(T308), pAkt(S473) and CD34 in prostate tissues. The evaluation of angiogenesis was made by CD34 immune marker. Serum levels of PSA were assayed by Immulite autoanalyser. RESULTS: The most relevant result showed that, among PC patients with pAkt (T308+,S473+) profile, patients that exhibit the (PSMA+,PSA+) clone have .higher serum PSA levels, tissue PSMA expression and angiogenic activity than those with (PSMA+,PSA-) clone. Although have the same (PSMA+,PSA+) prostate clone, BPH patients have distinct molecular-biological features compared to PC patients among pAkt (T308+,S473+) profile. In fact, among patients with maximal Akt activation, the (PSMA+,PSA+) PC clone is characterized by higher serum PSA levels, tissue PSMA production and intensive angiogenic activity than (PSMA+,PSA+) BPH clone. CONCLUSION: These findings emphasize the potential role of the full Akt activation (T308+,S473+) in expansion of several PSMA-PSA prostate clones capable of driving both human PC initiation as well as progression to a metastatic phenotype. Pinpoint patients according to PSMA-PSA clones could recapitulate the histological and molecular features of human PC and may offer a novel approach for controlling metastasis.

PSMA/PSA ratio evaluated by immunohistochemistry may improve diagnosis of prostate cancer.

Prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSMA) measured in serum are not fully satisfactory as biomarkers of prostate cancer (PC). Results obtained in this article indicated that PSMA/PSA ratio evaluated by immunohistochemistry in normal prostate (NP), benign prostatic hyperplasia (BPH), and PC at the individual level could be a useful tool for diagnosis and prognosis of PC. PSMA and PSA were equally expressed in NP and the PSMA/PSA ratio was 1.22 ± 0.15. Data also indicated that PSMA/PSA ratio fluctuates in BPH and PC compared to NP. In BPH, the PSMA/PSA ratio was around 0.47 ± 0.02, whereas it's significantly increased in PC, about 4.95 ± 0.83. In parallel, the highest PSMA/PSA ratio was associated with high intratumoral angiogenesis in PC patients with (PSMA+,PSA+) profile.

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.

Cellular distribution and heterogeneity of Psa and Psma expression in normal, hyperplasia and human prostate cancer.

BACKGROUND: As promising targets for in vivo diagnostic,prognostic and therapeutic approaches, the distribution and staining pattern of prostate specific antigen (PSA) and prostate specific membrane antigen (PSMA) in tumors are of significant interest. AIMS: To compare the cellular distribution and heterogeneity of PSA and PSMA expression in normal prostate (NP), benign prostatic hyperplasia (BPH) and primary prostatic tumors and to analyze their relation with the angiogenic activity according to Gleason grade (low, medium and high) in primary PC. METHODS: The study was carried out in 6 NP, 44 BPH and 39 PC. Immunohistochemical analysis was performed. Monoclonal antibodies 3E6 and ER-PR8 were used to assess PSMA and PSA expression respectively. The evaluation of angiogenesis was made by CD34 immune marker. RESULTS: In our study we noticed differences in the intracellular localization of the PSMA immunostaining which seem to be related to the normal and pathological context. A significant number of primary tumors presented with apical pattern of PSMA (28/39); whereas a relevant part of NP samples and BPH samples showed cytoplasmic localization (4/6 and 30/44,respectively) in luminal epithelial cells. Compared to PSMA, PSA was preferentially localized in cytoplasmic compartment in all type of prostate. A direct correlation between histological grade, PSMA expression and angiogenic activity could be demonstrated in primary PC. CONCLUSIONS: Simultaneous stains with PSA and PSMA in individual prostate tissue will greatly improve the detection rate and identify a high risk PC that could progress to metastatic phenotype. Our findings clearly support the feasibility but also direct the potential of PSMA-targeted in vivo therapeutic approaches in PC patients rather than PSA especially those with poorly differentiated adenocarcinoma.

Sudden death due to hydatid disease: a six-year study in the northern part of Tunisia.

Human ecchinococcosis also known as hydatid disease is a zoonotic infection caused by the tapeworm Ecchinococcus with 2-3 Million cases worldwide. We hereby report a 6 years period study of Sudden death due to hydatidosis aiming to analyze the epidemiological criteria, death circumstances, and autopsy observations attributed to hydatid disease. During the past 6 years, 26 death cases were due to hydatid disease. Our analysis shows that the sex ratio (M/F) was 1.6, the mean age was 31-year old, and 65% of the subjects lived in rural places. In 17 cases, death occurred in the victim's place, five victims died after a heavy exercise, and in two cases, death occurred immediately after trauma. At autopsy, 91% of the cysts were found in the liver. In three cases, death followed a septic state, and in two cases, it followed an acute respiratory failure. Death was attributed to anaphylaxis in 17 cases.

Co-expression and impact of prostate specific membrane antigen and prostate specific antigen in prostatic pathologies.

BACKGROUND: The present study was undertaken to relate the co-expression of prostate-associated antigens, PSMA and PSA, with the degree of vascularization in normal and pathologic (hyperplasia and cancer) prostate tissues to elucidate their possible role in tumor progression. METHODS: The study was carried out in 6 normal, 44 benign prostatic hyperplastic and 39 cancerous human prostates. Immunohistochemical analysis were performed using the monoclonal antibody CD34 to determine the angiogenic activity, and the monoclonal antibodies 3E6 and ER-PR8 to assess PSMA and PSA expression, respectively. RESULTS: In our study we found that in normal prostate tissue, PSMA and PSA were equally expressed (3.7 ± 0.18 and 3.07 ± 0.11). A significant difference in their expression was see in hyperplastic and neoplastic prostates tissues (16.14 ± 0.17 and 30.72 ± 0.85, respectively) for PSMA and (34.39 ± 0.53 and 17.85 ± 1.21, respectively) for PSA. Study of prostate tumor profiles showed that the profile (PSA+, PSMA-) expression levels decreased between normal prostate, benign prostatic tissue and primary prostate cancer. In the other hand, the profile (PSA-, PSMA+) expression levels increased from normal to prostate tumor tissues. PSMA overexpression was associated with high intratumoral angiogenesis activity. By contrast, high PSA expression was associated with low angiogenesis activity. CONCLUSION: These data suggest that these markers are regulated differentially and the difference in their expression showed a correlation with malignant transformation. With regard to the duality PSMA-PSA, this implies the significance of their investigation together in normal and pathologic prostate tissues.

[Four cases of deadly intoxication by Lepiota brunneoincarnata]. / Intoxication mortelle par Lepiota brunneoincarnata: à propos de 4 cas.

We report the case of a collective intoxication by ingestion of a mushroom "Lepiota brunneoincarnata" at the origin of the death of four members of the same family aged between 3 and 15 year old. We discuss the physiopathology and the prognosis factors of such intoxications through these four observations which highlight the clinical signs, biological disturbances due to the intoxication, autopsy and histology findings. The first observation concerns a six year old girl. She presented an abdominal pain with vomiting and aqueous diarrhea. She died during the early phase of the intoxication (seven hour after the ingestion of the mushroom), death was secondary to an acute dehydration. The three other observations concern children aged between three and fifteen year old. They presented typical phalloïdian syndrome symptoms evolution with first gastro-intestinal and then hepatic signs. They died after a period varying between three and eleven days without being able to profit from a hepatic transplantation. The autopsy findings showed the presence of an important cerebral edema and hemorrhagic zones of the liver in all the cases, the presence of hemorrhagic complications in two cases. Histology investigations showed the presence of a diffuse centrilobular and periportals necrosis.

Unusual suicides with band saws: two case reports and a literature review.

Suicides or suicide attempts with power saws (band, circular or chain saws) are rather rare events and only a few case reports exist in the forensic literature. The use of a band saw, in particular, has been extremely rare in cases of suicide. We report two cases of suicide that occurred in the same suburban area, three years apart. In each case, the victim was a carpenter and had a history of psychiatric disorder and/or of prior suicide attempts. We summarize the findings of the death scene investigations, the pertinent autopsy findings, and also summarize the world literature pertaining to suicide committed with power saws.

Analysis of 418 cases of sexual assault.

The aim of the study was to describe victim, assailant, assault characteristics for sexual assault victims according to the time between the last sexual assault and the examination, and to provide descriptive data on medico-legal findings. The study was based on 418 examined victims of sexual assault during the year 1998. Victims were referred from investigating police authorities. All examinations were performed with the use of colposcopy by physicians with special training in forensic medicine. Two groups of victims were defined:a first group of victims examined in emergency within 72 h after the last sexual assault;a second group of victims examined after 72 h. About 86% of the cases were female victims. The mean age of the cases of the first group was 22.4 years. Conversely, 76% of the victims examined after 72 h were under the age of 15 years. Vulnerability was present in 31% of the cases examined in emergency, including disabled and pregnant victims. Sexual assault happened once in 87% of the cases of the first group and in 64% of the cases of the second group. The victim's home was the most frequent place of sexual assault (35% of the cases of the first group and 56% of the cases of the second group). The assailant was a stranger in 51% of the cases of the first group. In the second group of the victims, the assailant was a family member in 58% of the cases (the father in 30% of the cases). There was a single assailant in the majority of the cases for the two groups. Threats were used by the assailant in 66% of the victims examined in emergency and in 33% of the cases of the second group. The type of sexual assault was penetration in the majority of the cases for the two groups. Vaginal, oral and anal penetration was respectively involved in 55, 23 and 13% of the cases of the first group. General body trauma was found in 39.1% of the cases examined in emergency and in 6.3% of the cases of the second group. Genital trauma occurred in 35.7% of the cases of the first group and in 19.5% of the cases of the second group. Hymenal, vulvo-vaginal and anal lesions were respectively found in 11, 20 and 7% of the cases examined in emergency. Toxicological analysis was performed in 14.3% of the cases examined in emergency. In 47% of the tested cases, drug was detected. Cytology was performed in 61.5% of the cases examined in emergency. Detection of spermatozoa was found in 30.3% of these cases. Our study has shown that sexual assault victims had different characteristics according to the time between the sexual assault and the examination. Public health campaigns against sexual abuse and rape as well as medical management of the sexually assaulted victims should adapt to the needs and the characteristics of these two different populations of victims.

Frequency of bone/cartilage lesions in stab and incised wounds fatalities.

A retrospective study was carried out on 58 fatalities due to stab or incised wounds. The frequency of bone or cartilage lesions was analysed according to the number of wounds, the circumstances of death and the anatomical site. Our findings showed that bone/cartilage lesions were present in about 53% of the cases. Cartilage lesions were more frequent than bone lesions. The mean number of wounds in the group with bone/cartilage lesions was statistically higher than the mean number of wounds in the group without lesions (P=0.0068). The main cause of death was thoracic injury in the groups with and without bone/cartilage lesions. In case of skeletal remains, only bone or cartilage lesions allow to diagnose stab or incised wounds. The discovery of these lesions, often of small size, justifies a complete and careful examination of skeletal remains with the help of stereomicroscopy.

Age estimation using radiographic analysis of laryngeal cartilage.

The laryngeal cartilages undergo age changes, including mineralization and ossification. Keen and Wainwright defined, in male and female subjects, recognizable stages of radiopacity of the thyroid, cricoid, and arytenoid cartilages. The present study analyzed quantitatively the degree of laryngeal radiopacity to determine whether radiography of the larynx can be used routinely in forensic pathology to estimate age at death. In each of 82 subjects, the larynx was removed during forensic autopsy and subjected to radiography in an anteroposterior orientation. Each radiograph was independently scored by two observers. For each case, the degree of laryngeal radiopacity was evaluated according to the classification of Keen and Wainwright. There was a positive correlation between the total score of laryngeal radiopacity and age (correlation coefficient = 0.74). It was concluded that this method is simple, fast, and nondestructive and has a good reproducibility between observers. Because there was a wide interindividual variability in the same age class, this method must be associated with more accurate methods.