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.

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.

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.

[Circadian and septadian variation in sudden cardiac death : Autopsy registry of the Tunisian North]

INTRODUCTION

Several studies have suggested a circadian and septadian pattern of incidence of sudden cardiac death with a morning peak and a Monday peak.

OBJECTIVE

To analyze the circadian and septadian pattern of occurrence of sudden cardiac death in the eight northern Tunisian governorates.

METHODS

We prospectively collected epidemiological and autopsy data of sudden cardiac death victims occurring in the northern region of Tunisia between January 2013 and December 2019.

RESULTS

The population included 1834 men (79.6%) and 468 women (20.4%) with a mean age of 56.5 ± 14 years. Smoking (53.9%) was the most prevalent cardiovascular risk factor. One-fifth (20.9%) of victims had known heart disease, and 3% had a family history of sudden death. ischemic heart disease was the leading cause of sudden death (46.8% of cases). One- fourth (25.7%) of autopsies were negative. Analysis of the circadian pattern of occurrence of sudden cardiac death identified a peak (36.1%, p < 0.001) between midnight and 6 am. This nocturnal excess mortality was significant (p < 0.001) and independent of sex (34.1 % in men and 43.8 % in women) and cause of death (39.3 % of cases of sudden ischemic death and 33.3 % of cases of nonischemic death). Moreover, there was a significant septadian variability in the occurrence of sudden death (p: 0.0015), with a peak on Friday (15.8 %, p: 0.042).

CONCLUSION

This study showed a peak of sudden death between midnight and 6 am, and on Fridays, confirming the modification of the classic circadian and septadian pattern of sudden death occurrence. These results may help optimize the deployment of emergency mobile teams and structures during the most vulnerable periods.

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.

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.

How to establish a medico-legal obstacle on the Medical Certificate of Death

Indicating a medico-legal obstacle to burial is not always evident for the pratician. In the absence of specific legal references and scientific Tunisian guidelines, we propose in this paper a practical guide to orientate the pratician on when and how to establish a medico-legal obstacle on the Medical Certificate of Death.

[Sudden cardiac death in women, data from the northern Tunisian sudden cardiac-death registry]

BACKGROUND

Sudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death.

METHODS

We prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed.

RESULTS

The study population included 1834 men and 468 women with a mean age of 56.5±14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P<0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P<0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P<0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P<0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P<0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes.

CONCLUSIONS

Women had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men.

Deaths among homeless in northern Tunisia: a 10-year study (2005-2014)

OBJECTIVE

To analyze the victims profile related to death among homeless people.

STUDY DESIGN

A descriptive, retrospective, and cross-sectional study.

METHODS

We included all deaths among homeless people that occurred during a 10-year period (2005-2014) that were autopsied in the Department of Legal Medicine of the Charles Nicolle Hospital of Tunis. Causes of death were classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision. Data were classified in three sections: sociodemographic data, circumstances of death, and autopsy findings. A univariate data analysis was performed.

RESULTS

The sex ratio (M/F) was of 7.45. The average age was of 59 years. The majority of deaths (80.9%) occurred in the metropolis of Tunis with a significant occurrence of cases in other governorates after the 2011 revolution (P = 0.002). Deaths occurred more often during winter (34.8%). The bodies were frequently discovered in public places (36.0%) and private locations (34.0%). The deaths of 55.3% of cases were attributed to natural causes, significantly affecting the elderly, whereas the accidental causes (25.7%) were more frequent before the age of 49 years, followed by suicides (3.9%) and homicides (3.3%).

CONCLUSIONS

Our study highlighted a phenomenon not yet studied in Tunisia. Our results highlight an urgent need for preventive measures focused on the improvement of healthcare measures among homeless people.