The altered osteocytic expression of connexin 43 and sclerostin in human cadaveric donors with alcoholic liver cirrhosis: Potential treatment targets.

Previous studies suggested that osteocyte lacunar network disruption could play a role in the complex pathophysiology of bone changes in aging and disease. Considering that particular research interest is lacking, we aimed to assess alcoholic liver cirrhosis (ALC)-induced changes in osteocyte lacunar network and bone marrow adiposity. Immunohistochemistry was conducted to assess changes in the micro-morphology of osteocyte lacunar network and bone marrow adiposity, and expression of connexin 43 and sclerostin in vertebral and femoral samples collected from 40 cadaveric men (age range between 44 and 70 years) divided into ALC group (n = 20) and control group (n = 20). Furthermore, the assessment of the potential association between bone changes and the severity of the hepatic disorder (given by Knodell's pathohistologic scoring) was conducted. Our data revealed fewer connexin 43-positive osteocytes per vertebral and femoral bone area (p < 0.01), suggesting defective signal transduction among osteocytes in ALC individuals. Moreover, we found an ALC-induced increase in the number of adipocytes in the vertebral bone marrow (p = 0.038). Considering significant associations between the severity of liver tissue disturbances and impaired functionality of osteocyte lacunar network (Pearson's correlation analyses, p < 0.05), we may assume that timely treatment of the liver disease may delay bone impairment. ALC induced an increase in osteocytic sclerostin expression (p < 0.001), suggesting its role in mediating low bone formation among ALC individuals. Hence, medicaments targeting low bone formation may be beneficial to attenuate the bone changes among ALC patients. However, future clinical studies are required to verify the therapeutic utility of these findings.

Atypical longitudinal self-inflicted incised wounds as a cause of death in an ecstasy user.

A 32-year-old chronic drug abuser was found dead at the entrance to his home, covered in blood. Pools of blood, bloody footprints and bloodstains were found across the apartment. A double-edged razor was recovered from the scene. Autopsy revealed multiple incised wounds: two on the palmar aspect of both forearms (37 cm and 33 cm long, oriented longitudinally). The cuts extended into the subcutaneous adipose tissue, muscles and blood vessels. There was an additional 30 cm cut extending across the middle of the torso anteriorly and two more cuts on the anteromedial aspect of the lower legs, set symmetrically (about 23 and 25 cm long). These three cuts were more shallow than the upper extremity wounds. No hesitation wounds were identified. Toxicological analysis identified MDMA (ecstasy). The cause of death was exsanguination. The deceased has been using ecstasy for the previous five years and had a history of inpatient psychiatric treatment due to psychosis with delusions and hallucinations. These self-inflicted incised wounds had many atypical features: location (torso, legs and arms), longitudinal orientation and symmetrical distribution, absence of hesitation injuries, use of both dominant and non-dominant hand. The absence of previous suicide attempts and suicide note suggest that these self-inflicted injuries were not planned beforehand, but were abrupt. We hypothesize that this injury pattern is associated with both acute and chronic effects of MDMA.

Bone quality analysis of jaw bones in individuals with type 2 diabetes mellitus-post mortem anatomical and microstructural evaluation.

OBJECTIVES: With the higher risk of dental implant failure with type 2 diabetes mellitus (T2DM), there is a need to characterize the jaw bones in those individuals. The aim of this post mortem study was to compare jaw bone quality of individuals with T2DM to healthy controls. MATERIAL AND METHODS: Bone cores from the edentulous lower first molar region and the region of mandibular angle were collected from male individuals with T2DM (n = 10, 70.6 ± 4.5 years) and healthy controls (n = 11, 71.5 ± 3.8 years) during autopsy. Within the T2DM, a subgroup treated with oral antidiabetics (OAD) and one on insulin were identified. Bone quality assessment encompassed evaluation of bone microstructure, matrix composition, and cellular activity, using microcomputed tomography (micro-CT), quantitative backscattered electron imaging (qBEI), Raman spectroscopy, and bone histomorphometry. RESULTS: In the mandibular angle, T2DM showed 51% lower porosity of the lingual cortex (p = 0.004) and 21% higher trabecular thickness (p = 0.008) compared to control. More highly mineralized bone packets were found in the buccal cortex of the mandibular angle in insulin-treated compared to OAD-treated T2DM group (p = 0.034). In the molar region, we found higher heterogeneity of trabecular calcium content in T2DM insulin compared to controls (p = 0.015) and T2DM OAD (p = 0.019). T2DM was associated with lower osteocyte lacunar size in the trabecular bone of the molar region (vs. control p = 0.03). CONCLUSIONS: Alterations in microstructure, mineralization, and osteocyte morphology were determined in jaw bone of individuals with T2DM compared to controls. CLINICAL RELEVANCE: Future studies will have to verify if the mild changes determined in this study will translate to potential contraindications for dental implant placements.

Ectopic right thoracic kidney associated with Bochdalek hernia as the cause of diagnostic confusion.

A 61-year-old man who was a psychiatric patient and an alcoholic was admitted to hospital after a fall in his bathroom. He showed signs of hemorrhagic shock, and CT scans showed the presence of the right kidney and part of the right retroperitoneum in the right hemithorax, surrounded by liquid. Surgery showed that the right hemidiaphragm was intact and that no intraabdominal viscera prolapsed into thoracic cavity. The bleeding in the right retroperitoneum was evacuated. The surgical report also stated that "the right kidney and ureter were explored and no injuries or active bleeding were found". The patient died the third day after admission. Autopsy revealed a livid swelling covered with parietal pleura in the right half of the thoracic cavity, behind the costophrenic sinus, about 20 × 15x12 cm in size, filled with about 1500 ml of blood, with ectopic right kidney in the right half of the thorax, slightly rotated posteriorly and downwards. The kidney was smaller (80 g in weight), compared to the normally positioned enlarged left kidney (300 g). The right hemidiaphragm was also intact with small Bochdalek's foramen behind the posterior edge, with communication between the right retropleural and retroperitoneal spaces, through which intact elongated right renal artery (15 cm), vein (14 cm) and ureter were passing. The cause of death was hemorrhagic shock due to retroperitoneal bleeding, with coagulation disorder as possible contributing factor. Intrathoracic kidneys may pose many diagnostic and management dilemmas for clinicians and pathologists. Association between a Bochdalek hernia and an intrathoracic renal ectopia is very rare and may be confusing for doctors in different clinical situations.

Suffocation by massive blood aspiration due to intraoral gun-shot injury -the oldest museum specimen in the Institute of Forensic Medicine in Belgrade.

The forensic museum specimen presented in this paper is the oldest specimen in the collection of the Institute of Forensic Medicine in Belgrade. It comprises a jar containing six cervical vertebras connected to a small amount of dry connective tissue. During the autopsy, the cervical part of the spine was completely opened posteriorly: the base of the odontoid process of the axis was crushed, but the transverse and posterior longitudinal ligaments and the spinal cord were intact. Attached to the specimen, there is a partly cored piece of lead which looks like a severely deformed handgun projectile, approximately 12 mm in diameter. The deceased was a 23-year-old man who committed suicide with a gun in a public park. The gun used was most probably a Nagant M1893 revolver, popular in the region until the end of the Second World War. The pathologist, Dr. Eduard Michel, concluded that the immediate cause of death was asphyxiation due to massive blood aspiration caused by an intraoral gunshot wound. Although the revolver model used is a low-velocity firearm, in such cases the shock wave secondary to the impact of the projectile on the second vertebral bone is likely to have been the cause of widespread neuro-axonal damage at the level of the spinal cord, however, Dr. Michel assumed that death was not instantaneous due to massive hemoaspiration. Nevertheless, without examination of all internal organs and the cervical spine, this case could have remained unexplained.

Cysticercosis and suicide - an example from a forensic collection.

In this case from 1937, the deceased was a 52-year-old female who was suffering from systemic cysticercosis, with prominent neurological and psychiatric symptoms. Given the protracted clinical course and autopsy findings it appears likely that the disease led the woman to commit suicide by ingesting lye, a corrosive substance, and the most common way to commit suicide in Belgrade at the time. The autopsy revealed many rounded transparent cysts, attached to the dura and pia-arachnoid, as well as encapsulated in the intercostal muscles, diaphragm and muscles of the arms, legs and the trunk. Solitary cysticercosis of muscles without involvement of the central nervous system is rare: most soft tissue and muscular cysticercal infections are associated with the central nervous system. Parasites usually lodge in the cerebral cortex or the subcortical white matter, due to the high vascular supply of these areas. Psychiatric symptoms in neurocysticercosis have been frequently reported, along with cognitive decline and intellectual deterioration, depressive disorders, behavioral disturbance and psychosis. Although sporadically, the disease is present even today, and neurocysticercosis is the leading cause of epilepsy in the developing world. To maintain its lifecycle, Taenia solium requires non-industrialized pig rearing conditions, consumption of undercooked pork, and low sanitation standards. Socioeconomic and sanitary improvement and educating people about food processing, the disease and antihelminthic therapy, are important factors contributing to a significant reduction in the prevalence of this potentially eradicable disease worldwide.

The banding phenomenon: injury or hypostasis?

Correct interpretation of autopsy findings related to neck structures can be challenging and has tremendous legal importance. We describe a case of a 30-year-old man who was found dead in a hotel courtyard, facedown. The window of his hotel room on the 5th floor was wide open. Police investigation revealed that he was a gambler with many debts, leading them to suspect foul play. The body was transported for a forensic autopsy in a supine position. External examination showed multiple lacerations and contusions of the face and limbs, without signs of external neck injuries. Layer-by-layer neck dissection was unremarkable. Upon opening the pharynx and esophagus, dark purple discoloration of the pharyngeal mucosa could be seen, with a clearly defined margin to the pale circumferential appearance of the rest of the mucosa. To exclude possible tissue bruising due to potential neck compression, histological examination of the mucosa was carried out. Where the mucosa was purple in appearance, there was blood inside the blood vessels, while the vessels of the macroscopically pale mucosa were empty. After forensic autopsy and a detailed police investigation, the manner of death was ruled suicide. In the neck, differential diagnosis between hypostasis and bruising can be especially difficult in rapid, congestive deaths. Forensic pathologists have to be aware of many possible autopsy artifacts in this topographical region, one of those being "banding" of the esophagus. Herein we propose a possible pathophysiological mechanism behind this phenomenon.

Micro-computed Tomography Study of Frontal Bones in Males and Females with Hyperostosis Frontalis Interna.

Hyperostosis frontalis interna (HFI) represents irregular thickening of the endocranial surface of the frontal bone, mostly seen in postmenopausal females. The microarchitecture of this condition is poorly studied. The aim of this cross-sectional autopsy study was to investigate and compare microarchitectural structure of the frontal bone affected with HFI in both sexes and to test whether HFI severity could be distinguished at the microarchitectural level. The sample was taken from human donor cadavers, 19 males (61 ± 15 years old) and 17 females (75 ± 15 years old). After classification of HFI severity (type A, B, C or D), samples of the frontal bone were taken and scanned using micro-computed tomography. Bone volume fraction was higher and total porosity lower only in the outer table of males with HFI, compared to females with HFI. Mean total sample thickness differed only between males with HFI type A and D. Bone microarchitecture between males and females with corresponding HFI types (e.g., male with type A versus female with type A) differed only in HFI type C regarding the fractal dimension of diploe. The degree of anisotropy differed between HFI subtypes in males, but the post hoc analysis revealed no significant differences between individual groups. Other microarchitectural parameters did not differ among males with different HFI subtypes, as well in females, in any part of the frontal bone. There is no difference in microarchitectural structure of the frontal bone between males and females with HFI, in general aspect and within corresponding HFI subtypes. HFI severity could not be distinguished at the microarchitectural level, neither in males nor in females.

Comparative Analysis of Femoral Macro- and Micromorphology in Males and Females With and Without Hyperostosis Frontalis Interna: A Cross-Sectional Cadaveric Study.

We hypothesized that subjects with hyperostosis frontalis interna (HFI), which represents local, endocranial thickening of the frontal bone, would express extra-calvarial manifestations of this condition. Therefore, we compared femoral bone mineral density, geometry, and microarchitecture of males and females with HFI to those without this condition as well as between males and females with HFI. The sample was taken from human donor cadavers, 38 males (19 with and 19 without HFI) and 34 females (17 with and 17 without HFI) that were age-matched within the same sex. The specimens of femoral bones were scanned using microcomputed tomography and dual-energy X-ray absorptiometry (DXA). Parameters of hip structure analysis (HSA) were calculated from data derived from DXA scans. Females with HFI had increased cortical bone volume fraction and their cortical bone was less porous compared to females without HFI. Males with HFI showed microarchitectural differences only with the trabecular bone. They had increased bone volume fraction and decreased trabecular separation compared to males without HFI, although with borderline significance. These microarchitectural changes did not have significant impact on femoral geometry and bone mineral density. The same, still unknown etiological factor behind HFI might be inducing changes at the level of bone microarchitecture at a remote skeletal site (femoral bone), in both sexes. These alterations still do not have the magnitude to induce obvious, straightforward overall increase of bone mineral density measured by DXA. HFI could be a systemic phenomenon that affects both males and females in a similar manner.

Exsanguination from a puncture wound to arteriovenous fistula as the method of suicide in a chronic kidney disease patient.

In this paper we present a case of a 65-year-old man, with chronic kidney insufficiency treated with hemodialysis, found dead by his wife, lying in his bed. Based on autopsy findings, toxicological analysis, the police report and circumstances of death, it was concluded that the death was suicidal and that the cause of death was hemorrhagic shock due to fatal blood loss through a small puncture wound in an arteriovenous fistula of the left forearm, inflicted by a small Swiss Army knife. Similarly to occupation-related suicides, the victim had used his knowledge about chronic kidney disease and the relatively high pressure in an arteriovenous fistula to inform his suicidal actions, and, thus, this case might be considered a disease-knowledge-related or medical-knowledge-related suicide.

Closed-head injuries followed by detached brain tissue in the external auditory canals.

We describe five cases of fatally injured males (occupational accident, car driver, pedestrian, motorcyclist and suicidal jump from great height) with one universal autopsy finding - the presence of brain tissue in one or both auditory canals. Internal examination revealed that all victims had multiple head fractures with dura lacerations. In four cases, the petrous part of the temporal bone was fractured (hinge fracture), while in one case the fracture of both the petrous part of the temporal bones and the occipital bone (ring fracture) was present. In all of these cases, considerable pressure was applied to the head, pushing brain tissue equally in all directions (due to incompressibility of the tissue). The tissue followed the path of least resistance, going through the lacerated dura into the fractured petrous part of the temporal bones and finally reaching the middle ear cavity and auditory canal. This phenomenon is almost exclusively encountered in closed-head injuries. In an open-head injury, brain tissue would be expelled through the open bone fracture and scalp wound. The presence of brain tissue in the ears could indicate a hinge or ring fracture in a closed-head injury which occurred as the result of excessive impulse force or considerable pressure applied to the head, i.e. the head was compressed and/or squeezed.

Mechanism of brain swelling in cases of brain evisceration due to catastrophic craniocerebral injury - an autopsy study.

Some previously reported cases of brain evisceration in catastrophic craniocerebral injuries showed the presence of brain swelling. The aim of this study was to observe the occurrence of focal or diffuse brain swelling in such cases in order to explain the underlying mechanism. An observational autopsy study included 23 adults, 18 males and 5 females, whose average age was 48 ± 22 years (range: 19-89 years) and who died as the result of catastrophic craniocerebral injury with brain evisceration. In all the examined cases, either focal (12 cases) or diffuse (11 cases) brain swelling was present. Grossly visible brain contusions (either cortical or deep) were rarely present - only in 6 out of 23 cases, while microscopic brain contusions were observed in 22 out of 23 cases, with 1 remaining case of microscopic subarachnoid bleeding. Blood aspiration in the lungs, as a vital reaction, was noted in 20 out of 23 cases. Microscopic examination showed absence of edema in 20 cases and mild edema in only 3 cases, while microscopic signs of moderate or severe edema were absent. Brain swelling in cases of brain evisceration likely represents a biomechanical reaction (i.e. decompression) due to a sudden decrease in intracranial pressure. The rapidity of death, together with marked absence of microscopic signs of edema, suggests that this is not a form of biological response to injury, but rather a pure physical phenomenon, strictly in a living person. In such cases, the occurrence of brain swelling and parenchymal microbleeding should be considered vital reactions.

Hyperostosis frontalis interna as an age-related phenomenon - Differences between males and females and possible use in identification.

Hyperostosis frontalis interna (HFI) is a condition manifested by thickening of the inner surface of the frontal bone and it could be useful when dealing with the identification of human remains in various anthropological and forensic investigations. We compared the macroscopic appearance and morphologic (metric) features of the skulls in cases with and without HFI, in both sexes, and wanted to establish whether age determined occurrence of HFI. To achieve this aim, we performed prospective autopsy study, covering ten-year period (2007-2016). Study group consisted of southeast Europe Caucasian subjects, with determined age and sex. The severity of HFI was classified by two forensic pathologists independently, according to the four types (A-D) proposed by Hershkovitz et al. Thicknesses of the frontal and temporal bones, as well as the longitudinal and frontal diameters of the skulls were measured. The sample consisted of 35 males and 112 females with HFI, and 55 males and 202 females without HFI (404 individuals in total). Type B was the most common type of HFI among males (45%) and type C among females (41%). HFI type D was almost four times more common in females than in males (OR = 3.73). Frontal and temporal bones were thicker in all subjects who have HFI. Thickness of the skull was not age-dependent, in the entire sample, or in subjects with HFI, or in the control group (in all the cases Spearman's Rho was <0.3). Age seemed to be a predicting factor for HFI occurrence only in females. Females younger than 55 years have similar risk for HFI occurrence as males. An unidentified skull with the general markers of old age and severe form HFI is most probably from a female decedent.

Simon's hemorrhages in a case of a fatal construction site accident as the result of body hyperextension in the upside-down position - a possible reconstruction of the injury mechanism.

An accident occurred at a construction site and a 27-year-old worker was fatally injured. Equipped with personal protective equipment (helmet and a safety belt), he was standing on an 8-meter-high platform holding a large hose that was attached to a pipe connected to a concrete pump truck. Whilst in use the pipe broke and the hose sent the man flying with force, knocking down the platform railing. Autopsy examination showed that man fell to the ground landing on his head. Prominent Simon's hemorrhages were noted on the L5-S1 and L4-L5 intervertebral discs. When the hose threw the man from the platform, for one brief moment he was suspended in the air, with the safety belt tied firmly to his waist. Simon's hemorrhages most probably emerged at that moment, due to forceful hyperextension and traction of the body in the upside-down position. A relatively unexpected appearance of Simon's hemorrhages contributed to the reconstruction of the injury mechanism.

An unusual case of pulmonary fat embolism following blunt trauma.

Fat embolism is markedly underdiagnosed, even though it is a well-known phenomenon following fractures of the long bones, injury to subcutaneous fat tissue, rupture of a fatty liver, surgical operations on fatty tissues, septicemia, burns and barotrauma. Forensic pathologists tend to "simplify" autopsy report conclusion in cases with multiple injuries where fat embolism and exsanguination could be considered to be the concomitant causes of death. Herein we present a case of 24-year-old male who was beaten with a metal rod by several persons. On admission to hospital his vital signs and laboratory findings indicated hemorrhagic shock with gradual respiratory failure; he died 17 h after injury. On internal autopsy examination the subcutaneous tissue of the limbs and back was severely bruised, corresponding to about 35% of the body surface area. He had fractures of several small bones. Injuries of the internal organs were absent, there was no free blood in the body cavities, and all other autopsy findings were unremarkable but suggestive of a significant blood loss. Microscopic examination showed a massive pulmonary fat embolism (grade III according to Sevitt), without systemic fat embolism. The cause of death was attributed to pulmonary fat embolism combined with severe blood loss, following extensive and severe bruising of the subcutaneous tissues and bone fractures.

Intestinal obstruction as a cause of death in the mentally disabled.

Two cases of intestinal obstruction in the mentally disabled are reported. The first case concerns 61-year-old oligophrenic woman who resided in a nursing home, where she was found hypotensive and unresponsive. Upon opening the peritoneal cavity at autopsy, extremely dilated (measuring on average 12 cm in diameter) loops of the colon emerged- they compressed the small intestine and other intraperitoneal organs, lifting both hemidiaphragms deep into the pleural cavity. Lodged firmly into the rectum, a partly disintegrated sanitary pad was found. In the second case, young man with Down syndrome was found dead in his room in a nursing facility. At autopsy, a massively dilated stomach and intestinal loops emerged, interposing one of the loops between the liver and right hemidiaphragm (pushing it to the 3rd intercostal space). This was caused by a volvulus - the cecum, the entire ascending colon and hepatic flexure were gangrenous, dilated (the maximum diameter was 15 cm) and twisted in a full circle around the mesenteric attachment. There were no signs of colon perforation. In both cases, intellectual disability was at the core of poor communication and delayed medical treatment, which led to a fatal outcome. Caregivers must be trained to recognize distress in the mentally disabled, especially since the symptoms and signs of gastrointestinal diseases may be subtle, or at least less recognizable. By performing careful physical examination medical staff should search more cautiously for these signs. Any suspicion of mistreatment or neglect of the mentally impaired requires a medico-legal investigation and autopsy.

Sodium nitrite food poisoning in one family.

Sodium nitrite is used as a coloring agent or preservative in food, as well as an antimicrobial agent in meat and fish and some cheeses. In high amounts it can be toxic for humans, causing methemoglobinemia. This is an unusual and potentially fatal condition in which hemoglobin is oxidized to methemoglobin (MHb), reducing the amount of oxygen that is released from hemoglobin, similar to carbon monoxide poisoning. MHb levels of 70% are generally lethal, but the existence of underlying anemia, acidosis, respiratory compromise, and cardiac disease may exacerbate the toxicity of MHb. We present a case of poisoning with sodium nitrite in three family members after eating homemade sausages given to them by their neighbor who was a butcher. According to the findings of the veterinary inspectorate in charge of food control in this case, the concentration of sodium nitrite in the homemade sausages was about 3.5 g per 1 kg of meat, almost 30 times higher than allowed according to legislation. In this case report, a 70-year-old man died about 7 h after consuming the meal, while two women, 53 and 67 years of age, respectively, were admitted to a toxicology clinic the following day due to food poisoning, with the maximum concentration of MHb in blood of 33.7 and 20.4%, respectively. They were discharged 3 days later. The autopsy of the deceased man showed sodium nitrite poisoning with a relatively low concentration of MHb in his blood - 9.87%. Death was attributed to the exacerbation of hypertensive and ischemic heart disease, resulting from accidental sodium nitrite poisoning. The presented cases illustrate the necessity of close cooperation between the authorities, medical staff, veterinary inspectorate, and forensic pathologists in determining the source of poisoning, the cause of death of the victim, and preventing the outbreak of poisoning among a greater number of consumers.

Suicidal head impalement with a hydraulic press machine - occupation-related suicide in a psychiatric patient.

A 63-year-old mechanic, diagnosed with schizophrenia, was found next to a hydraulic press used for removing car wheel bearings. He was in a sitting position, bent towards the machine, with his head placed between the piston and the pressing plate. His flexed left arm was resting on the lever beneath the machine pedestal, and on the right side there was a power switch that was still in the "on" position. His right arm was beside his body, but away from the machine. On the pressing plate, beneath the decedents head, was a piece of bloody cloth. Blood spatters were present on the left hand and left trouser leg. At autopsy there was a gaping laceration in the right temporal area extending to the right ear lobe, where a piece of helix was missing. This missing tissue was found on the inner surface of the left temporal bone. The temporal lobes and brain-stem were destroyed along the wound trajectory but there were no brain contusions present. There was blood aspiration in both lungs, but all other findings were unremarkable. Death was attributed to the fatal head injury that resulted from the low-velocity penetration of the hydraulic press piston. While the cause of death was self-evident and undoubted, the manner of death required medico-legal investigation. The protective cloth that had been placed on the pressing plate, a medical history of schizophrenia, and the absence of any defensive injuries, all led to the conclusion that this was a case of a rather unusual suicide, which could be regarded as related to the decedents occupation.

Patent foramen ovale, paradoxical embolism and fatal coronary obstruction.

A 75-year-old woman was admitted to the emergency room with chest pain and vomiting. An electrocardiogram and laboratory results were suggestive for myocardial infarction of the posterior cardiac wall. Echocardiography was indicative of aortic dissection, and a CT scan of the thoracic arteries showed a massive pulmonary thromboembolism and thrombotic occlusion of the right coronary artery (RCA). The woman died shortly after admission. Autopsy confirmed the presence of thromboemboli in the right pulmonary artery and its lobar branches. Also, the anterior aortic sinus was filled with a 9 cm long thromboembolus that extended into the RCA, making it dilated and completely occluded. Another 3.5 cm long thromboembolus extended from the beginning of the left subclavian artery. A patent foramen ovale (PFO) was present. On the posterior wall of the left ventricle, there was an area suggestive of myocardial infarction, and histopathological examination confirmed that it was 24-48 hours old. The coronary circulation was "co-dominant". The sources of thrombotic masses were the deep veins of the lower limbs. The cause of death was myocardial infarction, caused by RCA occlusion with thromboembolus originating from the deep veins of the left lower leg after paradoxical embolism via PFO. This case illustrates that although deep venous thrombosis, pulmonary thromboembolism, and PFO are not rare findings at autopsy, their combination could be a relatively rare cause of fatal coronary artery occlusion after paradoxical embolism.

Double suicidal gunshot wounds to the heart.

A case of double gunshot wounds to the heart is reported, where police investigations determined the manner of death to be suicide. In addition, the autopsy findings supported this conclusion. The localization, appearance, and mutual relations of the inflicted wounds, as well as the direction of the bullet trajectories, helped to determine the most probable sequence of events. The victim had been able to act after the first shot and inflict the second shot as the conduction system of the heart was at least partially preserved. Even when the circumstances indicate the most probable manner of death, multiple gunshot wounds represent a challenge for forensic pathologists; a victim's ability to act after the first shot must be determined with respect to the degree of initial incapacitation.