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The drug duloxetine (Cymbalta®) is a newer antidepressant which has been available in Australia since 2008. Duloxetine is a serotonin and noradrenaline reuptake inhibitor (SNRI), which is associated with adverse effects in the first 6 weeks of therapy, including tachycardia and worsening symptoms in people with advanced heart failure. It is also associated with serotonin toxicity in combination with certain drugs. Few reports have been published in the toxicology literature regarding duloxetine and its prevalence in coroners' cases. This study documents the prevalence of duloxetine in coronial cases between 2009 and 2012 and seeks to better understand the role of duloxetine in deaths where concomitant use with other drugs may cause adverse outcomes. Duloxetine was analyzed in blood specimens taken for the purpose of assisting the pathologist in determining a cause of death and analyzed using a validated LC-MS/MS method employed for overnight screening. There were 34 cases where duloxetine was detected of which 19 were attributed to drug toxicity. The median femoral blood concentration in the cohort was 0.14 mg/L (range 0.01-1.42 mg/L). Many deaths involved the concomitant use of numerous other medications; up to 13 other drugs were co-detected in a case. Over half of the deaths were attributed to fatal combined drug toxicity. SSRIs and venlafaxine that may have increased the risk of serotonin toxicity in combination with duloxetine were detected in five cases. Metoclopramide, contraindicated with duloxetine use, was detected in two cases. NSAIDs (n = 11), antipsychotics (n = 15) and benzodiazepines (n = 14) were also commonly co-detected. Heart disease was observed in over 40% of the cohort, mostly in the form of coronary artery disease or cardiomegaly. Death involving duloxetine alone was uncommon (n = 4); however with certain comorbidities and coadministered drugs, the risk of a fatal event is increased, particularly in the setting of other proserotonergic agents. In deaths where duloxetine is detected and the cause of death is believed to be natural or unascertained, it is essential that other serotonin drugs or inappropriate drug combinations be examined for their possible contribution to death. [ABSTRACT FROM AUTHOR]

Abstract: The 2009 Victorian Bushfires Disaster started on a record hot day in February 2009 and resulted in over 300 separate fires with a death toll of 173 and over 400 presentations to hospital emergency departments. This occurred a little over a week after a heat wave in which over 400 people were thought to have died prematurely in southeastern Australia. The Victorian Institute of Forensic Medicine in collaboration with the police force and the State Coroner''s Office and over 100 colleagues from all over Australia, Indonesia, New Zealand and Japan implemented a DVI process based on Interpol guidelines to identify the deceased persons. CT scanning was conducted on all remains collected and played a pivotal role in the identification processes in conjunction with experts in pathology, anthropology, forensic odontology and molecular biology. This paper outlines the scale of the disaster and the work, from a forensic medical perspective, to identify the deceased. [Copyright &y& Elsevier]

Abstract: This paper briefly describes Disaster Victim Identification (DVI) and reviews the history of the use of forensic anthropology in the identification process. The potential contributions made by forensic anthropology are illustrated through the presentation of a case study. In February 2009 the state of Victoria in south-eastern Australia experienced the most devastating bushfires in its history, resulting in catastrophic loss of life and public and private property. Within 48h of the disaster, forensic teams including pathologists, odontologists and anthropologists assembled at the Victorian Institute of Forensic Medicine in Melbourne to begin the task of identifying the deceased. This paper reviews the part played by forensic anthropologists in the identification process and outlines the important contribution anthropologists can make to DVI, especially at the scene, in the mortuary and in the reconciliation process. The anthropologist''s experience with differentially preserved human remains meant they played an important role identifying and recovering heavily fragmentary human skeletal remains, differentiating human from non-human remains, establishing basic biological information such as the sex and age of the individuals and confirming or denying the possibility of re-associating body parts for release to families. [Copyright &y& Elsevier]

Abstract: The February 7th 2009 bushfires in Victoria, Australia, resulted in the deaths of 173 individuals, of whom 164 were included in the subsequent DVI operation. The final stage of the International DVI protocol is a debrief, referred to as Phase 5. The Phase 5 operational debrief process conducted in the wake of this disaster was designed for the purpose of developing new strategies in light of this experience. The agencies involved included the Coroners Court of Victoria, the Victorian Institute of Forensic Medicine, the Department of Justice, and Victoria Police. During the course of this debriefing process strategies and protocols were developed which aim to improve the capacity of all agencies to respond and resolve future incidents. This paper outlines the Phase 5 debrief carried out in the 6 months following the final coronial identification board, and details the findings and recommendations made by the agencies involved. [Copyright &y& Elsevier]

Abstract: The identification of the victims of the 2009 Victorian bushfires disaster, as in other mass disasters, relied on a number of scientific disciplines – including DNA analysis. As part of the DVI response, DNA analysis was performed to assist in the identification of victims through kinship (familial matching to relatives) or direct (self source of sample) matching of DNA profiles. The majority of the DNA identifications made (82%) were achieved through kinship matching of familial reference samples to post mortem (PM) samples obtained from the victims. Although each location affected by the bushfires could be treated as a mini-disaster (having a small closed-set of victims), with many such sites spread over vast areas, DNA analysis requires that the short tandem repeat (STR) system used be able to afford enough discrimination between all the DVI cases to assign a match. This publication highlights that although a 9-loci multiplex was sufficient for a DVI of this nature, there were instances that brought to light the short comings of using a 9-loci multiplex for kinship matching – particularly where multiple family members are victims. Moreso it serves to reinforce the recommendation that a minimum of 12 autosomal STR markers (plus Amelogenin) be used for DNA identification of victims which relies heavily on kinship matching. [Copyright &y& Elsevier]

Abstract: CT scanning of the deceased is an established technique performed on all individuals admitted to VIFM over the last 5 years. It is used primarily to assist pathologists in determining cause and manner of death but is also invaluable for identification of unknown deceased individuals where traditional methods are not possible. Based on this experience, CT scanning was incorporated into phase 2 of the Institute''s DVI process for the 2009 Victorian bushfires. All deceased individuals and fragmented remains admitted to the mortuary were CT scanned in their body bags using established protocols. Images were reviewed by 2 teams of 2 radiologists experienced in forensic imaging and the findings transcribed onto a data sheet constructed specifically for the DVI exercise. The contents of 255 body bags were examined in the 28 days following the fires. 164 missing persons were included in the DVI process with 163 deceased individuals eventually identified. CT contributed to this identification in 161 persons. In 2 cases, radiologists were unable to recognize commingled remains. CT was utilized in the initial triage of each bag''s contents. If radiological evaluation determined that bodies were incomplete then this information was provided to search teams who revisited the scenes of death. CT was helpful in differentiation of human from non-human remains in 8 bags, recognition of human/animal commingling in 10 bags and human commingling in 6 bags. In 61% of cases gender was able to be determined on CT using a novel technique of genitalia detection and in all but 2 cases this was correct. Age range was able to be determined on CT in 94% with an accuracy of 76%. Specific identification features detected on CT included the presence of disease (14 disease entities in 13 cases), medical devices (26 devices in 19 cases) and 274 everyday metallic items associated with the remains of 135 individuals. CT scanning provided useful information prior to autopsy by flagging likely findings including the presence of non-human remains, at the time of autopsy by assisting in the localization of identifying features in heavily disfigured bodies, and after autopsy by retrospective review of images for clarification of issues that arose at the time of pathologist case review. In view of the success of CT scanning in this mass disaster, DVI administrators should explore the incorporation of CT services into their disaster plans. [Copyright &y& Elsevier]

Abstract: As part of the disaster victim identification (DVI) response to the 2009 Victorian bushfires disaster, a number of scientific disciplines contributed to the human identification process – forensic pathology, anthropology and odontology, as well as fingerprinting and DNA profiling. The DNA laboratory received 182 post-mortem (PM) samples from 120 DVI cases and 236 reference samples corresponding to 163 missing persons (and two non-DVI cases). DNA analysis yielded full DNA profiles for 102 DVI cases and 190 ante-mortem (AM) samples (relating to all 163 missing persons), respectively. Subsequent comparison of DNA profiles, through direct and kinship matching, resulted in the submission of 76 DNA reports to the DVI Reconciliation Centre which assisted in the identification of 67 deceased. This paper describes the contribution of DNA analysis towards the DVI response to the 2009 Victorian bushfires disaster. [Copyright &y& Elsevier]