Victorian Institute Of Forensic Medicine Research Articles

Incidence of quadricuspid pulmonary valves at postmortem examination

Quadricuspid pulmonic valve is a rare congenital abnormality and because of its difficult non-invasive assessment, it is usually discovered incidentally at autopsies (reported prevalence in post-mortem specimens ranges from 1 in 400 to 1 in 2000). Unlike a bicuspid pulmonary valve, it rarely presents with clinical complications, such as valvular insufficiency or stenosis. Abnormal function is rarely reported in cases that are not associated with other congenital heart disease. With increased sophistication of imaging coincidental quadricuspid valves autopsy studies are important to understand the anatomical consequences of this finding. Our case series identified 21 QPV cases from the Victorian Institute of Forensic Medicine, Melbourne and St George's University of London, Department of Cardiovascular Pathology. Cases were identified through local database searches and review of autopsy/cardiac examination reports over a 20-year period. Available photographs were also systematically examined. Fifteen cases had causes of death with no direct causality to cardiac valvular pathology alone. Six cases were considered unascertained or similar (sudden arrhythmic death syndrome and sudden unexpected death in epilepsy). The presence of QPV in these instances were uncertain but thought to be unlikely contributory to death, due to the absence of pulmonary valvular complications.

Differentiating fatal one-punch assaults from standing height falls based on skeletal trauma: a pilot study

ABSTRACTA fatal one-punch assault is defined as a single punch to a person’s head or neck resulting in death. In some of these assaults, it may be important to understand which injuries stemmed from the punch, the resulting fall, or both. The aim of this study was to identify if there were differences in skull and cervical fractures between deaths from a one-punch, one-punch with fall, and fall from standing height. Relevant cases were extracted from the Victorian Institute of Forensic Medicine’s database, and case circumstances and biological variables were recorded from coronial documentation. Fracture patterns and types were documented from post-mortem computed tomography scans. Trauma was analysed in the context of the variables using descriptive and bivariate models. Six one-punch, 15 one-punch with fall, and 30 standing height fall deaths were included. There were subtle fracture differences. All skull regions fractured in the three events; however, the frequency of fractures varied, and cervical vertebrae fractures did not occur in the isolated one-punch deaths. Variations of linear fractures resulted from falls while linear, diastatic and blowout fractures resulted from a punch. The findings augment the evidence base for trauma interpretations in one-punch assaults and provide the foundation for a large-scale study.

Sexual abuse during childhood and all-cause mortality into middle adulthood: an Australian cohort study.

To compare mortality from all causes, internal causes (eg, cancers, circulatory and respiratory system diseases), and external causes (eg, suicide, accidents, assault) among people who were sexually abused during childhood with mortality for the general population. Historical cohort study. 2759 people (2201 women, 79.8%) who had experienced medically assessed contact sexual abuse in Victoria while aged 16 years or younger during 1964-1995, as recorded in Victorian Institute of Forensic Medicine records. Mortality rate, based on linked National Death Index data (1980-2020), by five-year age group; sex- and age-standardised mortality ratios; comparison of rates with age- and sex-adjusted rates for the general Victorian population (incident rate ratio [IRR]). We included 115 deaths of people under 50 years of age in our analysis (4.2% of people sexually abused as children; 79 women, 36 men); 56 deaths were attributed to external, 56 to internal causes (cause of death information missing in three cases). In each age group from 15-19 years, the mortality rates for people sexually abused as children were higher than for the general population; age- and sex-standardised all-cause mortality ratios were highest for people aged 25-29 years (men: 16.5; 95% confidence interval [CI], 11.0-22.0; women: 19.2; 95% CI, 14.3-24.2). The age- and sex-adjusted mortality rate for people sexually abused as children was higher than in the general population for all-cause (IRR, 8.25; 95% CI, 5.92-11.5), internal cause (IRR, 5.92; 95% CI, 3.89-9.01), and external cause deaths (IRR, 12.6; 95% CI, 9.61-16.6); the differences in external cause mortality were greater for people who had experienced penetrative (IRR, 14.9; 95% CI, 10.9-20.5) than for those who had experienced non-penetrative sexual abuse as children (IRR, 8.92; 95% CI, 5.35-14.9). Sexual abuse during childhood is associated with higher mortality rates into mid-adulthood. Preventing child sexual abuse and intervening early to reduce the damage it inflicts is not only essential for the welfare of the child, but could also help reduce avoidable deaths later in life.

Myocarditis in the forensic setting

Diagnosis of myocarditis as the cause of death in the forensic setting at post-mortem is currently determined by a forensic pathologist. There is no systematic method for diagnosis and thus the determination is subject to inter-observer variability and is often non-reproducible. The primary aim of this study was to investigate the differences in the amount of inflammation between cases where myocarditis was deemed the cause of death, compared to cases where myocardial inflammation was incidentally present at autopsy, but not determined to be the cause of death. Participants were sourced from the Victorian Institute of Forensic Medicine (VIFM) database, from full autopsies conducted on reportable death in Victoria, Australia between the years 2011 and 2021.Cases of fatal myocarditis were significantly more likely to experience infection-like symptoms prior to death, and to be in hospital at the time of death. Histopathological examination revealed fatal cases had a significantly higher inflammatory index compared to the incidental group. Lethal cases were also significantly more likely to have myocyte necrosis, and a diffuse pattern of inflammation.There are significant differences between cases where myocardial inflammation has been determined to be the cause of death and cases where inflammation in the myocardium was an incidental finding. These results could be used in the forensic autopsy to help pathologists determine if inflammation should be considered fatal or incidental.

An illicit drug early warning system in Victoria, Australia: The role of forensic toxicology in clinical casework

In response to the evolving threat of illicit substance use in Australia, public health bodies and advisory committees have called for an enhanced public health response including greater visibility related to community illicit drug use, particularly novel psychoactive substances (NPS). Victorian state government agencies recommended the development of a state-wide illicit drug early warning system (EWS), utilising data-sharing collaborations between emergency physicians, forensic laboratories, researchers, and health services. Current monitoring modalities utilised in Australia, such as surveys, wastewater monitoring and coronial investigations, lack the specificity and/or responsiveness required for an effective EWS. Clinical toxicity observed in patients presenting to emergency departments (EDs) following exposure to an illicit drug provides an objective and timely measure of harm. Although illicit drug EWS exist in other jurisdictions, not all utilise high-quality forensic analysis and instead rely on patient-reported exposure. However, there is evidence demonstrating poor correlation between reported exposure and forensic analytical findings. The Emerging Drugs Network of Australia Victoria (EDNAV) was therefore created to provide a clinical registry collecting high-quality clinical and analytical data from Emergency Department (ED) illicit drug presentations, combined with a multi-disciplinary expert team to analyse registry data and provide intelligence to a state illicit drug EWS. The EDNAV is a Human Research Ethics Committee (HREC) approved project created in conjunction with a pilot project utilising data from wastewater analysis, syringe residue analysis and ED illicit drug presentations to provide health authorities with intelligence on community drug use. Patients 16 years of age or older presenting to one of eleven EDNAV project EDs with reported or suspected illicit drug related toxicity requiring a venipuncture as part of their standard clinical care are eligible for registry inclusion. Blood samples from cases are transferred weekly to the Victorian Institute of Forensic Medicine (VIFM) Toxicology Department. Overnight liquid chromatography-tandem mass spectrometry (LC-MS/MS) screens for 327 common pharmaceuticals and illicit substances (including ∼80 NPS), followed by a secondary NPS specific screen targeting 268 NPS. The NPS specific screen is actively updated based on emerging drug intelligence and literature reports. The HREC approved waiver of patient consent to include deidentified clinical and analytical data into a purpose built secure on-line (REDCap platform) registry. Forensic and clinical toxicologists/emergency physicians produce intelligence reports based on EDNAV registry data, which are provided to department of health policy officers to identify triggers and/or threats that lead to interventions designed to reduce community harm. There were 700 ED illicit drug presentations included in the EDNAV registry during the period September 2020–February 2022 (71% male, median age 33 years). Eighty-seven percent of patients arrived in ED via ambulance. Overall clinical acuity was high with 22% Australasian triage category 1 (require immediate treatment), and 62% category 2 (require treatment within 10 minutes), while 47% of patients were classified as having moderate, and 41% severe clinical toxicity. In additional to traditional illicit substances, novel substance detections included illicit benzodiazepines ( n = 10), cathinones ( n = 9), synthetic cannabinoid receptor agonists ( n = 6), and opioids ( n = 3). Forensic analyses revealed that in over 90% of cases there were different and/or additional drugs detected in comparison to the reported exposure, suggesting significant drug adulteration, drug substitution or under-reporting and highlighting the potential limitations of illicit drug EWS that do not utilise high-quality forensic analysis. Three public health alerts have been released in Victoria as the result of EDNAV registry intelligence, involving detections of N-ethylpentylone, 25B-NBOH, and paramethoxymethamphetamine. The EDNAV registry project has highlighted the critical role of a high-quality forensic analytical service in an illicit drug EWS in the state of Victoria.

Postmortem Interrogation of Cardiac Implantable Electronic Devices: A 15-Year Experience.

This study sought to define the feasibility and utility of postmortem cardiac implantable electronic device (CIED) interrogation. The diagnostic yield of routine postmortem interrogation of CIEDs including pacemakers, defibrillators, and implantable loop recorders has not been established. The study reviewed all CIED interrogations in deceased individuals undergoing medicolegal investigation of sudden or unexplained death by the Victorian Institute of Forensic Medicine between 2005 and2020. A total of 260 patients (68.8% male, median age 72.8 years [interquartile range: 62.7-82.2 years]) underwent CIED interrogation (202 pacemakers, 56 defibrillators, and 2 loop recorders) for investigation of sudden (n=162) or unexplained (n=98) death. CIEDs were implanted for median of 2.0 years (interquartile range: 0.7-5.0 years), with 19 devices at elective replacement indicator and 5 at end of life. Interrogation was successful in 256 (98.5%) cases. Potential CIED malfunction was identified in 20 (7.7%) cases, including untreated ventricular arrhythmias (n=13) and lead failures (n=3, 2 resulting in untreated ventricular arrhythmia). Interrogation directly informed cause of death in 131 (50.4%) cases. A total of 72 (27.7%) patients had abnormalities recorded in 30days preceding death: nonsustained ventricular tachycardia (n=26), rapid atrial fibrillation (n=17), elective replacement indicator or end-of-life status (n=22), intrathoracic impedance alarms (n=3), lead issues (n=3), or therapy delivered (n=1). In 6 cases in which the patient was found deceased after a prolonged period, interrogation determined time of death. In 1 case, CIED interrogation was the primary means of patient identification. Postmortem CIED interrogation frequently contributes important information regarding critical device malfunction, premortem abnormalities, mechanism, and time of death or patient identity. Device interrogation should be considered for select patients with CIEDs undergoing autopsy.

An evaluation of the differences in paediatric skeletal trauma between fatal simple short falls and physical abuse blunt impact loads: An international multicentre pilot study

In cases where a deceased child exhibits trauma as a result of a physical abuse blunt impact load, a parent/caregiver may provide a simple short fall (SSF) as the justification for that trauma. The skeletal fractures remain difficult to differentiate between a SSF and physical abuse however, as both are the result of a blunt impact load, and are therefore biomechanically alike, and the rare nature of these fatalities means only anecdotal research has been available to validate such claims. The aim of this pilot study was to investigate if there may be differences in the skeletal fracture patterns and types resulting from SSFs compared with those resulting from physical abuse blunt impacts. Paediatric (<10 years) cases of fatal SSFs (≤1.5 m) and physical abuse were collected from the Victorian Institute of Forensic Medicine (Australia), Institut Médico-Légal de Paris (France), University of Pretoria (South Africa) and Great Ormond Street Hospital (England). For each case the intrinsic and extrinsic variables were recorded from medico-legal reports and skeletal trauma was documented using post-mortem computed tomography scans and/or skeletal surveys. Three SSFs and 18 physical abuse cases were identified. Of the SSF cases, two exhibited fractures; both of which were simple linear neurocranial fractures. Comparatively, 12 of the physical abuse cases exhibited fractures and these were distributed across the skeleton; 58% located only in the skull, 17% only in the post-cranial and 25% located in both. Skull fracture types were single linear, multiple linear and comminuted. This pilot study suggests, anecdotally, there may be differences in the fracture patterns and types between blunt impact loads resulting from a SSF and physical abuse. This data will form the foundation of the Registry of Paediatric Fatal Fractures (RPFF) which, with further multicentre contributions, would allow this finding to be validated.

Systematic quantification of histologic ventricular fibrosis in isolated mitral valve prolapse and sudden cardiac death

Cardiac fibrosis in mitral valve prolapse (MVP) is implicated in the development of sudden cardiac death (SCD); however, the pattern remains poorly characterized. The purpose of this study was to systematically quantify left and right ventricular fibrosis in individuals with isolated MVP and SCD (iMVP-SCD), whereby other potential causes of death are excluded, compared to a control cohort. Individuals with iMVP-SCD were identified from the Victorian Institute of Forensic Medicine, Australia, and matched for age, sex, and body mass index to control cases with noncardiac death. Cardiac tissue sections were analyzed to determine collagen deposition in the left ventricular free wall (anterior, lateral, and posterior portions), interventricular septum, and right ventricle. Within the iMVP-SCD cases, the endocardial-to-epicardial distribution of fibrosis within the left ventricle was specifically characterized. Seventeen cases with iMVP-SCD were matched 1:1 with 17 controls, yielding 149 samples and 1788 histologic regions. The iMVP-SCD group had increased left ventricular (anterior, lateral, and posterior; all P <.001) and interventricular septum fibrosis (P <.001), but similar amounts of right ventricular fibrosis (P = .62) compared to controls. In iMVP-SCD, left ventricular fibrosis was significantly higher in the lateral and posterior walls compared to the anterior wall and interventricular septum (all P <.001). Within the lateral and posterior walls, iMVP-SCD cases had a significant endocardial-to-epicardial gradient of cardiac fibrosis (P <.01) similar to other known conditions that cause cardiac remodeling. Our study indicates that nonuniform left ventricular remodeling with both localized and generalized left ventricular fibrosis is important in the pathogenesis of SCD in individuals with MVP.

Human identification: a review of methods employed within an Australian coronial death investigation system.

Whilst many identification methods have been widely described and discussed in the literature, and considered in disaster and humanitarian contexts, there has been limited reporting and evaluation of the identification methods used in domestic medico-legal death investigation contexts. The aim of this study was to evaluate the identification methods utilised at the Victorian Institute of Forensic Medicine (VIFM), which forms part of a coronial medico-legal death investigation system. The method of identification and time taken to complete the identification were reviewed for all cases admitted to the VIFM over a five-year period from 1 July 2015 to 30 June 2020. The majority, 91%, of individuals admitted to the VIFM were visually identified. The remaining 9% of cases required identification by primary methods (i.e. fingerprints, DNA or dental) or, when those methods were not possible, by secondary methods (i.e. circumstantial). Visual identifications were the timeliest, taking an average of 1.5days, whilst primary identification methods required an average of 5days to complete. The triaging of identification methods, dependent on the case context, body preservation, availability of ante-mortem data, legal requirements and admissibility of the method, are determined by identification coordinators within the Human Identification Service (HIS) to ensure the most appropriate and timely method is employed. This review of human identification methods provides the foundation for future analyses to compare workflow processes and improve identification methods utilised in domestic medico-legal contexts.

Recording skeletal completeness in cases of fragmentary human remains: a pilot technical study using computed tomography volume rendering applications

ABSTRACT Documenting skeletal completeness is an essential element of the physical anthropology examination. Methods available to calculate skeletal completeness, that is how much of the complete skeleton is available for analysis, remain limited and subjective. This study aimed to develop an objective and standardized technique for recording skeletal completeness in adult individuals by establishing percentage values for complete and fragmentary skeletal elements. Percentages were established from 14 adult individuals from the Victorian Institute of Forensic Medicine’s post-mortem computed tomography database. Using Syngo.via’s digital editing tools, the volume of each whole bone and bone segment was measured. Percentages were established by calculating the proportion of each bone’s volume relative to the volume of the complete skeleton. Mean percentage values for each bone and bone segment from eight of the individuals were taken as the reference percentage value. Percentage values from the remaining six individuals were used to validate the reference percentages. Between 33.33% and 85.71% of the percentages calculated were congruent with the reference percentages. Results indicate this technique in its current form is not reliable or accurate and thus these reference percentages are not recommended for use. Rather, this study has identified a novel technique that, with further development and refinement, may provide a standardized means for recording skeletal completeness appropriate for use in forensic anthropology and biological archaeology practice.

High Throughput Detection of 327 Drugs in Blood by LC-MS-MS with Automated Data Processing.

The described procedure provides a rapid technique for the detection and semi-quantitation of a large number of drugs in blood. This procedure uses a minimal sample volume and employs a one-step liquid extraction and automated data processing to yield rapid turnaround times. A total of 327 of the most commonly used medicinal and illicit drugs in Australia were selected including various amphetamines, anesthetics, antidepressants, antipsychotics, anticonvulsants, benzodiazepines, beta blockers, opioid and nonopioid analgesics, stimulants, THC and a large number of synthetic cannabinoids and other novel psychoactive substances. The extracts were subject to 5-minute chromatography using a Kinetex C18 50×4.6mm 2.6μm solid-core analytical column and analyzed using a Sciex 3200 Q-TRAP MS-MS (+ ESI, MRM mode, two transitions per analyte). The method was fully validated in accordance with international guidelines. Matrix effects and extraction efficiencies were acceptable with most analytes showing > 80% response and low variation (within 25%RSD). Cannabinoids were most affected by the matrix and yielded poorest recovery values but were still detectable. Precision, accuracy, repeatability and multipoint linearity were assessed for all analytes. The method has been used in routine practice in the forensic toxicology service at the Victorian Institute of Forensic Medicine in over 6000 coronial investigations using both postmortem and clinical blood specimens. This technique has greatly increased throughput, reduced turnaround times and allowed for rapid same-day analysis of results when needed. The method is routinely used in routine overnight testing with results reported to pathologists within 4h of data acquisition. This rapid toxicological technique is used in conjunction with other investigative processes such as full-body CT imaging, review of case circumstances and medical histories to provide an efficient death investigation process.

260 The First Australian Multi-Source Sudden Cardiac Death Registry: Methodology and Early Findings

In 2019, the first multi-source registry of sudden cardiac arrest and death launched in Victoria, Australia. Sudden cardiac arrest / death (SCA/D) affects approximately one thousand younger Victorians per year. The Unexplained Cardiac Death Project enrols all SCA/D cases aged 1-50 years, whilst also offering family screening and access to psychological support through clinical sites and creating a genetic biorepository for whole-genome sequencing. Out of hospital cardiac arrest (OHCA) patients aged 1-50 years in Victoria, Australia are identified by either the existing Victorian Ambulance Cardiac Arrest Registry or the Victorian Institute of Forensic Medicine. Case adjudication is performed, and patients and first-degree relatives with a cardiac/unascertained cause of arrest referred to a clinical site (Royal Melbourne Hospital, St Vincent’s Hospital Melbourne, the Alfred Hospital or the Royal Children’s Hospital). Family screening is conducted, and the opportunity for index cases to contribute to a genetic biorepository offered (deceased cases have samples collected at post-mortem). To date, 509 OHCA patients aged 1-50 have been included in the registry. Of the cases enrolled, 434 (85%) died as a direct result of their cardiac arrest (377 (87%) deceased at scene). Genetic samples have been collected from 17 patients to commence the genetic biorepository. The launch of Australia’s first multi-source cardiac arrest surveillance registry highlights very high mortality in young and middle-aged OHCA patients. The registry will create a genetic biorepository of sudden cardiac arrest survivors and victims that will establish an ongoing Australian resource.

The role of voluntary and involuntary drug and alcohol consumption and premorbid mental health factors in drug-facilitated sexual assault.

In order to better understand risk factors associated with drug-facilitated sexual assault (DFSA), this study examined complainant-specific and contextual factors, as well as the toxicological profile of DFSA in Victoria, Australia. Clinical files and toxicological analysis results collected by the Victorian Institute of Forensic Medicine (VIFM) for all cases of alleged DFSA in Victoria that occurred between 1st January 2011 - 31st December 2013 were reviewed. Two hundred and four cases of alleged DFSA were identified; complainants were predominately female (93%), and their median age was 26years (range = 18-54). Self-reported premorbid depression (21.1%) and drug and alcohol abuse (9.8%) were four and two times higher than 12-month prevalence rates in Australia, respectively. All assailants were male, half were known to the complainant and half of alleged assaults occurred in private residences. Most (93.6%) complainants reported voluntary consumption of psychoactive substances prior to the alleged DFSA. Alcohol was the most commonly self-reported substance consumed (n = 164; 64%) and concomitant use of alcohol, prescription and illicit drugs was also commonly self-reported (24%). There were 14 cases that produced a positive toxicology result where the complainant did not report voluntary consumption, which suggests these drugs may have been used covertly to facilitate sexual assault. The results of this study indicate that Females in their mid-20's who exhibit higher rates of mental health concerns represent a sub-group of the Australian population with increased vulnerability to DFSA, which typically occurs in a familiar setting in the context of voluntary alcohol and other substance use.

Family violence in Victoria, Australia: a retrospective case-control study of forensic medical casework.

To identify the risk factors and assault characteristics of family violence among victims referred for forensic medical examination in Victoria, Australia. A retrospective 1:1 case-control study was conducted, comparing adult family violence victims and non-family violence victims examined by clinical forensic practitioners from the Victorian Institute of Forensic Medicine, between July 2015 and June 2016. Data were extracted from victims' forensic medical casework. Chi-square or Fisher's exact tests and Mann-Whitney U tests were used to examine group differences. A multiple logistic regression analysis was used to determine independent predictors of family violence. One hundred and forty-three family violence victims (97.2% female, Mdnage = 29, 90.2% intimate partner violence) were identified and gender- and age-matched with controls. Family violence victims had significantly higher odds of reporting a history of violence victimisation (OR = 5.20; 95% CI, 2.54to 10.66) and current pregnancy (OR = 5.28; 95% CI, 1.09to 25.46) than controls. Family violence was significantly more likely than non-family violence to occur in the victim's home, and to involve physical assault, use of weapon(s), trauma to the neck and anal sexual assault. Family violence victims sustained significantly more physical injuries, and were more likely to be injured to almost every bodily location, than controls. This study highlights the importance of assessing and managing risk for family violence following initial victimisation and throughout pregnancy. Findings further indicate that family violence is more dangerous (i.e. more likely to involve severe forms of assault and cause injury) than non-family violence.

The epidemiology of sexual assault of older female nursing home residents, in Victoria Australia, between 2000 and 2015.

Sexual assault is the least acknowledged, detected, and reported type of assault against nursing home residents. Nursing home staff are responsible for reporting suspected allegations to the police, who will contact a clinical forensic examiner to conduct a forensic medical examination. This study examined the epidemiology of sexual assaults of older women (aged 65 years and older) residing in nursing homes in Victoria, Australia, between 2000 and 2015, whose alleged incidents were referred to a clinical forensic examiner for a forensic medical examination. A retrospective analysis of alleged sexual assaults reported to the Clinical Forensic Medicine Unit at the Victorian Institute of Forensic Medicine between 1 January 2000 and 31 December 2015 was conducted. The study identified 28 forensic medical examinations performed for alleged sexual assault. The alleged victims frequently had cognitive impairments; injuries were infrequent; and alleged victims were cooperative. The forensic medical examiner responded within 72 h of reporting; and frequently noted limitations to physical examinations of the alleged victim. The actual number of sexual assaults during this period may be masked by under-reporting and, lack of identification by nursing home staff. There are many unresolved issues including: incidence, levels of reporting, nature of investigations, responses required to assist the victim, and the interventions needed to prevent sexual assault. Better data is vital. This data should be standardized, validated, reliable, and gathered prospectively across Australia and internationally.

Part I – Adult skeletal age estimation using CT scans of cadavers: Revision of the fourth rib methods

Abstract Objective CT scans have become a standard part of autopsy procedures in large medical-legal facilities, and forensic anthropologists are increasingly asked to contribute their knowledge of skeletal anatomy to volume-rendered images (VRIs) generated from CT scans. However, it is not clear if the age estimation methods created using skeletal remains can be reliably applied to VRIs. This study, along with the other two in this series, examines the applicability of three commonly used sites for adult skeletal age estimation on VRIs generated from CT scans of cadavers. Part I focuses on the fourth rib. Materials and methods CT scans of 420 cadavers from the Victorian Institute of Forensic Medicine were selected (age range 20–79 years). Siemens syngo.via software was used to view the DICOM images and create the VRIs. The Iscan et al. and Hartnett fourth rib methods of age estimation were used to create a revised method for VRIs. Results and conclusion Several features described by both Iscan et al. and Hartnett could be observed on the VRIs; however, features such as porosity inside the sternal rib and bone weight could not be assessed. A revised fourth rib method for use on VRIs was created. Significantly more individuals were placed in the correct age phase using the revised method compared to the Iscan et al. and Hartnett methods, and overall the revised method had significantly improved inaccuracy and bias scores. The revised method is reliable and should be tested on other populations using different software.

Part II-adult skeletal age estimation using CT scans of cadavers: Revision of the pubic symphysis methods

Abstract Objective When present, the most commonly used element to estimate adult skeletal age at death is the pubic symphysis. In the second manuscript of this series, the Suchey–Brooks and Hartnett pubic symphysis methods are assessed to for their applicability to volume-rendered images (VRIs) generated from CT scans of cadavers to assess their applicability to VRIs. Materials and Methods CT scans of 420 cadavers from the Victorian Institute of Forensic Medicine were selected (age range 20 to 79 years). Siemens syngo.via software was used to view the DICOM images and create the VRIs. The Suchey–Brooks and Hartnett pubic symphysis methods were used to create a revised method to estimate age for VRIs. Results and Conclusion Several features described by Suchey–Brooks and Hartnett could be observed on the VRIs, including billows on the symphysis face in younger individuals, the ventral rampart, and the dorsal margin. However, distinguishing features such porosity and bone weight for the older phases could not always be assessed. A revised pubic symphysis method for use on VRIs was created using both morphological features and bone quality to assess age. The revised method is strongly correlated with age, and over 70% of the sample was placed in the correct age phase. The Suchey–Brooks method was more accurate for individuals under 40 years of age while the revised method was more accurate for individuals over 40 years of age, similar to the findings from other studies. This revised method should be tested on other populations using different CT settings and software.

Part III – Adult skeletal age estimation using CT scans of cadavers: Revision of the auricular surface methods

Abstract Objective The auricular surface of the ilium is often found preserved in both archaeological and forensic contexts. In the final manuscript of this three-part series, the features used by biological and forensic anthropologists to estimate adult skeletal age from the auricular surface are tested on volume-rendered images (VRIs) generated from CT scans of cadavers. Materials and methods CT scans of 420 cadavers from the Victorian Institute of Forensic Medicine were selected (age range 20–79 years). Siemens syngo.via software was used to view the DICOM images and create the VRIs. The Lovejoy et al. auricular surface method of age estimation was assessed for use on VRIs and a new method for VRIs was created. Results and conclusion Most of the features described by Lovejoy et al. could not be observed on the VRIs, and as previously established by Villa et al. (2013) [13], the Buckberry and Chamberlain method cannot be used on VRIs. Features such as transverse organization, surface texture, and microporosity are not visible on VRIs; however, features of the auricular surface and retroauricular area were seen to progress in a manner similar to that described by Lovejoy and colleagues, and a revised auricular surface method for use on VRIs was developed. The revised method is strongly correlated with age, and over 70% of the sample was placed within one standard deviation of the mean of the correct phase. This revised method should be tested on more populations using different CT settings and software.

Arrhythmogenic Right Ventricular Cardiomyopathy: A Review of Living and Deceased Probands

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a potentially life-threatening genetic cardiomyopathy with a spectrum of clinical presentations including sudden cardiac death (SCD). Clinical and genetic data of 44 probands referred to a cardiac genetics clinic (2007-2017) who met 2010 Task Force Criteria (TFC) for ARVC diagnosis were included. Thirty-three (33) (75%) male, 20 (45%) were referred by the Victorian Institute of Forensic Medicine. Presentation that lead to diagnosis included ARVC-related SCD (n=19), SCD due to alternate cause of death (n=1), aborted cardiac arrest (n=6), stable symptomatic ventricular tachycardia (n=14), palpitations (n=3) and presyncope (n=1). Left ventricular involvement (50%) was more common in the SCD subgroup (84% vs 21%, p<0.001). Genetic testing (n=39) revealed a pathogenic mutation in 16 (commonest: plakophillin-2 (n=9)), a variant of uncertain significance (VUS) in 15, with no abnormality in eight. In the SCD subgroup, median age at death was 44.7 years and 74% were male. Genetic testing (n=16) in this subgroup revealed a pathogenic mutation in six patients (commonest: desmoplakin (n=4)). Comparison of the two commonest mutations (PKP2 and desmoplakin [DSP]) showed DSP mutation was more frequently associated with SCD (p<0.01) and LV involvement (p<0.001). Screening of 117 relatives has lead to ARVC diagnosis in 29 patients. Arrhythmogenic right ventricular cardiomyopathy has a heterogeneous and often severe clinical presentation. Sudden cardiac death and aborted cardiac arrest (ACA) are common, demonstrating electrical abnormalities appear early in the ARVC phenotype. Left ventricular involvement was common and may reflect a worse prognosis. Genetic testing is essential in family screening and may be helpful in risk assessment. Desmoplakin mutation is associated with LV involvement and may be indicative of worse prognosis and increased risk of SCD. Genetic screening of proband family members in a specialised multidisciplinary clinic is essential in early diagnosis of affected family members.

Increasing rates of quetiapine overdose, misuse, and mortality in Victoria, Australia

BackgroundQuetiapine is misused due to its anxiolytic and hedonic effects and has been associated with deliberate self-harm. This study analyzed quetiapine-related calls to the Victorian Poisons Information Centre (VPIC), coronial data from Victorian Institute of Forensic Medicine (VIFM) and prescribed data from the Pharmaceutical Benefits Scheme (PBS) to determine current trends in overdose, misuse and mortality. MethodsThis was a retrospective review of multiple databases. Calls to VPIC and coronial data from the VIFM were reviewed from 2006 to 2016. PBS prescription data from 2000 to 2015 was obtained from the Australian Statistics on Medicines website. ResultsVPIC data indicated a 6-fold increase in the number of quetiapine-related calls over the 11-year period of which most were overdose-related (77%). Overdose and misuse calls increased by 6-fold and 6.6-fold, respectively. Coronial data also indicated a rise in quetiapine-related harm; a 7.4-fold increase in quetiapine-related deaths was recorded for the same period. Similarly, Australian PBS data showed that quetiapine prescriptions increased 285-fold since 2000. There was a significant positive correlation between the increase in prescribing and overdose (r = 0.75, p < 0.001), and prescribing and mortality (r = 0.82, p < 0.01). ConclusionsThis study revealed an increasing trend of misuse, non-fatal and fatal overdoses in Victoria over the last decade. The increasing rates of prescriptions in Australia and thus increased quetiapine availability are likely to have contributed to increased poisoning and mortality. Further research is warranted to explore the reasons behind increased prescribing, including off-label use.