letter - les-crises.fr · 2016-06-07 · odontology, anthropology, photographic work, and dna...

the AFIP

LETTERVol. 159, No. 5October 2001

Visit our Web site athttp://www.afip.org

Armed Forces Institute of PathologyWashington, DC 20306-6000

Noble Eagle, to page 11

AFB (Delaware) Port Mortuary to identify the 188victims of the attack. “Our staff represented everybranch of the service,” said AFIP Director GlennN. Wagner, CAPT, MC, USN, who served as thesenior officer during the operation. “We alsoreceived tremendous support from the doctors,nurses, and technicians stationed at Dover whoparticipated in the investigation.”

The investigation mobilized AFIP assets inmany ways. In the hours following the crash ofAmerican Airlines Flight 77 into the Pentagon, theacting Armed Forces Medical Examiner, AbuBakrMarzouk, Col, USAF, MC, worked with FBI andlocal Virginia law enforcement officials to createan effective plan for recovering and identifying thevictims. At the same time, personnel from theOffice of the Armed Forces Medical Examiner(OAFME) positioned and staged equipment tobegin operations at Dover. Bruce Ensign, Maj,USAF, MC, served as AFIP’s team leader at thesite. “We immediately called in regional medicalexaminers from as far away as San Diego toparticipate,” he said. A total of 12 forensic patholo-gists, assisted by two AFIP staff pathologists,headed the OAFME investigation team.

Also arriving at Dover during those earlycritical hours were two other key AFIP groups:forensic scientists from OAFME’s Armed ForcesDNA Identification Laboratory (AFDIL) and oralpathologists from the Department of Oral andMaxillofacial Pathology. AFDIL scientists ensuredthat data systems and records were available tomake DNA identifications, while the oral pathol-ogy group created a triage area to conduct positivedental identifications. Contacts were also madewith family services personnel in each branch of

Operation Noble Eagle:

AFIP Responds to September 11th PentagonTerrorist Attacksby Christopher C. KellyAFIP Public Affairs Director

A multidisciplinary team of over 50forensic specialists, scientists, and supportpersonnel from the Armed Forces Institute

of Pathology (AFIP) played a major role in one ofthe most comprehensive forensic investigations inUS history following the September 11, 2001terrorist attack at the Pentagon. Code namedOperation Noble Eagle, AFIP’s team of forensicpathologists, odontologists, a forensic anthropolo-gist, DNA experts, investigators, and supportpersonnel worked for over 2 weeks at the Dover

AFIP Director Glenn N. Wagner, CAPT, MC, USN (center) describes the forensicinvestigations taking place in the morgue during Operation Noble Eagle to the ArmySurgeon General, James B. Peake, LTG, MC, USA. Looking on are Florabel G. Mullick,MD, SES, ScD, AFIP Principal Deputy Director and Col Joe Drobezko, the 436th SupportGroup Commander, Dover AFB. On the far right facing the autopsy table is Andrew Baker,Maj, USAF, MC, chief deputy medical examiner. Also at the table is Tom Holland (in thebeard), a forensic anthropologist from the Army’s Central Identification Laboratory, Hawaii(CILHI).

AFIP Letter / Vol. 159, No. 5 / October 20012

DIRECTOR’S MESSAGE

Glenn N. WagnerCAPT, MC, USNThe Director

AFIP’s Responseto September 11

This issue of the Letter is focused on the efforts of theAFIP to respond to the tragedy of September 11, 2001at the Pentagon, and secondarily to identification efforts at

the Somerset, Pa site. The Institute’s timely response to theseincidents underscores the importance of an intact infrastructure tosupport such activities, especially when they become extended.The medicolegal death investigation of the Pentagon incident hasextended over 2 months and has involved around-the-clocklaboratory testing. All avenues of forensic investigation wereexplored and deployed with zero defects. I am very proud of theeffort and the success of this multidisciplinary and multifactorialinvestigation. In such federal investigations, the Office of theArmed Forces Medical Examiner is the spear point for the AFIP’s911 response. The OAFME is the headquarters of the globalArmed Forces Medical Examiner System (AFMES) and the onlyfederal medical examiner system. It is routinely used by otherfederal agencies, including State, Justice, Treasury, and Transpor-tation, as well as by Veterans Affairs and DoD.

The Pentagon investigation highlighted the importance of amultidisciplinary effort. Forensic anthropology was a significantcomponent; made up of physical anthropologists from the AFIP,the Smithsonian Institution, and the US Army Central Identifica-tion Laboratory-Hawaii. A comprehensive dental team wasformed with expanded capabilities in digital imaging and com-parative analysis. The medical radiographic section included full-time, fully trained radiologists assisting the dentists, anthropolo-gists, and pathologists in the identification and characterization ofall specimens received. Where appropriate, both toxicology andDNA specimens were obtained in each case. This was the firsttime that military nursing staff was incorporated to assist theforensic pathologist in the postmortem physical examination andrecording of findings. This medical team was paired with forensicanthropologists, dieners, photographers, and evidence technicians.The entire operation remained under the watchful eye of the FBI,which had two teams on-site—a fingerprint team and a traceevidence team. All activities were coordinated between the FBI,AFIP/AFMEO, Dover AFB Base, Service Personnel Offices,Dover Port Mortuary, and DoD assets.

The success of this investigation and similar past experiencesunderscores the importance of a collaborative, cooperativeenterprise where consensus, commitment, and communication areprized.

Atlas of Tumor Pathology, Third Series, Fascicle 31

Tumors of the Liverand Intrahepatic Bile Ducts

Kamal G. Ishak, MD, PhD, Zachary D.Goodman, MD, PhD

Armed Forces Institute of Pathology, Washington, DC,

and J. Thomas Stocker, MDUniformed Services University of the Health Sciences,

Bethesda, MDArmed Forces Institute of Pathology, Washington, DC • 2001

ISBN: 1-881041-69-7

In the 12 years since publication of the second series fascicle on thissubject, there have been many advances in epidemiologic, histoge-netic, pathogenetic, and clinicopathologic aspects of tumors andtumor-like lesions of the liver and intrahepatic bile ducts. This thirdseries fascicle is divided into 14 chapters:

• Embryology, histology, and anatomy• Benign hepatocellular tumors• Benign cholangiocellular tumors• Benign mesenchymal tumors and pseudotumors• Miscellaneous benign tumors and pseudotumors• Hepatoblastoma• Putative precancerous lesions• Hepatocellular carcinoma• Fibrolamellar hepatocellular carcinoma• Intrahepatic cholangiocarcinoma and other malignant biliary

tumors• Miscellaneous malignant tumors• Malignant mesenchymal tumors• Primary hepatic lymphomas and suspected lymphomas• Metastatic tumors• and an appendix on the TNM classification of malignant tumorsof the liver.Several tumors and tumor-like lesions are extensively discussed,

commensurate with increased knowledge about them, such asperibiliary gland hamartoma (bile duct adenoma), hepatobiliarycystadenoma, biliary papillomatosis, lymphangioma, angiomyolipoma,miscellaneous heterotopias, hepatoblastoma, hepatocellular carcinoma,intrahepatic cholangiocarcinoma, epithelioid hemangioendothelioma,and primary hepatic lymphomas (including a section on diagnosis ofsuspected lymphoma).

Tumor entities not covered in the previous fascicle include ciliatedforegut cyst, peribiliary gland cysts, hereditary hemorrhagic telang-iectasia, myelolipoma, focal fatty change, Langerhans’ cell histiocyto-sis, solitary fibrous tumor, miscellaneous benign mesenchymal tumors(such as plexiform neurofibromatosis), hepatic pregnancy, putativeprecancerous lesions, malignant rhabdoid tumor, and two hithertoundescribed tumors: ossifying stromal-epithelial tumor and kaposiformangiosarcoma.

The 511 gross photographs and photomicrographs (most in color)are of outstanding quality. Only a few electron micrographs areincluded, in keeping with the authors’ belief that they are of limiteddiagnostic value. The chapters are extensively referenced. Imagingstudies of most of the tumors are briefly covered but only rarelyillustrated. This 356-page fascicle should be an essential reference forresidents, oncologists, hepatologists, gastroenterologists and patholo-gists in practice.

3AFIP Letter / Vol. 159, No. 5 / October 2001

On behalf of the staff andvolunteers at the NationalMuseum of Health

and Medicine of the ArmedForces Institute of Pathology, Iwould like to share our deepsadness over the abrupt andtragic losses endured in therecent terrorist activities at thePentagon, in New York, and inPennsylvania. We extend our mostheartfelt sympathies to thefamilies, friends, and colleaguesof the victims. But, we are proudto be part of an organization thatcan and does respond to theseunique challenges to our nation.The following article describessome of the Museum’s contribu-tions. We do this as a museumwith personnel of exceptionaltalents and backgrounds. We alsorespond as a component of theArmed Forces Institute of Pathol-ogy, which provided forensicspecialty services, under theleadership of the Institute Direc-tor, Captain Glenn N. Wagner,MC, USN, at the Dover Air ForceBase Port Mortuary. Dr. Wagnerassembled a team includingcivilians and members of everybranch of service to performforensic pathology, forensicodontology, anthropology,photographic work, and DNAservice for the individuals killed atthe Pentagon. Their experiences,in turn, become part of thecollective memory of the Institute,to be documented by theMuseum for lasting value to ournation and to the world.

Dr. Adrianne NoeDirectorNationalMuseum of Health andMedicine of the AFIP

The final terrorist event of September11 was the crash of United AirlinesFlight 93. The Boeing 757, carrying

38 passengers and a crew of 7, departedNewark International Airport at 8:01 a.m.and headed for San Francisco. Aftercrossing into Ohio, terrorists apparentlytook control of the plane and redirectedthe flight back into Pennsylvania. Using cell phones and onboardairfones, the hijacked passengers learnedof the earlier crashes at the World TradeCenter and the Pentagon. After a strugglebetween the passengers and the terroristsfor control of the plane, it crashed into anabandoned strip mine in Somerset County,Pa, shortly after 10 a.m. All aboard werekilled. On September 13, Paul Sledzik, curatorof Anatomical Collections at the NationalMuseum of Health and Medicine of theArmed Forces Institute of Pathology(AFIP), was asked by the US Departmentof Health and Human Service’s Office ofEmergency Preparedness to command theRegion III Disaster Mortuary OperationalResponse Team (DMORT) in providingvictim identification services for the UAFlight 93 crash. Sledzik has been teamcommander of Region III DMORT since1997. As part of the National DisasterMedical System, DMORT is composed ofprivate citizens and federal employeeswho are asked to provide forensic,mortuary, and family support servicesfollowing disasters. The teams (there are10 throughout the nation) are made up offorensic scientists, medicolegal investiga-tors, mortuary officers, logistics andadministrative support personnel, andothers. In addition to Sledzik, Lenore Barbian,PhD, the assistant curator of AnatomicalCollections at the Museum and a DMORTteam member, was also asked to respond.Barbian and Sledzik spent the next 2weeks in Somerset, Pa. The main focus oftheir work was to support the local coronerin identifying the victims of the crash andto aid the FBI in collecting evidence to beused when the terrorists are brought to

Operation Noble Eagle:Museum experts respond to Pennsylvania crash

Museum to page 14

justice. The DMORT team organized a morgue,set up the morgue operation, interviewedvictim’s families, and collected antemor-tem and postmortem information. Themorgue facility was located in the NationalGuard Armory outside Somerset, Pa. Withthe FBI as the lead agency in the investiga-tion, access to the morgue was strictlycontrolled. Sledzik views the combined DMORTand AFIP response to such incidents as agreat benefit to the families of those killedin disasters. As part of a package offederal resources, DMORT and AFIP haveworked together in previous incidents,particularly in the area of DNA identifica-tion. “In my estimation, the AFIP managedtwo of the three incidents following theSeptember 11 attacks: the Pentagon crashand the Somerset crash. My AFIP creden-tials opened more doors during theactivation than my DMORT association.Medicolegal disaster responders respectthe AFIP name,” Sledzik said. In fact, the Office of the Armed ForcesMedical Examiner provided forensic

Paul Sledzik and Lenore Barbian, PhD, reviewmuseum documents.


For weeks following the September11 terrorist attack on America, oneof the leading DNA laboratories in

the world focused its efforts on bringingclosure to the families of the victims. TheDepartment of Defense DNA Registry,which constitutes the Forensic DNADivision of AFIP’s Office of the ArmedForces Medical Examiner (OAFME),provided DNA identifications of victims intwo of the terrorist attack plane crashes:American Airlines Flight 77 at thePentagon and United AirlinesFlight 93 in Somerset County,Pennsylvania. “Identifyingvictims is a humanitarianissue,” said Army ColonelBrion Smith, chief deputymedical examiner and head ofthe Department of DefenseDNA Registry. “Familiesneed confirmation,” he said,“and we have a duty to assistthem in every way possible.”

The DoD DNA Registryhas two operational branches:the Armed Forces DNAIdentification Laboratory(AFDIL), which performs theforensic DNA testing, and theArmed Forces Repository ofSpecimen Samples for theIdentification of Remains(AFRSSIR). The AFRSSIR,which has been collecting DNA referencessince 1992 for Department of Defensepersonnel, has over 3.5 million samples —filter paper cards containing a smallamount of blood collected from active-duty and reserve componentservicemembers. They are carefully storedin freezers and left undisturbed, unlessthey are required for human remainsidentification. Such was the case, whenDoD authorities turned to DNA analysis toestablish the identification of victims fromthe terrorist attacks.

On September 12, COL Smith deployed

a two-person team to Dover to establishconnectivity for AFDIL’s computerizedevidence-tracking program known as theLaboratory Information System Applica-tion, or LISA. According to James Ross,the chief information officer for the DoDDNA Registry, forensic scientists in theDover morgue and at the DNA laboratoryrelied on LISA’s barcoded chain ofcustody system to quickly and efficientlyprocess evidence. “Every tissue sampleused for DNA analysis received a chain-of-custody number,” Ross said, “and this

number remained intact during the entireidentification process. It allowed us totrack evidence taken from victims through-out the operation, and saved AFDIL staffhundreds of man-hours by eliminating theneed for hand-labeling materials.”

Two-member teams from AFDILrotated from Rockville to Dover every 72hours to work alongside the forensicpathologists, odontologists, and anthro-pologists in coordinating the appropriatesampling of bone, teeth, and tissue. Thisarrangement insured the establishment of aproper chain of custody and expedited the


DNA Laboratory plays key role inPentagon, Somerset Countyvictim identificationsBy Michele Hammonds and Christopher C. KellyAFIP Public Affairs

overall identification process. Since manyof the Pentagon victims were active-dutyor reserve personnel, most had DNAreference cards already on file inAFRSSIR. “We had a total of 50 referencespecimens on file for military servicemembers who died in the Pentagon crash,”said David Boyer, the director of Opera-tions at AFRSSIR. “That expedites theDNA identification process, becauseimmediately we have a known referencefrom which we can reliably generate aDNA profile. And because many blood-stain cards also have the individual’sfingerprints, we were able to provide FBIexperts with another tool for obtaining apositive identification.”

As specimens arrived from the DoverMortuary back to AFDIL in Rockville,Md, teams of forensic scientists, under thedirection of Demris Lee, technical leaderof the Nuclear DNA Section, took over thedifficult chore of generating a DNA profileof the victims. Their work included notonly the Pentagon crash victims, but the

victims of the SomersetCounty, Pennsylvania crash aswell. Every one of theorganization’s 102 DNAanalysts, sample processors,logistics staff, and administra-tive personnel were in-volved— from collecting,tracking, analyzing DNAsamples, and gathering andlogging DNA referencematerial to preparing DNAreports. For 18 days followingthe terrorist attacks, AFDILemployees worked on 12-hourshifts, 7 days a week to meetthe mission requirements. The laboratory prepared toexpand its operation to includethe Somerset County crashalmost immediately. Boyer,

who is a nationally recognized expert incoordinating tissue collection servicesfollowing aircraft disasters, traveled toSomerset County directly after theincident. There, he discussed AFDIL’spotential role in identifying the Flight 93victims with federal and local officials,including the FBI and the NationalTransportation Safety Board.

AFDIL played a major role in identify-ing victims of previous major airlinedisasters, including Egypt Airlines Flight990 in 1999 and Alaska Airlines Flight261 in 2000, and was a logical choice to

At Dover, Asst. Technical Leader Amanda Blanchard uses automated evidenceprogram to log samples into database and generate labels.


provide DNA services to federal investigators in Pennsylvania.Once the lab received approval to conduct DNA testing, Rossestablished the LISA program there as well, and by September17 collections were underway in the temporary morgue atSomerset.

Only a few months before, Boyer, Lee, and James Canik,AFDIL’s deputy director, trained regional Disaster MortuaryOperational Response Team (DMORT) members in DNAcollecting procedures. Those same officials—forensic patholo-gists, anthropologists, and dentists, along with Boyer and DNAanalysts from AFDIL—worked together following the Pennsyl-vania crash. “Weactually had theDNA station set upas part of theDMORT operation,and it went verywell for being putinto practice for thefirst time.”

At AFDIL, DNAscientists dividedinto teams to handlethe Pentagon andSomerset Countycases. The AFDILexperts worked togenerate a DNAprofile on eachtissue specimenreceived, as well as developing a DNAprofile on known reference specimens.For servicemembers, reference specimensincluded the bloodstain cards on file atAFRSSIR. For civilians (andservicemembers if necessary), suitablereference specimens included tissue takenfrom biopsy specimens, Pap smears, hairfrom combs and brushes, extracted teeth,and even saliva found on toothbrushes.Surviving family members also providedblood specimens to confirm a geneticidentity. “The surviving family membersare an important link to our process,”Boyer said.

DNA is isolated from the bone, tissue,hair, and teeth specimens by a commonlyused organic extraction process. This step is followed by use ofthe polymerase chain reaction (PCR), which makes millions ofcopies of DNA identical to the original copy. PCR is oftendescribed as being like a DNA photocopy machine. PCR isparticularly advantageous for samples that are minute or highlydegraded. These conditions are the norm in cases that are eithervery old, or that have been exposed to severe environmentalchallenges such as heat and high impact forces. The PCRproducts are analyzed using short tandem repeat (STR) analysis.STRs are short stretches of a specific DNA sequence that aretandemly repeated throughout the nuclear genome. Anindividual’s “DNA type” is determined by the number of repeatsan individual has at a given locus in the genome. AFDIL utilizes

Caption:

a STR system that analyzes nine loci on the DNA simulta-neously. This system also provides the capability to determinegender.

In a like manner, DNA is also isolated from the referencespecimens and undergoes the same PCR and STR analysisprocesses as the unknown samples from the crash site. Directreferences are samples taken directly from the victim, such as thebloodstain cards from the repository. Unknown samples thatproduce the same DNA profile as the victim’s direct reference areconsidered a “DNA match.” Indirect references are referencesamples collected from immediate family members (mother,

father, children) of the victim. Parentsand their offspring share half of theirnuclear DNA. The DNA profileobtained from family members can beused to reconstruct the DNA profile ofthe victim.

The collection of reference samples forthe civilian victims proved to be a majorundertaking. Canik led a combined teamof personnel from AFIP and WalterReed Army Medical Center to establisha collections operation at the PentagonFamily Assistance Center (PFAC) inArlington, Va. The county coroner andthe FBI established a similar family

assistance center atSomerset, Pa. Forthose families notimmediatelyavailable, Canikworked closely withthe FBI and locallaw enforcementagencies to identifyand collect thesecritical references.The AFIP team atthe PFAC collectedover 176 familyreferences.

Scientiststhen analyzed theDNA profiles for apotential match andreported theirfindings back to the

forensic pathologists at Dover, or to the Somerset Countycoroner. AFDIL developed a computerized search program thatcompares the DNA profiles generated from the reference speci-mens against the DNA profiles generated from the unknownspecimens, and provides the best fit match. AFDIL laboratorystaff are hopeful that nearly all DNA identifications will becomplete in the coming weeks.

Boyer was extremely pleased with the total team effort, both atthe morgues and in the laboratory. “It was invaluable forlaboratory people to experience the front end of the DNAidentification program,” he said, “and I was impressed with theamount of professionalism and dedication everyone from theAFIP exhibited during this whole event.”

In Somerset, AFIP’s Dave Boyer collects DNA samples (top).Below: FBI fingerprint station.


One of the AFIP investigators whodeployed to Dover was Dr.William C. Rodriguez, III, an

internationally recognized forensicanthropologist whose skills are oftenutilized to help solve the most difficultcriminal cases. Rodriguez, who serves aschief deputy medical examiner in chargeof special investigations, is one of 35board-certified forensic anthropologists inthe nation, and the only one assigned full-time to a medical examiner’s office. Hishelp was invaluable following the Penta-gon attack.

“This was a unique situation because itwas a criminal act, and every piece ofevidence had to be fully documented andaccounted for,” Rodriguez said. He led ateam of seven forensic anthropologistsfrom the Army’s Central IdentificationLaboratory, Hawaii; the FBI; and theSmithsonian Institution that worked 12-hour days for over 2 weeks helping toidentify victims and return them to theirloved ones.

“We have a well-established system forprocessing mass casualties at Dover,”Rodriguez said, “and one of the first areasstaffed by the forensic anthropology teamwas triage.” There, he and his colleaguesprovided initial anatomic assessments andensured a smooth transition to experts infingerprint and dental identification.

Forensic anthropologists also workedclosely with the forensic pathologists atautopsy to determine anatomy or provide abiological profile of a specimen. “We’reable to provide specific characteristics,especially when having to re-associateremains of multiple individuals,” he said.This included questions of sex, race, age,and unique identifying factors. “We’reable to provide an accurate reconstructionof skeletal material when needed, and thisis really critical in the identificationprocess.”

The forensic anthropology team wasn’timmune to the enormity of what happenedon September 11. “Everybody was

shocked realizing that this operation wasthe result of a terrorist attack,”Rodriguez said. “It added to the magni-tude of our work. We were concernedthat another attack might be imminent,and it really felt as though we werefighting a war and doing science at thesame time. It was very challenging bothmentally and physically.”

The scale of the operation was alsoenormous. “This was the largest massfatality incident we’ve seen in years, andit required hundreds of decisions to bemade quickly and accurately, not only invictim identification but also in logisticsand personnel issues,” he said. “But, ourbiggest concern was always for thefamilies. We worked hard to get the jobdone and return the victims to their lovedones.”

– Christopher C. Kelly

Operation Noble Eagle:Forensic anthropologist provides expertisefollowing September 11 attack

Dr. William C. Rodriguez, III, reviews caseinformation with investigators at Dover (top) andexamines training specimens at his Rockville, Mdoffice.


AFIP’s Department of Oral and Maxillo-facial Pathology, under the direction ofDepartment Chair Colonel CharlesPemble, USAF, DC, played a critical rolein helping to identify victims of theSeptember 11th American Airlines Flight77 terrorist crash into the Pentagon. Atotal of eight AFIP military officers—fivestaff oral pathologists and three oralpathology residents—formed the coreinvestigative group at Dover. They werejoined by two oral pathologists, one eachfrom the National Naval Dental Center,Bethesda, Md, and the Naval Hospital,Portsmouth, Va. Supporting them were anadditional 43 personnel, including 9dentists and 19 dental technicians fromthe 436th Dental Flight at Dover AFB,Del, and 6 dentists and 9 dental techni-cians from the 81st Dental Squadron,Keesler AFB, Miss. “This combinedsupport really proved to be the idealsituation for us,” Pemble noted. “Theirpresence allowed for rotation of personnelin making identifications while alsocontinuing to operate the Dover dentalclinic. Sick call and other essential dentalcare continued uninterrupted.”

Preparations moved quickly on twofronts immediately following the Septem-ber 11 tragedy. As USAF dental personnelat Dover prepared the mortuary facilities


Forensic dentistry plays essential rolefollowing Pentagon terrorist crash

to handle the expected casualties, ColPemble alerted the Central PanorexStorage Facility in Monterey, Calif, thatantemortem panographic dental x-rays ofthe military victims would be needed.(Many servicemembers have a panograph,or full-mouth x-ray on file. Panographs area valuable comparison tool for makingpositive victim identification.) Withcommercial air traffic grounded, however,another source had to be found to transportthe records overnight, and DoD officialsexpedited the delivery through a dedicatedmilitary aircraft.

For the next 5 days, the dental contin-gent worked 12-hour shifts, completing anaverage of 22 exams a day. Col Pemblealso planned on using relief teams ofdentists, technicians, a computer specialist,and an administrative officer every 7 to 10days, in anticipation of even greatercasualty numbers. As recovery operationsslowed at the Pentagon, however, thoseteams weren’t needed. “We were able tocomplete our assignment with the desig-nated personnel,” said Pemble.

Three weeks into the mission, dentalidentifications were performed in over63% of the cases, and in 30% of the casesserved as the sole method of identification.The AFIP staff utilized a number oftechniques, including the charting of pre-

Operation Noble Eagle:Forensic Toxicology staffersprovide analysisA staff of 18 forensic scientists and administrative personnel inAFIP’s Division of Forensic Toxicology worked overtimefollowing the September 11 Pentagon attack to aid investigatorsin determining the cause and manner of death.

Experts conducted a number of tests on specimens that wereincluded in the final medical examiner reports. The divisionprovides expertise following military incidents or accidents toaid in medical and criminal investigations.

“Many of the personnel worked 12-hour days, includingweekends, to complete this mission in a timely manner. Theydid an outstanding job,” said Aaron Jacobs, COL, MS, USA,chief deputy medical examiner and head of the division.

existing dental conditions using antemor-tem and postmortem forms. A recentinnovation utilized at Dover was thedigital postmortem x-ray, which relies onsensors instead of film. The technique alsoeliminates chemical processing, whichsaves time and money and has minimalenvironmental impact. “We also chose toutilize an automated comparison tool,called WinID,” Pemble said, “primarilybecause we had over 170 potential deaths,and many were civilians with varyingdental records. WinID is a MicrosoftAccess-based system that runs underwindows and can link the antemortem andpostmortem dental charting to graphics.”

In the future, Col Pemble foresees thedevelopment of a dental image repositoryto further assist in the identificationprocess. “These are images that can becaptured digitally, or, if film, scanned andsent to the storage facility,” he said.


Air Force Colonel Charles Pemble led the dentalidentification team at Dover.

HM2 James E. Miller and SSgt Emilda Greenidge-Blake joined other divisionmembers in performing essential forensic toxicology testing.


Last spring, members of the 436th Dover Air Force Base(DAFB) medical group (dental and radiology) civilengineers, DAFB Port Mortuary staff, and CAPT Douglas

Arendt, USN, DC, held a 2-day brainstorming session to developa plan for possible retrofit of part of the triservice port mortuary(fig 1). Arendt, who serves as chief of Forensic Dentistry forAFIP’s Department of Oral and Maxillofacial Pathology, saidthat the goal was to upgrade conventional radiologic resources to

digital radiographic capture andto facilitate more efficient massdisaster identification triagealgorithms—“specifically, to setthe framework for a morefuturistic patient electronic datamanagement and retrievalsystem.”

AFIP initiated this newsystem following the tragic crash of American Airlines Flight 77into the Pentagon. Coincidentally, much of the equipment hadrecently arrived at Dover, and was waiting to be set up. Thisshort-fused evolution was aided by Mr. Manny Penna, a SchickCDR (computerized digital radiography) representative whowitnessed the collapse of the World Trade Center towers fromhis office across the river in New Jersey. Manny volunteered todrive to DAFB with missing x-ray sensors and expedited digitalradiography training for members of the 436th. As a result, we

successfullyintegrated theelectronic sensorswith laptops in thex-ray bays.

The otherelements of theproposed electronictriage ID systemwent into place on

Thursday afternoon,as staff networkedhardware andtroubleshot

new software protocols. Getting on line was a direct result of theincredible efforts of our computer strike team, composed of TSgtHines, HMC Butler, Mr Doug Oswell, and SSgt John Spreadbury.The bottom line is we set up an integrated system that acceptedand manipulated digital x-ray images and networked a massdisaster graphical interface and information-sorting program(WINID II) (fig 2).

As antemortem clinical records arrived, staff manuallyreviewed them and developed a historical composite of allclinical procedures, then converted this information to computercodes and entered it into WINID II. At the same time, antemor-tem images were scanned using a TPU (transparency adapter) andlinked with the antemortem clinical charting file in WINID II.

Other staffsimultaneouslyentered postmor-tem data,creating a hardcopy snapshot ofthe CDR digitalx-rays, andlinked them topostmortem datafiles. As the databanks increasedin size, computersearches andprioritizedmatches weredeveloped.

Once apossible matchwas generated,odontologiststhen examinedan odontogram(fig 3) (apictorial chartcomparingantemortem andpostmortemdental charting),followed byviewing theantemortem andpostmortem x-ray images onthe monitor (fig4). If a reason-


Electronic Mass Disaster Dental Identification Triageutilized following Pentagon attack“A step in the right direction!”

Fig 1—Lt Col Beecherand staff brainstormingin X-ray bays.

Fig 2—HMC Butlerand TSGT Hines

preparing networkcables.

Fig 3—Example of Odontogram

Fig 4—Antemortem and postmortem linkedx-ray images on monitor.

CAPT Douglas Arendt, USN, DC


Fig 6—Some Team members 13 Sept – 27 Sept 2001from AFIP, 436th DAFB and Keesler AFB):

Operation Noble Eagle:Mortality Surveillance Divisionprovides critical data collectionand case-tracking support

Lisa Pearse, MAJ, MC, USA, chief of OAFME’sMortality Surveillance Division, created and utilized anelectronic database that provided critical victim identifi-

cation information to investigators during Operation NobleEagle. “Because of thelarge-scale nature of theSeptember 11 events, datacollection and casetracking were essentialelements of the Dovermission,” she said. Hercontributions marked thefirst time that OAFMEutilized an electronictracking database tosupplement paper records,and allowed for real-timereporting throughout the mission.

Dr. Pearse is a preventive medicine physician, recentlyassigned to OAFME to conduct mortality surveillance. Thisincludes monitoring all active-duty deaths for trends, especiallythose that could represent emerging infections or a subtlebiological warfare attack. In Dover, Pearse quickly designed adatabase to describe and follow all victims through the identifi-cation process. “The database tracked demographic informationon the missing, and helped us focus on the presence or absenceof medical and dental records or DNA profiles on each of the188 individuals,” she said. “Finally, as identifications weremade, we utilized the database to keep track of who had beenidentified and by what method (dental, fingerprint, or DNA).”

Pearse continues to track identification data and producesdaily status reports as the investigation winds down. She’s alsoanalyzing data to evaluate the casualty identification modalities,injury patterns, and structural issues in the Pentagon that mighthave influenced survival patterns.


able match resulted, the files were pulled for the final visualcomparison, and a final report was generated documenting the

similar dentalfindings (fig 5).

CAPT Arendtfeels that thedecision to go “alldigital” on x-raycapture, as well as toimplement a net-worked graphicalimage and data-sorting program(WINID II), waswell worth the effort.“Without hesitation,I strongly believethat the high numberof positive identifi-cations produced in atimely mannerresulted because ofdedicated staff andcomputer enhance-ment,” he said (fig6). Arendt addedthat “no matter what

approach is used, if antemortem reference material (clinicalinformation) is not available or isn’t that of the victims beingprocessed at that time, no system can resolve that issue.”

A few thoughts for the future:• Implement a dedicated URL or email address and dissemi-nate that information broadly to law enforcement, so thathealth care professionals (military and civilian) can senddigital information to us directly.• Software issues: Whatever software is utilized in the future(WINID or CHCS), assure it has good “viewability” on themonitor and multiple graphical links. The digital x-ray captureshould “drop” directly into the program, rather than requiring avariety of steps to get to that point.• Network issues: Network the digital x-ray capture to thedissection bays and to the comparison section.

Fig 5—Example of final comparison report

Lisa Pearse, MAJ, MC, USA

Penny Rodriguez,executive assistant to theDirector, worked at Doverfor over two weeks tohelp coordinate andcommunicate forensicfindings to DoD officialsand family members.


Three weeks after the Pentagondisaster, most Department ofDefense personnel returned to their

jobs, including Special Agent RussellStrasser, chief of the Office of the ArmedForces Medical Examiner’s CriminalInvestigation Division, who returned witha new sense of patriotism. “AFIP isn’t

just a job. Its role in identifying victimsfollowing tragedies like September 11 is areal service we provide for families andthe United States as a whole, and just tohave been involved in something of thatmagnitude was astounding,” he said. “Itmade me realize how important the AFIPmission is and how great it is to be anAmerican.”

Strasser worked at the Dover Air ForceBase (Delaware) Port Mortuary for almost3 weeks following the September 11terrorist attacks. As victims of the attackarrived at the morgue, SA Strasser wasthere to ensure a smooth movementthrough eight designated stations in theidentification process. Those stationswere: arrival, scanning for explosiveordnance, photography, anthropology,fingerprinting, x-ray, dental, and autopsy.Strasser ensured that enlisted personnelassigned to move the deceased througheach station did so in a timely and

Operation Noble Eagle:Air Force Special Agent reflects on hisrole at Dover Port Mortuary

Operation Noble Eagle:Radiologic Pathology providesDover support

Radiologists from AFIP’s Department of RadiologicPathology played an important role in identifying casual-ties in Operation Noble Eagle. “COL Ted Harcke, a

reservist who recently served as a visiting scientist from theAmerican Roentgen Ray Society, staffed the mortuary for the first2 weeks,” said CAPT (Sel) Kelly Koeller, MC, USN, departmentchair. Dr. Koeller and MAJ Joseph Bifano, Chief of Radiology atDover AFB Clinic, also staffed the radiology section at Doverduring the operation.

The radiologists were responsible for reviewing whole-bodyradiographs in order to document injuries on the victims. “Bylooking at what types of injuries are present, we gain some insightinto whether they were the result of blast effects, blunt trauma, orheat, and this helped us place victims in specific locations whenthe event occurred,” Koeller said. The whole-body radiographalso enabled the radiology contingent to identify personal effects,jewelry, age of the victim, and any other materials present as partof the identification process. “Because this was a crime sceneinvestigation, we also searched for any objects, such as weaponsor aircraft parts, that might be helpful in the investigation.”

The radiologists also worked closely with forensic odontol-

ogists to identify the presence of teeth, an excellent source ofDNA. “Sometimes teeth aren’t readily observable during thephysical inspection, and our findings were a great help to theforensic dental team,” Koeller said.

The final whole-body x-ray report assisted others in theidentification process, and encouraged professionals at otherstations to compare their observations with the report and to seekout the radiologist for consultation and discussion. It provedbeneficial to increasing the accuracy of the information foundand provided great confidence in the conclusions.

“What we brought to this mission is a unique and trulyvaluable asset, one that really couldn’t be found anywhere else,”Koeller said.


Col Ted Harcke briefs LtGen Paul Carlton, USAFSurgeon General, on radiology operations at Dover.

appropriate manner.For 2 weeks following the terrorist

attack, AFIP’s team of forensic patholo-gists, anthropologists, odontologists,scientists, and investigators coordinatedall aspects of Operation Noble Eagle.Since arriving at AFIP 18 months ago, SAStrasser has worked on a dozen casesinvolving fatalities. The terrorist attack onthe Pentagon stands out most in his mindbecause of the number killed and thenational and international attention itattracted. Last October, he worked on theUSS Cole terrorist attack in Yemen inwhich 17 American servicemembers died.AFIP’s forensic team identified the 17Cole victims in only 3 days.

“We thought we had put in some prettyfull days working on the Cole victims,”Strasser said. “ However, there were a fewtimes in Dover when we processed 30casualties per day, but we had many morestaff available to do so.” Strasser wasimpressed by the teamwork he saw atDover. “It was good to see all the entitieswork together, ” he said. “Once we had apositive identification, we knew we couldbring closure to the victim’s family, andthat was important.”

– Michele Hammonds


AFIP utilized a well-defined andtested system for conducting the identifi-cations of the Pentagon victims. Whenremains arrived at the morgue, a scan-ning device searched for the presence ofunexploded ordinance or metallicforeign bodies. A computerized trackingsystem then assigned numbers to eachvictim for efficient tracking. FBIexperts collected trace evidence tosearch for chemicals from explosivedevices and conducted fingerprintidentifications. Forensic dentistryexperts from the Department of Oral andMaxillofacial Pathology then performeddental charting and comparison withantemortem dental records. Full-bodyradiographs followed to documentskeletal fractures and assist in theidentification process, followed byautopsy inspection.

At autopsy, forensic pathologistsdetermined the cause and manner ofdeath, aided by forensic anthropologistDr. William C. Rodriguez in determin-ing the race, sex, and stature of victimswhen necessary. A board-certifiedepidemiologist managed the trackingsystem for data collected during theautopsy process, and tissue samples werecollected for DNA identification andfurther toxicologic studies. Forensicphotographers, essential to any forensicinvestigation, documented injuries andpersonal effects. Finally, mortuaryspecialists then embalmed, dressed, andcasketed remains prior to release to next-of-kin.

For 8 days a full complement of AFIPforensic specialists worked 12-hourshifts to complete the operation. “This isthe largest mass fatality we’ve dealt within recent years,” Ensign said. “We havemodalities today that we didn’t havebefore. Our investigation was muchmore technology-intensive.”

Ensign noted that the entire teamworked well together. “Because of thecombined effort of all three services andthe FBI, we were very pleased with thespeed of the identification process.Essential records and references weresubmitted to us in a timely way.”Logistical help from AFIP also playedan important role. “We had tremendouslogistical issues obtaining equipment,especially with additional demands inNew York City and Somerset County,

Noble Eagle from page 1 Operation Noble Eagle:On the front line: OAFME’s Bob Veaseyensures investigators are ready to go

Bob Veasey, OAFME’s chief of Operational Investigations, is often on the frontlines following military aircraft mishaps. Veasey oversees and manageslogistics issues for OAFME investigators during search-and-recovery operations

by obtaining equipment, ensuring lodging and serving as the OAFME point-of-contactin the field to help expedite mission requirements. The team is mandated to launchworldwide in a number of hours, and Veasey makes sure equipment and supplies arepacked and ready to go. “We’re like firemen; we respond when we get the call,” hesaid.

And when the call came on September 11, Veasey packed, loaded and shippedsupplies and equipment to Dover. “We prestaged (packed) everything we had in myoffice within 6 hours once we received notification that we were going to Dover Air

Force Base,” he said. “Thetruck left AFIP the nextmorning, headed toDover.”Veasey ordered equipmentfor the forensic team ofpathologists, anthropolo-gists, odontologists, andother mortuary workerswho had been temporarilyassigned to work atDover’s Port Mortuary insupport of OperationNoble Eagle.“The operation at Dover

was so big, and theforensic teams and supportpersonnel kept using up somany supplies that I had to

constantly order more,” he said.As the number of casualties increased, and with it the requirement for expanded

morgue capabilities, Veasey had to estimate and order additional supplies within 24hours. “We were also put on alert for possible World Trade Center casualties andresponded to the Flight 93 crash in Pennsylvania,” he said. As a result, Veasey ex-panded the OAFME mass casualty response capability from 300 to 1,000, where itremains today if needed.

While Veasey is accustomed to working on crash cases in which there are causalities,the terrorists attack at the Pentagon and in Pennsylvania is a tragedy all by itself. “Thiswas very personal to me because a lot of the people killed were military, and I’m retiredmilitary,” he said. “We also had civilians and children on the aircraft. My desire is torecover, identify, and return the victims to their families so they can start the closureprocess.”


Bob Veasey with supplies and equipment used by OAFME staff.

Pennsylvania,” he said. “Fortunately ourlogistical support was terrific in helpingus get material in.”

Others also played essential roles.Histotechnicians from the Department ofScientific Laboratories served as autopsytechnicians, assisting pathologists withthe remains, while special agents

assigned by the various services helpedin the investigation. “It was a terrificteam effort,” he said.


“DNA is new technologywith the capability of provid-ing those answers back to thefamilies,” he said. Workingwith him were Air ForceCMSgt Ontee Biggs and TSgt.Charles A. Lattany, III, tomeet and interview familymembers. For almost 3 weeksCanik’s group worked 12-hourshifts, 7 days a week at thecenter.

“Working with the familieswas our primary focus,” Biggs said. “Wehelped to calm them down, and we madesure we were there to fulfill their needs.”The assignment of explaining the DNAprocess and the purpose of the tests todistraught family members wasn’t alwayseasy to watch, he said.

Taking the focus off himself andputting the family members first provedhelpful for Lattany. “In a situation likethat you forget about yourself and youreally look forward to helping out otherpeople. For them, having to lose lovedones is a hard thing to have to deal with,”Lattany said.

Operation Noble Eagle:Helping Pentagon families who lost lovedones, AFIP Personnel Staff SpecialAssistance Center

In the aftermath of the September 11terrorist attack at the Pentagon, AFIPexperts relied on DNA analysis to

provide a positive identification for manyof the victims. To make a DNA identifi-cation, however, a reference specimen isrequired—typically small amounts ofblood, tissue, hair, teeth, or other biologi-cal material from the deceased. Since1992, the AFIP has maintained a specialrepository of bloodstain cards for over 3.5million servicemembers for just such apurpose. In fact, 53 cards from therepository were used to help identifyactive-duty servicemembers and reservistskilled in the Pentagon attack. But, whatabout the civilians who died?

That’s where staff from the ArmedForces DNA Identification Laboratory(AFDIL) provided special assistance.Under the direction of James J. Canik,AFDIL’s deputy director, staff membersfrom AFIP and Walter Reed organized ablood collection center at the temporaryfamily assistance center in Crystal City,Virginia. Canik talked with families aboutthe importance of DNA in helping toidentify casualties.

Canik also met and interviewed familymembers of other civilian and militarycausalities who didn’t have DNAreference samples (bloodstain cards) onfile. “Dealing with the families one-on-one is difficult because of the circum-stances and the recent loss of a loved oneunder extremely traumatic conditions,”Canik said. “We saw the full range ofemotions— everything from happinessand thankfulness that we were thereworking on their behalf, to the anger andfrustration that normally surfaced as partof the grieving process.”

Due to the aircraft crashing into thePentagon and the subsequent fire, familymembers were told identification ofvictims would not be an easy task, andfamilies were asked to give blood to helpDNA experts in the process.

“Family members were being asked todo and provide different things, but bygiving their blood sample they realizedthey were doing something tangible andvitally important to assist in the identifi-cation of their family member. It was oneof the most positive things we had in ourinvolvement with the families – as wemade them part of the process in bringingthem the answers they sought,” Caniksaid.


CMSgt Ontee W. Biggs staffed the familyassistance center.

AFIP civilian photogra-phers who providedsupport at Dover were(from left) Steve Kruger,Veronica Ferris, and AndyMorataya.


For three recent graduates of AFIP’sTri-Service School of Histo-technology who served as autopsy

assistants at Dover following the Pentagonterrorist attack—the assignment wasonce-in-a-lifetime. One that A1C EarlGibson, Amn Tashanda Ashford, andHM3 Marco Mendoza, all histotech-nicians, will never forget.

It was the first time in the school’shistory that its students and some staffparticipated in a mass casualty identifica-tion operation. In all, about 30 histotech-nicians volunteered and deployed toDover to help forensic pathologists in theidentification process. The histotech-nicians rotated throughout the operation,working 3 or more days before beingreplaced by other histotechnician rein-forcements before returning to the AFIP.

“I volunteered to help because I wantedto learn something, and I knew AFIP hassome of the best pathologists in theworld,” said A1C Gibson. “Before I wentto Dover, I didn’t understand the wholeprocess of how casualties are handledthere.”

Traditionally, as part of their training,histotechnicians are taught to assistpathologists in autopsies in a sterilesetting at a medical facility. Up until theSeptember 11 terrorist attacks, the recentgraduates received most of their traininginside the classroom. When they weretasked to work at the Dover Air Force

Operation Noble Eagle:Histotechnicians provide valuable supportat Dover; all enlisted play vital role at AFIP

Base Port Mortuary, however, theirtraining took on new meaning.

In mass fatality operations atDover, forensic investigators utilize aseries of stations to conduct victimidentifications. And the histotech-nicians were there to help, movingvictims from station to station,assisting with the recovery of personaleffects, and even taking notes for thepathologists. Their valuable assis-tance was needed at every station.“They were terrific,” said team leaderBruce Ensign, Maj, USAF, MC.“Thanks to their help, our pathologistswere able to conduct their investiga-tions more rapidly and efficiently.”

HM3 Mendoza said working in themorgue proved to be a very movingexperience for him, with the knowledgethat just a few hours before, the victimshad been alive and serving their countryat the Pentagon. “It was real emotional,”he said. “I wanted to participate. In fact, alot of us wanted to help out, and being atDover gave us a chance to help theforensic pathologists.” Amn Ashford saidshe adjusted to her new role quickly.“This was nothing like I could everimagine. It was a really different experi-ence. I think the training has given me anedge over my counterparts.”

Behind the scenes at AFIP, ArmyMSG Daneen Harris and Air Force MSgtJoy Williams are two senior enlisted

Air Force MSgts Joy Williams and Chris Sepulvedaprovided support at AFIP.

advisors for their respective services.They coordinated and provided workschedules for 35 to 40 enlisted AFIPservicemembers to help out in theaftermath of the Pentagon terrorist attack.Servicemembers’ assignments rangedfrom driving, courier duties, and guardingAFIP’s perimeter to assisting pathologistsat Dover. Military personnel cut ordersfor personnel tasked to deploy to Dover.“Nearly all military personnel here wereinvolved in this mission,” MSgt Williamssaid.

Enlisted personnel and officers at AFIPhelped man a specially created Emer-gency Operations Center, headed by LtCol Larry Shaw, AFIP’s chief of staff forAdministrative Services, said Air ForceMSgt Chris Sepulveda, NCOIC of thedeployed histotechnicans. “Once it wasrecognized that the Pentagon terroristattack was an emergency, we needed aplace to track and record informationbetween the AFIP, the FBI, the SurgeonGeneral, and everyone who needed tocoordinate with us. The EmergencyOperations Center was the nerve center,and Lt Col Shaw ran it,” he said.


OAFME forensicphotography staff wholed the Dover operationfrom left: TSgt MichaelGodwin, USAF; TSgtLouis Briscese, USAF,NCOIC; PHC(SW/AW)Sean Doyle, USN,LCPO, and PH3Christopher Williams.Photo by TSgt Briscese.


Museum from page 3Operation Noble Eagle:

Supplies, equipment and facilities: a “round-the clock” operation for AFIP Logistics staff

Candy Moroz, finance and logistics support officer for AFIP’sCenter for Advanced Pathology works with a Dover staffmember.

pathology consultation for the Pennsyl-vania crash, and five staff members ofthe Armed Forces DNA IdentificationLaboratory collected DNA samples inthe Somerset morgue. Sledzik and Barbian, physicalanthropologists on staff of the NMHM/AFIP, oversee a collection of humanmedical and pathological specimens.They provide forensic anthropologyconsultation to several local and federalagencies and teach an annual AFIPcourse in forensic anthropology. “The methods of interpreting thebiological aspects of the human skeletonare similar, whether you are looking at aCivil War soldier or a recent disastervictim,” said Barbian. “The Museum is proud to supportthis work as a service to the nation,” saidDr. Adrianne Noe, Museum Director.“Yet, it is no surprise that we should beable to do so. Our efforts are an excellentexample of public service, combiningsupport for families with our uniqueexperiences and expertise at this criticaltime.”

Staff from AFIP’s Director-ate of Logistics providedessential supplies and

services for hundreds of personnelwho deployed to Dover forOperation Noble Eagle, accordingto William McCarthy, MAJ, MS,USA, Director of Logistics atAFIP. “We were on the scene, inplace, and ready to support themission before the first casualtiesbegan arriving at Dover,” he said.On the afternoon of September 11,McCarthy anticipated needingsupplies on short notice andcoordinated with the MEDCOMContracting Office, Northeast Region, and established a pipeline for a 24- hoursupport. He and Candy Moroz, finance and logistics support officer for AFIP’s Centerfor Advanced Pathology, headed to Dover 2 days later to establish a forward-deployedlogistics cell in support of the Office of the Armed Forces Medical Examiner. “Weworked closely with OAFME’s Bob Veasey and the permanent logistics staff at Doverto ensure the availability of the appropriate supplies, equipment, and facilities. Localhospitals also donated items we could not obtain in time,” he added.

AFIP spent over $700,000 for equipment, including protective suits, goggles, shoes,masks, and portable equipment for forensic and mortuary workers. “I ordered whateversupplies Mr. Veasey and his staff needed,” said Moroz, who spent almost 2 weeksproviding critical logistics support to the forensic investigators. With commercial airtravel completely shut down, supplies were unavailable through usual shippingmethods. Moroz often drove hundreds of miles each day to purchase and deliver itemsto the mortuary facility. “Many retail companies, including Lowes, Dymo Label andFitzco donated a large amount of supplies when they learned of the work going on atDover. Other companies such as Fisher Scientific also donated supplies and waivedshipping charges to help us carry out the mission,” she said.

Angela D. Washington, Lt Col, USAF, MSC, group administrator for AFIP’s annexin Rockville, Md, was responsible for arranging lodging, and billeting for manypersonnel. She accomplished this in a few short days, despite the limited supply ofavailable hotel rooms in the Dover area. Washington also organized an in-housecourier system, transporting forensic evidence from Dover to the Armed Forces DNAIdentification Laboratory in Rockville. “That was significant because we would leaveDover by 1 p.m. and arrive with the DNA samples at AFDIL by 4 p.m.,” she said.“Lab personnel could process the specimens the same day, speeding up the identifica-tion effort.”



DMEDepartment of Advanced Medical Education

2002 Continuing Medical Education Courses2002 Continuing Medical Education Courses

Department of Medical EducationArmed Forces Institute of Pathology14th Street & Alaska Avenue, NWWashington, DC 20306-6000

FOR MORE INFORMATION CONTACT:Telephone: 202.782.2634Toll Free: 1.800.577.3749 (U.S. only)FAX: 202.782.5020Toll Free FAX: 1/800.441.0094 (U.S. only)International FAX: 1/877.891.3482

Email: [email protected]: http://www.afip.org/edu/

DME

NEW COURSE!MUSCLE DISORDERS COURSE AND WORKSHOP

• May 10–11, 2002• Holiday Inn Select, Bethesda, Md.• The AFIP designates this educational activity for a maximum of 16

hours for Category 1 credit.

The AFIP muscle disorders course and workshop for clinicians,pathologists, and researchers will combine essential didactics with hands-on interpretation of histologic slides at prepared microscopic stations toallow participants to strengthen their understanding of muscle disordersand diagnostic muscle pathology. General introductory lectures alternat-ing with microscopic slide sessions will be followed by in-depth presen-tations on Duchenne’s muscular dystrophy, autoimmunity, inclusionbody myositis, mitochondrial disorders, and application of molecular/genetic methods to clinical and pathologic diagnosis. A series of clinico-pathologic correlations to allow participants to practice their diagnosticskills will close the workshop. This course should enrich the participants’understanding of:• Skeletal muscle histomorphology and utilization of various staining

modalities to identify pathologic features of disease.• Basic patterns of muscle disease (inflammatory, dystrophic, neuro-

genic, toxic, metabolic/mitochondrial) and derivation of differentialdiagnoses.

• The pathophysiology and pathogenesis of muscle disorders.• Pathology reports and correlation with clinical diagnosis and manage-

ment of patients with muscle diseases.For more information, contact course coordinator Mr. Ricky Giles.Telephone numbers, E-Mail, and Web site located in the green box below.

40th Annual Dr. Kenneth M. Earle MemorialNEUROPATHOLOGY REVIEW

• February 25–March 1, 2002/Hyatt Regency Bethesda, Bethesda, Md.• The AFIP designates this educational activity for a maximum of 31

credits.

This is the 40th iteration, which is dedicated to the memory of KennethM. Earle, MD, former Chairman, Department of Neuropathology. Thishighly structured 5-day course will provide a comprehensive review of

neuropathology for individuals interested in both NEUROSCIENCE andPATHOLOGY. Lectures will be illustrated by gross and microscopicphotographs and will be supplemented by a course syllabus containingnumerous COLOR PHOTOMICROGRAPHS, and the AFIP fascicle onTumors of the Central Nervous System. Participants can expect to gain:• Enhanced knowledge of the pathology and recent developments in the

pathophysiology of common and unique disorders of the central andperipheral nervous systems and skeletal muscle.

• Familiarization with recently recognized pathologic processes relatedto the central and peripheral nervous systems and skeletal muscle.

• Improved understanding of basic histopathologic, histochemical,immunohistochemical, and ultrastructural features of disorders of thecentral and peripheral nervous systems and skeletal muscle.

• Insight into clinical, radiologic, and pathologic correlations, andprognostic factors of central nervous system lesions.

For more information, contact course coordinator Mr. Ricky Giles.Telephone numbers, E-Mail, and Web site located in the green box below.

NEUROPATHOLOGY SEMINARS

• Location: Armed Forces Institute of Pathology, Washington, DC

• Session 1: GENERAL NEUROPATHOLOGYDate: January 7 – 18, 2002/24 Credit Hours

• Session 2: DEVELOPMENTAL AND GENETIC DISORDERSDate: January 22 – February 1, 2002/22 Credit Hours

• Session 3: TUMORS OF THE CENTRAL NERVOUS SYSTEMDate: February 4 – 15, 2002/24 Credit Hours

• Session 4: NEURODEGENERATIVE DISEASESDate: February 19 – 22, 2002/12 Credit Hours

• Session 5: 40th Annual KENNETH M. EARLENEUROPATHOLOGY REVIEWDate: February 25 – March 1, 2002/31 Credit Hours

• Session 6: NEUROMUSCULAR DISEASESDate: March 4 – 15, 2002/22 Credit Hours

• Session 7: INFECTIOUS DESEASES OF THE CNSDate: March 18 – 22, 2002/12 Credit Hours

• Session 8: NEURORADIOLOGYDate: March 25 – 29, 2002/37 Credit Hours

The AFIP Seminars in the Neuropathology series is a systematicreview of the major topics in diagnostic neuropathology. The seminarseries is designed to prepare pathology, neurology, neurosurgery, andneuroradiology residents for specialty board certification. The partici-pants receive a 1- to 1-1⁄2 hour lecture, followed by a microscopic tutorialsession, during which microscopic slides illustrating the lecture conceptsare presented and discussed. Approximately 1 day a week (depending onmaterial availability) the students participate in a 2-hour case-basedpresentation session, which incorporates interpretation of diagnosticradiographic images, intraoperative and gross speciman transparencies,and histopathologic sections. This session is conducted jointly by AFIPneuroradiology and neuropathology staff. The afternoons are reservedfor individual study, during which time the students are encouraged totake advantage of the wealth of educational materials available at theAFIP. Participants of each seminar will benefit by gaining:• Enhanced knowledge of the pathology and recent developments in the

pathophysiology of common and unique disorders of the central andperipheral nervous systems and skeletal muscle.


• Familiarization with recently recognized pathologic processes relatedto the central and peripheral nervous systems and skeletal muscle.

• Improved understanding of basic histopathologic, histochemical,immunohistochemical, and ultrastructural features of disorders of thecentral and peripheral nervous systems and skeletal muscle.

• Insight into clinical, radiologic, and pathologic correlations, andprognostic factors of central nervous system lesions.

For more information, contact course coordinator Mr. Ricky Giles.Telephone numbers, E-Mail, and Web site located in the green box onpage 15.

40th Annual Basic Science CourseOTOLARYNGOLOGY HEAD AND NECK SURGERY

• March 5 - 29, 2002• Uniformed Services University of the Health Sciences, Bethesda, Md.

The otolaryngology course is 4 weeks long and includes intensivereviews in pathology, anatomy, physiology, and clinical sciences relatedto the head and neck. The course is ideally suited for residents in trainingand practitioners wishing to review the basic sciences and obtain clinicalknowledge. Participants will be exposed to the material through lectures,microscopic examinations of personal glass slide collections, and ca-daver dissections. Participants will attend the MG Paul H. Streit Memo-rial Seminar that will focus on laryngology. A self-diagnostic slideexamination in histopathology will be given at the end of the course. It isrecommended each student purchase Wenig, Bruce, Atlas of Head andNeck Pathology, W.B. Saunders Company, Philadelphia, Pa 19093, orfrom a participating book vendor before attending the course.

For more information, contact course coordinator SSgt. StephenHuntington. Telephone numbers, E-Mail, and Web site located in thegreen box on page 15.

38th Annual FORENSIC IDENTIFICATION (DENTISTRY)AND EMERGING TECHNOLOGIES

The course is open to civilian & military and includes bothlectures and hands-on lab sessions.

• March 18–22, 2002• Hyatt Regency, Bethesda, Maryland• The course fills quickly, so you are encouraged to register early.

The course continues to evolve with the primary focus to bring theforensic scientist up to date with current industry standards. This year wehave added lectures by experts from Central Identification Lab, Hawaii,Criminal Justice Information Services Division, Investigative Graphics,and Armed Forces Center for Child Protection; a retrospective look at theMurrah Federal Building Disaster; and integrated computer mass disasterlab. The lab incorporates digital x-ray and gross specimen photographiccapture and manipulation, and WINID software navigation into the wetspecimen lab. In addition, we have added a craniofacial age assessmentlab.

The primary focus of this evolving course is to bring the forensicscientists up-to-date with current “e” technologies and cutting edgeidentification modalities, as well as to immerse them in the more tradi-tional forensic disciplines. While the primary emphasis is on forensicodontology, it also embraces and dovetails with other related disciplinesthat all forensic scientists need to know. Numerous medical specialists,including odontologists, medical examiners, anthropologists, and crimi-nologists, who attended this course in the past report that it significantlyimpacted their practices and that the involvement of such a wide range ofspecialists is an added value. Key topics include:• Digital Imaging (bitemark and medical imaging cases)• Computerized Digital Radiography & Superimposition Techniques• DNA (overview & cases)• Software Applications (WINID)• Forensic Pathology (Medical Examiner & Aerospace)• Anthropology

• Mass Disaster Organization, including DMORT & NTSB• Bitemark Analysis• Spouse, Child & Elder Abuse• Overview of Forensic Odontology• Criminal Profiling• Radiographic Aging techniques

For further information, contact course coordinator SSgt. StephenHuntington. Telephone numbers, E-Mail, and Web site located in the greenbox on page 15.

MICROSCOPE WORKSHOP: UPDATE ON RENALBIOPSIES IN MEDICAL RENAL DISEASES

• April 5–7, 2002• Holiday Inn Select, Silver Spring, Md.

This is a 3-day course designed to review the pathology of renaldiseases. The course should interest pathologists and nephrologists whoevaluate kidney biopsies in their practice, as well as physicians, residents,and fellows interested in renal pathology, and for preparation in theirspecialty board examination. The course format includes didactic lecturescovering clinical and pathologic aspects of nephrology and nephropathologyfollowed by laboratory sessions in the afternoons.

For more information contact course coordinator Mr. Ricky Giles.Telephone numbers, E-Mail, and Web site located in the green box on page15.

12th Annual ANATOMIC PATHOLOGY

• April 14–20, 2002/Holiday Inn Select, Bethesda, Md.• The AFIP designates this educational activity for a maximum of 70

credits.

This 1-week intensive review of anatomic pathology focuses on currentconcepts and diagnostic problems. Representative staff from each of theAFIP departments listed in the program will provide didactic lectures thatare complemented by an extensive syllabus and “hands-on” microscopicstudy sessions. In addition to 48 hours of lectures, there will be 22 hoursof microscope time intermixed with the lectures. A CD-ROM (PC) setcontaining selected digitized images of the study set slides will be providedto participants.

The course objectives for the course are to:• Prepare pathology residents in their final 2 years of training for their

boards.• Train practicing pathologists seeking a short, intense update-and-

review course.• Enable pathologists to maximize their overall anatomic pathology

skills by slide reviews of study sets.• Thoroughly brief pathologists on updated and current anatomic

pathology procedures and methods.For further information, contact course coordinator SSgt. Stephen

Huntington. Telephone numbers, E-Mail, and Web site located in the greenbox on page 15.

15th Annual FORENSIC ANTHROPOLOGY

• May 6–10, 2002• Uniformed Services University of the Health Sciences, Bethesda, Md.

Forensic anthropologists apply their skills to body search-and-recov-ery techniques, taphonomic analysis, trauma interpretation, bone DNA ,and mass disaster victim identification. This course uses hands-onlaboratory sessions to teach basic techniques of skeletal analysis. Lec-tures provide the methodological basis of the osteological techniques andintroduce additional applications of the field. Forensic pathologists,medicolegal investigators, forensic dentists, attorneys, and others in-volved in death investigations will find this course an excellent introduc-tion to the field.

For more information, contact course coordinator Mr. Ricky Giles.Telephone numbers, E-Mail, and Web site located in the green box onpage 15.


ABSTRACTS OF RECENT PUBLICATIONS BY AFIP STAFF

Coronary calcification:insights from sudden

coronary death victims

A. P. Burke, A. Taylor, A. Farb, G. T.Malcom, and R. Virmani

Summary. We studied 108 cases of suddencoronary death at autopsy. Any calcificationwas present in 55% of men and women under40 years; all hearts showed some calcificationby age 50 in men, and by age 60 in women. Theonly risk factor independently associated withincreased calcification was diabetes mellitus,in women only. The degree of calcification wasgreatest for acute and healed plaque ruptures,and the least for plaque erosion. Calcificationin coronary atherosclerosis appears to be de-layed in women, is greatest in women diabet-ics, and is associated with one type of plaqueinstability, namely plaque rupture.Z Kardiol. 2000;89(suppl 2):II49--II53.

Experimental evaluation of ashort transitional edgeprotection balloon for

intracoronary stentdeployment

Andrew J. Carter, David P. Lee, MD,Takeshi Suzuki, MD, Lynn Bailey,

Alexandra Lansky, MD, Russ Jones,and Renu Virmani, MD

The purpose of this study was to determine ifballoon injury to the adjacent arterial wall dur-ing intracoronary stent deployment influenceslate in-stent neointimal formation. Stent designand deployment techniques are considered im-portant factors in determining acute andlong-term success with intracoronary stenting.Experimental and clinical studies support thatthe extent of neointimal formation and theprobability for restenosis are influenced by themagnitude of arterial trauma induced withstenting. Nineteen 18-mm-long balloon-expandable stainless steel stents (MULTI-LINK

Influenza RNA not detectedin archival brain tissues fromacute encephalitis lethargicacases or in postencephalitic

Parkinson cases

Sherman McCall, MD, James M.Henry,MD, Ann H. Reid, MA, and

Jeffery K. Taubenberger, MD, PhD

Abstract. Encephalitis lethargica (EL) was amysterious epidemic, temporally associatedwith the 1918 Spanish influenza pandemic.Numerous symptoms characterized this dis-ease, including headache, diplopia, fever, fatalcoma, delirium, oculogyric crisis, lethargy, cata-tonia, and psychiatric symptoms. Many pa-tients who initially recovered subsequently de-veloped profound, chronic parkinsonism. Theetiologic association of influenza with EL iscontroversial. Five acute EL autopsies and morethan 70 postencephalitic parkinsonian autop-sies were available in the Armed Forces Insti-tute of Pathology (AFIP) tissue repository. Twoof these 5 acute EL cases had histopathologicchanges consistent with that diagnosis. Theremaining 3 cases were classified as possibleacute EL cases as the autopsy material wasinsufficient for detailed histopathologic ex-amination. RNA lysates were prepared from 29CNS autopsy tissue blocks from the 5 acutecases and 9 lysates from blocks containingsubstantia nigra from 2 postencephalitic cases.RNA recovery was assessed by amplificationof beta-2-microglobulin mRNA and 65% of thetissue blocks contained amplifiable RNA. Re-verse transcription-polymerase chain reaction(RT-PCR) for influenza matrix and nucleopro-tein genes was negative in all cases. Thus, it isunlikely that the 1918 influenza virus was neu-rotropic and directly responsible for the out-break of EL.J Neuropathol Exp Neurol. 2001;60:696-704.

Experimenting on the past:the enigma of von

Economo’s encephalitislethargica

Ann H. Reid, MA, Sherman McCall,MD, James M. Henry, MD, and Jeffery

K. Taubenberger, MD, PhD

Abstract. Encephalitis lethargica (EL) was acomplex and mysterious disease that appearedaround the same time as the great influenzapandemic of 1918. The contemporaneous rela-tionship of the 2 diseases led to speculation thatthey were causally related. Contemporary andsubsequent observers conjectured that the in-fluenza virus, directly responsible for the deathsof more than 20 million people, might also havebeen the cause of EL. A review of the extensiveliterature by observers of the EL epidemic

suggests that most contemporary clinicians,epidemiologists, and pathologists rejected thetheory that the 1918 influenza virus was di-rectly responsible for EL. Disappearance of theacute form of EL during the 1920s has pre-cluded direct study of this entity. However,modern molecular biology techniques havemade it possible to examine archival tissuesamples from victims of the 1918 pandernic inorder to detect and study the genetic structureof the killer virus. Similarly, tissue samplesfrom EL victims can now be examined forevidence of infection by the 1918 influenzavirus.J Neuropathol Exp Neurol. 2001;60:663-670.

Duet) were implanted at a 1:1 stent-to-arteryratio in the coronary arteries of swine with aconventional noncompliant balloon (n = 10) ora novel noncompliant balloon with short ta-pered shoulders to prevent edge dissection (n =9). Quantitative coronary angiography and his-tology were used to evaluate balloon and arteryinteractions and the chronic vascular responsesto the stents. Nineteen stents were implanted inthe coronary arteries of seven swines at aninflation pressure of 14 atm using a standardnoncompliant (n = 10) or a unique short transi-tional edge protection (n = 9) balloon. Histo-logic analysis at 28 days demonstratedballoon-associated barotrauma in 13 of 20 (65%)of adjacent nonstented arterial segments withthe conventional balloon and only 3 of 18(17%) of the adjacent nonstented arterial seg-ments with the short transition edge protectionballoon (P = 0.022). In-stent neointimal areaand % stenosis correlated with the severity ofperistent arterial injury (r = 0.43, P = 0.01).In-stent vessel injury scores were similar forstents with peristent injury (1.0 ± 0.3) versusstents without peristent injury (1.0 ± 0.03, P =0.73). In-stent neointimal area and % stenosiswere greater for stents with peristent injury(2.36 ± 0.74 mm2 , 32% ± 9%) as compared tostents without peristent injury (1.39 ± 0.70mm2, 20% ± 10%, P = 0.01). Arterial wallinjury adjacent to a stent after high-pressuredeployment contributes to late in-stentneointimal hyperplasia in this model. Theseexperimental data suggest that further study iswarranted to refine stent implantation tech-niques and that modifications of balloon shapeor material may be useful to optimize stentdeployment and reduce arterial trauma.Cathet Cardiovasc Intervent. 2000;51:112-119.

Influenza A virusneuraminidase: regions of

the protein potentiallyinvolved in virus-host

interactions

Thomas G. Fanning, Ann H. Reid, andJeffery K. Taubenberger

Phylogenetically informative amino acid posi-tions (PIPs) were identified in influenza Aneuraminidases of subtypes N1 and N2.Neuraminidase evolves in a lineage-specificway as the virus adapts to a new host or changesto evade the host’s immune system. Thus, manyPIPs undoubtedly identify positions involvedin virus-host interactions. Phylogeneticallyimportant regions (PIRs) are defined as severalPIPs near one another. There are 15 PIRs on N1and 12 on N2, seven of which are shared be-tween the two subtypes. Many PIRs are coinci-dent with antigenic or glycosylation sites. OtherPIRs may represent additional antigenic sitesor may be involved in other aspects of virus-hostbiology.Virology. 2000;276:417-423.

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1. Burke AP, Taylor A, Farb A, Malcom GT, Virmani R. Coronary calcification:insights from sudden coronary death victims. Z Kardiol. 2000;89(suppl2):II49-II53.

2. Carter AJ, Lee DP, Suzuki T, Bailey L, Lansky A, Jones R, Virmani R.Experimental evaluation of a short transitional edge protection balloon forintracoronary stent deployment. Cathet Cardiovasc Intervent.2000;51:112-119.

3. Fanning TG, Reid AH, Taubenberger JK. Influenza A virus neuraminidase:regions of the protein potentially involved in virus-host interactions.Virology. 2000;276:417-423.

4. Farb A, Tang AL, Shroff S, Sweet W, Virmani R. Neointimal responses 3months after 32p ß-emitting stent placement. Int J Radiat Oncol Biol Phys.2000;48:889-898.

5. Johnson LL, Schofield LM, Verdesca SA, Sharaf BL, Jones RM, Virmani R,Khaw BA. In vivo uptake of radiolabeled antibody to proliferating smoothmuscle cells in a swine model of coronary stent restenosis. J Nucl Med.2000;41:1535-1540.

6. Kim WH, Hong MK, Virmani R, Kornowski R, Jones R, Leon MB.Histopathologic analysis of in-stent neointimal regression in a porcinecoronary model. Coron Artery Dis. 2000;11:273-277.

7. McCall S, Henry JM, Reid AH, Taubenberger JK. Influenza RNA notdetected in archival brain tissues from acute encephalitis lethargica cases orin postencephalitic Parkinson cases. J Neuropathol Exp Neurol. 2001;60:696-704.

8. McCall SA, Lichy JH, Bijwaard KE, Aguilera NS, Chu W-S, TaubenbergerJK. Epstein-Barr virus detection in ductal carcinoma of the breast. J NatlCancer Int. 2001;93:148-150.

9. Miettinen M, Fernandez M, Franssila K, Gatalica Z, Lasota J, Sarlomo-RikalaM. Microphthalmia transcription factor in the immunohistochemicaldiagnosis of metastatic melanoma: comparison with four other melanomamarkers. Am J Surg Pathol. 2001;25:205-211.

10. Narula J,Kolodgie FD,Virmani R. Apoptosis and cardiomyopathy. Curr OpinCardiol. 2000;15:183-188.

11. Reid AH, McCall S, Henry JM, Taubenberger JK. Experimenting on the past:the enigma of von Economo’s encephalitis lethargica. J Neuropathol ExpNeurol. 2001;60:663-670.

12. Reid AH, Taubenberger JK, Fanning TG. The 1918 Spanish influenza:integrating history and biology. Microbes Infect. 2001;3:81-87.

13. Schneider DB, Vassalli G, Wen S, Driscoll RM, Sassani AB, DeYoung MB,Linnemann R, Virmani R, Dichek DA. Expression of Fas ligand in arteries ofhypercholesterolemic rabbits accelerates atherosclerotic lesion formation.Arterioscler Thromb Vasc Biol. 2000;20:298-308.

14. Scott DS, Arora UK, Farb A, Virmani R, Weissman NJ. Pathologic validationof a new method to quantify coronary calcific deposits in vivo usingintravascular ultrasound. Am J Cardiol. 2000;85:37-40.

15. Taylor AJ, Gorman PD, Hudak C, Tashko G, Sweet W, Farb A, Virmani R.The 90-day coronary vascular response to 9°Y-ß particle-emitting stents inthe canine model. Int J Radiat Oncol Biol Phys. 2000;46:1019-1024.

16. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons fromsudden coronary death: a comprehensive morphological classificationscheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol.2000;20:1262-1275.

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