Operation Noble Eagle Afip-Dec-01

the AFIP
LETTER Visit our Web site at

http://www.afip.org
Armed Forces Institute of Pathology Vol. 159, No. 5

Washington, DC 20306-6000 October 2001
Operation Noble Eagle:

AFIP Responds to September 11th Pentagon
Terrorist Attacks
by Christopher C. Kelly
AFIP Public Affairs Director
A
multidisciplinary team of over 50 AFB (Delaware) Port Mortuary to identify the 188
forensic specialists, scientists, and support victims of the attack. “Our staff represented every
personnel from the Armed Forces Institute branch of the service,” said AFIP Director Glenn
of Pathology (AFIP) played a major role in one of N. Wagner, CAPT, MC, USN, who served as the
the most comprehensive forensic investigations in senior officer during the operation. “We also
US history following the September 11, 2001 received tremendous support from the doctors,
terrorist attack at the Pentagon. Code named nurses, and technicians stationed at Dover who
Operation Noble Eagle, AFIP’s team of forensic participated in the investigation.”
pathologists, odontologists, a forensic anthropolo- The investigation mobilized AFIP assets in
gist, DNA experts, investigators, and support many ways. In the hours following the crash of
personnel worked for over 2 weeks at the Dover American Airlines Flight 77 into the Pentagon, the
acting Armed Forces Medical Examiner, AbuBakr
AFIP Director Glenn N. Wagner, CAPT, MC, USN (center) describes the forensic Marzouk, Col, USAF, MC, worked with FBI and
investigations taking place in the morgue during Operation Noble Eagle to the Army local Virginia law enforcement officials to create
Surgeon General, James B. Peake, LTG, MC, USA. Looking on are Florabel G. Mullick, an effective plan for recovering and identifying the
MD, SES, ScD, AFIP Principal Deputy Director and Col Joe Drobezko, the 436th Support
Group Commander, Dover AFB. On the far right facing the autopsy table is Andrew Baker,
victims. At the same time, personnel from the
Maj, USAF, MC, chief deputy medical examiner. Also at the table is Tom Holland (in the Office of the Armed Forces Medical Examiner
beard), a forensic anthropologist from the Army’s Central Identification Laboratory, Hawaii (OAFME) positioned and staged equipment to
(CILHI). begin operations at Dover. Bruce Ensign, Maj,
USAF, MC, served as AFIP’s team leader at the
site. “We immediately called in regional medical
examiners from as far away as San Diego to
participate,” 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 early
critical hours were two other key AFIP groups:
forensic scientists from OAFME’s Armed Forces
DNA Identification Laboratory (AFDIL) and oral
pathologists from the Department of Oral and
Maxillofacial Pathology. AFDIL scientists ensured
that data systems and records were available to
make DNA identifications, while the oral pathol-
ogy group created a triage area to conduct positive
dental identifications. Contacts were also made
with family services personnel in each branch of
Noble Eagle, to page 11
2 AFIP Letter / Vol. 159, No. 5 / October 2001
Atlas of Tumor Pathology, Third Series, Fascicle 31

DIRECTOR’S MESSAGE
Tumors of the Liver
and Intrahepatic Bile Ducts
Kamal G. Ishak, MD, PhD, Zachary D.
Goodman, MD, PhD
Armed Forces Institute of Pathology, Washington, DC,
AFIP’s Response and J. Thomas Stocker, MD
to September 11 Uniformed Services University of the Health Sciences,
Bethesda, MD
Armed Forces Institute of Pathology, Washington, DC • 2001
T
his issue of the Letter is focused on the efforts of the
AFIP to respond to the tragedy of September 11, 2001 ISBN: 1-881041-69-7
at the Pentagon, and secondarily to identification efforts at In the 12 years since publication of the second series fascicle on this
the Somerset, Pa site. The Institute’s timely response to these subject, there have been many advances in epidemiologic, histoge-
incidents underscores the importance of an intact infrastructure to netic, pathogenetic, and clinicopathologic aspects of tumors and
support such activities, especially when they become extended. tumor-like lesions of the liver and intrahepatic bile ducts. This third
The medicolegal death investigation of the Pentagon incident has series fascicle is divided into 14 chapters:
extended over 2 months and has involved around-the-clock • Embryology, histology, and anatomy
laboratory testing. All avenues of forensic investigation were • Benign hepatocellular tumors
explored and deployed with zero defects. I am very proud of the • Benign cholangiocellular tumors
effort and the success of this multidisciplinary and multifactorial • Benign mesenchymal tumors and pseudotumors
investigation. In such federal investigations, the Office of the • Miscellaneous benign tumors and pseudotumors
Armed Forces Medical Examiner is the spear point for the AFIP’s • Hepatoblastoma
911 response. The OAFME is the headquarters of the global • Putative precancerous lesions
Armed Forces Medical Examiner System (AFMES) and the only • Hepatocellular carcinoma
federal medical examiner system. It is routinely used by other • Fibrolamellar hepatocellular carcinoma
federal agencies, including State, Justice, Treasury, and Transpor- • Intrahepatic cholangiocarcinoma and other malignant biliary
tumors
tation, as well as by Veterans Affairs and DoD.
• Miscellaneous malignant tumors
The Pentagon investigation highlighted the importance of a
• Malignant mesenchymal tumors
multidisciplinary effort. Forensic anthropology was a significant
• Primary hepatic lymphomas and suspected lymphomas
component; made up of physical anthropologists from the AFIP, • Metastatic tumors
the Smithsonian Institution, and the US Army Central Identifica- • and an appendix on the TNM classification of malignant tumors
tion Laboratory-Hawaii. A comprehensive dental team was of the liver.
formed with expanded capabilities in digital imaging and com- Several tumors and tumor-like lesions are extensively discussed,
parative analysis. The medical radiographic section included full- commensurate with increased knowledge about them, such as
time, fully trained radiologists assisting the dentists, anthropolo- peribiliary gland hamartoma (bile duct adenoma), hepatobiliary
gists, and pathologists in the identification and characterization of cystadenoma, biliary papillomatosis, lymphangioma, angiomyolipoma,
all specimens received. Where appropriate, both toxicology and miscellaneous heterotopias, hepatoblastoma, hepatocellular carcinoma,
DNA specimens were obtained in each case. This was the first intrahepatic cholangiocarcinoma, epithelioid hemangioendothelioma,
time that military nursing staff was incorporated to assist the and primary hepatic lymphomas (including a section on diagnosis of
forensic pathologist in the postmortem physical examination and suspected lymphoma).
recording of findings. This medical team was paired with forensic Tumor entities not covered in the previous fascicle include ciliated
anthropologists, dieners, photographers, and evidence technicians. foregut cyst, peribiliary gland cysts, hereditary hemorrhagic telang-
The entire operation remained under the watchful eye of the FBI, iectasia, myelolipoma, focal fatty change, Langerhans’ cell histiocyto-
which had two teams on-site—a fingerprint team and a trace sis, solitary fibrous tumor, miscellaneous benign mesenchymal tumors
evidence team. All activities were coordinated between the FBI, (such as plexiform neurofibromatosis), hepatic pregnancy, putative
AFIP/AFMEO, Dover AFB Base, Service Personnel Offices, precancerous lesions, malignant rhabdoid tumor, and two hitherto
Dover Port Mortuary, and DoD assets. undescribed tumors: ossifying stromal-epithelial tumor and kaposiform
The success of this investigation and similar past experiences angiosarcoma.
The 511 gross photographs and photomicrographs (most in color)
underscores the importance of a collaborative, cooperative
are of outstanding quality. Only a few electron micrographs are
enterprise where consensus, commitment, and communication are
included, in keeping with the authors’ belief that they are of limited
prized.
diagnostic value. The chapters are extensively referenced. Imaging
studies of most of the tumors are briefly covered but only rarely
Glenn N. Wagner illustrated. This 356-page fascicle should be an essential reference for
CAPT, MC, USN residents, oncologists, hepatologists, gastroenterologists and patholo-
The Director gists in practice.
AFIP Letter / Vol. 159, No. 5 / October 2001 3

Museum experts respond to Pennsylvania crash
T
he final terrorist event of September
11 was the crash of United Airlines
O
n behalf of the staff and
Flight 93. The Boeing 757, carrying
volunteers at the National
38 passengers and a crew of 7, departed
Museum of Health
Newark International Airport at 8:01 a.m.
and Medicine of the Armed
and headed for San Francisco. After
Forces Institute of Pathology, I
crossing into Ohio, terrorists apparently
would like to share our deep
took control of the plane and redirected
sadness over the abrupt and
the flight back into Pennsylvania.
tragic losses endured in the
Using cell phones and onboard
recent terrorist activities at the
airfones, the hijacked passengers learned
Pentagon, in New York, and in
of the earlier crashes at the World Trade
Pennsylvania. We extend our most
Center and the Pentagon. After a struggle
heartfelt sympathies to the
between the passengers and the terrorists
families, friends, and colleagues
for control of the plane, it crashed into an
of the victims. But, we are proud
abandoned strip mine in Somerset County,
to be part of an organization that
Pa, shortly after 10 a.m. All aboard were
can and does respond to these
killed.
unique challenges to our nation.
On September 13, Paul Sledzik, curator
The following article describes
of Anatomical Collections at the National
some of the Museum’s contribu-
Museum of Health and Medicine of the
tions. We do this as a museum Paul Sledzik and Lenore Barbian, PhD, review
Armed Forces Institute of Pathology
with personnel of exceptional museum documents.
(AFIP), was asked by the US Department
talents and backgrounds. We also
of Health and Human Service’s Office of justice.
respond as a component of the
Emergency Preparedness to command the The DMORT team organized a morgue,
Armed Forces Institute of Pathol-
Region III Disaster Mortuary Operational set up the morgue operation, interviewed
ogy, which provided forensic
Response Team (DMORT) in providing victim’s families, and collected antemor-
specialty services, under the
victim identification services for the UA tem and postmortem information. The
leadership of the Institute Direc-
Flight 93 crash. Sledzik has been team morgue facility was located in the National
tor, Captain Glenn N. Wagner,
commander of Region III DMORT since Guard Armory outside Somerset, Pa. With
MC, USN, at the Dover Air Force
1997. the FBI as the lead agency in the investiga-
Base Port Mortuary. Dr. Wagner
As part of the National Disaster tion, access to the morgue was strictly
assembled a team including
Medical System, DMORT is composed of controlled.
civilians and members of every
private citizens and federal employees Sledzik views the combined DMORT
branch of service to perform
who are asked to provide forensic, and AFIP response to such incidents as a
forensic pathology, forensic
mortuary, and family support services great benefit to the families of those killed
odontology, anthropology,
following disasters. The teams (there are in disasters. As part of a package of
photographic work, and DNA
10 throughout the nation) are made up of federal resources, DMORT and AFIP have
service for the individuals killed at
forensic scientists, medicolegal investiga- worked together in previous incidents,
the Pentagon. Their experiences,
tors, mortuary officers, logistics and particularly in the area of DNA identifica-
in turn, become part of the
administrative support personnel, and tion.
collective memory of the Institute,
others. “In my estimation, the AFIP managed
to be documented by the
In addition to Sledzik, Lenore Barbian, two of the three incidents following the
Museum for lasting value to our
PhD, the assistant curator of Anatomical September 11 attacks: the Pentagon crash
nation and to the world.
Collections at the Museum and a DMORT and the Somerset crash. My AFIP creden-
Dr. Adrianne Noe team member, was also asked to respond. tials opened more doors during the
Director Barbian and Sledzik spent the next 2 activation than my DMORT association.
NationalMuseum of Health and weeks in Somerset, Pa. The main focus of Medicolegal disaster responders respect
Medicine of the AFIP their work was to support the local coroner the AFIP name,” Sledzik said.
in identifying the victims of the crash and In fact, the Office of the Armed Forces
to aid the FBI in collecting evidence to be Medical Examiner provided forensic
used when the terrorists are brought to Museum to page 14
overall identification process. Since many

Operation Noble Eagle: of the Pentagon victims were active-duty
DNA Laboratory plays key role in or reserve personnel, most had DNA
reference cards already on file in
Pentagon, Somerset County AFRSSIR. “We had a total of 50 reference
specimens on file for military service
victim identifications members who died in the Pentagon crash,”
said David Boyer, the director of Opera-
tions at AFRSSIR. “That expedites the
By Michele Hammonds and Christopher C. Kelly DNA identification process, because
AFIP Public Affairs
immediately we have a known reference
from which we can reliably generate a
F
or weeks following the September a two-person team to Dover to establish DNA profile. And because many blood-
11 terrorist attack on America, one connectivity for AFDIL’s computerized stain cards also have the individual’s
of the leading DNA laboratories in evidence-tracking program known as the fingerprints, we were able to provide FBI
the world focused its efforts on bringing Laboratory Information System Applica- experts with another tool for obtaining a
closure to the families of the victims. The tion, or LISA. According to James Ross, positive identification.”
Department of Defense DNA Registry, the chief information officer for the DoD As specimens arrived from the Dover
which constitutes the Forensic DNA DNA Registry, forensic scientists in the Mortuary back to AFDIL in Rockville,
Division of AFIP’s Office of the Armed Dover morgue and at the DNA laboratory Md, teams of forensic scientists, under the
Forces Medical Examiner (OAFME), relied on LISA’s barcoded chain of direction of Demris Lee, technical leader
provided DNA identifications of victims in custody system to quickly and efficiently of the Nuclear DNA Section, took over the
two of the terrorist attack plane crashes: process evidence. “Every tissue sample difficult chore of generating a DNA profile
American Airlines Flight 77 at the used for DNA analysis received a chain-of- of the victims. Their work included not
Pentagon and United Airlines custody number,” Ross said, “and this only the Pentagon crash victims, but the
Flight 93 in Somerset County, victims of the Somerset
Pennsylvania. “Identifying County, Pennsylvania crash as
victims is a humanitarian well. Every one of the
issue,” said Army Colonel organization’s 102 DNA
Brion Smith, chief deputy analysts, sample processors,
medical examiner and head of logistics staff, and administra-
the Department of Defense tive personnel were in-
DNA Registry. “Families volved— from collecting,
need confirmation,” he said, tracking, analyzing DNA
“and we have a duty to assist samples, and gathering and
them in every way possible.” logging DNA reference
The DoD DNA Registry material to preparing DNA
has two operational branches: reports. For 18 days following
the Armed Forces DNA the terrorist attacks, AFDIL
Identification Laboratory employees worked on 12-hour
(AFDIL), which performs the shifts, 7 days a week to meet
forensic DNA testing, and the the mission requirements.
Armed Forces Repository of The laboratory prepared to
Specimen Samples for the expand its operation to include
Identification of Remains At Dover, Asst. Technical Leader Amanda Blanchard uses automated evidence the Somerset County crash
program to log samples into database and generate labels.
(AFRSSIR). The AFRSSIR, almost immediately. Boyer,
which has been collecting DNA references number remained intact during the entire who is a nationally recognized expert in
since 1992 for Department of Defense identification process. It allowed us to coordinating tissue collection services
personnel, has over 3.5 million samples — track evidence taken from victims through- following aircraft disasters, traveled to
filter paper cards containing a small out the operation, and saved AFDIL staff Somerset County directly after the
amount of blood collected from active- hundreds of man-hours by eliminating the incident. There, he discussed AFDIL’s
duty and reserve component need for hand-labeling materials.” potential role in identifying the Flight 93
servicemembers. They are carefully stored Two-member teams from AFDIL victims with federal and local officials,
in freezers and left undisturbed, unless rotated from Rockville to Dover every 72 including the FBI and the National
they are required for human remains hours to work alongside the forensic Transportation Safety Board.
identification. Such was the case, when pathologists, odontologists, and anthro- AFDIL played a major role in identify-
DoD authorities turned to DNA analysis to pologists in coordinating the appropriate ing victims of previous major airline
establish the identification of victims from sampling of bone, teeth, and tissue. This disasters, including Egypt Airlines Flight
the terrorist attacks. arrangement insured the establishment of a 990 in 1999 and Alaska Airlines Flight
On September 12, COL Smith deployed proper chain of custody and expedited the 261 in 2000, and was a logical choice to
provide DNA services to federal investigators in Pennsylvania. a STR system that analyzes nine loci on the DNA simulta-
Once the lab received approval to conduct DNA testing, Ross neously. This system also provides the capability to determine
established the LISA program there as well, and by September gender.
17 collections were underway in the temporary morgue at In a like manner, DNA is also isolated from the reference
Somerset. specimens and undergoes the same PCR and STR analysis
Only a few months before, Boyer, Lee, and James Canik, processes as the unknown samples from the crash site. Direct
AFDIL’s deputy director, trained regional Disaster Mortuary references are samples taken directly from the victim, such as the
Operational Response Team (DMORT) members in DNA bloodstain cards from the repository. Unknown samples that
collecting procedures. Those same officials—forensic patholo- produce the same DNA profile as the victim’s direct reference are
gists, anthropologists, and dentists, along with Boyer and DNA considered a “DNA match.” Indirect references are reference
analysts from AFDIL—worked together following the Pennsyl- samples collected from immediate family members (mother,
vania crash. “We father, children) of the victim. Parents
actually had the and their offspring share half of their
DNA station set up nuclear DNA. The DNA profile
as part of the obtained from family members can be
DMORT operation, used to reconstruct the DNA profile of
and it went very the victim.
well for being put The collection of reference samples for
into practice for the the civilian victims proved to be a major
first time.” undertaking. Canik led a combined team
At AFDIL, DNA of personnel from AFIP and Walter
scientists divided Reed Army Medical Center to establish
into teams to handle a collections operation at the Pentagon
the Pentagon and Family Assistance Center (PFAC) in
Somerset County Arlington, Va. The county coroner and
cases. The AFDIL the FBI established a similar family
experts worked to assistance center at
generate a DNA Somerset, Pa. For
profile on each Caption:
those families not
tissue specimen immediately
received, as well as developing a DNA available, Canik
profile on known reference specimens. worked closely with
For servicemembers, reference specimens the FBI and local
included the bloodstain cards on file at law enforcement
AFRSSIR. For civilians (and agencies to identify
servicemembers if necessary), suitable and collect these
reference specimens included tissue taken critical references.
from biopsy specimens, Pap smears, hair The AFIP team at
from combs and brushes, extracted teeth, the PFAC collected
and even saliva found on toothbrushes. over 176 family
Surviving family members also provided references.
blood specimens to confirm a genetic Scientists
identity. “The surviving family members then analyzed the
are an important link to our process,” DNA profiles for a
Boyer said. potential match and
DNA is isolated from the bone, tissue, In Somerset, AFIP’s Dave Boyer collects DNA samples (top). reported their
Below: FBI fingerprint station.
hair, and teeth specimens by a commonly findings back to the
used organic extraction process. This step is followed by use of forensic pathologists at Dover, or to the Somerset County
the polymerase chain reaction (PCR), which makes millions of coroner. AFDIL developed a computerized search program that
copies of DNA identical to the original copy. PCR is often compares the DNA profiles generated from the reference speci-
described as being like a DNA photocopy machine. PCR is mens against the DNA profiles generated from the unknown
particularly advantageous for samples that are minute or highly specimens, and provides the best fit match. AFDIL laboratory
degraded. These conditions are the norm in cases that are either staff are hopeful that nearly all DNA identifications will be
very old, or that have been exposed to severe environmental complete in the coming weeks.
challenges such as heat and high impact forces. The PCR Boyer was extremely pleased with the total team effort, both at
products are analyzed using short tandem repeat (STR) analysis. the morgues and in the laboratory. “It was invaluable for
STRs are short stretches of a specific DNA sequence that are laboratory people to experience the front end of the DNA
tandemly repeated throughout the nuclear genome. An identification program,” he said, “and I was impressed with the
individual’s “DNA type” is determined by the number of repeats amount of professionalism and dedication everyone from the
an individual has at a given locus in the genome. AFDIL utilizes AFIP exhibited during this whole event.”

Forensic anthropologist provides expertise
following September 11 attack
O
ne of the AFIP investigators who
deployed to Dover was Dr.
William C. Rodriguez, III, an
internationally recognized forensic
anthropologist whose skills are often
utilized to help solve the most difficult
criminal cases. Rodriguez, who serves as
chief deputy medical examiner in charge
of special investigations, is one of 35
board-certified forensic anthropologists in
the nation, and the only one assigned full-
time to a medical examiner’s office. His
help was invaluable following the Penta-
gon attack.
“This was a unique situation because it
was a criminal act, and every piece of
evidence had to be fully documented and
accounted for,” Rodriguez said. He led a
team of seven forensic anthropologists
from the Army’s Central Identification
Laboratory, Hawaii; the FBI; and the
Smithsonian Institution that worked 12-
hour days for over 2 weeks helping to
identify victims and return them to their
loved ones.
“We have a well-established system for
processing mass casualties at Dover,” shocked realizing that this operation was
Rodriguez said, “and one of the first areas the result of a terrorist attack,”
staffed by the forensic anthropology team Rodriguez said. “It added to the magni-
was triage.” There, he and his colleagues tude of our work. We were concerned
provided initial anatomic assessments and that another attack might be imminent,
ensured a smooth transition to experts in and it really felt as though we were
fingerprint and dental identification. fighting a war and doing science at the
Forensic anthropologists also worked same time. It was very challenging both
closely with the forensic pathologists at mentally and physically.”
autopsy to determine anatomy or provide a The scale of the operation was also
biological profile of a specimen. “We’re enormous. “This was the largest mass
able to provide specific characteristics, fatality incident we’ve seen in years, and
especially when having to re-associate it required hundreds of decisions to be
remains of multiple individuals,” he said. made quickly and accurately, not only in
This included questions of sex, race, age, victim identification but also in logistics
and unique identifying factors. “We’re and personnel issues,” he said. “But, our Dr. William C. Rodriguez, III, reviews case
able to provide an accurate reconstruction biggest concern was always for the information with investigators at Dover (top) and
of skeletal material when needed, and this families. We worked hard to get the job examines training specimens at his Rockville, Md
is really critical in the identification done and return the victims to their loved office.
process.” ones.”
The forensic anthropology team wasn’t – Christopher C. Kelly
immune to the enormity of what happened
on September 11. “Everybody was

Forensic dentistry plays essential role
following Pentagon terrorist crash
AFIP’s Department of Oral and Maxillo- to handle the expected casualties, Col
facial Pathology, under the direction of Pemble alerted the Central Panorex
Department Chair Colonel Charles Storage Facility in Monterey, Calif, that
Pemble, USAF, DC, played a critical role antemortem panographic dental x-rays of
in helping to identify victims of the the military victims would be needed. Air Force Colonel Charles Pemble led the dental
September 11th American Airlines Flight (Many servicemembers have a panograph, identification team at Dover.
77 terrorist crash into the Pentagon. A or full-mouth x-ray on file. Panographs are
total of eight AFIP military officers—five a valuable comparison tool for making existing dental conditions using antemor-
staff oral pathologists and three oral positive victim identification.) With tem and postmortem forms. A recent
pathology residents—formed the core commercial air traffic grounded, however, innovation utilized at Dover was the
investigative group at Dover. They were another source had to be found to transport digital postmortem x-ray, which relies on
joined by two oral pathologists, one each the records overnight, and DoD officials sensors instead of film. The technique also
from the National Naval Dental Center, expedited the delivery through a dedicated eliminates chemical processing, which
Bethesda, Md, and the Naval Hospital, military aircraft. saves time and money and has minimal
Portsmouth, Va. Supporting them were an For the next 5 days, the dental contin- environmental impact. “We also chose to
additional 43 personnel, including 9 gent worked 12-hour shifts, completing an utilize an automated comparison tool,
dentists and 19 dental technicians from average of 22 exams a day. Col Pemble called WinID,” Pemble said, “primarily
the 436th Dental Flight at Dover AFB, also planned on using relief teams of because we had over 170 potential deaths,
Del, and 6 dentists and 9 dental techni- dentists, technicians, a computer specialist, and many were civilians with varying
cians from the 81st Dental Squadron, and an administrative officer every 7 to 10 dental records. WinID is a Microsoft
Keesler AFB, Miss. “This combined days, in anticipation of even greater Access-based system that runs under
support really proved to be the ideal casualty numbers. As recovery operations windows and can link the antemortem and
situation for us,” Pemble noted. “Their slowed at the Pentagon, however, those postmortem dental charting to graphics.”
presence allowed for rotation of personnel teams weren’t needed. “We were able to In the future, Col Pemble foresees the
in making identifications while also complete our assignment with the desig- development of a dental image repository
continuing to operate the Dover dental nated personnel,” said Pemble. to further assist in the identification
clinic. Sick call and other essential dental Three weeks into the mission, dental process. “These are images that can be
care continued uninterrupted.” identifications were performed in over captured digitally, or, if film, scanned and
Preparations moved quickly on two 63% of the cases, and in 30% of the cases sent to the storage facility,” he said.
fronts immediately following the Septem- served as the sole method of identification. – Christopher C. Kelly
ber 11 tragedy. As USAF dental personnel The AFIP staff utilized a number of
at Dover prepared the mortuary facilities techniques, including the charting of pre-

Forensic Toxicology staffers
provide analysis
A staff of 18 forensic scientists and administrative personnel in
AFIP’s Division of Forensic Toxicology worked overtime
following the September 11 Pentagon attack to aid investigators
in determining the cause and manner of death.
Experts conducted a number of tests on specimens that were
included in the final medical examiner reports. The division
provides expertise following military incidents or accidents to
aid in medical and criminal investigations.
“Many of the personnel worked 12-hour days, including
weekends, to complete this mission in a timely manner. They
did an outstanding job,” said Aaron Jacobs, COL, MS, USA, HM2 James E. Miller and SSgt Emilda Greenidge-Blake joined other division
chief deputy medical examiner and head of the division. members in performing essential forensic toxicology testing.

Electronic Mass Disaster Dental Identification Triage
utilized following Pentagon attack
“A step in the right direction!”
ast spring, members of the 436th Dover Air Force Base
L
new software protocols. Getting on line was a direct result of the
(DAFB) medical group (dental and radiology) civil incredible efforts of our computer strike team, composed of TSgt
engineers, DAFB Port Mortuary staff, and CAPT Douglas Hines, HMC Butler, Mr Doug Oswell, and SSgt John Spreadbury.
Arendt, USN, DC, held a 2-day brainstorming session to develop The bottom line is we set up an integrated system that accepted
a plan for possible retrofit of part of the triservice port mortuary and manipulated digital x-ray images and networked a mass
(fig 1). Arendt, who serves as chief of Forensic Dentistry for disaster graphical interface and information-sorting program
AFIP’s Department of Oral and Maxillofacial Pathology, said (WINID II) (fig 2).
that the goal was to upgrade conventional radiologic resources to As antemortem clinical records arrived, staff manually
digital radiographic capture and reviewed them and developed a historical composite of all
to facilitate more efficient mass clinical procedures, then converted this information to computer
disaster identification triage codes and entered it into WINID II. At the same time, antemor-
algorithms—“specifically, to set tem images were scanned using a TPU (transparency adapter) and
the framework for a more linked with the antemortem clinical charting file in WINID II.
futuristic patient electronic data Other staff
management and retrieval simultaneously
system.” entered postmor-
CAPT Douglas Arendt, USN, DC
AFIP initiated this new tem data,
system following the tragic crash of American Airlines Flight 77 creating a hard
into the Pentagon. Coincidentally, much of the equipment had copy snapshot of
recently arrived at Dover, and was waiting to be set up. This the CDR digital
short-fused evolution was aided by Mr. Manny Penna, a Schick x-rays, and
CDR (computerized digital radiography) representative who linked them to
witnessed the collapse of the World Trade Center towers from postmortem data
his office across the river in New Jersey. Manny volunteered to Fig 3—Example of Odontogram files. As the data
drive to DAFB with missing x-ray sensors and expedited digital banks increased
radiography training for members of the 436th. As a result, we in size, computer
successfully searches and
integrated the prioritized
electronic sensors matches were
with laptops in the developed.
x-ray bays. Once a
The other possible match
elements of the was generated,
proposed electronic odontologists
triage ID system then examined
went into place on an odontogram
(fig 3) (a
Thursday afternoon, pictorial chart
as staff networked comparing
Fig 1—Lt Col Beecher hardware and antemortem and
and staff brainstorming troubleshot postmortem
in X-ray bays. dental charting),
followed by
viewing the
Fig 4—Antemortem and postmortem linked antemortem and
x-ray images on monitor.
postmortem x-
Fig 2—HMC Butler ray images on
and TSGT Hines
preparing network the monitor (fig
cables. 4). If a reason-
able match resulted, the files were pulled for the final visual Operation Noble Eagle:
comparison, and a final report was generated documenting the
similar dental Mortality Surveillance Division
findings (fig 5).
CAPT Arendt
provides critical data collection
feels that the and case-tracking support
decision to go “all
L
digital” on x-ray isa Pearse, MAJ, MC, USA, chief of OAFME’s
capture, as well as to Mortality Surveillance Division, created and utilized an
implement a net- electronic database that provided critical victim identifi-
worked graphical cation information to investigators during Operation Noble
image and data- Eagle. “Because of the
sorting program large-scale nature of the
(WINID II), was September 11 events, data
well worth the effort. collection and case
“Without hesitation, tracking were essential
I strongly believe elements of the Dover
that the high number mission,” she said. Her
of positive identifi- contributions marked the
cations produced in a first time that OAFME
timely manner utilized an electronic
resulted because of tracking database to
dedicated staff and supplement paper records, Lisa Pearse, MAJ, MC, USA
computer enhance- and allowed for real-time
Fig 5—Example of final comparison report ment,” he said (fig reporting throughout the mission.
6). Arendt added Dr. Pearse is a preventive medicine physician, recently
that “no matter what assigned to OAFME to conduct mortality surveillance. This
approach is used, if antemortem reference material (clinical includes monitoring all active-duty deaths for trends, especially
information) is not available or isn’t that of the victims being those that could represent emerging infections or a subtle
processed at that time, no system can resolve that issue.” biological warfare attack. In Dover, Pearse quickly designed a
A few thoughts for the future: database to describe and follow all victims through the identifi-
• Implement a dedicated URL or email address and dissemi- cation process. “The database tracked demographic information
nate that information broadly to law enforcement, so that on the missing, and helped us focus on the presence or absence
health care professionals (military and civilian) can send of medical and dental records or DNA profiles on each of the
digital information to us directly. 188 individuals,” she said. “Finally, as identifications were
• Software issues: Whatever software is utilized in the future made, we utilized the database to keep track of who had been
(WINID or CHCS), assure it has good “viewability” on the identified and by what method (dental, fingerprint, or DNA).”
monitor and multiple graphical links. The digital x-ray capture Pearse continues to track identification data and produces
should “drop” directly into the program, rather than requiring a daily status reports as the investigation winds down. She’s also
variety of steps to get to that point. analyzing data to evaluate the casualty identification modalities,
• Network issues: Network the digital x-ray capture to the injury patterns, and structural issues in the Pentagon that might
dissection bays and to the comparison section. have influenced survival patterns.
– Christopher C. Kelly
Penny Rodriguez,
executive assistant to the
Director, worked at Dover
for over two weeks to
help coordinate and
communicate forensic
Fig 6—Some Team members 13 Sept – 27 Sept 2001
findings to DoD officials
from AFIP, 436th DAFB and Keesler AFB): and family members.
appropriate manner.
Operation Noble Eagle: For 2 weeks following the terrorist
Air Force Special Agent reflects on his attack, AFIP’s team of forensic patholo-
gists, anthropologists, odontologists,
role at Dover Port Mortuary scientists, and investigators coordinated
all aspects of Operation Noble Eagle.
Since arriving at AFIP 18 months ago, SA
just a job. Its role in identifying victims Strasser has worked on a dozen cases
following tragedies like September 11 is a involving fatalities. The terrorist attack on
real service we provide for families and the Pentagon stands out most in his mind
the United States as a whole, and just to because of the number killed and the
have been involved in something of that national and international attention it
magnitude was astounding,” he said. “It attracted. Last October, he worked on the
made me realize how important the AFIP USS Cole terrorist attack in Yemen in
mission is and how great it is to be an which 17 American servicemembers died.
American.” AFIP’s forensic team identified the 17
Strasser worked at the Dover Air Force Cole victims in only 3 days.
Base (Delaware) Port Mortuary for almost “We thought we had put in some pretty
3 weeks following the September 11 full days working on the Cole victims,”
terrorist attacks. As victims of the attack Strasser said. “ However, there were a few
arrived at the morgue, SA Strasser was times in Dover when we processed 30
there to ensure a smooth movement casualties per day, but we had many more
staff available to do so.” Strasser was
T
hree weeks after the Pentagon through eight designated stations in the
disaster, most Department of identification process. Those stations impressed by the teamwork he saw at
Defense personnel returned to their were: arrival, scanning for explosive Dover. “It was good to see all the entities
jobs, including Special Agent Russell ordnance, photography, anthropology, work together, ” he said. “Once we had a
Strasser, chief of the Office of the Armed fingerprinting, x-ray, dental, and autopsy. positive identification, we knew we could
Forces Medical Examiner’s Criminal Strasser ensured that enlisted personnel bring closure to the victim’s family, and
Investigation Division, who returned with assigned to move the deceased through that was important.”
a new sense of patriotism. “AFIP isn’t each station did so in a timely and – Michele Hammonds
ogists to identify the presence of teeth, an excellent source of

Operation Noble Eagle: DNA. “Sometimes teeth aren’t readily observable during the
Radiologic Pathology provides physical inspection, and our findings were a great help to the
forensic dental team,” Koeller said.
Dover support The final whole-body x-ray report assisted others in the
identification process, and encouraged professionals at other
R
adiologists from AFIP’s Department of Radiologic stations to compare their observations with the report and to seek
Pathology played an important role in identifying casual- out the radiologist for consultation and discussion. It proved
ties in Operation Noble Eagle. “COL Ted Harcke, a beneficial to increasing the accuracy of the information found
reservist who recently served as a visiting scientist from the and provided great confidence in the conclusions.
American Roentgen Ray Society, staffed the mortuary for the first “What we brought to this mission is a unique and truly
2 weeks,” said CAPT (Sel) Kelly Koeller, MC, USN, department valuable asset, one that really couldn’t be found anywhere else,”
chair. Dr. Koeller and MAJ Joseph Bifano, Chief of Radiology at Koeller said.
Dover AFB Clinic, also staffed the radiology section at Dover – Christopher C. Kelly
during the operation.
The radiologists were responsible for reviewing whole-body
radiographs in order to document injuries on the victims. “By
looking at what types of injuries are present, we gain some insight
into whether they were the result of blast effects, blunt trauma, or
heat, and this helped us place victims in specific locations when
the event occurred,” Koeller said. The whole-body radiograph
also enabled the radiology contingent to identify personal effects,
jewelry, age of the victim, and any other materials present as part
of the identification process. “Because this was a crime scene
investigation, we also searched for any objects, such as weapons
or aircraft parts, that might be helpful in the investigation.”
The radiologists also worked closely with forensic odontol-
Col Ted Harcke briefs LtGen Paul Carlton, USAF
Surgeon General, on radiology operations at Dover.
Noble Eagle from page 1 Operation Noble Eagle:

AFIP utilized a well-defined and On the front line: OAFME’s Bob Veasey
tested system for conducting the identifi-
cations of the Pentagon victims. When
ensures investigators are ready to go
remains arrived at the morgue, a scan-
ning device searched for the presence of
B
ob Veasey, OAFME’s chief of Operational Investigations, is often on the front
unexploded ordinance or metallic lines following military aircraft mishaps. Veasey oversees and manages
foreign bodies. A computerized tracking logistics issues for OAFME investigators during search-and-recovery operations
system then assigned numbers to each by obtaining equipment, ensuring lodging and serving as the OAFME point-of-contact
victim for efficient tracking. FBI in the field to help expedite mission requirements. The team is mandated to launch
experts collected trace evidence to worldwide in a number of hours, and Veasey makes sure equipment and supplies are
search for chemicals from explosive packed and ready to go. “We’re like firemen; we respond when we get the call,” he
devices and conducted fingerprint said.
identifications. Forensic dentistry And when the call came on September 11, Veasey packed, loaded and shipped
experts from the Department of Oral and supplies and equipment to Dover. “We prestaged (packed) everything we had in my
Maxillofacial Pathology then performed office within 6 hours once we received notification that we were going to Dover Air
dental charting and comparison with Force Base,” he said. “The
antemortem dental records. Full-body truck left AFIP the next
radiographs followed to document morning, headed to
skeletal fractures and assist in the Dover.”
identification process, followed by Veasey ordered equipment
autopsy inspection. for the forensic team of
At autopsy, forensic pathologists pathologists, anthropolo-
determined the cause and manner of gists, odontologists, and
death, aided by forensic anthropologist other mortuary workers
Dr. William C. Rodriguez in determin- who had been temporarily
ing the race, sex, and stature of victims assigned to work at
when necessary. A board-certified Dover’s Port Mortuary in
epidemiologist managed the tracking support of Operation
system for data collected during the Noble Eagle.
autopsy process, and tissue samples were “The operation at Dover
collected for DNA identification and was so big, and the
further toxicologic studies. Forensic forensic teams and support
photographers, essential to any forensic Bob Veasey with supplies and equipment used by OAFME staff. personnel kept using up so
investigation, documented injuries and many supplies that I had to
personal effects. Finally, mortuary constantly order more,” he said.
specialists then embalmed, dressed, and As the number of casualties increased, and with it the requirement for expanded
casketed remains prior to release to next- morgue capabilities, Veasey had to estimate and order additional supplies within 24
of-kin. hours. “We were also put on alert for possible World Trade Center casualties and
For 8 days a full complement of AFIP responded to the Flight 93 crash in Pennsylvania,” he said. As a result, Veasey ex-
forensic specialists worked 12-hour panded the OAFME mass casualty response capability from 300 to 1,000, where it
shifts to complete the operation. “This is remains today if needed.
the largest mass fatality we’ve dealt with While Veasey is accustomed to working on crash cases in which there are causalities,
in recent years,” Ensign said. “We have the terrorists attack at the Pentagon and in Pennsylvania is a tragedy all by itself. “This
modalities today that we didn’t have was very personal to me because a lot of the people killed were military, and I’m retired
before. Our investigation was much military,” he said. “We also had civilians and children on the aircraft. My desire is to
more technology-intensive.” recover, identify, and return the victims to their families so they can start the closure
Ensign noted that the entire team process.”
worked well together. “Because of the – Michele Hammonds
combined effort of all three services and
the FBI, we were very pleased with the
speed of the identification process. Pennsylvania,” he said. “Fortunately our assigned by the various services helped
Essential records and references were logistical support was terrific in helping in the investigation. “It was a terrific
submitted to us in a timely way.” us get material in.” team effort,” he said.
Logistical help from AFIP also played Others also played essential roles.
an important role. “We had tremendous Histotechnicians from the Department of
logistical issues obtaining equipment, Scientific Laboratories served as autopsy
especially with additional demands in technicians, assisting pathologists with
New York City and Somerset County, the remains, while special agents

Helping Pentagon families who lost loved
ones, AFIP Personnel Staff Special
Assistance Center
I
n the aftermath of the September 11 “DNA is new technology
terrorist attack at the Pentagon, AFIP with the capability of provid-
experts relied on DNA analysis to ing those answers back to the
provide a positive identification for many families,” he said. Working
of the victims. To make a DNA identifi- with him were Air Force
cation, however, a reference specimen is CMSgt Ontee Biggs and TSgt.
required—typically small amounts of Charles A. Lattany, III, to
blood, tissue, hair, teeth, or other biologi- meet and interview family
cal material from the deceased. Since members. For almost 3 weeks
1992, the AFIP has maintained a special Canik’s group worked 12-hour
repository of bloodstain cards for over 3.5 shifts, 7 days a week at the
million servicemembers for just such a center.
purpose. In fact, 53 cards from the “Working with the families CMSgt Ontee W. Biggs staffed the family
repository were used to help identify was our primary focus,” Biggs said. “We assistance center.
active-duty servicemembers and reservists helped to calm them down, and we made
killed in the Pentagon attack. But, what sure we were there to fulfill their needs.” Canik also met and interviewed family
about the civilians who died? The assignment of explaining the DNA members of other civilian and military
That’s where staff from the Armed process and the purpose of the tests to causalities who didn’t have DNA
Forces DNA Identification Laboratory distraught family members wasn’t always reference samples (bloodstain cards) on
(AFDIL) provided special assistance. easy to watch, he said. file. “Dealing with the families one-on-
Under the direction of James J. Canik, Taking the focus off himself and one is difficult because of the circum-
AFDIL’s deputy director, staff members putting the family members first proved stances and the recent loss of a loved one
from AFIP and Walter Reed organized a helpful for Lattany. “In a situation like under extremely traumatic conditions,”
blood collection center at the temporary that you forget about yourself and you Canik said. “We saw the full range of
family assistance center in Crystal City, really look forward to helping out other emotions— everything from happiness
Virginia. Canik talked with families about people. For them, having to lose loved and thankfulness that we were there
the importance of DNA in helping to ones is a hard thing to have to deal with,” working on their behalf, to the anger and
identify casualties. Lattany said. frustration that normally surfaced as part
of the grieving process.”
Due to the aircraft crashing into the
Pentagon and the subsequent fire, family
members were told identification of
victims would not be an easy task, and
families were asked to give blood to help
DNA experts in the process.
“Family members were being asked to
do and provide different things, but by
AFIP civilian photogra- giving their blood sample they realized
phers who provided they were doing something tangible and
support at Dover were vitally important to assist in the identifi-
(from left) Steve Kruger, cation of their family member. It was one
Veronica Ferris, and Andy of the most positive things we had in our
Morataya. involvement with the families – as we
made them part of the process in bringing
them the answers they sought,” Canik
said.
– Michele Hammonds

Histotechnicians provide valuable support
at Dover; all enlisted play vital role at AFIP
F
or three recent graduates of AFIP’s Base Port Mortuary, however, their
Tri-Service School of Histo- training took on new meaning.
technology who served as autopsy In mass fatality operations at
assistants at Dover following the Pentagon Dover, forensic investigators utilize a
terrorist attack—the assignment was series of stations to conduct victim
once-in-a-lifetime. One that A1C Earl identifications. And the histotech-
Gibson, Amn Tashanda Ashford, and nicians were there to help, moving
HM3 Marco Mendoza, all histotech- victims from station to station,
nicians, will never forget. assisting with the recovery of personal
It was the first time in the school’s effects, and even taking notes for the
history that its students and some staff pathologists. Their valuable assis-
participated in a mass casualty identifica- tance was needed at every station.
tion operation. In all, about 30 histotech- “They were terrific,” said team leader
nicians volunteered and deployed to Bruce Ensign, Maj, USAF, MC.
Dover to help forensic pathologists in the “Thanks to their help, our pathologists
identification process. The histotech- were able to conduct their investiga-
nicians rotated throughout the operation, tions more rapidly and efficiently.”
working 3 or more days before being HM3 Mendoza said working in the
replaced by other histotechnician rein- morgue proved to be a very moving
Air Force MSgts Joy Williams and Chris Sepulveda
forcements before returning to the AFIP. experience for him, with the knowledge provided support at AFIP.
“I volunteered to help because I wanted that just a few hours before, the victims
to learn something, and I knew AFIP has had been alive and serving their country advisors for their respective services.
some of the best pathologists in the at the Pentagon. “It was real emotional,” They coordinated and provided work
world,” said A1C Gibson. “Before I went he said. “I wanted to participate. In fact, a schedules for 35 to 40 enlisted AFIP
to Dover, I didn’t understand the whole lot of us wanted to help out, and being at servicemembers to help out in the
process of how casualties are handled Dover gave us a chance to help the aftermath of the Pentagon terrorist attack.
there.” forensic pathologists.” Amn Ashford said Servicemembers’ assignments ranged
Traditionally, as part of their training, she adjusted to her new role quickly. from driving, courier duties, and guarding
histotechnicians are taught to assist “This was nothing like I could ever AFIP’s perimeter to assisting pathologists
pathologists in autopsies in a sterile imagine. It was a really different experi- at Dover. Military personnel cut orders
setting at a medical facility. Up until the ence. I think the training has given me an for personnel tasked to deploy to Dover.
September 11 terrorist attacks, the recent edge over my counterparts.” “Nearly all military personnel here were
graduates received most of their training Behind the scenes at AFIP, Army involved in this mission,” MSgt Williams
inside the classroom. When they were MSG Daneen Harris and Air Force MSgt said.
tasked to work at the Dover Air Force Joy Williams are two senior enlisted Enlisted personnel and officers at AFIP
helped man a specially created Emer-
gency Operations Center, headed by Lt
Col Larry Shaw, AFIP’s chief of staff for
Administrative Services, said Air Force
OAFME forensic
MSgt Chris Sepulveda, NCOIC of the
photography staff who
deployed histotechnicans. “Once it was
led the Dover operation
recognized that the Pentagon terrorist
from left: TSgt Michael
attack was an emergency, we needed a
Godwin, USAF; TSgt
place to track and record information
Louis Briscese, USAF,
between the AFIP, the FBI, the Surgeon
NCOIC; PHC(SW/AW)
General, and everyone who needed to
Sean Doyle, USN,
coordinate with us. The Emergency
LCPO, and PH3
Operations Center was the nerve center,
Christopher Williams.
and Lt Col Shaw ran it,” he said.
Photo by TSgt Briscese.
Museum from page 3

pathology consultation for the Pennsyl- Operation Noble Eagle:
vania crash, and five staff members of
the Armed Forces DNA Identification
Laboratory collected DNA samples in
Supplies, equipment and facilities: a “round-
the Somerset morgue. the clock” operation for AFIP Logistics staff
Sledzik and Barbian, physical
S
anthropologists on staff of the NMHM/ taff from AFIP’s Director-
AFIP, oversee a collection of human ate of Logistics provided
medical and pathological specimens. essential supplies and
They provide forensic anthropology services for hundreds of personnel
consultation to several local and federal who deployed to Dover for
agencies and teach an annual AFIP Operation Noble Eagle, according
course in forensic anthropology. to William McCarthy, MAJ, MS,
“The methods of interpreting the USA, Director of Logistics at
biological aspects of the human skeleton AFIP. “We were on the scene, in
are similar, whether you are looking at a place, and ready to support the
Civil War soldier or a recent disaster mission before the first casualties
victim,” said Barbian. began arriving at Dover,” he said.
“The Museum is proud to support On the afternoon of September 11, Candy Moroz, finance and logistics support officer for AFIP’s
this work as a service to the nation,” said McCarthy anticipated needing Center for Advanced Pathology works with a Dover staff
Dr. Adrianne Noe, Museum Director. supplies on short notice and member.
“Yet, it is no surprise that we should be coordinated with the MEDCOM
able to do so. Our efforts are an excellent Contracting Office, Northeast Region, and established a pipeline for a 24- hour
example of public service, combining support. He and Candy Moroz, finance and logistics support officer for AFIP’s Center
support for families with our unique for Advanced Pathology, headed to Dover 2 days later to establish a forward-deployed
experiences and expertise at this critical logistics cell in support of the Office of the Armed Forces Medical Examiner. “We
time.” worked closely with OAFME’s Bob Veasey and the permanent logistics staff at Dover
to ensure the availability of the appropriate supplies, equipment, and facilities. Local
hospitals 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 whatever
supplies Mr. Veasey and his staff needed,” said Moroz, who spent almost 2 weeks
providing critical logistics support to the forensic investigators. With commercial air
travel completely shut down, supplies were unavailable through usual shipping
methods. Moroz often drove hundreds of miles each day to purchase and deliver items
to the mortuary facility. “Many retail companies, including Lowes, Dymo Label and
Fitzco donated a large amount of supplies when they learned of the work going on at
Dover. Other companies such as Fisher Scientific also donated supplies and waived
shipping charges to help us carry out the mission,” she said.
Angela D. Washington, Lt Col, USAF, MSC, group administrator for AFIP’s annex
in Rockville, Md, was responsible for arranging lodging, and billeting for many
personnel. She accomplished this in a few short days, despite the limited supply of
available hotel rooms in the Dover area. Washington also organized an in-house
courier system, transporting forensic evidence from Dover to the Armed Forces DNA
Identification Laboratory in Rockville. “That was significant because we would leave
Dover 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.”
Department of Advanced Medical Education

2002 Continuing Medical Education Courses
NEW COURSE!
MUSCLE DISORDERS COURSE AND WORKSHOP
DME
neuropathology for individuals interested in both NEUROSCIENCE and
PATHOLOGY. Lectures will be illustrated by gross and microscopic
photographs and will be supplemented by a course syllabus containing
• May 10–11, 2002 numerous COLOR PHOTOMICROGRAPHS, and the AFIP fascicle on
• Holiday Inn Select, Bethesda, Md. Tumors of the Central Nervous System. Participants can expect to gain:
• The AFIP designates this educational activity for a maximum of 16 • Enhanced knowledge of the pathology and recent developments in the
hours for Category 1 credit. pathophysiology of common and unique disorders of the central and
peripheral nervous systems and skeletal muscle.
The AFIP muscle disorders course and workshop for clinicians,
• Familiarization with recently recognized pathologic processes related
pathologists, and researchers will combine essential didactics with hands-
to the central and peripheral nervous systems and skeletal muscle.
on interpretation of histologic slides at prepared microscopic stations to
• Improved understanding of basic histopathologic, histochemical,
allow participants to strengthen their understanding of muscle disorders
immunohistochemical, and ultrastructural features of disorders of the
and diagnostic muscle pathology. General introductory lectures alternat-
central and peripheral nervous systems and skeletal muscle.
ing with microscopic slide sessions will be followed by in-depth presen-
• Insight into clinical, radiologic, and pathologic correlations, and
tations on Duchenne’s muscular dystrophy, autoimmunity, inclusion
prognostic factors of central nervous system lesions.
body myositis, mitochondrial disorders, and application of molecular/
For more information, contact course coordinator Mr. Ricky Giles.
genetic methods to clinical and pathologic diagnosis. A series of clinico-
Telephone numbers, E-Mail, and Web site located in the green box below.
pathologic correlations to allow participants to practice their diagnostic
skills will close the workshop. This course should enrich the participants’
understanding of: NEUROPATHOLOGY SEMINARS
• Skeletal muscle histomorphology and utilization of various staining
modalities to identify pathologic features of disease. • Location: Armed Forces Institute of Pathology, Washington, DC
• Basic patterns of muscle disease (inflammatory, dystrophic, neuro-
genic, toxic, metabolic/mitochondrial) and derivation of differential • Session 1: GENERAL NEUROPATHOLOGY
diagnoses. Date: January 7 – 18, 2002/24 Credit Hours
• The pathophysiology and pathogenesis of muscle disorders.
• Pathology reports and correlation with clinical diagnosis and manage- • Session 2: DEVELOPMENTAL AND GENETIC DISORDERS
ment of patients with muscle diseases. Date: January 22 – February 1, 2002/22 Credit Hours
For more information, contact course coordinator Mr. Ricky Giles. • Session 3: TUMORS OF THE CENTRAL NERVOUS SYSTEM
Telephone numbers, E-Mail, and Web site located in the green box below. Date: February 4 – 15, 2002/24 Credit Hours
• Session 4: NEURODEGENERATIVE DISEASES
40th Annual Dr. Kenneth M. Earle Memorial Date: February 19 – 22, 2002/12 Credit Hours
NEUROPATHOLOGY REVIEW • Session 5: 40th Annual KENNETH M. EARLE
NEUROPATHOLOGY REVIEW
• February 25–March 1, 2002/Hyatt Regency Bethesda, Bethesda, Md. Date: February 25 – March 1, 2002/31 Credit Hours
• The AFIP designates this educational activity for a maximum of 31
credits. • Session 6: NEUROMUSCULAR DISEASES
Date: March 4 – 15, 2002/22 Credit Hours
This is the 40th iteration, which is dedicated to the memory of Kenneth
M. Earle, MD, former Chairman, Department of Neuropathology. This • Session 7: INFECTIOUS DESEASES OF THE CNS
highly structured 5-day course will provide a comprehensive review of Date: March 18 – 22, 2002/12 Credit Hours
• Session 8: NEURORADIOLOGY
DME Date: March 25 – 29, 2002/37 Credit Hours
The AFIP Seminars in the Neuropathology series is a systematic
Department of Medical Education review of the major topics in diagnostic neuropathology. The seminar
Armed Forces Institute of Pathology series is designed to prepare pathology, neurology, neurosurgery, and
neuroradiology residents for specialty board certification. The partici-
14th Street & Alaska Avenue, NW pants receive a 1- to 1-1⁄2 hour lecture, followed by a microscopic tutorial
Washington, DC 20306-6000 session, during which microscopic slides illustrating the lecture concepts
are presented and discussed. Approximately 1 day a week (depending on
FOR MORE INFORMATION CONTACT: material availability) the students participate in a 2-hour case-based
presentation session, which incorporates interpretation of diagnostic
Telephone: 202.782.2634 radiographic images, intraoperative and gross speciman transparencies,
Toll Free: 1.800.577.3749 (U.S. only) and histopathologic sections. This session is conducted jointly by AFIP
FAX: 202.782.5020 neuroradiology and neuropathology staff. The afternoons are reserved
for individual study, during which time the students are encouraged to
Toll Free FAX: 1/800.441.0094 (U.S. only) take advantage of the wealth of educational materials available at the
International FAX: 1/877.891.3482 AFIP. Participants of each seminar will benefit by gaining:
Email: [email protected] • Enhanced knowledge of the pathology and recent developments in the
URL: http://www.afip.org/edu/ pathophysiology of common and unique disorders of the central and
peripheral nervous systems and skeletal muscle.
• Familiarization with recently recognized pathologic processes related • Mass Disaster Organization, including DMORT & NTSB
to the central and peripheral nervous systems and skeletal muscle. • Bitemark Analysis
• Improved understanding of basic histopathologic, histochemical, • Spouse, Child & Elder Abuse
immunohistochemical, and ultrastructural features of disorders of the • Overview of Forensic Odontology
central and peripheral nervous systems and skeletal muscle. • Criminal Profiling
• Insight into clinical, radiologic, and pathologic correlations, and • Radiographic Aging techniques
prognostic factors of central nervous system lesions. For further information, contact course coordinator SSgt. Stephen
For more information, contact course coordinator Mr. Ricky Giles. Huntington. Telephone numbers, E-Mail, and Web site located in the green
Telephone numbers, E-Mail, and Web site located in the green box on box on page 15.
page 15.
MICROSCOPE WORKSHOP: UPDATE ON RENAL
40th Annual Basic Science Course BIOPSIES IN MEDICAL RENAL DISEASES
OTOLARYNGOLOGY HEAD AND NECK SURGERY
• April 5–7, 2002
• March 5 - 29, 2002 • Holiday Inn Select, Silver Spring, Md.
• Uniformed Services University of the Health Sciences, Bethesda, Md.
This is a 3-day course designed to review the pathology of renal
The otolaryngology course is 4 weeks long and includes intensive diseases. The course should interest pathologists and nephrologists who
reviews in pathology, anatomy, physiology, and clinical sciences related evaluate kidney biopsies in their practice, as well as physicians, residents,
to the head and neck. The course is ideally suited for residents in training and fellows interested in renal pathology, and for preparation in their
and practitioners wishing to review the basic sciences and obtain clinical specialty board examination. The course format includes didactic lectures
knowledge. Participants will be exposed to the material through lectures, covering clinical and pathologic aspects of nephrology and nephropathology
microscopic examinations of personal glass slide collections, and ca- followed by laboratory sessions in the afternoons.
daver dissections. Participants will attend the MG Paul H. Streit Memo- For more information contact course coordinator Mr. Ricky Giles.
rial Seminar that will focus on laryngology. A self-diagnostic slide Telephone numbers, E-Mail, and Web site located in the green box on page
examination in histopathology will be given at the end of the course. It is 15.
recommended each student purchase Wenig, Bruce, Atlas of Head and
Neck Pathology, W.B. Saunders Company, Philadelphia, Pa 19093, or
from a participating book vendor before attending the course. 12th Annual ANATOMIC PATHOLOGY
For more information, contact course coordinator SSgt. Stephen • April 14–20, 2002/Holiday Inn Select, Bethesda, Md.
Huntington. Telephone numbers, E-Mail, and Web site located in the • The AFIP designates this educational activity for a maximum of 70
green box on page 15. credits.
This 1-week intensive review of anatomic pathology focuses on current
38th Annual FORENSIC IDENTIFICATION (DENTISTRY) concepts and diagnostic problems. Representative staff from each of the
AND EMERGING TECHNOLOGIES AFIP departments listed in the program will provide didactic lectures that
are complemented by an extensive syllabus and “hands-on” microscopic
The course is open to civilian & military and includes both study sessions. In addition to 48 hours of lectures, there will be 22 hours
lectures and hands-on lab sessions. of microscope time intermixed with the lectures. A CD-ROM (PC) set
containing selected digitized images of the study set slides will be provided
• March 18–22, 2002 to participants.
• Hyatt Regency, Bethesda, Maryland The course objectives for the course are to:
• The course fills quickly, so you are encouraged to register early. • Prepare pathology residents in their final 2 years of training for their
The course continues to evolve with the primary focus to bring the boards.
forensic scientist up to date with current industry standards. This year we • Train practicing pathologists seeking a short, intense update-and-
have added lectures by experts from Central Identification Lab, Hawaii, review course.
Criminal Justice Information Services Division, Investigative Graphics, • Enable pathologists to maximize their overall anatomic pathology
and Armed Forces Center for Child Protection; a retrospective look at the skills by slide reviews of study sets.
Murrah Federal Building Disaster; and integrated computer mass disaster • Thoroughly brief pathologists on updated and current anatomic
lab. The lab incorporates digital x-ray and gross specimen photographic pathology procedures and methods.
capture and manipulation, and WINID software navigation into the wet For further information, contact course coordinator SSgt. Stephen
specimen lab. In addition, we have added a craniofacial age assessment Huntington. Telephone numbers, E-Mail, and Web site located in the green
lab. box on page 15.
The primary focus of this evolving course is to bring the forensic
scientists up-to-date with current “e” technologies and cutting edge
15th Annual FORENSIC ANTHROPOLOGY
identification modalities, as well as to immerse them in the more tradi- • May 6–10, 2002
tional forensic disciplines. While the primary emphasis is on forensic • Uniformed Services University of the Health Sciences, Bethesda, Md.
odontology, it also embraces and dovetails with other related disciplines Forensic anthropologists apply their skills to body search-and-recov-
that all forensic scientists need to know. Numerous medical specialists, ery techniques, taphonomic analysis, trauma interpretation, bone DNA ,
including odontologists, medical examiners, anthropologists, and crimi- and mass disaster victim identification. This course uses hands-on
nologists, who attended this course in the past report that it significantly laboratory sessions to teach basic techniques of skeletal analysis. Lec-
impacted their practices and that the involvement of such a wide range of tures provide the methodological basis of the osteological techniques and
specialists is an added value. Key topics include: introduce additional applications of the field. Forensic pathologists,
• Digital Imaging (bitemark and medical imaging cases) medicolegal investigators, forensic dentists, attorneys, and others in-
• Computerized Digital Radiography & Superimposition Techniques volved in death investigations will find this course an excellent introduc-
• DNA (overview & cases) tion to the field.
• Software Applications (WINID) For more information, contact course coordinator Mr. Ricky Giles.
• Forensic Pathology (Medical Examiner & Aerospace) Telephone numbers, E-Mail, and Web site located in the green box on
• Anthropology page 15.
ABSTRACTS OF RECENT PUBLICATIONS BY AFIP STAFF Duet) were implanted at a 1:1 stent-to-artery
ratio in the coronary arteries of swine with a
conventional noncompliant balloon (n = 10) or
Influenza RNA not detected suggests that most contemporary clinicians, a novel noncompliant balloon with short ta-
epidemiologists, and pathologists rejected the pered shoulders to prevent edge dissection (n =
in archival brain tissues from 9). Quantitative coronary angiography and his-
theory that the 1918 influenza virus was di-
acute encephalitis lethargica rectly responsible for EL. Disappearance of the tology were used to evaluate balloon and artery
cases or in postencephalitic acute form of EL during the 1920s has pre- interactions and the chronic vascular responses
cluded direct study of this entity. However, to the stents. Nineteen stents were implanted in
Parkinson cases the coronary arteries of seven swines at an
modern molecular biology techniques have
Sherman McCall, MD, James M. made it possible to examine archival tissue inflation pressure of 14 atm using a standard
samples from victims of the 1918 pandernic in noncompliant (n = 10) or a unique short transi-
Henry,MD, Ann H. Reid, MA, and tional edge protection (n = 9) balloon. Histo-
Jeffery K. Taubenberger, MD, PhD order to detect and study the genetic structure
of the killer virus. Similarly, tissue samples logic analysis at 28 days demonstrated
Abstract. Encephalitis lethargica (EL) was a from EL victims can now be examined for balloon-associated barotrauma in 13 of 20 (65%)
mysterious epidemic, temporally associated evidence of infection by the 1918 influenza of adjacent nonstented arterial segments with
with the 1918 Spanish influenza pandemic. virus. the conventional balloon and only 3 of 18
Numerous symptoms characterized this dis- (17%) of the adjacent nonstented arterial seg-
J Neuropathol Exp Neurol. 2001;60:663-670.
ease, including headache, diplopia, fever, fatal ments with the short transition edge protection
coma, delirium, oculogyric crisis, lethargy, cata- balloon (P = 0.022). In-stent neointimal area
tonia, and psychiatric symptoms. Many pa- Coronary calcification: and % stenosis correlated with the severity of
tients who initially recovered subsequently de- insights from sudden peristent arterial injury (r = 0.43, P = 0.01).
veloped profound, chronic parkinsonism. The In-stent vessel injury scores were similar for
etiologic association of influenza with EL is
coronary death victims stents with peristent injury (1.0 ± 0.3) versus
controversial. Five acute EL autopsies and more stents without peristent injury (1.0 ± 0.03, P =
A. P. Burke, A. Taylor, A. Farb, G. T.
than 70 postencephalitic parkinsonian autop- 0.73). In-stent neointimal area and % stenosis
Malcom, and R. Virmani were greater for stents with peristent injury
sies were available in the Armed Forces Insti-
tute of Pathology (AFIP) tissue repository. Two Summary. We studied 108 cases of sudden (2.36 ± 0.74 mm2 , 32% ± 9%) as compared to
of these 5 acute EL cases had histopathologic coronary death at autopsy. Any calcification stents without peristent injury (1.39 ± 0.70
changes consistent with that diagnosis. The was present in 55% of men and women under mm2, 20% ± 10%, P = 0.01). Arterial wall
remaining 3 cases were classified as possible 40 years; all hearts showed some calcification injury adjacent to a stent after high-pressure
acute EL cases as the autopsy material was by age 50 in men, and by age 60 in women. The deployment contributes to late in-stent
insufficient for detailed histopathologic ex- only risk factor independently associated with neointimal hyperplasia in this model. These
amination. RNA lysates were prepared from 29 increased calcification was diabetes mellitus, experimental data suggest that further study is
CNS autopsy tissue blocks from the 5 acute in women only. The degree of calcification was warranted to refine stent implantation tech-
cases and 9 lysates from blocks containing greatest for acute and healed plaque ruptures, niques and that modifications of balloon shape
substantia nigra from 2 postencephalitic cases. and the least for plaque erosion. Calcification or material may be useful to optimize stent
RNA recovery was assessed by amplification in coronary atherosclerosis appears to be de- deployment and reduce arterial trauma.
of beta-2-microglobulin mRNA and 65% of the layed in women, is greatest in women diabet- Cathet Cardiovasc Intervent. 2000;51:112-119.
tissue blocks contained amplifiable RNA. Re- ics, and is associated with one type of plaque
verse transcription-polymerase chain reaction instability, namely plaque rupture.
(RT-PCR) for influenza matrix and nucleopro- Z Kardiol. 2000;89(suppl 2):II49--II53. Influenza A virus
tein genes was negative in all cases. Thus, it is neuraminidase: regions of
unlikely that the 1918 influenza virus was neu-
rotropic and directly responsible for the out- Experimental evaluation of a the protein potentially
break of EL. short transitional edge involved in virus-host
J Neuropathol Exp Neurol. 2001;60:696-704.
protection balloon for interactions
Experimenting on the past: intracoronary stent Thomas G. Fanning, Ann H. Reid, and
the enigma of von deployment Jeffery K. Taubenberger
Economo’s encephalitis Andrew J. Carter, David P. Lee, MD, Phylogenetically informative amino acid posi-
tions (PIPs) were identified in influenza A
lethargica Takeshi Suzuki, MD, Lynn Bailey,
neuraminidases of subtypes N1 and N2.
Alexandra Lansky, MD, Russ Jones, Neuraminidase evolves in a lineage-specific
Ann H. Reid, MA, Sherman McCall, and Renu Virmani, MD
MD, James M. Henry, MD, and Jeffery way as the virus adapts to a new host or changes
The purpose of this study was to determine if to evade the host’s immune system. Thus, many
K. Taubenberger, MD, PhD PIPs undoubtedly identify positions involved
balloon injury to the adjacent arterial wall dur-
Abstract. Encephalitis lethargica (EL) was a ing intracoronary stent deployment influences in virus-host interactions. Phylogenetically
complex and mysterious disease that appeared late in-stent neointimal formation. Stent design important regions (PIRs) are defined as several
around the same time as the great influenza and deployment techniques are considered im- PIPs near one another. There are 15 PIRs on N1
pandemic of 1918. The contemporaneous rela- portant factors in determining acute and and 12 on N2, seven of which are shared be-
tionship of the 2 diseases led to speculation that long-term success with intracoronary stenting. tween the two subtypes. Many PIRs are coinci-
they were causally related. Contemporary and Experimental and clinical studies support that dent with antigenic or glycosylation sites. Other
subsequent observers conjectured that the in- the extent of neointimal formation and the PIRs may represent additional antigenic sites
fluenza virus, directly responsible for the deaths probability for restenosis are influenced by the or may be involved in other aspects of virus-host
of more than 20 million people, might also have magnitude of arterial trauma induced with biology.
been the cause of EL. A review of the extensive stenting. Nineteen 18-mm-long balloon- Virology. 2000;276:417-423.
literature by observers of the EL epidemic expandable stainless steel stents (MULTI-LINK
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Recent Publications by AFIP Staff

1. Burke AP, Taylor A, Farb A, Malcom GT, Virmani R. Coronary calcification: 9. Miettinen M, Fernandez M, Franssila K, Gatalica Z, Lasota J, Sarlomo-Rikala
insights from sudden coronary death victims. Z Kardiol. 2000;89(suppl M. Microphthalmia transcription factor in the immunohistochemical
2):II49-II53. diagnosis of metastatic melanoma: comparison with four other melanoma
2. Carter AJ, Lee DP, Suzuki T, Bailey L, Lansky A, Jones R, Virmani R. markers. Am J Surg Pathol. 2001;25:205-211.
Experimental evaluation of a short transitional edge protection balloon for 10. Narula J,Kolodgie FD,Virmani R. Apoptosis and cardiomyopathy. Curr Opin
intracoronary stent deployment. Cathet Cardiovasc Intervent. Cardiol. 2000;15:183-188.
2000;51:112-119. 11. Reid AH, McCall S, Henry JM, Taubenberger JK. Experimenting on the past:
3. Fanning TG, Reid AH, Taubenberger JK. Influenza A virus neuraminidase: the enigma of von Economo’s encephalitis lethargica. J Neuropathol Exp
regions of the protein potentially involved in virus-host interactions. Neurol. 2001;60:663-670.
Virology. 2000;276:417-423. 12. Reid AH, Taubenberger JK, Fanning TG. The 1918 Spanish influenza:
4. Farb A, Tang AL, Shroff S, Sweet W, Virmani R. Neointimal responses 3 integrating history and biology. Microbes Infect. 2001;3:81-87.
months after 32p ß-emitting stent placement. Int J Radiat Oncol Biol Phys. 13. Schneider DB, Vassalli G, Wen S, Driscoll RM, Sassani AB, DeYoung MB,
2000;48:889-898. Linnemann R, Virmani R, Dichek DA. Expression of Fas ligand in arteries of
5. Johnson LL, Schofield LM, Verdesca SA, Sharaf BL, Jones RM, Virmani R, hypercholesterolemic rabbits accelerates atherosclerotic lesion formation.
Khaw BA. In vivo uptake of radiolabeled antibody to proliferating smooth Arterioscler Thromb Vasc Biol. 2000;20:298-308.
muscle cells in a swine model of coronary stent restenosis. J Nucl Med. 14. Scott DS, Arora UK, Farb A, Virmani R, Weissman NJ. Pathologic validation
2000;41:1535-1540. of a new method to quantify coronary calcific deposits in vivo using
6. Kim WH, Hong MK, Virmani R, Kornowski R, Jones R, Leon MB. intravascular ultrasound. Am J Cardiol. 2000;85:37-40.
Histopathologic analysis of in-stent neointimal regression in a porcine 15. Taylor AJ, Gorman PD, Hudak C, Tashko G, Sweet W, Farb A, Virmani R.
coronary model. Coron Artery Dis. 2000;11:273-277. The 90-day coronary vascular response to 9°Y-ß particle-emitting stents in
7. McCall S, Henry JM, Reid AH, Taubenberger JK. Influenza RNA not the canine model. Int J Radiat Oncol Biol Phys. 2000;46:1019-1024.
detected in archival brain tissues from acute encephalitis lethargica cases or 16. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from
in postencephalitic Parkinson cases. J Neuropathol Exp Neurol. 2001; sudden coronary death: a comprehensive morphological classification
60:696-704. scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol.
8. McCall SA, Lichy JH, Bijwaard KE, Aguilera NS, Chu W-S, Taubenberger 2000;20:1262-1275.
JK. Epstein-Barr virus detection in ductal carcinoma of the breast. J Natl
Cancer Int. 2001;93:148-150.

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LETTER Visit our Web site at

Armed Forces Institute of Pathology Vol. 159, No. 5

Operation Noble Eagle:

Atlas of Tumor Pathology, Third Series, Fascicle 31

Operation Noble Eagle:

overall identification process. Since many

Operation Noble Eagle:

Operation Noble Eagle:

Operation Noble Eagle:

Operation Noble Eagle:

ast spring, members of the 436th Dover Air Force Base

ogists to identify the presence of teeth, an excellent source of

Noble Eagle from page 1 Operation Noble Eagle:

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Operation Noble Eagle:

Museum from page 3

Department of Advanced Medical Education

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