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Development of a quality, high throughput DNA analysis procedure for skeletal samples to assist with the identification of victims from the World Trade Center attacks.
The attacks on the World Trade Center (WTC) Towers on September 11, 2001, represented the single largest terrorist-related mass fatality incident in the history of the United States. More than 2,700 individuals of varied racial and ethnic background lost their lives that day. Through the efforts of thousands of citizens, including recovery workers, medical examiners, and forensic scientists, the identification of approximately 1,500 victims had been accomplished through June 2003 (the majority of these identifications were made within the first 8-12 months). The principal role of The Bode Technology Group (Bode) in this process was to develop a quality, high throughput DNA extraction and short tandem repeat (STR) analysis procedure for skeletal elements, and to provide STR profiles to the Office of the Chief Medical Examiner (OCME) in New York City to be used for identification of the victims. A high throughput process was developed to include electronic accessioning of samples, so that the numbering system of the OCME was maintained; rapid preparation and sampling of skeletal fragments to allow for the processing of more than 250 fragments per day; use of a 96-well format for sample extraction, DNA quantification, and STR analysis; and use of the Applied Biosystems 3100 and 3700 instrumentation to develop STR profiles. Given the highly degraded nature of the skeletal remains received by Bode, an advanced DNA extraction procedure was developed to increase the quantity of DNA recovery and reduce the co-purification of polymerase chain reaction (PCR) amplification inhibitors. In addition, two new STR multiplexes were developed specifically for this project, which reduced the amplicon size of the STR loci, and therefore, enhanced the ability to obtain results from the most challenged of samples. In all, the procedures developed allowed for the analysis of more than 1,000 skeletal samples each week. Approximately 13,000 skeletal fragments were analyzed at least once, for a total of more than 18,000 analyses, and greater than 8,000 of the skeletal samples produced STR results (65%). The percentage of successful results was low in relation to previous mass fatality incidents involving airline disasters. However, when this same process was applied to the analysis of skeletal remains from the American Airlines Flight 587 disaster that occurred on November 12, 2001, the success rate was in line with expected results (ie, greater than 92% of the skeletal remains produced results). This illustrated the quality aspects of the procedure and the degree of degradation that had occurred for the remains of the WTC victims. For future mass fatality incidents, the quality, high throughput procedures developed by Bode will allow for more rapid DNA analysis of victim remains, more rapid identification of victims, and thus more rapid return of remains to family members.
Facts about the disaster at Eschede.
On June 3, 1998, at 10:59 a.m., a high-speed train (Intercity Express, ICE) traveling at 200 kilometers per hour collided with a bridge at Eschede, Germany, causing it to collapse. The force of the collision, combined with the speed of the train's rear engine, propelled the rear wagons into the structure. The accident caused 101 deaths and 103 injuries. Four minutes after the accident, the alarm was reported; sixteen minutes after the accident, the first doctor on emergency call was on the scene, arriving from Celle, approximately twenty kilometers away. In the first four hours after the crash, different rescue organizations brought a total of 1,844 people to the accident site, including 461 ambulance personnel and paramedics. Thirty-nine aircraft, including helicopters and army aircraft, were available at the scene. Ninety-five passengers passed away on site. Many of the surviving passengers had multiple injuries and were stuck in the train; although they had to be rescued from the severely damaged wagons, all patients, with one exception, were on the way to hospitals by 12:55 p.m. The casualties were distributed among twenty-two hospitals; two victims later had to be transferred to other hospitals for medical reasons. This paper details the factors that were responsible for the success of the rescue operations at Eschede.
Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster.
Both the naturally occurring and deliberate release of a biological agent in a population can bring catastrophic consequences. Although these bioevents have similarities with other disasters, there also are major differences, especially in the approach to triage management of surge capacity resources. Conventional mass-casualty events use uniform methods for triage on the basis of severity of presentation and do not consider exposure, duration, or infectiousness, thereby impeding control of transmission and delaying recognition of victims requiring immediate care. Bioevent triage management must be population based, with the goal of preventing secondary transmission, beginning at the point of contact, to control the epidemic outbreak. Whatever triage system is used, it must first recognize the requirements of those Susceptible but not exposed, those Exposed but not yet infectious, those Infectious, those Removed by death or recovery, and those protected by Vaccination or prophylactic medication (SEIRV methodology). Everyone in the population falls into one of these five categories. This article addresses a population approach to SEIRV-based triage in which decision making falls under a two-phase system with specific measures of effectiveness to increase likelihood of medical success, epidemic control, and conservation of scarce resources.
[Organizational provision for the sanitary and epidemiological safety of the population in the regions of the Stavropol Territory affected by the flood].
Materials on the organizational provision and financing of measures taken with a view to ensure the sanitary and epidemiological safety in the Stavropol Territory in connection with the high flood of 2002 are presented. Due to the joint efforts of sanitary, antiepidemic and medico-prophylactic services of the Territory, administrative organs and institutions, as well as other relevant departments, not only high quality restoration works were carried out and completed in a short time, medical assistance was given to the victims and the appearance of mass infectious diseases prevented, but also the growth social tensions in the affected areas was averted.
[Diagnosis and management of anxiety in victims of psychological trauma].
Management of psychic injury has been developing in France recently. Community catastrophies like wars or natural events, individual's stress are more and more related. Physicians are qualified for the treatment of their psychic consequences. Family doctors know people and local geographic situations and are often the first medical managers on the scene of the disaster.
Meeting blood requirements following terrorist attacks: the Israeli experience.
PURPOSE OF REVIEW: Blood services worldwide must be prepared to meet surges in demand for blood components needed by casualties of domestic disasters and acts of terrorism. Israel's National Blood Services, operated by Magen David Adom, has extensive experience in managing blood collections and supply in emergencies. This review summarizes the structure and function of Magen David Adom's national blood program, and relates its experience to other practices that have been reported in the medical literature. RECENT FINDINGS: Between 2000 and 2005, 7497 victims (85% civilians) were involved in 1645 terrorist attacks in Israel. On-site triage resulted in 967 (13%) deaths at the scene, 615 (8%) with severe injuries, 897 (12%) with moderate injuries and 5018 (67%) with mild injuries. Requests for blood averaged 1.3 blood units and 0.9 components per casualty, or 6.7 units and 4.5 components per severe and moderately injured patient. Public appeals for blood donations were managed centrally to match supply with demand and prevent wastage. SUMMARY: This experience illustrates the advantages of a comprehensive program for managing blood operations in emergency situations. A coordinated national program can stabilize in-hospital inventories during routine activities, ensure instant access to precisely defined inventories, facilitate sufficient supply in times of disasters, and minimize outdating and wastage.
Malignant memories. Reluctance to utilize mental health services after a disaster.
This report describes the reluctance of individuals exposed to a man-made disaster to utilize formal mental health services. Measures were obtained in an initial screening 6 months after a shooting for 24 exposed school personnel. Data from the initial screening were compared for those who did not participate in a follow-up screening 12 months later (N = 11) and those who did (N = 13). Follow-up nonparticipants reported: more posttraumatic stress disorder symptoms, especially avoidance; recall of life threat during the event; feeling depressed; and an increase in positivity toward victims but not about their work or mental health professionals. The authors conclude that some individuals may avoid formal mental health services because they serve as cues for malignant memory retrieval and discuss implications for service delivery.
Community medical response to the Fairchild mass casualty event.
BACKGROUND: On June 20, 1994, a discharged serviceman with a psychiatric history opened fire with a MAC-90 assault rifle at Fairchild Air Force Base in Spokane, Washington. The attack killed 5 people and wounded 22. This report reviews the communication, triage, transport, injuries, and the community medical response to this mass casualty. METHODS: Data for the review were obtained from city-wide debriefing sessions, medical records, and evaluation forms from prehospital agencies. RESULTS: A total of 19 patients were triaged to four community hospitals, while 3 victims with comparatively minor injuries stayed at the Base hospital. All fatalities except a child in utero died at the scene. All victims surviving to hospital were discharged recovered from their injuries. Two patients were undertriaged, 1 of whom sustained a pelvic and buttock wound. CONCLUSIONS: Rapid triage was possible due to: (1) initial treatment by military medical personnel; (2) an established and practiced disaster plan; (3) the use of disaster packs and triage tags; (4) the immediate initiation of triage and transport; and (5) coordinated ground and air transport.
Radiology in forensic expert team operations.
Radiological methods are widely used in forensic pathology. Their most common applications are in complementing human identification, particularly in investigations of mass disasters and decomposed bodies, and in searching for foreign material inside corpses. A team of Finnish forensic experts investigated human skeletal remains in Bosnia and Herzegovina (1996) and in Kosovo, the Federal Republic of Yugoslavia (1998). It also investigated more recently deceased victims in Kosovo (1999). In these investigations, the benefit of X-ray was in the detection of foreign material inside victims and their remains. For identification purposes, X-rays were mainly used to provide the best evidence possible of any pathological changes, physical characteristics, and injuries present.
Comparative study of efficiency of dental methods for identification of burn victims in two bus accidents in Spain.
This article deals with the usefulness and limitations of dental identification methods of human burn victims of two buses accidents in Spain. The first accident happened in Bailen in 1996 and involved 28 badly burned Spanish victims. In the second, in Illescas in 1997, 8 Japanese and 2 Spanish victims lost their lives. In both accidents, postmortem forensic procedures for identification were used, including external and internal examination, routine photographs, and dental examination. Dental identification was established in 57% of the cases in the Bailen accident and 80% in the Illescas accident. The success rate of dental identification varies considerably depending on the nature of the accident, the nationality and country of residence of the victims, the incidence of dental treatment, the availability of adequate dental records, and the degree of dental injuries. A discussion of procedures and methods for identification recommended when dealing with burn victims is included.
The long-term psychological impact of Bloody Sunday on families of the victims as measured by The Revised Impact of Event Scale.
OBJECTIVES: In 1972, 13 civil rights marchers were killed in Londonderry, Northern Ireland, on what is known as Bloody Sunday. This study aimed to assess the psychological impact of this event on the families of victims as measured by the Revised Impact of Event Scale. DESIGN: Cross-sectional self-report based study. METHODS: The Impact of Event Scale-Revised was administered to 72 members of the families (immediate family, children of immediate family, cousins, and second cousins) of those killed on Bloody Sunday. RESULTS: High levels of intrusion, avoidance, and hyperarousal were found. In addition, significant group differences were found. Those family members closest to the victims reported the highest levels of psychological distress. CONCLUSION: The findings were discussed within the transgenerational trauma context.
[Therapeutic aid to the victims of the earthquake in Armenia (December, 1988)].
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Who is at risk of death in an earthquake?
Although, theoretically, the impacts of a disaster are not randomly distributed across health and socioeconomic classes, empirical evidence of this claim is scarce. In a population-based cohort study, the authors identified risk factors for mortality from the September 21, 1999, Taiwan earthquake, which occurred in the middle of the night. Among 297,047 earthquake victims in central Taiwan who experienced partial or complete dwelling damage, 295,437 (noncases) survived the earthquake and 1,610 (cases) died between September 21 and October 31, 1999. Odds ratios were adjusted for both micro-level individual variables and macro-level neighborhood variables. People with mental disorders (odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.1, 3.5), people with moderate physical disabilities (OR = 1.7, 95% CI: 1.2, 2.3), and people who had been hospitalized just prior to the earthquake (OR = 1.4, 95% CI: 1.2, 1.7) were the most vulnerable. The degree of vulnerability increased with decreasing monthly wage (measured in New Taiwanese dollars (NT$)) (NT$20,000 approximately NT$39,999: OR = 1.5, 95% CI: 1.1, 2.1; <NT$20,000: OR = 2.2, 95% CI: 1.6, 3.0). The significant associations of both prequake health status and socioeconomic status with earthquake death suggest that earthquake death did not occur randomly. These results might help to guide allocation of public resources for reducing casualties.
Epidemiology. DNA identifications after the 9/11 World Trade Center attack.
The attack on the World Trade Center on 9/11/2001 challenged current approaches to forensic DNA typing methods. The large number of victims and the extreme thermal and physical conditions of the site necessitated special approaches to the DNA-based identification. Because of these and many additional challenges, new procedures were created or modified from routine forensic protocols. This effort facilitated the identification of 1594 of the 2749 victims. In this Policy Forum, the authors, who were were members of the World Trade Center Kinship and Data Analysis Panel, review the lessons of the attack response from the perspective of DNA forensic identification and suggest policies and procedures for future mass disasters or large-scale terrorist attacks.
Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake.
OBJECTIVES: This study aimed to provide an overview of morbidity and mortality among patients admitted to the Hospital of the Medicine Faculty of Uludag University, Bursa, Turkey, after the 1999 Marmara earthquake. METHODS: Retrospective analysis of the medical records of 645 earthquake victims. Patients' demographic data, diagnosis, dispositions, and prognosis were reviewed. RESULTS: A total of 330 patients with earthquake related injuries and illness admitted to our hospital were included and divided into three main groups: crush syndrome (n = 110), vital organ injuries (n = 57), and non-traumatic but earthquake related illness (n = 55). Seventy seven per cent of patients were hospitalised during the first three days after the earthquake. The rate of mortality associated with the crush syndrome, vital organ injury, and non-traumatic medical problems was 21% (23/110), 17.5% (10/57), and 9% (5/55), respectively. The overall mortality rate was 8% (50/645). CONCLUSIONS: In the first 24-48 hours after a major earthquake, hospital emergency departments are flooded with large numbers of patients. Among this patient load, those patients with crush syndrome or vital organ injuries are particularly at risk. Proper triage and prompt treatment of these seriously injured earthquake victims may decrease morbidity and mortality. It is hoped that this review of the challenges met after the Marmara earthquake and the lessons learned will be of use to emergency department physicians as well as hospital emergency planners in preparing for future natural disasters.
[The experience of the All-Union Center for Surgery of the Academy of Medical Science of the USSR and its Yerevan branch in treating the victims of the earthquake in Armenia].
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Extinction from a paleontological perspective.
Extinction of widespread species is common in evolutionary time (millions of years) but rare in ecological time (hundreds or thousands of years). In the fossil record, there appears to be a smooth continuum between background and mass extinction; and the clustering of extinctions at mass extinctions cannot be explained by the chance coincidence of independent events. Although some extinction is selective, much is apparently random in that survivors have no recognizable superiority over victims. Extinction certainly plays an important role in evolution, but whether it is constructive or destructive has not yet been determined.