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May 28, 2008,
10:19 am
Violence and Healthcare: The Tip of the Iceberg
In 2005 there were over 308,000 hospitalizations in the U.S. related to violence, totaling $2.3 billion. The causes of these hospitalizations were: self-inflicted violence, assaults and physical and/or emotional abuse. Boys and men accounted for 82.4% of the hospital stays for assaults; girls and women accounted for 63.9% of the stays related to physical and/or emotional abuse and 58.5% of the stays related to self-inflicted violence.
Injuries to the skull, brain and face from assault were 38.6% of the hospital admissions. Injuries to the skull, brain and face from physical abuse were 7.5%. The vast majority of the admissions were through emergency rooms with 2% of the total admissions dying while in the hospital.Violence is a major cause of preventable hospital admissions and a source of a significant portion of our health care expense dollars. It is also a source of brain injuries and psychiatric illnesses which will have lifelong implications for the victims.What we see of the violence related hospital admissions is comparable to what we see with an iceberg. About 10% is visible and 90% lies below the water. What we don't immediately see in the already large statistics are the long term costs to society, both visible and invisible, for the victims throughout their lives.
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9:35 am
TBI and the Prison Population
Death Row is home to an alarming number of individuals with histories of neurological injuries. Dorothy Lewis, M.D., in her classic study revealed that 95% of the Death Row inmates she studied had signs and symptoms of neurological injuries or disease, including histories of multiple brain injuries.While 8.5% of non-incarcerated individuals have a history of TBI, the studies of individuals in the prison populations with TBI range from 25-87%. In a recent study in Minnesota of male inmates 82.8% reported having one or more head injury in their lifetime. Assaults, automobile accidents and sports injuries were the major causes of TBI in this group.In a study of women in federal prisons, a high percentage report histories of multiple concussions, including concussive injuries sustained in prison assaults. A study of the prison population in Wyoming reveals similar high numbers of brain injuries in both the male and female prison populations.
Is Traumatic Brain Injury a factor in the cause of incarceration? We do know that TBI is a factor in domestic violence. In the mid-1970’s when I was operating a forensic clinic, we saw a significant number of individuals involved in the court process and in prison with signs and symptoms of neurological injuries and disease. Many of these individuals suffered childhood accidents, came from abusive homes or grew up having many fights. They almost universally had problems with irritability, substance abuse and temper control. Screening individuals for brain injury needs to become part of the criminal justice system in terms of pre-trial and pre-sentence evaluations and as part of the prison health assessment. We also need to develop resources for individuals with a history of brain injury who are leaving prison and returning to the community. Without adequate screening and support, these individuals are likely to re-offend and return to the criminal justice system.
Doctor Lewis’ study alerted us to the high incidence of brain injury in the prison population. More recent studies in several states as well as national studies continue to indicate that the problem is great. Incarceration is not rehabilitation and treatment and certainly rehabilitation for brain injury. Many of the individuals with brain injury who are in prison also have problems with substance abuse and co-existing psychiatric disorders.These problems will enhance their risk for continuing problems while in prison and upon their release. It is important that we establish screening to determine who has a brain injury and, of equal importance, to devote resources to these individuals to prevent the problems that will return them to the criminal justice system. The issue of violence and TBI is well covered in Brain Injury Professional, V.5, Issue 1and is worth reading.
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May 15, 2008,
5:21 pm
Veterans and Mild Brain Injury: The Debate Continues
In the Correspondence section of the New England Journal of Medicine, Volume 358:2177-2179, May 15, 2008, Number 20, the issue of diagnosing Mild Brain Injury in U.S. soldiers continues. Dr. Hoge and his colleagues defend their position from their January 31st article in the NEJM. Yet, we as brain injury professionals have recognized for years that Mild TBI is difficult to diagnosis and often co-exists with other psychiatric symptoms which serve to complicate it’s diagnosis. Doctors Xydakis and Robbins, in response to Dr.Hoge, wisely point to the diagnosis of Mild TBI as one which can only be made over time.They clearly understand the deficits may not be identified without the person and their physicians being able to notice functional changes. Dr. Stonesifer, in his response to Dr. Hoge, raised the issue of pituitary dysfunction in a large number of brain injury cases as causing neuropsychological and neurobehavioral deficits.
The issue of Mild Brain Injury in the population of returning veterans who were exposed to IED explosions should not be a matter of deciding that PTSD is a more likely diagnosis or one that exists to the exclusion of TBI. Untreated Mild Traumatic Brain Injury will have a very serious effect on the individual and will produce a significant psychological response.
There are great advances being made in screening for Diffuse Axonal Injury which need to be applied to our returning soldiers. We cannot allow a debate to continue over Mild Brain Injury vs. PTSD while veterans either accidentally or intentionally die from overdoses while attending marginal outpatient services as have 15 soldiers at the Brooke Army Hospital over recent months. Our troops need to be afforded the best diagnostic and restorative services available. The hospital at Balad is amazingly capable of saving lives. We could, at least, extend that capability to identifying and appropriately treating Traumatic Brain Injury at all levels.
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3:38 pm
Young People with TBI in Nursing Homes
The magic of 18 is more than a coming of age event for a young person with a brain injury living in a residential care facility. That birthday may signal placement in a skilled nursing facility filled with older adults, isolating them from peers, school, family and the community. Young people with severe disabilities resulting from traumatic brain injury may require a level of care which can only be funded in a nursing home facility based on the current restrictions in funding. At this point there are few other options available for a growing number of young people who face a lifetime of disability and require significant physical care.
The odds favor survival for young people involved in serious accidents and medical advancements are allowing more individuals to survive. Unfortunately, the options for placement other than home are limited to facilities where there may be few other young adults and little in the way of programs and services which can sustain progress. A far cry from the school programs and pediatric facilities designed to serve young people with disabilities.
There is a need for specialized facilities and programs which can serve young people with severe disabilities from brain injury. These places don’t have to be nursing homes and, in fact, other care environments may enhance independence and community participation and add to a quality of life. In order to create alternatives we need to revise the restrictions placed by Medicare and Medicaid. Some states have implemented brain injury waiver programs to support home, community and specialized services and have fostered the development of effective alternatives. A story in the New York Times of May 15, 2008 addresses the needs of people with severe disabilities who are turning 18 and frames out the issues.
Click here to read the NY Times story
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May 13, 2008,
9:03 am
New Measures for Brain Injury
Medpage today’s John Gever reports that a new MRI innovation called diffusion tensor tractography will allow for improved measurements of multifocal nerve damage within the brain. Researchers share that this technology may help track the progress and help predict outcomes after severe traumatic brain injury. Gever (2008) reports:
In an interview, Dr. Diaz-Arrastia said the goal is to find a good measure for diffuse axonal injury, an “overlooked and understudied” phenomenon that increasingly appears to be an important factor in head-injured patients.
He said it used to be considered a rare form of injury, but mainly because it was hard to see with technologies such as CT imaging.
Recent studies suggest it plays a role in at least half of fatal head injuries,” he added. Diffuse axonal injury may also explain puzzling cases in which people with apparently mild head injuries suffer lingering disability.
Diffusion tensor tractography measures water movement within tissues on the basis of MRI data. When nerve cell axons are damaged, as they frequently are in severe head trauma, they swell, absorbing water from surrounding tissues. That reduces movement of extracellular water.
On the other hand, when axons later die, they release water, thereby increasing extracellular water flows.
Click here to read the full article in MedPage Today
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May 7, 2008,
2:13 pm
Ingredients for the Perfect Storm
On a daily basis, through the newspapers and television, we hear and read stories about the problems faced by veterans returning from Iraq and Afghanistan with physical and psychological problems. At the APA conference this week the problem of 300,000 military members with PTSD was presented. Last week the number of drug overdoses, intentional and accidental, in wounded military personnel undergoing outpatient rehabilitation and other treatment was revealed. These soldiers are housed in transitional quarters on military bases, away from family, receiving limited services and case management. Many of these soldiers are disabled from traumatic brain injury and have other physical and psychological problems. Another story focused on the high number of suicides in military exceeding the number of war related deaths. The picture being painted for us is bleak and dangerous. Our soldiers need immediate help. The hidden psychological injuries must be identified and treated. The overt injuries and related disabilities cannot continue to be shuttled off into waiting lines and minimal treatment while task forces and committees are convened.
Disabilities from any cause affect every aspect of a person's life and treatment cannot be deferred. We need to move rapidly to bring the resources that are available in the civilian world to the members of our military who need help.
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May 2, 2008,
11:50 am
Treatment Concerns for Returning Soldiers Continue
Returning soldiers with brain injuries and other disabilities, Post Traumatic Stress Disorder (PTSD) and mental health problems are at risk while they are in treatment at Walter Reed Army Medical Center and other military hospitals. At the Army hospitals serving our injured military personnel there have been 15 deaths of soldiers due to drug overdoses in recent months. The Army, through it's Surgeon General, Lt. General Eric Schoonmaker, is looking into the deaths as is a Congressional panel. It appears that many of the soldiers who have overdosed have been prescribed multiple medications with often limited communication between physicians and a lack of case management and coordination of care. In some cases, the soldiers had consumed alcohol which may have exacerbated the effects of the prescribed medications. There is also the unanswered issue of suicide which is known to be prevalent as a risk for traumatic brain injury and PTSD. The soldiers housed in Warrior Transition Units are a group at risk due to the low supervision and oversight of their care.
The problem underscores the need for integrated care and comprehensive case management. The Army must consider what services are needed by people with brain injuries, physical disabilities and mental health problems which affect their cognitive abilities and capacities to live independently. Currently the Army has banned alcohol in these Warrior Transition Units, but still has not provided the level of supervision that many of these individuals need to maintain safety and well being. Investigations and inquiries are important, but we do know the solution to the problem. Simply banning alcohol in a residence will not prevent soldiers from drinking there or in the community. The returning soldiers need program services and case management which are designed to meet their needs. We have those programs in the civilian world. Why wait for more overdoses and deaths?
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May 1, 2008,
3:13 pm
VA Still Experiencing Problems Meeting the Needs of Veterans with Brain Injury
A recent story by Hope Yen, states that veteran’s needs post-TBI are still not being met. After a study of 52 VA TBI patients during a seven month post injury period in 2004, and the 2006 IG review which found problems 16 months post injury, the VA had promised to address the shortcomings.
The article shares “10 of the 41 veterans who agreed to be interviewed said they weren’t getting needed help for health care, vocational rehabilitation, family support or housing. At least four patients specifically cited trouble in getting primary or specialty eye care, while others reported gaps with family counseling for problems such as depression and anger”.
Yen reports:
“This is very troubling,” said Michael O’Rourke, assistant director for veterans health policy at Veterans of Foreign Wars. “The fact of the matter is from the very beginning VA and Defense went in with too little, too short (on resources), because they weren’t expecting this to be a prolonged conflict of war.
“I’ve seen a lot of effort to correct problems that exist. But constant vigilance is required,” he said. “Veterans deserve to be treated for problems they may or may not know of.”
The report included a VA response in which the department acknowledged problems with case management but stated that with recent improvements it now had “systems in place to ensure that all veterans with TBI are being followed as their clinical needs require.”
According to the article in an attempt to improve care the VA is proposing to call “570,000 recent combat veterans to make sure they know what services are available to them”.
Click here to read the full article
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6:49 am
Deep Brain Stimulation Treats Depression
John Gever reports in Medpage today that a recent study shows that deep brain stimulation may work to alleviate severe depression. In this study the 17 patients received a Medtronic Soletra implantable pulse generator, 1 of which did not complete the study. According to Ali R. Rezai, M.D. of the Cleveland Clinic, “eight of the 16 patients showed at least 50% improvement in depression scores… and had significant improvement in quality of life, returning back to work, getting engaged, dating”. Gever reports:
Two patients had a return of depressive symptoms and suicidal ideation when their pulse generators were accidentally turned off. Restarting them again led to symptom improvement, Dr. Rezai said.
The pulse generators can stop working when exposed to strong magnetic fields, such as in metal detectors, or when the batteries run out, he explained.
He said the next step would be a randomized, controlled trial.
He said Medtronic is currently sponsoring a double-blind, cross-over trial. All patients will have the devices implanted, but half the patients will not have the units switched on immediately so that they can serve as controls.
Click here to read the full article in MedPage Today
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