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Jack Sisson's TBI Blog

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GovernmentExecutive.com published an interesting article last week that raised some serious questions about how the military decides which assessment tool they're going to use in combat situations. Sounds to me like something funny was going on with their latest study (results have never been published); maybe they didn't like the results? Here's an excerpt:
Senior Defense Department officials have stressed repeatedly in public they are doing everything they can to provide the best care possible to U.S. troops injured in Iraq and Afghanistan. But that might not be the case for the tens of thousands of troops who have experienced some form of brain injury.

Four years ago, a group of Air Force doctors treating wounded soldiers at field hospitals in Iraq sought a better way to evaluate the impact of blast injuries on soldiers' brains when there were no visible head wounds -- a condition known as mild traumatic brain injury. Mild TBI can be deceptive, because it often occurs without any outward signs of trauma. A soldier can recover completely from mild TBI, but left undiagnosed and untreated, it can lead to serious impairment over time, especially if the individual is exposed to additional blasts later on.

Lacking an adequate tool to help determine when it was safe to send soldiers back to combat, Air Force doctors in 2006 began using an off-the-shelf, Web-enabled assessment tool called the Cognitive Stability Index, developed by a small, New York-based company called Headminder. At least one of the Air Force doctors had used it before, liked it, and believed it could work well in the field.

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The Air Force doctors in Iraq were impressed enough with the CSI's clinical performance in the field that they sought and received approval from a military institutional review board to conduct a scientific study comparing the CSI to two other tools the military uses: a computer-based tool the Army developed in 1984, called the Automated Neuropsychological Assessment Metrics; and a basic screening tool developed by military medical personnel in 2006 called the Military Acute Concussion Evaluation.

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What happened next with the study is the subject of some disagreement among those with knowledge of it.

What is undisputed is the data from the 2006-2007 combat study has never been published in a peer-reviewed journal, an essential step in validating the teams' findings. Without such review by disinterested peer scientists, the doctors' findings and conclusions are in limbo.

Jeffrey Barth, chief of medical psychology at the University of Virginia School of Medicine and medical director of the school's Neuropsychology Assessment Laboratories, is an expert in mild traumatic brain injury and served as an outside adviser on the study. He said he doesn't know why the study was never published, or if it was even completed. "We certainly had sufficient data to put together [a manuscript for] publication," he said. "All I know is we were writing an article and the last I heard about it [was] in the middle of 2008."

In a May 28, 2008, memo, then-assistant secretary of Defense for health affairs Dr. S. Ward Casscells directed all three service chiefs to immediately begin using ANAM as the assessment tool of choice "until ongoing studies to obtain evidence-based outcomes of various neurocognitive assessment tools are completed."

"The issue here would be, did the DoD know there was a superior product available?" Barth said. He doesn't know the answer to that. "This particular paper these folks were writing, which I was reviewing and being a consultant on, did show in a sort of head-to-head evaluation that CSI from Headminder did a better job in correlation with the RBANS than the ANAM did," he said. If the study had been sent out for review, "and if those peers ... thought that the findings were correct ... that would at least be one piece of information the Department of Defense should want to utilize in determining what they're going to use in theater."

Read the complete article here. (It's kind of long but quite interesting.) And whatever is, or was, going on with that study, I certainly hope that those in charge keep the welfare of our service men and women at the forefront of their decisions. Cost-cutting or favoritism deserve no place in selecting the best assessment tool possible. Our troops are giving a lot; they have earned the best medical care this country can provide.

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MedScape Today reports:
A new study using polysomnography confirms sleep disturbances in patients with traumatic brain injury (TBI), including increased wake after sleep onset (WASO) and reduced sleep efficiency, an average of 14 months after their injury compared with healthy control subjects.

Other findings, including reduced evening melatonin production in these patients, as well as increased levels of depression and anxiety, may be contributing to these problems. Slow-wave sleep was also higher in patients with TBI vs healthy controls after controlling for depression.

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Asked to comment on these findings on behalf of the American Academy of Neurology, Maurizio Corbetta, MD, from Washington University in St. Louis, Missouri, pointed out that although the association between TBI and sleep disturbance is not novel, "the result of lower melatonin in a TBI group is intriguing."

This is an important topic, Dr. Corbetta noted. "It's very common in these patients to have sleep problems, and it's well known that when you don't sleep very well your cognitive function is worse. Many of the cognitive deficits we see in people with TBI, postconcussive problems with concentration and working memory, attention, and irritability, sometimes are related to lack of sleep." Treating these sleep issues can improve these symptoms, so "finding some markers would be important," he added.

Read the complete article.

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The war in Iraq is in its seventh year. The war in Afghanistan, in its ninth year, is the longest war in our history. Our thanks to AlterNet for the following information:

1. To date, there have been 90,955 documented U.S. troop casualties in the current wars in Afghanistan and Iraq.

2. The Department of Defense last year warned that as many as 20 percent of veterans (360,000) may have suffered traumatic brain injury from IED blasts in Iraq and Afghanistan.

3. 508,152 Iraq and Afghanistan veterans are patients in the VA system. Thousands more are waiting as much as a year for VA treatment for serious ailments including traumatic brain injury.

4. Every day, five U.S. soldiers attempt suicide, a 500 percent increase since 2001.

5. Every day 18 U.S. veterans attempt suicide, more than four times the national average.

6. Female veteran suicide is rising at a rate higher than male veteran suicides.

7. A 2004 study of veterans with PTSD reported that 71 percent of women seeking treatment said they were sexually assaulted or raped while serving in the military.

8. The number of U.S. service men and women killed in Afghanistan has doubled in the first quarter of 2010. compared to the same quarter last year.

9. 2,052,405 service men and women have been deployed to Iraq and Afghanistan since 2001. Over 40 percent of them have been deployed two or more times.

10. Estimates of civilian deaths from violence in Iraq alone range from a conservative 105,000 (Iraq Body Count project) to over 1.2 million (UK pollster Opinion Research Business), with estimates by Johns Hopkins at 655,000.

Read the entire article.

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Here's something you don't read about every day. Can you imagine waking up and speaking with a foreign accent? An accent from a language you don't even know? I'd heard about this strange syndrome before, but never knew too much about it. I can certainly see how this could severely impact someone's life.

From The Washington Post:
Some people fall on their heads and wake up with their memories wiped out. A few revive with their personalities totally changed. Others die. Robin Jenks Vanderlip fell down a stairwell, smacked her head and woke up speaking with a Russian accent.

Vanderlip has never been to Russia. She doesn't remember ever hearing a Russian accent. She lives in Fairfax County, was born in Pennsylvania and went to college on the Eastern Shore. Yet since that fall in May 2007, the first question she gets from strangers is: "Where are you from?"

"They say your life can change in an instant," she said in what sounds like a thick Russian accent. "Mine did."

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What she has, Braun and other doctors say, is Foreign Accent Syndrome -- a legitimate though rare and little understood medical condition that can follow a serious brain injury. "It does sound strange," Braun said. "It certainly does sound like someone has a foreign accent."

The syndrome was first described by a neurologist in the closing days of World War II, when a Norwegian woman injured by a shrapnel hit to the head fell into a coma and woke up speaking -- most unfortunately for her -- with a German accent. (Fellow Norwegians ostracized her as a result, according to the medical literature.)

Read the whole article.

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Some sad news. According to L.A. Weekly Blogs:
Actor Gary Coleman died at a Provo, Utah hospital of a brain hemorrhage Friday, possibly after family members decided to take him off life support, according to various reports. He reportedly fell inside his home and hit his head Wednesday before being rushed to a hospital, where he remained. He was 42.
Rest in peace, Gary Coleman.

Keep reading the article.

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From The Philadelphia Inquirer:

The wars in Iraq and Afghanistan have drawn more attention to the plight of brain-injury survivors, as has the NFL's recent acknowledgment that some of its players are suffering neurological consequences from repeated concussions. But our health policies and treatment practices have yet to catch up to the staggering toll of this complex and insidious condition.

Five million Americans are living with disabilities from brain injuries. There are 80,000 to 90,000 new long-term disabilities from brain injuries each year, and a new traumatic brain injury is sustained every 23 seconds.

For all our lifesaving modern technology and medicine, we know little about brain-injury survivors' lives. How do they cope? How can they find new meaning and purpose in life? And how can we help them?

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We chronically underfund disability and rehabilitation research, according to the Institute on Medicine, and brain-injury survivors have limited access to cognitive rehabilitation services. Far too often, we fail to consider or evaluate how policies affect the lives of brain-injury survivors.

For people whose brain injuries are labeled "mild" - those that involved little or no loss of consciousness - the challenges are particularly acute. The vast majority of the 1.4 million brain injuries diagnosed in emergency rooms every year are classified as mild. Most of those patients fully recover.

Yet the estimated 10 to 20 percent who suffer long-term consequences from those injuries - memory loss, difficulty making decisions, irritability, loss of coordination, fatigue, hearing and vision loss, and inability to complete tasks - are seen as malingerers. They are called lazy, stupid, or crazy.

Keep reading this article.

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The Daily Times of Maryland is running a series of articles on Traumatic Brain Injury this month. The author, Paul Rendine, has this to say about them:
Several years ago, I wrote a series of articles about traumatic brain injuries. Surprisingly to me, I received one of the largest numbers of comments and questions -- more than 67 -- during the life of that series. I thought that this month might be the best time to both review those comments, while updating the current scientific, medical and rehabilitation programs that seem now to provide the best outlook or answers for this least understood but still highly prevalent disability.
Just click on one of the dates below to link to that day's article.

Excerpt from May 2, 2010 article:
As I write this, traumatic brain injury is a major public health problem in America, especially among male adolescents and young adults ages 15-24, as well as among elderly people of both sexes 75 years and older. Children aged 5 and younger are also at high risk for TBI, vis-à-vis shaken baby syndrome, for example.

Today, TBI costs the country more than $56 billion a year, and more than 5 million Americans alive today have had a TBI resulting in a permanent need for help in performing daily activities. Survivors of TBI are often left with significant cognitive, behavioral and communicative disabilities, and some patients develop long-term medical complications, such as epilepsy.

Excerpt from May 9, 2010 article:
Skull fractures can cause bruising of brain tissue called a contusion. A contusion is a distinct area of swollen brain tissue mixed with blood released from broken blood vessels. A contusion can also occur in response to shaking of the brain back and forth within the confines of the skull, an injury called contrecoup. This injury often occurs in car accidents after high-speed stops and in shaken baby syndrome, a severe form of head injury that occurs when a baby is shaken forcibly enough to cause the brain to bounce against the skull.

In addition, contrecoup can cause diffuse axonal injury, also called shearing, which involves damage to individual nerve cells (neurons) and loss of connections among neurons. This can lead to a breakdown of overall communication among neurons in the brain.

Excerpt from May 16, 2010 article:
Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that arise as a result of the injury to the brain. Although complications are rare, the risk increases with the severity of the trauma.

Complications of TBI include immediate seizures, hydrocephalus or post-traumatic ventricular enlargement, CSF leaks, infections, vascular injuries, cranial nerve injuries, pain, bed sores, multiple organ system failure in unconscious patients and polytrauma (trauma to other parts of the body in addition to the brain).

Excerpt from May 23, 2010 article:
Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory and reasoning), sensory processing (sight, hearing, touch, taste and smell), communication (expression and understanding) and behavior or mental health (depression, anxiety, personality changes, aggression, acting out and social inappropriateness).

Within days to weeks of the head injury, approximately 40 percent of TBI patients develop a host of troubling symptoms collectively called post-concussion syndrome. A patient need not have suffered a concussion or loss of consciousness to develop the syndrome, and many patients with even a mild TBI can suffer from post-concussion syndrome. Symptoms include headache, dizziness, vertigo (a sensation of spinning around or of objects spinning around the patient), memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for post-concussion syndrome may include medicines for pain and psychiatric conditions and psychotherapy and occupational therapy to develop coping skills.

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This article from The Miami Herald makes my blood boil. There is no excuse, after all this time, for the Veteran's Administration to continue dropping the ball like this.
Nearly 30,000 veterans have suffered some kind of traumatic brain injury in the wars in Afghanistan and Iraq, an estimated 2,000 of them severe enough to put the warriors into comas or leave them with severe disabilities. Yet more than eight years after the invasion of Afghanistan, testimony before Congress shows that veterans still suffer yawning gaps in coverage for what's become the conflicts' signature wound.

"It requires someone screaming and fighting on behalf of that soldier," said Sen. Richard Burr of North Carolina, the top Republican on the Senate Veterans' Affairs Committee.

Many veterans and family members say that veterans with consistent help - a spouse or parent, usually - are best able to navigate the system. Others are left scrambling to seek assistance.

"There's almost a culture of no at the VA," Burr said.

"For the average service member or family member that asks, 'Can we do this?' the automatic answer is no," he said. "Can we get that service locally? No. Can we go to an outside rehabilitation facility? No."
It's especially reprehensible considering these injuries were received while the patients were serving our country in a war. Definitely worth calling or writing Congress about. Let them know that our vets deserve better, much better, than this!

Read the entire article.

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This is a follow-up to our April 25th post on a brain hemorrhage suffered by Bret Michaels (front man for the rock band Poison, star of reality show Rock of Love, and a contestant on this season's Celebrity Apprentice) .

From People Magazine:
According to his doctor, Michaels was readmitted to the hospital this week after experiencing numbness on the left side of his body, particularly to his face and hands.

He was diagnosed with suffering a Transient Ischemic Attack, or TIA, described as a mini-stroke or warning stroke that causes stroke-like syptoms but doesn't cause lasting neurological damage. MRI and CT scans then discovered that Michaels had a hole in his heart.

"There is no doubt that [this] is devastating news to Bret and his family," says Zabramski. "The good news is that it is operable and treatable and we think we may have diagnosed the problem that caused the Transient Ischemic Attack."
Now, Bret is enroute to New York from Arizona, hoping to make it to the finale of "Celebrity Apprentice," where he is one of two finalists. Donald Trump is to announce a season's winner tonight.

His private jet left Arizona this morning, but made an unscheduled stop in Nashville because Michaels was "complaining of a headache, lower back pain and some cramping in his legs," sources at the airport told PEOPLE. Michaels reboarded the plane after a brief stop and was reported again on his way to New York.

It's too soon to tell whether this decision was too risky, and if Michaels put his health in serious jeopardy by flying across country so soon after a stroke. For now we wish him good luck and best wishes for a complete recovery.

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Another sports casualty, this one from college football.

The Huffington Post, May 10, 2010:
It was a difficult weekend for Eastern Oregon University. On Sunday, Dylan Steigers, a 21 year-old transfer from the University of Montana, passed away from injuries sustained during a spring football scrimmage.

The injury occurred during the EOU Mountaineers football program's spring scrimmage during the second to last series of plays in the game. Steigers left the field under his own power, but later vomited on the sidelines, a sign of concussion. Following protocol, an EOU certified trainer called 911. Steigers was transported to Grand Ronde Hospital, and then sent via LifeFlight to Saint Alphonsus Regional Medical Center in Boise. Medical staff told university officials that he suffered an acute subdural hematoma as a result of contact to the head.
Read the entire article.

 
WASHINGTON, May 4 /PRNewswire-USNewswire/ --
Emergency physicians are urging the public to put helmets on as outdoor activities increase and temperatures warm up. May is motorcycle safety month and a prime opportunity to remind the public about the importance of safety helmets. Helmets save lives and reduce the risk of brain injury, the nation's emergency physicians said today. They see firsthand the tragic consequences of people who don't wear them.

Helmet use is the best way to reduce bicycle head injuries and fatalities from crashes. More than 300,000 children are treated in emergency departments with bike injuries every year and nearly two-thirds (70 percent) were because of head injuries that could have been prevented by wearing a helmet according the National Highway Transportation Safety Administration (NHTSA).

Facts about Bicycle Helmet Use:

* Bicycle helmets are nearly 90 percent effective in preventing brain injuries, according to NHTSA.
* Universal bicycle helmet use by children ages 4 to 15 would prevent 39,000 to 45,000 head injuries.
* About 540,000 bicyclists seek emergency care with injuries each year. Of those, 67,000 have head injuries and 27,000 of them have injuries serious enough to be hospitalized.
Keep reading article.

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From Norwich Bulletin:
Over the past 30 years, the number of women participating in team sports has steadily increased. Many now begin as young girls and continue through college and into the professional ranks. While this expanded involvement has been a positive step, the number of catastrophic injuries in women has also risen.

During the 1982-83 academic year — the first time period data was collected — only one female catastrophic injury was recorded. Over the past 28 years, there has been an average of 8 1/2 catastrophic injuries per year reported in females.

Among the catastrophic injuries most commonly seen is mild traumatic brain injury in the form of concussions. Concussions can span all three classifications of catastrophic injury. Typical symptoms include headache, dizziness and inability to concentrate.

A recent study reviewed 1,425 patients who had suffered concussions and looked at the severity of post-concussion symptoms three months after injury. The severity of symptoms was significantly greater in females. Specifically, the symptoms were most severe in women of childbearing age. This suggests a possible association between concussions and hormonal balance.

Women are believed to under-report concussions and render themselves susceptible to repeat injury. Multiple head injuries can lead to prolonged cognitive impairment.
Read article.

 
From RecordNet.com:
A congressional bill aimed at improving care for U.S. military veterans who have suffered traumatic brain injuries - considered the signature wounds of the Iraq and Afghanistan conflicts - was signed into law Wednesday in the White House by President Barack Obama.

The bill helps develop policies for better care and rehabilitation of veterans with traumatic brain injuries, or TBI, by immediately establishing a special panel to assess how well the VA treats veterans with the disorder and to make annual recommendations for improvements. It also will help establish TBI-specific education and training programs for VA health professionals.

The incidence of such brain injuries has grown dramatically since 2000, when the number of service members diagnosed was 10,963. As of December, it had reached 27,862, according to the Defense and Veterans Brain Injury Center. The leading causes among active duty military members are war-zone blasts, gunfire and shrapnel.

Keep reading article.

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