Author Archives: tbionthehill

At Home Brain Care

Last week, the University of Arkansas for Medical Sciences received a three-year, $450,000 grant from the U.S. Department of Health and Human Services Administration for Community Living, in addition to the $75,000 annual gift they are receiving from the Arkansas Department of Health.  The federal grant is to be applied to the University’s Traumatic Brain Injury State Partnership Program State Funding Opportunity.  “Among the goals of the program… are incorporating telemedicine and other technologies into TBI services to survivors, raising awareness of clinical and educational services for survivors, caregivers and families…”  Telemedicine increases healthcare access for all, particularly those is rural areas and others that cannot easily visit medical facilities, such as those with tbi who need aid in transportation.

Although it may seem to be a relatively modern invention, forms of telemedicine have been in existence since man could verbally communicate.  The more modern view of telemedicine, involving both verbal and visual communication with the medic, was first seen in 1924 in, “an imaginative cover for the magazine Radio News foreshadowed telemedicine in its depiction of a ‘radio doctor’ linked to a patient not only by sound but also by a live picture.”  Though at the time, the ideas of television and telemedicine were merely fantasies, the first television transmission occurred only 3 years later.  Video communication between doctor and patient, however, is usually first dated to 1959.  1959 is also the year of the first neurologic examination through telemedicine, occurring at the University of Nebraska.  Five years later, means to treat patients with brain injury and neurological disorders were found, as, “they established a telemedicine link… to provide speech therapy, neurological examinations, diagnosis of difficult psychiatric cases, case consultations, research seminars, and education and training.”

The above paragraph primarily comes from information in a 1996 article that can be found on the site of the National Academy of Sciences.  In 1996, the government recognized that there was a vast need for telemedicine, since its envisionment to the present day.  With both new technology and increased forms of communication, telemedicine has gone far above what could have been imagined 22 years ago.  For example, a 71-page report penned by the Undersecretary of Defense to the House Chair of the Committee of Armed Services, states that, “the Department of Defense views telemedicine as an important set of tools to improve access to Psychological Health and TBI care services in both deployed and non-deployed settings.  In June 2018, the FDA approved the distribution of MindMotion GO, a type of mobile therapy that focuses on speech and task therapies.  As far as brain injury diagnosis, while CT scans and other such tests may need to occur at medical facilities, medical professionals are now using communication technology to diagnose another neurological disorder (autism) and to evaluate others (computerized concussion assessment).
 

The Importance of PLAY(S)

Children generally have more physical energy than their adult counterparts. As a consequence, many participate in youth sports leagues, which not only provide physical activity, but also teach them to work effectively with their peers.  Last year, Senator Capito (WV) proposed Senate Resolution 227 which marked July 16 – 22 as National Youth Sports Week.  According to the bill, the week is, “a celebration of youth sports participation and all of the benefits youth derive from engagement in sports.”

In 2018, “[this] week… thousands of youth sports coaches, athletic directors, recreation directors, association members, sponsors, young athletes, and parents across the country show their support focusing on P.L.A.Y.S. ~ Physical activity, Living healthy, Access, Youth development, Safety.”  While having access to the physical activity and youth development provided by sports, which is a key part of healthy living, is important, the S (safety) should always be included in the celebration.

***The bones of children are still in development and, therefore, weaker.  Additionally, the coating of myelin, neuron fibers, in the brain of youth is still in development.  Because of this, physical injury, including skull injury, is more common and more severe in children, than in adults.  Particularly this can be found in sports, most notably in youth football, youth hockey and youth soccer, but the risk is present in all sports.  (For example, this month, the CDC published an article that identifies brain infection/injury as a rare, but possible result of fresh water swimming.)  Additionally, beyond physical safety, sports may affect the brain psychologically, but this affect can also be positive.  New Jersey, among other states, has a youth sports concussion law, “to help reduce the risk of student-athletes suffering concussion, and its long-term consequences.”  Included as a possible long-tern consequence is a traumatic brain injury.

Alexa and Her Friends Promote Independence

The new technology of smart homes has sparked the interest of all Americans, as they imagine Alexa and other such tools closing the blinds, turning off the stove and other such activities at a specific time.  For those with a brain injury and/or other disabilities, the possibilities are even greater, allowing them to, “independently plan, organize and complete everyday activities.”

Nearly a decade ago, in 2009, the government saw the potential of smart homes for the disabled, when it concluded, “more outcomes-based research and collaboration among stakeholders is essential in order to establish guidance for designing, selecting and implementing individualized smart home solutions for those with neurological disability.”  To identify both the needs of those with brain injuries, as well as their caregivers and their rehabilitation and home healthcare providers in smart homes, the government conducted such studies, as that in 2016.  To condense the findings of this study, it found that “to meet participation needs of people with ABI, the design of smart homes must consider all categories of daily and social activities.”  More so, the VA found that smart homes actually aid in cognitive rehabilitation, as VA smart homes send technological reminders when someone goes “off track”.  The VA has stated smart homes have been described as a ‘cognitive prosthetic‘, telling someone when to take their medication and even such things as notifying someone how long they have been shaving.

Last month, the Gary Sinise Foundation, an organization whose mission is to “serve our nation by honoring our defenders, veterans, first responders, their families, and those in need,” built a smart home in Wildwood, Missouri for a veteran who lost both his legs and suffered a brain injury after stepping on an IED in Afghanistan.  This month, the Gary Sinise Foundation gave a smart home that they built in Richland County, Ohio to a former Army Sergeant who also suffered a traumatic brain injury and leg injuries while serving in Afghanistan.  As smart homes become more available, for both individual residence and community living, further independence can be known to many more with brain injuries.

Revolutionary Treatment in the 18th Century

When one thinks of Revolutionary War combat injuries, one tends to think of physical trauma or even death.  Head injury is generally not considered, even though when one thinks of war injuries, head injuries are known to occur all too often.  Because of this reality, during the War of Independence, American doctors began to study neurosurgery and treat soldiers accordingly.  A manual, titled Plain Concise Practical Remarks on the Treatment of Wounds and Fractures and authored by Dr. John Jones, was published in 1775, “to give the young unexperienced Surgeon, fome general and clear ideas of the nature and treatment of this difficult and dangerous brain of chirurgical difeafes” sic.  Dr. Jones’ experience included founding King’s College Medical School, now known as Columbia College of Physicians and Surgeons.  (Manual chapters include: Of Blows on the Head, Of Injuries Arifing from Concussion or Commotion, Of Injuries Arifing from Fracture of the Skull.)

Medical Mystery Appears Again Across the Globe

Last year, America removed its diplomats from Cuba after some reported mysteriously experiencing the symptoms of mild brain injury.  This year, the same symptoms are being experienced by American diplomats and their families in Guangzhou, China:  sleeplessness, headache, nausea, and memory recall issues.  These are the same symptoms one feels, “following [a] concussion or minor traumatic brain injury.”

Secretary of State Mike Pompeo notes that what has now being reported as occurring in China is, “very similar and entirely consistent with the medical indications that have taken place to Americans working in Cuba.”  It both cases, there is no known culprit, though those in the State Department continue to say that it is likely to be caused by sonic attacks.  Toxins and sounds emitted by listening devices, as well as simply mass hysteria, have also been mentioned as possible causes.  (Twenty-five percent of those who reported brain injury in Cuba were found not to have it, based on medical tests following their return to America.)  The U.S. government suspects that either Russia or China may be causing the attacks in China.  The idea that Cubans could be generating the attacks is not thought in this incidence.

Are sound attacks the new means of warfare?  The news examines this question, citing the known effects of infrasonic and ultrasonic sound.  Infrasonic sound causes such effects as nausea and involuntary bowel evacuation.  Ultrasonic sound can heat up the cells of the body and can cause cavitation, “when the pressure difference between a strong push and a strong pull in a very loud sound causes bubbles to form”.  Generally, ultrasound sound is named as the culprit of the sonic attacks, however nausea, an effect of infrasound attacks,  was reported by some.  Another possibility is that ultrasonic attacks are an effect of eavesdropping, not the means of attack, as ultrasound is used is surveillance.

Hit by Dementia on the Battlefield

Last year, I reported on the correlation between traumatic brain injury and dementia.  Specifically, I linked to a study that found that those with a TBI had a 4.5 percent greater risk of dementia (in some studies, this percentage is a bit lower).  While terrible, that was not a complete surprise, when one is referring to moderate and severe brain injuries.  (The report that found that mild TBI is not so mild for the elderly is upsetting, but not unbelievable.)  However, since that time, government-funded studies, as well as other studies, have broadened that research and discovered that even a mild brain injury without loss of consciousness (loc) can more than double one’s chance of developing dementia, no matter what age that person is when that mTBI occurs.  A study of more than 350,000 veterans found that those who had a mild TBI, a single jolt to the head, without loc had a 2.36 percent greater risk of developing dementia.  For those in the study who had a mild TBI with loc, there was a 2.51 percent higher risk of developing dementia, not that much higher.

“One working theory is that somehow these injuries either cause an overproduction of normal waste proteins, or make it impossible to clear these proteins,” notes the study.  However, this is just a working theory because no one fully understands how the brain works, or rather why and how it stops working.  Responding to the above studies results, the director of the Army’s traumatic brain injury program questioned, “”Is blast exposure hurting service members or soldiers?  And if it is… how can we modify our equipment or the way we operate to prevent injury?”

Beyond the military, why is the risk of dementia higher after a TBI for working age adults, in general?  Additionally, the NCBI sponsored a nationwide study that found that, “the risk of dementia diagnosis decreased over time after TBI… [but] it was still evident >30 years after the trauma.”  Based on this information, how can we modify our diet, our physical activity, etc., during our TBI recovery and after, to prevent this?  As of now, research on cognitive decline, mild cognitive impairment, and dementia prevention has been “encouraging but inconclusive”.  However, the assumed prevention tactics of cognitive training, blood pressure management (for those with hypertension), and increased physical activity are beneficial regardless.

Trump Gives Credit to Caregivers

“Trump donates his presidential paycheck to VA caregivers,” read the headline on The Military Times website yesterday, May 17, 2018.   Specifically, the President’s quarterly paycheck of $100,000 is the first check that the President has donated to the VA (earmarked for the caregivers) and the fifth paycheck that he has donated to various governmental departments.  “President Trump understands the critical role of caregivers,” said Acting VA Secretary Robert Wilkie of this quarter’s donation. Apart from financial support, caregivers support the health and healthcare of dependents and provide much needed social interaction.

Earlier this year, the “Trump tax cut”, H.R. 1, that passed in March, states that, “The [tax] credit [for caregivers]… shall be increased by $500 for each dependent of the taxpayer.”  A dependent is defined as a relative who lives with the caregiver, earns less than $4,050 annually and that the caregiver financially supports.  This is a description that applies to many brain-injured individuals.

Menopause Increases Stroke Risk – Part 2

by Caitlin D.

Whether you consider a cerebrovascular disease, commonly known as a stroke, a traumatic brain injury in and of itself or simply the effect of a tbi (a stroke is an acquired brain injury), the negative effects of it do not lessen.  If one has an ischaemic stroke, as opposed to a haemorrhagic stroke, they then have a 25% – 30% higher chance of either developing vascular cognitive impairment (VCI) or vascular dementia (VaD), collaboratively known as VCID.  Strokes may not always be the cause of VCID, but strokes and VCID do have similar risk factors.  (For this reason, a stroke may co-occur with a VCID, but not be directly caused by it.)  And, just like a stroke, “symptoms of vascular dementia and VCI can begin suddenly…. [but they] worsen or improve over time.”

“Vascular dementia is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain.”  Because of their similar effects, vascular dementia is often confused with Alzheimer’s disease.  However, the difference is that vascular dementia is caused by the blockage of blood through the brain, whereas the cause of Alzheimer’s disease is not fully understood.  For this reason, “Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients (‘at risk brains’) from those with better prognosis or to discriminate Alzheimer’s disease dementia from [vascular dementia].”

A relatively newly named condition, vascular cognitive impairment, “refers to the contribution of vascular pathology to any severity of cognitive impairment, ranging from subjective cognitive decline and mild cognitive impairment to dementia.”  It is not an age-restricted condition, though the vast amount of those who are inflicted are elderly.

Last year, the National Heart, Lung and Blood Institute funded a study that proved that exercise helps prevent against vascular dementia.    However, beyond that, little research has been done on how to prevent or cope with vascular dementia or vascular cognitive impairment.  As the government noted, in 2015, “there are limited treatment options to improve cognition and function in VCI.”  That still seems to be accurate.  Since strokes are often the cause of vascular cognitive impairment and vascular dementia and since vascular dementia seems to mirror the effects of Alzheimer’s disease, research on how to cope with and later deal with strokes and Alzheimer’s would be beneficial.

While it is true that America is aging, as the world’s population is living longer, stroke and dementia should not be as much of a concern for those who live a healthy lifestyle.  Thirty years ago, a person who was injured through a traumatic injury or a person who developed an acquired brain injury had almost no hope of survival.  Now many such people can survive and even thrive.  Hoping for that type of result for dementia in the same timetable seems very realistic.

Menopause Increases Stroke Risk – Part 1

by Rebecca M.

As covered in-depth by the NIH, women that are through menopause, who have a different hormonal make-up than younger women, have a higher risk of stroke, an acquired brain injury.  This is due to changes in hormones, especially those linked to estrogen, which drops significantly after menopause.  Stroke was once thought to be primarily a male disease, but the number of women that are having strokes has been increasing.  Although men still have a greater risk of stroke overall, the risk of stroke for women between the ages of 50 and 60 (the median menopause age is 51) is greater than that of men at that age.  This is true for women of all races.  (As stress also contributes to stroke rates, I wonder if women with stressful jobs that have been through menopause might be at an even higher risk, as there is evidence that higher stress is contributing to more strokes in younger people.

Currently, legislation does not appear to address strokes or heart disease in any way, but it is addressed by the executive branch of the federal government.  Sometime between the years 2003 and 2005, statistical data was ordered by George W. Bush’s first Secretary of Health and Human Services Tommy Thompson.  The following report called for strengthening the nation’s public health capacity at the state and federal levels. The plan, though created nationally, required community level action to catch risk factors for stroke and heart disease and make changes accordingly, especially those changes that could be implemented through environmental change.  (Environmental change is what a federal agency or legislation would be able to focus on, not on biologically predetermined risks.)  There was also a call for more research in all areas, including the genetic area, so that individuals could be properly tracked and helped before they suffered any risks.   At the time of the report, heart disease and stroke required 3% of the U.S. budget to address and that number was expected to rise as more “baby boomers” reached old age.

It is a bit surprising that there has not been a follow-up on statistics since 2010.  The surprise is not so much based on inaction in the Trump Presidency, which has been less than a year and a half, but during the Obama Presidency, when healthcare was such a signature issue, especially in his first term. There was no continuity from the Bush years.

Though this report focuses on heart disease, as well as on stroke, it is noted early on that the public health burden from stroke has grown at a faster rate, possibly because disability resulting from stroke requires long-term care.  The goal of the report was to strengthen programs that allow for early detection of the two types of disease and thus ensure strong and economically-sound responses to the epidemics.  The hope was that better models for detection and for treatment could be developed nationally and by the international CDC that would be used at the community level. I did not, however, find more up-to-date reports like this, which was issued roughly 14 years ago.  At the time of the report, heart disease was the #1 cause of death in all people in the U.S. over 65, and stroke was the #1 cause of disability.

Illegal Immigrants and Brain Injury

A hot topic in the past few decades, illegal immigration has now come to the forefront because of America’s current president and his border wall.  (For the past 10 years, the estimated number of illegal immigrants in America has stayed relatively stable at about 11 million.  During the presidencies of Bill Clinton and George W. Bush, it was steadily rising.)  As for brain injury and undocumented residents, there are many cause-and-effect questions that, when answered, are quite sobering.

To begin, what if the illegal immigrant is the culprit?  What if the illegal immigrant causes someone to have a brain injury, either intentionally or inadvertently?  First, the police or whomever is pursuing the case must find them.  Since illegal immigrants are largely undocumented, this can be a hard task.  For better or worse, depending on your political ideology, a number of states are now allowing an illegal immigrant to legally obtain a driver’s license and register their car.  In January 2015, for example, California signed into law AB60, which, “requires the [DMV] to issue an original driver’s license to an applicant who is unable to submit satisfactory proof of legal presence in the United States.”  New Jersey, with the support of Governor Phil Murphy, is now preparing for a similar bill, Assembly Bill No. 1738, to pass.  If this bill passes, it will make New Jersey the 13th state, plus the District of Columbia, to allow this.  (What the consequences are for an illegal immigrant who inflicts injury on another person, such as through a car accident and even if they are legally licensed, is unclear.  They are subject to criminal charges, but civil action may be more difficult.  As they are illegal, and many do not submit tax returns, which would show their yearly income, monetary consequences to cover such things as rehabilitation costs are not possible.)

More so, the government does not seem to account for the economic costs of brain injury:  For the victim, there will be a lose of future wages as, even if the victim is able to return to work, they will be away for a bit.  Additionally, when returning to work, a brain injured individual may have to pursue a career that is less cognitively and/or physically demanding and often less lucrative than their previous occupation.  For the Internal Revenue Service (IRS), this means less taxable dollars are earned.  Also, the brain injured individual may stay longer or indefinitely on Medicare and/or Medicaid.  The government then is required to help pay for their doctors’ visits, their medication, etc.

But, how about when the illegal immigrant is the victim?  No one wants to see a person, legal or not, suffer or even die due to lack of medical care.  All told, the government is financing about $18.5 billion a year for medical care to unauthorized immigrants.  Of this total, “federal taxpayers provided $11.2 billion in subsidized care to unauthorized immigrants in 2016.”  (“A relatively small number of undocumented immigrants, perhaps in the tens of thousands, obtain health insurance through private employers,” states a 2016 article.)  However, a page on the NIH website, written by an individual who had authored other pages on ethics, as it relates to illegal immigrants, notes that, “the Patient Protection and Affordable Care Act of 2010 ignored the health care of undocumented immigrants and will not provide relief to undocumented patients with catastrophic illness like ESRD, cancer, or traumatic brain injuries.”

There are local health clinics, hospital emergency rooms and free medical school clinics that must treat everyone, regardless of legality.*  Additionally, some doctors will treat undocumented immigrants, off the record.  Treatment for brain injury though, requires more than a brief trip to the doctor.  As an article from 2009, when illegal immigrants were treated differently by the government than now, is titled, “Struggling to find post-acute care for undocumented and uninsured immigrants.”  Should ethics trump legality, no pun intended?

*Another article recounts the story of an illegal man, without insurance, who suffered a stroke.  Though the hospital legally had to treat him, his care would be uncertain the second he stepped out of the hospital grounds.  Would receiving care for his stroke result in a “medical deportation”?  Ultimately, the hospital was able to find the man’s family in Mexico, but the trip to return him to his family cost $50,000 and was paid entirely by the government.

Note: The above post is not a personal comment on illegal immigration.