Govt struggles to cope with wounded GIs
Sat, 23 Jun 2007 18:08:20 GMTBy MARILYNN MARCHIONE, AP Medical Writer
More than 800 of them have lost an arm, a leg, fingers or toes. More than 100 are blind. Dozens need tubes and machines to keep them alive. Hundreds are disfigured by burns, and thousands have brain injuries and mangled minds.
These are America's war wounded, a toll that has received less attention than the 3,500 troops killed in Iraq. Depending on how you count them, they number between 35,000 and 53,000.
More of them are coming home, with injuries of a scope and magnitude the government did not predict and is now struggling to treat.
"If we left Iraq tomorrow, we would have the legacy of all these people for many years to come," said Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine and an adviser to the U.S. Department of Veterans Affairs. "The military simply wasn't prepared for its own success" at keeping severely wounded soldiers alive, he said.
Survival rates today are even higher than the record levels set early in the war, thanks to body armor and better care. For every American soldier or Marine killed in Iraq, 15 others have survived illness or injury there.
Unlike previous wars, few of them have been shot. The signature weapon of this war — the improvised explosive device, or IED — has left a signature wound: traumatic brain injury.
Soldiers hit in the head or knocked out by blasts — "getting your bell rung" is the military euphemism — sometimes have no visible wounds but a fog of war in their minds. They can be addled, irritable, depressed and unaware they are impaired.
Only an estimated 2,000 cases of brain injury have been treated, but doctors think many less obvious cases have gone undetected. One small study found that more than half of one group of wounded troops arriving at Walter Reed Army Medical Center had brain injuries. Around the nation, a new effort is under way to check every returning man and woman for this possibility.
Some of those on active duty may have subtle brain damage that was missed when they were treated for more visible wounds. Half of those wounded in action returned to duty within 72 hours — before some brain injuries may have been apparent. The military just adopted new procedures to spot these cases, too.
Back home, concerns grow about care. The Walter Reed hospital scandal and problems with some VA nursing homes have led Republicans and Democrats to call for better care for this new crop of veterans.
A lucky few get Cadillac care at one of the VA's four polytrauma centers, where the most complex wounds are treated with state-of-the-art techniques and whiz-bang devices like "power knee" or "smart ankle" prosthetics. Others battle bureaucracy to see doctors or get basic benefits in less ideal settings.
Mental health problems loom large. More than a third of troops received psychological counseling shortly after returning from Iraq, and a third of those were diagnosed with a problem, a recent Pentagon study found. The government plans to add 200 psychologists and social workers to help treat post-traumatic stress disorder and other issues.
No one knows what the ultimate cost will be. Harvard University economist Linda Bilmes estimates the lifetime health-care tab for these troops will be $250 billion to $650 billion — a wide range but a huge sum no matter how you slice it.
Who are the wounded?
Lee Jones, 24, of Lumberton, N.C., was severely burned on the face, hands, feet and legs when his Humvee was hit with an IED two years ago. A partial amputee with speech and other problems from a severe brain injury, he now does work therapy delivering mail at a VA hospital and tries to re-establish life in a nearby apartment with a wife and baby daughter.
Marine Cpl. Joshua Pitcher, 22, from upstate New York, is a Purple Heart recipient who returned to Iraq after he was shot in 2005. Half of his skull was removed to allow his brain to swell as he now recovers from a brain injury and shrapnel wounds from a grenade blast in February.
Maj. Thomas Deierlein, 39, is a New York City marketing executive who served five years after graduating from West Point. Twelve years later, called up as a reservist, he nearly died of bullet wounds that shattered his pelvis, leaving him with a colostomy and learning to walk again.
Joseph "Jay" Briseno, 24, of Manassas Park, Va., was shot in the back of the neck by an Iraqi in the early months of the war. One of the most severely wounded, he is now a quadriplegic, on a breathing machine, blind and unable to speak, but aware of what has happened to him.
"The mistake in Vietnam was, we hid the injured away from folks so they didn't get to tell their stories. Now it's important that we let them tell their stories to the public," said Dr. Steven Scott, director of the Polytrauma Rehabilitation Center at the Tampa VA Medical Center in Florida.
Counting the wounded can be contentious. Earlier this year, the Department of Defense changed how it tallies war-related injuries and illness, dropping those not needing air transport to a military hospital from the bottom-line total.
Bilmes, the economist, thinks this is disingenuous.
"An accident that happens while they're there is a cost of war, particularly when you factor in the length of deployment" and injury-inducing conditions like very hot weather, carrying heavy packs, and more vehicle accidents because it is not safe to walk anywhere, she said.
As of June 2, 25,830 troops had been wounded in action. Of these, 7,675 needed airlifts to military hospitals and the rest were treated and remained in Iraq.
There were another 27,103 non-battle-related air transports. Of those, 7,188 had injuries. Most occurred from vehicle accidents, training or work-related accidents. Ten percent were sports injuries, said Dr. Michael Kilpatrick, who tracks this information for the Defense Department.
Nearly 20,000 of these "non-hostile" airlifts were for illnesses or medical issues: general symptoms like fever or pain needing tests or evaluation; back problems; psychological problems adjusting to being in a war zone; "affective psychoses" ; neuroses; respiratory or chest symptoms; depression; head and neck problems ; epilepsy; infections, and muscle pulls and strains.
"I don't want to try to say these are not war-related. Being in the military is a very physically demanding job," Kilpatrick said.
For stress-related problems, the military tries "three hots and a cot" — warm meals and a chance to sleep. Most of the time it works and troops return to their unit, Kilpatrick said.
Of the troops air evacuated to the military hospital in Landstuhl, Germany, 20 percent return to Iraq and 80 percent go back to the United States for more care or disability discharge.
Of the half-million troops who have left active duty and are eligible for VA health care, about one-third have sought it. The most complicated cases end up at one of the four polytrauma centers, in Tampa, Fla.; Richmond, Va.; Palo Alto, Calif.; and Minneapolis.
These were formed after doctors realized they were missing problems — amputees who were confused and unable to put on their prosthetics because of undiagnosed brain injuries, and guys who could remember their therapy dog's name but not their doctor's, or who could carry on a conversation but not recall what they had for breakfast.
Troops at these hospitals have an average of six major impairments and 10 specialists treating them.
"The important thing to realize is you could have all of them at once" — trouble speaking, seeing, walking, hearing, etc., Scott said.
Most of these injuries are caused by IED blasts, which send a pressurized air wave through delicate tissues like the brain, sometimes send it smacking against the inside of the skull and shearing fragile nerve connections that control speech, vision, reasoning, memory and other functions. Lungs, eardrums, spinal cords — virtually anything — can be damaged by the pressure wave. Injuries also come from collapsing buildings, flying debris, heat, burns or inhaled gases and vapors.
"Many of these you can't see on an X-ray," such as glass shards that can cause internal bleeding, Scott said.
In prior wars, one of every five to seven troops surviving a war-related wound had a traumatic brain injury, the military estimates. It's much higher in this war.
A pilot project at Walter Reed in 2003 to screen 155 patients returning from Iraq found that 62 percent had a brain injury.
"This is a very rapidly evolving area as a disease," with no screening test, agreed-upon set of symptoms for diagnosis, or even a billing code, said Kilpatrick, the military doctor.
Much needs to be learned about how to treat these injuries, he said, but credited the military medical staff for having the chance.
"It's just amazing to me every day when I look at these numbers," he said. "The good news is that the majority of these people who become ill or injured ... are going to survive and are going to be able to return either to the military or to civilian life and be productive."
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On the Net:
Government casualty data: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/castop.htm
State breakdowns: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/STATE_OEF_OIF.pdf
Defense and Veterans Brain Injury Center: http://www.dvbic.org
Harvard economist report: http://www.va.gov/
Department of Defense: http://www.defenselink.mil/
Study links blood sugar to newborn risks
Sat, 23 Jun 2007 05:49:31 GMTBy CARLA K. JOHNSON, Associated Press Writer
CHICAGO - The higher a pregnant woman's level of blood sugar, the greater the risk to her newborn — whether the mother has diabetes or not, the largest study on the problem suggests. The findings released Friday may lead to more women being diagnosed with diabetes during pregnancy and given stricter diet advice or medication to lower blood sugar.
The research involved more than 23,000 pregnant women in nine countries. It found a surprisingly strong relationship between the blood sugar levels of the women and the rate of big babies and first-time Caesarean sections, said lead investigator Dr. Boyd Metzger of Northwestern University.
The newborns also were more likely to have low blood sugar levels and high insulin levels if their mothers' blood sugar levels were higher. The problems can lead to obesity, diabetes and high blood pressure later in life.
Large babies risk shoulder damage and other injuries if delivered vaginally and lead to more C-sections, which also pose health risks to mothers and babies.
Large babies were defined in the study as those bigger than 90 percent of those born in the local population, so large Thai babies would be smaller than large U.S. babies.
Researchers reported the findings Friday at the American Diabetes Association's annual scientific meeting.
The higher the mother's blood sugar, the more risk for the newborns, the study found. Researchers took into account obesity, age and family history of diabetes and still found the mother's blood sugar independently affected the infant's size and health.
It's long been known that gestational diabetes — a type of diabetes that starts during pregnancy and often goes away after birth — is unhealthy for a woman and her baby. The study is the largest to document the frequency of newborn problems at increasing levels in mother's blood sugar and the first to find that levels now considered acceptable posed some risks.
"We have established without any question that levels of blood sugar less elevated than typical diabetes carry risks," Metzger said. Currently, the goal for a pregnant woman's fasting blood sugar is below 95 milligrams per deciliter during the final few months of pregnancy.
A new target of 90 may be more reasonable, Metzger said. Researchers are not making recommendations for now, he said. New guidelines may come next year after international experts meet to analyze the findings, he said.
In the study, large babies were born 5 percent of the time to women with the lowest level of fasting blood sugar . The rate of large babies was 27 percent at the highest level .
Other measures of gestational diabetes in the pregnant women, such as glucose tolerance tests, also correlated with infant risk.
The risk was seen in babies in the United States, Canada, Barbados, Britain, Israel, Thailand, Australia, Singapore and Hong Kong. The $19 million study was funded by the National Institutes of Health and the diabetes association.
Gestational diabetes affects about 4 percent of pregnant women, about 135,000 a year in the United States. That number may climb by tens of thousands of women a year if guidelines are revised, Metzger said.
"The question is, what is the best blood sugar to have? Probably there is no threshold. The lower, the better," said Dr. Joel Zonszein, director of the Clinical Diabetes Center at New York's Montefiore Medical Center.
Dr. John Kitzmiller, a maternal and fetal health expert at Santa Clara Valley Medical Center in San Jose, Calif., said the study will raise debate over how to treat women with mild elevations in blood sugar. More evidence may be needed to show that treatment works.
Women with gestational diabetes are treated with special diets that limit carbohydrates and include high-fiber foods in frequent smaller meals. They sometimes also require injected insulin at a cost of $80 to $120 a month and need regular doctor checkups.
Some doctors use glyburide, a generic glucose-lowering pill, but large studies of the drug's safety in pregnant women have not been done.
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On the Net:
American Diabetes Association: http://www.diabetes.org
Patients death jeopardizes hospital
Sat, 23 Jun 2007 02:38:12 GMTBy JEREMIAH MARQUEZ, Associated Press Writer
LOS ANGELES - When Edith Isabel Rodriguez showed up in the emergency room of an inner-city hospital complaining of severe stomach pain, the staff was already familiar with her.
It was at least her third visit to Los Angeles County's public Martin Luther King Jr.-Harbor Hospital in as many days. "You have already been seen, and there is nothing we can do," a nurse told her.
Minutes later, the 43-year-old mother of three collapsed on the floor screaming in pain and began vomiting blood. Employees ignored her, and she was soon dead.
Now state and federal regulators are threatening to close the hospital or pull its funding unless it can be improved, and Rodriguez has become a symbol of everything wrong with the facility derisively known as "Killer King."
After she collapsed, surveillance cameras show that Rodriguez was left for dead on the floor.
Nurses walked past her. A janitor cleaned up around her. No one did anything until police were called to cart her away. They didn't get far before she went into cardiac arrest and died.
"This needs to stop," state Health Services Director Sandra Shewry said Thursday as the agency moved to revoke the hospital's license. "We're doing this in response to the egregious incidents that have come to light in the last six weeks."
The hospital, formerly known as Martin Luther King Jr.-Drew Medical Center, was built after the 1965 Watts riot to bring health care to poor, minority communities in south Los Angeles.
But it had been plagued by patient deaths blamed on sloppy nursing care, among other things. The county attempted over the last few years to correct the problems with a multimillion dollar rescue effort, disciplining workers, reorganizing management, closing the trauma unit and reducing the number of beds from 200 to 48.
After Rodriguez's death, federal reports showed those efforts were failing and patients were in "immediate jeopardy." Of the 60 cases reviewed between February and June, more than a quarter received substandard care, according to the U.S. Centers for Medicare and Medicaid Services.
In February, a brain tumor patient languished in the emergency room for four days before his family drove him to another hospital for emergency surgery. A pregnant woman who complained of bleeding was given a pregnancy test and left, only to return three days later and have a miscarriage after waiting more than four hours to see a doctor.
The findings have sent county officials scrambling to improve care before a federal inspection due by Aug. 15 that could determine whether the hospital keeps its federal funding. The county might close the facility without that money.
The hospital, meanwhile, could contest the state allegations in a hearing before a Department of Health Services administrative law judge.
"I'm losing hope," Zev Yaroslavsky, member of the county Board of Supervisors that oversees King-Harbor, told hospital managers earlier this week. "We need to be prepared for the worst-case scenario."
On Friday, the county's Department of Health Services released a contingency plan to deal with closing hospital departments and relocating patients if they must. The plan, which also lays out how the hospital could eventually be reopened if a private partner is found, will be presented to the Board of Supervisors on Tuesday, said Bruce Chernof, director of the department.
Even though hospitals nationwide struggle with too many patients and not enough staff, the scope and severity of King-Harbor's problems are rare.
"Most hospitals in America have long waits, they have crowded ERs," said Dr. Bruce Siegel, former chief of New York City's public hospitals and a George Washington University professor. "But they don't let people die in the waiting room after they call 911. This is a whole new level here."
Rodriguez, who struggled with drug addiction over the years, had visited King-Harbor several times for stomach pain in the days before she died. Each time, she was sent home, in some cases with pain medication, after doctors said she suffered from gallstones.
"They discharged me, but I don't feel good. I feel sick," she told her sister, Marcela Sanchez.
At the urging of her sister, Rodriguez returned to the hospital.
Early on May 9, she was wheeled into the ER by county police officers.
"Thanks a lot, officers, she's a regular here," a nurse said. "She has already been seen and was discharged."
After the nurse again refused to help, Rodriguez slid off her wheelchair and onto her knees in a fetal position, screaming in pain, according to a federal report based in part on surveillance videotape.
Over the next half hour, hospital staff walked past her. Soon, her boyfriend, Jose Prado, who had left for about an hour, returned to the hospital.
"When I came back, I found her lying on the floor with blood coming out of her mouth," Prado said. "She said, 'Honey, help me! Nobody will help me here!'"
He pleaded with medical staff and then a county police sergeant to intervene, but no one did.
"I told him she had blood in her mouth," Prado says he told the sergeant. "But he told me, 'Don't worry, she just has chocolate in her mouth."
Then he called 911.
"My wife is dying and the nurses don't want to help her out," he said in Spanish through an interpreter
"What's wrong with her?" a dispatcher asked.
"She's vomiting blood," Prado said.
When the dispatcher refused assistance, he hung up and frantically ran back to Rodriguez.
"I just hugged her. I didn't know what else to do. I couldn't think of anything else," he said.
Eventually, officers arrested her on a parole violation.
Police wheeled her out of the ER, then returned minutes later after Rodriguez's heart had stopped. Autopsy results revealed she died of a perforated bowel that probably developed in the previous 24 hours, a condition that is often treatable if caught early enough.
"They took her outside to die like an animal," Prado said.
After her death, a triage nurse was put on leave, resigned and was reported to the state Nursing Board for investigation. Six others — a nurse, two nursing assistants, and three hospital finance workers — were disciplined. Sheriff's detectives, meanwhile, have opened a homicide investigation.
Rodriguez's family said little will ease their grief. They plan to sue and are seeking copies of the video surveillance tapes, which are being held as part of a criminal investigation.
"They took my sister," Sanchez said. "It wasn't time for her to go."
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Associated Press writer Peter Prengaman contributed to this report.
New treatment promising for Parkinsons
Sat, 23 Jun 2007 00:35:31 GMTBy MALCOLM RITTER, AP Science Writer
NEW YORK - An experimental treatment for Parkinson's disease seemed to improve symptoms — dramatically so, for one 59-year-old man — without causing side effects in an early study of a dozen patients. The gene therapy treatment involved slipping billions of copies of a gene into the brain to calm overactive brain circuitry.
The small study focused on testing the safety of the procedure rather than its effectiveness, and experts cautioned it's too soon to draw conclusions about how well it works. But they called the results promising and said the approach merits further studies.
"We still have quite a bit more testing to do," said Dr. Michael Kaplitt of Weill Cornell Medical College in New York, an author of the study. Still, "the initial results are extremely encouraging."
Kaplitt and collaborators report their results in this week's issue of the British medical journal, The Lancet.
They're not alone in trying gene therapy for Parkinson's. In April, another team told a medical meeting that its experiments, which delivered a different kind of gene to a different part of the brain, also appeared safe and gave a preliminary hint of benefit.
More than half a million Americans have Parkinson's. They endure symptoms that include tremors, rigidity in their limbs, slowness of movement and impaired balance and coordination. Eventually they can become severely disabled.
Nathan Klein, a 59-year-old freelance television producer in Port Washington, N.Y., said the disease left him "pretty messed up." It weakened his voice, impaired his walking and made his hand tremble so badly he couldn't hold a glass of wine without spilling it all.
Klein was the first patient to be treated with Kaplitt's gene therapy procedure in 2003, and he said his symptoms gradually subsided afterward. Nowadays, he said, apart from freezing now and then when he wants to walk, the symptoms are basically gone.
"I'm elated," said Klein, who continues to take his regular pills for the disease. "It's unbelievable."
Kaplitt, who has a financial interest in Neurologix Inc., which paid for the research, noted that the 12 patients in the study still have Parkinson's symptoms. The amount of medication they were already taking for their symptoms didn't change significantly in the year after the surgery.
Current medicines can control symptoms, but can't stop the disease from getting worse over time, and they can produce troublesome side effects like uncontrollable movement.
Some patients gain relief from a surgical treatment called deep brain stimulation, in which electrodes are placed in the brain and connected to a programmable stimulator.
Kaplitt's procedure was aimed at achieving the same goal as that surgery, calming overactive circuitry in the brain. It gets overactive because it loses the normal supply of a chemical called GABA. The gene therapy was designed to make the brain produce more GABA.
For the gene therapy surgery, a tube about the width of a hair was threaded through a hole about the size of a quarter at the top of the skull. The tube delivered a dose of a virus engineered to ferry copies of a gene into cells of a brain region called the subthalamic nucleus. The gene copies enable the cells to pump out more GABA.
The Lancet paper reports that over a year, patients showed no side effects from the procedure. What's more, they showed improvements in an overall assessment of symptoms like tremors, stiffness and walking problems.
The improvements were evident at a checkup three months after the procedure and persisted to the end of the study, one year after the surgery, researchers reported. By that time, the overall amount of improvement from before surgery was about 24 percent when measured at times that patients were off their normal medication, and 27 percent at times when they were on medication.
Most of the effect appeared on just one side of the body. Because of concerns about safety with the untested procedure, the researchers treated only the brain circuitry controlling one side of the body.
Dr. Karl Kieburtz of the University of Rochester Medical Center, who didn't participate in Kaplitt's work, said the lack of any apparent side effects is itself significant.
But he urged caution in interpreting the evidence of benefits in symptoms. Other experimental therapies that looked good at such a preliminary stage have failed to pan out in more rigorous studies, he said, so more research is needed.
Future studies could include a head-to-head test against deep brain stimulation to see which relieves symptoms better, said neurosurgeon Dr. Guy M. McKhann of the Columbia University Medical Center in New York.
Dr. J. Timothy Greenamyre of the University of Pittsburgh, who was also familiar with the results, said the new study and prior research in animals leave him "very optimistic" about Kaplitt's approach.
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On the Net:
Lancet: http://www.thelancet.com
Information on Parkinson's disease:
http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_disease.htm
