Blogged Health

A new and extensive federal report released this week concludes that roughly one in four of our US Veterans of the 1990-1991 Gulf War suffer from Gulf War illness.  According to the 452 page report, “Scientific evidence leaves no question that Gulf War illness is a real condition with real causes and serious consequences for affected veterans.”  

Soldiers diagnosed with Gulf War syndrome have wide-ranging problems including headaches, dizziness and loss of balance, memory problems, chronic fatigue, loss of muscle control and shortness of breath.  It is believed that brain cancer deaths and Lou Gehrig’s disease are also potentially connected to service during the Gulf War.
 
Hopefully, this new study will lead to the necessary treatment that these wonderful veterans certainly deserve.
 

Research on sophisticated diagnostic tests were presented this weekend at the annual meeting of the society for neuroscience in Washington, D.C.  According to a report published in USA Today, researchers from the University of California-San Diego combined “two advanced brain scanning techniques-MEG (Magnetoencephalography) and DTI (Diffusion Tensor Imaging)- that permitted them to detect brain damage in patients with mild traumatic brain injury in which conventional MRI and CT scans had been normal.  Mingxiong Huang, the presenting researcher from this study, stated “More research is needed before the dual technology can be used clinically in patients with such injuries (MTBI).”

Also presenting at the annual meeting were researchers from the University of Miami (Andrew Maudsley) who “reported that they used a new all-brain method of magnetic resonance spectroscopic imaging (MRSI) to detect for the first time widespread brain damage that sometimes fails to show up in conventional brain scans of patients with mild to moderate TBI.

The researchers studied 17 patients admitted to a trauma unit with closed head injuries.  According to USA Today, “They looked at changes in three major brain chemicals and compared them with healthy brain images.  They found the MRSI images picked up diffuse chemical changes in the TBI patients, even in people who had been classified as having very mild injury.”

Clearly, the day is coming when patients with mild traumatic brain injury will have their injuries confirmed by objective diagnostic testing which obviously will have a significant impact on neurolitigation.

At present, the gold standard for objectively proving that an individual sustained a mild traumatic brain injury is through neuropsychological testing.  As we know, standard diagnostic testing such as CT scans, MRIs and EEGs, due to their lack of sensitivity, rarely if ever detect brain abnormalities in patients with mild traumatic brain injury.

However, advances in neuroimaging may soon eliminate the need for neuropsychological testing to diagnose brain damage.  Advances in FMRI and diffusion tensor imaging (DTI) will soon become the gold standard.

I recently read an article published in Brain entitled “Structural Dissociation of Attentional Control and Memory in Adults with and without Mild Traumatic Brain Injury”.  The article by S. N. Niogi et al, noted that executive function such as attention and memory are among the most significant human brain processes impacting overall cognitive function.  The study contained 43 patients prospectively recruited with mild TBI, (28 males, 15 females) who were imaged at least one month post injury and 23 healthy volunteers, (17 males, 6 females).  There was no significant difference in mean age, gender, handedness, or level of education between the mild TBI group and the control group.  Those with a prior history of TBI, a history of neurological or psychiatric illness were excluded.  All subjects underwent diffusion tensor imaging along with conventional MRI.  The study provided clear evidence that DTI may serve as a microstructural imaging biomarker for cognitive dysfunctions and variations within normal cognitive functions.  Hopefully, further research will confirm this finding.  DTI has already been accepted in our courts as a reliable neuroimaging mechanism to detect brain injury from trauma.  Further studies such as this will only strengthen its admissibility.

I have written several times in the past on the validity of Word Memory Testing in diagnosing and treating traumatic brain injuries. A new study calls into question statements continuously made by Paul Green that the SVT measures on the Word Memory Test requires minimal to no cognitive effort.  Reporting in this month’s issue of the Journal International Neuropsychological Society (2008), 14, 1074-1080, Batt et al., from the Department of Psychology McQuarie University, Sydney, New South Wales, Australia, measures the effect of distraction on the Word Memory Test (WMT) and Test of Memory Malingering (TOMM) performance in patients with a severe brain injury. 

According to the paper, the “research compares the performance of a sample of non-litigating participants with severe brain injury on both the WMT and TOMM under conditions of (1) full effort, (2) distraction, or (3) simulated malingering.”  The study included sixty participants with a severe brain injury.  The study revealed that while both tests demonstrated excellent sensitivity, the false positive rates for the WMT were significantly greater than those for the TOMM.  It was concluded that the so-called “effort” components of the WMT required more cognitive capacity than was previously believed.
 
In the discussion portion of the paper, the authors noted that the findings of those participants who failed the WMT had significantly lower estimated pre-morbid intelligence than those who passed, which further supported the notion that the WMT results are influenced by cognitive ability.  The authors also noted:  "In addition to this, false positives on the WMT were unacceptably high, which decreased the specificity of the test to unacceptable level."
 
The authors noted that this unacceptably high rate of false positives may not satisfy Daubert standards.

United States Representative Bill Pascrell, Jr. of New Jersey, the co-founder and co-chairman of the Congressional Brain Injury Task Force, applauded the Department of Veterans’ Affairs for increasing disability payments for veterans diagnosed with mild traumatic brain injury (mTBI). The VA estimates that compensation for mTBI victims will increase from about $117 per month to as much as $600 per month. The VA states that these changes will help roughly 3,500 to 5,000 veterans each year.

A recent study estimates that up to 320,000 troops who served in Iraq and Afghanistan have suffered from a traumatic brain injury. “I’m pleased that the VA has finally opened its eyes, and more importantly its wallet, to the thousands of veterans and their families who have silently suffered from traumatic brain injury,” stated Representative Pascrell.  “This decision was a long time coming, but marks significant progress.  Unfortunately, there is still long way to go before I am fully satisfied with the services available to America’s brain injured veterans.”

Representative Pascrell is awaiting a response to his September 19, 2008 request for the Department of Defense Secretary Robert Gates to expand TRICARE to cover cognitive rehabilitation therapy for TBI victims.  The letter was supported by a bipartisan coalition of 67 House of Representatives members.