Brain Injury and Medical Malpractice

The prevalence of brain injury in the United States is alarming as it is the second leading cause of disability in the country. Often referred to as the silent epidemic, approximately 3.17- 5.3 million Americans suffer from traumatic brain injuries, another 4.7 million have brain injuries from strokes, and another 500,000 have cerebral palsy (brain injury due to an event of oxygen deprivation). Causes of brain injury that may give rise to a medical malpractice lawsuit are further described below: 

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Brain Injury from Birth: a medical malpractice lawsuit may arise may when a child's brain is negligently deprived of oxygen during pregnancy, labor and delivery. This may result in the child later developing cerebral palsy, mental retardation, seizures, blindness, deafness, and learning disabilities. Oxygen deprivation that injures a baby's brain may arise from any of the following events: 

*Compression of the umbilical cord during delivery

*Maternal Infection present during the pregnancy or delivery

*Placental abruption or uterine rupture prior to birth

*Maternal high blood pressure during the pregnancy (preclampsia)

*Breeched vaginal position of the baby (feet first rather than head first)

*Improper administration or doasage of epidural or labor inducing drugs during the delivery

*Failure to timely perform an emergency c-section

*Fetal macrosomia (oversized baby) unable to navigate the birth canal 

Brain Injury in Adults and Children: a medical malpractice lawsuit may arise as a result of errors in diagnosis and treatment of a serious medical condition. A few of the causes of brain injury in children and adults that may involve medical malpractice include: 

*Medication errors

*Anesthesia errors

*Surgical errors

*Radiology errors 

*Emergency room errors

*Delay in diagnosis/treatment of heart attack or cardiac arrest

*Delay in diagnosis/treatment of a stroke, aneurysm, or blood clot

*Delay in diagnosis/treatment of meningitis or encephalitis

*Delay in diagnosis/treatment of a spreading infection or abscess

*Delay in diagnosis/treatment of internal bleeding

*Delay in diagnosis/treatment of hydrocephalus 

*Delay in diagnosis/treatment of diabetes/diabetic coma/insulin shock

In addition to the above mentioned causes of brain injury, many other errors involving patient treatment and care may give rise to a lawsuit.  One of the most common causes occurs when a hospital patient or nursing home patient falls (due to inadequate protective measures) and the patient suffers a traumatic brain injury.  In fact, falls are the leading cause of traumatic brain injury in our country surpassing even motor vehicle accidents. For a detailed guide to the incidence, prevalence, and epidemiology of brain injury, see The Essential Brain Injury Guide prepared under the auspices of the Brain Injury Association of America.     

Increased Fluid Around the Heart May Cause Cardiac Tamponade

Pericardial effusion occurs when there is an abnormal amount of fluid around the heart.  The heart is normally surrounded by a thin membranous sac called the pericardium.  The space between the pericardium and the muscle that is the heart is referred to as the perciardial space.  Normal levels of pericardial fluid within the pericardial space are from 15 to 50 mL, or about 1-3 tablespoons.

iStock_000003834803XSmall.jpgAn effusion, therefore, represents  an abnormal accumulation of fluid in the pericardial space.   Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to increased intrapericardial pressure and this can negatively affect heart function.  Cardiac tamponade occurrs when there is a  large enough pericardial effusion causing enough pressure to adversely affect heart function.  This is an emergent life threatening condition.

Pericardial effusion symptoms may include difficulty breathing (dyspnea), shortness of breath when lying down (orthopnea), chest pain, cough, dizziness, low grade fever, rapid heart rate (tachycardia), and a feeling of anxiety  

Pericardial effusion may be caused by:

-a disturbed equilibrium between the production and re-absorption of pericardial fluid,

-a structural abnormality that allows fluid to enter the pericardial cavity

-inflammation of the pericardium (pericarditis)

-bacterial or viral infections

-injury to the heart from a medical procedure

-cancer

-heart attack

-autoimmune disorders

Unfortunately, pericardial effusion and cardiac tamponade may result from improper placement of a central venous catheter during a medical procedure involving an infant.  This may arise when there is an inadvertent perforation into the pericardial space by the CVC and fluids are artificially infused into the space thereby causing the tamponade. Upon recognition of this situation, emergent removal of this fluid via a needle inserted through the chest wall and into the pericardial space (pericardiocentesis) can improve the infant's chance of survival. It is suggested that routine radiography be performed to readily identify the CVC tip in all cases when these lines are placed into babies.    Increased awareness of this complication may decrease the mortality associated with CVC related pericardial effusions.   

Treatment depends on the underlying cause and the severity of the heart impairment. Pericardial effusion due to a viral infection sometimes goes away within a few weeks without treatment.  Some pericardial effusions remain small and never need treatment.  If the pericardial effusion is due to an autoimmune condition treatment with anti-inflammatory medications may help. If the effusion is compromising heart function and causing cardiac tamponade, it will need to be drained, most commonlyby a pericardiocentesis.  In some cases, surgical drainage may be required by cutting through the pericardium creating what is referred to as a pericardial window

Deep Venous Thrombosis and Medical Malpractice

Deep venous thrombosis is the development of a blood clot in the large, deep veins of the lower leg and thigh. Thrombi can cause tissue injury due to vascular occlusion or distal embolization. However, venous obstruction can be offset by collateral blood vessels. Thrombi can also cause local pain and edema due to the blockage of blood flow. If the clot breaks off and travels through the blood, it is referred to as an embolism. An embolism can become trapped in the brain, lungs, or heart leading to major injury. Pulmonary embolus (PE) is a common complication and life threatening if not treated quickly with anticoagulants. PE presents with shortness of breath, chest pain, and cough with blood in sputum

iStock_000012053156XSmall.jpgDVT can occur with stasis or in hypercoaguable states. It is commonly seen following trauma, surgery, or burns, which contribute to decreased physical activity, damage to vessels, and release of procoagulant substances from tissues. Reduced physical activity causes a decline in the milking action of lower leg muscles and slows venous return. Risk factors for DVT include advanced age, bed rest, immobilization, smoking, birth control pills, family history of blood clots, fractures in the pelvis or legs, giving birth within the last 6 months, heart failure, and obesity.  To prevent DVT, patients should move their legs during long flights or when they are immobile for long periods of time.

Although many DVTs are asymptomatic, they can recur. Some individuals suffer from post-phlebitic syndrome, which involves chronic pain and swelling in the leg. The major symptoms of DVT include changes in a patient’s leg such as redness, increased temperature, pain, and tenderness. Diagnosis is based on the physical exam, which should demonstrate a red, swollen leg. Diagnostic tests include a D-dimer blood test along with other blood tests to check for hypercoagulability such as activated protein C resistance, anti-thrombin III levels, antiphospholipid antibodies, and genetic testing for mutations with a predisposition towards blood clots. Imaging studies of the legs include Doppler ultrasound, plethysmography, and radiography.

The primary treatment for DVT is anti-coagulants, also known as blood thinners. They prevent the formation of new clots and the growth of old clots. However, they cannot dissolve existing clots. Patients are more likely to bleed on these medications. Heparin is an IV administered anticoagulant given in a hospital setting.  Warfarin (Coumadin) is an oral anticoagulant that takes several days to work; thus, Heparin cannot be stopped until Warfarin is functioning at an effective dose for a minimum of two days. Many patients wear pressure stockings on their legs to improve blood flow and decrease their risk of DVT.  When medications are ineffective, patients may need to undergo surgery. A filter can be placed in the body’s largest vein to prevent thrombi from migrating to the lungs. Also, surgery may be necessary to remove large thrombi.  

Meningitis and Medical Malpractice

Meningitis is inflammation of the meninges, the membranes that cover the brain and spinal cord. It is commonly caused by infection, but other causes include chemical irritants, drug allergies, fungi, and tumors. Based on the clinical evolution of the illness and the type of inflammatory exudate present in the cerebral spinal fluid (CSF), infectious meningitis is categorized into acute pyogenic (usually bacterial), aseptic (usually viral), and chronic (usually tuberculosis, spirochetal, cryptococcal).

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Early diagnosis is essential for bacterial meningitis because it can result in death or brain damage if left untreated. In bacterial meningitis, a correlation exists between bacterial organism and age. The most likely organism in neonates may be Escherichia Coli or group B Streptococci. In the elderly, it may be Streptococcus Pneumonia or Listeria Monocytogenes. In young adults, it may be Neisseria Meningitides. In contrast, most viral infections are due to enteroviruses but only a small number of people who develop enteroviral infections present with meningitis. Other viral infections that can cause meningitis include mumps, herpes virus, measles, and influenza. Chronic meningitis can be caused by pathogens such as mycobacteria and spirochetes. Thus, medical attention is necessary to differentiate between bacterial, viral, and chronic meningitis.

Risk factors include individuals over the age of 60 or below the age of 5, diabetes mellitus, renal or adrenal insufficiency, hypoparathyroidism, cystic fibrosis, immunosuppression, HIV, crowding (military recruits and college residents), recent exposure to those with meningitis, etc. The symptoms have a rapid onset and include fever, chills, mental status changes, nausea, vomiting, photophobia, severe headache, and meningismus (stiff neck). Additional symptoms include agitation, bulging fontanelles, decreased consciousness, tachypnea, poor feeding or irritability in children, and opisthotonos (unusual posture, with head and neck arched backwards).

To confirm a diagnosis, a lumbar puncture (spinal tap) should generally be performed on anyone suspected of meningitis to sample and culture the CSF for abnormal cell counts, glucose, and protein. Other diagnostic tests include blood culture, chest x-ray, and MRI or CT scan of the head. The underlying cause of the meningitis needs to be determined to administer proper treatment and define the severity of each case. Unlike bacterial meningitis, viral meningitis usually does not involve treatment and patients generally recover within two weeks; however, in certain instances (such as with the herpes simplex virus) antiviral medications may be indicated.

Antibiotic treatment for bacterial meningitis is dependent on the underlying bacterium. By treating the most common types, the risk of dying is reduced to below 15%. Symptoms such as brain swelling, shock, and seizures are treated with other medications and intravenous fluids. Possible complications of meningitis include brain damage, subdural effusion, hearing loss, hydrocephalus, and seizures. To prevent contraction of meningitis, the meningococcal vaccination is recommended for populations at risk.

 

Advanced Diagnostic Imaging for Acquired Brain Injury

One of the first steps in evaluating brain injury is diagnostic imaging. Imaging refers to various methods of viewing the structures and processes residing in the brain. Some of the more familiar modalities are CT (or CAT) scans, which use X-rays to evaluate intracranial structures. MRI, Magnetic Resonance Imaging, uses magnetic fields to illustrate the brain. However, in cases of traumatic brain injury (TBI), more advanced methods may be needed for proper diagnosis.

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An MRI machine can use special software to perform a brain scan called Diffusion Tensor Imaging (DTI). This scan detects the diffusion of water across brain cells and highlights certain areas that may be associated with injury. These injuries may not be apparent on conventional MRI’s.

PET scan (Positron Emission Tomography) measures uptake and metabolism of glucose from a small radioactive “tagged” sample injected into the patient.  The scanner monitors this sample as the brain utilizes it. The metabolic uptake and usage may differ in patients who have suffered a brain injury. This helps define the extent and type of injury.

In SPECT (Single Photon Emission Computed Tomography), the tagged sample is not absorbed or utilized in the brain cells. Instead, it remains in the blood stream and demonstrates the blood movement or perfusion through the brain. Areas of brain injury or damage may not have normal blood flow so the SPECT scan helps define these areas.

Brain injuries can result from medical malpractice. A baby may suffer birth trauma during labor and delivery. A child may have a concussion or sports injury misdiagnosed or improperly evaluated by a physician. An individual injured in a car accident may not have the indicated testing done by the emergency room. Although scientific progress in imaging studies has improved the ability to diagnose and evaluate brain injuries, these tests need to be utilized in the appropriate situations so patient results and outcomes can improve.  

Brain Injuries and Birth

The brain is responsible for higher motor and sensory functions. It requires a constant source of oxygen in order to continue its vital functions. When the flow of oxygen is interrupted, the consequences can be devastating.  Severe injury can occur when the brain lacks the oxygen needed to continue functioning. A total lack of oxygen can be referred to as “anoxic” injury whereas a partial lack of flow can be referred to as “hypoxic” injury.

Brain injury can occur in an unborn baby if the flow of oxygen from the mother’s circulation to the baby’s is interrupted. This can happen from a number of causes. For example, the placenta can become partially detached from the wall of the uterus (placental abruption), which can interrupt the flow of oxygen to the baby. This complication can arise in pregnant patients with untreated or inadequately treated high blood pressure. Close monitoring of mother and baby, along with timely delivery and/or C-Section when needed can prevent these complications.

 

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Excessive contractions of the uterus (sometimes called “uterine hyperstimulation” or “tetanic contractions”) from labor, or from medicines used to accelerate labor, like pitocin, can cause problems with the baby’s oxygen supply. The rapid, powerful contractions of the uterus can prevent maternal oxygen from reaching the baby. If the flow of oxygen to the baby is interrupted, hypoxic or anoxic brain injury can occur. The consequences of this can be severe and may include seizures, brain damage, developmental delay, cerebral palsy, and other problems with motor or cognitive functions. Use of medications like pitocin must be closely monitored by dosage and effect on the mother and baby. If contractions are too strong or too frequent, the dosage may need to be decreased, the medicine may need to be stopped entirely, or special medication to reverse the effects may be given.

Brain injuries may occur in infants, children, and adults. Stroke, cardiac arrest, or choking can all interrupt the flow of oxygen to the brain. Patients who are undergoing surgery, or are in an intensive care unit in a hospital often have their oxygen levels monitored to be sure they are getting a sufficient supply. If they are not properly monitored or complications occur, hypoxic or anoxic brain injuries may result.

Medical malpractice that results in brain injury is devastating for the victim as well as families and loved ones. The extent of disability from hypoxic or anoxic brain injury varies greatly, but many people require extensive care and rehabilitation to regain function and improve their quality of life.

Normal Pressure Hydrocephalus and Medical Malpractice

iStock_000015502953XSmall.jpgCerebrospinal fluid (CSF) is a clear fluid that surrounds the brain and spinal cord. This fluid is continually produced and stored in ventricles, which are cavities of the brain. CSF cushions the brain, supplies the brain with nutrients, and removes wastes.  Excess fluid drained from the brain is absorbed by other tissues.

Hydrocephalus is a condition in which there is an abundance of CSF in the ventricles due to interference in proper drainage and absorption. To accommodate the extra fluid, the ventricles enlarge causing compression of  different parts of the brain.

Normal pressure hydrocephalus (NPH) is a type of hydrocephalus that occurs commonly in older adults. NPH is different from other types of hydrocephalus because it develops gradually. The slow enlargement of the ventricles causes the fluid pressure in the brain to not be as high as in other types of hydrocephalus. However, the enlarged ventricles still press on normal brain tissue

NPH often presents with the following clinical triad of findings: urinary incontinence, gait disturbance, and dementia, with urinary symptoms appearing later in the sequence.  Gait disturbance is often the initial and most prominent symptom of the triad. It may be progressive due to the expansion of the ventricular system. It generally presents as unsteadiness or impaired balance. Eventually, gait disturbances can lead to a need for canes or walkers. An increased tendency to fall backwards is also common. In the very late stages, the patient can progress to an inability to stand, sit, and rise from a chair. 

Dementia presents as apathy, forgetfulness, and a dullness of thinking. Memory problems are often predominant, which can contribute to a misdiagnosis of Alzheimer's disease. Although recall is severely impaired in NPH, recognition, a hallmark of Alzheimer’s, is either normal or slightly impaired.

Idiopathic NPH is normal pressure hydrocephalus occurring without a known cause; however, it can be attributed to any condition that blocks the flow of CSF such as bleeding from an abnormal blood vessel, an aneurysm, a closed head injury, meningitis or similar infections, and surgery on the skull.

The diagnosis of NPH is made by performing a lumbar puncture (spinal tap). If the initial pressure measurement is elevated, it points to a diagnosis of NPH. Clinical improvement after removal of CSF has a high predictive value for treatment success.  A CT scan of the brain will show enlarged ventricles, and an MRI may show certain technical findings consistent with enlarged ventricles and elevated cerebral pressures. Imaging alone cannot differentiate between NPH and other dementia causing conditions such as Alzheimer’s disease, Atherosclerotic vascular disease, and Parkinson’s disease.  

Treatment for NPH is surgical diversion of the excess CSF. A shunt is implanted to drain CSF from the intracranial ventricular system to a different location such as the peritoneal space in the abdomen. The most common shunts utilized today are called the ventriculoperitoneal (VP) and ventriculoatrial (VA) shunts.  Placement of a shunt is a neurosurgical procedure performed under general anesthesia, and usually takes less than an hour to complete. Cognitive impairment associated with dementia has been reported to improve in more than fifty percent of cases. Successful treatment for NPH is available; therefore, it is medicaly negligent to misdiagnose NPH as Alzheimer’s dementia, where responses to the latest therapy innovations are only temporary.   

Electrical brain mapping and epilepsy surgery

Epilepsy is one of the most common neurologic diseases in the world and is present in 4% 
of the world's population. The majority 
of patients with epilepsy can be managed medically. Intracranial surgery involves inherent 
risks; thus, surgery is only indicated if the benefits outweigh the risks of uncontrolled
 seizures. If surgery is indicated, the patient must undergo a pre-surgical evaluation that involves an extensive medical history focusing on
 seizure activity, type, frequency, and duration. In addition a physical exam must be performed to ensure 
there are no alternative causes for the seizures. The patient is considered a candidate for surgery for a variety of reasons such as inadequate response to medications; inability to tolerate medications due to side effects; seizures that significantly affect quality of life; seizures caused by a lesion such as scar tissue, brain tumor,arteriovenous malformation, or birth defect; partial seizures that always start in one area of the brain; and seizure discharges that spread to the whole brain (secondary generalization). 

iStock_000017465619XSmall.jpgOnce the patient meets the criteria for surgery, electrical brain mapping or electrocorticography is done to provide the surgeon with the necessary information about the brain
 to safely and accurately perform the surgery. Brain mapping is performed to localize the seizure focus, the area of the brain where the seizures begin. In addition, brain mapping identifies significant structures in the brain so the seizure focus may be removed without injuring vital brain structures relating to speech, comprehension, sight, movement, sensation, etc. Brain mapping is essential 
to determine whether the surgery is possible and the potential dangers to the surrounding 
brain regions.

Brain mapping determines the function of a particular area by providing direct stimulation via a current applied to a small area of the brain’s surface. Initially, the physician applies the lowest current and gradually the current is increased until a preset maximum is reached or a significant response is seen. The current interferes with how that area normally functions, but once the current is stopped that area of the brain resumes its usual activity. For example, if a current causes the patient to stop speaking, or to speak unclearly or incoherently, then that area is likely essential for language function. Once the function of an area is identified, a new location in that region is chosen and the physician starts over with the lowest current. Thus, a map is created that illustrates individual functions of different brain areas.

Electrode mapping can be performed in two ways: in a two-stage procedure (the most common way) or directly during the surgery itself. Generally, the current utilized is neither painful nor felt by the patient. However, an electrode occasionally makes contact with the membranes surrounding the brain and at these locations, the patient may experience pain or a tingling sensation when the current is applied. These contacts are easily identified and avoided because physicians always start at a low current.

In the two stage procedure, the surgeon creates an opening in the cranium that exposes the surface of the brain. Electrodes (small electrical contacts) are placed, the scalp is closed, and the patient is then closely monitored in a hospital bed. The electrodes then record the patient’s seizures identifying the seizure focus and map the areas of the brain under electrodes. The two stage procedure utilizes extra-operative brain mapping because it happens outside of an operating room. The patient is always awake, conscious, and able to fully participate during the mapping. The second stage of the procedure is the surgery itself, which removes the abnormal brain tissue using the information gathered from the electrical recordings and brain mapping.

Electrical brain mapping can also be performed during any surgery that exposes part of the brain. Therefore, it is an intraoperative procedure because it occurs during an operation. The surgeon tests locations on the brain’s surface using small electrical probes to create a map of functions. Even if the patient is under anesthesia, areas involved with movement can still be identified electrically; however, the patient must actively participate to map areas involving language, sensation, or vision. The patient is awakened from anesthesia and is given the necessary medications to eliminate pain. Intraoperative mapping is generally done when prior extraoperative mapping discovered important functions adjacent to the area targeted for removal.

Every neurosurgical procedure involves risks such as infection, bleeding, and cerebral edema (accumulation of water in the brain). The major risk for this procedure, specifically for individuals with epilepsy, is that a seizure may be triggered because mapped areas are in close proximity to where the seizures usually begin. Applying electrical currents to areas near the seizure focus can set off a seizure so physicians must closely monitor the patient’s brainwaves during the stimulation. If electrical discharges are noted that could evolve into a seizure, the stimulation is immediately stopped. If a patient suffers from a seizure, the mapping is stopped until the patient fully recovers. If the area being mapped is very sensitive, the patient is often given a powerful anti-seizure medication before receiving any further electrical stimulation.

If the surgeon collects incorrect data during electrical brain mapping and/or excises excessive brain tissue during surgery, the patient may be left with permanent neurological impairment. It is in these scenarios, among others, that a medical malpractice claim could arise. 

Child Abuse and Neglect

Child neglect is the most prevalent form of child maltreatment in the US. According to the National Child Abuse and Neglect Data System (NCANDS), approximately 899,000 children in the US who were victims of abuse and neglect in 2005, 62.8% suffered from neglect alone. Child neglect is a failure by parents or caregivers to provide for a child’s basic physical, educational, and emotional needs. It is difficult to define because it varies with the age and development of the child; therefore, it is problematic to determine the extent of the problem. Risk factors for abuse include: preexisting mental or physical illness, poverty, familial stress, substance abuse by parents or caregives. Physicians, nurses, day care personnel, relatives, and neighbors are generally the ones to suspect and report neglect; however, they may be the culprits too. Often times, signs of child neglect may include inadequate medical or custodial care.

Physical neglect encompasses the majority of neglect cases and it involves the parent/caretaker not granting the child basic necessities such as food, clothing, medical care, and shelter. By depriving the child of these essential things, his or her physical health, well being, psychological growth and development is jeopardized. Failure to thrive, malnutrition, serious illness, physical injury due to lack of supervision, and low self-esteem are a some of the byproducts of physical neglect. As an unfortunate example, infants are sometimes mistakenly left behind in cars or vans by their caregivers when the outside temperature is very hot, resulting in heat stroke or death to these infants. 

Regarding child abuse, medical neglect is the failure to deliver necessary healthcare for a child thereby endangering the child’s well being. Situations involving medical neglect include when a parent refuses medical care for a child in an emergency or when a parents does not follow recommendations for a child with a treatable chronic disease or disability. Medical neglect often correlates with poverty; however, there is a difference between an inability to provide the appropriate care due to finances or cultural norms and being purposefully neglectful.

If one suspects child neglect, the first step is to report the incident to local child protective services agency in the county or state. The majority of states have a child abuse hotline or you can use the Childhelp National Child Abuse Hotline (1-800-4-A-CHILD). Professionals involved with children have a duty to report reasonable suspicion of abuse and neglect. Reasonable suspicion is based on objective evidence which includes firsthand observation or statements made by a parent or child. Symptoms of negelect include: difficulties in school, eating disorders, low self esteem, depression, anxiety, signs of physical injury, rebellious behavior, sleep disorders, and other vague physical complaints.

Fungal Meningitis Outbreak- over 300 infected, 25 deaths

An outbreak of fungal meningitis due to contaminated epidural methylpredinsolone (steroid) injections, made by the New England Compounding Center, has been ongoing throughout the United States. Meningitis is a disease caused by inflammation of the meninges, the membranes that cover the brain and spinal cord. It can be caused by bacteria, viruses, fungus, physical injury, cancer, and certain medications. Fungal meningitis is generally rare and non-contagious. In the recent outbreak of fungal meningitis, the contaminant was an environmental mold known as Exerohilum rostratum, a plant pathogen that rarely causes human disease. It was identified by polymerase chain reaction assay from CSF in at least 25 patients and it has been detected in at least one unopened vial from the implicated batch of methylprednisolone . A quarter of the steroid vials in a bin at the England Compounding center contained “greenish black foreign matter” and several rooms utilized to produce sterile products demonstrated mold or bacterial overgrowth according to the FDA

All locations that received contaminated injections were notified and individuals who received injections from these locations were informed of the possibility of fungal infection. It is likely that not every individual who underwent an injection will contract fungal meningitis. However, individuals with underlying health conditions, circumstances surrounding the injection, and the level of contamination of a particular vial may increase susceptibility. The New England compounding center, where the injections were produced, was closed and all their products were recalled. The CDC currently reports over 300 infected and 25 deaths in patients who received contaminated injections

Patients should inform physicians of any symptoms such as new-onset headache, neck stiffness, photophobia, fever, or a stroke-like presentation. The incubation period is 1-4 weeks after receiving the contaminated injection. Any individual can contract fungal meningitis; however, it is often seen in individuals with weakened immune systems, such as AIDs or cancer, or individuals taking immune-suppressants, like steroids or anti-TNF medications.

Blood cultures, imaging (Xray or CT), and lumbar puncture are used to diagnose meningitis. A definitive diagnosis is generally made by evaluating cerebrospinal fluid collected from a lumber puncture, also known as a spinal tap. CSF findings in fungal meningitis are increased pressure, increased protein, decreased glucose, and increased lymphocytes. It is essential to diagnose the specific cause of meningitis to determine treatment and severity of illness.  Fungal meningitis is generally treated with long courses of high dose intravenous antifungal medications, such as amphotericin B or flucytosine. The length of treatment depends on the patient’s immune status and type of fungus. Individuals with weakened immune systems need to remain on treatment for longer.

Pituitary Adenomas and Medical Malpractice

A pituitary adenoma is generally a benign, slow growing tumor that occurs in the pituitary gland. The pituitary gland is a small, bean shaped structure that lies at the base of the brain. It has a central role in the regulation of hormones that affect the body such as Adrenocorticotropic hormone (ACTH), Growth hormone (GH), Prolactin, and Thyroid-stimulating hormone (TSH).

Approximately 1 in 1,000 individuals have pituitary adenomas. They are generally not cancerous but may invade nearby structures.  They are classified based on size. A microadenoma is less than 1 cm in diameter whereas a macroadenoma is larger than 1 cm in size.

iStock_000017548218XSmall.jpgBased on whether the pituitary adenoma is a hormone-producing or hormone-inactive tumor, the patient will present with different symptoms. Hormone-producing tumors will make excessive amounts of an active hormone so symptoms present as a hormonal imbalance. The three most common hormone-producing adenomas are Prolactinomas, Growth hormone-secreting pituitary adenoma, and ACTH-secreting pituitary adenoma.

If the patient has a large hormone-inactive or hormone-producing tumor, it may compress surrounding brain structures due to its size.  Large pituitary tumors may compress the pituitary gland contributing to pituitary failure, which can lead to sexual dysfunction, inadequate body cortisol levels, and hypothyroidism. Other possible presentations relating to compression of brain structures include visual loss, headache, the “stalk effect”, and pituitary apoplexy.  The “stalk effect” is due to the compression of the pituitary stalk, the structure connecting the brain to the pituitary gland, which leads to a mild elevation in the hormone prolactin. Higher levels of prolactin in females can contribute to irregular menstrual cycles. Pituitary apoplexy presents with an abrupt headache and visual loss. It can occur under two different situations. The pituitary adenoma can bleed internally causing a sudden increase in size or the tumor can outgrow its blood supply and the dead tissue will swell.

Pituitary adenomas can be diagnosed based on endocrine function testing, imaging, and visual field testing. Often times, visual problems may be the only symptom present.  Optometrists and ophthalmologists should seriously consider the possibility of a pituitary tumor when the patient presents with an unexplained loss of visual field (especially peripheral vision), double vision, or blurred vision as the growth of a pituitary tumor can cause compression on the visual pathway (retina, optic nerve, etc). A delay in diagnosis of a pituitary adenoma may result in permanent loss of vision due to the damage caused by this compression. Endocrine function testing evaluates cortisol, follicle-stimulating hormone, lutenizing hormone, insulin growth factor-1, prolactin, testosterone/estradiol, and thyroid hormone levels. The preferred method of imaging is MRI, which screens for adenomas larger than 4 mm.

Treatment for pituitary adenomas depends on the presence of hormone production, size of the tumor, invasion of the tumor into surrounding structures, and the age and health of the patient. Drug therapy is used to treat hormone-producing tumors. For example, bromocriptine and cabergoline are used to treat tumors secreting prolactin because these medications decrease prolactin levels and tumor size. Pituitary adenomas that require surgery are usually minimally invasive techniques, where the tumor is removed through the nose.  On the other hand, radiation therapy involves high doses of radiation being delivered to the tumor. It is a treatment utilized for pituitary adenomas that cannot be controlled by drug therapy or surgical intervention. Patients have the best outlook when the entire tumor can be removed. 

Lumbar Puncture - Indications and Usage

Lumbar puncture is a procedure performed in the lower back area, where a needle is inserted between two vertebrae to remove a sample of cerebrospinal fluid (CSF). The patient flexes his/her back to widen the spaces between the vertebrae so it is easier for the physician to access the region. The back is washed with antiseptic soap or iodine and covered with a sterile sheet. A local anesthetic is used to numb the area and then a thin hollow needle is inserted through the spinal membrane and into the spinal canal. During this portion of the procedure, the patient generally feels pressure. The CSF pressure is measured, a small amount of fluid is removed, and the pressure is measured again. The needle is removed and the site is bandaged. The total procedure takes about 45 minutes.

Thumbnail image for Thumbnail image for iStock_000016020161XSmall.jpgLumbar puncture is used to collect CSF for analysis to help in diagnosing conditions such as subarachnoid hemorrhage (typically caused by ruptured aneurysm or traumatic brain injury), meningitis (inflammation of the membranes around the brain), and cancers of the brain or spinal cord. Lumbar Puncture may also be utilized to inject anesthetic medications, chemotherapeutic drugs, contrast material, or radioactive substances into CSF. 

Lumbar Puncture may be used to identify increased or decreased CSF pressure.  Increased CSF pressure can be caused by increased intracranial pressure as is seen with traumatic brain injury, ruptured aneurysm, and sometimes hydrocephalus. On the other hand, decreased CSF pressure can be caused by spinal cord tumor, shock, fainting, or diabetic coma.  Normal CSF appears clear and colorless. When an infection is present, the CSF may look cloudy and be yellow or pink in color. Infection may be suspected if there is an increased level of white blood cells and/or protein. Increased CSF glucose indicates hyperglycemia whereas decreased CSF glucose may reflect hypoglycemia, bacterial or fungal infection, tuberculosis, or meningitis. If tumor cells are detected, the patient may have cancer in the brain, spinal cord, or CSF.  If there are increased gamma globulin levels, the patient may be suffering from multiple sclerosis, neurosyphilis, or Guillan-Barre syndrome. The analysis of the CSF by the lab and the measuring of CSF pressure recorded from the lumbar puncture help in determining a diagnosis in many serious clinical situations.  

Premature Birth May Result in Injury to the Newborn

Premature birth can often result in complications for the newborn. Preterm or premature birth refers to babies born before 37 weeks of a normal 40 week long pregnancy

Some complications that can affect babies born prematurely are lung complications from lack of pulmonary maturity or development. Eye problems can result in vision difficulties or blindness. Premature babies may be more prone to infections and intestinal problems. They also are at increased risk for bleeding in the brain which can have devastating effects. Conditions ranging from learning disabilities to cerebral palsy and seizures are more common in babies born prematurely.

Thus it is extremely important that premature labor be diagnosed in a timely fashion by the patient’s health care provider. Steps can be taken to treat the underlying cause of the preterm labor. For example, if a maternal infection is present that is related to the preterm contractions , the infection needs to be diagnosed and treated. Certain conditions, such as twins, increase the risk of premature labor. Also, some anatomic abnormalities of the cervix or uterus can elevate the risk as well.

Although it may not be possible to prevent premature birth, certain steps can be taken to prolong the time until delivery. This may give time for medications to be administered that may significantly improve the newborns outcome by enhancing lung development or decreasing the risk of intestinal problems. Infections that are properly diagnosed and treated may likewise improve the premature baby’s situation.

Medical malpractice may occur when a pregnant patient’s symptoms, such as premature contractions, bleeding, or rupture of membranes are not properly evaluated and managed. If needed interventions such as medication to improve lung function, or antibiotics, are not given in cases where they are indicated, malpractice may have occurred. An evaluation by attorneys with experience and knowledge of these complex medical and legal issues can help clarify issues for victims of medical malpractice.