Factors that Decrease Inequities in the Healthcare System

Does healthcare inequities exist for minority populations and the poor in the United States?

The family of Thomas Eric Duncan thinks so. They are upset about the “unfair” medical care he received at Texas Health Presbyterian Hospital in Dallas, Texas. Mr. Duncan was from Liberia. He was the first person to die of Ebola in the U.S. after being infected with the Ebola virus.

Mr. Duncan’s nephew, Joe Weeks, told ABC News he felt Duncan had “unfair” medical treatment. Mr. Weeks suggested that Mr. Duncan did not get the same treatment being given to Ebola patient Ashoka Mukpo, in a Nebraska hospital. He did not cite the differences in care.

Although hospital officials told the family they were capable of managing Mr. Duncan’s care, the family questioned why Mr. Duncan was not moved to Emory University Hospital, where two American health workers had been successfully treated following an infection with the Ebola virus while in Liberia. Mr. Weeks said the family was also frustrated that Mr. Duncan was not given donated blood from Ebola survivors to pass on their antibodies of the virus to Mr. Duncan. The hospital officials told the family “that the blood wasn’t a match.”

The jury is still out regarding the facts surrounding Mr. Duncan’s case, and the major snafu that occurred when he initially went to the emergency room for care, but was released and sent home with treatment from antibiotics, thus culminating in his death.

What can we do, in the meantime, as healthcare professionals to ensure that all patients perceive the quality of medical care they receive as being excellent, regardless of their race or economic status?

The racial and ethnic health inequities don’t just reflect income. More African American, Native American, Latino and Pacific Islanders are in poor or less fair health than whites at practically every income level (although recent Latino immigrants report better health).

Ethnic differences highlight the need to further examine social support, socioeconomic status, access to care, and cultural factors to guide future health-related quality of life (HR-QOL). Health includes physical, mental, and social realms.

On the individual level, this includes physical and mental health perceptions pertaining to health risks and conditions, functional status, social support, and socioeconomic status. On the community level, HRQOL includes resources, conditions, policies, and practices that influence a population’s health perceptions and functional status.

HRQOL enables health agencies to legitimately address broader areas of healthy public policy around a common theme in collaboration with a wider circle of health partners, including social service agencies, community planners, and business groups.

The evaluation, diagnosis, treatment, and management of medical conditions will result in significant positive outcomes when there is a clear pathway regarding the objectives to promote healthy behaviors. The implementation of transparent programs and intervention services along with proper allocation of resources is necessary to close health care gaps and decrease priority disparities.

In addition to HRQOL elements, the cultural competency of health care workers is important, and includes five factors that influence health communication.

  1. Behaviors or the manner in which health care workers conduct themselves through their actions and responses with patients from varied demographics. Is the healthcare worker tolerant and attentive or standoffish and impatient?
  2. Language or methods used to ask questions and receive answers for the purpose of exchanging information in a clear and concise manner, which can be understood and recognized by all parties involved. This is extremely important for the purpose of providing medical care and treatment intervention. Does the healthcare facility have a language interpreter for patients that may speak English as a second language so that thoughts and ideas may be conveyed and received properly?
  3. Customs-Is the healthcare worker trained to recognize actions or ways of behaving that are common and traditional among people in a particular group. For example, it is a custom in some religious groups to never leave the woman alone with a male that is not her relative. Does the healthcare organization or facility make concessions for this?
  4. Beliefs or feelings of being sure that someone or something exists or that something is true. Does the healthcare organization have an Imam, priest, and rabbi present for patients and their loved ones who are spiritual believers seeking spiritual guidance and comfort from a ‘Higher Power?’
  5. Perspectives or mental thoughts, feelings, and emotions within and about the environment. Is there a meeting of the minds during the initial contact? Is the communication and explanation process regarding medical treatment between the patient and their family with the hospital staff comprehended? Are next steps going forward understood?

Clearly, these factors are important for achieving accuracy during triage and during the continuum of medical care. The takeaway from the events that transpired in Dallas, Texas is that if healthcare disparities are present, they will often result in suboptimal care, misunderstandings, the potential threat of legal action, and a public relations nightmare.

The Complex Funding of an Afghanistan Troop Drawdown

May 9, 2012

By Melissa Bynes Brooks

A myriad of questions persist following President Obama’s recent pact with Afghanistan President Hamid Karzai. The pact signals the transition of responsibility and leadership to the Afghan people for their own security as the U.S. drawdown continues with 23,000 troops leaving Afghanistan this summer.

The International Security Assistance Force (ISAF), whose main role has been to assist the Afghan government in the establishment of a secure and stable environment, will have more supportive responsibilities but will still be available for combat if needed.

There are uncertainties vis-à-vis conditions on the ground, capabilities of the Afghan security forces, and the extent of U.S. involvement beyond 2014 when the Afghans are projected to be completely responsible.

What we know for sure, is that the war ending agreement is closely aligned with the sentiment of the majority of Americans. Many are war weary due to the number of casualties, impeding progress, and perceived corruption of the Afghan government.

At least 1,842 members of the U.S. military have died in Afghanistan as a result of the U.S.-led invasion in late 2001.

A Reuters/Ipsos poll on May 4, found Seventy-seven percent of Americans said they wanted all U.S. combat troops to leave Afghanistan by the end of 2012. This does not include trainers and Special Forces. 73 percent said they did not want the United States to establish any permanent military bases in Afghanistan. The poll had a credibility interval of plus or minus 4.1 percentage points.

Managing the complexity of cost related items and estimating the impact of future expenditures is a major concern. President Obama has acted to properly resource the Afghan war. Many of the problems faced prior to him taking office might have been avoided with proper management during the Bush Administration.

Since the 9/11 attacks, Congress has approved a total of $1.283 trillion for military operations, base security, reconstruction, foreign aid, embassy costs, and veterans’ health care for the three operations initiated.

Congressional Research Service (CRS) estimates Operation Enduring Freedom (OEF), covering primarily Afghanistan and other small Global War on Terror (GWOT) operations ranging from the Philippines to Djibouti, will receive $444 billion (35%) of the $1.283 trillion total.

Were it not for the diversion of the Iraq war, incurred costs for reliance on the Reserves and National Guard may have been diminished. 82,800 to 142,000 active duty troops stationed in Iraq between May 2003 and January 2005 would have been assigned to Afghanistan instead. Reservists cost more than active-duty personnel during wartime because of the additional cost of paying full-time rather than part-time salaries.

Furthermore, costs related to contracts with private military security firms would have been lower. Private security guards working for Blackwater in Iraq, in 2007, were earning up to $1,222 a day to over $445,000 a year. Compare that to an Army sergeant earning $140 to $190 a day in pay and benefits for a total of $51,100 to $69,350 a year.

But it is what it is.

It is a documented fact that Operation and Maintenance (O&M) funds grow faster than troop levels. O&M are used to transport troops and their equipment to Afghanistan, conduct military operations, provide in-country support at bases, and repair war-worn equipment.

Operation & Maintenance (O&M) funding nearly doubled between FY2004 and FY2008, from $42.0 billion to $79.1 billion, an increase of $37.1 billion.

However, troop levels are one of the key factors in driving costs in the Afghan war. The Administration cited $1 million per troop per year in Afghanistan to justify its $30 billion supplemental request for FY2010.

Troop downsizing is a big part of the Obama administration’s plan to save $259 billion over the next five years and $487 billion in defense cuts over 10 years.

The FY2013 Department of Defense (DOD) budget request includes a total of $613.9 billion indiscretionary budget authority: $525.4 billion for the so-called “base budget” (excluding operations in Afghanistan and Iraq), and $88.5 billion for war costs or “Overseas Contingency Operations” (OCO).

Overall, that request is $31.8 billion less than was appropriated for DOD in FY2012, with most of the reduction accounted for by the continuing drawdown of U.S. forces in Afghanistan.

Additional funding will be needed and the acquisition of support from other entities will not occur without incident.

A successful Afghanistan transition will require the collaboration and assistance from various donor countries. There is no doubt; each country will indicate their expected benchmarks for signs of improvement in order to solicit funds from their respective legislatures.

This will be an agenda item at the upcoming North Atlantic Treaty Organization (NATO) Summit with leaders from around the world which President Obama will host in Chicago from May 20-21.

Earlier this month, NATO Secretary General Anders Fogh Rasmussen stressed the importance of this month’s Chicago Summit to the future of the Alliance and its mission in Afghanistan. He said the Chicago Summit will be a crucial one for the Alliance that consists of 28 independent member countries. The Summit will have three main goals: Afghanistan, capabilities and partnerships.

There is an aura of optimism in the midst of conjecture.

At the Department of Defense on May 1, during a background briefing on the Section 1230 Report on Progress toward Security and Stability in Afghanistan, a Sr. State Department Official said, “There- we’re slowly but surely making it to our 1 billion euro challenge. So we hope to make it.”

Melissa Bynes Brooks is the editor of BrooksSleepReview.

Contact information: melissabynesbrooks@comcast.net

Follow on Twitter @Mlbbrooks

References

Bureau of Public Affairs, U.S. Department of State. (2006). North Atlantic Treaty Organization (NATO). Retrieved May 6, 2012, from http://future.state.gov/what/special/76741.htm.

Charles, D., Thomas Reuters (2012). Americans favor limited U.S. role in Afghanistan. Retrieved May 5, 2012, from http://www.reuters.com/article/2012/05/05/us-afghanistan-usa-poll-idUSBRE84401420120505.

Congressional Budget Office (2012). CBO Releases An Analysis of the President’s 2013 Budget. Retrieved May 6, 2012, from http://www.cbo.gov/publication/43103.

Congressional Research Service, CRS Report for Congress Prepared for Members and Committees of Congress (2012). The Cost of Iraq, Afghanistan, and Other Global War on Terror Operations since 9/11. Retrieved May 4, 2012, from http://www.fas.org/sgp/crs/natsec/RL33110.pdf.

Cordesman, A.H., CSIS Center for Strategic and International Studies (2012). Afghanistan: The Death of a Strategy. Retrieved May 6, 2012, from http://csis.org/publication/afghanistan-death-strategy.

Davies, D., NPR (2008). Excerpt: ‘The Three Trillion Dollar War’ by Joseph Stieglitz and Linda Bilmes: Factors Driving Up Spending. Retrieved May 7, 2012, from http://www.npr.org/templates/story/story.php?storyId=87801279#.

FY2013 Defense Budget Request: Overview and Context. Retrieved May 5, 2012, from http://www.fas.org/sgp/crs/natsec/R42489.pdf.

Garamone, J., U.S. Department of Defense (2012). Panetta Announces Fiscal 2013 Budget Priorities Trip. Retrieved May 6, 2012, from http://www.defense.gov/news/newsarticle.aspx?id=66940.

North Atlantic Treaty Organization (2012). NATO Secretary General stresses importance of Chicago Summit to Alliance’s future at Berlin Talks. Retrieved May 6, 2012, from http://www.nato.int/cps/en/SID-5D80DEE8-6B8008EF/natolive/news_86869.htm.

Parrish, K., American Forces Press Service (2012). Dempsey: Military Contracting Costs Must Shrink. Retrieved, March 6, 2012, from  http://www.defense.gov/news/newsarticle.aspx?id=67440.

The White House (2012). Remarks by President Obama in Address to the Nation from Afghanistan. Retrieved May 5, 2012, from http://www.whitehouse.gov/the-press-office/2012/05/01/remarks-president-obama-address-nation-afghanistan.

U.S. AID/Afghanistan (2012). Afghanistan: Facts & Figures. Retrieved May 6, 2012, from http://afghanistan.usaid.gov/en/about/facts_figures.

U.S. Department of Defense. Defense Secretary’s Panetta Message (2012). Trip Message: Kyrgyzstan, Afghanistan, United Arab Emirates. Retrieved May 6, 2012, from http://www.defense.gov/home/features/2011/0711_message1/.

U.S. Department of Defense, Office of the Assistant Secretary of Defense (Public Affairs) News Transcript (2012). Presenter: Senior Defense Department Official; Senior State Department Official. Section 1230 Report on Progress toward Security and Stability in Afghanistan. Retrieved May 6, 2012 from http://www.defense.gov/transcripts/transcript.aspx?transcriptid=5023

President Obama’s Export Economy

By Melissa Bynes Brooks
April 14, 2012

The accurate forecasting of export trends and developments in the foreign market place by the Obama Administration, demonstrates this administration’s competence for reviewing and analyzing financial data that affects the economy. The outcome epitomizes their proficiency for implementing strategies that influences growth in a positive direction.

The President launched the National Export Initiative (NEI) during his State of the Union address on January 27, 2010 and established a national goal of doubling U.S. exports by the end of 2014. This was to done so that U.S. Government agencies are focused and working together to ensure that U. S. companies have access to these markets, and that all companies, large and small, get the assistance they need to compete on a fair and level basis with foreign competitors.
Here is some insight regarding the steady improvement of the economy under the Obama Administration with respect to exports.

Specifically, U.S. export sales grew by more than 11 percent in 2010 in real terms, the fastest growth since 1997. In terms of job creation, the number of U.S. total export-supported jobs increased by almost 6 percent in 2010, even as the overall economy was still losing jobs.

IHS Global Insight expects trade to soften in 2012, with export values increasing only 4.8% while import values rise 5.8%, due to the Eurozone’s sovereign debt crisis. However, the driver for exports continues as fast-growing countries with increasing middle class sizes and infrastructure needs creates a demand for U.S. goods such as machinery, transportation, and chemicals industries. It’s estimated that U.S. export growth will average 8% annually over the next 10 years, outpacing imports which will advance by 4.8%. As a result, the U.S. trade deficit should continue to decrease as opportunities to sell goods globally increase.

Data released on April 12, 2012, by the U.S. Bureau of Economic Analysis and U.S. Census Bureau, showed the U.S. monthly international trade deficit decreased in February 2012. The deficit decreased from $52.5 billion (revised) in January to $46.0 billion in February, as imports decreased and exports increased. The previously published January deficit was $52.6 billion. The goods deficit decreased $6.0 billion from January to $61.4 billion in February, and the services surplus increased $0.5 billion to $15.4 billion.

Exports of goods and services increased $0.2 billion in February to $181.2 billion, reflecting an increase in exports of services. The increase in exports of services was mostly accounted for by increases in travel, other private services (which includes items such as business, professional, and technical services, insurance services, and financial services), and royalties and license fees.

Exports of goods decreased. The decrease in exports of goods was more than accounted for by decreases in automotive vehicles, parts, and engines and foods, feeds, and beverages. Increases in other goods and consumer goods were partly offsetting.

In data released by the Bureau of Economic Analysis on March 29, 2012, real gross domestic product (GDP) after changes of inflation are taken into account, increased at an annual rate of 3.0 percent in the fourth quarter of 2011 (from the third quarter to the fourth quarter), according to the “third” estimate released by the Bureau of Economic Analysis. In the third quarter, real GDP increased 1.8 percent. What’s notable here is that exports contributed to the increase in real GDP in the fourth quarter although imports, a subtraction in the calculation of GDP, increased.

Many Americans continue to grapple with higher levels of unemployment and poverty as the labor market recovery continues. However, the economy has added jobs continuously since October 2010 and had 2.2 million more jobs in February 2012 than in June 2009, when the economic recovery started. The private sector has added 2.8 million jobs during this period.

In keeping his commitment to improve the economy, President Obama continues to be engaged in economic activities and is currently attending the Sixth Summit of the Americas held in Cartagena, Colombia from April 14-15, 2012, where he will be promoting U.S.-Latin America trade ties to help accelerate private sector job growth.

References

IHS Global Insight (2012). U.S. Metro Economies: Exports in the Next Decade. Retrieved April 14, 2012, from http://usmayors.org/exportsandports/media/metro-exports-report.pdf

Istrate, E. Associate Fellow and Senior Research Analyst, and Marchio, N. Research Assistant, Metropolitan Policy Program, the Brookings Institution (2012). Export Nation 2012: How U.S. Metropolitan Areas Are Driving National Growth. Exports, Competitiveness, U.S. Economic Growth, Cities, Regions And States. Retrieved April 14, 2012, from http://www.brookings.edu/reports/2012/0308_exports.aspx#3

Kuhnhenn, J. Associated Press (2012). Obama Seeks CEOs’ Help in Latin America. In Colombia, Obama urges private sector to help governments promote jobs, prosperity. Retrieved 4/14/12, from http://finance.yahoo.com/news/obama-seeks-ceos-help-latin-173245009.html

United States of America Trade Promotion Coordinating Committee Washington, D.C. (2011). Export Strategy Powering the National Export Initiative. Retrieved April 13, 2012, from http://www.trade.gov/publications/pdfs/nes2011FINAL.pdf

U.S. Bureau of Economic Analysis and the U.S. Census Bureau (2012). February 2012 Trade Gap is $46.0 Billion. Retrieved April 12, 2012, from http://www.bea.gov/newsreleases/international/trade/tradhighlights.pdf

U.S. Bureau of Economic Analysis and the U.S. Census Bureau (2012). National Income and Product Accounts Gross Domestic Product, 4th quarter 2011 and annual 2011 (third estimate); Corporate Profits, 4th quarter 2011 and annual 2011. Retrieved April 14, 2012, from
http://www.bea.gov/newsreleases/national/gdp/gdpnewsrelease.htm

Weller, C.E. Weller on the State of the Economy (2012). Economic Snapshot for March 2012. Retrieved April 14, 2012, from
http://www.americanprogress.org/issues/2012/03/march_econ_snapshot.html

THE IMPACT OF PTSD AND TBI DURING COMBAT THEATER ON THE HEALTHCARE SYSTEM

By Melissa Bynes Brooks

Friday, March 30, 2012

Expenditures for the treatment of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) in soldiers returning from combat theater in Iraq and Afghanistan has an exponential impact on the U.S. health care system. PTSD and TBI are common conditions in soldiers that witness trauma and are exposed to explosions.

On March 28, 2012, U.S. Senator Barbara A. Mikulski (D-Md.), a senior member of the Senate Appropriations Committee, during a Senate Defense Appropriations Subcommittee hearing that examined the health care of wounded soldiers said, “Just because a war is over for us doesn’t mean it is over for the soldier, or his spouse, or her children. Some bear the permanent injuries of war, but all bear the permanent impact.”

There is no doubt that increased health care spending is related to the number of PTSD and TBI diagnosed cases. The U.S. spends approximately 17% of its gross domestic product (GDP), on health care. GDP is important because it serves as an indicator of the condition, of a country’s economy. No other country spends more than 12% of its GDP on health care and the U.S. does worse than most other countries in every measure of health outcomes.

It’s estimated that PTSD occurs in 11 to 20 veterans out of every 100, for the Iraq and Afghanistan wars. Since 2000, 229,000 soldiers have been diagnosed with TBI. Since 2005, TBI has occurred in 17,000 Iraq and Afghanistan soldiers during combat theater. 89,000 deployed veterans have been diagnosed with PTSD. The Department of Defense (DoD) focuses on acute detection while the U.S. Department of Veterans Affairs (VA) focuses on long term complications. The number of TBI injuries according to data from the DoD, which provides medical care to service members while deployed, totaled 30, 380 during the fourth quarter of 2011 (October through December).

In February 2012, the Congressional Budget Office (CBO) did a study that examined costs for the Veterans Health Administration (VHA), which provides health care after service members return from deployment, for the treatment of PTSD and TBI. The findings indicated the VHA spent about $2 billion in fiscal year 2010, from October 1 to September 30, to treat combat veterans. The medical costs per veteran during the first year of treatment averaged $8,300.00 for PTSD; $11, 700.00 for TBI; $13, 800.00 for PTSD and TBI combined; and $2,400.00 for recent veterans with neither condition. In subsequent years of treatment, the costs decreased when compared to the first year. Amounts did not include initial care provided by the DoD or care by other providers outside of the VHA. The VHA has also hired more than 7,500 mental health professionals to serve the growing population of veterans and has established specialized rehabilitation centers for veterans with multiple complex injuries including TBI since 2005. This increased costs also.

It is important to estimate the required costs for providing necessary evaluation, diagnosis, treatment and management for combat veterans. However, forecasts regarding costs are ambiguous without knowing the number of veterans that will actually be diagnosed with PTSD and TBI, and without knowing the number of veterans that will seek treatment. Some policymakers have questioned whether DoD and VHA have the resources and capacity to serve the veteran population with PTSD and TBI.

There is some hope. The Affordable Care Act which was signed into law by President Barack Obama on March 23, 2010, includes measures aimed at making health care less expensive and more accessible, including upgrades to government-run Medicare and Medicaid. There are provisions in the law for veterans with advanced appropriations to ensure efficient, timely, and predictable medical services. Unfortunately, if the law is repealed, implications for veterans will consist of higher costs and fewer choices for services. The Affordable Care Act may be a tenable solution within the context of a costly health care system and should be upheld by the U.S. Supreme Court.

REFERENCES

i) U.S. Senator Barbara A. Mikulski (D-Md) (2012). Mikulski Stands Up For Access to Treatment and Care for Wounded Service Members. Retrieved March 30, 2012, from http://www.mikulski.senate.gov/media/pressrelease/3-28-2012-1.cfm

ii) Organization for Economic Cooperation and Development (2011). Health at a Glance. Retrieved March 30, 2012, from http://www.oecd.org/dataoecd/12/16/49084355.pdf

iii) U.S. Department of Veteran Affairs National Center for PTSD Public Section Information on Trauma and PTSD Veterans General Public and Family (2012). Retrieved March 28, 2012, from
http://MILITARYFAMILY.ABOUT.COM/GI/O.HTM?ZI=1/XJ&ZTI=1&SDN=MILITARYFAMILY&CDN=PARENTING&TM=18&GPS=287_4_1366_650&F=00&TT=12&BT=0&BTS=0&ZU=HTTP%3A//WWW.PTSD.VA.GOV/

iv) Curtin, L. and Mirkin, M. (2012). Healing the injured brain: VA, DOD Joins Forces on
Research to Combat TBI, PTSD. Retrieved March 28, 2012, from
http://home.fhpr.osd.mil/press-newsroom/fhpr-news/current_news/12-02-10/Healing_the_injured_brain_VA_DoD_join_forces_on_research_to_combat_TBI_PTSD.aspx?id=?id

v) Defense Medical Surveillance System (DMSS) and Theater Medical Data Store (TMDS) Prepared by Armed Forces Health Surveillance Center (AFHSC) (2012). TBI Numbers By Severity – All Armed Forces. Retrieved March 29, 2012 from,
http://www.dvbic.org/pdf/dod-tbi-2011Q4-as-of-120210.pdf

vi) Congress of the United States Congressional Budget Office (2011). The Veterans Administration Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans. Retrieved March 28, 2012, from http://www.cbo.gov/sites/default/files/cbofiles/attachments/02-09-PTSD.pdf

vii) The White House Washington. Health Reform for American Veterans and Military Personnel. (2010). Retrieved March 29, 2012, from http://www.whitehouse.gov/sites/default/files/rss_viewer/health_reform_for_veterans.pdf

THE AFGHANISTAN MASSACRE: MURDER OR SLEEP VIOLENCE?

By Melissa Bynes Brooks
March 26, 2012

No one could have ever predicted the massacre involving Staff Sgt. Robert Bales who was charged on Friday, March 23, 2012, with 17 counts of murder and six counts of attempted murder, along with other charges, in Afghanistan. Or could they? The warning signs were there in his history of traumatic brain injury and multiple deployments to Iraq.

Research findings at the Puget Sound Veterans Affairs hospital in Washington indicate providers should screen for anger and aggression among Iraq and Afghanistan War veterans who exhibit symptoms of Post-traumatic stress disorder (PTSD) and incorporate relevant anger treatments into early intervention strategies. PTSD is an anxiety disorder some people develop after seeing or living through an event that caused or threatened serious harm or death. Symptoms may include strong and unwanted memories of the event, bad dreams, emotional numbness, intense guilt or worry, angry outbursts, feeling “on edge,” and avoiding thoughts and situations that are reminders of the trauma.

The impetus for a review of the Army’s Post Traumatic Stress Disorder program comes after statistics showed staff at Madigan Medical Center on Joint Base Lewis McCord (JBLM), the home base of Staff Sgt. Robert Bales, had reversed the PTSD diagnoses of 40% of the troops they evaluated, according to Sen. Patty Murray, Washington-D, who recently raised the issue at a hearing on Capitol Hill.

It bodes well if the Army considers implementing a screening program that includes the use of a sleep study known as a polysomnogram (PSG). A PSG can confirm a diagnosis for the parasomnia, REM sleep behavior disorder (RBD), for soldiers with PTSD. REM sleep behavior disorder (RBD) is a frequent complaint in people who have suffered a traumatic brain injury. Traumatic brain injury (TBI) is acquired when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue.

Sleep disorders are a common finding after the acute or sudden onset phase of TBI. This can result in daytime sleepiness, heightened anxiety, a poor individual sense of wellbeing, insomnia and depression. Sleep changes and disturbed sleep are common in chronic TBI, defined as 3 months to 2 years after an injury has occurred. Neuroimaging studies have shown highly significant relation¬ships between reduced prefrontal cortical size or prefrontal corti¬cal activity with increased aggression and violence. A large study of head injuries in combat veterans found damage to the frontal lobes was associated with an increased risk for violent behavior.

Head trauma may contribute to the development of REM sleep behavior disorder (RBD) during arousals from REM sleep when most dreams occur. RBD is noticeable by intense and frightening dreams. Normally, the muscles of the body are temporarily paralyzed while dreaming. With RBD, the muscles are not temporarily paralyzed and people can act out their dreams. This is when behaviors such as sleep walking, sleep talking, and vigorous, violent episodes occur that can cause serious bodily injury. Between 33% and 65% of RBD patients have been reported to have sleep related injury to self or bed partner. Persons experiencing RBD episodes are usually unaware of the events as they are taking place.

Violent behavior, in the case of sleepwalking, occurs only after the sleepwalking episode has been triggered and is underway. During the sleepwalking episode, while moving about the environment, the sleepwalking individual encounters someone else – most likely a family member. This person may approach, block, touch, or grab the sleepwalker, triggering a violent reaction.

Simultaneous video and sleep study (PSG) recording is essential for evaluating patients with suspected RBD, so that vocalizations and limb movements can be captured and viewed concurrently with PSG data. When vocalizations, excessive muscle activity in the chin and/or limb movements emerge during REM sleep, without associated seizure activity, the diagnosis of RBD is established.

John Henry Browne, the leading defense attorney for Army Staff Sgt. Robert Bales, said about Sgt. Bales, “He has an early memory of that evening, and he has a later memory of that evening, but he doesn’t have a memory of in between.” Because all persons with REM sleep behavior disorder have a history of acting out their dreams, one can only ponder whether a sleep study screening to evaluate RBD in Army Staff Sgt. Robert Bales, might have revealed a propensity for sleep violence, which could have thwarted such a wretched tragedy.

Melissa Bynes Brooks is the editor of BrooksSleepReview. She is the Clinical Coordinator of Coral Springs Medical Center Sleep Disorders Center, accredited by the American Academy of Sleep Medicine, in Broward County, Fl. She is a Registered Polysomnographic Technologist and Certified Respiratory Therapist with a B.S. in Respiratory Therapy from FAMU and MBA from Nova Southeastern University.

Contact information: melissabynesbrooks@comcast.net
Follow@Mlbbrooks on twitter

REFERENCES

[i] Raison, Charles (2012). What’s the link between PTSD, TBI and violence? Retrieved March 23, 2012, from
http://www.cnn.com/2012/03/22/health/raison-robert-bales-tbi-ptsd/index.html

[ii] Jakupcak, M., Conybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Felker, B., Klevens, M. and McFall, M. E.
(2007), Anger, hostility, and aggression among Iraq and Afghanistan war veterans

[iii] National Institutes of Health Fact Sheet (2010). Post-traumatic stress disorder (PTSD). Retrieved March 22,
2012, from http://report.nih.gov/NIHfactsheets/Pdfs/PostTraumaticStressDisorder(NIMH).pdf

[iv] Shaughnessy, Larry (2012). Army Reviewing PTSD Evaluation Program. Retrieved March 21, 2012, from
http://www.cnn.com/2012/03/21/us/army-ptsd-evaluation-program/index.html

[v] Boeve, B. F. (2010), REM sleep behavior disorder. Annals of the New York Academy of Sciences, 1184: 15–
54. doi: 10.1111/j.1749-6632.2009.05115. National Institute of Neurological Disorders and Stroke (2012). NINDS Traumatic Brain Injury Information Page. Retrieved March 24, 2012, from http://www.ninds.nih.gov/disorders/tbi/tbi.htm

[vi] National Institute of Neurological Disorders and Stroke (2012). NINDS Traumatic Brain Injury Information
Page. Retrieved March 24, 2012, from http://www.ninds.nih.gov/disorders/tbi/tbi.htm

[vii] Verma A; Anand V; Verma NP. Sleep disorders in chronic traumatic brain injury. J Clin SleepMed 2007;3(4):357-362.

[viii] Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a
critical review. Journal of Neu¬rology, Neurosurgery & Psychiatry 2001;71:720-6.

[ix] Aurora RN; Zak RS; Maganti RK; Auerbach SH; Casey KR; Chowdhuri S; Karippot A; Ramar K; Kristo DA; Mergenthaler TI. Best practice guide for the treatment of remsleep behavior disorder (rbd). J Clin Sleep Med
2010;6(1):85-95.

[x] Pressman MR. Disorders of arousal from sleep and violent be¬havior: the role of physical contact and proximity.
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[xi] Boeve, B. F. (2010), REM sleep behavior disorder. Annals of the New York Academy of Sciences, 1184:
15–54. doi: 10.1111/j.1749-6632.2009.05115.

[xii] CNN Wire Staff (2012). Lawyer Suspect in Afghan Massacre Has Memory Loss, Lawyer Says. Retrieved
March 24, 2012, from
http://articles.cnn.com/2012-03-19/asia/world_asia_afghanistan-shooting_1_afghan-forces-shooting-rampage-
afghan-massacre? s=PM:ASIA