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UW Hospital Says It Wasn't Negligent After Treating CJD Patient

July 23, 2009

MADISON, Wisconsin - University of Wisconsin Hospital officials denied on Friday the hospital was negligent in any way regarding the possible transmission of a rare and fatal neurological disease to 53 people.

Infectious disease and other hospital officials said the staff did everything they could and adhered to the U.S. Centers for Disease Control and Prevention polices after learning a patient who underwent brain surgery was infected with the rare neurological disease called Cruetzfeldt-Jakob disease, or CJD.

UW Hospital officials have sent letters to the 53 patients by FedEx and have either reached them by phone or left messages. The hospital on Friday made follow-up phone calls to the patients after discovering they might have been exposed to CJD.

Hospital officials held a news conference on Friday morning and denied that any negligence was involved in this matter. They said they planned no changes in how they sterilize neurosurgical instruments.

The surgical instruments were the potential route of disease transmission to the 53 patients. At the news conference, doctors tried to reassure the patients who've all had brain surgery during a recent 40-day period.

"Someone who we are notifying should not have cause to feel upset, worried or concerned," said Dr. Carl Getto, UW Hospital chief medical officer.

At issue is whether the 53 patients were exposed to virulent infectious agents called prions via surgical instruments. That's possible because the instruments in their brain surgeries were also used to remove a brain tumor from a woman in her 50s who died Tuesday of CJD.

Doctors didn't suspect she had CJD at the time of her June 11 surgery, so they didn't use disposable instruments or re-sterilize the instruments according to federal CJD guidelines. After the woman rapidly declined over the next month after her surgery, the hospital sent a brain tissue biopsy taken from the earlier surgery to a national center to test for the illness.

The preliminary report came back positive for CJD on July 20. At that point, hospital officials said that they started identifying anyone who had neurological surgeries between June 11 and July 20 who might have come into contact with the surgical instruments used on the CJD patient who died and stopped using the instruments.

The 53 patients are being notified that they face "an extremely small risk" of being exposed to the infectious agents responsible for CJD, officials said. However, infectious disease doctors at the UW said that they don't believe any of the 53 people being contacted will develop symptoms for CJD.

"Our efforts are to reassure them, to let them know that this happened (and) that there is a very, very small possibility but there is no reason for fear, being scared or changing their activities," Getto said.

The 53 patients are between the ages of 3 and 83, officials said.

The CJD case was finally confirmed at a national lab more than five weeks later, after an earlier hospital test failed to detect it.

"What they didn't see was the classic signs of CJD, which is the spongiform changes that would have led them to suspect it. Had they seen that at the time, we would of course been notified of that, but that was not present there," said Dr. Nasia Safdar, UW Hospital infection control director.

"If there had been a suspicion that this was CJD, we would have used disposable instruments," Getto said.

Since doctors didn't suspect the woman had CJD, regular surgical instruments were used and re-used after only the regular cleaning process. Now, the instruments have now been re-sterilized following the CDC protocols and put back into use.

Some hospitals have different procedures. Meriter Hospital said it incinerates any instruments linked to CJD cases. But the UW Hospital called its process "watertight."

Worldwide, there are only two known cases of CJD transmission through surgical instruments, but it can take decades for the symptoms to surface.

CJD affects about one person in a million per year worldwide. Health officials said this classic case of the disease is very different from the variant form of CJD, more commonly known as mad cow disease. Variant CJD includes psychiatric behavioral symptoms and delayed neurologic signs, according to the CDC.

Classic CJD symptoms include rapidly progressing dementia, with death often coming within a year.

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