More than 25,000 veterans from Iraq and Afghanistan are enrolled at the VA Medical Center in San Diego. An estimated 20 percent of those vet have some level of Traumatic Brain Injury (TBI).

Credit: Courtesy of Julian Cook

Above: Julian Cook before he left the military in Feb 2010

You would never guess, looking at 25 year old Julian Cook, that he has been through two major roadside bomb blasts while serving Army deployments in Iraq. he doesn’t show any visible wounds. Cook didn’t admit to himself that anything was wrong when he got home in 2009.

“I just thought that it would go away,” he said. he told himself he just had a headache. “But sometimes,” he said, “it just gets way too painful to ignore.”

There were other symptoms that really bothered Cook, like when he was sitting talk with someone and all of a sudden he just stropped talking.

“And don’t know where I was going with it, don’t remember what I was talking about. and you know, it can happen at the most random moments.”

Cook finally sought help. He’s been working for several months in a program called CogSMART, the brain child of UCSD psychiatrist Elizabeth Twamley.

“People with mild to moderate TBI look just like everybody else,” Twamley said. “So it’s really an invisible disability.”

Twamley said she’s proved that CogSMART helps her mentally ill clients. now she’s working with the VA to see if it’s an effective treatment for the new vets like Julian Cook who are trying to get a job.

Cook’s partner in the treatment program is employment specialist Laurie Arnold. She’s been working with him on basic things like how to deal with his chronic sleep problems.

When they started the program Cook said he was sleeping maybe three hours a night. now he says he sleeps between five and six hours. “So I did gain a couple of hours,” he said.

Cook learned how to consciously observe his own body to relax. he also learned tricks to help him control the bouts of anger that sometimes gripped him unexpectedly. he would focus on his heart rate and try consciously to slow it down.

He and Arnold also worked on practical skills to help him focus because he seemed unable to make headway on anything he set his mind on. He’s taking a master’s degree in business studies, and found it almost impossible to concentrate on long lectures, or take effective notes. Arnold gave him a smart pen — a little tape recorder to record lectures, and he’s learning how to identify the important points to take notes on.

But remembering things continues to be a challenge. Cook described a technique he calls “overlearning” that he uses if he gets a call from a doctor’s office. he repeats information back to the person on the other end of the phone, writes it down and then reads it to himself after the call is ended.

“So I just said it, read it, and wrote it,” he explained,” so I’m three more times likely to remember it.”

As with any program, it’s not just the skills, it’s the people that make the difference. Laurie Arnold is constantly encouraging Cook. She’s his number one advocate and reminds him of everything he accomplished when he was in the military.

“I’ve seen other resumes and they’re not as diversified,” Arnold told Cook “.so I think you’re not giving your self credit in realizing you were a project manager, and you had this medical background and you were a team leader. so they were giving you these responsibilities because they felt that you were capable.”

“Yes, yes,” Cook agreed, soaking up the support.

Cook already has a degree in business that he earned while he was in the military. he said he studied nights and in between shifts while he was deployed. But though he’s been back in the civilian world for well over a year now, he’s had no luck landing a job that would use that qualification. Instead he was spotted by a talent scout and offered a job modeling. his good looks make up for his memory problems.

But Cook isn’t ready to settle for this. he said his main goal is to land a more legitimate job. he remembers only too well the responsibility he had in the military, before the bomb blasts and the headaches. he said the modeling job is a “just until” job.

“Just until I finish school, just until I find a more reputable job,” he said. “Until then, I’ll just be modeling.”

Elizabeth Twamley, who developed CogSMART, said there are thousands of vets in Cook’s position, who suffer from TBI symptoms that noone can guarantee will go away.

“It’s a population for which we formerly didn’t have any interventions,” she said, “and yet there are a lot of people seeking help for their cognitive problems. so VA clinicians and researchers are trying to respond to that need. the jury is still out. we are still collecting data on what treatments work.”

Ironically, Twamley said the new GI bill has made it more difficult to recruit vets for her study. That’s because so many returning vets have chosen to go back to school and take the generous living allowance that goes with it. at $2,200 a month on top of tuition, they don’t need to find a job to survive.

But Twamley said many of these vets are struggling to learn effectively with lingering TBI symptoms. and if the economy doesn’t improve by the time they graduate, they may find it difficult to find a job in a competitive marketplace, she explained.

In the mean time, Twamley said the rate of employment for veterans with TBI in her supportive study group is lower than for her mental health patients — only about 30 percent of them have found jobs so far. she said this is a population that faces numerous barriers — from cognitive to emotional. she said many have family crises that are difficult to resolve after years in the military, and cognitive training alone won’t necessarily open the door to a new future.

HONG KONG (Reuters) – The next time you cough or sneeze, there is good reason to cover your mouth.

As many as 20,000 viruses are expelled in an average cough, which may be sufficient to infect many people — particularly those who are not vaccinated.

Julian Tang, a consultant at Singapore’s National University Hospital’s Division of Microbiology, said as many as 3,000 tiny droplets are produced in a standard cough.

Using previous research on influenza viral loads in nasal secretions, and assuming that each coughed airborne droplet measures between 1 to 5 micrometers in diameter, that adds up to many, many viruses in a single cough.

A micrometer, or micron, is one millionth of a meter, or one thousandth of a millimeter.

"Based on this research and assuming about 3,000 droplets are produced per cough, this range of influenza viruses produced per cough is about 195 to 19,500," Tang told Reuters.

He added that this figure of 3,000 droplets refers to those that remain suspended in the air for considerable periods — long enough to infect people.

"this (3,000) is also the number of droplets estimated to remain suspended in air for long periods — so-called droplet nuclei. Larger droplets carrying influenza viruses may also be produced during a cough, but these will fall to the ground relatively quickly and will no longer be considered to be significant in the airborne transmission of influenza," he said.

With a new H1N1 influenza virus spreading around the world, governments in many countries have revived advertisements entreating people to observe personal hygiene.

In Indonesia, a slick TV advertisement features a young woman remonstrating a suitor at a village sing-a-long, telling him to get to a health clinic because "that’s not a normal cough."

Aimed at the poorly-educated masses, the adverts are set to a dangdut (traditional pop music) theme and feature an easy-to-remember slogan and theme song.

However, experts are uncertain as to what constitutes an infective dose when it comes to influenza viruses.

But as a guide, previous research has found that it takes just one to 10 organisms to cause viral hemorrhagic fevers, and 10 to 100 organisms to cause viral encephalitis.

Tang said an infective dose of flu virus would depend on a variety of factors, such as the constitution of people breathing in these droplets and whether they had been vaccinated.

"it is difficult to give an exact number for the infectious dose — and this may even differ for the same individual throughout the year. but probably for immune people, the infectious dose will be higher than for non-immune people — hence, the benefits of vaccination," Tang said.

"those previously vaccinated or naturally infected to the same or similar virus can develop a rapid antibody response and clear the virus in the respiratory tract before the virus can take hold and cause disease."

"(But) even immune hosts may develop symptoms if the viral load exposure is sufficiently high," he added.

Doctors say most airborne flu transmissions occur within a one meter range, although it can also be transmitted by direct contact with contaminated objects, like toys.

"Wearing masks may well help to reduce the transmission of these infections, as well as covering the mouth with your hand or a tissue when coughing or sneezing — simply by using a barrier to prevent dissemination of the virus," Tang said.

(Additional reporting by Sunanda Creagh in Jakarta; Editing by Valerie Lee)

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