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UW Hospital Put Patients at Risk of Rare, Fatal Brain Disorder

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The University of Wisconsin Hospital and Clinics has informed 53 patients that they all have an “extremely small” risk of contracting a rare, fatal brain disorder called Creutzfeldt-Jakob disease, because surgical instruments used on the brain a patient later diagnosed with the disease were re-used without adequate sterilization in the neurosurgeries of each of the 53 patients.

The hospital didn’t detect the presence of Creutzfeldt-Jakob in the woman in question until her death last Tuesday, at which time tests came back positive for the disease.

UW Hospital epidemiologist Nasia Safdar said the surgical instruments weren’t removed from circulation when the sample was sent in because none of the physicians working on the case suspected it was Creutzfeldt-Jakob.

"The patient’s symptoms did not fit the classic pattern of the disease; she had multiple other medical issues going on; and the sample was sent solely in order to rule out CJD," Safdar said in a statement. -Stacy Forster and Mark Johnson of the Journal Sentinel

Creutzfeldt-Jakob disease is one of several brain disorders, including mad cow disease, believed to be caused by malformed proteins called prions. No treatment or cure currently exists. Prions are capable of surviving the normal sterilization techniques for surgical instruments; this is why the patients in question are at risk for contracting the disease. Typically, instruments are pressure cooked in an auto-clave for 15 to 20 minutes; instruments in a suspected CJD case are cooked for an hour, in sodium hydroxide instead of water. If all instruments were sterilized this rigorously, they would only last a few cycles, and costs would soar.

"General practice is that if you suspect CJD you don’t use the instruments," said Patrick Bosque, a prion researcher and professor of neurology at Denver Health Medical Center.

"Although the likelihood of CJD transmission is virtually nonexistent, we have taken immediate and extraordinary aggressive measures to ensure that all surgical instruments used during this procedure are re-sterilized according to the CJD-specific sterilization processes recommended by the Centers for Disease Control," said Carl Getto, senior vice president of clinical affairs for UW Hospital and Clinics. Stacy Forster and Mark Johnson of the Journal Sentinel

Since transmission of CJD requires that the contaminated instruments directly touch either brain tissue or spinal cord fluid, no one but the 53 patients in question is at risk for contracting the disease as a result of this incident. So far, none of the 53 has shown symptoms of CJD, but there is no test to determine whether any of them has it.
The hospital has informed patients that it did not act negligently in exposing patients to this disease, but this is not its call to make. Medical providers have to accept personal responsibilty for the harms they cause.