Occult Head Research Articles

Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department.

Clinical Practice Guidelines for Assessment and Management of Patients with Substance Intoxication Presenting to the Emergency Department.

Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children’s Hospitals

Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. Use of neuroimaging by CT or MRI. Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001). This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.

Branhijalna cista vrata - šta je zaista važno? - prikaz slučaja

Introduction: Branchial cleft anomalies are considered to develop from the branchial apparatus that did not completely obliterate during the embryogenesis of the head and neck. These anomalies pose a significant challenge in terms of surgical management, particularly followed by misdiagnosis due to its rarity. The aim of this case report was to present the review of literature and treatment of a rare anomaly such as a second branchial cleft cyst with a particular focus on clinical as well as histopathological aspects. Case report: A 24-year-old woman was admitted to the otolaryngology department with a three-month history of painless right-sided neck swelling, following a previously resolved upper respiratory infection. The patient underwent complete excision of the cystic mass, with excellent cosmetic results and no signs of recurrence after a one-year follow-up. Conclusion: Therefore, surgery should always be the gold standard of treatment. In patients aged over 40 years, cystic metastasis from the occult head and neck primary carcinoma must be considered.

P-253 What is the impact of COVID-19 on the diagnosis and treatment of patients with cancer?

Presented by: Mafalda Martins Sousa (mafaldajmsousa@gmail.com) Introduction The early diagnosis and treatment of cancer patients is crucial in order to improve the prognosis. Multiple screening methods are nationally implemented. However the COVID-19 pandemic had a serious impact on the performance of the national health system: patients are afraid to go to the hospitals and, during the first lockdown, the programmed clinical activity was markedly reduced or suspended. The purpose of this work is to evaluate the impact of the COVID-19 pandemic on the diagnosis and treatment of patients with pharyngolaryngeal cancer. Materials and Methods Retrospective study of successive patients that underwent suspension laryngoscopy with biopsy, in a Tertiary Hospital, between January 2019 and December 2020. Patients whose result revealed a malignant neoplasm were included. Those with occult head and neck cancer were excluded. Results In a total of 108 patients, 48 patients were included due to pharyngolaryngeal neoplasia. 62.5% of the patients were evaluated before the COVID-19 pandemic. The average age was 60.77 years (40–80) and 45 patients were male, without significant differences between groups. The most common antecedents were smoking in 54.2% and smoking and heavy alcohol consumption in 27.1%. During the pandemic, 66.7% of the patients had symptoms for more than 6 months (vs 50% before the pandemic;p = 0.04). A stage ≥T3 was found in 83.3% of the patients during the pandemic (vs 53.3% previously;p < 0.05). Patients who had symptoms for more than 6 months had a higher tumor stage (p = 0.03). Before the pandemic, 66.3% of the patients underwent surgical treatment (vs 33.3% during the pandemic;p = 0.04). Conclusions This study demonstrates that during the COVID-19 pandemic, oncologic patients took longer to seek medical care, which translated into a higher tumor stage and, consequently, in more patients being treated with chemotherapy/radiotherapy instead of surgery. Thus, it is crucial to raise awareness to the importance of timely diagnosis, despite the COVID-19 pandemic.

Head computed tomography in suspected physical abuse: time to rethink?

BackgroundNational guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma.ObjectivesTo investigate whether...

More data, more questions: No simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma

Abusive head trauma (AHT) is the leading cause of fatal child physical abuse. Victims may initially present with clinically occult AHT without overt signs of head trauma or with only subtle, nonspecific symptoms, which can make timely recognition of AHT challenging. Research has shown missed opportunities for early detection of AHT in the medical setting are common and can lead to repeated injury. Neuroimaging is needed to diagnose clinically occult AHT but is not without risk. Researchers have worked to understand the yield of neuroimaging in detection of clinically occult AHT and to identify risk factors, yet findings have varied widely across studies. Identifying which children undergoing physical abuse evaluations are at highest risk of clinically occult AHT is key to development of evidence-based imaging decision support tools for clinicians. Here we discuss the recent literature, identify potential reasons for variation across studies, and offer opportunities for future research.

Occult head injuries in infants evaluated for physical abuse

BackgroundAbusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3–37.3 %. Objectives(1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries. Participants and SettingWe conducted a retrospective, stratified, random systematic sample of 529 infants <12 months evaluated for physical abuse at 4 urban children’s hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded. MethodsSampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age <6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests. ResultsOf 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants <6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6–12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury. ConclusionsOccult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.

Occult head injury is common in children with concern for physical abuse.

Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. This was a retrospective, secondary analysis of data collected by an observational study of 20U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. Our results show a high prevalence of occult head injury in patients <2years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2years of age.

Occult Head Injury in Children Less Than 2 Years With Suspected Child Abuse in the Emergency Department.

This study aims to determine the frequency of clinically significant findings requiring emergent neurosurgical intervention on computed tomography (CT) in neurologically intact children admitted to the hospital with suspected abuse. This was a retrospective review of neurologically stable children (0-24 months) in whom both skeletal survey and CT head were performed for child abuse evaluation from 2000 to 2011. A total of 132 patients met inclusion criteria (mean age, 7.6 mo; 55% male, 52% Caucasian, and 34% African-American). Computed tomography scans demonstrated occult head injury in 5%; none required neurosurgical intervention or had any neurological deterioration. Average length of stay was 4 days, with average time to CT scan being 12.8 hours from triage, and average time to magnetic resonance imaging (MRI) scan of 70.5 hours. Five MRIs were performed, and 4 had identical results on CT scan. No clinically significant brain injury (requiring intervention) was seen in this cohort. These findings support delaying imaging in neurologically intact children to obtain MRI after hospital admission, thus, limiting radiation exposure.

Correlations between morphology and ultrasound exam in cases with nasal and paranasal sinuses pathology

Abstract BACKGROUND. Ultrasonography has been used in rhinology for diagnosing trauma lesions (fractures, hemosinus), second opinion in tumoral pathology, screening for sinusitis, but on a small scale and with future prospects of cost efficiency. OBJECTIVE. We hope to grow awareness of the possible use of ultrasound in screening for nasal and paranasal sinuses pathology at the level of ENT emergency departments. MATERIAL AND METHODS. We describe the technique for ultrasound examination of this region, emphasizing the need for a profound anatomical knowledge characteristic for ENT specialists. Any specialist having access to an ultrasound machine is encouraged to experiment with this imaging procedure. Two cases benefited from the use of ultrasonography in order to receive a better management and a swift treatment. One case presented with a maxillary sinus tumor and another with a paranasal tumor neighbouring the orbit. CONCLUSION. Ultrasonography of nasal and paranasal sinuses permits serial examination without irradiating the patient; it could be implemented as an addition to FAST-like protocols at the level of emergency departments in order to screen for occult head and neck pathology prior to conventional radiology and CT imaging and thus reducing costs

Protocolul terapeutic pentru metastazele limfoganglionare laterocervicale de carcinom spinocelular cu punct de plecare neprecizat

Cervical lymph node metastases of squamous cell carcinoma from occult primary constitute about 3-5% of all patients with carcinoma of unknown primary site (CUP). Identification of subgroups with favorable prognosis is of decisive importance for the therapy of patients with CUP syndrome, including prolonged survival from directed treatment. The patients with neck node metastases from occult head and neck cancer have clinical features and prognosis similar to other head and neck malignancies. Treatment of patients with metastatic squamous cell carcinoma involving cervical lymph nodes of an unknown primary origin should be similar to that of patients with locally advanced carcinoma of the head and neck. Therapeutic approaches include surgery (lymph node excision or neck dissection), with or without post-operative radiotherapy, radiotherapy alone and radiotherapy followed by surgery. In early stages (N1), neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases (N2, N3) necessitate combined approaches. The extent of radiotherapy (irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy) remains debatable. A potential benefit from extensive radiotherapy should be weighted against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence. The role of other methods, such as chemotherapy and hyperthermia, remains to be determined.

Craniofacial Pain Secondary to Occult Head and Neck Tumors

To review the natural history of occult head and neck malignancy presenting with facial pain and evaluate the risk factors, diagnostic workup, and management of facial pain in the setting of occult malignancy. Retrospective chart review. Tertiary care center. All patients presenting from 1980 to 2010 with facial pain and a delayed diagnosis of a head and neck cancer were reviewed. Thirty-eight patients were included. Onset of pain was rapid or sudden in 94.7%, intermittent in 84.2%, and sharp in 86.8%. Facial nerve weakness was present in 15.8%. Five patients had a history of locoregional skin cancer, and 14% had a history of malignancy. Average delay to diagnosis was 18.4 months. On average, the suspicious lesion was identified on the second scan (mean, 2.1; range, 1-4 scans). Diagnosis was suggested by magnetic resonance imaging in 54.8% and computed tomography in 38.7% of patients. The most common pathology was squamous cell carcinoma (39.5%), and the predominant location was the parotid gland (28.9%). Surgical resection (66%) was the most common intervention. In patients who received treatment and had clinical follow-up available for review, 97.0% (32/33) reported symptomatic improvement. In our series, sudden-onset, intermittent, sharp facial pain without resolution or improvement was associated with occult malignancy and should be considered in the differential diagnosis for facial pain. Based on the high incidence of early negative imaging, consideration should be given to repeat imaging when there is concern for malignancy. Therapeutic interventions often result in improvement of facial pain.

Facial Pain Secondary to Occult Head and Neck Tumors

Objectives: 1) Review the natural history of occult head and neck malignancy presenting with facial pain. 2) Evaluate the risk factors, diagnostic workup, and management of facial pain in the setting of occult malignancy. Methods: A retrospective chart review was conducted of all patients who presented to a tertiary care center between 1980 and 2010 with the chief complaint of facial pain and a delayed diagnosis of a head and neck cancer. Clinical, radiographic, and pathologic data were reviewed. Results: Thirty-eight patients met inclusion criteria. Initial diagnoses consisted of trigeminal neuralgia, herpetic neuralgia, temporo-mandibular joint disorder, and atypical facial pain. Average delay to diagnosis was 18.4 months (1.9 - 76.8 mo). Twenty-two patients had negative magnetic resonance imaging or computed tomography imaging between onset of symptoms and tumor diagnosis, with an average of 1.05 non-diagnostic scans per patient. Tumor etiologies included squamous cell carcinoma (39.5%), adenocarcinoma (10.5%), adenoid cystic carcinoma (7.9%), and acinic cell carcinoma (7.9%). Primary intervention consisted of surgical tumor removal (66%); chemotherapy, radiation therapy, or both (26%); gamma knife (5%); and conservative therapy (3%). Thirty-two out of the 33 patients (97.0%) who underwent therapy reported partial or complete resolution of their facial pain. Conclusions: Occult tumors of the head and neck may present as symptomatic facial pain in the absence of other clinical or radiographic findings and should be considered in the workup of facial pain. Therapeutic and palliative interventions often result in marked improvement of pain symptoms.

18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Assessment of Occult Primary Head and Neck Cancers — An Audit and Review of Published Studies

AimsTo assess the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with squamous cell and undifferentiated cancer neck nodes and no primary site on conventional assessment. Materials and methodsSeventy-eight patients with neck nodal metastases from an unknown primary cancer were studied. PET/CT was carried out in all patients, 1h after FDG injection. ResultsUptake suspicious of an occult primary cancer was found in 46/78 (59.0%) patients. Subsequent investigations confirmed a primary site in the base of the tongue in 14, pharyngeal palatine tonsil in 14, post cricoid in one, lung in one. PET/CT diagnosed primary cancers in 30/78 patients (38.5%); sensitivity, specificity, positive predictive value, negative predictive value: 30/30 (100.0%), 32/48 (66.7%), 30/46 (65.2%), 32/32 (100.0%), respectively. PET/CT detected additional disease in four patients: contralateral nodal disease in two, mediastinal nodal disease in one and liver metastases in one. ConclusionsFDG PET/CT is of value in the assessment of patients with occult head and neck primary cancers. However, false-positive results remain a limitation of the investigation.

Role of PET/CT in maxillo-facial surgery

PET/CT has an established and key role in the management of squamous cell carcinoma of the head and neck. It should be considered in all patients with occult head and neck tumours and before major interventions particularly in those patients with a high risk of distant metastases. This article outlines the physical principles of the technique and illustrates the clinical applications in maxilllo facial surgery.

Histologic Identification of Human Papillomavirus (HPV)-Related Squamous Cell Carcinoma in Cervical Lymph Nodes: A Reliable Predictor of the Site of an Occult Head and Neck Primary Carcinoma

Patients with head and neck squamous cell carcinoma (SCC) often present with cervical lymph node metastasis. Occasionally the primary tumor site remains unknown even after thorough investigation. Management of such cases is problematic and may result in over-treatment and consequent increased morbidity. High risk HPV has been advocated recently as an important etiologic factor for a subset of head and neck SCC. These are believed to have a special predilection for the oropharyngeal tonsils and are characterized by nonkeratinizing basaloid morphology, and a strong reactivity to p16 immunostain. Identifying HPV-related SCC in the lymph nodes may thus provide a means for localizing the primary tumor site. Ninety-three cases of SCC metastatic to the neck from known primary tumors were classified morphologically into conventional keratinizing SCC (KSCC) and non-keratinizing SCC (NKCa). In situ hybridization (ISH) for high risk HPV as well as immunostaining for p16 were performed on all metastsatic and primary tumors. Of the 93 cases of metastatic carcinomas 32 were oropharyngeal, 35 oral, and 26 arose in the laryx/hypopharynx. Twenty-three cases were found to be HPV+ by ISH, of which 22/23 had oropharyngeal origin (P < 0.0001), with 95.7% sensitivity and 85.7% specificity. Twenty-one of these HPV+ oropharyngeal tumors were NKCa (P < 0.0001). The remaining case showed overlapping NKCa/KSCC hybrid morphology. All NKCa were HPV+ and stained diffusely and strongly with p16 antibodies. We have demonstrated that HPV status of the lymph node metastasis can be assessed not only by ISH and p16 immunoreactivity but also histomorphologically. In addition, a positive microscopic identification of HPV-related carcinoma is a reliable predictor of oropharyngeal origin.

Evaluation of normal FDG uptake in palatine tonsil and its potential value for detecting occult head and neck cancers: A PET CT study

The aims of the study were to (1) evaluate the range of physiological FDG uptake in normal pharyngeal palatine tonsil, and (2) investigate the possibility of establishing a cut-off threshold to distinguish between normal pharyngeal palatine tonsil FDG uptake from occult pharyngeal palatine tonsil primary cancer. FDG PET CT of 43 consecutive patients with a low risk of head and neck cancer were reviewed by two observers. Axial PET CT was used to identify foci of FDG uptake related to the pharyngeal palatine tonsil. The highest standardized uptake value, SUVmax, of the left and right pharyngeal palatine tonsil was calculated. Similar analysis was performed on 10 consecutive patents with histologically proven occult pharyngeal palatine tonsil primary cancer. The mean SUVmax of the 43 right pharyngeal palatine tonsils was 4.82 (range, 1.16-12.74) and 4.68 (range, 0.88-13.65) for the 43 left pharyngeal palatine tonsils with no statistical difference observed (P=0.4). Normal pharyngeal palatine tonsil uptake was generally symmetrical and there was a positive correlation between SUVmax from the left and right sides which was statistically significant (r=0.9, P<0.0001). In the same patient the difference in SUVmax between left and right pharyngeal palatine tonsil ranged from 0.01 to 2.66 and patients with occult pharyngeal palatine tonsil primary cancer it ranged from 0.85 to 11.08. ROC analysis showed that an 'SUVmax difference' cut-off of 0.83 would achieve a sensitivity of 100% and specificity of 81% for detecting occult pharyngeal palatine tonsil primary cancers. There is considerable variation of pharyngeal palatine tonsil FDG uptake in patients with no pharyngeal palatine tonsil primary cancer. However, in the same patient there is generally only a small difference in uptake between left and right sides. The absolute difference in SUVmax between left and right pharyngeal palatine tonsil is a potentially useful parameter for distinguishing between normal FDG uptake in pharyngeal palatine tonsil from occult pharyngeal palatine tonsil primary cancer.

Management of the unknown primary carcinoma: Long‐term follow‐up on a negative PET scan and negative panendoscopy

The unknown primary carcinoma in the head and neck has been estimated to represent up to 7% of all head and neck carcinomas. In an attempt to identify the occult primary tumor the evaluation of this patient population has included a complete head and neck examination, flexible fiberoptic endoscopy, and imaging with CT/MRI. More recently, positron emission tomography (PET) has been advocated as a tool to detect primary tumors. A cohort of 31 patients with fine-needle aspiration biopsy-confirmed squamous cell carcinoma were prospectively entered into a diagnostic protocol to identify the occult primary tumor. The diagnostic protocol included a comprehensive head and neck examination (including flexible endoscopy) and CT and/or MRI. If the initial diagnostic evaluation failed to identify a primary tumor, the patients then underwent whole body PET imaging followed by staging endoscopy with biopsy of the at-risk occult tumor sites. The outcome measures included the accuracy of the PET to predict the presence of occult tumor at staging endoscopy and the accuracy of the negative PET and negative panendoscopy in predicting the subsequent development of a primary tumor in the upper aerodigestive tract during follow-up. The PET detected 9 occult primary tumors in the 31 patients (detection rate, 29%). Five occult primary tumors (2 base of tongue and 3 palatine tonsil) were detected during panendoscopy despite a negative PET. The combination of PET and panendoscopy detected 45.2% of the unknown primary tumors. Seventeen patients (N1, n = 7; N2a, n = 4; N2b, n = 2; N3, n = 4) had no primary tumor detected and were treated as an unknown primary carcinoma with primary neck dissection +/- radiation therapy +/- chemotherapy. In this series of 17 patients, there were 3 neck recurrences (17.6%). In addition, only 1 patient (5.8%) developed a primary tumor of the upper aerodigestive tract with a mean follow-up of 31.1 months (range, 21-60 months). A negative PET study in patients with an occult primary head and neck carcinoma does not preclude the need for panendoscopy with biopsy to detect the occult primary tumor. The risk of subsequent primary tumor appears to be low in the patients with a negative PET and a negative panendoscopy (<6%).

Comprehensive Head and Neck Trauma Screening: The USS Cole Experience

A prospective study was designed to determine the incidence of occult head and neck injuries after initial triage of patients following the USS Cole terrorist bombing. All 39 patients evacuated to Landstuhl Regional Medical Center underwent comprehensive head and neck examinations, regardless of known diagnoses at the time of arrival. Appropriate interventions were performed, and detailed summaries were added to the patients' records. Initial triage listed nine of 39 patients as having sustained head and neck injuries. After screening by an otolaryngology team, 23 of 39 patients were identified as having head and neck injuries requiring further care. The majority of head and neck injuries were not initially reported to the head and neck trauma service. Our conclusion is that occult head and neck injuries are common after blast injuries. Early identification and intervention by a subspecialty head and neck trauma team can aid in achieving optimal outcomes after blast injury.

Intracranial Trauma in Young Children Who Are Physically Abused

Clinicians are keenly aware that failing to recognize physical abuse could end up costing a child's life: Abused children who sustain head injuries, however, can be asymptomatic. But how aggressive are doctors, and how aggressive should they be, in evaluating young children for occult head trauma …