Defining and detecting missed ligamentous injuries of the occipitocervical complex.

STUDY DESIGN: Retrospective radiographic and clinical review of patients in a comprehensive trauma database. OBJECTIVE: The primary aim of this study was to detect occipitocervical complex (OCC) injuries initially missed at a level 1 trauma center. SUMMARY OF BACKGROUND DATA: Recent case series demonstrate that OCC injuries are potentially survivable. Delay in diagnosis can lead to increased morbidity and mortality. METHODS: Normative maximum values that included 97.5% of the population were defined, with a sample of 251 consecutive normal computed tomographic (CT) scans for the Basion-Dens Interval (BDI), atlantooccipital interval, and lateral mass interval (LMI) of C1-C2. Subsequently, 844 cervical CT scans from consecutive polytrauma patients were reviewed for the evidence of OCC injury. Measurements greater than the normative maximum values were considered suspicious for injury. A BDI greater than 12 mm or a BDI greater than 10 mm with a confirmatory magnetic resonance imaging was considered a definite evidence of an OCC injury, as was an LMI 4 mm or greater with confirmatory magnetic resonance imaging. The electronic medical record was reviewed to determine whether an injury was detected on any final neuroradiology report or during follow-up. RESULTS.: Five patients had evidence of atlantooccipital dissociation (AOD), and two had atlantoaxial dissociation (AAD). Of these, three cases of AOD and two cases of AAD were missed on the final report by the neuroradiologist. The undiagnosed patients were subsequently diagnosed by orthopedic surgeons consulted for axial spine or other musculoskeletal trauma. No patients who were diagnosed with AAD or AOD in the electronic medical record were missed by using the criteria of BDI greater than 10 mm and LMI 4 mm or greater to define OCC injuries. CONCLUSION: OCC injuries can be missed even with standardized multidetector CT with multiplanar reconstructions. High-quality normative data used to determine a reliable picture archiving and communication system-based measurement of the OCC anatomy can detect ligamentous injuries initially missed in polytrauma patients.

Documentation, assessment, and treatment of aggression in patients with newly diagnosed dementia.

Practice guidelines recommend a search for underlying biopsychosocial causes and initial use of nonpharmacologic interventions. Using guidelines as a benchmark for standard care, we examined medical records to assess the documentation, assessment, and treatment of aggression in patients newly diagnosed with dementia. Study participants were at least 60 years old and diagnosed with dementia at the Michael E. DeBakey VA Medical Center in Houston, TX, from 2001 to 2004. Of 385 eligible patients screened by telephone using 3 probes from the Ryden Aggression Scale, 75 had positive response to 1 or more of 3 probes from the Ryden. Medical records of these patients were reviewed for 12 months before and 3 months after telephone screening. Aggression had been documented in 31 (42%), nonpharmacologic interventions had been used in 11 (35%), and pharmacologic interventions had been used in all 31. Among the 44 patients without previously documented aggression, pharmacologic interventions were used in 34 (79%) patients. Patients with documented aggression had more psychiatric comorbidities and received more psychotropic medications than patients with undocumented aggression. We conclude that dementia patients should be systematically screened for aggression and that new strategies to increase use of nonpharmacologic interventions and decrease use of pharmacologic interventions, particularly antipsychotics, should be identified.