Concussion Symptoms and Neurocognitive Performance of Children and Adolescents on Antidepressants.

INTRODUCTION/PURPOSE: There is a well-established association between preexisting depression/anxiety and greater postconcussion symptom burden, but the potential impact of antidepressant medications has not been fully explored. The primary objective of this study was to compare preinjury/baseline and postinjury concussion symptom scores and neurocognitive performance of athletes on antidepressant medications, both with healthy controls and with those with depression/anxiety not on antidepressants. METHODS: This is a cross-sectional study using data collected from 49,270 junior and high school athletes from computerized neurocognitive assessments (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) administered between 2009 and 2018 held by the Massachusetts Concussion Management Coalition. The main outcome measures were symptom scores and neurocognitive performance measures, all of which were assessed both at baseline and postinjury. Statistical analysis included analysis of variance and Tukey pairwise comparisons for continuous variables and Fisher's exact test for categorical variables. Multivariate regression models were used to adjust for potential confounding variables. RESULTS: Both at baseline and postinjury, athletes with depression/anxiety had mean total symptom scores that were more than double that of healthy controls regardless of antidepressant use. Although there were no significant differences in neurocognitive performance at baseline, depression/anxiety was associated with small but significant decreases in postinjury visual memory and visual motor scores. CONCLUSIONS: Both at baseline and after sustaining a concussion, young athletes with depression/anxiety experience significantly greater symptom burden compared with healthy controls regardless of antidepressant use.

Abortion Restrictiveness and Infant Mortality: An Ecologic Study, 2014-2018.

INTRODUCTION: The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018. METHODS: A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023. RESULTS: There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055). CONCLUSIONS: State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality.

Factors Associated with Symptom Resolution after Aerobic Exercise Intervention in Adolescent and Young Adults with Concussion.

BACKGROUND: Aerobic exercise facilitates postconcussion symptom resolution at the group level, but patient-level characteristics may affect the likelihood of treatment efficacy. PURPOSE: This study aimed to investigate demographic and clinical characteristics, which differentiate postconcussion aerobic exercise treatment efficacy from nonefficacy in the intervention arm of a randomized clinical trial. METHODS: Adolescent and young adult participants initiated a standardized aerobic exercise intervention within 14 d of concussion, consisting of self-selected exercise for 100 min·wk -1 at an individualized heart rate (80% of heart rate induced symptom exacerbation during graded exercise testing). Treatment efficacy was defined as symptom resolution within 28-d postconcussion. Treatment efficacy and nonefficacy groups were compared on demographics, clinical characteristics, intervention adherence, and persistent symptom risk using the Predicting Persistent Postconcussive Problems in Pediatrics (5P) clinical risk score. RESULTS: A total of 27 participants (16.1 ± 2.3 yr old; range, 11-21 yr; 52% female) began the intervention, with a mean of 9.5 ± 3.7 d after concussion; half ( n = 13; 48%) demonstrated treatment efficacy (symptom resolution within 28 d postconcussion). Those whose symptoms resolved within 28 d had significantly lower preintervention postconcussion symptom inventory scores (21.2 ± 13.2 vs 41.4 ± 22.2; P < 0.01), greater adherence to the intervention (77% vs 36%; P = 0.05), and longer average exercise duration (median [interquartile range], 49.7 [36.8-68.6] vs 30.4 [20.7-34.7] min; P < 0.01) than those whose symptoms lasted more than 28 d. Groups were similar in age, sex, timing of intervention, and preintervention 5P risk score. CONCLUSIONS: A standardized aerobic exercise intervention initiated within 14 d of concussion demonstrated efficacy for approximately half of participants, according to our definition of treatment efficacy. This multisite aerobic exercise intervention suggests that lower symptom severity, higher intervention adherence, and greater exercise duration are factors that increase the likelihood of symptoms resolving within 28 d of concussion.

Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where.

Objectives: Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions. Methods: This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods. Results: Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4-22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods. Conclusions: Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.

Adolescents With More Oculomotor and Vestibular Signs of Sport-Related Concussion Benefit from Aerobic Exercise: An Exploratory Analysis.

Abstract Early targeted heart rate (HR) aerobic exercise has been shown to reduce the duration of recovery from sport-related concussion (SRC) as well as the incidence of persistent post-concussive symptoms (PPCS). It is not known, however, if more severe oculomotor and vestibular presentations of SRC benefit from a prescription of aerobic exercise. The current study is an exploratory analysis of two published randomized controlled trials that compared aerobic exercise within 10 days of injury with a placebo-like stretching intervention. Combining the two studies yielded a larger sample size to stratify severity of concussion based on the number of abnormal physical examination signs present at the initial office evaluation, which were confirmed with self-reported symptoms and recovery outcomes. The most discriminant cut-off was between those who had ≤3 oculomotor and vestibular signs and those who had >3 signs. Aerobic exercise (hazard ratio = 0.621 [0.412, 0.936], p = 0.023) reduced recovery times even when controlling for site (hazard ratio = 0.461 [0.303, 0.701], p < 0.001), severity (hazard ratio = 0.528 [0.325, 0.858], p = 0.010) and the interaction term of intervention and severity (hazard ratio = 0.972 [0.495, 1.909], p = 0.935). Adolescents who presented with >3 signs and were assigned to the placebo-like stretching group had a PPCS incidence of 38%, which was the highest of all subgroups (aerobic exercise and ≤3 findings: 8%; stretching and ≤3 findings: 11%; aerobic exercise and >3 findings: 21%). This exploratory study provides pilot evidence that prescribed sub-symptom threshold aerobic exercise treatment early after SRC may be effective for adolescents with more oculomotor and vestibular physical examination signs and should be validated in future adequately powered trials.

Optimizing Choice and Timing of Behavioral Outcome Tests After Repetitive Mild Traumatic Brain Injury: A Machine Learning-Based Approach on Multiple Pre-Clinical Experiments.

Repetitive mild traumatic brain injury (rmTBI) is a potentially debilitating condition with long-term sequelae. Animal models are used to study rmTBI in a controlled environment, but there is currently no established standard battery of behavioral tests used. Primarily, we aimed to identify the best combination and timing of behavioral tests to distinguish injured from uninjured animals in rmTBI studies, and secondarily, to determine whether combinations of independent experiments have better behavioral outcome prediction accuracy than individual experiments. Data from 1203 mice from 58 rmTBI experiments, some of which have already been published, were used. In total, 11 types of behavioral tests were measured by 37 parameters at 13 time points during the first 6 months after injury. Univariate regression analyses were used to identify optimal combinations of behavioral tests and whether the inclusion of multiple heterogenous experiments improved accuracy. k-means clustering was used to determine whether a combination of multiple tests could distinguish mice with rmTBI from uninjured mice. We found that a combination of behavioral tests outperformed individual tests alone when distinguishing animals with rmTBI from uninjured animals. The best timing for most individual behavioral tests was 3-4 months after first injury. Overall, Morris water maze (MWM; hidden and probe frequency) was the behavioral test with the best capability of detecting injury effects (area under the curve [AUC] = 0.98). Combinations of open field tests and elevated plus mazes also performed well (AUC = 0.92), as did the forced swim test alone (AUC = 0.90). In summary, multiple heterogeneous experiments tended to predict outcome better than individual experiments, and MWM 3-4 months after injury was the optimal test, also several combinations also performed well. In order to design future pre-clinical rmTBI trials, we have included an interactive application available online utilizing the data from the study via the Supplementary URL.

Examining racial and ethnic disparities in adult emergency department patient visits for concussion in the United States.

Background: Racial and ethnic differences in emergency department (ED) visits have been reported among adolescent patients but are unsubstantiated among adults. Therefore, our purpose in this study was to examine the relationship between race/ethnicity and adult ED visits for concussions, their injury mechanisms, and computed tomography (CT) scan use among a nationally representative sample. Methods: We used the National Hospital Ambulatory Medical Care Survey database from 2010-2015 to examine 63,725 adult (20-45 years old) patient visits, representing an estimated 310.6 million visits presented to EDs. Of these visits, 884 (4.5 million national estimate) were diagnosed with a concussion. Visit records detailed patient information (age, sex, race/ethnicity, geographic region, primary payment type), ED visit diagnoses, injury mechanism (sport, motor vehicle, fall, struck by or against, "other"), and head CT scan use. The primary independent variable was race/ethnicity (non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, non-Hispanic multiracial or another, and non-Hispanic White). We used multivariable logistic and multinomial regression models with complex survey sampling design weighting to examine the relationship between concussion ED visits, injury mechanisms, and CT scan use separately by race/ethnicity while accounting for covariates. Results: There were no associations between race/ethnicity and concussion diagnosis among adult ED visits after accounting for covariates. Relative to sports-related injuries, non-Hispanic Black or African American patient visits were associated with a motor vehicle (OR = 2.69, 95% CI: 1.06-6.86) and "other" injury mechanism (OR = 4.58, 95% CI: 1.34-15.69) compared to non-Hispanic White patients. Relative to sports-related injuries, non-Hispanic Asian, multiracial, or patients of another race had decreased odds of falls (OR = 0.20, 95% CI: 0.04-0.91) and "other" injuries (OR = 0.09, 95% CI: 0.01-0.55) compared to non-Hispanic White patients. The odds of a CT scan being performed were significantly lower among Hispanic/Latinx patient visits relative to non-Hispanic White patients (OR = 0.52, 95% CI: 0.30-0.91), while no other race/ethnicity comparisons differed. Conclusion: Our findings indicate that the overarching concussion ED visit likelihood may not differ by race/ethnicity in adults, but the underlying mechanism causing the concussion and receiving a CT scan demonstrates considerable differences. Prospective future research is warranted to comprehensively understand and intervene in the complex, multi-level race/ethnicity relationships related to concussion health care to ensure equitable patient treatment.

Early analgesic administration and headache presence 7 days post-concussion in children.

OBJECTIVE: This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth. METHODS: A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models. RESULTS: 2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)]. CONCLUSIONS: Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

RéSUMé: OBJECTIF: Cette étude vise à déterminer si un traitement aigu à l'ibuprofène, à l'acétaminophène ou aux deux est associé à la résolution des maux de tête ou à la réduction de la douleur des maux de tête 7 jours après la commotion cérébrale chez les enfants et les adolescents. MéTHODES: Une analyse secondaire de l'étude de cohorte prospective Predicting and Preventing Post-concussive Problems in Pediatrics (5P) a été réalisée. Des personnes âgées de 5 à 18 ans souffrant d'une commotion cérébrale aiguë se présentant dans neuf services d'urgence pédiatriques (SU) canadiens ont été inscrites d'août 2013 à juin 2015. Le résultat primaire était la présence de maux de tête à 7 jours, mesurée à l'aide du Post-Concussion Symptom Inventory. L'association entre l'administration aiguë d'ibuprofène, d'acétaminophène ou des deux et la présence de maux de tête à 7 jours a été étudiée à l'aide de scores de propension et de modèles de régression multivariés ajustés. RéSULTATS: 2277 (74,3%) des 3063 participants avaient des maux de tête lors de la présentation aux urgences. Parmi ces participants, 1 543 (67,8%) ont reçu un médicament analgésique avant ou pendant leur visite aux urgences [ibuprofène 754 (33,1%), acétaminophène 445 (19,5%), les deux 344 (15,1%); ou aucun médicament 734 (32,2%)]. L'analyse multivariée a porté sur 1707 participants avec des scores de propension basés sur les caractéristiques personnelles et les symptômes; 877 (51,4%) ont signalé des maux de tête 7 jours après la commotion cérébrale. Aucune association n'est apparue entre le traitement et la présence de céphalées à 7 jours [ibuprofène vs non traité: (risque relatif (RR) = 1,12 (95%CI:0,99,1,26); acétaminophène vs non traité RR = 1,02 (95% IC: 0,87,1,22); les deux vs non traité RR = 1,02 (95% IC: 0,86,1,18)]. CONCLUSIONS: L'exposition à l'ibuprofène, à l'acétaminophène ou aux deux dans la phase aiguë ne diminue pas le risque de céphalées 7 jours après la commotion. Les analgésiques non opioïdes comme l'ibuprofène ou l'acétaminophène peuvent être prescrits pour soulager les maux de tête à court terme, mais les cliniciens doivent faire attention à la surconsommation de médicaments à long terme chez les personnes dont les symptômes de maux de tête persistent.

Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury.

OBJECTIVE: To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN: We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS: There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS: Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.

Racial Disparities in Diagnosis of Concussion and Minor Head Trauma and Mechanism of Injury in Pediatric Patients Visiting the Emergency Department.

OBJECTIVE: To determine if racial/ethnic differences exist in the diagnosis and mechanism of injury among children and adolescents visiting the emergency department (ED) for concussion and minor head trauma (MHT). STUDY DESIGN: A retrospective, cross-sectional study of patient (age ≤19 years) visits to the ED for concussion between 2010-2015, using the National Hospital Ambulatory Medical Care Survey, was completed. The primary study exposure was race/ethnicity. Outcome measures included ED visits that resulted in a concussion/MHT diagnosis and mechanism of injury. Mechanism categories included sport, motor vehicle collision, fall, assault, and other mechanism. A multivariable logistic regression and multinomial logistic regression were conducted to assess relationships between race/ethnicity and outcomes. Findings were weighted to reflect population estimates. RESULTS: In total, 1263 child/adolescent visits for concussion/MHT were identified, representing an estimated 6.6 million child/adolescent visits nationwide. Compared with non-Hispanic White pediatric patients, non-Hispanic Black patients were least likely to have an ED visit for a concussion/MHT (P < .001; OR, 0.66; 95% CI, 0.52-0.83) The odds of non-Hispanic Black children/adolescents (OR, 3.80; 95% CI, 1.68-8.55) and children/adolescents of other race/ethnicity (OR, 4.93; 95% CI, 1.09-22.23) sustaining a concussion/MHT resulting from assault vs sport was higher. CONCLUSIONS: Amid the emerging focus on sport-related concussion, these ethnic/racial differences in ED diagnosis of concussion/MHT demonstrate sociodemographic differences that warrant further attention. Assault may be a more common mechanism of concussion among children/adolescents of a racial minority.

Revisits, readmissions, and outcomes for pediatric traumatic brain injury in California, 2005-2014.

Long-term outcomes related to emergency department revisit, hospital readmission, and all-cause mortality, have not been well characterized across the spectrum of pediatric traumatic brain injury (TBI). We evaluated emergency department visit outcomes up to 1 year after pediatric TBI, in comparison to a referent group of trauma patients without TBI. We performed a longitudinal, retrospective study of all pediatric trauma patients who presented to emergency departments and hospitals in California from 2005 to 2014. We compared emergency department visits, dispositions, revisits, readmissions, and mortality in pediatric trauma patients with a TBI diagnosis to those without TBI (Other Trauma patients). We identified 208,222 pediatric patients with an index diagnosis of TBI and 1,314,064 patients with an index diagnosis of Other Trauma. Population growth adjusted TBI visits increased by 5.6% while those for Other Trauma decreased by 40.7%. The majority of patients were discharged from the emergency department on their first visit (93.2% for traumatic brain injury vs. 96.5% for Other Trauma). A greater proportion of TBI patients revisited the emergency department (33.4% vs. 3.0%) or were readmitted to the hospital (0.9% vs. 0.04%) at least once within a year of discharge. The health burden within a year after a pediatric TBI visit is considerable and is greater than that of non-TBI trauma. These data suggest that outpatient strategies to monitor for short-term and longer-term sequelae after pediatric TBI are needed to improve patient outcomes, lessen the burden on families, and more appropriately allocate resources in the healthcare system.

Concussion Symptom Profiles Among Child, Adolescent, and Young Adult Athletes.

OBJECTIVES: (1) To examine how age influences initial symptom presentation following concussion; and (2) to determine whether specific symptom profiles are associated with duration of postconcussion symptoms, and whether they vary by age group. DESIGN: A total of 689 patients (20% children 7-12 years of age, 69% adolescents 13-18 years of age, and 11% young adults 19-30 years of age) were seen and diagnosed with a concussion within 21 days after injury. Patients completed the Post-Concussion Symptom Scale (PCSS) and were followed until they no longer required care. SETTING: Two specialty care sport concussion clinical practices. MAIN OUTCOME MEASURES: Overall PCSS score was obtained, as well as severity ratings from somatic, vestibular-ocular, cognitive, sleep, and emotional symptom domains. We also calculated total symptom duration time. RESULTS: No significant main effect of age, or age by sex associations were identified among the symptom domains. Females endorsed a higher somatic symptom severity rating than males (9.8 ± 6.7 vs 8.1 ± 6.7; P = 0.03). For patients between 7 and 12 years of age, higher somatic [ß-coefficient = 1.57, 95% confidence interval (CI), 1.47-1.67] and cognitive (ß-coefficient = 2.50, 95% CI, 2.32-2.68) symptom severities were associated with longer duration of concussion symptoms. Among adolescents, longer total symptom duration was associated with more severe somatic (ß-coefficient = 1.25, 95% CI, 0.34-2.15) and vestibular-ocular (ß-coefficient = 2.36, 95% CI, 1.49-3.23) symptoms. CONCLUSIONS: Within 21 days after concussion, symptom-reporting behavior seems to be similar across the age spectrum, but the relationship between symptom profiles and time to symptom resolution varies by age. Although overall symptom ratings are beneficial in determining clinical pathways, symptom domain use may provide a beneficial method to determine individualized patient care that differs between children and adolescents after concussion.

Identifying Persistent Postconcussion Symptom Risk in a Pediatric Sports Medicine Clinic.

BACKGROUND: Although most children report symptom resolution within a month of a concussion, some patients experience persistent postconcussion symptoms (PPCS) that continues for more than 1 month. Identifying patients at risk for PPCS soon after an injury can provide useful clinical information. PURPOSE: To determine if the Predicting Persistent Post-concussive Problems in Pediatrics (5P) clinical risk score, an emergency department (ED)-derived and validated tool, is associated with developing PPCS when obtained in a primary care sports concussion setting. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We conducted a study of patients seen at a pediatric sports medicine concussion clinic between May 1, 2013, and October 1, 2017, who were <19 years of age and evaluated within 10 days of a concussion. The main outcome was PPCS, defined as symptoms lasting >28 days. Nine variables were used to calculate the 5P clinical risk score, and we assessed the association between the 5P clinical risk score and PPCS occurrence. The secondary outcome was total symptom duration. RESULTS: We examined data from 230 children (mean age, 14.8 ± 2.5 years; 50% female; mean time from injury to clinical assessment, 5.6 ± 2.7 days). In univariable analyses, a greater proportion of those who developed PPCS reported feeling slowed down (72% vs 44%, respectively; P < .001), headache (94% vs 72%, respectively; P < .001), sensitivity to noise (71% vs 43%, respectively; P < .001), and fatigue (82% vs 51%, respectively; P < .001) and committed ≥4 errors in tandem stance (33% vs 7%, respectively; P < .001) than those who did not. Higher 5P clinical risk scores were associated with increased odds of developing PPCS (adjusted odds ratio [OR], 1.62 [95% CI, 1.30-2.02]) and longer symptom resolution times (ß = 8.40 [95% CI, 3.25-13.50]). Among the individual participants who received a high 5P clinical risk score (9-12), the majority (82%) went on to experience PPCS. The area under the curve for the 5P clinical risk score was 0.75 (95% CI, 0.66-0.84). After adjusting for the effect of covariates, fatigue (adjusted OR, 2.93) and ≥4 errors in tandem stance (adjusted OR, 7.40) were independently associated with PPCS. CONCLUSION: Our findings extend the potential use for an ED-derived clinical risk score for predicting the PPCS risk into the sports concussion clinic setting. While not all 9 predictor variables of the 5P clinical risk score were independently associated with the PPCS risk in univariable or multivariable analyses, the combination of factors used to calculate the 5P clinical risk score was significantly associated with the odds of developing PPCS. Thus, obtaining clinically pragmatic risk scores soon after a concussion may be useful for early treatments or interventions to mitigate the PPCS risk.

Burden of USA hospital charges for traumatic brain injury.

OBJECTIVES: This study sought to estimate charges associated with USA hospital visits for traumatic brain injury (TBI), compare charges from 2006-2010 and evaluate factors associated with higher charges. METHODS: The Nationwide Emergency Department Sample database, 2006-2010, was used to estimate charges for emergency department visits and inpatient hospital stays associated with TBI and trends in charges over time were compared. Multivariable linear regression was used to evaluate factors associated with visit charges. RESULTS: In 2010, there were $21.4 billion (95% confidence interval (CI) = $17.7-$25.2 billion) in charges for TBI-related admissions, an increase of 22% from 2006. Charges for ED visits resulting in discharge or transfer were $8.2 billion (95% CI = $7.4-$8.9 billion), an increase of 94% from 2006. The proportion of charges for TBI-related visits was disproportionately higher than the proportion of visits for TBI across all years of the study (p < 0.001). Patient age and gender, West region, trauma centre status, non-paediatric hospital designation, metropolitan location and hospital ownership were independently associated with higher charges. CONCLUSIONS: There was a substantial charge burden from TBI-related hospital visits and charges increased disproportionately to visit volume. There are patient and hospital factors independently associated with higher charges. These findings, as well as methods to reduce the charge burden and charge disparities, deserve further study.

Initial somatic symptoms are associated with prolonged symptom duration following concussion in adolescents.

AIM: To determine which initial postinjury symptom domains are independently associated with symptoms lasting >28 days in youth athletes who sustained sport-related concussions. METHODS: Patients who presented for care at a sport concussion clinic completed the postconcussion symptom scale. They were classified into two groups: those who reported symptom resolution within 28 days of injury and those who did not. Logistic regression models were constructed for children and adolescents to determine the independent association between symptom recovery and potential predictor variables: initial symptom scores in 5 postconcussion symptom scale domains (somatic, vestibular-ocular, cognitive, sleep and emotional), sex, loss of consciousness or amnesia at the time of injury, history of prior concussion, prior treatment for headaches or migraines, or family history of concussion. RESULTS: Sixty-eight child (8-12 years of age) and 250 adolescent (13-18 years of age) athletes were included. For adolescents, initial somatic symptom severity was independently associated with prolonged symptom duration (adjusted odds ratio = 1.162; 95% CI: 1.060, 1.275) and no other predictor variables were. No potential predictor variables were independently associated with prolonged symptom duration for children. CONCLUSION: Among adolescent athletes, a high initial somatic symptom burden (e.g. headache, nausea, vomiting, etc.) is associated with increased odds of symptoms beyond 28 days postinjury.

Physical Activity Level and Symptom Duration Are Not Associated After Concussion.

BACKGROUND: Physical rest after a concussion has been described as a key component in the management of the injury. Evidence supporting this recommendation, however, is limited. PURPOSE: To examine the association between physical activity and symptom duration in a cohort of patients after a concussion. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This study included 364 patients who were diagnosed with a concussion, were seen by a physician within 3 weeks of injury, and completed a questionnaire at the initial clinic visit. The questionnaire assessed the postconcussion symptom scale (PCSS) score, previous number of concussions, presence of the loss of consciousness or amnesia at the time of injury, and prior treatment for headaches. During each follow-up clinic visit, physical activity level was self-reported. A Cox proportional hazard model was constructed to determine the association between symptom duration, initial clinic visit responses, and self-reported physical activity level after the injury. RESULTS: Study participants ranged in age from 8 to 27 years (mean age, 15.0 years) and had sustained a mean of 0.8 prior concussions; 222 patients (61%) were male. On initial examination, the mean PCSS score was 34.7. The mean symptom duration was 48.9 days after the injury. Among the variables included in the model, initial PCSS score and female sex were independently associated with symptom duration, while physical activity level after the injury was not. For participants aged between 13 and 18 years, however, higher levels of physical activity after the injury were associated with a shorter symptom duration. CONCLUSION: Results from this study indicate that physical activity after the injury may not be universally detrimental to the recovery of concussion symptoms.

Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits.

OBJECTIVE: To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. STUDY DESIGN: This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use. RESULTS: Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs. CONCLUSION: There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.

Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma.

OBJECTIVE: Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries. METHODS: We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time. RESULTS: We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation. CONCLUSIONS: An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries.