Using machine learning to discover traumatic brain injury patient phenotypes: national concussion surveillance system Pilot.

OBJECTIVE: The objective is to determine whether unsupervised machine learning identifies traumatic brain injury (TBI) phenotypes with unique clinical profiles. METHODS: Pilot self-reported survey data of over 10,000 adults were collected from the Centers for Disease Control and Prevention (CDC)'s National Concussion Surveillance System (NCSS). Respondents who self-reported a head injury in the past 12 months (n = 1,364) were retained and queried for injury, outcome, and clinical characteristics. An unsupervised machine learning algorithm, partitioning around medoids (PAM), that employed Gower's dissimilarity matrix, was used to conduct a cluster analysis. RESULTS: PAM grouped respondents into five TBI clusters (phenotypes A-E). Phenotype C represented more clinically severe TBIs with a higher prevalence of symptoms and association with worse outcomes. When compared to individuals in Phenotype A, a group with few TBI-related symptoms, individuals in Phenotype C were more likely to undergo medical evaluation (odds ratio [OR] = 9.8, 95% confidence interval[CI] = 5.8-16.6), have symptoms that were not currently resolved or resolved in 8+ days (OR = 10.6, 95%CI = 6.2-18.1), and more likely to report at least moderate impact on social (OR = 54.7, 95%CI = 22.4-133.4) and work (OR = 25.4, 95%CI = 11.2-57.2) functioning. CONCLUSION: Machine learning can be used to classify patients into unique TBI phenotypes. Further research might examine the utility of such classifications in supporting clinical diagnosis and patient recovery for this complex health condition.

Association Between Lifetime Sexual Violence and Recent Traumatic Brain Injury Among Adults: 2017 Connecticut Behavioral Risk Factor Surveillance System.

Sexual violence (SV) is a critical public health problem that is associated with numerous negative health consequences, including immediate- and long-term physical and mental health conditions and health-risk behaviors. Some of these health-risk behaviors (e.g., substance use, unsafe driving practices, poor mental health, lower impulse control, and abnormal brain circuitry) might increase the risk for sustaining a traumatic brain injury (TBI). A TBI causes neurological or neuropsychological changes and may also lead to various symptoms that affect a person's cognition, mobility, behavior, and mental health. Determining if those who have experienced SV are at increased risk of sustaining a TBI in their lifetime is critical given the high prevalence and health impacts of SV, the potential vulnerability to TBI after SV, and the known detrimental effects of TBI. This exploratory study examined data from the 2017 Connecticut behavioral risk factor surveillance system and found that lifetime SV victimization (controlling for age and sex) was associated with increased odds of reporting a recent TBI in the past 12 months (adjusted odds ratio [AOR] = 2.1; 95% confidence interval [CI] [1.03, 4.21]). Further research is needed to better understand how SV history is related to the risk of sustaining a TBI. Healthcare professionals can support patients who experience SV by providing resources to help reduce associated physical and mental health conditions and health-risk behaviors.

Factors That May Influence Americans' Views on When Children Should Start Playing Tackle Football.

CONTEXT: American football is associated with the largest number of emergency department visits for pediatric sport-related traumatic brain injury, including concussions. Tackling is responsible for almost two-thirds of football concussions. Some have recommended implementing age restrictions on tackling in youth football. OBJECTIVE: To determine whether the public would support age restrictions and the factors that may drive such support. DESIGN: Cross-sectional study. SETTING: Summer wave of Porter Novelli's 2020 US ConsumerStyles survey. PARTICIPANTS: A total of 4053 adults. MAIN OUTCOME MEASURE(S): Respondents answered questions about a good age for children to start playing tackle football, past football playing history, concerns about safety, and the benefits and risks of playing football. RESULTS: Most respondents believed that middle (32.8%) or high (27.8%) school was a good age to start playing tackle football. About 1 in 5 (19.8%) respondents reported that children should never play tackle football. Certain groups of individuals were more likely to support children starting to play tackle football at high school age or above or to say that they should never play tackle football, including those with a bachelor's degree or higher (rate ratio [RR]HS+ = 1.41, 95% CI = 1.14, 1.76; RRNEVER = 2.70, 95% CI = 1.93, 3.78), those who did not have children under 18 (RRHS+ = 1.54, 95% CI = 1.26, 1.90; RRNEVER = 1.54, 95% CI = 1.14, 2.07), those who were not football fans (RRNEVER = 3.07, 95% CI = 2.32, 4.06), and those who were very (RRHS+ = 3.94, 95% CI = 2.87, 5.42; RRNEVER = 11.52, 95% CI = 7.32, 18.15) or somewhat (RRHS+ = 1.88, 95% CI = 1.41, 2.52) concerned about the safety of children. CONCLUSION: Despite acknowledging the benefits of playing football, many adults expressed concern about safety and endorsed high school age and older or never as a good age to start playing tackle football, highlighting a disconnect with current football program practices regarding age.

Refinement of a Preliminary Case Definition for Use in Traumatic Brain Injury Surveillance.

OBJECTIVE: Current methods used to measure incidence of traumatic brain injury (TBI) underestimate its true public health burden. The use of self-report surveys may be an approach to improve these estimates. An important step in public health surveillance is to define a public health problem using a case definition. The purpose of this article is to outline the process that the Centers for Disease Control and Prevention undertook to refine a TBI case definition to be used in surveillance using a self-report survey. SETTING: Survey. PARTICIPANTS: A total of 10 030 adults participated via a random digit-dial telephone survey from September 2018 to September 2019. MAIN MEASURES: Respondents were asked whether they had sustained a hit to the head in the preceding 12 months and whether they experienced a series of 12 signs and symptoms as a result of this injury. DESIGN: Head injuries with 1 or more signs/symptoms reported were initially categorized into a 3-tiered TBI case definition (probable TBI, possible TBI, and delayed possible TBI), corresponding to the level of certainty that a TBI occurred. Placement in a tier was compared with a range of severity measures (whether medical evaluation was sought, time to symptom resolution, self-rated social and work functioning); case definition tiers were then modified in a stepwise fashion to maximize differences in severity between tiers. RESULTS: There were statistically significant differences in the severity measure between cases in the probable and possible TBI tiers but not between other tiers. Timing of symptom onset did not meaningfully differentiate between cases on severity measures; therefore, the delayed possible tier was eliminated, resulting in 2 tiers: probable and possible TBI. CONCLUSION: The 2-tiered TBI case definition that was derived from this analysis can be used in future surveillance efforts to differentiate cases by certainty and from noncases for the purpose of reporting TBI prevalence and incidence estimates. The refined case definition can help researchers increase the confidence they have in reporting survey respondents' self-reported TBIs as well as provide them with the flexibility to report an expansive (probable + possible TBI) or more conservative (probable TBI only) estimate of TBI prevalence.

Rationale for the Development of a Traumatic Brain Injury Case Definition for the Pilot National Concussion Surveillance System.

BACKGROUND: Current methods of traumatic brain injury (TBI) morbidity surveillance in the United States have primarily relied on hospital-based data sets. However, these methods undercount TBIs as they do not include TBIs seen in outpatient settings and those that are untreated and undiagnosed. A 2014 National Academy of Science Engineering and Medicine report recommended that the Centers for Disease Control and Prevention (CDC) establish and manage a national surveillance system to better describe the burden of sports- and recreation-related TBI, including concussion, among youth. Given the limitations of TBI surveillance in general, CDC took this recommendation as a call to action to formulate and implement a robust pilot National Concussion Surveillance System that could estimate the public health burden of concussion and TBI among Americans from all causes of brain injury. Because of the constraints of identifying TBI in clinical settings, an alternative surveillance approach is to collect TBI data via a self-report survey. Before such a survey was piloted, it was necessary for CDC to develop a case definition for self-reported TBI. OBJECTIVE: This article outlines the rationale and process the CDC used to develop a tiered case definition for self-reported TBI to be used for surveillance purposes. CONCLUSION: A tiered TBI case definition is proposed with tiers based on the type of sign/symptom(s) reported the number of symptoms reported, and the timing of symptom onset.

The Role of Level of Play in Concussions in High School Athletes.

OBJECTIVES: To examine level of play (LOP) as a risk factor for concussion severity and recovery-related outcomes among high school athletes, stratified by sex, and among boys, by sport (football, non-football male sports). DESIGN/SETTING: Secondary analysis of data collected through the High School Reporting Information Online surveillance system for academic years 2007-2008 through 2018-2019. PARTICIPANTS: A total of 9916 concussions were reported between the academic years 2007-2008 and 2018-2019 from 9 sports (5189 from football; 2096 from non-football male sports; 2631 from female sports). MAIN OUTCOME MEASURE: Examined the association between LOP (Freshman, Junior Varsity [JV], and Varsity teams) and concussion outcomes (number of concussion symptoms, symptom resolution time [SRT], and time to return to play [RTP]). RESULTS: Compared with Varsity football athletes, concussed JV football athletes had on average 0.19 fewer concussion symptoms, longer SRT (>1 week vs <1 week: odds ratio [OR] = 1.3; 95% confidence interval [CI], 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.2-1.9; >3 weeks vs <1 week: OR = 1.6; 95% CI, 1.1-2.3). Compared with Varsity football athletes, Freshman football athletes had on average 0.48 fewer concussion symptoms, longer SRT (OR = 1.3; 95% CI, 1.1-1.5), and longer RTP (1-3 weeks vs <1 week: OR = 1.5; 95% CI, 1.1-2.0; >3 weeks vs <1 week: OR = 2.0; 95% CI, 1.3-3.0). Similarly, compared with female athletes on Varsity teams, concussed JV female athletes had longer RTP (1-3 weeks vs <1 week: OR = 1.8; 95% CI, 1.2-2.7). Trend analyses revealed an increase in the number of concussion symptoms between 2015-2016 and 2018-2019, a decrease between 2009-2010 and 2018-2019 for SRT of less than 1 week, and an increase between 2014-2015 and 2018-2019 for RTP of less than 1 week among Varsity football athletes. Among Varsity female athletes, there was a linear decrease during the study period for RTP of less than 1 week. CONCLUSIONS: Despite a higher number of symptoms overall and in recent years, Varsity football players had shorter RTP than Freshman and JV athletes.

Estimated prevalence of helmet use while bicycling, rollerblading, and skateboarding among middle school students in selected U.S. States- Youth Behavior Risk Survey, 2013-2019.

BACKGROUND: Helmet use helps prevent severe and fatal head and brain injuries from bicycle, rollerblade, and skateboard crashes. This study explores the prevalence of self-reported helmet use among middle school students while bicycling, skateboarding, and rollerblading. METHODS: Data from the Middle School Youth Risk Behavior Survey (YRBS) for selected states were analyzed. Self-reported prevalence (frequency) of helmet use while bicycling, rollerblading, or skateboarding and other variables (sex, grade level, and race/ethnicity) are reported. RESULTS: The overall prevalence of rarely or never wearing a helmet while bicycling among middle school students in selected states was 68.6%; decreasing from 71.7% in 2013 to 67.1% in 2019. The overall prevalence of rarely or never wearing a helmet while rollerblading or skateboarding in middle school students in selected states was 74.6%; decreasing from 76.4% in 2013 to 73.5% in 2019. Students in 7th and 8th grade and students of non-Hispanic race/ethnicity had significantly higher odds of rarely or never wearing a helmet while bicycling or while rollerblading and skateboarding than students in 6th grade and non-Hispanic White students. CONCLUSIONS: While helmet use among middle school students improved over time, overall helmet use during bicycling, rollerblading, and skateboarding remained low. These estimates illustrate the continued call for universal implementation of helmet use efforts among kids using established strategies. PRACTICAL APPLICATIONS: Future research on helmet use among youth who rollerblade and skateboard, as well as multi-pronged efforts to promote helmet use among middle schoolers who bicycle, skateboard, and rollerblade (inclusive of education, helmet distribution, and social marketing techniques, as well as the provision of helmets at no-cost) may be beneficial for addressing perceived risks for injury and other barriers.

Special Report from the CDC Healthcare provider influence on driving behavior after a mild traumatic brain injury: Findings from the 2021 SummerStyles survey.

INTRODUCTION: Research shows that a mild traumatic brain injury (mTBI) impairs a person's ability to identify driving hazards 24 h post injury and increases the risk for motor vehicle crash. This study examined the percentage of people who reported driving after their most serious mTBI and whether healthcare provider education influenced this behavior. METHODS: Self-reported data were collected from 4,082 adult respondents in the summer wave of Porter Novelli's 2021 ConsumerStyles survey. Respondents with a driver's license were asked whether they drove right after their most serious mTBI, how safe they felt driving, and whether a doctor or nurse talked to them about when it was ok to drive after their injury. RESULTS: About one in five (18.8 %) respondents reported sustaining an mTBI in their lifetime. Twenty-two percent (22.3 %) of those with a driver's license at the time of their most serious mTBI drove within 24 h, and 20 % felt very or somewhat unsafe doing so. About 19 % of drivers reported that a doctor or nurse talked to them about when it was safe to return to driving. Those who had a healthcare provider talk to them about driving were 66 % less likely to drive a car within 24 h of their most serious mTBI (APR = 0.34, 95 % CI: 0.20, 0.60) compared to those who did not speak to a healthcare provider about driving. CONCLUSIONS: Increasing the number of healthcare providers who discuss safe driving practices after a mTBI may reduce acute post-mTBI driving. PRACTICAL APPLICATIONS: Inclusion of information in patient discharge instructions and prompts for healthcare providers in electronic medical records may help encourage conversations about post-mTBI driving.

Neuroimaging for mild traumatic brain injury in children: cross-sectional study using national claims data.

BACKGROUND: Current guidelines recommend healthcare professionals avoid routine use of neuroimaging for diagnosing mild traumatic brain injury (mTBI). OBJECTIVE: This study aimed to examine current use of CT and MRI among children and young adult patients with mTBI and factors that increase likelihood of neuroimaging in this population. MATERIALS AND METHODS: Data were analyzed using the 2019 MarketScan commercial claims and encounters database for the commercially insured population for both inpatient and outpatient claims. Descriptive statistics and logistic regression models for patients ≤24 years of age who received an ICD-10-CM code indicative of a possible mTBI were analyzed. RESULTS: Neuroimaging was performed in 16.9% (CT; 95% CI=16.7-17.1) and 0.9% (MRI; 95% CI=0.8-0.9) of mTBI outpatient visits (including emergency department visits) among children (≤18 years old). Neuroimaging was performed in a higher percentage of outpatient visits for patients 19-24 years old (CT=47.1% [95% CI=46.5-47.6] and MRI=1.7% [95% CI=1.5-1.8]), and children aged 15-18 years old (CT=20.9% [95% CI=20.5-21.2] and MRI=1.4% [95% CI=1.3-1.5]). Outpatient visits for males were 1.22 (95% CI=1.10-1.25) times more likely to include CT compared to females, while there were no differences by sex for MRI or among inpatient stays. Urban residents, as compared to rural, were less likely to get CT in outpatient settings (adjusted odds ratio [aOR]=0.55, 95% CI=0.53-0.57). Rural residents demonstrated a larger proportion of inpatient admissions that had a CT. CONCLUSIONS: Despite recommendations to avoid routine use of neuroimaging for mTBI, neuroimaging remained common practice in 2019.

Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care. OBJECTIVE: To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies. METHODS: Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated. RESULTS: During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%). CONCLUSION: Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

Provision of Concussion Information From Coaches and the Presence of Athletic Trainers: Findings From the 2021 YouthStyles Survey.

Coaches play an important role in concussion safety, and their views on concussion influence those of their athletes and the athletes' reporting behaviors. In this 2021 survey of youth, we examined how often coaches provide concussion safety information to their athletes and the association between coaches' provision of concussion information to athletes and the presence of athletic trainers (ATs) at a team's games and practices. More than 4 in 10 youth who played sports reported that their coaches did not provide any sort of concussion education or information to them in the past 12 months. Among those youth who always or sometimes had ATs at practices or games, 76.3% received some type of coach education on concussion in the past 12 months, compared with 31.9% of those who rarely or never had ATs at practices or games (P < .0001). Increasing access to ATs and adapting current concussion training and educational materials for coaches to increase coach-athlete communication may be beneficial.

A Description of Suspected Concussions in Football-Related Activities among K-12 Students in Utah.

The circumstances and nature of concussions among youth who play tackle, flag, or touch football are not well understood. This study used data from Utah's Student Injury Reporting System (SIRS) to explore suspected concussions among K-12 students sustained during participation in football-related activities (tackle, flag, or touch football). Descriptive statistics and chi-square analyses showed that 54.7% of suspected concussions due to football-related activity were among elementary and middle school and 41.3% were among high school students. Most suspected concussions resulted from being struck by or against something (81.9%) and occurred during school-sanctioned games and practices (37.9%), lunch, lunch recess, and recess (34.8%), or physical education class (22.7%). The type of school activity and context for suspected concussions varied by school level. School nurses and others in Utah may use study findings to customize concussion prevention efforts by school level and activity.

Return to Learn ECHO: Telementoring for School Personnel to Help Children Return to School and Learning After Mild Traumatic Brain Injury.

BACKGROUND: Return to learn (RTL) after mild traumatic brain injury (mTBI) presents unique challenges for school professionals. A multidisciplinary team approach is necessary yet training school professionals is logistically difficult. This paper describes an innovative pilot RTL program and its evaluation. METHODS: Utilizing the telehealth/telementoring program Project ECHO® (Extension for Community Healthcare Outcomes), this study utilized a multidisciplinary team of subject matter experts to deliver five 1-hour sessions across 5 cohorts of school-based professionals (total of 133 participants). The evaluation used a mixed-methods approach of post-session and post-program participant surveys and post-program participant focus groups. RESULTS: Participants who completed a post-program survey reported statistically significant improvements in essential aspects of RTL knowledge and self-efficacy. This included improvements in how to manage a student with an mTBI (44.8% to 86.9%), benefits of early return to school for students following mTBI (31.8% to 86.9%), and the importance of written RTL policies/procedures (55.1% to 97.1%). CONCLUSIONS: This study demonstrates that RTL training via a telementoring approach may be a positive and effective way to train school-based professionals and improve knowledge and self-efficacy, especially when attending face-to-face trainings are difficult. This model has the potential to produce programmatic and systematic improvements for RTL education.

Challenges and opportunities in diagnosing and managing mild traumatic brain injury in rural settings.

INTRODUCTION: There is some evidence to suggest that Americans living in rural areas are at increased risk for sustaining a traumatic brain injury (TBI) compared to those living in urban areas. In addition, once a TBI has been sustained, rural residents have worse outcomes, including a higher risk of death. Individuals living in rural areas tend to live farther from hospitals and have less access to TBI specialists. Aside from these factors, little is known what challenges healthcare providers practicing in rural areas face in diagnosing and managing TBI in their patients and what can be done to overcome these challenges. METHODS: Seven focus groups and one individual interview were conducted with a total of 18 healthcare providers who mostly practiced in primary care or emergency department settings in rural areas. Providers were asked about common mechanisms of TBI in patients that they treat, challenges they face in initial and follow-up care, and opportunities for improvement in their practice. RESULTS: The rural healthcare providers reported that common mechanisms of injury included sports-related injuries for their pediatric and adolescent patients and work-related accidents, motor vehicle crashes, and falls among their adult patients. Most providers felt prepared to diagnose and manage their patients with TBI, but acknowledged a series of challenges they face, including pushback from parents, athletes, and coaches and lack of specialists to whom they could refer. They also noted that patients had their own barriers to overcome for timely and adequate care, including lack of access to transportation, difficulties with cost and insurance, and denial about the seriousness of the injury. Despite these challenges, the focus group participants also outlined benefits to practicing in a rural area and several ways that their practice could improve with support. CONCLUSION: Rural healthcare providers may be comfortable diagnosing, treating, and managing their patients who present with a suspected TBI, but they also face many challenges in their practice. In this study it was continually noted that there was lack of resources and a lack of awareness, or recognition of the seriousness of TBI, among the providers' patient populations. Education about common symptoms and the need for evaluation after an injury is needed. The use of telemedicine, an increasingly common technology, may help close some gaps in access to services. People living in rural areas may be at increased risk for TBI. Healthcare providers who work in these areas face many challenges but have found ways to successfully manage the treatment of this injury in their patients.

Examination of Behaviors and Health Indicators for Individuals with a Lifetime History of Traumatic Brain Injury with Loss of Consciousness: 2018 BRFSS North Carolina.

BACKGROUND Evidence suggests that those who have sustained a traumatic brain injury (TBI) are at increased risk of adverse behaviors and health indicators, such as certain chronic physical and mental health conditions. However, little is known about the prevalence of these behaviors and health indicators among these individuals, information that could help decrease their risk of developing such conditions.METHODS Data (N = 4733) from the 2018 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) were analyzed to determine the prevalence of behaviors and health indicators among individuals who report having a lifetime history of TBI with loss of consciousness (LOC).RESULTS North Carolinians who report a lifetime history of TBI with LOC were at increased risk of reporting a range of 3 negative health behaviors: less than always seatbelt use (adjusted odds ratio [AOR] = 1.7; 95% confidence interval [CI] = 1.2-2.4), HIV risk behaviors (AOR = 1.7; 95% CI = 1.1-2.6), and reporting less than 7 hours of sleep (AOR = 1.5; 95% CI = 1.2-1.8); more difficulty obtaining health care (not seeing a doctor due to health care cost in the past 12 months [AOR = 1.3; 95% CI = 1.0-1.8]; not getting a routine medical check-up in the past 12 months [AOR = 1.5; 95% CI = 1.2-2.0]); worse self-reported health (fair or poor general health [AOR = 1.8; 95% CI = 1.4-2.3]); and reporting fair or poor mental health (AOR = 2.1; 95% CI = 1.6-2.8) compared with individuals who did not report a history of TBI.LIMITATIONS There are several limitations to the study, such as the sample being biased toward more severe brain injuries. Additionally, because the data in the BRFSS are retrospective and cross-sectional, it is not possible to determine temporality and causality between TBI history and the behaviors and health indicators examined.CONCLUSION Despite these limitations, this paper is one of the first to directly examine the association between history of TBI with LOC and a range of current behaviors and health care utilization. Assessing positive and negative behaviors and health indicators can help identify and tailor evidence-based interventions for those who have a history of TBI.

Association Between Self-Reported Disability and Lifetime History of Traumatic Brain Injury With Loss of Consciousness Among Veterans and Nonveterans in North Carolina.

BACKGROUND: Compared with civilians, service members and veterans who have a history of traumatic brain injury (TBI) are more likely to experience poorer physical and mental health. To investigate this further, this article examines the association between self-reported history of TBI with loss of consciousness and living with 1 or more current disabilities (ie, serious difficulty with hearing, vision, cognition, or mobility; any difficulty with self-care or independent living) for both veterans and nonveterans. METHODS: A cross-sectional study using data from the North Carolina Behavioral Risk Factor Surveillance System for 4733 veterans and nonveterans aged 18 years and older. RESULTS: Approximately 34.7% of veterans residing in North Carolina reported having a lifetime history of TBI compared with 23.6% of nonveterans. Veterans reporting a lifetime history of TBI had a 1.4 times greater risk of also reporting living with a current disability (adjusted prevalence ratio = 1.4; 95% confidence interval, 1.2-1.8) compared with nonveterans. The most common types of disabilities reported were mobility, cognitive, and hearing. CONCLUSIONS: Compared with nonveterans, veterans who reported a lifetime history of TBI had an increased risk of reporting a current disability. Future studies, such as longitudinal studies, may further explore this to inform the development of interventions.

Prevalence of Suspected Concussions Among K-12 Students in Utah: Findings From Utah's Student Injury Reporting System.

BACKGROUND: To inform prevention strategies, this study provides incidence, factors, and actions taken when a suspected concussion occurred in K-12 schools in Utah. METHODS: Data were collected using Utah's Student Injury Reporting System (SIRS) from the academic years 2011-2012 to 2018-2019. SIRS is a unique online system that tracks injuries that occur in the school setting among K-12 students in Utah. Descriptive statistics were computed to characterize students with a suspected concussion. Chi-square (χ2 ) analysis looking at characteristics by school level was also conducted. RESULTS: Over 63,000 K-12 students in Utah sustained an injury at school during the study period. Suspected concussions comprised 10% of all injuries. The prevalence of concussions was highest among males (60.6%) and elementary school students (42.6%) and most often occurred outdoors (57.6%) or on a playground/playfield (33.9%), and in sports- and recreation-related activities (75.1%) (specifically contact sports, 24.0%). Most students with a suspected concussion were absent 1 day or less from school (71.4%) but about 68% were seen by a medical professional. Further, there were differences by school level. Females and students playing contact sports had a higher percentage of suspected concussions as school level increased, whereas males and concussions sustained during school hours had a lower percentage of suspected concussions as school level increased. CONCLUSIONS: SIRS enables schools in Utah to identify groups at risk for concussion, as well as activities most commonly associated with these injuries, within the school environment. Using this information, schools may implement targeted prevention strategies to protect students.

Traumatic Brain Injury-Related Hospitalizations and Deaths in Urban and Rural Counties-2017.

STUDY OBJECTIVE: A better understanding of differences in traumatic brain injury incidence by geography may help inform resource needs for local communities. This paper presents estimates on traumatic brain injury-related hospitalizations and deaths by urban and rural county of residence. METHODS: To estimate the incidence of traumatic brain injury-related hospitalizations, data from the 2017 Healthcare Cost and Utilization Project's National Inpatient Sample were analyzed (n=295,760). To estimate the incidence of traumatic brain injury-related deaths, the Centers for Disease Control and Prevention's National Vital Statistics System multiple-cause-of-death files were analyzed (n=61,134). Datasets were stratified by residence, sex, principal mechanism of injury, and age group. Traumatic brain injury-related hospitalizations were also stratified by insurance status and hospital location. RESULTS: The rate of traumatic brain injury-related hospitalizations was significantly higher among urban (70.1 per 100,000 population) than rural residents (61.0), whereas the rate of traumatic brain injury-related deaths was significantly higher among rural (27.5) than urban residents (17.4). These patterns held for both sexes, individuals age 55 and older, and within the leading mechanisms of injury (ie, suicide, unintentional falls). Among patients with Medicare or Medicaid, the rate of traumatic brain injury-related hospitalizations was higher among urban residents; there was no urban/rural difference with other types of insurance. Nearly all (99.6%) urban residents who were hospitalized for a traumatic brain injury received care in an urban hospital. Additionally, approximately 80.3% of rural residents were hospitalized in an urban hospital. CONCLUSION: Urban residents had a higher rate of traumatic brain injury-related hospitalizations, whereas rural residents had a higher rate of traumatic brain injury-related deaths. This disparity deserves further study using additional databases that assess differences in mechanisms of injury and strategies to improve access to emergency care among rural residents.

Differences in State Traumatic Brain Injury-Related Deaths, by Principal Mechanism of Injury, Intent, and Percentage of Population Living in Rural Areas - United States, 2016-2018.

Traumatic brain injuries (TBIs) have contributed to approximately one million deaths in the United States over the last 2 decades (1). CDC analyzed National Vital Statistics System (NVSS) mortality data for a 3-year period (2016-2018) to examine numbers and rates of TBI-related deaths, the percentage difference between each state's rate and the overall U.S. TBI-related death rate, leading causes of TBI, and the association between TBI and a state's level of rurality. During 2016-2018, a total of 181,227 TBI-related deaths (17.3 per 100,000 population per year) occurred in the United States. The percentage difference between state TBI-related death rates and the overall U.S. rate during this period ranged from 46.2% below to 101.2% above the overall rate. By state, the lowest rate was in New Jersey (9.3 per 100,000 population per year); the states with the highest rates were Alaska (34.8), Wyoming (32.6), and Montana (29.5). States in the South and those with a higher proportion of residents living in rural areas had higher rates, whereas states in the Northeast and those with a lower proportion of residents living in rural areas had lower TBI-related death rates. In 43 states, suicide was the leading cause of TBI-related deaths; in other states, unintentional falls or unintentional motor vehicle crashes were responsible for the highest numbers and rates of TBI-related deaths. Consistent with previous studies (2), differences in TBI incidence and outcomes were observed across U.S. states; therefore, states can use these findings to develop and implement evidence-based prevention strategies, based on their leading causes of TBI-related deaths. Expanding evidence-based prevention strategies that address TBI-related deaths is warranted, especially among states with high rates due to suicide, unintentional falls, and motor vehicle crashes.