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An estimated 1.7 million people sustain a traumatic brain injury (TBI) annually in the United States. We sought to examine factors contributing to mortality among TBI patients aged ≥65 y in the United States. TBI data from the Nationwide Inpatient Sample were combined from 2000-2010. Patients were stratified by age, sex, mechanism of injury, payer status, comorbidity, injury severity, and other factors. Odds of death were explored using an adjusted multivariable logistic regression. A total of 950,132 TBI-related hospitalizations and 107,666 TBI-related deaths occurred among adults aged ≥65 y from 2000-2010. The most common mechanism of injury was falling, and falls were more common among the oldest age groups. Logistic regression analysis showed highest odds of death among male patients, those whose mechanism of injury was motor vehicle related, patients with three or more comorbidities, and patients who were designated as self-paying., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To characterize and identify trends in sports-related traumatic brain injury (TBI) emergency department (ED) visits from 2006-2011., Methods: This study reviewed data on sports-related TBI among individuals under age 65 from the Nationwide Emergency Department Sample from 2006-2011. Visits were stratified by age, sex, injury severity, payer status and other criteria. Variations in incidence and severity were examined both between groups and over time. Odds of inpatient admission were calculated using regression modelling., Results: Over the period examined, 489 572 sports-related TBI ED visits were reported. The majority (62.2%) of these visits occurred among males under the age of 18. The average head Abbreviated Injury Severity score among these individuals was 1.93 (95% CI = 1.93-1.94) and tended to be lowest among those in middle school and high school age groups; these were also less likely to be admitted. The absolute annual number of visits grew 65.9% from 2006 until 2011, with the majority of this growth occurring among children under age 15. Hospitalization rates dropped 35.6% over the same period., Conclusion: Changes in year-over-year presentation rates vs. hospitalization rates among young athletes suggest that players, coaches and parents may be more aware of sports-related TBI and have developed lower thresholds for seeking medical attention.

Objective: To evaluate the hypothesis that educational attainment, a marker of cognitive reserve, is a predictor of disability-free recovery (DFR) after moderate to severe traumatic brain injury (TBI)., Methods: Retrospective study of the TBI Model Systems Database, a prospective multicenter cohort funded by the National Institute on Disability and Rehabilitation Research. Patients were included if they were admitted for rehabilitation after moderate to severe TBI, were aged 23 years or older, and had at least 1 year of follow-up. The main outcome measure was DFR 1 year postinjury, defined as a Disability Rating Scale score of zero., Results: Of 769 patients included, 214 (27.8%) achieved DFR at 1 year. In total, 185 patients (24.1%) had <12 years of education, while 390 (50.7%) and 194 patients (25.2%) had 12 to 15 years and ≥16 years of education, respectively. DFR was achieved by 18 patients (9.7%) with <12 years, 120 (30.8%) with 12 to 15 years, and 76 (39.2%) with ≥16 years of education (p < 0.001). In a logistic regression model controlling for age, sex, and injury- and rehabilitation-specific factors, duration of education of ≥12 years was independently associated with DFR (odds ratio 4.74, 95% confidence interval 2.70-8.32 for 12-15 years; odds ratio 7.24, 95% confidence interval 3.96-13.23 for ≥16 years)., Conclusion: Educational attainment was a robust independent predictor of 1-year DFR even when adjusting for other prognostic factors. A dose-response relationship was noted, with longer educational exposure associated with increased odds of DFR. This suggests that cognitive reserve could be a factor driving neural adaptation during recovery from TBI.

Post-acute inpatient rehabilitation services are associated with improved functional outcomes among persons with traumatic brain injury (TBI). We sought to investigate racial and insurance-based disparities in access to rehabilitation. Data from the Nationwide Inpatient Sample from 2005-2010 were analyzed using standard descriptive methods and multivariable logistic regression to assess race- and insurance-based differences in access to inpatient rehabilitation after TBI, controlling for patient- and hospital-level variables. Patients with moderate to severe TBI aged 18-64 years with complete data on race and insurance status discharged alive from inpatient care were eligible for study. Among 307,675 TBI survivors meeting study criteria and potentially eligible for discharge to rehabilitation, 66% were white, 12% black, 15% Hispanic, 2% Asian, and 5% other ethnic minorities. Most whites (70%), Asians (70%), blacks (59%), and many Hispanics (49%) had insurance. Compared with insured whites, insured blacks had reduced odds of discharge to rehabilitation (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.75-0.95). Also, insured Hispanics (OR 0.52; 95% CI 0.44-0.60) and insured Asians (OR 0.54; 95% CI 0.39-0.73) were less likely to be discharged to rehabilitation than insured whites. Compared with insured whites, uninsured whites (OR 0.57; 95% CI 0.51-0.63), uninsured blacks (OR 0.33; 95% CI 0.26-0.42), uninsured Hispanics (OR 0.27; 95% CI 0.22-0.33), and uninsured Asians (OR 0.40; 95% CI 0.22-0.73) were less likely to be discharged to rehabilitation. Race and insurance are strong predictors of discharge to rehabilitation among adult TBI survivors in the United States. Efforts are needed to understand and eliminate disparities in access to rehabilitation after TBI.

Background: Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI., Materials and Methods: Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1-6 requiring MV in the National Trauma Data Bank 2007-2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity., Results: Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07-1.08)., Conclusions: Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Traumatic brain injury (TBI) is a leading cause of death and disability among United States adolescents. The authors sought to determine causes and trends for TBI-related hospitalizations in the United States adolescent population (10-19 years). The authors identified common causes and trends of adolescent TBI, overall and within 2-year age categories, using hospitalization data from 2005 to 2009 in the Nationwide Inpatient Sample. The leading cause of adolescent TBI overall was motor vehicle occupant accidents (35%), which are also the leading cause in the 14-15, 16-17, and 18-19 year age groups. Falls were the cause of most TBI in the 10-11 year (23%) and 12-13 year (20%) age groups. For both unintentional and intentional mechanisms of injury, there was evidence of increasing hospitalizations with increasing age. From 2005 to 2009, the overall annual incidence of adolescent TBI hospitalizations decreased 21% from an estimated 75.5-59.3 per 100,000 (p<0.001). These rates declined for mild, moderate, and severe TBI, and decreased for 2-year age groups, except for the 18-19 year-old group. For TBI attributable to motor vehicle occupants, rates declined 27% from 27.6 to 20.2 per 100,000 (p<0.001). Motor vehicle occupant injuries account for 42% of in-hospital mortality from adolescent TBI; however, firearms are the most lethal mechanism with 46% proportional mortality among victims of firearm-related TBI. Rates of adolescent TBI-related hospitalizations have decreased overall. Motor vehicle accidents and firearms were identified as leading causes of injury and mortality for adolescent TBI, and represent potential targets for intervention.

Background: US combat operations in Iraq and Afghanistan have resulted in a greater proportion of service members with head and neck wounds caused by explosions compared with that of previous wars. Although penetrating traumatic brain injury (TBI) is frequently associated with these wounds, the epidemiology of penetrating TBI from these conflicts has not been well described., Methods: The Joint Theater Trauma Registry was queried for January 2003 through December 2010 to identify all patients with moderate-to-severe brain injury with a maximum Abbreviated Injury Scale (AIS) score of the head of 3 or greater and a diagnosis of penetrating or closed TBI in accordance with the Department of Defense Traumatic Brain Injury Surveillance definition. The epidemiology of these injuries was examined, including demographics, TBI severity, overall injury severity, and surgical interventions provided., Results: A total of 1,255 TBI patients (774 penetrating, 481 closed) meeting criteria were identified. Penetrating brain injuries were more severe, more likely to be battle related, and less likely to be isolated injuries than a group of moderate-to-severe closed TBIs within the same range of anatomic injury severity. During the 5-year period of the Iraq war with the largest numbers of TBIs (2004-2008), the numbers of penetrating TBIs exceeded closed TBIs by a ratio of 2:1. During the 3-year period of the Afghanistan war with the greatest numbers of TBIs (2008-2010), the ratio of penetrating to closed TBIs was substantially lower, approximately 1.3:1., Conclusion: This study represents the first comprehensive report on the epidemiology of moderate-to-severe penetrating and closed TBIs resulting from the wars in Iraq and Afghanistan using Joint Theater Trauma Registry data. With the maturing theater of conflicts, penetrating TBIs were substantially less predominant compared with closed TBIs. While this finding may reflect changes in the use of protective measures and tactics or improvements in diagnosis of closed TBIs, additional research is needed to identify the reason for this shift and the subsequent effect on outcome after combat-related TBIs., Level of Evidence: Epidemiologic study, level III.

Background: Weekend admission is associated with mortality in cardiovascular emergencies and stroke but the effect of weekend admission for trauma is not well defined. We sought to determine whether differences in mortality outcomes existed for older adults with substantial head trauma admitted on a weekday versus over the weekend., Methods: Data from the 2006, 2007, and 2008 Nationwide Inpatient Sample were combined and head trauma admissions were isolated. Abbreviated injury scale (AIS) scores were calculated using ICDMAP-90 Software. Individuals aged 65 to 89 y with head AIS equal to 3 or 4 and no other region score <3 were included. Individual Charlson comorbidity scores were calculated and individuals with missing mortality, sex, or insurance data were excluded. Wilcoxon rank sum and Student t-tests compared demographics, length of stay, and total charges for weekday versus weekend admissions. The χ2 tests compared sex and head injury severity. Logistic regression modeled mortality adjusting for age, sex, injury severity, comorbidity, and insurance status., Results: Of the 38,675 patients meeting criteria, 9937 (25.6%) were admitted on weekends. Mean age was similar (78.4 versus 78.4, P = 0.796) but more weekend admissions were female (51.6% versus 50.2%, P = 0.022). Weekend patients demonstrated slightly lower comorbidity (mean Charlson = 1.07 versus 1.14, P < 0.001) and head injury severity (58.3% versus 60.8% AIS = 4, P < 0.001). Median weekend length of stay was shorter (4 versus 5 d, P < 0.001). Weekend and weekday median total charges did not differ ($27,128 versus $27,703, respectively, P = 0.667). Proportional mortality was higher among weekend patients (9.3% versus 8.4%, P = 0.008). After adjustment, weekend patients demonstrated 14% increased odds of mortality (OR 1.14, 95% CI 1.05-1.23)., Conclusion: Older adults with substantial head trauma admitted on weekends are less severely injured, carry less comorbidity, and generate similar total charges compared with those admitted on weekdays. However, after accounting for known risk confounders, weekend patients demonstrated 14% greater odds of mortality. Mechanisms behind this disparity must be determined and eliminated., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To assess the relationship between The International Classification of Diseases, Ninth Revision, Clinical Modification-derived conscious status and mortality rates in trauma centres (TC) vs. non-trauma centres (NTC). Methods: Patients in the 2006-2011 Nationwide Emergency Department Sample meeting, The Centers for Disease Control and Prevention criteria for traumatic brain injury (TBI), with head/neck Abbreviated Injury Scale (AIS) scores ≥3 were included. Loss of consciousness (LOC) was computed for each patient. Primary outcomes included treatment at a level I/II TC vs. NTC and in-hospital mortality. We compared logistic regression models controlling for patient demographics, injury characteristics, and AIS score with identical models that also included LOC. Results: Of 66,636 patients with isolated TBI identified, 15,761 (23.6%) had missing LOC status. Among the remaining 50,875 patients, 59.0% were male, 54.0% were ≥65 years old, 56.7% were treated in TCs, and 27.3% had extended LOC. Patients with extended LOC were more likely to be treated in TCs vs. those with no/brief LOC (71.1% vs. 51.4%, p < 0.001). Among patients aged <65, TC treatment was associated with increased odds of mortality [Adjusted Odds Ratio (AOR) 1.79]; accounting for LOC substantially mitigated this relationship [AOR 1.27]. Similar findings were observed among older patients, with reduced effect size. Conclusion: Extended LOC was associated with TC treatment and mortality. Accounting for patient LOC reduced the differential odds of mortality comparing TCs vs. NTCs by 60%. Research assessing TBI outcomes using administrative data should include measures of consciousness. [ABSTRACT FROM AUTHOR]