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OBJECTIVE: To document age-related patterns of nonfatal hospitalization associated with traumatic brain injury (TBI) among children younger than 2 years of age, by intent/cause and diagnosis. METHODS: Data describing 2536 nonfatal TBI-related hospitalizations in 15 states for the year 1999 were obtained from the Centers for Disease Control and Prevention Central Nervous System Injury surveillance system for children younger than 2 years of age (0-23 months) at the time of injury. MAIN OUTCOME MEASURES: Incidence rates (overall, by intent/cause, and by diagnosis) were calculated by combining TBI surveillance data with population data from the US Census Bureau and the National Center for Health Statistics. RESULTS: Overall rates of nonfatal TBI-related hospitalization peaked at 1 month of age (178.0 cases per 100,000 person-years) followed by a secondary peak at 8 months of age (127.9 cases per 100,000 person-years). Rates for fall-related (unintentional) cases and assault-related cases were significantly higher for infants (0-11 months) than for 1-year-olds (12-23 months), with rates for both types of cases peaking in the earliest months of life. Rates for cases with diagnoses of skull fracture and/or intracranial injury were also significantly higher for the younger group. Assault-related cases frequently coincided with a diagnosis of intracranial injury regardless of age. CONCLUSIONS: Prevention efforts should focus on falls and assaults, which account for the majority of TBI-related hospitalizations in early childhood. Such efforts may also need to emphasize the unusually high risk during the first few months of life. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the epidemiologic and clinical characteristics of older persons (ie, those aged 65-74, 75-84, and > or = 85 years) hospitalized with traumatic brain injury (TBI). METHODS: Data from the 1999 CDC 15-state TBI surveillance system were analyzed. RESULTS: In 1999, there were 17,657 persons 65 years and older hospitalized with TBI in the 15 states for an age-adjusted rate of 155.9 per 100,000 population. Rates among persons aged 65 years or older increased with age and were higher for males. Most TBIs resulted from fall- or motor vehicle (MV)-traffic-related incidents. Most older persons with TBI had an initial TBI severity of mild (73.4%); however, the proportions of both moderate and severe disability for those discharged alive and of in-hospital mortality were relatively high (23.5%, 9.7%, and 12%, respectively). Persons who fell were also more likely to have had 3 or more comorbid conditions than were those who sustained a TBI from an MV-traffic incident. CONCLUSIONS: TBI is a substantial public health problem among older persons. As the population of older persons continues to increase in the United States, the need to design and implement proven and cost-effective prevention measures that focus on the leading causes of TBI (unintentional falls and MV-traffic incidents) becomes more urgent. [ABSTRACT FROM AUTHOR]

Problem/Condition: Previous studies indicate that each year in the United States, approximately 1.5 million Americans sustain a traumatic brain injury (TBI). Of those injured, approximately one quarter million are hospitalized. Approximately one third of adults hospitalized with TBI still need help with daily activities 1 year after their discharge.Reporting Period: This report summarizes surveillance data for TBI in the United States for January-December 1997.Description of the System: Data are from 14 states that participated in an ongoing CDC-funded TBI surveillance system. State health departments used CDC guidelines to identify TBI cases from hospital discharge data or from other statewide injury data systems. Supplementary information was abstracted from medical records.Results: The overall age-adjusted TBI-related live hospital discharge rate was 69.7/100,000 population. Rates were highest for American Indians and Alaska Natives (75.3/100,000) and Blacks (74.4/100,000). The age-adjusted rate for males was approximately twice as high as for females (91.9 versus 47.7/100,000 respectively). For both sexes, the rates were highest among those aged 15-19 years and >/=65 years. Motor-vehicle crashes, falls, and assaults were the leading causes of injury for TBI-related discharges (27.9, 22.5, and 7.3/100,000 respectively). TBI-related discharge rates for falls were highest among those aged >/=65 years (82.3/100,000). Black males and American Indian/Alaska Native males had the highest rates of TBI attributable to assault (31.3 and 29.5 per 100,000, respectively), approximately 4 times the rate for white males. An estimated 46% of injured motor-vehicle occupants, 53% of motorcyclists, and 41% of pedal cyclists reportedly were not using personal protective equipment (PPE) (e.g., seat belts or helmets) at the time of their TBI. With regard to outcome assessed before discharge from the hospital, approximately 17% of persons hospitalized with TBI had moderate to severe disability.Interpretation: Data in this report, the most extensive to date from a multistate population-based TBI surveillance system, indicate the importance of TBI as a public health problem. Population-based information regarding TBI hospitalizations can be useful in assessing the effect of prevention efforts and planning for the service needs of persons with TBI. [ABSTRACT FROM AUTHOR]

From January 1990 to December 1991, 16 patients with multidrug-resistant tuberculosis (MDR-TB) caused by Mycobacterium tuberculosis resistant to isoniazid, rifampin, and streptomycin were diagnosed at Elmhurst Hospital. Compared with other TB patients, MDR-TB patients were more likely to have human immunodeficiency virus (HIV) infection (14/16 vs. 21/204, P < .001) and a prior admission (10/16 vs. 3/204, P < .001). HIV-infected patients hospitalized for > 10 days within three rooms of an infectious MDR-TB patient had higher risk of acquiring MDR-TB than did HIV-infected patients with shorter hospitalizations or locations further from the MDR-TB patient(s) (6/28 vs. 2/90, P < .001). Isolates of 6 of 8 MDR-TB patients in a chain of transmission were identical by restriction fragment length polymorphism DNA typing. Ambulation on the wards of inadequately masked TB patients and lack of negative pressure in isolation rooms probably facilitated transmission. This report documents nosocomial transmission of MDR-TB and underscores the need for effective isolation practices and facilities in health care institutions. [ABSTRACT FROM AUTHOR]

Objectives: To describe the frequencies and rates of mild traumatic brain injury (mTBI) emergency department (ED) visits, analyze the trend across the years, and compare sociodemographic characteristics of visits by mTBI type (ie, mTBI as the only injury, or present along with other injuries)., Design: Population-based descriptive study using data from the Nationwide Emergency Department Sample (2006-2012)., Methods: Joinpoint regression was used to calculate the average annual percent changes of mTBI incidence rates. Characteristics between isolated and nonisolated visits were compared, and the odds ratios were reported., Results: The rate per 100 000 population of mTBI ED visits in the United States increased significantly from 569.4 (in 2006) to 807.9 (in 2012). The highest rates were observed in 0- to 4-year-olds, followed by male 15- to 24-year-olds and females 65 years and older; the lowest rates were among 45- to 64-year-olds. The majority (70%) of all visits were nonisolated and occurred more frequently in residents of metropolitan areas. Falls were the leading external cause. Most visits were privately insured or covered by Medicare/Medicaid, and the injury occurred on weekdays in predominantly metropolitan hospitals in the South region., Conclusions: The burden of mTBI in US EDs is high. Most mTBI ED visits present with other injuries. Awareness of sociodemographic factors associated with nonisolated mTBI may help improve diagnosis in US EDs. This information has implications for resource planning and mTBI screening in EDs.

Importance: Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained., Objective: To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury., Design, Setting, and Participants: In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected., Main Outcomes and Measures: Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion., Results: A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%])., Conclusions and Relevance: The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.

Objective: To describe the circumstances, characteristics, and trends of emergency department (ED) visits for nonfatal, playground-related traumatic brain injury (TBI) among persons aged ≤14 years., Methods: The National Electronic Injury Surveillance System-All Injury Program from January 1, 2001, through December 31, 2013, was examined. US Census bridged-race population estimates were used as the denominator to compute rates per 100 000 population. SAS and Joinpoint linear weighted regression analyses were used to analyze the best-fitting join-point and the annual modeled rate change. These models were used to indicate the magnitude and direction of rate trends for each segment or period., Results: During the study period, an annual average of 21 101 persons aged ≤14 years were treated in EDs for playground-related TBI. The ED visit rate for boys was 39.7 per 100 000 and 53.5 for persons aged 5-9 years. Overall, 95.6% were treated and released, 33.5% occurred at places of recreation or sports, and 32.5% occurred at school. Monkey bars or playground gyms (28.3%) and swings (28.1%) were the most frequently associated with TBI, but equipment involvement varied by age group. The annual rate of TBI ED visits increased significantly from 2005 to 2013 (P < .05)., Conclusions: Playgrounds remain an important location of injury risk to children. Strategies to reduce the incidence and severity of playground-related TBIs are needed. These may include improved adult supervision, methods to reduce child risk behavior, regular equipment maintenance, and improvements in playground surfaces and environments., (Copyright © 2016 by the American Academy of Pediatrics.)

Importance: Sports- and recreation-related traumatic brain injuries (SRR-TBIs) are a growing public health problem affecting persons of all ages in the United States., Objective: To describe the trends of SRR-TBIs treated in US emergency departments (EDs) from 2001 to 2012 and to identify which sports and recreational activities and demographic groups are at higher risk for these injuries., Design: Data on initial ED visits for an SRR-TBI from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for 2001-2012 were analyzed., Setting: NEISS-AIP data are drawn from a nationally representative sample of hospital-based EDs., Participants: Cases of TBI were identified from approximately 500,000 annual initial visits for all causes and types of injuries treated in EDs captured by NEISS-AIP., Main Outcome Measure(s): Numbers and rates by age group, sex, and year were estimated. Aggregated numbers and percentages by discharge disposition were produced., Results: Approximately 3.42 million ED visits for an SRR-TBI occurred during 2001-2012. During this period, the rates of SRR-TBIs treated in US EDs significantly increased in both males and females regardless of age (all Ps < .001). For males, significant increases ranged from a low of 45.8% (ages 5-9) to a high of 139.8% (ages 10-14), and for females, from 25.1% (ages 0-4) to 211.5% (ages 15-19) (all Ps < .001). Every year males had about twice the rates of SRR-TBIs than females. Approximately 70% of all SRR-TBIs were reported among persons aged 0 to 19 years. The largest number of SRR-TBIs among males occurred during bicycling, football, and basketball. Among females, the largest number of SRR-TBIs occurred during bicycling, playground activities, and horseback riding. Approximately 89% of males and 91% of females with an SRR-TBI were treated and released from EDs., Conclusion and Relevance: The rates of ED-treated SRR-TBIs increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Prevention's Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.

Objective: To estimate the overall and by age-group characteristics at admission and discharge from rehabilitation between 2001 and 2010 of all late-teens and adults undergoing inpatient rehabilitation for a primary diagnosis of traumatic brain injury (TBI) in the United States., Design: Secondary data analysis., Setting: Acute inpatient rehabilitation facilities., Participants: Patients aged 16 years and older receiving inpatient rehabilitation for a primary diagnosis of TBI between 2001 and 2010., Main Outcome Measures: Functional independence, level of disability, and living situation., Results: The incidence of TBI by age group found the largest proportion of cases to be aged 80 years and older, with a gradual decline in incidence in the age group of 30 years, at which point there was a slight increase. Injuries resulted predominantly from falls (49.8%) and motor vehicle crashes (40.8%); however, injuries to the youngest individuals were largely from motor vehicle crashes with decreasing rates as age increased, while injuries due to falls rose as age increased, with the oldest age groups most likely to incur a TBI. Preinjury alcohol misuse and substance use were found to occur in 22.9% and 12.2% of the total population, respectively; however, age distributions demonstrated high preinjury use among individuals younger than 50 years (eg, 46.4% and 30.6% for those aged 20 and 29 years, respectively) with decreasing misuse as age increased. Of the total population, 49.2% were retired, 31.1% employed, 14.1% not working, and 5.6% students. Trends by age showed that younger individuals were more likely to be students or employed (eg, 14.5% and 62.0% for those aged 20 and 29 years, respectively), with employment status peaking for those aged 30 to 39 years, and declining to 3.2% for the oldest age group (80 years and older). The trend of person(s) living alone between pre- and postrehabilitation showed the least amount of change for those aged 16 to 19 years with steadily increasing changes as age increased. Similar trends were seen for residence changes pre- and postrehabilitation, with the youngest most likely to return to living at a private residence, and a gradual decrease in return to living at a private residence as age increased. FIM instrument ("FIM") Motor and Cognitive subscale scores demonstrated that younger individuals had lower scores at admission to rehabilitation and higher scores at rehabilitation discharge., Conclusion: This study provides population estimates for all patients 16 years of age and older receiving inpatient rehabilitation for a primary diagnosis of TBI in the United States between 2001 and 2010. A recent trend shows the aging of the inpatient TBI rehabilitation population. Many characteristics important to rehabilitation outcomes are influenced by age, with older individuals trending toward being female, having less severe TBIs, incurring TBIs as a result of falls, but showing less improvement during rehabilitation, greater resulting disability, and more changes in their living situation postrehabilitation. These findings are of particular interest, as the oldest age groups considered in these analyses did not include the baby boom population.

Background: Data limited to emergency department and inpatient visits undoubtedly underestimate the medical charges associated with traumatic brain injury. The objective of this study was to estimate the direct medical charges of pediatric traumatic brain injuries across all clinical settings in one large, pediatric hospital in the United States., Methods: Traumatic brain injuries sustained by children ≤20 years of age treated across all clinical settings at one large pediatric hospital from August 1, 2010-July 31, 2011 were identified using ICD-9-CM codes 310.2, 800-801.9, 803-804.9, 850-854.16, and 959.01., Results: 3,971 individuals ≤20 years of age were seen during 5,429 traumatic brain injury-related visits. Total medical charges for pediatric traumatic brain injury-related visits were $13,131,547. Inpatient (68.7%) and emergency department (16.1%) visits accounted for the highest proportion of TBI-related charges; however, >15% of all charges were associated with visits to clinic outpatient, urgent care, and diagnostic/therapy outpatient settings. Fracture of the vault or base of the skull (37.1%) and brain injury with contusion, laceration, or hemorrhage (27.1%) accounted for the largest proportion of total charges. Although unspecified head injuries made up almost half of all TBI-related visits (47.4%), they accounted for only 12.6% of total charges. Mild traumatic brain injuries accounted for 92.0% of all traumatic brain injury-related visits but only 44.7% of all traumatic brain injury-related charges. Mild traumatic brain injuries treated in the emergency department had a higher median total charge than those treated in urgent care (p < 0.0001) or clinic outpatient setting (p < 0.001)., Conclusions: This study, the first to evaluate the direct medical charges of pediatric traumatic brain injury across all clinical settings at one large pediatric hospital, found that pediatric traumatic brain injuries present to a wide variety of clinical settings, and differences exist in total charges by diagnosis, severity of the injury, and clinical site/setting. Investigating traumatic brain injuries across the full spectrum of clinical care is needed for a better understanding of the true medical cost and public health burden of pediatric traumatic brain injury.

Objective: To estimate the number of adults in the United States from 2006 to 2012 who manifest selected health and social outcomes 5 years following a traumatic brain injury (TBI) that required acute inpatient rehabilitation., Design: Secondary data analysis., Setting: Acute inpatient rehabilitation facilities., Participants: Patients 16 years and older receiving acute inpatient rehabilitation for a primary diagnosis of TBI., Main Outcome Measures: Mortality, functional independence, societal participation, subjective well-being, and global outcome., Results: Annually from 2001 to 2007, an average of 13 700 patients aged 16 years or older received acute inpatient rehabilitation in the United States with a primary diagnosis of TBI. Approximately 1 in 5 patients had died by the 5-year postinjury assessment. Among survivors, 12% were institutionalized and 50% had been rehospitalized at least once. Approximately one-third of patients were not independent in everyday activities. Twenty-nine percent were dissatisfied with life, with 8% reporting markedly depressed mood. Fifty-seven percent were moderately or severely disabled overall, with 39% having deteriorated from a global outcome attained 1 or 2 years postinjury. Of those employed preinjury, 55% were unemployed. Poorer medical, functional, and participation outcomes were associated with, but not limited to, older age. Younger age groups had poorer mental and emotional outcomes. Deterioration in global outcome was common and not age-related., Conclusions: Significant mortality and morbidity were evident at 5 years postinjury. The deterioration in global outcomes observed regardless of age suggests that multiple influences contribute to poorer outcomes. Public health interventions intended to reduce post-acute inpatient rehabilitation mortality and morbidity rates will need to be multifaceted and age-specific.

Introduction: Trauma is one of the leading causes of morbidity and mortality in the world and in India., Objective: To describe 1) selected epidemiological and clinical characteristics of persons with traumatic brain injury (TBI) who died within 24 h after admission to the emergency departments (EDs) of two medical facilities in rural India and 2) the methods used to transport these patients from the locale of the injury incident to the study sites., Materials and Methods: Medical records of all injured patients regardless of age or sex who died within 24 h after admission to both EDs during January 31, 2007 through December 31, 2009 were reviewed and abstracted. Demographic variables and information on prehospital care, time and mechanism of injury, mode of transport to EDs, and primary hospital resuscitation were abstracted and analyzed., Results: Of the 113 injured patients in this study, 42 had TBI and died within 24 h of ED admission. All of these TBI patients were transported to the ED by relatives or bystanders in non-ambulance vehicles. Most of the patients with TBI (78.5%) were 21-50-years-old; and overall 90.0% were males. Persons working near or along busy roads struck by vehicles accounted for 80.9% of all TBI cases. Severe TBIs were present in 97.6% of the patients; of these, 92.8% had a Glasgow Coma Scale (GCS) score of 3 on arrival. Other concurrent injuries included superficial lacerations (85.7%), facial injuries (57.1%), and upper (35.7%) and lower (30.9%) extremity fractures. Common lesions recognized on computed tomography (CT) scan were acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%); in 21.4% of cases, the CT scan were reported normal., Conclusion: Most of the TBI patients who died within 24 h after admission to EDs in this study were not transported to EDs in emergency medical vehicles; most were of working age (ages 20-50 years); were male; and were day laborers working on busy interstate roads where they were hit by vehicles.

Objective: To synthesize the best available evidence regarding the risk of dementia and chronic cognitive impairment (CCI) after mild traumatic brain injury (MTBI)., Data Sources: MEDLINE and other databases were searched (2001-2012) using a previously published search strategy and predefined criteria. Peer-reviewed reports in 6 languages were considered., Study Selection: Systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies, with a minimum of 30 MTBI cases in subjects of any age, assessing the risk of dementia or CCI after MTBI were selected., Data Extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (ie, with a low risk of bias) into evidence tables., Data Synthesis: Evidence from accepted studies was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria, and prognostic information was prioritized as exploratory or confirmatory according to design. Of 77,914 records screened, 299 articles were eligible and reviewed. Methodological quality was acceptable for 101 (34%) articles, of which 1 article considered dementia and 7 articles considered CCI. The study examining the risk of dementia after MTBI did not find an association. One randomized controlled trial found that being informed about possible cognitive dysfunction after MTBI was associated with worse cognitive performance on standard tests. Children with MTBI and intracranial pathology ("complicated" MTBI) performed worse than did children without intracranial pathology. Children showed higher rates of cognitive symptoms a year after MTBI than did a control group., Conclusions: There is a lack of evidence of an increased risk of dementia after MTBI. In children, objective evidence of CCI exists only for complicated MTBI. More definitive studies are needed to inform clinical decisions, assessment of prognosis, and public health policy., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To synthesize the best available evidence on prognosis after sport concussion., Data Sources: MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "sports." Reference lists of eligible articles were also searched., Study Selection: Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases., Data Extraction: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables., Data Synthesis: Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing 19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms., Conclusions: The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis. Our findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To extend the representativeness of the Traumatic Brain Injury Model Systems National Database (TBIMS-NDB) for individuals 16 years and older, admitted for acute, inpatient rehabilitation in the United States with a primary diagnosis of traumatic brain injury (TBI) analyses completed by Corrigan and colleagues by comparing this data set to national data for patients admitted to inpatient rehabilitation with identical inclusion criteria that included 3 additional years of data and 2 new demographic variables., Design: Secondary analysis of existing data sets and extension of previously published analyses., Setting: Acute inpatient rehabilitation facilities., Participants: Patients 16 years and older with a primary rehabilitation diagnosis of TBI; the US TBI Rehabilitation population, n = 156 447; and the TBIMS-NDB population, n = 7373., Interventions: None., Main Outcome Measures: Demographics, functional status, and length of stay in hospital., Results: The TBIMS-NDB was largely representative of patients 16 years and older, admitted for rehabilitation in the United States with a primary diagnosis of TBI on or after October 1, 2001, and discharged as of December 31, 2010. The results of the extended analyses were similar to those reported by Corrigan and colleagues. Age accounted for the largest difference between the samples, with the TBIMS-NDB including a smaller proportion of patients 65 years and older than all those admitted for rehabilitation with a primary diagnosis of TBI in the United States. After partitioning each data set at age 65, most distributional differences found between samples were markedly reduced; however, differences in the preinjury vocational status of the employed and rehabilitation lengths of stay between 1 and 9 days remained robust. The subsamples of patients 64 years and younger were found to differ only slightly on all remaining variables, whereas those 65 years and older were found to have meaningful differences in insurance type and age distribution., Conclusions: These results reconfirm that the TBIMS-NDB is largely representative of patients with TBI receiving inpatient rehabilitation in the United States. Differences between the 2 data sets were found to be stable across the 3 additional years of data, and new differences were limited to those involving newly introduced variables. To use these data for population-based research, it is strongly recommended that statistical adjustment be conducted to account for the lower percentage of patients older than 65 years, inpatient rehabilitation stays less than 10 days, and preinjury vocational status in the TBIMS-NDB.

Problem: Traumatic Brain Injury (TBI) is a public health problem in the United States. In 2009, approximately 2.4 million [corrected] patients with a TBI listed as primary or secondary diagnosis were hospitalized and discharged alive (N=300,667) or were treated and released from emergency departments (EDs; N=2,077,350), outpatient departments (ODs; N=83,857), and office-based physicians (OB-P; N=1,079,338). In addition, 52,695 died with one or more TBI-related diagnoses., Methods: Federal TBI-related laws that have guided CDC since 1996 were reviewed. Trends in TBI were obtained by analyzing data from nationally representative surveys conducted by the National Center for Health Statistics (NCHS)., Findings: CDC has developed and is implementing a strategy to reduce the burden of TBI in the United States. Currently, 20 states have TBI surveillance and prevention systems. From 1995-2009, the TBI rates per 100,000 population increased in EDs (434.1 vs. 686.0) and OB-Ps (234.6 vs. 352.3); and decreased in ODs (42.6 vs. 28.1) and in TBI-related deaths (19.9 vs. 16.6). TBI Hospitalizations decreased from 95.5 in 1995 to 77.9 in 2000 and increased to 95.7 in 2009., Conclusions: The rates of TBI have increased since 1995 for ED and PO visits. To reduce of the burden and mitigate the impact of TBI in the United States, an improved state- and territory-specific TBI surveillance system that accurately measures burden and includes information on the acute and long-term outcomes of TBI is needed., (Published by Elsevier Ltd.)

Introduction: Traumatic brain injury (TBI) can be complicated among older adults due to age-related frailty, a greater prevalence of chronic conditions and the use of anticoagulants. We conducted this study using the latest available, nationally-representative emergency department (ED) data to characterize visits for TBI among older adults., Methods: We used the 2006-2008 National Hospital Ambulatory Medical Care - Emergency Department (NHAMCS-ED) data to examine ED visits for TBI among older adults. Population-level estimates of triage immediacy, receipt of a head computed tomography (CT) and/or head magnetic resonance imaging (MRI), and hospital admission by type were used to characterize 1,561 sample visits, stratified by age <65 and ≥65 years of age., Results: Of ED visits made by persons ≥65 years of age, 29.1% required attention from a physician within 15 minutes of arrival; 82.1% required a head CT, and 20.9% required hospitalization. Persons ≥65 years of age were 3 times more likely to receive a head CT or MRI compared to younger patients presenting with TBI (adjusted odds ratio [aOR] 3.2; 95% confidence interval [CI], 1.8-5.8), and were 4 times more likely to be admitted to an intensive care unit, step-down unit, or surgery (aOR 4.1; 95% CI 2.1-8.0) compared to younger patients presenting with TBI, while controlling for sex and race., Conclusion: Results demonstrate increased emergent service delivery for older persons presenting with TBI. As the United States population ages and continues to grow, TBI will become an even more important public health issue that will place a greater demand on the healthcare system.

Objective: To describe factors associated with inpatient mortality in a field hospital established following the 2010 Haiti earthquake., Design: Data were abstracted from medical records of patients admitted to the University of Miami Global Institute/Project Medishare hospital. Decedents were compared to survivors in terms of age, sex, length of stay, admission ward, diagnosis, and where relevant, injury mechanism and surgical procedure. Three multivariate logistic regression models were constructed to determine predictors of death among all patients, injured patients, and noninjured patients., Results: During the study period, 1,339 patients were admitted to the hospital with 100 inpatient deaths (7.5 percent). The highest proportion of deaths occurred among patients aged < or = 15 years. Among all patients, adult intensive care unit (ICU) admission (adjusted odds ratio [AOR] = 7.6 and 95% confidence interval [CI] = 3.4-16.8), neonatal ICU/pediatric ICU (NICU/PICU) admission (AOR = 7.8 and 95% CI = 2.7-22.9), and cardiac/respiratory diagnoses (AOR = 8.5 and 95% CI = 4.9-14.8) were significantly associated with death. Among injured patients, adult ICU admission (AOR = 7.4 and 95% CI = 1.7-33.3) and penetrating injury (AOR = 3.3 and 95% CI = 1.004-11.1) were significantly associated with death. Among noninjured patients, adult ICU admission (AOR = 6.6 and 95% CI = 2.7-16.4), NICU/PICU admission (AOR = 8.2 and 95% CI = 2.1-31.8), and cardiac/ respiratory diagnoses (AOR = 6.5 and 95% CI = 3.6-12.0) were significantly associated with death., Conclusions: Following earthquakes in resource-limited settings, survivors may require care in field hospitals for injuries or exacerbation of chronic medical conditions. Planning for sustained post-earthquake response should address these needs and include pediatric-specific preparation and long-term critical care requirements.

Problem/condition: Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Approximately 53,000 persons die from TBI-related injuries annually. During 1989-1998, TBI-related death rates decreased 11.4%, from 21.9 to 19.4 per 100,000 population. This report describes the epidemiology and annual rates of TBI-related deaths during 1997-2007., Reporting Period: January 1, 1997-December 31, 2007., Description of System: Data were analyzed from the CDC multiple-cause-of-death public-use data files, which contain death certificate data from all 50 states and the District of Columbia., Results: During 1997-2007, an annual average of 53,014 deaths (18.4 per 100,000 population; range: 17.8-19.3) among U.S. residents were associated with TBIs. During this period, death rates decreased 8.2%, from 19.3 to 17.8 per 100,000 population (p = 0.001). TBI-related death rates decreased significantly among persons aged 0-44 years and increased significantly among those aged ≥75 years. The rate of TBI deaths was three times higher among males (28.8 per 100,000 population) than among females (9.1). Among males, rates were highest among non-Hispanic American Indian/Alaska Natives (41.3 per 100,000 population) and lowest among Hispanics (22.7). Firearm- (34.8%), motor-vehicle- (31.4%), and fall-related TBIs (16.7%) were the leading causes of TBI-related death. Firearm-related death rates were highest among persons aged 15-34 years (8.5 per 100,000 population) and ≥75 years (10.5). Motor vehicle-related death rates were highest among those aged 15-24 years (11.9 per 100,000 population). Fall-related death rates were highest among adults aged ≥75 years (29.8 per 100,000 population). Overall, the rates for all causes except falls decreased., Interpretation: Although the overall rate of TBI-related deaths decreased during 1997-2007, TBI remains a public health problem; approximately 580,000 persons died with TBI-related diagnoses during this reporting period in the United States. Rates of TBI-related deaths were higher among young and older adults and certain minority populations. The leading external causes of this condition were incidents related to firearms, motor vehicle traffic, and falls., Public Health Actions: Accurate, timely, and comprehensive surveillance data are necessary to better understand and prevent TBI-related deaths in the United States. CDC multiple-cause-of-death public-use data files can be used to monitor the incidence of TBI-related deaths and assist public health practitioners and partners in the development, implementation, and evaluation of programs and policies to reduce and prevent TBI-related deaths in the United States. Rates of TBI-related deaths are higher in certain population groups and are primarily related to specific external causes. Better enforcement of existing seat belt laws, implementation and increased coverage of more stringent helmet laws, and the implementation of existing evidence-based fall-related prevention interventions are examples of interventions that can reduce the incidence of TBI in the United States.

Background: The aims of this study are to develop estimates of discharge rates and frequencies for all injury-related hospitalizations in the United States for the year 2000 and to characterize patterns of hospitalized injury and anatomic region using a modified Barell Matrix. The utility of the Nationwide Inpatient Sample (NIS) for providing national estimates of hospitalized injuries will be discussed., Methods: This study is a retrospective analysis of hospital discharge data using the Nationwide Inpatient Sample. All hospital discharges with a primary diagnosis of injury were selected. Total number of hospitalizations, annual discharge rates, and 95% confidence intervals were calculated by body region, nature of injury, and injury mechanism. Number of injuries by age, sex, body region, and nature of injury were also calculated for falls and motor vehicle crashes., Results: In 2000, there were an estimated 1,690,780 hospital discharges with a primary injury diagnosis. Discharge rates were highest for the oldest age groups. Falls and motor vehicle crashes were the leading causes of hospitalization. Fracture was the most common diagnosis and lower extremity injury was the most common anatomic region., Conclusions: Hospital discharge data adds another dimension to our understanding of the total injury burden. The Nationwide Inpatient Sample may be useful in providing national estimates of hospital discharges.

The WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury performed a comprehensive search and critical review of the literature published between 1980 and 2002 to assemble the best evidence on the epidemiology, diagnosis, prognosis and treatment of mild traumatic brain injury. Of 743 relevant studies, 313 were accepted on scientific merit and comprise our best-evidence synthesis. The current literature on mild traumatic brain injury is of variable quality and we report the most common methodological flaws. We make recommendations for avoiding the shortcomings evident in much of the current literature and identify topic areas in urgent need of further research. This includes the need for large, well-designed studies to support evidence-based guidelines for emergency room triage of children with mild traumatic brain injury and to explore more fully the issue of prognosis after mild traumatic brain injury in the elderly population. We also advocate use of standard criteria for defining mild traumatic brain injury and propose a definition.

Objective: We undertook a best-evidence synthesis on the incidence, risk factors and prevention of mild traumatic brain injury., Methods: Medline, Cinahl, PsycINFO and Embase were searched for relevant articles. After screening 38,806 abstracts, we critically reviewed 169 studies on incidence, risk and prevention, and accepted 121 (72%)., Results: The accepted articles show that 70-90% of all treated brain injuries are mild, and the incidence of hospital-treated patients with mild traumatic brain injury is about 100-300/100,000 population. However, much mild traumatic brain injury is not treated at hospitals, and the true population-based rate is probably above 600/100,000. Mild traumatic brain injury is more common in males and in teenagers and young adults. Falls and motor-vehicle collisions are common causes., Conclusion: Strong evidence supports helmet use to prevent mild traumatic brain injury in motorcyclists and bicyclists. The mild traumatic brain injury literature is of varying quality, and the studies are very heterogeneous. Nevertheless, there is evidence that mild traumatic brain injury is an important public health problem, but we need more high-quality research into this area.

In response to the emergence of severe acute respiratory syndrome (SARS), the United States established national surveillance using a sensitive case definition incorporating clinical, epidemiologic, and laboratory criteria. Of 1,460 unexplained respiratory illnesses reported by state and local health departments to the Centers for Disease Control and Prevention from March 17 to July 30, 2003, a total of 398 (27%) met clinical and epidemiologic SARS case criteria. Of these, 72 (18%) were probable cases with radiographic evidence of pneumonia. Eight (2%) were laboratory-confirmed SARS-coronavirus (SARS-CoV) infections, 206 (52%) were SARS-CoV negative, and 184 (46%) had undetermined SARS-CoV status because of missing convalescent-phase serum specimens. Thirty-one percent (124/398) of case-patients were hospitalized; none died. Travel was the most common epidemiologic link (329/398, 83%), and mainland China was the affected area most commonly visited. One case of possible household transmission was reported, and no laboratory-confirmed infections occurred among healthcare workers. Successes and limitations of this emergency surveillance can guide preparations for future outbreaks of SARS or respiratory diseases of unknown etiology.

Objective: To develop state-level estimates of the annual number of nonfatal cases of traumatic brain injury (TBI) resulting in hospitalization., Methods: The estimation process incorporates annual nonfatal TBI hospitalization case counts from 15 states funded by the Centers for Disease Control and Prevention to conduct TBI surveillance; annual fatal TBI case counts based on National Center for Health Statistics data for all 50 states; and an index reflecting the urban/rural character of each state. These data are used to develop a negative binomial regression model that yields estimates of the annual number of nonfatal TBI hospitalization cases for each state not funded to conduct TBI surveillance., Results: Sensitivity analysis suggests that on average the estimates fall within +/- 15% of the case counts that would be obtained directly from surveillance., Conclusion: In combination, the TBI case count data and the urban/rural index support effective modeling and estimation of annual nonfatal TBI hospitalization case counts at the state level.

Background: Vaccination-promoting strategies in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) have been shown to produce dramatic improvements in coverage and other health outcomes., Objectives: To determine national and state-specific population-based vaccine coverage rates among preschool children who participate in the WIC program, and to describe the strategies for promoting vaccination in WIC., Design/methods: Demographic data, WIC participation, and vaccination histories for children aged 24 to 35 months in 1999 were collected from parents through the National Immunization Survey. The healthcare providers for the children in the survey were contacted to verify and complete vaccination information. We defined children as up-to-date (UTD) if they had received four doses of diphtheria and tetanus toxoids and pertussis vaccine (DPT), three doses of poliovirus vaccine, one dose of measles-mumps-rubella vaccine (MMR), and three doses of Haemophilus influenzae type b vaccine (Hib) by 24 months. Description of state-level vaccination-promoting activities in WIC was collected through an annual survey completed by the state WIC and immunization program directors., Results: Complete data were collected on 15,766 children, of whom 7783 (49%) participated in WIC sometime in their lives. Nationally, children who had ever participated in WIC were less well-immunized at 24 months compared to children who had not: 72.9% UTD (95% CI, 71.3-74.5) versus 80.8% UTD (95% CI, 79.5-82.1), respectively. In 42 states, 24-month coverage among WIC participants was less than among non-WIC participants, including 13 states where the difference was > or = 10%. Vaccination activities linked with WIC were reported from 76% of 8287 WIC sites nationwide. States conducting more-frequent interventions and reaching a higher proportion of WIC participants had 40% higher vaccination coverage levels for the WIC participants in that state (p<0.05)., Conclusions: Children served by WIC remain less well-immunized than the nation's more-affluent children who do not participate in WIC. Thus, WIC remains a good place to target these children. This study provides evidence that fully implemented WIC linkage works to improve vaccination rates. Strategies that have been shown to improve the vaccination coverage levels of WIC participants should be expanded and adequately funded to protect these children.

Pediatric patients on dialysis should receive all the vaccines currently recommended by the ACIP and the AAP for healthy children, except the oral polio vaccine (34, 35). Adult patients should receive the hepatitis B vaccine series, pneumococcal vaccine, yearly influenza vaccinations, tetanus-diphtheria toxoids, and varicella vaccine, if they are susceptible (33, 48, 69). Vaccines are well tolerated by these patients (33), but higher doses and/or additional boosters may be required periodically to adequately protect dialysis patients from vaccine-preventable diseases (33, 36, 37, 82, 83). Following vaccination, antibody concentrations for hepatitis B vaccine should be measured annually and booster doses administered when antibody concentrations fall below protective levels (33, 38). Although both children and adults on dialysis may show an impaired and/or delayed immunologic response to certain antigens, particularly hepatitis B virus and S. pneumoniae, appropriate immunizations can significantly reduce the risk of serious complications from vaccine-preventable diseases (11, 84). Because the protection these vaccines provide may be incomplete or transient, infection control strategies at hospitals and other health care facilities should be implemented simultaneously. Health care providers are encouraged to assess each patients need for vaccinations individually and formulate immunization strategies early in the course of progressive renal disease, ideally before the patient requires dialysis.

Objectives: This study was done to assess progress in hepatitis B vaccination of children from 1994 through 1997., Methods: We used data from the National Immunization Survey (NIS), a random-digit-dialed telephone survey that includes a mail survey to verify vaccination providers' records. The NIS is conducted in 78 geographic areas (50 states and 28 selected urban areas) in the United States., Results: A total of 32,433 household interviews were completed in the 1997 NIS. An estimated 83.7% of children aged 19 to 35 months received 3 or more doses of hepatitis B vaccine. Coverage with 3 doses was greater (86.7%) among children in states that had day care entry requirements for hepatitis B vaccination than among children in states without such requirements (83.0%) and was greater among children from families with incomes at or above the poverty level (85.0%) than among children below the poverty level (80.6%). Hepatitis B vaccination of children increased from 1994 through 1996, from 41% to 84%, but coverage reached a constant level of 84% to 85% in 1996/97., Conclusion: Although substantial progress has been made in fully vaccinating children against hepatitis B, greater efforts are needed to ensure that all infants receive 3 doses of hepatitis B vaccine.

Objectives: 1) To determine the proportion of preschool children receiving immunizations from providers enrolled in the Vaccines for Children (VFC) program; 2) to assess whether their immunization providers serve as their medical home for primary care; and 3) to examine the relationship between various provider characteristics and immunization status., Design: Two-phase national survey consisting of parent interviews verified by provider record check., Setting: A total of 78 survey areas (50 states, the District of Columbia, and 27 urban areas)., Patients or Other Participants: Noninstitutionalized children from 19 to 35 months of age in 1997., Interventions: None., Outcome Measures: VFC penetration rate (the percentage of children who received all or some vaccines from a VFC-enrolled provider); the frequency with which children received all or some vaccines within a medical home; the number of parent-reported immunization providers; and 4:3:1:3 up-to-date status at 19 to 35 months of age., Results: OFF 28 298 children interviewed for whom consent to contact providers was obtained, complete provider data were available for 21 522 (76%). Of these children, approximately 75% received all or some immunizations from a VFC-enrolled provider, 73% received all or some immunizations within a medical home, and 75% had one immunization provider. Children received all or some immunizations from a VFC-enrolled provider more frequently when vaccinated by pediatricians versus family physicians or in public facilities versus private practice. After controlling for poverty, immunization coverage varied only slightly with receipt of vaccines from a VFC-enrolled provider, receipt of vaccines within a medical home, and the number of parent-reported providers. Among children vaccinated within a medical home, those vaccinated solely by pediatricians were 1.63 times as likely to be 4:3:1:3 up-to-date than were those vaccinated solely by family physicians after removing the effects of poverty., Recommendations: Greater numbers of children are likely to benefit from an even higher participation rate among immunization providers in the VFC program, particularly among family physicians and private physicians. The public-private collaboration developed by the VFC program should be capitalized on so that public sector resources can help pediatricians and family physicians practice according to the Standards for Pediatric Immunization Practices.

From July through October 1991, an outbreak of hepatitis A virus (HAV) infection involving 26 hospital staff, inpatients and household contacts occurred in a pediatric hospital. All ill staff members had cared for one inpatient who had profuse diarrhea with gross fecal contamination of the environment, negative HAV serology and idiopathic immunodeficiency. HAV infection in this patient was later confirmed by polymerase chain reaction. Among hospital staff HAV attack rates were highest in nursing personnel (15%). A retrospective cohort study of nurses found that the risk of infection was greatest in those who handled the source patient's soiled bed pad (relative risk, 6.7; 95% confidence intervals, 1.6, 27.8), diaper (relative risk, 5.4; 95% confidence intervals, 0.8, 39.2) or gown (relative risk, 2.9; 95% confidence intervals, 1.1, 7.8). Glove use during these activities was not associated with a lower risk of infection, possibly because of gross environmental contamination or less use than reported. This situation was unusual because the patient was HAV-infected but had negative serology, probably because of immunodeficiency. In situations of potentially extensive environmental contamination, such as with a diapered or incontinent patient with suspected or confirmed hepatitis A, careful attention to frequent handwashing is an essential protective measure; in addition strict glove use whenever entering the patient's room should be followed to provide additional protection.

Objective: We attempted to determine if an increase in resistance to ciprofloxacin occurred among nosocomial pathogens, especially Pseudomonas aeruginosa and Staphylococcus aureus., Methods: We examined 1989-1992 ciprofloxacin susceptibility results from 8,517 P aeruginosa and 9,021 S aureus isolates associated with nosocomial infections reported to the National Nosocomial Infections Surveillance System., Results: For S aureus, 27.1% of isolates were resistant to ciprofloxacin; of methicillin-resistant S aureus isolates, 80% also were resistant to ciprofloxacin. A logistic regression model found that ciprofloxacin resistance was more common among S aureus isolated from the urinary and respiratory tracts than from other sites of isolation, and among isolates that were methicillin resistant. After controlling for these factors, the model showed a 123% increase in the odds of ciprofloxacin resistance from 1989-1990 to 1991-1992. For P aeruginosa, 4.7% of the isolates were resistant to ciprofloxacin. Resistance varied by site of infection and rose most dramatically for respiratory tract isolates from 2.0% in 1989-1990 to 5.3% in 1991-1992., Conclusion: Resistance to ciprofloxacin is more frequent among nosocomial S aureus than among P aeruginosa and is increasing rapidly among S aureus isolates and from selected sites among P aeruginosa isolates.