BACKGROUND: Limited information about school outcomes among children (especially early childhood) with lifetime history of head injury, including traumatic brain injury (TBI), may inhibit efforts to support their academics and physical and mental health. METHODS: Baseline data (2016-2018) from the Adolescent Brain Cognitive Development (ABCD) study were analyzed to describe associations between parent-proxy reported lifetime history of head injury or TBI before age 9 and school outcomes and behavioral challenges among 9- and 10-year-old children. RESULTS: Having a lifetime history of head injury before age 9 was associated with increased odds of parent-perceived poor school performance (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.14-1.81), a drop in grades (AOR = 1.28, 95%CI = 1.06-1.54), recent receipt of detentions or suspensions (AOR = 1.29, 95%CI = 1.02-1.65), and receipt of special educational services (AOR = 1.23, 95%CI = 1.08-1.41). Of those with a lifetime history of head injury, males displayed poorer school outcomes and greater behavioral challenges than females. Similar associations were observed between lifetime history of TBI before age 9 and worse school outcomes, with males continuing to demonstrate stronger associations. CONCLUSIONS: These findings underscore the importance of screening for history of head injury and TBI and providing training for school professionals to help ensure students with a history of head or traumatic brain injury have appropriate supports in place.

CONTEXT: International Classification of Diseases (ICD) codes are used for billing but also for surveillance for injuries such as traumatic brain injuries (TBI). While specificity is possible in the ICD-10-CM scheme, use of the code for unspecified injury of head (SO9.9) remains high. OBJECTIVES: This process evaluation sought to understand medical ICD-10-CM coding behaviors for TBI in emergency department (ED) settings. DESIGN: Semi-structured interviews explored the processes that facilitate or hinder ED physicians from selecting specific ICD codes for TBI and potential points of intervention for increased coding specificity and reducing the use of unspecified codes. SETTING: Video interviews were conducted with a nationwide sample in the United States. PARTICIPANTS: A purposive snowball sampling strategy was used to recruit 26 ED physicians with experience diagnosing TBI. INTERVENTION: Semi-structured interviews identified factors related to the selection of specific ICD codes for head injury. MAIN OUTCOME MEASURE: Thematic analysis of transcribed data. RESULTS: Four main themes emerged from the data: the impact of training and expertise, factors related to diagnosis, unclear connections with medical coders, and actionable recommendations. Interviews underscored the context surrounding "unspecified" codes for TBI, including demands from patient care, time pressures, issues around how a diagnosis may impact patient management decisions, and considerations related to mapping within the electronic medical record (EMR) where options may default to an unspecified code. CONCLUSIONS: Findings from this analysis indicate that ED providers may benefit from more robust training on how documentation can better support ICD-10-CM coding for this type of trauma. Revised EMR structures could support efficient coding specificity and clarity.

CONTEXT: In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the "unspecified head injury" code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED. OBJECTIVE: This evaluation explores medical coders' perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED. DESIGN: This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders' perspectives, processes, and coding determinations for head injuries in the ED. SETTING: Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023. PARTICIPANTS: Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15 years of experience. MAIN OUTCOMES: Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders' assumptions and code determination processes. RESULTS: Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes. CONCLUSIONS: This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

INTRODUCTION: Previous international research suggests that the incidence of head injuries may follow seasonal patterns. However, there is limited information about how the numbers and rates of head injuries, particularly sports- and recreation-related head injuries, among adults and children evaluated in the emergency department (ED) vary by month in the USA. This information would provide the opportunity for tailored prevention strategies. METHODS: We analysed data from the National Electronic Injury Surveillance System-All Injury Program from 2016 to 2019 to examine both monthly variation of ED visit numbers and rates for head injuries overall and those due to sports and recreation. RESULTS: The highest number of head injuries evaluated in the ED occurred in October while the lowest number occurred in February. Among males, children ages 0-4 years were responsible for the highest rates of head injury-related ED visits each year, while in females the highest rates were seen in both children ages 0-4 and adults ages 65 and older. The highest number of head injuries evaluated in the ED due to sports and recreation were seen in September and October. Head injury-related ED visits due to sports and recreation were much more common in individuals ages 5-17 than any other age group. CONCLUSION: This study showed that head injury-related ED visits for all mechanisms of injury, as well as those due to sports- and recreation-related activities, followed predictable patterns-peaking in the fall months. Public health professionals may use study findings to improve prevention efforts and to optimise the diagnosis and management of traumatic brain injury and other head injuries.

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. © 2023 National Safety Council and Elsevier Ltd

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. 2023 National Safety Council and Elsevier Ltd

OBJECTIVE: American football is associated with the largest number of emergency department visits for pediatric sports-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. It is unclear whether the public would support such restrictions and what factors may drive support. DESIGN: Cross-sectional. SETTING AND PARTICIPANTS: Data were collected from 4,053 adults in the summer wave of Porter Novelli's 2020 U.S. Consumer Styles survey. MAIN MEASURES: Respondents answered questions about when is a good age to start 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 school (27.8%) was a good age to start playing tackle football. About one in five (19.8%) respondents reported children should never play tackle football. Certain groups of individuals were more likely to support having children start to play tackle football at high school age or above or to say that children should never play tackle football, including those with a bachelor's degree or more (rate ratio [RR]HS+ = 1.41, 95% confidence interval [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 concerned (RRHS+ = 1.88, 95% CI = 1.41-2.52) about kids' safety. CONCLUSION: Despite acknowledging 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.

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.

BACKGROUND: Promoted as a safer alternative to tackle football, there has been an increase in flag football participation in recent years. However, examinations of head impact exposure in flag football as compared with tackle football are currently limited. HYPOTHESIS: Tackle football athletes will have a greater number and magnitude of head impacts compared with flag football athletes. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: Using mouthguard sensors, this observational, prospective cohort study captured data on the number and magnitude of head impacts among 524 male tackle and flag football athletes (6-14 years old) over the course of a single football season. Estimates of interest based on regression models used Bayesian methods to estimate differences between tackle and flag athletes. RESULTS: There were 186,239 head impacts recorded during the study. Tackle football athletes sustained 14.67 (95% CI 9.75-21.95) times more head impacts during an athletic exposure (game or practice) compared with flag football athletes. Magnitude of impact for the 50th and 95th percentile was 18.15g (17.95-18.34) and 52.55g (51.06-54.09) for a tackle football athlete and 16.84g (15.57-18.21) and 33.51g (28.23-39.08) for a flag football athlete, respectively. A tackle football athlete sustained 23.00 (13.59-39.55) times more high-magnitude impacts (≥40g) per athletic exposure compared with a flag football athlete. CONCLUSION: This study demonstrates that youth athletes who play tackle football are more likely to experience a greater number of head impacts and are at a markedly increased risk for high-magnitude impacts compared with flag football athletes. CLINICAL RELEVANCE: These results suggest that flag football has fewer head impact exposures, which potentially minimizes concussion risk, making it a safer alternative for 6- to 14-year-old youth football athletes.

Head impacts in American football may lead to brain injuries called concussions. To study head impacts in young people who play American football, we collected data using sensors in mouthguards worn by young American football players. The sensors counted the number of hits and bumps to the head (head impacts) that players of American tackle and flag football got during the football season. We found that tackle football players had about 15 times more head impacts during a game or practice than flag football players had, and 23 times more hard head impacts. Learning more about head impacts in young American football players can help scientists find ways to lower the chances of concussions and other injuries. That way, kids can enjoy the benefits of sports while keeping their brains safe.

BACKGROUND: Concussion, a commonly reported injury among young athletes, can lead to short- and long-term physical, cognitive, emotional, and sleep-related symptoms. Parents are in a unique position to help identify a possible concussion and to support an athlete's recovery. METHODS: This qualitative study used a focus group methodology to explore five research questions focused on two main topics: (1) parents' perception of concussion and (2) parent-athlete communication. Two authors independently reviewed notes from each of the focus groups and then generated a list of emerging themes related to five research questions. RESULTS: Parents in this study valued and were interested in discussing concussion with their athletes. However, parents were uncertain about their role in promoting concussion safety and often rely on coaches to communicate with athletes about concussion reporting and recovery. Participants described barriers their athletes may face in concussion reporting and suggested strategies to improve communication about both reporting and recovery. CONCLUSION: Concussion education efforts may benefit from promoting specific actions parents can take to prevent concussion and how to communicate effectively with their child about reporting a possible concussion.

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance.

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. © 2023

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.

INTRODUCTION: The reliability of self-reported brain injury data relies on how well people interpret the questions. OBJECTIVE: This study examines how different yet commonly used questions may impact traumatic brain injury (TBI) estimates. METHODS: Self-report data were collected from 4,053 respondents in the summer wave of Porter Novelli's 2020 ConsumerStyles survey. Respondents were randomized to be asked about lifetime experience of either concussion or mild TBI (mTBI) and then asked follow-up questions. RESULTS: Approximately 25.5% of respondents reported sustaining a concussion in their lifetime while 17.2% reported an mTBI. The circumstances of the injuries, such as location and mechanism of injury, were similar. A greater percentage of individuals who were asked about concussions (91.1%) reported receiving a diagnosis for their most serious injury compared to those who were asked about diagnosis of an mTBI (69.9%). DISCUSSION: A greater percentage of respondents reported a lifetime history of concussion than mTBI. More respondents with a lifetime history of concussion reported receiving a diagnosis. These results suggest that the terminology used can impact reporting. These findings suggest that there is a meaningful difference in the understanding of the terms 'concussion' and 'mild TBI,' with people perceiving mTBI as a more serious injury.

The Centers for Disease Control and Prevention (CDC) HEADS UP youth sports coach materials are the most widely adopted form of concussion education for coaches across the United States-reaching millions of youth sports coaches over the last decade. These materials focus on concussion symptom identification, response, and management (e.g., return to school and sports), while also addressing the importance of communicating to athletes and their families about concussion safety. The purpose of this study was to assess the effectiveness of CDC HEADS UP materials on coach knowledge and communication with youth athletes about concussion safety. This is the first randomized control study of the CDC HEADS UP materials in real world youth sport conditions. Participants were 764 unique coaches at 15 YMCA associations. Cluster randomization was used to assign branches within associations to the intervention (CDC HEADS UP) and control (treatment as usual) conditions. Coaches completed surveys prior to and at the end of the competitive season. Communication with athletes about concussion increased among coaches in the intervention group (aRR=1.24, 95% CI=1.14, 1.36) but not the control group (aRR=1.09, 95% CI=0.90, 1.31), in multivariate analyses controlling for coach demographic characteristics and baseline communication practices. Concussion symptom knowledge and communication intentions also significantly increased in the intervention group but not in the control group. This study provides evidence that CDC HEADS UP materials increase the likelihood that youth sport coaches communicate with their athletes about concussion safety. As youth sports organizations increasingly mandate concussion education for coaches, CDC HEADS UP materials may be considered a leading resource for adoption and setting-relevant implementation.

Coaches play an important role in concussion safety and their views on concussion influence those of their athletes and athletes' reporting behaviors. This 2021 survey of youth examined how often coaches provide concussion safety information to their athletes and the association between the presence of athletic trainers (ATs) at a team's games and practices and coaches' provision of concussion information to athletes. More than 4 in 10 youth who played sports reported that their coaches did not provide any sort of concussion education/information to them in the past 12 months. Among those youth who always/sometimes had ATs at practices or games, 76.3% received some type of coach education on concussion in the past 12 months, compared to 31.9% of those who rarely/never had ATs at practices or games (p<0.0001). Increasing access to ATs and adapting current concussion trainings and educational materials for coaches to increase coach-athlete communication may be beneficial.

BACKGROUND: Concussions affect millions of youths in the United States each year, and there is concern about long-term health effects from this injury. PURPOSE: To examine the association between sports- or physical activity-related concussion and health risk behaviors among middle and high school students in 9 states. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Data from the 2019 middle school and high school Youth Risk Behavior Survey were used for this analysis. Nine states were identified that included the same question on concussion and similar questions on health risk behaviors in their 2019 Youth Risk Behavior Survey. Students were asked to self-report whether they had ≥1 sports- or physical activity-related concussions during the 12 months preceding the survey. Self-reported concussion was the primary outcome of interest. Other variables included sex, race/ethnicity, played on a sports team, were physically active 5 or more days/week, ever tried cigarette smoking, ever used an electronic vapor product, academic grades, drank alcohol, were in a physical fight, seriously considered attempting suicide, made a suicide plan, and attempted suicide. RESULTS: Among the 9 states, 18.2% of middle school students and 14.3% of high school students self-reported ≥1 sports- or physical activity-related concussions. Among both middle school and high school students, the prevalence of ≥1 sports- or physical activity-related concussions was higher among students who played on a sports team, were physically active 5 or more days per week, had ever tried cigarette smoking, had ever used an electronic vapor product, had seriously considered attempting suicide, had made a suicide plan, and had attempted suicide compared with those who had not engaged in those behaviors. The prevalence of sports- or physical activity-related concussion was consistently higher among middle school students than high school students across sex, race/ethnicity, and adverse health behaviors. CONCLUSION: Middle school students with a history of concussion warrant attention as an at-risk population for concussions and adverse health behaviors. Health care providers may consider screening students for adverse health behaviors during preparticipation examinations and concussion evaluations.

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.

BACKGROUND: Concussion education for parents/guardians (hereafter referred to as parents) has the potential to play an important role in youth athlete concussion safety. The goal of this study was to evaluate the impact of the Centers for Disease Control and Prevention's (CDC) HEADS UP handout on parent-child communication about concussion. METHODS: YMCA branches from 15 associations from across the United States were randomized to CDC HEADS UP intervention condition or education as usual control condition using a cluster randomization strategy. In the intervention condition, coaches shared parent- and athlete-specific handouts with parents and asked parents to share and discuss the athlete-specific handouts with their child. Generalized estimating equations, with repeated measures to account for the correlation among matched participants and YMCA associations, were employed. RESULTS: Multivariable analyses exploring the relationship between time (pre- and post-intervention) and communication showed that the percent of parents who talked to their child about concussion increased in the intervention group (aRR=1.33, 95% CI=1.22, 1.44), but not in the control group. CONCLUSION: CDC HEADS UP handouts help families talk about concussion safety. Sports organizations seeking to educate parents of athletes about concussion should consider using CDC HEADS UP handouts and following a similar dissemination strategy.

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.

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.

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 (χ(2) ) 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.

BACKGROUND: Little is known about the effectiveness of school district concussion policies on reducing the concussion prevalence among students. METHODS: Data from the 2016 School Health Policies and Practices Study and 2017 Youth Risk Behavior Survey for 10 school districts were linked. The outcome variable was having a sports- or physical activity-related concussion during the 12 months before of the survey. Exposure variables were 2 district policies, including district-funded professional development and prioritizing return to the classroom before returning to athletics. Logistic regression models estimated the odds of a concussion among students in districts with one, both, or neither policy (referent). RESULTS: In districts with district-funded professional development, the odds of students self-reporting ≥2 sports- or physical activity-related concussions were 1.4 times higher than in districts with neither policy. In districts with a policy prioritizing a return to the classroom before returning to athletics, the odds of students self-reporting ≥2 concussions were significantly lower (OR = 0.6) than in districts with neither policy. CONCLUSION: School district concussion policies may have positive effects by identifying and reducing multiple concussions among students.

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.

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.

Information is limited about signs and symptoms experienced by individuals who self-report a concussion within surveys. The objective of this study was to assess the number and types of signs/symptoms adults experienced and whether or not medical attention was reported after sustaining a self-reported concussion in the past year. A sample of 3,624 adults responded to the web-based 2019 FallStyles survey. Respondents were asked if they had sustained a concussion in the past 12 months and if so, which (if any) signs/symptoms they experienced following the injury. The frequency and percentages of symptoms were calculated. Approximately 2.9% of respondents reported a concussion in the past year. Approximately two-thirds of respondents who reported sustaining a recent concussion stated that they experienced two or more signs/symptoms; the remaining one-third reported zero or one symptom. The findings suggest self-report concussion questions need additional improvement, particularly those that capture concussion using a single question, to improve the validity of self-reports.

Background: Many healthcare providers do not consistently implement recommendations contained in clinical guidelines on mild traumatic brain injury (mTBI). As such, the Centers for Disease Control and Prevention (CDC) created the HEADS UP to Healthcare Providers online training to promote uptake of five key recommendations in the CDC Pediatric mTBI Guideline. Methods: Using data from modules in the CDC HEADS UP to Healthcare Providers online training, healthcare providers’ self-reported knowledge and self-efficacy prior to and immediately following completion of the training was analyzed. Results: Improvements for 8 out of the 10 knowledge questions had a high level of practical significance. The knowledge question with the highest level of practical significance pre- to post-test improvement was for the key guideline recommendation on neuroimaging (pre-test correct: 70.2%; post-test correct: 87.8%; (p < 0.0001, Cohen's g = 0.39). Four out of the six questions had a self-efficacy level increase of a high level of practical significance (r > 0.50) between the pre- and post-tests. The self-efficacy question with pre- to post-test improvement with the highest level of practical significance was “I am confident in my ability to manage the return to sports progression for my patients” (p < 0.001; r = 0.54). Conclusions: The HEADS UP to Healthcare Providers online training led to significant improvements in knowledge and self-efficacy related to mTBI diagnosis and management. Expanded use of this training among healthcare providers who commonly provide care for pediatric patients with mTBI may be beneficial. Practical Applications: This study highlights several factors guideline developers may take into consideration when creating an implementation tool, such as using health behavior theories, working with partners and key stakeholders, and focusing on digital-based tools. © 2021

Bicycling leads to the highest number of sport and recreation-related emergency department (ED) visits for traumatic brain injuries (TBIs) in the United States (1). Because bicycling continues to grow in popularity,* primarily among U.S. adults, examining the strategies that mitigate the risk for TBI is important. CDC analyzed data from the National Electronic Injury Sursveillance System-All Injury Program (NEISS-AIP) to determine the incidence of EDs for bicycle-related TBIs during 2009-2018. An estimated 596,972 ED visits for bicycle-related TBIs occurred in the United States during the study period. Rates of ED visits were highest among adult males (aged ≥18 years) and among children and adolescents aged 10-14 years during 2009-2018. Overall, the rate of ED visits for bicycle-related TBIs decreased by approximately one half (48.7%) among children and by 5.5% among adults. As the number of persons riding bicycles increases, expansion of comprehensive bicycling safety interventions for bicyclists and drivers by states and local communities, such as interventions to increase driver compliance with traffic laws and helmet use among riders, improvements in bicycling infrastructure, and customized interventions for males and other groups at high risk might help reduce bicycle-related injuries.