Sex and Age Differences in Atypical Chief Complaints for Acute Decompensated Heart Failure in Emergency Department Visits.

Objectives: Around one million United States emergency department (ED) visits annually are due to acute decompensated heart failure (ADHF) symptoms. Characterizing ED symptom presentation of ADHF patients may improve clinical care, yet sex and age differences in ED chief complaints have not been thoroughly investigated. This paper aims to describe differences in chief complaints and comorbid conditions for ED patients with a ADHF diagnosis, stratified by sex and age. Methods: Retrospective analysis of adults presenting to North Carolina EDs in NC DETECT, a statewide syndromic surveillance system, between 2010 and 2016 with a diagnosis of ADHF. Frequencies of chief complaint categories for ED visits and comorbid conditions, stratified by sex and age, were evaluated and standardized differences computed. Results: Top chief complaints were dyspnea (19.1%), chest pain (13.5%), and other respiratory complaints (13.4%). In the 18-44 age group, females when compared to males reported more nausea/vomiting (6.7% versus 4.1%) and headache (4.2% versus 2.0%). In those 45-64 and 65+ years old, complaints were similar by sex. When stratified by age group alone, the 18-44 and 45-64 age groups had more complaints of chest pain, whereas balance issues, weakness, and confusion were more common in the 65+ age group. Conclusion: Sex and age differences in atypical ADHF symptoms were seen in in ED patients with ADHF. Characterizing variation of ADHF symptoms in ED patients can inform the identification of ED patients with ADHF and the management of ADHF-related symptoms.

EMS injury cause codes more accurate than emergency department visit ICD-10-CM codes for firearm injury intent in North Carolina.

BACKGROUND: The timeliness, accuracy, and completeness of data for firearm injury surveillance is crucial for public health surveillance efforts and informing injury prevention measures. While emergency department (ED) visit data can provide near real-time information on firearms injuries, there are concerns surrounding the accuracy of intent coding in these data. We examined whether emergency medical service (EMS) data provide more accurate firearm injury intent coding in comparison to ED data. METHODS: We applied a firearm injury definition to EMS encounter data in NC's statewide syndromic surveillance system (NC DETECT), from January 1, 2021, through December 31, 2022. We manually reviewed each record to determine intent, and the corresponding manual classifications were compared to the injury cause codes entered in the EMS data and to ED visit records where EMS-ED record linkage was possible. We then calculated the sensitivity, specificity, positive and negative predictive values for each intent classification in SAS 9.4 using the manually reviewed intent classifications as the gold standard. RESULTS: We identified 9557 EMS encounters from January 1, 2021, through December 31, 2022 meeting our firearm injury definition. After removing false positives and duplicates, 8584 records were available for manual injury classification. Overall, our analysis demonstrated that manual and EMS injury cause code classifications were comparable. However, for the 3401 EMS encounters that could be linked to an ED visit record, sensitivity of the ED ICD-10-CM codes was low for assault and intentional self-harm encounters at 18.2% (CI 16.5-19.9%) and 22.2% (CI 16-28.5%), respectively. This demonstrates a marked difference in the reliability of the intent coding in the two data sources. CONCLUSIONS: This study illustrates both the value of examining EMS encounters for firearm injury intent, and the challenges of accurate intent coding in the ED setting. EMS coding has the potential for more accurate intent coding than ED coding within the context of existing hospital-based coding guidance. This may have implications for future firearm injury research, especially for nonfatal firearm injuries.

Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic.

Long-term impacts of the COVID-19 pandemic on racial and ethnic disparities in motor vehicle crash (MVC) injuries and death are poorly understood. This study aimed to characterize trends and investigate the heterogeneity of MVC-related disparities in North Carolina across several data sources. Crash reports, emergency department visit records, and death certificates from 2018 to 2021 were used to calculate monthly population-rates of MVC-related public health outcomes. We estimated trendlines using joinpoint regression and compared outcomes across racial and ethnic classifications. MVC and MVC-related injury rates declined in conjunction with NC's stay-at-home order, while rates of severe outcomes remained unimpacted. By December 2021 rates of MVC-related outcomes met or exceeded pre-pandemic levels, with the highest rates observed among non-Hispanic Black individuals. Racial and ethnic disparities in MVC-related outcomes remained prevalent throughout the COVID-19 pandemic. These results highlight the importance of a holistic approach to traffic injury surveillance when assessing the impact of MVCs.

Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021: A Population-Based Surveillance Study.

Introduction: Pregnancy-associated complaints are a common reason for emergency department visits for women of reproductive age. Emergency department utilization during pregnancy is associated with worse birth outcomes for both mothers and infants. We used statewide North Carolina emergency department surveillance data between 2016 and 2021 to describe the sociodemographic factors associated with the use of emergency department for pregnancy-associated problems and subsequent hospital admission. Methods: North Carolina Disease Event Tracking and Epidemiologic Collection Tool is a syndromic surveillance system that includes all emergency department encounters at civilian acute-care facilities in North Carolina. We analyzed all emergency department visits between January 1, 2016 and December 31, 2021 for female patients aged 15-44 years residing in North Carolina with at least 1 ICD-10-CM code (analysis occurred in July 2021-October 2022). Each emergency department visit was categorized as pregnancy-associated if assigned ICD-10-CM code(s) indicated pregnancy. We stratified visits by age, race, ethnicity, county of residence, and insurance and compared them with estimated pregnant population proportions using 1-sample t-tests. We used multivariable logistic regression to determine whether pregnancy-associated visits were more likely to be associated with hospital admission and then to determine sociodemographic predictors of admission among pregnancy-associated emergency department visits. Results: More than 6.4 million emergency department visits were included (N=6,471,197); 10.1% (n=655,476) were pregnancy-associated, significantly higher than the proportion of women estimated to be pregnant at any given time in North Carolina (4.6%, p<0.0001) and increased over time (8.6% in 2016 vs 11.1% in 2021, p<0.0001). Pregnancy-associated visits were lower than expected for ages 25-44 years and higher than expected for those aged 15-24 years, for those of Black race, and for patients residing in rural or suburban areas. The proportion admitted was higher for pregnancy-associated emergency department visits than for nonpregnancy associated (15.6% vs 7.0%, AOR=3.06 [95% CI=3.03, 3.09]). Pregnancy-associated emergency department visits for patients of Black race had 0.58 times (95% CI=0.57, 0.59) the odds of admission compared with White patients. Conclusions: Emergency department utilization during pregnancy is common. The proportion of pregnancy-associated emergency department visits among reproductive-age women is increasing, as are inpatient admissions from the emergency department for pregnancy-associated diagnoses. Use of public health surveillance databases such as the North Carolina Disease Event Tracking and Epidemiologic Collection Tool may help identify opportunities for improving disparities in maternal health care, especially related to access to care.

Feasibility of linking violent death decedents to prior-month emergency department visits in North Carolina, 2019-2020.

OBJECTIVE: Linking data between violent death decedents and other sources can provide valuable insight, highlighting opportunities for prevention of violent injury. This study investigated the feasibility of linking North Carolina Violent Death Reporting System (NC-VDRS) records with North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) emergency department (ED) visit data to identify prior-month ED visits among this population. METHODS: NC-VDRS death records from 2019 through 2020 were linked to NC DETECT ED visit data from December 2018 through 2020 using a probabilistic linkage approach. Linkage variables included date of birth, age, sex, zip code and county of residence, date of event (death/ED visit) and mechanism of injury. Potential linkable ED visits were filtered to those occurring in the month prior to death and manually reviewed for validity. Linked records were compared with the NC-VDRS study population to assess linkage performance and generalisability. RESULTS: Among the 4768 violent deaths identified, we linked 1340 NC-VDRS records to at least one ED visit in the month prior to death. A higher proportion of decedents dying in medical facilities (ED/outpatient, hospital inpatient, hospice or nursing/long-term care facility) linked to a prior-month visit (80%) relative to those dying in other locations (12%). When stratified by place of death, linked decedents demographically resembled the overall NC-VDRS study population. CONCLUSIONS: Though resource intensive, an NC-VDRS-to-NC DETECT linkage was successful in identifying prior-month ED visits among violent death decedents. This linkage should be leveraged to further analyse ED utilisation prior to violent death, expanding the knowledge base surrounding prevention opportunities for violent injuries.

The effect of increased emergency department demand on throughput times and disposition status for pediatric psychiatric patients.

OBJECTIVES: Emergency department (ED) crowding has been shown to increase throughput measures of length of stay (LOS), wait time, and boarding time. Psychiatric utilization of the ED has increased, particularly among younger patients. This investigation quantifies the effect of ED demand on throughput times and discharge disposition for pediatric psychiatric patients in the ED. METHODS: Using electronic medical record data from 1,151,396 ED visits in eight North Carolina EDs from January 1, 2018, through December 31, 2020, we identified 14,092 pediatric psychiatric visits. Measures of ED daily demand rates included overall occupancy as well as daily proportion of non-psychiatric pediatric patients, adult psychiatric patients, and pediatric psychiatric patients. Controlling for patient-level factors such as age, sex, race, insurance, and triage acuity, we used linear regression to predict throughput times and logistic regression to predict disposition status. We estimated effects of ED demand by academic versus community hospital status due to ED and inpatient resource differences. RESULTS: Most ED demand measures had insignificant or only very small associations with throughput measures for pediatric psychiatric patients. Notable exceptions were that a one percentage point increase in the proportion of non-psychiatric pediatric ED visits increased boarding times at community sites by 1.06 hours (95% CI: 0.20-1.92), while a one percentage point increase in the proportion of pediatric psychiatric ED visits increased LOS by 3.64 hours (95% CI: 2.04-5.23) at the academic site. We found that ED demand had a minimal effect on disposition status, with small increases in demand rates favoring <1 percentage point increases in the likelihood of discharge. Instead, patient-level factors played a much stronger role in predicting discharge disposition. CONCLUSIONS: ED demand has a meaningful effect on throughput times, but a minimal effect on disposition status. Further research is needed to validate these findings across other state and healthcare systems.

Database selection matters: A case study in child restraint use and injury patterns using North Carolina motor vehicle traffic crash report and trauma registry data.

OBJECTIVE: While proper restraint use is protective against motor traffic vehicle crash (MVTC)-associated morbidity and mortality, it is inconsistently measured across health and MVTC data sources. This project addresses this gap by assessing differences in child restraint measures between two North Carolina (NC) datasets and comparing the utility of these sources to evaluate patterns of child restraint use and associated health outcomes. METHODS: We analyzed 2018 NC MVTC and NC Trauma Registry (NCTR) data for children ≤15 years old, both separately and as linked MVTC-NCTR records. We calculated mean and standard deviation for continuous variables and frequency and proportion for categorical variables. Among linked records, we compared reported restraint use and performed age-adjusted logistic regression to estimate associations between restraint use and severe injury. RESULTS: A lower proportion of pediatric MVTC victims were reported as unrestrained in the MVTC (14.7%) versus NCTR (25.8%) data. Among linked MVTC-NCTR records, only 41.3% featured perfect concordance of restraint information between datasets. Among linked records, child restraint was reported for 31.3% of children, while the NCTR data allowed more granular coding of child restraint (30.3% overall), including child booster seat (13.5%), child car seat (8.7%), infant car seat (4.8%), and unrestrained in child car seat (3.4%). Age-adjusted regression analyses of the linked data revealed that lap/shoulder seatbelt use was significantly associated with lower likelihood of severe injury compared to being unrestrained whether informed by MVTC (OR = 0.39; 95% CI: 0.16, 0.93) or NCTR (OR = 0.38; 95% CI: 0.15, 0.96) data. While the association between reported use of a child car seat and severe injury was not statistically significant in the MVTC data (OR = 0.50; 95% CI: 0.19, 1.32), child car seat use reported in the NCTR data revealed a significant association (OR = 0.16; 95% CI: 0.03, 0.93). CONCLUSIONS: Linked crash and trauma center data allow for identifying important patterns of restraint use among pediatric passengers in MVTCs. Dataset-dependent differences in measuring restraint use have critical public health implications and illustrate the importance of careful dataset selection prior to analysis, as the use of different data sources may impact overall study conclusions.

A 7 Year Summary of Emergency Department Visits by Patients With Mental Health Disorders.

OBJECTIVES: Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time. METHODS: Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category. RESULTS: Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits. CONCLUSION: Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.

Linking Emergency Medical Services and Emergency Department Data to Improve Overdose Surveillance in North Carolina.

INTRODUCTION: Linking emergency medical services (EMS) data to emergency department (ED) data enables assessing the continuum of care and evaluating patient outcomes. We developed novel methods to enhance linkage performance and analysis of EMS and ED data for opioid overdose surveillance in North Carolina. METHODS: We identified data on all EMS encounters in North Carolina during January 1-November 30, 2017, with documented naloxone administration and transportation to the ED. We linked these data with ED visit data in the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. We manually reviewed a subset of data from 12 counties to create a gold standard that informed developing iterative linkage methods using demographic, time, and destination variables. We calculated the proportion of suspected opioid overdose EMS cases that received International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for opioid overdose in the ED. RESULTS: We identified 12 088 EMS encounters of patients treated with naloxone and transported to the ED. The 12-county subset included 1781 linkage-eligible EMS encounters, with historical linkage of 65.4% (1165 of 1781) and 1.6% false linkages. Through iterative linkage methods, performance improved to 91.0% (1620 of 1781) with 0.1% false linkages. Among statewide EMS encounters with naloxone administration, the linkage improved from 47.1% to 91.1%. We found diagnosis codes for opioid overdose in the ED among 27.2% of statewide linked records. PRACTICE IMPLICATIONS: Through an iterative linkage approach, EMS-ED data linkage performance improved greatly while reducing the number of false linkages. Improved EMS-ED data linkage quality can enhance surveillance activities, inform emergency response practices, and improve quality of care through evaluating initial patient presentations, field interventions, and ultimate diagnoses.

A Mixed-Methods Comparison of a National and State Opioid Overdose Surveillance Definition.

OBJECTIVES: We assessed the differences between the first version of the Centers for Disease Control and Prevention (CDC) opioid surveillance definition for suspected nonfatal opioid overdoses (hereinafter, CDC definition) and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) surveillance definition to determine whether the North Carolina definition should include additional International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and/or chief complaint keywords. METHODS: Two independent reviewers retrospectively reviewed data on North Carolina emergency department (ED) visits generated by components of the CDC definition not included in the NC DETECT definition from January 1 through July 31, 2018. Clinical reviewers identified false positives as any ED visit in which available evidence supported an alternative explanation for patient presentation deemed more likely than an opioid overdose. After individual assessment, reviewers reconciled disagreements. RESULTS: We identified 2296 ED visits under the CDC definition that were not identified under the NC DETECT definition during the study period. False-positive rates ranged from 2.6% to 41.4% for codes and keywords uniquely identifying ≥10 ED visits. Based on uniquely identifying ≥10 ED visits and a false-positive rate ≤10.0%, 4 of 16 ICD-10-CM codes evaluated were identified for NC DETECT definition inclusion. Only 2 of 25 keywords evaluated, "OD" and "overdose," met inclusion criteria to be considered a meaningful addition to the NC DETECT definition. PRACTICE IMPLICATIONS: Quantitative and qualitative trends in coding and keyword use identified in this analysis may prove helpful for future evaluations of surveillance definitions.

Examining the Effect of Pedestrian Crashes on Vulnerable Populations in North Carolina.

BACKGROUND: Over the last several years, pedestrian fatalities have increased in North Carolina; however, fatalities represent a small proportion of the total number of nonfatally injured pedestrians. Therefore, we linked statewide motor vehicle crash (MVC) and emergency department (ED) visit data to better understand the circumstances and characteristics of pedestrians treated in North Carolina emergency departments (EDs) for injuries related to crashes. METHODS: We linked information for pedestrians and bicyclists from 2017 North Carolina police-reported MVCs to population-based ED visit data using hierarchical deterministic methods. RESULTS: We linked 45% of pedestrian crash records to ED visit records (N = 1383 incident ED visits). The rate of pedestrians treated in North Carolina EDs for their injuries was 13.6 ED visits per 100,000 person years. For pedestrian injuries treated in North Carolina EDs, rates (per 100,000 person years in parentheses) were higher among men (15.5) and Black pedestrians (22.7) than women (10.6) and White pedestrians (8.2). Sociodemographic characteristics associated with serious injuries included age, sex, race/ethnicity, and expected source of payment for the ED visit. Crash characteristics associated with serious injuries included posted speed limit, ambient light, number of lanes, and striking vehicle type. LIMITATIONS: The study involved the use of secondary data, not collected specifically for pedestrian injury surveillance. CONCLUSIONS: Pedestrian injuries and fatalities place a considerable burden on the population of North Carolina, especially among persons of color and older adults. Injury prevention programs are actively addressing this problem, but more needs to be done.

Impact of School Nurse Ratios and Health Services on Selected Student Health and Education Outcomes: North Carolina, 2011-2016.

BACKGROUND: Determination of adequate school nurse staffing is a complex process. School nurse-to-student ratios and the health services school nurses provide to students should be considered. The purpose of this study was to examine the impact of North Carolina school nurse-to-student ratios and school nurse health services on the health and education outcomes (eg, absences, grades, self-management) of students receiving services for asthma and diabetes. METHODS: This study of all 115 school districts in North Carolina used the Annual School Health Services Report Survey from 2011 to 2016. Descriptive statistics for health services, programs and outcomes, and generalized linear modeling were used to estimate the association of ratios and health services with asthma and diabetes outcomes. RESULTS: By the 2015-2016 school year, the average ratio decreased to 1:1086 in North Carolina public schools. Annually, 100,187 students received services for asthma, 3832 students received services for type 1 diabetes, and 913 students received services for type 2 diabetes. Lower ratios and nurse health services were associated with improved student outcomes, including decreased absences (p = .05), improved grades (p = .05), and student self-management of their health condition (p = .05). CONCLUSIONS: Lower school nurse-to-student ratios and services were associated with improvements in students' health and education outcomes.

The impact of the COVID-19 pandemic on the utilization of emergency department services for the treatment of injuries.

CONTEXT: The global COVID-19 pandemic has had a major impact on the utilization of healthcare services; however, the impact on population-level emergency department (ED) utilization patterns for the treatment of acute injuries has not been fully characterized. OBJECTIVE: This study examined the frequency of North Carolina (NC) EDs visits for selected injury mechanisms during the first eleven months of the COVID-19 pandemic. METHODS: Data were obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), NC's legislatively mandated statewide syndromic surveillance system for the years 2019 and 2020. Frequencies of January - November 2020 NC ED visits were compared to frequencies of 2019 visits for selected injury mechanisms, classified according to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) injury diagnosis and mechanism codes. RESULTS: In 2020, the total number of injury-related visits declined by 19.5% (N = 651,158) as compared to 2019 (N = 809,095). Visits related to motor vehicle traffic crashes declined by a greater percentage (29%) and falls (19%) declined by a comparable percentage to total injury-related visits. Visits related to assault (15%) and self-harm (10%) declined by smaller percentages. Medication/drug overdose visits increased (10%), the only injury mechanism studied to increase during this period. CONCLUSION: Both ED avoidance and decreased exposures may have contributed to these declines, creating implications for injury morbidity and mortality. Injury outcomes exacerbated by the pandemic should be addressed by timely public health responses.

An Appraisal of School Nurse Health Services and Programs in North Carolina Public Schools, 2006-2016.

School nurses are instrumental in delivering health services to children in schools. This study addresses the gap in school nurse health services data, examining patterns in health services and programs provided by school nurses between 2006 and 2016 for students in North Carolina public schools. This study focused on services and programs related to asthma and diabetes, two health conditions that affect millions of children in the United States. Over 1.46 million children attend North Carolina public schools. In 2006, the average school nurse-to-student ratio was 1:1,340. By 2016, the average school nurse-to-student ratio decreased to 1:1,086, a 19% improvement. Over the 10-year study time period, there were statistically significant increases in the rate of occurrence of all health conditions that students received health services for (p < .001), asthma (p < .001), type I diabetes (p = .0003), orders for all health-care procedures (p = .01), all school nurse-led health counseling (p = .004), and diabetes health counseling (p < .01).

Selected characteristics and injury patterns by age group among pedestrians treated in North Carolina emergency departments.

OBJECTIVE: The objective of this study was to describe pedestrian demographic characteristics, crash characteristics, selected health outcomes, and injury patterns by age using linked North Carolina (NC) crash-emergency department (ED) visit data for the period October 1, 2010, to September 30, 2015. METHODS: This was a descriptive epidemiologic study. To examine both crash and health outcomes, NC pedestrian crash records were linked to statewide NC ED visit records using hierarchical deterministic methods. Pearson chi-square tests were used to compare the frequencies of pedestrians treated in NC EDs by sex, race/ethnicity, crash location, rurality, estimated driver speed at impact, ambient light, hospitalization/death, location of injury, and nature of injury, stratified by the following age groups: 0-14, 15-24, 25-64, and ≥65 years. RESULTS: Most pedestrians treated in NC EDs were male (57.5%), except among adults ≥65 years old (47.5%). Over half of all injured pedestrians aged 0-14 (52.6%) and 15-24 (50.5%) years were Black/African American, and 70.8% of injured pedestrians ≥65 years were white. Among pedestrians aged 25-64 years, no single racial/ethnic group was the majority. Though most pedestrians were injured on trafficways (71.7%) and at speeds ≤35 mph (80.1%), adults ≥65 years were less likely to be involved in on-trafficway crashes (51.0%) and pedestrians aged 15-24 years were more likely to be involved in >35 mph crashes (22.9%) compared to other age groups. Most pedestrians were injured under daylight conditions (56.9%). Regarding selected health outcomes, the highest frequency of hospitalization/death was for pedestrians aged ≥65 years (26.3%), compared to those aged 0-14 years (18.8%) and 15-64 years (12.4%). In terms of location of injury, 0- to 14-year-olds had the highest proportion of head injuries (39.5%), and adults ≥65 years of age had the highest proportion of spinal column/vertebral column (12.6%) and upper extremity injuries (33.2%). For nature of injury, 0- to 14-year-olds had the highest proportion of traumatic brain injuries (11.4%) and superficial wounds and contusions (62.8%). Adults aged ≥65 years had the highest proportion of open wounds/amputations and fractures (16.1%). Adults aged 25-64 years had the highest proportion of strains/sprains/dislocations (18.7%). CONCLUSIONS: There were considerable differences in demographic characteristics, crash characteristics, frequency of hospitalization/death, and injury patterns by age group. It is important to design streets and implement transportation policies and programs that improve safety for all pedestrians.

Begin risk assessment for falls in women at 45, not 65.

The clinical and epidemiological literature provides guidelines for fall prevention starting at age 65; however, the focus on age ≥65 is not evidence based. Therefore, this study examined state-wide North Carolina emergency department visit data to examine the characteristics of falls across the age spectrum, identify the age at which the incidence of fall-related emergency department visits started to increase and determine whether these trends were similar for men and women. We determined that incidence rates of fall-related emergency department visits began to increase in early middle age, particularly for women. Since fall risk assessment and prevention activities should be initiated prior to an injurious fall, we recommend beginning these activities before age 65.

Characteristics of sports and recreation-related emergency department visits among school-age children and youth in North Carolina, 2010-2014.

BACKGROUND: Sports and recreational activities are an important cause of injury among children and youth, with sports-related traumatic brain injuries (TBIs) being of particular concern given the developing brain. This paper reports the characteristics of sport and recreation-related (SR) emergency department (ED) visits among school-age children and youth in a statewide population. METHODS: This study included all injury-related visits made to all North Carolina 24/7 acute-care civilian hospital-affiliated EDs by school-age youth, 5-18 years of age, during 2010-2014 (N = 918,662). Population estimates were based on US decennial census data. Poisson regression methods were used to estimate incidence rates and rate ratios. RESULTS: During the five-year period, there were 767,075 unintentional injury-related ED visits among school-age youth, of which 213,518 (27.8%) were identified as SR injuries. The average annual absolute number and incidence rate (IR) of SR ED visits among school-age youth was 42,704 and 2374.5 ED visits per 100,000 person-years (95% confidence interval [CI], 2364.4-2384.6), respectively. In comparison to other unintentional injuries among school-age youth, SR ED visits were more likely to be diagnosed with an injury to the upper extremity (Injury Proportion Ratio [IPR] = 1.28; 95% CI, 1.27-1.29), the lower extremity (IPR = 1.14; 95% CI, 1.13-1.15), and a TBI or other head/neck/facial injury (IPR = 1.12; 95% CI, 1.11-1.13). Among ED visits made by school-age youth, the leading cause of SR injury was sports/athletics played as a group or team. The leading cause of team sports/athletics injury was American tackle football among boys and soccer among girls. The proportion of ED visits diagnosed with a TBI varied by age and sex, with 15-18 year-olds and boys having the highest population-based rates. CONCLUSIONS: Sports and recreational activities are an important component of a healthy lifestyle, but they are also a major source of injury morbidity among school-age youth. Physical activity interventions should take into account sex and age differences in SR injury risk.

Snakebites Treated in North Carolina Emergency Departments, October 2013-September 2015.

INTRODUCTION: North Carolina (NC) is home to more than 30 species of indigenous venomous and nonvenomous snakes. Snakebites can cause debilitating and potentially fatal injuries. However, there is a lack of current information available describing the incidence of snakebites in NC. Therefore, we performed this study of snakebites treated in NC emergency departments (EDs) using the statewide syndromic surveillance system, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). METHODS: This was a descriptive epidemiologic study characterizing NC ED visits collected by NC DETECT between October 1, 2013 and September 30, 2015 with an assigned International Classification of Diseases, 9th Revision, Clinical Modification code or keyword indicating a snakebite. RESULTS: Over the 2-year period, the absolute count of snakebite-related ED visits was 2080 visits with an incidence rate of 10.4 visits per 100 000 person-years (95% confidence interval: 10.0-10.9). The frequency of snakebite was highest during the summer months and evening hours. Men had higher incidence rates of snakebite-related ED visits than women, and residents of the Coastal Plain geographic region of NC had higher incidence rates than persons in other regions. CONCLUSIONS: The current study indicated that snakebites are common injuries treated at NC EDs, with a strong seasonal and geographic component. Additional research is needed to further characterize the circumstances associated with snakebites for the development of preventive measures and public health education.