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Firearm injury, particularly self-directed, is a major source of preventable morbidity and mortality among older adults. Older adults are at elevated risk of serious illness, cognitive impairment, and depression-all known risk factors for suicide and/or unintentional injury. Healthcare providers are often the first to identify these conditions and, although they commonly deliver safety guidance to such patients, little is known about how they approach firearm safety conversations with older adults.We conducted semi-structured interviews with healthcare providers who care for older adults (November 2020-May 2021). We used inductive and deductive thematic analyses to develop themes. We present themes and representative quotes from our analysis.We interviewed 13 healthcare providers who regularly care for older adult firearm owners. Emergent themes were: circumstances that prompt firearm safety conversations; strategies for addressing firearm safety in routine and acute circumstances; barriers to addressing firearm safety; and available or desired resources.Planning for firearm safety should occur "early and often" as part of a longitudinal relationship with older adult patients. Age-related safety issues such as driving are regularly addressed with older adult patients, likely because there are standard processes and established pathways. Establishing processes and provider/ patient resources would help improve provider efficacy to address firearm safety and relinquishment for older adult firearm owners. Integrating firearm safety conversations into routine encounters (e.g., Medicare Annual Wellness Visit, problem-focused visits) templates could be a promising initial step but resources for follow-up to the firearm screening must be available to both provider and patient.

BACKGROUND: Many older adults face the difficult decision of when to stop driving. We sought to test whether an online driving decision aid (DDA) would improve decision quality. METHODS: This prospective two-arm randomized trial enrolled English-speaking licensed drivers (age ≥70 years) without significant cognitive impairment but with ≥1 diagnosis associated with increased likelihood of driving cessation); all participants received primary care in clinics associated with study sites in three states. The intervention was the online Healthwise® DDA for older adults addressing “Is it time to stop driving?”; control was web-based information for older drivers only. The primary outcome was decision conflict as estimated by the Decisional Conflict Scale (DCS; lower scores indicate higher quality). Secondary outcomes were knowledge and decision self-efficacy about driving decisions. We examined post-randomization differences in primary and secondary outcomes by study arm using generalized linear mixed-effects models with adjustment for site and pre-randomization scores. RESULTS: Among 301 participants (mean age: 77.1 years), 51.2% identified as female and the majority as non-Hispanic (99.0%) and White (95.3%); 98.0% lived in an urban area. Participant characteristics were similar by study arm but differed across sites. Intervention participants had a lower mean DCS score (12.3 DDA vs 15.2 control; adjusted mean ratio [AMR] 0.76, 95%CI 0.61–0.95; p=0.017). Intervention participants had higher mean knowledge scores (88.9 DDA vs 79.9 control; OR 1.13, 95%CI 1.01–1.27, p=0.038); there was no difference between groups in self-efficacy scores. The DDA had high acceptability; 86.9% of those who viewed it said they would recommend it to others in similar situations. CONCLUSIONS: The online Healthwise® DDA decreased decision conflict and increased knowledge in this sample of English-speaking, older adults without significant cognitive impairment, although most chose to continue driving. Use of such resources in clinical or community settings may support older adults as they transition from driving to other forms of mobility. TRIAL REGISTRATION: ClinicalTrials.gov identifier “Advancing Understanding of Transportation Options (AUTO)” NCT04141891.

Reducing firearm access during times of risk is a key component of suicide prevention, including the person at risk voluntarily, temporarily storing firearms outside the home. However, this approach relies on the participation of storage providers (ranges/retailers and law enforcement agencies (LEAs)). Our objective was to describe stakeholders' views and experiences surrounding voluntary, temporary out-of-home firearm storage for suicide prevention.We conducted individual interviews with (1) firearm ranges/retailers; (2) LEAs (in Colorado or Washington State); and (3) state/national organizations involved in policy development or enactment; public health; or firearm rights. Transcripts were analyzed using a team-based mixed inductive-deductive approach.Across 100 interviews (October-May 2021), potential storage providers were supportive of voluntary storage programs, often reporting a desire to help their customers and community. However, potential storage suppliers cited civil liability, regulatory, and legal concerns associated with storing and/or returning firearms (to people who had previously expressed suicide risk). Stakeholders offered suggested strategies meant to address liability and increase storage accessibility.Understanding stakeholder views supports the development of acceptable, feasible programs for out-of-home firearm storage during times of suicide risk. Clarification of existing regulations or creation of new policies is necessary to address potential providers' concerns.

BACKGROUND: Driving has not been considered as part of the social cost of acute illness and may go unnoticed in the post-hospital care of older adults. Decreases in driving after hospitalization and at-risk populations has not been investigated. OBJECTIVE: To determine the association between driving reduction and cessation and hospitalization in older adults by using nationally representative data. DESIGN: Retrospective cohort analysis SETTING: Health and Retirement Study survey from 2004 to 2014 PARTICIPANTS: Adults aged 65 years and older who were able to drive and had an available car (n = 12,110; 40,364 interviews) MEASUREMENTS: Self-report of a hospitalization requiring an overnight stay, changes in driving patterns including driving cessation or limitations over a 2-year period, comorbid conditions, health utilization and behaviors. RESULTS: Of hospitalizations in adults aged 65 years and older, 22% were associated with a decrease in driving patterns within 2 years. The relative risk of a reduction or cessation in driving was 1.62 (95% CI: 1.54, 1.70, p < 0.001) when there was a hospitalization compared to when a hospitalization did not occur. Baseline functional, cognitive, and visual impairment, fair or poor self-rated health, and diabetes were identified as independent risk factors for decreased driving patterns following hospitalization. CONCLUSIONS: Changes in driving patterns are common after a hospitalization in older adults. The findings suggest that driving, although not a current goal of post-hospital care, is important to the continued autonomy and community mobility of older adults and needs to be addressed as part of discharge planning and their recovery.

OBJECTIVES: To prospectively validate and refine the 5-item "CRASH" screening tool for identifying older drivers needing a behind-the-wheel (BTW) test. DESIGN: Prospective observational study. SETTING: Geriatric and internal medicine primary care clinics affiliated with a tertiary care hospital and a local BTW program. PARTICIPANTS: Cognitively intact drivers aged 65 and older (N = 315). MEASUREMENTS: Participants completed baseline questionnaire (including CRASH tool) and assessments and BTW test (evaluator blinded to questionnaire results) and participated in 1-month telephone follow-up. Analysis included descriptive statistics and examination of predictive ability of the CRASH tool to discriminate normal (pass) from abnormal (conditional pass or fail) on the BTW test, with logistic regression and CART techniques for tool refinement. RESULTS: Two hundred sixty-six participants (84%) had a BTW test; of these, 17% had a normal rating and 83% an abnormal rating. Forty-five percent of those with an abnormal score were advised to limit driving under particular conditions. Neither the CRASH tool nor its individual component variables were significantly associated with the summary BTW score; in refined models with other variables, the best-performing tool had approximately 67% sensitivity and specificity for an abnormal BTW score. Most participants found the BTW test useful and were willing to pay a median of $50. At 1-month follow-up, no participants had stopped driving. CONCLUSION: The CRASH screening tool cannot be recommended for use in clinical practice. FINDINGS on older adults' perceived utility of the BTW test and the stability of driving patterns at 1-month follow-up could be useful for future research studies and for design of older driver programs.© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society. Language: en

Objectives To estimate the prevalence of self-harm, suicidal ideation (SI), and suicide attempts (SA) in older adults in the emergency department (ED), including differences according to age, sex, and race and ethnicity. Design Quasi-experimental, multiphase, eight-center study with prospective review of consecutive charts during enrollment shifts (November 2011–December 2014). Setting Eight EDs in seven states, all with protocols for nurses to screen every patient for suicide risk (universal screening). Participants Adults (≥18 years) registered in the ED. Measurements Demographic characteristics; documented screening for self-harm, SI, or SA; and positive self-harm, SI, or SA in those with screening performed. Results Of 142,534 visits, 23.3% were of individuals aged 60 and older. Documented screening for self-harm, SI, or SA declined with age, from approximately 81% in younger age groups to a low of 68% in those aged 85 and older. The prevalence of positive screens for self-harm, SI, or SA also declined with age, with peaks in young and middle-age (9.0%) and reaching the lowest point after the age of 75 (1.2%). Conclusion Documented screening for suicide risk declined with age in this large sample of individuals in the ED. Although the reason for this finding is unclear, at least part of the decline may be related to increasing rates of altered mentation or other individual-level barriers to screening in the older population. These findings support the need for more-detailed examination of the best methods for identifying—and treating—suicide risk in older adults.

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness’ epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general, and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.

OBJECTIVES: We sought to describe epidemiological patterns of acute injuries treated in emergency department (ED) and outpatient primary care settings in the United States. DESIGN: Retrospective cross-sectional analysis of data from the 2009 and 2010 National Health Care Surveys. SETTING: Emergency departments and outpatient primary care clinics. PARTICIPANTS: Older adults (≥65) with initial visits for acute injuries. MEASUREMENTS: Frequencies and incidence rates of medically attended injury according to participant characteristics and care setting. RESULTS: Of the 19.7 million medically attended acute injuries in older adults in 2009-10, 50% were treated at EDs and 50% at outpatient primary care clinics. The annual incidence rate of medically attended injuries rose with age, from 20.8 (95% confidence interval (CI) = 17.0-24.6) per 100 in those aged 65 to 74 to 41.5 (95% CI = 33.5-49.4) per 100 for those aged 85 and older. Of injury-related ED visits, 60% occurred outside standard business hours, 36% were triaged as low acuity, and 25% resulted in admission. Only 9% of injury-related primary care visits had injury prevention counseling documented. CONCLUSION: Medically attended injuries area common in older adults, and their incidence increases with advancing age. Half of all initial visits for acute injuries in older adults are to primary care clinics. Most injured individuals are discharged home, and injury prevention counseling is rarely documented. To inform injury prevention efforts appropriately and to avoid underestimating the burden of injury, future injury studies should include a range of outpatient and inpatient care settings. Language: en

Objectives The objective was to describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed. Methods This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt; suicidal ideation; or nonsuicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity. Results Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% confidence interval [CI] = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males

Suicide rates are higher at high altitudes; some hypothesize that hypoxia is the cause. We examined 8,871 suicides recorded in 2006 in 15 states by the National Violent Death Reporting System, with the victim's home county altitude determined from the National Elevation Dataset through FIPS code matching. We grouped cases by altitude (low

All suicides by Hispanics (n = 434) and non-Hispanic Whites (n = 3,370) in Colorado from 2004 to 2008 using the Violent Death Reporting System were examined. Hispanic victims were significantly younger. Adjusting for age and gender, Hispanic victims were less likely to have reported depressed mood [odds ratio (OR) 0.78; 95% confidence interval (CI) 0.63-0.97], mental health diagnosis (OR 0.53; 95% CI 0.41-0.7), or current psychiatric treatment (OR 0.47; 95% CI 0.43-0.77). There were no differences in reports of financial, relationship, job, or legal stresses. Hispanic suicides were equally likely to be by overdose, firearm, or hanging, but more likely to be in jail (OR 2.68; 95% CI 1.55-4.65). To prevent suicides, stronger partnerships are needed among public health, medical, mental health, and criminal justice professionals.

The association between home firearms and the likelihood and nature of suicidal thoughts and plans was examined using the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of 9,483 respondents, 7.4% reported past-year suicidal thoughts, 21.3% with a plan. Similar proportions of those with and without a home firearm reported suicidal thoughts, plans, and attempts. Among respondents with suicidal plans, the odds of reporting a plan involving a firearm were over seven times greater among those with firearms at home, compared with those without firearms at home. The results suggest people with home firearms may not be more likely to be suicidal, but when suicidal they may be more likely to plan suicide by firearm.

OBJECTIVES: To assess whether resident physicians (MDs) could complete a death certificate for elderly patients with injury-related fatalities and whether their abilities were related to training or other factors. SETTING: A large tertiary teaching hospital in Boston, Massachusetts. PARTICIPANTS: Three hundred thirty-six MDs. DESIGN: Through an anonymous Web-based test, MDs were questioned regarding prior training and experience in completion of death certificates. The MDs read a case of an elderly patient who died from intracranial bleeding after a fall and then completed a test death certificate. Whether proper completion was associated with MD characteristics such as year of residency, self-assessment, or previous death certificate experience was examined. RESULTS: Almost two-thirds (63.6%) of MDs completed the test. Of participants, 52% (95% confidence interval (CI)=46-59%) filled out the death certificate with the correct primary cause of death and 10% (95% CI=6-14%) listed the three major contributing causes of death. Only 35% (95% CI=28-41%) correctly reported injury as a contributing cause of death, but 51% of the participants reported a high level of confidence in their ability to complete a death certificate accurately. CONCLUSION: Accurate completion of the sample death certificate and identification of injury was low, and MDs overrated their abilities. Death certificates completed by MDs may not be accurate and may underestimate the contribution of injury to elderly mortality. Language: en

The extent to which Basic Confidence Scales predicted career decision-making self-efficacy was studied in a sample of 627 undergraduate students. Six confidence variables accounted for 49% of the variance in career decision-making self-efficacy. Leadership confidence was the most important, but confidence in science, mathematics, writing, using technology, and cultural sensitivity all contributed significant incremental variance. There were some differences as a function of race and gender, but leadership confidence was the most significant predictor in all subgroups. Implications for educational and career counseling are discussed.

The author provides a brief overview of A. Bandura's (1977, 1997) self-efficacy theory, followed by a discussion of the value of this theory to career counselors, which includes particularly useful features of the concept of self-efficacy and suggestions for its application in career assessment and counseling, with a special focus on group interventions.

The present study indicated that both attachment bonds and self-rated attachment style were significantly related to fear of commitment and, to a lesser extent, career decision-making self-efficacy. Given previous research showing that fear of commitment is related to career indecisiveness and “floundering,” the possible importance of attention to attachment bonds and styles in career counseling is suggested.

In this response, the author highlights the contributions of E. P. Cook, M. J. Heppner, and K. M. O'Brien's (2002) ecological approach to women's career development and reviews the ways that the case studies in this special section illustrate that model. Although this model may enrich and improve career theories and counseling, the author urges caution in assuming that the emphases of an ecological model apply to all women. The concept of individual differences within, as well as between, the genders must remain paramount in career theory and counseling approaches. The author urges further attention to research and counseling interventions that help explicate the utility of the ecological model. Cook, Heppner, and O'Brien's (2002) article "Career Development of Women of Color and White Women: Assumptions, Conceptualization, and Interventions From an Ecological Perspective" is based on the premise that much of the theory and research in the career counseling literature is insufficient to adequately assist large numbers of women because the theory and research are based on fundamental assumptions that do not describe the lives of many women-both women of color and White women. In a nutshell, much of career theory and technique is based on the following assumptions: (a) that work is the most important aspect of people's lives; (b) that career decisions can and should be based on a rational matching of the individual's traits and attributes to the characteristics of occupations; (c) that career development should progress along a rational path showing continued upward movement toward greater responsibility, job complexity, and, it goes without saying, rank and financial rewards; and (d) that talent and hard work will be rewarded. It is a model based on the values of individualism and autonomy. Cook et al. (2002), suggested, in contrast, that for many women and for cultures other than White western European, the family/group/collective may be more important than has been previously factored into people's reasons for working and their decisions about what work to pursue. For many women, meeting and balancing the demands of family and work are the most salient, and often the most stressful, aspects of at least part of adult life. Career development may not be linear and progressive, as pointed out in the landmark work of Super (1957), Harmon (1967), Wolfson (1976), and Betz (1984) on the variety of career patterns found among women. Linearity and progressive advancement may be more easily disrupted in the career paths of women versus men by commitments to family and by environmental/structural barriers (see also Fitzgerald & Betz's, 1994, extensive discussion of such barriers as a function of gender, race, social class, and sexual orientation). Cook et al. (2002), accordingly, suggested incorporation of what they term an ecological perspective in career counseling: "A person's behavior is, therefore, a representation of the complex interaction among the myriad factors that constitute her or his life, referred to as the ecosystem" (p. 296). Using ideas from previous writers in ecological psychology (e.g., Bronfenbrenner, 1977), they suggested that an ecological perspective includes environmental interventions that focus on social support and on individually oriented interventions targeted toward increasing individuals' abilities to deal with environmental barriers to their goals and objectives. The authors (Cook et al., 2002) provided several examples of how an ecological perspective might be implemented in career counseling-interventions in organizations and schools; changing policies about child care; educational interventions that are designed to reduce sexual harassment; creating supportive networks, including access to mentors and role models; and devising strategies for increasing salaries (which are still less than those of comparably employed men). In summary, Cook et al. (2002) reminded counselors that their focus must include the environment (ecosystem) of the individual with whom they are working, as well as the individual difference variables emphasized in traditional vocational psychology/career counseling. …

We present a psychometric scale that assesses risk taking in five content domains: financial decisions (separately for investing versus gambling), health/safety, recreational, ethical, and social decisions. Respondents rate the likelihood that they would engage in domain-specific risky activities (Part I). An optional Part II assesses respondents' perceptions of the magnitude of the risks and expected benefits of the activities judged in Part I. The scale's construct validity and consistency is evaluated for a sample of American undergraduate students. As expected, respondents' degree of risk taking was highly domain-specific, i.e. not consistently risk-averse or consistently risk-seeking across all content domains. Women appeared to be more risk-averse in all domains except social risk. A regression of risk taking (likelihood of engaging in the risky activity) on expected benefits and perceived risks suggests that gender and content domain differences in apparent risk taking are associated with differences in the perception of the activities' benefits and risk, rather than with differences in attitude towards perceived risk. Copyright © 2002 John Wiley & Sons, Ltd.

In this multiple regression model, self-efficacy beliefs are the best predictor of career indecision, and outcome expectations are the best predictor of exploration intentions. When indecision was entered as a predictor, it also was a significant predictor of exploration intentions—students who were less decided were also more likely to plan career exploration. Career efficacy and outcome expectations relate significantly more strongly within the group of college men than within the group of college women. Implications for social cognitive career theory and practice are discussed.

A measure of unconditional self-regard (USR) derived from Rogerian (client-centered) theory was evaluated in four studies. Results indicated that USR was highly reliable and was strongly related to other measures of self-esteem and negatively related to depression, anxiety, and symptoms of psychological distress. The measure was significantly related to the control and commitment dimensions of psychological hardiness but not to its challenge dimension. Evidence for discriminant validity was provided by findings that USR was unrelated to social desirability or private self-consciousness. Finally, female students'self-regard was significantly related to the unconditional positive regard they reported receiving from their mothers. Other correlations between self-regard and perceived regard from others, although nonsignificant, were often large in absolute value. Implications for counseling interventions are discussed.

In this article it is argued that “career” and “personal” counseling should not be viewed as different types of counseling because: (a) the holistic philosophy of counseling emphasizes helping “whole” persons whose lives contain many important and meaningful roles; (b) recent research on the implications of gender and race for career development further demonstrates the inseparability of our career and “personal” lives; and (c) there are numerous commonalities in the “career” and “personal” counseling process.

This article discusses the use of career self-efficacy theory in counseling individuals having low career-related self-efficacy.

Background: Emergency departments (EDs) serve as a central point of interaction between the public and the medical system. Emergency physicians need education in public health in order to optimize their clinical care and their ability to evaluate potential public health interventions in the ED. Methods: As part of the Centers for Disease Control and Prevention (CDC) and the Association of American Medical College's (AAMC) national initiative for “Regional Medicine-Public Health Education Centers-Graduate Medical Education”, we designed and implemented a new public health curriculum for the emergency medicine residents. Over four sessions during regular didactic time, we used a modular approach to link a basic public health principle, such as environmental hazard assessment, to a relevant clinical topic, such as violent patients and ED safety. Each session emphasized resident involvement, including small group work and role-plays. Journal clubs and quality assurance projects supplemented the curriculum. We sought resident feedback through focus groups and anonymous online pre- and post-tests for each session. Assessment: Both before and after the curriculum, 76% of responders felt it was important for physicians to receive training in public health. The program appeared to have a positive effect on residents’ comfort level with various public health topics, and felt the residency program had taught them the skills necessary to implement public health principles in clinical practice (23.8%, versus 11.5% before; p

OBJECTIVE: Death certificates are a common data source for injury research, but their legitimacy depends on proper completion by physicians (MDs). We sought to assess MD accuracy and training in completion of death certificates. METHODS: We tested the ability of 361 MDs at a University hospital to complete a sample death certificate. The test was conducted via an anonymous web-based system. We questioned MDs regarding the type of death certificate instruction they had received. The test included a description of a patient with a death due to intracranial bleeding after a fall, and the MDs completed a mock death certificate. Language: en

Vascular smooth muscle cells are of major interest for the evaluation of atherosclerotic processes. By the use of two-dimensional gel electrophoresis and subsequent silver staining we investigated the protein expression of smooth muscle cells in the native thoracic aorta, immediately after enzymatic disaggregation, in subconfluent proliferating and in postconfluent nonproliferating primary cell cultures. Compared to the native thoracic aorta the protein composition of smooth muscle cells in cell culture is changed dramatically. Furthermore, significant differences in protein expression between proliferating and nonproliferating smooth muscle cells in cell culture were found.

The time dependence of the fluorescence of O−2 centers following picosecond-pulse excitation is studied. The risetime of the spontaneous fluorescence yields an upper bound for the relaxation time in the excited state: τ*R < 20 ps. The fluorescence decay time decreases from 92 ns at 4.2 K to 50 ns at 300 K. By comparing the results to superfluorescence experiments a lower bound for the relaxation time in the ground state is obtained: τR ⪆ 50 ps. Die Zeitabhangigkeit der Fluoreszenz von O−2−Zentren nach einer Picosekunden-Pulsanregung wird untersucht. Das Anklingen der spontanen Fluoreszenz liefert eine obere Schrankefur die Relaxationszeit im angeregten Zustand: τ*R < 20 ps. Die Abklingzeit der Fluoreszenz nimmt bei Erhohung der Temperatur von einem Wert von 92 ns bei 4,2 K ab auf 50 ns bei 300 K. Durch Vergleich mit Resultaten aus Superfluoreszenzexperimenten ist es auch moglich, eine Schranke fur die Relaxationszeit im Grundzustand anzugeben: τR ⪆ 50 ps.