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Introduction Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America. Methods We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test. Results Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities. Conclusions Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.

Background We discuss barriers to recruitment, retention, and intervention delivery in a randomized controlled trial (RCT) of patients presenting with firearm injuries to a Level 1 trauma center. The intervention was adapted from the Critical Time Intervention and included a six-month period of support in the community after hospital discharge to address recovery goals. This study was one of the first RCTs of a hospital- and community-based intervention provided solely among patients with firearm injuries. Main text Barriers to recruitment included limited staffing, coupled with wide variability in length of stay and admission times, which made it difficult to predict the best time to recruit. At the same time, more acutely affected patients needed more time to stabilize in order to determine whether eligibility criteria were met. Barriers to retention included insufficient patient resources for stable housing, communication and transportation, as well as limited time for patients to meet with study staff to respond to follow-up surveys. These barriers similarly affected intervention delivery as patients who were recruited, but had fewer resources to help with recovery, had lower intervention engagement. These barriers fall within the broader context of system avoidance (e.g., avoiding institutions that keep formal records). Since the patient sample was racially diverse with the majority of patients having prior criminal justice system involvement, this may have precluded active participation from some patients, especially those from communities that have been subject to long and sustained history of trauma and racism. We discuss approaches to overcoming these barriers and the importance of such efforts to further implement and evaluate hospital-based violence intervention programs in the future. Conclusion Developing strategies to overcome barriers to data collection and ongoing participant contact are essential to gathering robust information to understand how well violence prevention programs work and providing the best care possible for people recovering from injuries. Trial registration ClinicalTrials.govNCT02630225. Registered 12/15/2015.

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

Intimate partner violence (IPV) is a serious public health problem in the United States with adverse consequences for affected individuals and families. Recent reviews of the literature suggest that economic policies should be further investigated as part of comprehensive strategies to address IPV. The Earned Income Tax Credit (EITC) is the nation’s largest anti-poverty program for working parents, and especially benefits low-income women with children, who experience an elevated risk of IPV. The EITC may prevent IPV by offering financial resources; such resources may help individuals experiencing IPV leave abusive relationships or address IPV risk factors, thereby preventing entry into abusive relationships. However, the association between EITC generosity and IPV has not been previously examined. We used state-level and individual-level datasets to examine the association between EITC generosity and IPV. Our state-level data source was the nationally representative National Crime Victimization Survey (NCVS; N = ~ 95,000 households per year). For NCVS, we used a difference-in-difference approach to investigate the relationship between state EITC generosity and IPV rates. We also used individual-level longitudinal data from the Fragile Families and Child Well-being Study (n = 13,422 person-waves). Using this cohort of US families at higher risk for IPV, we evaluated associations between estimated EITC benefits based on the mother’s state of residence and number of children and self-reported IPV. In both state- and individual-level analyses, no significant association between state EITC benefits and IPV was found. Factors that may account for these null findings include program ineligibility for individuals who separate from abusive spouses. Future research efforts should more closely examine EITC policy implementation processes and the lived experience of participating in anti-poverty programs for people experiencing IPV.

ObjectivesTo determine if an association exists between the number of driving under the influence (DUI) convictions required to activate federal firearms prohibitions and annual firearm homicide and suicide rates by state.MethodsEcological cross-sectional study of all US states from 2013 to 2017. We collected DUI law data from Thomson Reuters Westlaw database and firearm mortality data from the Centers for Disease Control and Prevention Vital Statistics programme.ResultsFive states had laws such that one or two DUI convictions could result in prohibitions to firearms access according to federal law. Four states had no legal framework that would restrict firearms access because of DUI convictions; the remaining states could activate federal restrictions at three or more DUI convictions. Firearm-specific homicide (victimisations) rates were 19% lower among women in states where federal restrictions of firearms access occurred after one or two DUI offences (incidence rate ratio (IRR) 0.81; 95% CI 0.64 to 1.01) and 18% lower in states with firearm prohibitions after three or more offences (IRR 0.82; 95% CI 0.71 to 0.95) compared with the states with no legal framework for prohibiting firearms after DUI convictions. There was no association between number of DUI activations and overall, or firearm-specific, suicide among the entire population (men and women) or among only women, or only men.ConclusionsDUI penalties that activate federal firearms prohibitions may be one pathway to reduce firearm homicide of female victims.

Objectives. To determine differences among US states in how driving under the influence of alcohol (DUI) laws activate federal firearm possession and purchase prohibitions. Methods. We performed primary legislative research to characterize DUI laws in each state. The primary outcome was the number of DUI convictions an individual must be convicted of in each state to activate the federal firearm possession and purchase prohibition. We also determined the time interval in which previous DUI convictions count for future proceedings. Results. Forty-seven states had DUI laws that activated the federal prohibition of firearm possession and purchase for a threshold number of repeated DUIs. Variation exists among states in the number of convictions (1–4) and length of liability period (5 years–lifetime) required to prohibit firearm possession and purchase. Conclusions. Variation in state laws on DUI results in differences in determining who is federally prohibited from possessing and purchasing firearms. Future research should explore whether these federal prohibitions arising from DUI convictions are enforced and whether an association exists between stricter DUI policies and reduction in firearm crimes, injuries, and deaths.

Background Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries. Methods We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the Level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization. Results Neither assignment to, or engagement with, the intervention, defined as having at least 1 contact point with the Support Specialist, was associated with risk of arrest at 2 years post hospital discharge (Relative Risk for intervention assignment = 1.15; 95% CI: 0.90, 1.48; Relative Risk for intervention engagement = 1.07; 95% CI: 0.74, 2.19). There was similarly no association observed for subsequent injury. Conclusions This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program. Level of evidence Care Management, level II.RegistrationRegistered at clinicaltrials.gov NCT02630225.

Background In the United States, 74% of homicides and 51% of suicides involve firearms. Using extreme risk protection order (ERPO) laws, petitioners can request restricting firearm access for individuals (known as "respondents") who pose a risk to themselves or others. Objective To characterize respondents and circumstances of ERPOs. Design Descriptive study. Setting State of Washington. Participants All ERPO respondents during 8 December 2016 to 10 May 2019. Measurements Reason for filing the ERPO; characteristics of respondents; respondent's reported history of domestic violence perpetration, mental illness, substance misuse, and suicide ideation or attempt; number and type of firearms removed; and ERPO petition outcome (granted or not granted). Results The ERPOs were filed for concerns about harm to self (n = 67), harm to others (n = 86), or harm to both self and others (n = 84). Of all ERPOs, 87% were filed by law enforcement and 81% were granted. At least 1 firearm was removed from 64% of respondents, with a total of 641 firearms removed. The petitioner reported prior domestic violence perpetration by the respondent in 24% of cases, and a prior diagnosis of a mental health condition and substance misuse for the respondent in 40% and 47% of cases, respectively. Of all respondents, 62% had a history of suicidal ideation or attempt according to the petitioner. As part of the ERPO process, the court ordered mental health evaluation in 30% of cases. Limitation Filing of the forms was inconsistent. Conclusion Laws regarding ERPOs are a potential tool to help protect patients or family members from harming themselves or others by restricting firearm possession and purchase. Further studies are needed to determine the long-term effects of these laws and identify approaches to increase their use. Primary funding source State of Washington.

Economic insecurity is a risk factor for intimate partner homicide (IPH). The Earned Income Tax Credit (EITC) is the largest cash transfer programme to low-income working families in the USA. We hypothesised that EITCs could provide financial means for potential IPH victims to exit abusive relationships and establish self-sufficiency. We conducted a national, quasiexperimental study of state EITCs and IPH rates in 1990–2016 using a difference-in-differences approach. The national rate of IPH decreased from 1.9 per 100 000 adult women in 1990 to 1.3 per 100 000 in 2016. We found no statistically significant association between state EITC generosity and IPH rates (coefficient indicating change in IPH rates per 100 000 adult female years for additional 10% in amount of state EITC, measured as the percentage of federal EITC: 0.02, 95% CI −0.03 to 0.08). Financial control associated with abuse and current EITC eligibility rules may prevent potential IPH victims from accessing the EITC.

Objective To assess the relationship between the presence and generosity of state-level Earned Income Tax Credits (EITC) and multiple self-reported measures of general health. Data sources Data on state-level tax credits and covariates were obtained from the National Bureau of Economic Research and University of Kentucky Center for Poverty Research, respectively. These data were merged with Behavioral Risk Factor Surveillance System survey records from 1993-2016. Study design Using difference-in-differences approaches and survey-weighted Poisson regression that accounted for clustering of observations and included state and year fixed-effects, we assessed relationships between EITC and self-reported overall health, frequent mental distress, and frequent poor physical health in the prior 30 days. Covariates included state minimum wage, state GDP, and adoption of Medicaid expansion. Sensitivity analyses revealed that parallel trends were plausible; there were no significant lead and lag effects. Data extraction methods Analyses were restricted to respondents with no more than a high school diploma or equivalent because less-educated adults are more likely to be low-wage earners and therefore qualify for EITC. Principal findings Among adults with no education beyond high school (n = 2 884 790), each additional 10-percentage-point increase in the generosity of state EITC-relative to the federal credit-was associated with fewer reports of frequent mental distress (-97.3 per 100 000; 95% CI: -237.2, 42.6) and frequent poor physical health (-149.6 per 100 000; 95% CI: -284.4, -14.9). When restricted to individuals interviewed during the three months when tax rebates are commonly disbursed, the magnitude of the association between EITC and prevalence of reported frequent mental distress was greater (-329.7 per 100 000; 95% CI: -636.0, -23.5). Conclusions The generosity of state EITC policies is positively associated with significant reductions in frequent mental distress and poor physical health, especially during months when the credit is received. Interventions to reduce poverty may positively impact health by reducing material hardship and stress.

Temporary transfers of firearms from suicidal persons is a strategy to reduce the incidence of suicide deaths. We discuss a barrier to the effective operation of voluntary temporary firearm transfer laws: the dearth of guidance on the liability for returning firearms to persons who voluntarily surrender them. We examine the laws of all 50 US states that regulate temporary surrenders of firearms and evaluate whether any provisions govern liability for returning temporarily surrendered firearms. Although 14 states create background check exceptions to permit temporary transfers of firearms from an owner to family, friends, retailers, or law enforcement, no states prescribe procedures for returning those firearms.ability for returning the firearms to people who voluntarily surrendered them. We recommend amending state laws to clarify the process and liability for returning temporarily surrendered firearms to the original owner. Such amendments would be intended to mitigate the potential chilling effect that lack of clarity and presumption of liability may impose on efficiently reducing firearm access to protect firearm owners at risk for suicide.

Conducting case–control studies using the National Violent Death Reporting System (NVDRS) has the potential to introduce selection bias and misclassification through control selection. Some studies that use NVDRS compare groups of individuals who died by one mechanism, intent or circumstance, to individuals who died by another mechanism, intent or circumstance. For aetiological studies within NVDRS, the use of controls who had a different type of violent death has the potential to introduce selection bias, while relying on narrative summaries for exposure measurement may result in misclassification. We discuss these two methodological issues, and identify an unusual circumstance in which selection of live controls within NVDRS can be employed.

Violence in its many forms can affect the health of people who are the targets, those who are the perpetrators, and the communities in which both live. In this article we review the literature on the health consequences of many forms of violence, including child physical and sexual abuse, intimate partner violence, elder abuse, sexual violence, youth violence, and bullying. The biological effects of violence have become increasingly better understood and include effects on the brain, neuroendocrine system, and immune response. Consequences include increased incidences of depression, anxiety, posttraumatic stress disorder, and suicide; increased risk of cardiovascular disease; and premature mortality. The health consequences of violence vary with the age and sex of the victim as well as the form of violence. People can be the victims of multiple forms of violence, and the health effects can be cumulative.

Background: Research on disparities in traumatic injury has not been well characterized, limiting understanding of gaps in research and development of successful interventions. We conducted a scoping review to identify and synthesize research on disparities in intentional and unintentional traumatic injuries. Methods: The review was guided by PRISMA Extension for Scoping Reviews. PubMed, PsycINFO, Web of Science, and CINAHL and systematic reviews from 2007 to 2017 were searched. Eligible articles were peer reviewed; conducted in the United States; and reported on clearly defined physical trauma and disparity, defined by Cochrane PROGRESS-Plus criteria. One reviewer assessed article titles and a second reviewer validated the inclusion with a random sample. Abstract and full-text review by two reviewers determined final inclusion. Results: Of 7382 unique articles screened, 653 articles were included; inter-rater agreement was high (K=0.995). Studies reported on disparities in the acute hospital setting (104) or postacute/rehabilitation (86), with fewer focused on prevention (57) and policy development (6). Research methods used were quantitative (593) with 25 intervention studies, qualitative (45), qualitative/quantitative (7), and community-based participatory research (8). Age ranges of included studies were all ages (124), adults (318), pediatric/youth/adolescents (172), and older adults (40). Racial disparities were most commonly measured (439 studies); 38 created a white/nonwhite binary. Other commonly measured disparities were place of residence (122), insurance (111 studies), gender (89), age (75), and socioeconomic status measures (61). Disparities were noted in all of the categories. Studies commonly aggregated all types of traumatic injuries (129) or all types of violence (105). Conclusions: The extant injury literature lacks research on prevention and policy to address disparities. Many studies aggregated types of trauma and patient groups, preventing an understanding of distinctions between groups and potential interventions. Intervention and community-based research strategies were limited. Future research can better specify measurement of understudied equity categories, trauma types and intent, and racial groups.

Individuals who sustain nonfatal gunshot wound (GSW) injuries are at substantially increased risk of subsequent firearm injury. There is a dearth of literature examining what, if any, firearm-related behavior changes occur among adults as a result of GSW injuries. Using survey data on firearm-related behaviors from an ongoing randomized controlled trial, we sought to describe changes in reported firearm-related behaviors among GSW patients following their injury. Our results suggest that patients with a GSW, especially firearm owners, may change their firearm-related behaviors following injury, some by increasing firearm-related safety and others by increasing frequency of behaviors that may place them at increased risk of subsequent injury. This study highlights the need for further examination of firearm-related behavior change among GSW patients and development of interventions to promote firearm safety among this population.

Background Single-failure survival models are commonly used in injury research. We aimed to demonstrate the application of multiple failure survival models in injury research by measuring the association between arrest and IPV recidivism. Methods We used data from a population-based cohort of 5466 male-female couples with a police-reported, male-perpetrated incident of IPV against their female partners that occurred in Seattle, WA during 1999–2001. We estimated the risk of physical and psychological IPV recidivism (separately) for the 12 months following the index event, according to perpetrator arrest or non-arrest for the index event. We used time-dependent extended Cox regression analyses for time-to-first IPV event and Prentice, Williams and Peterson model-based analyses for time-to-multiple IPV events. Results Arrest was associated with a reduction in time-to-first physical IPV recurrence but was not associated with time-to-first psychological IPV recurrence during the 12-month follow-up. Arrest was associated with a significantly decreased risk of physical and psychological IPV during the 12-month follow-up in the multiple failure models. The association between arrest and lower risk of physical IPV recidivism increased with increasing number of follow-up IPV events. Conclusions We found arrest to be a plausible deterrent for recurrent IPV reduction. Our study also illustrates the use of multiple failure survival analyses in injury research. Such techniques facilitate inference about estimands that may have greater public health relevance and properly account for injury recurrence. By using multiple failure models, we were able to more deeply understand the relationship between arrest and IPV over time.

Firearm carriage is a key risk factor for interpersonal firearm violence, a leading cause of adolescent (age \ 18) mortality. However, the epidemiology of adolescent firearm carriage has not been well characterized. This scoping review examined four databases (PubMed; Scopus; EMBASE; Criminal Justice Abstracts) to summarize research on patterns, motives, and underlying risk/protective factors for adolescent firearm carriage. Of 6156 unique titles, 53 peer-reviewed articles met inclusion criteria and were reviewed. These studies mostly examined urban Black youth, finding that adolescents typically carry firearms intermittently throughout adolescence and primarily for self-defense/protection. Seven future research priorities were identified, including: (1) examining adolescent carriage across age, gender, and racial/ethnic subgroups; (2) improving on methodological limitations of prior research, including disaggregating firearm from other weapon carriage and using more rigorous methodology (e.g., random/systematic sampling; broader population samples); (3) conducting longitudinal analyses that establish temporal causality for patterns, motives, and risk/protective factors; (4) capitalizing on m-health to develop more nuanced characterizations of underlying motives; (5) increasing the study of precursors for first-time carriage; (6) examining risk and protective factors beyond the individual-level; and, (7) enhancing the theoretical foundation for firearm carriage within future investigations.

Research on spatial injury patterns is limited by a lack of precise injury occurrence location data. Using linked hospital and death records, we examined residence and injury locations for firearm assaults and homicides in or among residents of King County, Washington, USA from 1 January 2010 to 31 December 2014. In total, 670 injuries were identified, 586 with geocoded residence and injury locations. Three-quarters of injuries occurred outside the census tract where the victim resided. Median distance between locations was 3.9 miles, with victims 18–34 having the greatest distances between residence and injury location. 40 of 398 tracts had a ratio of injury incidents to injured residents of >1. Routine collection of injury location data and homelessness status could decrease misclassification and bias. Researchers should consider whether residential address is an appropriate proxy for injury location, based on data quality and their specific research question.

Background Firearm violence is a public health problem that disparately impacts areas of economic and social deprivation. Despite a growing literature on neighborhood characteristics and injury, few studies have examined the association between neighborhood disadvantage and fatal and nonfatal firearm assault using data on injury location. We conducted an ecological Bayesian spatial analysis examining neighborhood disadvantage as a social determinant of firearm injury in Seattle, Washington. Methods Neighborhood disadvantage was measured using the National Neighborhood Data Archive disadvantage index. The index includes proportion of female-headed households with children, proportion of households with public assistance income, proportion of people with income below poverty in the past 12 months, and proportion of the civilian labor force aged 16 and older that are unemployed at the census tract level. Firearm injury counts included individuals with a documented assault-related gunshot wound identified from medical records and supplemented with the Gun Violence Archive between March 20, 2016 and December 31, 2018. Available addresses were geocoded to identify their point locations and then aggregated to the census tract level. Besag-York-Mollie (BYM2) Bayesian Poisson models were fit to the data to estimate the association between the index of neighborhood disadvantage and firearm injury count with a population offset within each census tract. Results Neighborhood disadvantage was significantly associated with the count of firearm injury in both non-spatial and spatial models. For two census tracts that differed by 1 decile of neighborhood disadvantage, the number of firearm injuries was higher by 21.0% (95% credible interval: 10.5, 32.8%) in the group with higher neighborhood disadvantage. After accounting for spatial structure, there was still considerable residual spatial dependence with 53.3% (95% credible interval: 17.0, 87.3%) of the model variance being spatial. Additionally, we observed census tracts with higher disadvantage and lower count of firearm injury in communities with proximity to employment opportunities and targeted redevelopment, suggesting other contextual protective factors. Conclusions Even after adjusting for socioeconomic factors, firearm injury research should investigate spatial clustering as independence cannot be able to be assumed. Future research should continue to examine potential contextual and environmental neighborhood determinants that could impact firearm injuries in urban communities.

Background Nearly 1800 homicides were reported in 2018 among individuals aged 60 years or older in the US. The characteristics and circumstances of these homicides are understudied. We investigated the trends of homicides over time and compared victim, perpetrator, and incident characteristics by mechanism (firearm vs. non-firearm) among adults aged 60 years or older. Methods We examined cross-sectional restricted-access data from the National Violent Death Reporting System from 2003 to 2017. Fatal Injury Data by CDC provided age-adjusted homicide rates. We quantitatively summarized victim, perpetrator, and incident characteristics for firearm and non-firearm homicides. We also reviewed 150 qualitative narratives to better understand the context of older adult homicides perpetrated by firearms. All data were analyzed in February 2020. Results Overall and firearm-specific older adult homicide rates increased between 2014 and 2017. Of the 6188 victims, 62% were male. The majority of victims (68%) were killed at home. Firearms (44%), sharp (19%) and blunt weapons (15%) were common mechanisms used in older adult homicides. The perpetrator was an intimate partner in 39% of firearm homicides and 12% of non-firearm homicides (prevalence difference = 27%; 95% CI: 25, 30%). Similarly, homicide-suicides (prevalence difference = 21%; 95% CI: 19, 22%) and multiple-victim incidents (prevalence difference = 7%; 95% CI: 5, 8%) were more common in firearm (23 and 13%, respectively) than in non-firearm (2 and 6%, respectively) homicides. Common contexts of firearm homicides were familial/intimate partner problems, robbery/burglary, argument, and illness. Conclusions A substantial number of older adults were killed with firearms and by their intimate partners. Further research to identify violence victimization prevention strategies in this group, especially those that limit access to firearms by potential perpetrators, is warranted.

Objectives The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults. Methods We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older. Results Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died. Conclusions Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

Prior research has illustrated the importance of some types of local community crime for adolescents' outcomes. However, we have little knowledge about the extent to which gun homicides within adolescents' neighborhoods affect their mental health and behavioral outcomes. This is important because local gun homicide incidents may be uniquely harmful for adolescents and their association with adolescents' mental health and behavior may represent an underappreciated externality of the U.S.‘s gun violence epidemic. In this study, we used data on the geocoded location of gun homicides linked with restricted Fragile Families and Child Wellbeing Study data to examine whether gun homicides incidents near adolescents' homes and/or schools were associated with their mental health and behavioral outcomes. We found that the occurrence of a gun homicide near an adolescent's home or school was associated with significantly worse symptoms of anxiety and depression for girls and, in some cases, with symptoms of anxiety for boys. We further found that these relationships varied depending on the distance of gun homicide incidents to homes and schools., Highlights • Gun homicides are relatively frequent occurrences in the neighborhoods of urban, low-income adolescents. • Local gun homicides are associated with symptoms of anxiety and depression for girls. • Gun homicides are associated with anxiety for boys when gun homicides occur within half a mile of their homes or schools. • The cost of the gun violence epidemic may be underestimated without considering the effects of gun violence on communities.

* Abbreviation: AAP — : American Academy of Pediatrics Firearm injury and mortality is a major public health concern that has taken a devastating toll on young Americans for decades. In 2018, 3335 young people (aged 1–19) died of firearm injuries, specifically homicide (55%), suicide (39%), and unintentional injury (3%).1 In a recent article, the Firearm Safety Among Children and Teens Consortium2 recommended increased attention to safe firearm storage in the home and other places (eg, cars) where individuals

Background The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments. Objective To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury. Design Before-after study. Setting Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana. Participants Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017. Measurements Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes. Results Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8 158 786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41 255 916 ($70 644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17 806 per member) for those discharged from the ED and 2138% (from $4118 to $92 151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized. Limitation Firearm injury intent was not specified because of misclassification concerns. Conclusion In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable. Primary funding source None.

Importance Laws mandating a minimum age to purchase or possess firearms are viewed as a potentially effective policy tool to reduce homicide by decreasing young adults’ access to firearms. Objective To evaluate whether state laws that raised the minimum age to purchase and/or possess a handgun to 21 years were associated with lower rates of firearm homicide perpetrated by young adults aged 18 to 20 years. Design, Setting, and Participants In this difference-in-differences analysis of a national cohort, young adult–perpetrated homicide rates were compared between states that did and did not implement stricter minimum age laws than the 1994 federal statute, adjusting for state-level factors. Under 1994 US federal law, the minimum age to purchase a handgun from a licensed dealer is 21 years; to purchase a handgun from an unlicensed dealer, 18 years; and to possess a handgun, 18 years. The 12 states that raised the minimum ages to purchase and/or possess a handgun beyond those set by federal law before 1994 were excluded from the stricter implementation group. Data were collected from January 1, 1995, to December 31, 2017, and analyzed from November 7, 2019, to June 23, 2020. Exposures Implementation of state law to raise the minimum age to purchase and/or possess a handgun beyond federal minimum age laws. During the study period, Massachusetts, Maryland, New Jersey, New York, and Wyoming raised the minimum age from 18 to 21 years to purchase a handgun from all dealers. With the exception of Wyoming, these states also increased the minimum age from 18 to 21 years to possess a handgun. Main Outcomes and Measures Firearm homicides perpetrated by young adults aged 18 to 20 years. Homicide data were obtained from the Supplementary Homicide Reports. Results During the study period, 35 960 firearm homicides were perpetrated by young adults aged 18 to 20 years. There was no statistically significant change in the rates of homicide perpetrated by this age group in the 5 states that imposed stricter age limits compared with the 32 that did not (crude incidence rate ratio, 1.10; 95% CI, 0.86-1.40). The adjusted incidence rate ratio was 1.14 (95% CI, 0.89-1.45) in states that implemented stricter minimum age laws compared with those that did not. Conclusions and Relevance This study found that stricter state minimum age laws were not associated with significantly lower rates of young adult–perpetrated homicide in states that adopted them compared with states that did not, and policy makers should reassess their use.

ObjectiveTo determine if a brief intervention, called Signpost, Assess, Facts, Emotion, Recommend (SAFER), designed to motivate changes in behaviour to secure firearms and medications to prevent future suicide is feasible to implement in community-based settings such as gun shows, acceptable to participants at higher risk for suicide including veterans and men in the middles years (35–64) and improves firearm and medication locking behaviours.Methods1175 people received SAFER over a 12-month period at 18 gun shows and community events in 2019 and completed a preassessment measuring firearms ownership, storage practices, knowledge about suicide as the leading type of firearm fatality and attitudes about suicide prevention. 372 responded to a brief postassessment using comparable measures.Results85% of participants reported keeping firearms at home. 43.7% reported current or prior military service. 53.2% were males between the ages of 35 and 64. Among those who responded to the postassessment, 61% of participants reported SAFER to be highly valuable. Safe firearms storage improved among participants who completed the preassessment and postassessment (51.2% pre, 66.0% post; pConclusionsIt is feasible, acceptable and effective to reach groups at elevated risk for suicide using a brief intervention strategy in unconventional settings. Community-based interventions to improve safe storage motivated by suicide prevention messaging should be prioritised because men in the middle years are less likely to use mental health services.

To better understand motivations behind purchase and storage of firearms during the COVID-19 pandemic, we used Amazon Mechanical Turk to conduct an online survey of individuals who did and did not purchase a firearm since 1 January 2020 in response to COVID-19. The survey was fielded between 1 and 5 May 2020. We asked about motivations for purchase, changes in storage practices and concern for themselves or others due to COVID-19. There were 1105 survey respondents. Most people who purchased a firearm did so to protect themselves from people. Among respondents who had purchased a firearm in response to COVID-19 without prior household firearm ownership, 39.7% reported at least one firearm was stored unlocked. Public health efforts to improve firearm-related safety during COVID-19 should consider increasing access to training and framing messages around the concerns motivating new firearm purchase.

ObjectiveIncome inequality has been rising in the US and thought to be associated with violence especially homicide. About 75% of homicides involve firearms. We quantified the association between county-level income inequality and all-race/ethnicity and race/ethnicity-specific firearm homicide rates among individuals aged 14–39 years.MethodsWe conducted a cohort study of US counties to examine the association of Gini Index (ranging from 0 [perfect income equality] to 1.0 [perfect income inequality]) separately measured in 1990 and 2000 with all-race/ethnicity and race/ethnicity-specific firearm homicide rates in 2005–2015. Generalised linear mixed models with Poisson distribution including a random intercept for state provided IRRs and 95% CIs. Bayesian Poisson-lognormal hierarchical modelling with integrated nested Laplace approximations was used in exploratory spatial analyses. Models accounted for county-level age, sex and race/ethnicity composition, crime rate, deprivation, social capital, urbanicity, and firearm ownership.FindingsThe Gini Index was associated with firearm homicide rates among all races/ethnicities. After accounting for contextual determinants of firearm homicide, the association persisted among African–Americans. In this group, a 1 SD greater Gini Index in 1990 (IRR=1.09; 95% CI 1.02 to 1.16) and 2000 (IRR=1.09; 95% CI 1.01 to 1.17) was associated with greater firearm homicide rates in 2005–2015. Exploratory spatial analyses did not materially change the results.ConclusionPolicies addressing the gap between the rich and the poor deserve further considerations for reducing firearm homicide rates. Incorporating income inequality to refine measures of socioeconomic position may advance public health and clinical research and practice for firearm violence prevention.

Background A frequent response for prenatal substance exposure (PSE) is intervention by child protective services (CPS). Previous research has examined differences in reports to CPS regarding PSE by substance exposure and by maternal race. However, little is known regarding the frequency of immediate removals by CPS relating to PSE and maternal race. Methods We investigated hospital reports to CPS and CPS removals of PSE infants by using linked birth, hospital discharge, and CPS records for all children born in Washington State between 2006 and 2013 (N = 760,863). We identified PSE using diagnostic codes, calculated prevalence by substance type and maternal race, and tested for differences by interactions of race and substance using multinomial logistic regression. Results Prevalence of PSE births varied by race with 8.1% of Native American, 2.8% of black, 1.9% of white, and 0.8% of Hispanic births diagnosed with PSE. Opioids was the most common type of PSE diagnosis at 48.2%. The majority of PSE infants (86.7%) were not removed by CPS but variations by substance type were observed. Of the interactions in the multinomial logistic regression model, only black infants exposed to alcohol were more likely to result in reports to CPS without removal than the referent group of white infants exposed to opioids. Conclusions Findings indicate that most infants diagnosed with PSE were not removed by CPS and minority PSE infants were not reported to CPS or removed by CPS more than white infants. Racial differences identified in the prevalence of PSE present opportunities for targeted prevention efforts.

Firearm storage method is a potentially modifiable risk factor for suicide. Using data from a large, multi-state survey, we sought to determine whether there is an association between mental health and household firearm storage practices, and characterize that association by state of residence. Participants who endorsed the presence of a household firearm and answered the mental health questions in the 2016–2017 Behavioral Risk Factor Surveillance System from eight states were included (n=26,949). Exposures were recent poor mental health (≥14 vs. 0–13 days/past month), and diagnosis of depression. Outcomes were household firearm storage practices (loaded, and both loaded and unlocked). Using Poisson regression, we calculated adjusted prevalence ratios (aPR) overall and stratified by state of residence. Of adults endorsing a household firearm, 35.1% reported storing a firearm loaded, and of those, 53.4% reported that the firearm was both loaded and unlocked. Neither recent poor mental health nor depression was associated with loaded (aPR 1.14 [95% CI: 0.95–1.37] and aPR 0.94 [95% CI 0.80–1.09], respectively) or loaded and unlocked (aPR 1.08 [95% CI 0.88–1.42] and aPR 1.04 [95% CI 0.88–1.22], respectively) firearm storage. In the setting of highly prevalent loaded firearm storage, no differences in storage practices by mental health indicators were observed across eight states despite disparate firearm policies and local culture. The lack of difference in storage practices by mental health indicators across several states highlights an opportunity to improve means safety counseling practices, and the need for dedicated evaluation of state-level firearm storage policies.

OBJECTIVE To examine whether patients with traumatic brain injury (TBI) are at higher risk for subsequent crime perpetration compared with injured patients without TBI and those hospitalized for reasons other than injury. SETTING AND PARTICIPANTS Patients hospitalized in Washington State from 2006-2007. DESIGN A retrospective cohort study using linked statewide datasets. MAIN MEASURES Primary outcomes were arrest for any violent or nonviolent crime within 5 years of discharge. Adjusted subhazard ratios were calculated using regression models incorporating death as a competing risk. RESULTS Compared with uninjured patients (n = 158 247), the adjusted rate of arrest for any crime was greater among injured patients with TBI (n = 6894; subdistribution hazard ratios [sHR], 1.57; 95% confidence interval [CI], 1.49-1.62) and without TBI (n = 40 035; sHR, 1.55; 95% CI, 1.49-1.62). When patients with TBI were directly compared with injured patients without TBI, no effect of TBI on subsequent arrests was found (sHR, 1.02; 95% CI, 0.94-1.11). TBI did not increase the likelihood of either violent or nonviolent crime when these outcomes were examined separately. CONCLUSIONS TBI survivors do not appear to be at increased risk for criminality compared with injured individuals without TBI. However, injured persons with or without TBI may be at elevated risk of crime perpetration compared with those who are uninjured.

This case series study examines firearm deaths in homes in King County, Washington, from 2011 to 2018.

Objective Trauma patients are at increased risk of suicidal behavior. The association between assault injury and subsequent suicidal behavior relative to unintentional injury remains under-studied. This study hypothesized that trauma patients with assault injuries would demonstrate greater risk of subsequent suicide attempt hospitalization compared to patients with unintentional injury. Method Trauma patients hospitalized in Washington State were identified via administrative records. Proportional hazard analysis was conducted to test differences in risk of suicide attempt hospitalization up to 5 years after the initial trauma hospitalization, and time to onset of first suicide attempt hospitalization by subgroup. Results Approximately 2% (n = 1264) of trauma inpatients were subsequently hospitalized for attempted suicide, and 0.3% died by suicide (n = 177) during the follow-up period. Relative to patients with unintentional injuries, those with assault-related injuries (aHR = 1.38, 95% CI: 1.02 to 1.86), and self-inflicted injuries (aHR = 8.22, 95% CI: 7.24 to 9.33) demonstrated greater risk of suicide attempt hospitalization after discharge. Conclusion These findings demonstrate a greater risk of suicidal behavior among trauma patients with assault injuries relative to patients with unintentional injuries. This suggests the importance of intentional cause of injury as a risk factor for suicidal behavior to be considered in assessment of suicidality and discharge planning for trauma patients.

OBJECTIVES Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI. METHODS Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score. RESULTS Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment. CONCLUSIONS Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

BACKGROUND: Chronic Pseudomonas aeruginosa lung infection is associated with significant morbidity and mortality in cystic fibrosis (CF). It is not known whether recent advances in care have affected the rates of chronic infection. We aimed to determine if the rates of developing new chronic P. aeruginosa infection among adolescents and adults with CF significantly changed over time. METHODS: The cohort consisted of individuals with CF followed in the Cystic Fibrosis Foundation Patient Registry aged ≥13 years without chronic P. aeruginosa at baseline. Multivariable regression models accounting for within-patient correlation were used to assess the change in rate of developing chronic P. aeruginosa infection between 2003 and 2012. RESULTS: A total of 15504 individuals were followed for a median of 5 (interquartile range, 2–9) years. The annual rates of developing new chronic P. aeruginosa decreased from 14.3% in 2003 to 6.4% in 2012. After adjusting for potential confounders, relative risk (RR) of developing chronic P. aeruginosa infection decreased significantly over time compared to 2003 (P value test of trend < .001). Compared with 2003, the RR of developing chronic P. aeruginosa infection in 2012 was 0.33 (95% confidence interval, 0.30–0.37). No significant increases in risk of chronic infections with other major CF bacterial pathogens relative to 2003 were identified. CONCLUSIONS: Among individuals with CF, a significant decrease in the risk and rates of developing chronic P. aeruginosa infection between 2003 and 2012 was observed. Whether this decline results in changes in clinical outcomes warrants further exploration.

Recent large-scale chikungunya virus (CHIKV) and Zika virus epidemics in the Americas pose a growing public health threat. Given that mosquito bite prevention and vector control are the main prevention methods available to reduce transmission of these viruses, we assessed adherence to these methods in the United States Virgin Islands (USVI). We interviewed 334 USVI residents between December 2014 and February 2015 to measure differences in mosquito prevention practices by gender, income, presence of CHIKV symptoms, and age. Only 27% (91/334) of participants reported having an air conditioner, and of the 91 with air-conditioners, 18 (20%) reported never using it. Annual household income > $50,000 was associated with owning and using an air conditioner (41%; 95% confidence interval [CI]: 28–53% compared with annual household income ≤ $50,000: 17%; 95% CI: 12–22%). The majority of participants reported the presence of vegetation in their yard or near their home (79%; 265) and a cistern on their property (78%; 259). Only 52 (16%) participants reported wearing mosquito repellent more than once per week. Although the majority (80%; 268) of participants reported having screens on all of their windows and doors, most (82%; 273) of those interviewed still reported seeing mosquitoes in their homes. Given the uniformly low adherence to individual- and household-level mosquito bite prevention measures in the USVI, these findings emphasize the need for improved public health messaging and investment in therapeutic and vaccine research to mitigate vector-borne disease outbreaks.

IMPORTANCE: Understanding global variation in firearm mortality rates could guide prevention policies and interventions. OBJECTIVE: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. DESIGN, SETTING, AND PARTICIPANTS: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. EXPOSURES: Firearm ownership and access. MAIN OUTCOMES AND MEASURES: Cause-specific deaths by age, sex, location, and year. RESULTS: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P

Purpose Safe firearm storage practices are associated with a lower risk of self-inflicted injury and death. Whether such practices and relevant beliefs differ between households of adolescents with and without mental illness is unknown. Methods We used survey and administrative data to perform a two-stage cross-sectional study of parents/guardians of adolescents who were 11–17 years, enrolled in a managed care plan in 2004 and living in a household with a firearm. Multivariable Poisson models compared the prevalence of three firearm storage practices between households of adolescents with (depression or bipolar disorder) and without mental illness (no psychiatric or substance use disorder), including whether all firearms were locked, any firearms were loaded, and all firearms were locked and unloaded. We used chi-square tests to compare responses to Likert items assessing beliefs relevant to storage practices between households. Results Adolescents with mental illness were present in 141 (50.5%) of 279 study households. Their mean age was 14.5 years, and 54.8% were male. The mean age of parent/guardian respondents was 47.0 years, and 17.9% were male. Respondents from nearly 70% of households reported that all household firearms were stored locked and unloaded. In unadjusted and adjusted analyses, there were no significant differences in the prevalence of three firearm storage practices or in beliefs relevant to those practices between households of adolescents with and without mental illness. Conclusions These findings add to a growing body of evidence suggesting that firearm storage practices do not differ based on household mental health risk factors for self-harm.

BACKGROUND In the treatment of pediatric traumatic brain injury (TBI), timely treatment of patients can affect the outcome. Our objectives were to examine the treatment process of acute pediatric TBI and the impact of non-value-added time (NVAT) on patient outcomes. METHODS Data for 136 pediatric trauma patients (age < 18 years) with severe TBI from 2 trauma centers in the United States were collected. A process flow and value stream map identified NVATs and their sources in the treatment process. Cluster and regression analysis were used to examine the relationship between NVAT, as a percentage of the patient's length of stay (LOS), and the patient outcome, measured by their corresponding Glasgow outcome scale. RESULTS There were 14 distinct sources of NVAT identified. A regression analysis showed that increased NVAT was associated with less favorable outcomes (relative ratio = 1.015, confidence interval = [1.002-1.029]). Specifically, 1% increase in the NVAT-to-LOS ratio was associated with a 1.5% increase in the chance of a less favorable outcome (i.e., death or vegetative state). CONCLUSION The NVAT has a significant impact on the outcome of pediatric TBI, and every minute spent on performing non-value-added processes can lead to an increase in the likelihood of less favorable outcomes.

Drowning is a global health problem that can be addressed with multiple strategies including utilisation of lifeguards in recreational swim areas. However, few studies have described lifeguard prevention activities. We conducted a retrospective analysis using lifeguard activity data collected in real time with a Computer-Aided-Dispatch (CAD) system to characterise the nature of lifeguard primary and secondary drowning prevention at a popular ocean beach in California. Preventative actions constituted the majority (232 065/423 071; 54.8%) of lifeguard activities, while rescues represented 1.9%. Most preventative actions and rescues occurred during summer months, weekends and afternoons. Statistically significant geographical clusters of preventative actions were identified all over the beach, while rescue clusters were primarily restricted to two sites. Using the most reliable and valid collection system to date, these data show spatial and temporal patterns for ocean lifeguard provision of primary prevention as well as secondary drowning prevention (rescue).

BackgroundSafe firearm storage practices are associated with a lower risk of unintentional and self-inflicted firearm injuries among household members, though many firearms remain unlocked and/or loaded.ObjectivesConduct a preliminary evaluation of a community-based firearm safety intervention and assess participants’ preferences for firearm locking devices and their comfort with potential firearm safety counsellors.Design/MethodsBaseline event and follow-up surveys among adult participants to assess changes in firearm storage practices, including whether all household firearms were stored locked, all were unloaded, all ammunition was locked, and a composite measure assessing whether all firearms were locked and unloaded and all ammunition was stored locked.ResultsA total of 206 out of 415 participants completed both surveys and were included. Nearly 9 in 10 respondents preferred the firearm lock box rather than a trigger lock. At follow-up, a significantly greater proportion reported that all household firearms were locked (+13.7%) and unloaded (+8.5%) and a non-significantly greater proportion reported that all ammunition was locked (+6.3%). A significantly greater proportion reported practising all three safe firearm and ammunition storage practices at follow-up (+12.6%). A majority reported they would becomfortableorvery comfortablediscussing firearm safety with various safety counsellors, though women were less likely to do so than men.ConclusionThis intervention that included distribution of a free, participant-selected locking device improved safe firearm storage practices among participants. Differences in participant preferences for devices and safety counsellors suggest that a ‘one size fits all’ approach may be inadequate in affecting population-level storage practices.

Background Prior studies suggest potential benefit using monitored aerobic exercise to treat youth with persistent concussion symptoms, but these studies have been small. Objectives To explore the safety and potential benefits of a rehabilitative exercise intervention, the Sub-symptom Threshold Exercise Program (SSTEP), for treating youth with persistent concussion symptoms >1 month. Methods We conducted a retrospective cohort study of 83 youth who participated in SSTEP, completing trajectory analysis of concussion symptoms using the symptom subscale of the Sport Concussion Assessment Tool, version 2 (SCAT-2). Results The average age of patients was 14.9+/-2.3 years and 54% were female. Most concussions (76%) were due to sports, the majority from football and girls' soccer, and 55% had a previous concussion. Comorbidity was not uncommon: 14% had history of ADHD and 16% history of depression and/or anxiety. Most patients improved following the intervention, and none reported worsening. Symptoms decreased exponentially following initiation of SSTEP, and trajectory did not differ by duration of symptoms at presentation ( 12 weeks). Conclusions Monitored exercise programs appear to be safe and potentially beneficial for youth with persistent concussive symptoms. Large-scale controlled studies are needed to examine efficacy, ideal timing and duration.

OBJECTIVE Prior studies have suggested that traumatic brain injury may affect cardiac function. Our study aims were to determine the frequency, longitudinal course, and admission risk factors for systolic dysfunction in patients with moderate-severe traumatic brain injury. DESIGN Prospective cohort study. SETTING Level 1 trauma center. MEASUREMENTS Transthoracic echocardiogram within 1 day and over the first week after moderate-severe traumatic brain injury; transthoracic echocardiogram within 1 day after mild traumatic brain injury (comparison group). MEASUREMENTS AND MAIN RESULTS Systolic function was assessed by transthoracic echocardiogram, and systolic dysfunction was defined as fractional shortening less than 25%. Multivariable Poisson regression models examined admission risk factors for systolic dysfunction. Systolic function in 32 patients with isolated moderate-severe traumatic brain injury and 32 patients with isolated mild traumatic brain injury (comparison group) was assessed with transthoracic echocardiogram. Seven (22%) moderate-severe traumatic brain injury and 0 (0%) mild traumatic brain injury patients had systolic dysfunction within the first day after injury (p < 0.01). All patients with early systolic dysfunction recovered in 1 week. Younger age (relative risk, 0.87; 95% CI, 0.79-0.94; for 1 yr increase in age) and lower admission Glasgow Coma Scale score (relative risk, 0.34; 95% CI, 0.20-0.58; for one unit increase in Glasgow Coma Scale) were independently associated with the development of systolic dysfunction among moderate-severe traumatic brain injury patients. CONCLUSIONS Early systolic dysfunction can occur in previously healthy patients with moderate-severe traumatic brain injury, and it is reversible over the first week of hospitalization. Younger age and lower admission Glasgow Coma Scale score are independently associated with the development of systolic dysfunction after moderate-severe traumatic brain injury.

Objective:Each year in the United States, 1.5–2.5 million individuals require hospitalization for an injury. Multiple mental, substance use, and chronic general medical disorders are endemic among injury survivors with and without traumatic brain injury (TBI), yet few studies have assessed the association between the cumulative burden of these conditions and health care outcomes. This study of patients hospitalized for an injury assessed associations between comorbid mental, substance use, and general medical disorders, TBI, and violent events or suicide attempts and the postinjury outcomes of recurrent hospitalization and death.Methods:Recurrent hospitalization and all-cause mortality were examined in this population-based retrospective cohort study. A total of 76,942 patients hospitalized for an injury in Washington State during 2006–2007 were followed for five years. ICD-9-CM codes identified conditions prior to or at the index injury admission. Index admissions related to injuries from firearms, assau...

After the 2014–2015 outbreak of chikungunya virus in the US Virgin Islands, we compared the prevalence of persistent arthralgia among case-patients and controls. Prevalence was higher in case-patients than controls 6 and 12 months after disease onset. Continued vaccine research to prevent acute illness and long-term sequelae is essential.

BACKGROUND Maternal education in a child's early life may directly affect the child's adult cardiometabolic health, but this is difficult to disentangle from biological, social, and behavioral life course processes that are associated with maternal education. These processes may also differ between males and females. METHODS Using data from the National Longitudinal Study of Adolescent to Adult Health (1995-2009) (N = 4,026 females and 3,192 males), we estimated sex-stratified associations between maternal attainment of less than high school (

Author(s): Simonetti, Joseph A.; Simeona, Cassie; Gallagher, Chelsie; Bennett, Elizabeth; Rivara, Frederick; Rowhani-Rahbar, Ali | Abstract: Introduction: Safe firearm storage is associated with a lower risk of firearm-related injury and death. Although providing firearm locking devices is a key component of firearm safety interventions, little is known about the types and characteristics of devices preferred by firearm users or others who make decisions about firearm storage. The aim of this study was to describe preferences for firearm locking devices and device features among firearm safety event participants.Methods: We conducted a cross-sectional survey in the State of Washington in 2016 that assessed participants’ preferences for five firearm locking devices (eg, trigger lock) and seven device features (eg, quick access). We categorized respondents (n=401) as adults in households with 1) all firearms locked, 2) at least one unlocked firearm, and 3) no firearms. We analyzed data in 2017.Results: Device ownership and feature preferences varied substantially but were similar across the three household categories. Of those residing with unlocked firearms, 84% reported they would consider using or definitely use a lock box, whereas 11% reported they would never use a trigger lock. Additionally, of those residing with unlocked firearms, 80% and 89% reported that the ability to lock a firearm while loaded and unlock it quickly were, respectively, “very important” or “absolutely essential.”Conclusion: Participants had differing preferences for firearm locking devices and device features, although preferences were largely similar across households with locked, unlocked, or no firearms. At least eight in ten participants reported “great importance” regarding the ability to lock a firearm while loaded and unlock it quickly, which is likely related to perceptions about the utility of safely stored firearms for household protection. Designing firearm safety interventions to match the needs and preferences of those who make firearm storage decisions may improve their effectiveness.

Importance Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality. Objective The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development–funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic. Evidence Review A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium. Findings Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement. Conclusions and Relevance These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.

Chikungunya virus (CHIKV), an alphavirus that causes fever and severe polyarthralgia, swept through the Americas in 2014 with almost 2 million suspected or confirmed cases reported by April 2016. In this study, we estimate the direct medical costs, cost of lost wages due to absenteeism, and years lived with disability (YLD) associated with the 2014–2015 CHIKV outbreak in the U.S. Virgin Islands (USVI). For this analysis, we used surveillance data from the USVI Department of Health, medical cost data from three public hospitals in USVI, and data from two studies of laboratory-positive cases up to 12 months post illness. On average, employed case-patients missed 9 days of work in the 12 months following their disease onset, which resulted in an estimated cost of $15.5 million. Estimated direct healthcare costs were $2.9 million for the first 2 months and $0.6 million for 3–12 months following the outbreak. The total estimated cost associated with the outbreak ranged from $14.8 to $33.4 million (approximately 1% of gross domestic product), depending on the proportion of the population infected with symptomatic disease, degree of underreporting, and proportion of cases who were employed. The estimated YLDs associated with long-term sequelae from the CHIKV outbreak in the USVI ranged from 599–1,322. These findings highlight the significant economic burden of the recent CHIKV outbreak in the USVI and will aid policy-makers in making informed decisions about prevention and control measures for inevitable, future CHIKV outbreaks., Author summary Chikungunya, a virus carried and transmitted by mosquitoes, causes fever, headache, and severe joint pain in humans that often resolves within 7–10 days. However, a proportion of cases, up to 79% in some outbreaks, report persistent joint pain and chronic inflammatory rheumatism, resulting in decreased quality of life for months to years following initial infection. In 2014, chikungunya virus swept through the Americas, resulting in almost 2 million suspected or confirmed cases reported by April 2016. Previous studies have noted the large resource burden from chikungunya outbreaks, including high healthcare costs, lost wages due to absenteeism, and decreased quality of life for months following infection. Our work aimed to estimate the direct medical costs, cost of lost productivity due to absenteeism, and years lived with disability associated with the chikungunya outbreak in the U.S. Virgin Islands. This information may aid policy-makers in making informed decisions about prevention and control measures for inevitable, future chikungunya outbreaks.

Our objective in this study was to evaluate how well proxy variables for firearm ownership used in county-level studies measure firearm ownership. We applied Bayesian spatial smoothing methods to calculate county-level estimates of household firearm ownership using Behavioral Risk Factor Surveillance System (BRFSS) data (2013–2018). We compared these estimates to four proxies for county-level firearm ownership: the proportion of suicides that were firearm suicides, the average of the proportion of suicides that were firearm suicides and the proportion of homicides that were firearm homicides, gun shops per capita, and federal firearm licenses per capita. U.S. counties for which BRFSS data on household firearm ownership were collected and available for release (n = 304) were included. The median (interquartile range) prevalence of household firearm ownership was 46.6% (37.2%, 56.4%). The per capita rate of federal firearm licenses was most strongly correlated with household firearm ownership (r = 0.70; 95% CI: 0.63, 0.75) followed by the proportion of suicides that were firearm suicides (r = 0.45; 95% CI: 0.36, 0.54). These correlations were stronger among counties with populations of ≥250,000 people. The per capita rate of federal firearm licenses was the best proxy variable for firearm ownership at the county level, however, a better proxy should be identified.