Violent reinjury and mortality among youth seeking emergency department care for assault-related injury: a 2-year prospective cohort study

Emergency Department Usage Patterns Among Pediatric Victims of Gun Violence and Physical Assault

OBJECTIVE

Violent injuries are a common reason for pediatric emergency department (ED) visits, with gun violence being the leading cause of violent death among children. The objective of this study was to assess for patterns of pediatric ED usage that are associated with future ED visits for violent injuries.

METHODS

This case-control study included youths aged 6 to 19 years who presented to a pediatric ED over a 3-year period due to a physical assault (PA) or their first known gunshot wound (GSW). We compared them with age-, race-, and sex-matched youths presenting for nonviolent medical complaints. All previous ED visits were coded as (1) injuries due to a previous PA, (2) mental/behavioral health visits, (3) sexual/reproductive health visits, (4) sexual assault, or (5) concerns for child abuse. We used multivariate logistic regression to identify patterns of previous ED usage associated with future ED visits for injuries related to PA and/or GSW.

RESULTS

The PA and GSW groups used the ED for previous PAs, mental/behavioral health, sexual/reproductive health, sexual assault, and/or child abuse concerns on average 4 to 8 times as often as the control group. Previous ED visits for mental/behavioral health (odds ratio [OR] 5), sexual/reproductive health (OR 3), sexual assault (OR 9), and prior PA (OR 8) were predictive of a future ED visit for PA. Male sex (OR 6) and previous ED visits for PA (OR 5) were predictive of a future ED visit for GSW. Two percent of the PA group and 9% of the GSW group returned to the ED with a subsequent GSW in the following 16 to 40 months.

CONCLUSIONS

Emergency department visits due to interpersonal violence, mental/behavioral health, sexual/reproductive health, and sexual assault are associated with recurrent ED visits for violent injuries. Awareness of patterns of ED usage may aid in identifying patients at high risk for violence and increase opportunities for preventative interventions.

Systematic Screening and Assessment of Hospital-Based Youth Violence Prevention Programs

Youth violence is a preventable public health issue. Few hospital-based programs intentionally focus on youth violence prevention. This project aimed to describe the Systematic Screening and Assessment (SSA) methodology used to identify existing hospital-based youth violence prevention (HBYVP) programs ready for future rigorous evaluation. To identify promising HBYVP programs currently in use and assess readiness for evaluation, data from the 2017 American Hospital Association (AHA) Annual Survey of Hospitals was used to identify hospitals with Level I-III trauma centers with reported HBYVP programs. Information for each program was gathered via environmental scan and key informant interviews. A total of 383 hospital-based violence prevention programs were identified. Two review panels were conducted with violence prevention experts to identify characteristics of programs suitable for an evaluability assessment (EA). Fifteen programs focused on youth (10-24 years old) and were identified to be promising and evaluable. Three of the 15 programs were determined to have the infrastructure and readiness necessary for rigorous evaluation. Lessons learned and best practices for SSA project success included use of streamlined outreach efforts that provide program staff with informative and culturally tailored project materials outlining information about the problem, project goals, proposed SSA activities, and altruistic benefit to the community at the initial point of contact. In addition, success of review panels was attributed to use of software to streamline panelist review processes and use of evaluation and data analysis subject matter experts to serve as panel facilitators. Communities experiencing high youth violence burden and hospitals serving these communities can improve health outcomes among youth by implementing and evaluating tailored HBYVP programs.

Experiencing violence and other predictors of within-person same-day use of multiple substances in youth: a longitudinal study in emergency settings

Background: Although experiencing violence is a risk factor for substance use among youth, its association with same-day use of multiple substances (a form of polysubstance use) and mitigating factors is less well understood.Objectives: To identify whether prosocial factors modified the effect of experiencing violence on the frequency of same-day use, and examine gender-specific risk/protective factors for same-day use.Methods: We analyzed longitudinal data from a cohort of youth who use drugs aged 14-24 (n = 599; 58% male) presenting to an urban emergency department between 2009-2011 and assessed biannually for two years. Using Poisson-generalized linear models with person-level fixed effects, we estimated within-person associations between self-reported experiencing violence and same-day use and analyzed gender and peer/parent support as effect modifiers. We adjusted for negative peer influence, parental drug and alcohol use, family conflict, anxiety and depression, and age.Results: Overall, positive parental support corresponded to lower rates of same-day use (rate ratio [RR]:0.93, 95% CI:0.87-0.99) and experiencing violence was associated with higher rates of same-day use (RR:1.25, 95% CI:1.10-1.41). Violence exposure was a risk factor among males (RR:1.42, 95% CI:1.21-1.66), while negative peer influences and parental substance use were risk factors among females (RR:1.63, 95% CI:1.36-1.97 and RR:1.58, 95% CI:1.35-1.83, respectively). Positive peer support reduced the association between violence exposure and same-day use among males (RR:0.69, 95% CI:0.57-0.84, p < .05).Conclusions: Tailored interventions may address gender differences in coping with experiencing violence - including interventions that promote parental support among males and reduce influence from parental substance use among females.

Association Between Child Maltreatment and Aggression in Chinese Early Adolescents: The Mediating Role of Irritability

Child maltreatment (CM) is a major global public health issue, and a strong association exists between CM and aggression. However, the underlying mechanism of this association has not been understood to date. The objective of this study was to explore the mediating role of irritability in the association between CM and aggression in Chinese early adolescents. A cross-sectional study was conducted using a self-report questionnaire to evaluate the levels of CM, aggression, and irritability in 5,724 middle school students from the Anhui Province, China. Structural equation modeling was used to test the hypothesis of the mediating effect of irritability on the relationship between CM and aggression. We further investigated gender differences in this association using multiple group analyses. CM was positively related to both irritability and aggression, and irritability was positively associated with aggression (p < .01). The mediating effects of irritability between CM and aggression were significant (β = .107, 95% confidence intervals [CI]: 0.077-0.133, p < .05). Males had a higher indirect effect size of the pathway from CM to aggression via irritability compared with females. Overall, irritability was a crucial mediator in the relationship between CM and aggression in Chinese adolescents, and males were more prone to engage in aggression compared with females through the pathway of irritability. Therefore, early irritability characteristics should be carefully monitored in adolescents, and they should be provided adequate support to acquire critical emotion regulation skills.

Assault Injury and Community Violence

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

A remote brief intervention plus social media messaging for cannabis use among emerging adults: A pilot randomized controlled trial in emergency department patients

INTRODUCTION

Interventions addressing cannabis use among emerging adults (ages 18-25) are currently needed to prevent negative outcomes. Emergency Department (ED) visits provide an opportunity to initiate interventions. In this pilot study, we created a brief intervention (BI), extended with private social media messaging for emerging adult ED patients who use cannabis regularly. Study aims were to examine intervention feasibility, acceptability, and descriptive outcomes.

METHODS

We recruited and randomized N = 58 emerging adults (M age 21.5 years, 65.5% female) who used cannabis from an ED in-person and remotely after their ED visit (given COVID-19 restrictions). Participants randomized to the intervention (N = 30) received a Motivational Interviewing-based BI and 4 weeks of health coaching via private social media; control participants received a resource brochure and entertaining social media messaging. Follow-ups occurred at 1-month and 3-months.

RESULTS

Most intervention participants liked the BI (95.8%), found it helpful to discuss cannabis use in the BI (91.7%), and liked interacting with coaches on social media (86.3%). Social media content (e.g., video clips, images/still pictures/memes) were highly rated. Descriptively, the intervention group showed theory-consistent changes in importance of and intentions to change cannabis (increases vs. decrease/stability in control group), whereas findings for cannabis consumption/consequences were mixed.

CONCLUSIONS

This BI paired with social media messaging was acceptable in a sample of emerging adults from an ED who used cannabis regularly. Despite feasibility challenges due to COVID-19, this intervention warrants future investigation with a larger sample and longer follow-up period, with attention to the changing cannabis landscape when measuring outcomes.

The Ethics of Discharge Planning After Violent Injury

INTRODUCTION

Victims of violence (VoV) are at disproportionate risk for future violence, making consideration of patient safety by Emergency Medicine (EM) physicians and Trauma Surgeons (TS) essential when discharge planning (DP) for VoV. Practice patterns and ethical perspectives in DP for VoV, and their respective scenario- and specialty-specific variations, are unknown.

METHODS

We surveyed 118 EM and 37 TS physicians at a level 1 trauma center. Three clinical scenarios were presented (intimate partner violence, elder abuse, gun violence), each followed by four questions assessing practices and ethical dilemmas in DP. Responses were compared using Chi-Square testing.

RESULTS

Response rate was 51.6%. EM physicians more frequently supported patient autonomy to proceed with a potentially unsafe discharge plan after an episode of Intimate Partner Violence (P = .013) and believed that admission could facilitate change in the victim's social situation after an episode of Elder Abuse (P = .026). TS physicians were more likely to offer social admission, providing additional time to navigate safe discharge planning (P = .003), less likely to see social admission as an inappropriate use of limited resources (P = .030) and less likely to support patient autonomy to proceed with a potentially unsafe discharge (P = .003) after gun-related violence.

CONCLUSION

There appears to exist scenario- and specialty-specific variability in the practice patterns and ethical perspectives of EM and TS physicians when discharge planning for victims of violence. These findings highlight the need for further evaluation of specific factors underlying variability by situation and specialty, and their implications for patient-centered outcomes.

Implementation of an emerging hospital-based violence intervention program: a multimethod study

Background

Individuals who experience assaultive firearm injury are at elevated risk for violent reinjury and multiple negative physical and psychological health outcomes. Hospital-based violence intervention programs (HVIPs) may improve patient outcomes through intensive, community-based case management.

Methods

We conducted a multimethod evaluation of an emerging HVIP at a large trauma center using the RE-AIM framework. We assessed recruitment, violent reinjury outcomes, and service provision from 2020 to 2022. Semistructured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes from the data. We also conducted clinician surveys to assess awareness and referral patterns.

Results

Of the 319 HVIP-eligible individuals who presented with non-fatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 to 5.2; p=0.01). Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Fear of disclosure to police was cited as a key barrier to enrollment. For the Effectiveness domain, enrollment was not associated with reinjury (OR 0.70, 95% CI 0.16 to 3.1). Participants identified key areas of focus where needs were not met including housing and mental health. Limited awareness of HVIP services was a barrier to Adoption. Participants described strengths of Implementation, highlighting the deep relationships built between clients and administrators. For the long-term Maintenance of the program, both clinicians and HVIP clients reported that there is a need for HVIP services for individuals who experience violent injury.

Conclusions

Credible messengers facilitate engagement with potential participants, whereas concerns around police involvement is an important barrier. Inpatient admission provides an opportunity to engage patients and may facilitate recruitment. HVIPs may benefit from increased program intensity.

Level of evidence

IV.

Hospital-based violence prevention programmes in South Wales Emergency Departments: A process evaluation protocol

BACKGROUND

Addressing violence related harm is a global public health priority. While violence is primarily managed in the criminal justice system, healthcare supports and manages those injured by violence. Emergency Departments (EDs), the primary destination for those seriously injured, have emerged as a candidate location for violence prevention initiatives. There is limited evaluation of ED-based violence prevention, and a lack of guidance for the implementation and delivery of them. Nurse-led Violence Prevention Teams (VPTs) have been developed and implemented in two EDs in Wales, UK. This protocol describes methods used in the process evaluation of these VPTs.

AIM

To understand how VPTs function, how they were implemented, and mechanisms of impact, as well as the exploration of wider contextual factors influencing their function.

METHODS

Adopting a critical realist approach and informed by the Medical Research Council (MRC) guidance for process evaluations, the process evaluation will employ qualitative methods to collect and analyse data: a scoping review of evidence of effectiveness that considers the causal mechanisms underpinning violence; a documentary analysis to determine operational considerations concerning the development, implementation and delivery of the VPTs; a descriptive analysis of routine ED data to characterise the prevalence of violence-related attendances in each ED; interviews with professional stakeholders (N = 60) from the violence prevention ecologies in which the VPTs are embedded.

DISCUSSION

This protocol outlines a process evaluation of a novel, nurse led violence prevention intervention. Findings will be used to inform policy makers' decision making on whether and how VPTs should be used in practice in other EDs across the UK, and the extent that a single operational model should be adjusted to address the local characteristic of violence. To the authors knowledge, this is the first process evaluation of a UK-based, nurse led Emergency Department Violence Prevention Team.

TRIAL REGISTRATION

Protocol registration ISRCTN: 15286575. Registered 13th March, 2023.

Engagement with a youth violence intervention programme is associated with lower re-attendance after violent injury: A UK major trauma network observational study

The hospital based Redthread Youth Violence Intervention Programme (YVIP) utilises experienced youth workers to support 11-24 year olds following an episode of violent injury, assault or exploitation who present to the Emergency Department (ED) at the East Midlands Major Trauma Centre (MTC), Nottingham, UK. The YVIP aims to promote personal change with the aim of reducing the incidence of further similar events. We conducted a retrospective, observational, cohort study to examine the association between engagement with the YVIP and re-attendance rates to the ED following a referral to Redthread. We also examined factors associated with engagement with the full YVIP. We found that 573 eligible individuals were referred to the YVIP over two years. Assault with body parts 34.9% (n = 200) or a bladed object 29.8% (n = 171) were the commonest reason for referral. A prior event rate ratio (PERR) analysis was used to compare rates of attendance between those who did and did not engage with the full YVIP. Engagement was associated with a reduction in re-attendances of 51% compared to those who did not engage (PERR 0.49 [95% 0.28-0.64]). A previous attendance to the ED by an individual positively predicted engagement. (OR 2.82 [95% CI 1.07-7.42], P = 0.035). A weekend attendance (OR 0.26 [0.15-0.44], P<0.001) and a phone call approach (OR 0.25 [0.14-0.47], P = 0.001), rather than a face-to-face approach by a Redthread worker, negatively impacted engagement. In conclusion, assaults with or without a weapon contributed to a significant proportion of attendances among this age group. The Redthread YVIP was associated with reduced rates of re-attendance to the East Midlands MTC among young persons who engaged with the full programme.

The gap between hospital-based violence intervention services and client needs: A systematic review

BACKGROUND

Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs reduce reinjury. It is unclear how well they meet clients' reported needs. This systematic review aimed to quantify how well hospital-based violence intervention program services addressed clients' reported needs.

METHODS

Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing hospital-based violence intervention programs services and intentional injury survivors' needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, hospital-based violence intervention program services, and client needs assessments before and after receiving hospital-based violence intervention program services.

RESULTS

Of the 3,339 citations identified, 13 articles were selected for inclusion. Hospital-based violence intervention programs clients' most reported needs included mental health (10 studies), employment (7), and education (5) before receiving hospital-based violence intervention programs services. Only 4 studies conducted quantitative client needs assessments before and after receiving hospital-based violence intervention program services. All 4 studies were able to meet at least 50% of each of the clients' reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time-intensive long-term needs were least met, including employment 60% to 86% of clients, education 47% to 73%, and housing 50% to 71%.

CONCLUSION

Few hospital-based violence intervention programs studies considered clients' reported needs. Employment, education, and housing must be a stronger focus of hospital-based violence intervention programs.

Characteristics and neighborhood-level opportunity of assault-injured children in Milwaukee

BACKGROUND

Multiple studies have explored demographic characteristics and social determinants of health in relation to the risk of pediatric assault-related injuries and reinjury. However, few have explored protective factors. The Child Opportunity Index (COI) uses neighborhood-level indicators to measure 'opportunity' based on factors such as education, social environment, and economic resources. We hypothesized that higher 'opportunity' would be associated with less risk of reinjury in assault-injured youth.

METHODS

This was a single-institution, retrospective study at a Level 1 Pediatric Trauma Center. Trauma registry and electronic medical record data were queried for children ≤ 18 years old with assault-related injuries from 1/1/2016 to 5/31/2021. Reinjured children, defined as any child who sustained more than one assault injury, were compared to non-reinjured children. Area Deprivation Index (ADI), a marker of socioeconomic status, and COI were determined through census block and tract data, respectively. A post-hoc analysis examined COI between all assault-injured children, unintentionally injured children, and a state-based normative cohort representative of non-injured children.

RESULTS

There were 55,862 traumatic injury encounters during the study period. Of those, 1224 (2.3%) assault injured children were identified, with 52 (4.2%) reinjured children and 1172 (95.8%) non-reinjured children. Reinjured children were significantly more likely to be older (median age 15.0 [IQR 13.8-17.0] vs. median age 14.0 [IQR 8.8-16.0], p < 0.001) and female (55.8% vs. 37.5%, p = 0.01) than non-reinjured children. COI was not associated with reinjury. There were also no significant differences in race, ethnicity, insurance status, ADI, or mechanism and severity of injury between cohorts. Post-hoc analysis revealed that assault-injured children were more likely to live in areas of lower COI than the other cohorts.

CONCLUSIONS

Compared to children who sustained only one assault during the study period, children who experienced more than one assault were more likely to be older and female. Furthermore, living in an area with more or less opportunity did not influence the risk of reinjury. However, all assault-injured children were more likely to live in areas of lower COI compared to unintentionally injured and a state-based normative cohort. Identification of factors on a social or environmental level that leads to assaultive injury warrants further exploration.

Implementing a hospital-based violence intervention program for assault-injured youth: implications for social work practice

Youth in the U.S. experience a high rate of assault-related injuries resulting in physical, psychological and social sequelae that require a wide range of services after discharge from the hospital. Hospital-based violence intervention programs (HVIP's) have been developed to engage youth in services designed to reduce the incidence of violent injury in young people. HVIP's combine the efforts of medical staff with community-based partners to provide trauma-informed care to violently-injured people and have been found to be a cost-effective means to reduce re-injury rates and improve social and behavioral health outcomes. Few studies have explored the organizational and community level factors that impact implementation of these important and complex interventions. The objective of this study was to develop an in-depth understanding of the factors that impact HVIP implementation from the perspectives of 41 stakeholders through qualitative interviews. Thematic analysis generated three themes that included the importance of integrated, collaborative care, the need for providers who can perform multiple service roles and deploy a range of skills, and the importance of engaging clients through extended contact. In this article we explore these themes and their implications for healthcare social work.

History repeats itself: Impact of mental illness on violent reinjury and hospital reencounters among female victims of interpersonal violence

BACKGROUND

Violence-related reinjury impacts both patients and health care systems. Mental illness (MI) is prevalent among violently injured individuals. The relationship between preexisting MI and violent reinjury among women has not been fully characterized. Our objective was to determine if risk of hospital reencounter-violent reinjury and all-cause-was associated with preexisting MI at time of index injury among female victims of violence.

METHODS

All females (15-100 + years) presenting to a level I trauma center with violent injury (2002-2019) surviving to discharge were included (N = 1,056). Exposure was presence of preexisting MI. The primary outcome was hospital reencounters for violent reinjury and all-cause within one year (through 2020). The secondary outcome was the development of a new MI within one year of index injury. Odds of reencounter and development of new MI for those with and without preexisting MI were compared with multivariable logistic regression, stratified for interaction when appropriate.

RESULTS

There were 404 women (38%) with preexisting MI at time of index injury. Approximately 11% of patients with preexisting MI experienced violent reinjury compared to 5% of those without within 1 year ( p < 0.001). Specifically, those with MI in the absence of concomitant substance use had more than three times the odds of violent reinjury (adjusted Odds Ratio, 3.52 (1.57, 7.93); p = 0.002). Of those with preexisting MI, 64% had at least one reencounter for any reason compared to 46% of those without ( p < 0.001 ) . Odds of all-cause reencounter for those with preexisting MI were nearly twice of those without (adjusted Odds Ratio, 1.81 [1.36, 2.42]; p < 0.0001).

CONCLUSION

Among female victims of violence, preexisting MI is associated with a significantly increased risk of hospital reencounter and violent reinjury within the first year after index injury. Recognition of this vulnerable population and improved efforts at addressing MI in trauma patients is critical to ongoing prevention efforts to reduce violent reinjury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Community-Level Social Vulnerability and Patterns of Adolescent Injury

Objective

To describe adolescent injuries by the community-level social vulnerability, focusing on injuries related to interpersonal violence.

Background

The Center for Disease Control and Prevention's social vulnerability index (SVI) is a tool used to characterize community-level vulnerability.

Methods

Injured adolescent trauma patients (13-17 years old) cared for at a large Level I trauma center over a 10-year period were identified. Injuries were classified by intent as either intentional or unintentional. Census tract level SVI was calculated by composite score and for 4 subindex scores (socioeconomic, household composition/disability, minority/language, housing type/transportation). Patients were stratified by SVI quartile with the lowest quartile designated as low-, the middle two quartiles as average-, and the highest quartile as high vulnerability. The primary outcome was odds of intentional injury. Demographic and injury characteristics were compared by SVI and intent. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI.

Results

A total of 1993 injured adolescent patients (1676 unintentional and 317 intentional) were included. The composite SVI was higher in the intentional injury cohort (mean, SD: 66.7, 27.8 vs. 50.5, 30.2; P < 0.001) as was each subindex SVI. The high SVI cohort comprised 31% of the study population, 49% of intentional injuries, and 51% of deaths. The high SVI cohort had significantly increased unadjusted (odds ratio, 4.5; 95% confidence interval, 3.0-6.6) and adjusted (odds ratio, 1.8; 95% confidence interval, 1.6-2.8) odds of intentional injury.

Conclusions

Adolescents living in the highest SVI areas experience significantly higher odds of intentional injury. SVI and SVI subindex details may provide direction for community-level interventions to decrease the impact of violent injury among adolescents.

Adolescent Violent Delinquency Associated With Increased Emergency Department Usage in Young Adulthood

Limited research has examined the extent to which adolescent delinquency predicts healthcare usage in young adulthood, including emergency department (ED) visits. This study used data from 3,310 adolescents (52.05% female; mean age at Wave I = 16.04 years) from the sibling subsample of the National Longitudinal Study of Adolescent to Adult Health (Add Health). We examined whether adolescent delinquency at Wave I predicted ED visits at Wave III using sibling fixed effects models to adjust estimates for within-family unobserved heterogeneity. Increased violent, but not nonviolent, delinquency predicted a higher number of ED visits in early adulthood in the sibling fixed effects models. To our knowledge, this is the first study to examine the relationship between delinquency and ED usage using a sibling fixed effects design. Findings demonstrate that violent adolescent delinquency may increase healthcare usage and suggest the potential role of healthcare providers in improving outcomes for delinquent youth.

A Technology-Enhanced Intervention for Violence and Substance Use Prevention Among Young Black Men: Protocol for Adaptation and Pilot Testing

BACKGROUND

Black boys and men from disinvested communities are disproportionately survivors and perpetrators of youth violence. Those presenting to emergency departments with firearm-related injuries also report recent substance use. However, young Black men face several critical individual and systemic barriers to accessing trauma-focused prevention programs. These barriers contribute to service avoidance, the exacerbation of violence recidivism, substance use relapse, and a revolving-door approach to prevention. In addition, young Black men are known to be digital natives. Therefore, technology-enhanced interventions offer a pragmatic and promising opportunity to mitigate these barriers, provide vital life skills for self-led behavior change, and boost service engagement with vital community resources.

OBJECTIVE

The study aims to systematically adapt and pilot-test Boosting Violence-Related Outcomes Using Technology for Empowerment, Risk Reduction, and Life Skills Preparation in Youth Based on Acceptance and Commitment Therapy (BrotherlyACT), a culturally congruent, trauma-focused digital psychoeducational and service-engagement tool tailored to young Black men aged 15-24 years. BrotherlyACT will incorporate microlearning modules, interactive safety planning tools for risk assessment, goal-setting, mindfulness practice, and a service-engagement conversational agent or chatbot to connect young Black men to relevant services.

METHODS

The development of BrotherlyACT will occur in 3 phases. In phase 1, we will qualitatively investigate barriers and facilitators influencing young Black men's willingness to use violence and substance use prevention services with 15-30 young Black men (aged 15-24 years) who report perpetrating violence and substance use in the past year and 10 service providers (aged >18 years; any gender; including health care providers, street outreach workers, social workers, violence interrupters, community advocates, and school staff). Both groups will be recruited from community and pediatric emergency settings. In phase 2, a steering group of topic experts (n=3-5) and a youth and community advisory board comprising young Black men (n=8-12) and service providers (n=5-10) will be involved in participatory design, alpha testing, and beta testing sessions to develop, refine, and adapt BrotherlyACT based on an existing skills-based program (Achieving Change Through Values-Based Behavior). We will use user-centered design principles and the Assessment, Decision, Administration, Production, Topical, Experts, Integration, Training, and Testing framework to guide this adaptation process (phase 2). In phase 3, a total of 60 young Black men will pilot-test the adapted BrotherlyACT over 10 weeks in a single-group, pretest-posttest design to determine its feasibility and implementation outcomes.

RESULTS

Phase 1 data collection began in September 2021. Phases 2 and 3 are scheduled to start in June 2023 and end in September 2024.

CONCLUSIONS

The development and testing of BrotherlyACT is a crucial first step in expanding an evidence-based psychoeducational and service-mediating intervention for young Black men involved in violence. This colocation of services shifts the current prevention strategy from telling them why to change to teaching them how.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43842.

Challenges, Successes, and the Future of Firearm Injury Prevention

Policy Points Firearm injury is a leading cause of death in the United States, with fatality rates increasing 34.9% over the past decade (2010-2020). Firearm injury is preventable through multifaceted evidence-based approaches. Reviewing past challenges and successes in the field of firearm injury prevention can highlight the future directions needed in the field. Adequate funding, rigorous and comprehensive data availability and access, larger pools of diverse and scientifically trained researchers and practitioners, robust evidence-based programming and policy implementation, and a reduction in stigma, polarization, and politicization of the science are all needed to move the field forward.

A multicenter, citywide report on recurrent violent injury

INTRODUCTION

The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts.

METHODS

A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission.

RESULTS

The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate.

CONCLUSION

The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.

Emergency Department-Attended Injuries Resulting from School-Based Violence in Baltimore Adolescents, 2019-2020

BACKGROUND

Our objective is to describe violence-related injuries to early adolescents that occurred at school, resulting in emergency department (ED) evaluation.

METHODS

This retrospective cohort study at an urban academic pediatric ED in Baltimore, MD, identified patients 10-15 years old who presented with an injury from intentional, interpersonal violence that occurred at school between January 2019-December 2020. Descriptive statistics were used to summarize patient and event characteristics.

RESULTS

Of 819 youth 10-15 years of age evaluated for a violence-related injury, school was the location in 115 cases (14.0%). All events occurred prior to the statewide stay at home order (March 30, 2020). School-injured youth had a mean age of 12.7 ± 1.7 years and were predominantly male (64.3%). Of the 115 cases, 75 (65.2%) involved an altercation with a peer, 26 (22.6%) involved a teacher or school staff, 6 (5.2%) involved a family member, 1 (0.9%) involved police, 6 (5.2%) involved an unknown party, and 1 (0.9%) involved an unrelated but known adult. All injured youth were discharged from the ED.

CONCLUSIONS

School-based violence is a well-recognized cause of traumatic injuries to adolescents and may involve peers, teachers, or school staff.

Epidemiology of Injuries to Early Adolescents from Family Violence Evaluated in an Urban Pediatric Emergency Department

BACKGROUND

Exposure to family violence during childhood and adolescence increases the risk for experiencing or perpetrating future violence. Social distancing protocols combined with reduction in access to youth/family services during the COVID-19 pandemic may have intensified the risk of exposure to familial violence.

OBJECTIVES

This study describes the epidemiology of violence-related injuries to 10- to 15-year-old children from family violence, including child maltreatment and physical fighting, resulting in emergency department (ED) evaluation.

METHODS

This retrospective cohort study located in an urban academic pediatric ED in the mid-Atlantic region is a review of electronic medical records between January 2019 and March 2020 (prepandemic period) and March to December 2020 (pandemic period). This review focused on visits for youth aged 10 to 15 years who presented for evaluation of an injury due to a violent event involving a family member. Demographic and clinical data were abstracted, including circumstances of the event. Descriptive statistics were used to summarize data and compare prepandemic to postpandemic proportions.

RESULTS

Of 819 youth aged 10 to 15 years evaluated for a violence-related injury, 448 (54.7%) involved a family member. Of these, most involved parents/guardians, 343 (76.6%), and occurred at home (83.9%). Most patients were girls (54.0%), Black/African American (84.4%), and were enrolled in a public insurance plan (71.2%). Most youth were transported to the hospital by police (66.7%). Overall, alcohol, drugs, and weapons were involved in 10.0%, 6.5%, and 10.7% of events, respectively, and their involvement significantly increased during the pandemic period to 18.8%, 14.9%, and 23.8% ( P < 0.001). Most patients (98.7%) were discharged from the ED.

CONCLUSIONS

More than half of violence-related injuries treated in the ED in this population resulted from family violence. Family violence is a prevalent and possibly underrecognized cause of injuries during adolescence. Further research should explore the potential of the ED as a setting for preventive interventions.

Violent Injury as a Predictor of Subsequent Assault-Related Emergency Department Visits Among Adolescents

PURPOSE

To measure the risk of a subsequent assault-related emergency department (ED) visit in assault injured adolescents as compared to those who initially presented for non-assault related injuries.

METHODS

This was a historical cohort study of youth (ages 10-18 years) seen at two pediatric EDs between 2016 and 2019. Participants were included if their visit had an International Classification of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and then used survival analysis to compare time to subsequent ED visit with an assault-related injury between study and comparison groups.

RESULTS

A total of 6125 adolescents met inclusion criteria (Assault: n = 2782, 45.4%; MVC: n = 1834, 29.9%; Sports n = 1509, 24.6%). The overall rate per 100 person years of a subsequent assault-related ED visit was 5.6 (n = 344). Patients who initially presented with an assault-related injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier time to event analysis found that patients in the assault injury group have a higher probability of a subsequent ED visit for an assault-related injury compared to patients in the MVC injury group (adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42]).

CONCLUSIONS

Adolescents injured by assault are more likely to return to the ED for a subsequent assault-related injury compared to adolescents who initially present with non-assault-related injuries.

Emergency department visit patterns in the recently discharged, violently injured patient: Retrospective cohort review

BACKGROUND

Analysis of the costs associated with emergency department (ED) visits after discharge for violent injury could highlight subgroups for the development of cost-effective interventions to support healing and prevent treatment failures in violently injured patients.

METHODS

A retrospective cohort review was conducted of all patients with return ED visits within 90 days of discharge after treatment for a violent injury occurring between July 1, 2016, and June 30, 2018. Hospital costs were calculated for each incidence and analyzed against demographic and injury type variables to identify trends.

RESULTS

218 return ED visits were identified. Hospital costs showed a high frequency of low-cost visits. For more complex visits, distinct cost patterns were observed for Black and LatinX males compared to White males as a function of age.

CONCLUSIONS

Analysis of hospital cost per visit identified trends among different subgroups. Underlying etiologies presumably vary between groups, but hypothesis-driven further investigation and needs assessment is required. Understanding the driving forces behind these cost trends may aid in developing effective interventions.

Interpersonal violence affecting the pediatric population: Patterns of injury and recidivism

PURPOSE

We aim to describe interpersonal violence-related injury patterns in the pediatric trauma population and to identify predictors of recidivism.

METHODS

In this retrospective analysis from a single institution, we included pediatric patients (≤17 years) treated (2006-2020) for traumatic injury related to interpersonal violence (IPV). Patient characteristics were compared among mechanism types and between recidivists and non recidivists using two sample t-tests, Wilcoxon rank-sum tests, and Pearson's chi-squared. Multivariate analysis was performed using logistic regression to identify predictors of repeat injury.

RESULTS

We identified 635 pediatric patients who sustained injuries owning to IPV: firearm (N = 266), assault (stab/blunt; N = 243), and abuse (N = 126). The average age of the firearm, assault, and abuse groups was 15.5, 14.7, and 1.1 years (SD = 2.2, 3.4, 2.4 years), respectively. Majority of the overall cohort was male (77.5%) and publicly- or un insured (67.8%), with 28.0% being Black. Of the 489 firearm and assault patients who survived the first injury, 30 (6.1%) had repeat injury owning to IPV requiring treatment at our center with a median time of 40 months (IQR 17-62 months) between first and second injury. The majority of recidivists (83.3%) were victims of gun violence whereas the distribution between assault and firearm in the non recidivists was more even at 51 and 49%, respectively (p < 0.001). Eighteen (60.0%) of the recidivist patients had the same mechanism between the first and second injury. In the logistic regression analysis, Black race and firearm injury were associated with greater than 3-fold higher likelihood of repeat injury compared to white race after adjusting for age, sex, insurance, and child opportunity index.

CONCLUSIONS

We found that survivors of firearm injuries and assault comprise a vulnerable patient cohort at risk for repeat injury, and Black race is an independent predictor of repeat injury owning to IPV. These findings provide guidance for developing violence prevention programs.

TYPE OF STUDY

Retrospective Comparative Study LEVEL OF EVIDENCE: Level III.

Understanding factors associated with firearm possession: Examining differences between male and female adolescents and emerging adults seeking emergency department care

Firearm possession increases the likelihood of hospital visits among adolescents and emerging adults for both males and females. To better inform prevention practices, we examine data among adolescents and emerging adults (A/EAs; ages 16 to 29) presenting to an urban emergency department for any reason to understand the differences in firearm possession between males and females (N = 1312; 29.6% male; 50.5% Black). Regression identified firearm possession correlates, such as male sex (AOR = 2.26), firearm attitudes (AOR = 1.23), peer firearm possession (AOR = 9.84), and community violence exposure (AOR = 1.02). When stratified by sex (e.g., male vs female), regression results yielded differences in correlates for firearm possession: in males, peer firearm possession (AOR = 8.96) were significant, and in females, firearm attitudes (AOR = 1.33) and peer firearm possession (AOR = 11.24) were significant. An interaction between sex and firearm attitudes demonstrated that firearm attitudes were differentially associated with firearm possession between female and male A/EAs (AOR = 1.28). Overall, we found that females are more likely to endorse retaliatory firearm attitudes, and both males and females are highly influenced by their perception of peer firearm possession. These results help inform prevention strategies across multiple settings, especially for hospital-based violence interventions, and suggest that tailored approaches addressing differences between male and female A/EAs are appropriate when addressing firearm violence and injury risk among A/EAs.

Firearm safety counseling among caregivers of high-school age teens: Results from a National Survey

Firearms are the leading cause of death for high-school age teens. To inform prevention efforts, we characterize the prevalence of healthcare provider (HCP) counseling of caregivers of teens around firearm safety, safety conversation elements, and caregiver receptivity towards counseling. A cross-sectional web survey (6/24/2020-7/22/2020) was conducted among caregivers (n = 2924) of teens (age:14-18). Weights were applied to generate nationally representative estimates. Bivariate analyses and multivariate regressions were examined. Among respondents, 56.0% were women, 75.1% were non-Hispanic White, and mean (SD) age was 47.4. Firearm safety was the least discussed topic among caregivers reporting their teen received HCP preventative counseling (14.9%). For caregivers receiving counseling, the most common issues discussed were household firearms screening (75.7%); storing firearms locked (66.8%); and storing firearms unloaded (53.0%). Only 24.6% of caregivers indicated firearm safety was an important issue for teen HCPs to discuss and only 21.9% trusted teen HCPs to counsel about firearm safety. Female caregivers (aOR = 1.86;95%CI = 1.25-2.78), those trusting their teen's HCP to counsel on firearm safety (aOR = 9.63;95%CI = 6.37-14.56), and those who received teen HCP firearm safety counseling (aOR = 5.14;95%CI = 3.02-8.72) were more likely to favor firearm safety counseling. Caregivers of teens with prior firearm safety training (aOR = 0.50;95%CI = 0.31-0.80) were less likely to agree that firearm safety was an important preventative health topic. In conclusion, few caregivers receive preventive counseling on firearm safety from their teen's HCP, with trust a key barrier to effective intervention delivery. Future research, in addition to understanding barriers and establishing effective strategies to increase safety practices, should focus on increasing provider counseling competency.

Documentation of Firearm Safety Screening During Emergency Department Visits for Assault-Related Injury

Assault-injured youth have an increased risk of future violence. Identifying firearm access among youth in the emergency department (ED) creates an opportunity for interventions aimed at reducing future violent events. We performed this study to determine the extent to which children with assault-related injuries are screened for access to firearms in the ED. We performed a retrospective chart review of all medical records from adolescent ED visits to an academic, tertiary care pediatric hospital in Washington DC with ICD-10 codes related to assault in a 3-month period. We found that among 252 assault-related encounters, none had any documentation of firearm access in the provider note, social work note, or psychiatry consultant note. Therefore, we concluded that firearm access screening is rarely documented in ED visits among patients who present for an assault, highlighting an important missed opportunity for firearm access screening among this high-risk group.

A phenomenological study identifying facilitators and barriers to Black and Latinx youth's engagement in hospital-based violence intervention programs

Black and Latinx youth are disproportionately affected by violence in the United States. Hospital-based violence intervention programs (HVIPs) have emerged as an effective response to this epidemic; however, participation rates remain low. This study aimed to identify facilitators and barriers to recruitment and engagement amongst black and Latinx youth from the perspective of HVIP staff. Employing a phenomenological approach, a purposive sample of key informants was recruited. Focus groups and semi-structured interviews lasting approximately 90 min were conducted with representatives (N = 12) from five HVIPs in U.S. cities across the Midwest and Northeast, making up 15% of all HVIPs in the United States. Each interview was recorded and transcribed verbatim. The research team employed rigorous content analysis of the data. Three themes and subsequent categories resulted from the analysis: (1) Interpersonal/Relational Facilitators (building rapport; connecting with youth; enhancing the teachable moment; building relational health); (2) Structural/Systemic Barriers (lack of reinforcement; difficulties connecting after discharge from the hospital; hospital workflow; institutional challenges); (3) Structural/Systemic Facilitators (embedding the HVIP; trauma-informed practices and policies). Given the limited research on black and Latinx youth and the disproportionate rate of violent injuries amongst these groups, an evidence-based systematic approach to engage youth is essential to promote health equity. The findings from this study suggest that there are several steps that HVIPs and hospitals can take to enhance their recruitment and engagement of youth and their families.

Repeat assault injuries: A scoping review of the incidence and associated risk factors

OBJECTIVE

Individuals who experience assault are at high risk of being re-assaulted. Our objective was to identify reported incidences of re-assault and associated risk factors to better inform prevention strategies.

METHODS

We conducted a scoping review and searched databases (MEDLINE, PsychINFO, CINAHL, Cochrane Reviews, and Scopus) and grey literature. We performed abstract and full-text screening, and abstracted incidence of re-assault and information related to age, sex, socioeconomic status, mental illness, and incarceration.

RESULTS

We included 32 articles. Studies varied based on setting where index assaults were captured (n=18 inpatient only, n=13 emergency department or inpatient, n=1 other). Reported incidences ranged from 0.8% over one month to 62% through the lifetime. Important risk factors identified include young age, low socioeconomic status, racialized groups, history of mental illness or substance use disorder, and history of incarceration.

CONCLUSIONS

Rates of re-assault are high and early intervention is necessary for prevention. We identified notable risk factors that require further in-depth analysis, including sex, gender and age-stratified analyses.

POLICY IMPLICATIONS

Key risk factors identified should inform timely and targeted intervention strategies for prevention.

Development of a clinical prediction instrument to estimate risk of initial violent injury

BACKGROUND

Interpersonal violent injury is a public health crisis, disproportionately affecting young people of color. We aimed to evaluate associations between sociobehavioral predictors and first-time violent injury, and to develop a predictive risk score for violent injury.

METHODS

We performed a retrospective case-cohort study of adolescents aged 12-18 years. Multivariable logistic regression was used to estimate associations between 35 candidate variables and interpersonal first-time violent injury resulting in an emergency department (ED) visit. Multiple imputation was used to account for missing values and a risk score was developed by multiplying regression coefficients by 10 to generate a composite tool to predict initial violent injury (IVI). Discrimination and calibration were assessed using 10-fold cross validation.

RESULTS

19,210 adolescents were included, 276 (1.4%) as victims of IVI. The final model, the Initial Violent Injury Risk Prediction Tool (IVI-RPT), included: age, fight within the prior year, trouble with the law, and alcohol use. IVI-RPT scores were categorized as: 0-7 (low risk), 8-16 (moderate), and 17-26 (high), and IVI prevalence was 0.8% (95% confidence interval [CI]: 0.6%, 0.9%), 2.5% (95% CI: 1.9%, 3.1%), and 5.3% (95% CI: 4.1%, 6.6%), respectively. The area under the receiver operating characteristic curve was 0.70 (95% CI: 0.66, 0.73), while the slope of the calibration curve was 1.1 (95% CI: 0.9, 1.2).

CONCLUSIONS

We developed a promising clinical prediction instrument, the IVI-RPT, that categorizes individuals into risk groups with increasing probabilities of violent injury. External validation of this tool is required prior to clinical practice implementation.

Examining Associations between Adverse Childhood Experiences and Posttraumatic Stress Disorder Symptoms among Young Survivors of Urban Violence

Our study examines the association between Adverse Childhood Experience (ACE) exposure and posttraumatic stress disorder (PTSD) symptoms among survivors of violence. In this cross-sectional study, an ACE questionnaire and PTSD Checklist for DSM-5 (PCL-5) were completed by 147 participants ≤ 3 months after presenting to a Philadelphia, PA emergency department between 2014 and 2019 with a violent injury. This study treated ACEs, both separate and cumulative, as exposures and PTSD symptom severity as the outcome. Most participants (63.3%) met criteria for provisional PTSD, 90% reported experiencing ≥ 1 ACE, and 39% reported experiencing ≥ 6 ACEs. Specific ACEs were associated with increasing PCL-5 scores and increased risk for provisional PTSD. Additionally, as participants' cumulative ACE scores increased, their PCL-5 scores worsened (b = 0.16; p < 0.05), and incremental ACE score increases predicted increased odds for a positive provisional PTSD screen. Results provide further evidence that ACEs exacerbate the development of PTSD in young survivors of violence. Future research should explore targeted interventions to treat PTSD among survivors of interpersonal violence.

Not All Survivors Are the Same: Qualitative Assessment of Prior Violence, Risks, Recovery and Perceptions of Firearms and Violence Among Victims of Firearm Injury

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.

Identifying Risk Factors and Advancing Services for Violently Injured Low-Income Black Youth

Violent exposure among low-income, Black youth has reached alarming rates. Using administrative data that centers racial equity to understand risk factors and aid in prevention is a promising approach to address this complex problem. Medical records were linked to a comprehensive county-level integrated data system using a case–control design. Chi-square tests, T-tests, and multivariate logistic regression assessed for between and within group differences among (1) youth who presented to an emergency department (N = 429) with an assault or gunshot wound (GSW) and a matched sample of non-injured youth (N = 5000); and, (2) youth with GSW injuries (N = 71) compared to assault injuries (N = 358). Injured youth present with greater early adversity, trauma, and prolonged poverty compared to non-injured peers. Youth with GSW injuries differ from assault in several key ways. An ecosystem of care is needed to address the multifaceted causes of Black youth’s severe violence exposure that are rooted in systemic racism and poverty. Integrated data using a racial equity lens can help to illuminate opportunities in this ecosystem of care.

Changes in Health Care Spending, Use, and Clinical Outcomes After Nonfatal Firearm Injuries Among Survivors and Family Members : A Cohort Study

BACKGROUND

Despite increasing awareness of firearm-related deaths, evidence on the clinical and economic implications of nonfatal firearm injuries is limited.

OBJECTIVE

To measure changes in clinical and economic outcomes after nonfatal firearm injuries among survivors and their family members.

DESIGN

Cohort study.

SETTING

MarketScan Medicare and commercial claims data, 2008 to 2018.

PARTICIPANTS

6498 survivors of firearm injuries matched to 32 490 control participants and 12 489 family members of survivors matched to 62 445 control participants.

INTERVENTION

Exposure to nonfatal firearm injury as a survivor or family member of a survivor.

MEASUREMENTS

Changes in health care spending, use, and morbidity from preinjury through 1 year postinjury relative to control participants, on average and by type and severity of firearm injury.

RESULTS

After nonfatal firearm injury, medical spending increased $2495 per person per month (402%) and cost sharing increased $102 per person per month (176%) among survivors relative to control participants (P < 0.001) in the first year after injury, driven by an increase in the first month of $25 554 (4122%) in spending and $1112 (1917%) in cost sharing per survivor (P < 0.001). All categories of health care use increased relative to the control group. Survivors had a 40% increase in pain diagnoses, a 51% increase in psychiatric disorders, and an 85% increase in substance use disorders after firearm injury relative to control participants (P < 0.001), accompanied by increased pain and psychiatric medications. Family members had a 12% increase in psychiatric disorders relative to their control participants (P = 0.003). These overall clinical and economic changes were driven by intentional firearm injuries and more severe firearm injuries.

LIMITATION

Precision of diagnostic codes and generalizability to other patient populations, including Medicaid and uninsured patients.

CONCLUSION

In survivors, nonfatal firearm injuries led to increases in psychiatric disorders, substance use disorders, and pain diagnoses, alongside substantial increases in health care spending and use. In addition, mental health worsened among family members.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Healthcare utilization and mental health outcomes among nonfatal shooting assault victims

Victims of nonfatal shooting (NFS) assaults suffer from emotional and physical trauma; however, little is understood about clinical care utilization patterns among victims. This study examines the healthcare utilization and mental health outcomes before and after an index NFS victimization. A longitudinal dataset of police and clinical data were linked at the individual level to define a cohort of NFS victims with one or more clinical encounter in the 24-months preceding an index NFS injury (N = 2,681) in Indianapolis, Indiana between 2005 and 2018. Mental health was defined using ICD diagnosis codes from any emergency department, inpatient, or outpatient encounter and clinical care utilization was the number of unique encounters within the 24-months preceding and following an index NFS injury. Multivariable logistic regression was conducted to examine factors associated with a mental health diagnosis in the post injury period. Analyses were conducted in October 2021-March 2022. Overall clinical care utilization (Mean: pre = 277.7 (SD 235.3) vs. post = 333.9 (SD 255.1), p < 0.001) and mental health prevalence (14.4% pre vs. 18.8% post, p < 0.001) increased in the 24-months following an index NFS compared to the prior 24-months. Preinjury mental health utilization increased the odds of receiving a mental health diagnosis in the 24-months following an index NFS injury - particularly for Black victims (Odds Ratio 1.69, 95% CI 1.01, 2.85). The findings indicate missed opportunities within the healthcare system to connect NFS victims with needed mental health services, as well as the importance of premorbid connection to mental health care.

Retaliatory attitudes as mediator of exposure to violence and firearm aggression among youth: The protective role of organized activity involvement

Firearm injury is a significant public health concern among youth living in the United States. Youth with exposure to violence (ETV) are more susceptible to carrying and using a firearm. Few researchers, however, have examined psychological mechanisms undergirding the association between ETV and firearm aggression. Retaliatory attitudes have been discussed as a potential mediator linking ETV with firearm aggression. Moreover, organized activity participation may disrupt direct and indirect pathways connecting ETV to firearm aggression. We tested: (a) the mediating role of retaliatory attitudes in the ETV-firearm aggression link, and (b) the moderating role of organized activity participation among 570 youth with past year illicit drug use and seeking emerging department care in an urban emergency department (ages 14-24; 58.8% males). Using multigroup path analysis, ETV indirectly influenced firearm aggression through retaliatory attitudes for youth not involved organized activities. Organized activities also buffered the association between retaliatory attitudes (mediator) and firearm aggression (outcome). Organized activities may, therefore, prevent firearm aggression by reducing retaliatory attitudes among youth contending with ETV. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Characteristics of Adult Patients for Violence-Related Injuries Presenting to a Level 1 Trauma Center in Midwest United States

BACKGROUND

Hospital violence intervention programs (HVIPs) have recently been initiated in trauma centers across the United States. However, violence-related injuries have unique factors and issues that should be addressed in the health care provided in emergency departments.

PURPOSE

This study aimed to characterize the patient population presenting at a level 1 ACS verified trauma center, with a chief complaint of violent trauma, and identify characteristics of patients most at risk for violence-related trauma.

METHODS

The cross-sectional retrospective study examined patients' electronic health records, at least 18 years, with a diagnosis of blunt or penetrating injury treated by the emergency and trauma team at level 1 ACS verified trauma center in the Midwest.

RESULTS

Assault injuries accounted for most of the mechanisms that required treatment at the hospital and disposed to home. Nearly 80% of the population had no documentation of the relationship of the assailant. The average age of the patients was 33 years and black males. Eleven patients were treated in the emergency department twice for a trauma-related injury during the six-month data collection.

CONCLUSION

Injuries from violence require comprehensive care from various healthcare disciplines, similar to managing acute and chronic illnesses. The American College of Surgeons (ACS) guidelines support the development of an HVIP to identify risk factors and treatment plans for any patient exposed to violence. This research demonstrates that HVIPs should provide standardized screening and follow-up care while in the emergency department or immediately following the hospital to reduce the cyclical events.

State firearm laws and nonfatal firearm injury-related inpatient hospitalizations: A nationwide panel study

BACKGROUND

Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period.

METHODS

In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law.

RESULTS

Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates.

CONCLUSION

State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Experiencing Bullying Is Associated With Firearm Access, Weapon Carriage, Depression, Marijuana Use, and Justice Involvement in Adolescents

OBJECTIVES

The aims of this study were to assess whether bullying experience among youths is associated with firearm access and to evaluate assault perpetration risk factors between bullied and nonbullied adolescents.

METHODS

This was a secondary analysis of a cross-sectional survey designed to measure self-reported social determinants of health and behavioral health risks among adolescents (13-21 years) in a pediatric emergency department between July 2017 and August 2019. Participants were included in this subanalysis if they responded to a survey item that assessed bullying. Multivariable logistic regression was used to measure the association of firearm access, weapon carriage, and assault perpetration factors (violence, mental health, substance abuse, and justice involvement) with bullying after adjustment for sex, race/ethnicity, and insurance status.

RESULTS

Of the 369 participants meeting inclusion criteria, 147 adolescents (40.5%) reported experiencing bullying. Bullied teenagers had higher odds of a gun in the home (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.2-7.8]), weapon carriage (aOR, 5.6; 95% CI, 1.6-18.8), witnessing an assault (aOR, 3.0; 95% CI, 1.6-5.6), negative experience with law enforcement (aOR, 4.5; 95% CI, 2.2-9.2), mental health diagnosis (aOR, 3.9; 95% CI, 2.3-6.7), and marijuana use (aOR, 2.7; 95% CI, 1.1-7.0]).

CONCLUSIONS

More than 1 in 3 adolescents presenting to the emergency department report having ever experienced bullying. Bullied teenagers have a higher likelihood of firearm access, weapon carriage, and violent injury perpetration risk factors compared with nonbullied youths. Further studies are needed to understand the relationship between bullying and assault perpetration.

The association between perceived community violence, police bias, race, and firearm carriage among urban adolescents and young adults

Firearms are a leading cause of death among youth and young adults. Given community violence is an important correlate of youth firearm carriage, we evaluated: 1) If the association between perceived community violence and firearm carriage is stronger when perceived police bias is greater; and 2) If this moderated association differs by race. Cross-sectional data came from screening data for a longitudinal study of firearm behaviors among young adults seeking urban emergency department treatment between July 2017-June 2018 (N = 1264). We estimated Poisson regressions with robust error variance to evaluate associations between perceived community violence, police bias, race, and firearm carriage. Community violence was positively associated with firearm carriage (average marginal effect [AME]: 0.05; 95% Confidence Interval [CI]: 0.03, 0.07). We also found that the positive association between community violence and firearm carriage increased with higher perceptions of police bias (interaction p < 0.05). We did not find evidence of a three-way interaction by which the moderated association between violence exposure and firearm carriage by perceived police bias varied by race of the respondents. Our findings suggest that community-level strategies to reduce violence and police bias may be beneficial to decrease youth firearm carriage in socio-economically disadvantaged urban settings.

Translating Violence Prevention Programs from Research to Practice: SafERteens Implementation in an Urban Emergency Department

BACKGROUND

Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care.

OBJECTIVES

To examine the translation of the SafERteens program into clinical care.

METHODS

Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework.

RESULTS

SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes.

CONCLUSIONS

Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation.

Within-Person Predictors of Same-Day Alcohol and Nonmedical Prescription Drug Use Among Youth Presenting to an Urban Emergency Department

OBJECTIVE

Simultaneous alcohol and nonmedical prescription drug use (NMPDU) increases acute risks (e.g., overdose) associated with each; understanding social, substance use, and mental health predictors of same-day use may suggest intervention targets.

METHOD

At an urban emergency department, research assistants recruited youth ages 14-24 reporting past-6-month substance use (n = 599; 58.8% male). Participants self-administered validated measures of alcohol consumption, cannabis use severity (quantity and consequences), mental health symptoms, and social influences at baseline and at four biannual follow-ups. In addition, participants completed Timeline Followback calendars that assessed same-day use of alcohol and prescription drugs. We used negative binomial regression with person-level fixed effects to isolate within-person predictor effects on same-day use frequency.

RESULTS

Between 6.0% (baseline) and 8.6% (6-month follow-up) of youth reported same-day alcohol use and NMPDU across follow-ups. Within-person increases in alcohol consumption, cannabis use severity, and depression and anxiety symptoms all corresponded to greater same-day alcohol and NMPDU frequency, with consistent findings across genders. Increased positive peer behaviors corresponded to decreased same-day use frequency among males but not females. Decreased parental support and increased delinquent peer exposures corresponded to greater same-day use frequency among females but not males.

CONCLUSIONS

Substance use and mental health symptom escalation are robust predictors of greater same-day use frequency, whereas the roles of social factors appear gender-specific. Interrupting worsening trajectories of substance use and mental health symptoms, and enhancing social support and reducing delinquent peer exposures, may reduce same-day use frequency.

A simulation study of regression approaches for estimating risk ratios in the presence of multiple confounders

Background

Risk ratio is a popular effect measure in epidemiological research. Although previous research has suggested that logistic regression may provide biased odds ratio estimates when the number of events is small and there are multiple confounders, the performance of risk ratio estimation has yet to be examined in the presence of multiple confounders.

Methods

We conducted a simulation study to evaluate the statistical performance of three regression approaches for estimating risk ratios: (1) risk ratio interpretation of logistic regression coefficients, (2) modified Poisson regression, and (3) regression standardization using logistic regression. We simulated 270 scenarios with systematically varied sample size, the number of binary confounders, exposure proportion, risk ratio, and outcome proportion. Performance evaluation was based on convergence proportion, bias, standard error estimation, and confidence interval coverage.

Results

With a sample size of 2500 and an outcome proportion of 1%, both logistic regression and modified Poisson regression at times failed to converge, and the three approaches were comparably biased. As the outcome proportion or sample size increased, modified Poisson regression and regression standardization yielded unbiased risk ratio estimates with appropriate confidence intervals irrespective of the number of confounders. The risk ratio interpretation of logistic regression coefficients, by contrast, became substantially biased as the outcome proportion increased.

Conclusions

Regression approaches for estimating risk ratios should be cautiously used when the number of events is small. With an adequate number of events, risk ratios are validly estimated by modified Poisson regression and regression standardization, irrespective of the number of confounders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12982-021-00107-2.

Longitudinal within- and between-person associations of substance use, social influences, and loneliness among adolescents and emerging adults who use drugs

Loneliness is a public health problem causing morbidity and mortality. Individuals with substance use problems are often lonelier than the general population. We evaluate the longitudinal associations between social influences, substance use, and loneliness among adolescents and young adults recruited from an urban Emergency Department (ED). We use secondary data from a natural history study of N=599 youth (ages 14-24) who used drugs at baseline and completed biannual assessments for 24 months; 58% presented to the ED for an assault-related injury and a comparison group comprised 42% presenting for other reasons. Measures assessed cannabis use, alcohol use, and loneliness. Using GEE models, we evaluated the relationships between social influences (peers, parents), substance use, and loneliness via longitudinal data, de-coupling within- and between-person effects. Men reported lower loneliness over time. At the between-person level, individuals with greater alcohol and cannabis use severity and negative peer influences had greater loneliness; positive parental influences were associated with less loneliness. At the within-person level, greater alcohol use severity, negative peer influences, and parental substance use corresponded to increases in loneliness; positive parental influences corresponded to decreases in loneliness. Youth with more severe alcohol and cannabis use had greater loneliness over time. Within individuals, peer and parental social influences were particularly salient markers of loneliness. An ED visit provides an opportunity for linkage to personalized, supportive interventions to curtail negative outcomes of substance use and loneliness.

Assault-injured youth in the emergency centres of Khayelitsha, South Africa: A prospective study of recidivism and mortality

INTRODUCTION

Violence is a major cause of death worldwide among youth. The highest mortality rates from youth violence occur in low and middle-income countries (LMICs). We sought to identify risk factors for violent re-injury and emergency centre (EC) recidivism among assault-injured youth in South Africa.

METHODS

A prospective follow up study of assault injured youth and controls ages 14-24 presenting for emergency care was conducted in Khayelitsha, South Africa from 2016 to 2018. Sociodemographic and behavioral factors were assessed using a questionnaire administered during the index EC visit. The primary outcomes were return EC visit for violent injury or death within 15 months. We used multivariable logistic regression to compute adjusted odds ratios (OR) and 95% confidence intervals (CI) of associations between return EC visits and key demographic, social, and behavioral factors among assault-injured youth.

RESULTS

Our study sample included 320 assault-injured patients and 185 non-assault-injured controls. Of the assault-injured, 80% were male, and the mean age was 20.8 years. The assault-injured youth was more likely to have a return EC visit for violent injury (14%) compared to the control group (3%). The non-assault-injured group had a higher mortality rate (7% vs 3%). All deaths in the control group were due to end-stage HIV or TB-related complications. The strongest risk factors for return EC visit were prior criminal activity (OR = 2.3, 95% CI = 1.1-5.1), and current enrollment in school (OR = 2.1, 95% CI = 1.0-4.6). Although the assault-injured group reported high rates of binge drinking (73%) at the index visit, this was not found to be a risk factor for violence-related EC recidivism.

DISCUSSION

Our findings suggest that assault-injured youth in an LMIC setting are at high risk of EC recidivism and several sociodemographic and behavioral factors are associated with increased risk. These findings can inform targeted intervention programs.

Psychiatric and Physical Health Outcomes Associated with Interpersonal Violence: A Propensity Score Matching Approach

This study examined the association between interpersonal violence and a range of psychiatric and physical health outcomes and assessed whether these associations changed when controlling for a stress-related diagnosis. An observational case-control study was conducted on a sample of 4,059 victims of violence. Using propensity score matching a number of risk factors (assessed five years prior assault) were used. Controls were matched 10:1 using the Danish Central Registry System. Outcomes were ICD-10 diagnoses of a range of psychiatric and physical health outcomes in the 15 years post-injury. Statistically significant associations were found for all psychiatric conditions and a diagnosis of a drug or substance misuse disorder. These findings remained even after controlling for a diagnosis of a stress-related disorder. Large scale case-control studies using the Danish nationwide registers enables a powerful way of assessing the relative impact of exposure to interpersonal violence on the development of psychiatric and physical health problems.

Emergency Department Visits for Pediatric Firearm Injuries by Trauma Center Type

OBJECTIVES

This study aimed to characterize pediatric visits to emergency departments (EDs) for firearm injuries and examine differences by trauma center type.

METHODS

Analyses included all patients younger than 19 years from the National Trauma Data Bank, years 2009 to 2014. Trauma centers were categorized as adult, mixed adult and pediatric, or pediatric based on certification level. Baseline characteristics were compared between subgroups using χ2 tests. Multivariable logistic regression was used to examine risk of death.

RESULTS

Of 466,403 pediatric ED visits, 21,416 (4.6%) resulted from a firearm injury. Most firearm injuries were treated at an adult (64.9%) or mixed trauma center (29.1%) and involved patients that were male (87.1%), in the 15- to 18-year age group (83.2%), and black or African American (61.3%). Most visits were for injuries resulting from assault (78.1%), followed by unintentional (12.6%) and self-inflicted (4.7%) injuries, undetermined intent (3.7%), and legal intervention (0.8%). Patients visiting EDs for firearm injuries had more than 7 times the odds of dying compared with patients with other injuries (odds ratio, 7.30; 95% confidence interval, 6.82-7.72), and firearm injuries were responsible for more than a quarter (26.1%) of the total pediatric deaths in the National Trauma Data Bank (n = 2866). Assault-related injuries resulted in the most deaths (n = 2010; 70.1%), but the case fatality rate was highest for self-inflicted (n = 453; 44.6%).

CONCLUSION

We identified more than 20,000 firearm-related ED visits by pediatric patients from 2009 to 2014, averaging nearly 10 visits per day. Findings from this study can inform strategic planning in hospitals focused on preventing firearm injuries in children and adolescents.

Characteristics of pediatric emergency department visits for youth 10-15 years old with injuries due to interpersonal violence

This retrospective cohort study at an urban academic pediatric emergency department (ED) in the United States identified all visits for youth 10-15 years of age for injury due to intentional interpersonal violence between January 2019 and December 2020. Demographic and clinical data were abstracted, including circumstances of the event. Data analysis included a comparison of pre-pandemic visits to pandemic visits after a statewide stay-at-home order was issued (March 30, 2020). Of 2780 10-15 year old youth evaluated for any injury, 819 (29.5%) had intentional/violence-related injuries. Most patients were male (53.1%), Black/African-American (84.1%), and were enrolled in a public insurance plan (75.0%). Although peer-violence related injuries comprised a substantial proportion (19.2%), the majority resulted from family violence (54.7%), which may include child maltreatment or physical fighting. Most injuries occurred at home (53.9%). Alcohol, drugs and weapons were significantly more likely to be involved in violent events during the pandemic in comparison to pre-pandemic (12.5 vs 5.0%, 11.4% vs 3.0%, 30.4% vs 8.5%; p < 0.001). Our findings support the need for ED-based efforts to screen and intervene for family and peer violence and other contributory factors (including personal, family and peer alcohol, drug and weapons access) when youth present with intentional injuries, which can be critical to preventing future violence.