Epidemiology and prevention of severe assault and gun injuries to children in an urban community

Engaging East Harlem, New York youth in action gun violence prevention research and child rights: a preliminary study

BACKGROUND

The aim of the study was to have youth participate in the design and implementation of a research project set within a child rights framework to better understand high schoolers' perceptions of safety in their school and community.

RESULTS

Between June 2020 and March 2021, a team of East Harlem, New York high school students, participated as co-researchers to modify the United Nations Children's Fund Child Friendly Cities Initiative Survey to suit their needs. Due to the COVID-19 pandemic, the final survey was conducted through an online remote classes system during advisory school classes, accompanied by brief focused group discussions. The novel process of conducting an interactive qualitative and quantitative virtual survey during a pandemic via youth participatory action research is outlined in this paper.

CONCLUSIONS

Our results demonstrate that youth participatory action research can be utilized as part of a child rights framework approach to assess the views of youth regarding community safety and violence prevention.

Firearm-Related Injuries and Deaths in Children and Youth: Injury Prevention and Harm Reduction

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. They are also an important cause of injury with long-term physical and mental health consequences. A multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth. Interventions should be focused on the individual, household, community, and policy level. Strategies for harm reduction for pediatric firearm injuries include providing anticipatory guidance regarding the increased risk of firearm injuries and deaths with firearms in the home as well as the principles of safer firearm storage. In addition, lethal means counseling for patients and families with individuals at risk for self-harm and suicide is important. Community-level interventions include hospital and community-based violence intervention programs. The implementation of safety regulations for firearms as well as enacting legislation are also essential for firearm injury prevention. Increased funding for data infrastructure and research is also crucial to better understand risks and protective factors for firearm violence, which can then inform effective prevention interventions. To reverse this trend of increasing firearm violence, it is imperative for the wider community of clinicians, public health advocates, community stakeholders, researchers, funders, and policy makers to collaboratively address the growing public health crisis of firearm injuries in US youth.

Firearm-Related Injuries and Deaths in Children and Youth

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Readmission and reinjury patterns in pediatric assault victims

INTRODUCTION

Repeated pediatric assault should be a never event. The purpose of this study was to evaluate the readmission and reinjury patterns in pediatric victims of assault including readmissions to different hospitals across the US.

METHODS

The 2010-2014 Nationwide Readmissions Database was queried for all nonelective admissions for patients under the age of 18 years. Primary outcomes were readmission or reinjury within 1 year. Results were weighted for national estimates.

RESULTS

Assault-related injury occurred in 46,294 pediatric patients with 11.4% of patients being readmitted within 1 year. Of those readmitted, 35.2% presented to a different hospital. Reinjury within 1 year occurred in about 1% of patients, with 14.8% of those presenting to a different hospital. Age < 13 years, firearm-injury, ISS > 15, female gender, and leaving AMA were found to be independent prognostic indicators of readmission within 1 year among pediatric assault patients.

CONCLUSION

Care of children who are admitted and discharged for assault injuries is more fragmented that previously thought. Quality metrics fail to capture this previously hidden population. Our results identify treatable factors which could improve the care of children after assault.

Risk factors for nonelective 30-day readmission in pediatric assault victims

PURPOSE

Hospital readmission in trauma patients is associated with significant morbidity and increased healthcare costs. There is limited published data on early hospital readmission in pediatric trauma patients. As presently in healthcare outcomes and readmissions rates are increasingly used as hospital quality indicators, it is paramount to recognize risk factors for readmission. We sought to identify national readmission rates in pediatric assault victims and identify the most common readmission diagnoses among these patients.

METHODS

The Nationwide Readmission Database (NRD) for 2013 was queried for all patients under 18years of age with a non-elective admission with an E-code that is designed as assault using National Trauma Data Bank Standards. Multivariate logistic regression was implemented using 18 variables to determine the odds ratios (OR) for non-elective readmission within 30-days.

RESULTS

There were 4050 pediatric victims of assault and 92 (2.27%) died during the initial admission. Of the surviving patients 128 (3.23%) were readmitted within 30days. Of these readmitted patients 24 (18.75%) were readmitted to a different hospital and 31 (24.22%) were readmitted for repeated assault. The variables associated with the highest risk for non-elective readmission within 30-days were: length of stay (LOS) >7days (OR 3.028, p<0.01, 95% CI 1.67-5.50), psychoses (OR 3.719, p<0.01, 95% CI 1.70-8.17), and weight loss (OR 4.408, p<0.01, 95% CI 1.92-10.10). The most common readmission diagnosis groups were bipolar disorders (8.2%), post-operative, posttraumatic, or other device infections (6.2%), or major depressive disorders and other/unspecified psychoses (5.2%).

CONCLUSIONS

Readmission after pediatric assault represents a significant resource burden and almost a quarter of those patients are readmitted after a repeated assault. Understanding risk factors and reasons for readmission in pediatric trauma assault victims can improve discharge planning, family education, and outpatient support, thereby decreasing overall costs and resource burden. Psychoses, weight loss, and prolonged hospitalization are independent prognostic indicators of readmission in pediatric assault patients.

LEVEL OF EVIDENCE

Level IV - Prognostic and Epidemiological - Retrospective Study.

The Flexible Woman

In the US, as more poor women must work to support their house holds, and state support for women/caregivers is consistently reduced, we find an increase in violence and domestic conflict and the abandonment and neglect of children. The 1996 welfare laws exacerbate this situation as they force more poor women into the low-paid or unpaid labor force, to the further cost of poor children. These new laws reflect and reinforce a shift in what was viewed by the welfare state as legitimate dependence for mothers and children. It is no longer sufficient, if it ever was, to talk of male or female domination or subordination among poor people in the United States. In the 1990s, arenas of power for men are contradicted by other arenas of power or access to resources from the state for women. Thus in spite of the utility of analyses that dealt with the experiences of men and women separately, only an analysis that portrays the integral inter dependencies of the two interlocking/conflicting gender hierarchies in terms of class, poverty and state regulations can elucidate the parameters of the new poverty and the violence it generates.

The Flexible Woman

■ In the US, as more poor women must work to support their house holds, and state support for women/caregivers is consistently reduced, we find an increase in violence and domestic conflict and the abandonment and neglect of children. The 1996 welfare laws exacerbate this situation as they force more poor women into the low-paid or unpaid labor force, to the further cost of poor children. These new laws reflect and reinforce a shift in what was viewed by the welfare state as legitimate dependence for mothers and children. It is no longer sufficient, if it ever was, to talk of male or female domination or subordination among poor people in the United States. In the 1990s, arenas of power for men are contradicted by other arenas of power or access to resources from the state for women. Thus in spite of the utility of analyses that dealt with the experiences of men and women separately, only an analysis that portrays the integral inter dependencies of the two interlocking/conflicting gender hierarchies in terms of class, poverty and state regulations can elucidate the parameters of the new poverty and the violence it generates.

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Guns and states: pediatric firearm injury

BACKGROUND

A recent report indicates that firearm-related injuries are responsible for 30% of pediatric trauma fatality. The literature is however limited in examining pediatric firearm injuries and variations in state gun control laws. Therefore, we sought to examine the association between pediatric firearm injuries and the Stand-Your-Ground (SYG) and Child Access Protection (CAP) laws.

METHODS

All pediatric (age, 0-20 years) hospitalizations with firearm injuries were identified from the Kids' Inpatient Database from 2006 and 2009. States were compared for SYG and CAP laws.

RESULTS

A total of 19,233 firearm injury hospitalizations were identified, with 64.7% assault, 27.2% accidental, and 3.1% suicide injury. Demographics for assault injury were as follows: mean age of 17.6 years, 88.4% male, 44.4% black, 18.2% Hispanic, 70.5% from metropolitan areas, and 50.1% from the poorest median income neighborhoods. Suicide injury cases were more likely to be white (57.8% vs. 16.6%, p < 0.001) and female (15.1% vs. 9.8%, p < 0.001). States with the SYG law were associated with increased accidental injury (odds ratio [OR], 1.282; p < 0.001). There was no statistical association between CAP law and the incidence of accidental injury or suicide. Multivariate logistic regression analysis found other predictive demographic factors for firearm injury: black (OR, 6.164), urban areas (OR, 1.557), poorest median income neighborhoods (OR, 2.785), male (OR, 28.602), and 16 years or older (OR, 37.308). Total economic burden was estimated at more than $1 billion dollars, with a median length of stay of 3 days, 8.4% discharge to rehabilitation, and 6.2% in-hospital mortality.

CONCLUSION

Pediatric firearm injuries continue to be a significant source of morbidity, mortality, and economic burden. A significant increase in accidental firearm injuries in states with the SYG law may highlight inadvertent effects of the law. Race, sex, and median income are additional contributing factors. Advocacy and focused educational efforts for specific socioeconomic and racial groups may potentially reduce firearm injuries.

LEVEL OF EVIDENCE

Prognostic study, level II.

Community beliefs about intentional injury and responsibility for prevention

Community beliefs related to intentional injury inflicted by others were examined in a population-based telephone survey (n = 1032) in Queensland, Australia. Young adults 18 to 24 years old were nominated as the most likely to be intentionally injured. It was found that 89.1% of respondents nominating this group believed that the injury incidents occur in alcohol environments. Though respondents from this age group also identified 18- to 24-year-olds as most likely to be intentionally injured, this was at a significantly lower level when compared with parents or 25- to 64-year-olds respondents. Responsibility for preventing injuries was placed on proprietors of licensed premises, schools, and parents/family of the victim for alcohol, school, and home environments, respectively. Beliefs were aligned with prevalence data on intentional injury, demonstrating a high level of awareness in the community about likely victims and situations where intentional injuries occur. Interventions could target families of young adults to capitalize on high levels of awareness about young adult vulnerability.

Workplace assault is independently associated with mortality: a national trauma data bank analysis

OBJECTIVE

Outcome comparisons between workplace versus nonworkplace ssaults have not been studied. We hypothesize that workplace attacks are more lethal.

METHODS

Utilizing the National Trauma Data Bank v 7.0, cases of assault with a work-related status were examined. Outcomes (complications and mortality) between the workgroup and the nonworkgroup are compared.

RESULTS

Of 48,541 cases, 2439 (5.0%) were workgroup. Mortality was 6.4% in the workgroup versus 5.3% in the nonworkgroup (P = 0.02). For firearms, mortality was 14.6% versus 10.9%, respectively (P < 0.01). The incidence of complications was 5.2% versus 1.3% (P < 0.01), respectively. An assault perpetrated at the workplace was independently associated with mortality and complications.

CONCLUSIONS

Workplace assault independently predicts death, particularly in relation to firearms. Measures must be taken to reduce this risk to the workforce.

Fresh Start: a multilevel community mobilization plan to promote youth development and prevent violence

While much has been written about community mobilization for health, few detailed expositions of the formation of community mobilization, especially focused on youth violence prevention exist. The Columbia Center for Youth Violence Prevention, in collaboration with the UNIDOS Inwood Coalition, developed a Community mobilization plan to guide youth violence prevention in Inwood. The plan was developed within the context of an evidence-based organizing framework-Communities that Care (CTC) and takes a multi-level approach to service coordination that includes activities at the Individual, Family, Block, Organizational and Built Environment levels. This article describes how the Community mobilization plan was created, illustrates the use of evidence-based practices to lead to the development of the plan, outlines the plan's community/organizational activities, and summarizes the principles and processes that can be replicated in other communities seeking to start their own community mobilization efforts to reduce youth violence.

Developing the Miami-Dade County Injury Surveillance System: using surveillance to build community capacity for injury prevention

The Miami-Dade County Injury Surveillance System was created as part of a hospital-based injury prevention program associated with the Injury Free Coalition for Kids. Initially the program utilized trauma center and mortality data to describe injury. However, as community programming and coalition-building developed, so did the demands on the surveillance system. Coalition partners and potential partners desired a more comprehensive and population-based system. As a result of the county-wide approach and open access to results, the surveillance system has engaged new partners and leveraged additional resources to injury prevention.

A prospective study into the demographics and treatment of paediatric facial lacerations

To evaluate the demographics and treatment of facial lacerations occurring in a paediatric patient cohort. We undertook a prospective study of 106 children who sustained a soft tissue facial injury and who presented to an Accident and Emergency department in a UK district general hospital supporting a population of 750,000. Approximately 31,000 are dependent children between the age of 0-12 years. Our results show that the majority of paediatric patients who sustained a facial laceration were male (62%). The frequency of this injury was greatest amongst males across all age groups. The majority of children above 3 years of age sustained their injury outdoors. The peak time for injury varied for different age groups. The 0-3 year olds sustained the highest incidence of injuries around 17:00 h. A bi-modal time pattern was seen in the 4-6 year age group, initially at 12:00 h with a second peak at 17:00 h. The most frequent aetiology was play. A significant finding was that 8% of the injuries that were managed resulted from a dog bite. Almost 50% of children above 4 years of age, who required primary closure of their laceration, were able to tolerate their treatment being performed under local anaesthesia. The pattern of facial lacerations in our study supports the results of previous studies. Our data has provided further insight into the presentation of these injuries. These studies are valuable in targeted injury prevention programmes aimed at potentially reducing the nature, incidence and severity of facial soft tissue trauma in children in the UK.

A national program for injury prevention in children and adolescents: the injury free coalition for kids

Injury is the leading cause of death and a major source of preventable disability in children. Mechanisms of injury are rooted in a complex web of social, economic, environmental, criminal, and behavioral factors that necessitate a multifaceted, systematic injury prevention approach. This article describes the injury burden and the way physicians, community coalitions, and a private foundation teamed to impact the problem first in an urban minority community and then through a national program. Through our injury prevention work in a resource-limited neighborhood, a national model evolved that provides a systematic framework through which education and other interventions are implemented. Interventions are aimed at changing the community and home environments physically (safe play areas and elimination of community and home hazards) and socially (education and supervised extracurricular activities with mentors). This program, based on physician-community partnerships and private foundation financial support, expanded to 40 sites in 37 cities, representing all 10 US trauma regions. Each site is a local adaptation of the Injury Free Coalition model also referred to as the ABC's of injury prevention: A, "analyze injury data through local injury surveillance"; B, "build a local coalition"; C, "communicate the problem and raise awareness that injuries are a preventable public health problem"; D, "develop interventions and injury prevention activities to create safer environments and activities for children"; and E, "evaluate the interventions with ongoing surveillance." It is feasible to develop a comprehensive injury prevention program of national scope using a voluntary coalition of trauma centers, private foundation financial and technical support, and a local injury prevention model with a well-established record of reducing and sustaining lower injury rates for inner-city children and adolescents.

Nonfatal and fatal firearm-related injuries among children aged 14 years and younger: United States, 1993-2000

OBJECTIVE

To provide national estimates of fatal and nonfatal firearm-related (FA) injuries among children < or =14 years old and to examine the circumstances under which these injuries occurred.

METHODS

For nonfatal FA injuries among children, we analyzed data on emergency department (ED) visits from the National Electronic Injury Surveillance System for 1993 through 2000. National estimates of injured children who were treated in hospital EDs were examined by selected characteristics, such as age, gender, race/ethnicity of the patient, primary body part affected, intent of the injury, the relationship of the shooter to the patient, where the injury occurred, and activity at the time of injury. For fatal FA injuries among children, we analyzed mortality data from the National Vital Statistics System for 1993 through 2000. Data from both sources were used to calculate case-fatality rates.

RESULTS

From 1993 through 2000, an estimated 22,661 (95% confidence interval [CI]: 16,668-28,654) or 4.9 per 100,000 (95% CI: 3.6-6.2) children < or = 14 years old with nonfatal FA injuries were treated in US hospital EDs. Assaults accounted for 41.5% of nonfatal FA injuries, and unintentional injuries accounted for 43.1%. Approximately 4 of 5 children who sustained a nonfatal, unintentional FA injury were reportedly shot by themselves or by a friend, a relative, or another person known to them. During this period, 5542, or 1.20 per 100,000 (95% CI: 1.17, 1.23), children < or =14 years old died from FA injuries; 1 of every 5 children who were wounded by a firearm gunshot died from that injury. Most FA deaths were violence related, with homicides and suicides constituting 54.7% and 21.9% of these deaths, respectively. For individuals < or =14 years old, the burden of morbidity and mortality associated with FA injuries falls disproportionately on boys, blacks, and children 10 to 14 years old. Both fatal and nonfatal injury rates declined >50% during the study period.

CONCLUSIONS

Although rates of nonfatal and fatal FA injuries declined during the period of study, FA injuries remain an important public health concern for children. Well-designed evaluation studies are needed to examine the effectiveness of potential interventions aimed at reducing FA injuries among children.

Preventing injury and injury-related disability in children and adolescents

Injury is the leading cause of death and a prevalent source of disability and excess health expenditures in children and adolescents. There are predictable patterns to injury that provide clues to prevention. Epidemiologically-based theoretical frameworks are available to guide development of injury prevention strategies, to add structure to our observations, and focus to our prevention activities. While all-cause injury mortality rates have decreased in children and adolescents over the last 20 years, large ethnic disparities persist, indicating the need for intensified efforts in high-risk communities. Strong leadership from pediatric surgeons and pediatricians operating hospital-based community injury prevention programs has produced successful reductions in child and adolescent injury rates in resource-limited and minority neighborhoods. Among the program features considered essential are: (1) an ongoing injury surveillance system; (2) well-focused, multifaceted prevention activities, including both passive and active prevention approaches; (3) education; (4) enlistment of other health professionals, local government officials, community leaders, and the public; and (5) evaluation and refinement of prevention activities.

Psychological aspects of traumatic injury in children and adolescents

Each year millions of children are exposed to some form of extreme traumatic stressor. These traumatic events include natural disasters (e.g., tornadoes, floods, hurricanes), motor vehicle accidents, life-threatening illnesses and associated painful medical procedures (e.g., severe burns, cancer, limb amputations), physical abuse, sexual assault, witnessing domestic or community violence, kidnapping, and sudden death of a parent. During times of war, violent and nonviolent trauma (e.g., lack of fuel and food) may have terrible effects on children's adjustment. The events of September 11, 2001 and the unceasing suicidal attacks in the Middle East underscore the importance of understanding how children and adolescents react to disasters and terrorism. The body of literature related to children and their responses to disasters and trauma is growing. Mental health professionals are increasing their understanding about what factors are associated with increased risk (vulnerability) and affect how children cope with traumatic events. Researchers recognize that children's responses to major stress are similar to adults' (reexperiencing the event, avoidance, and arousal) and that these responses are not transient. A review of the literature indicates that PTSD is the most common psychiatric disorder after traumatic experiences, including physical injuries. There is also evidence for other comorbid conditions, including mood, anxiety, sleep, conduct, learning, and attention problems. In terms of providing treatment, CBT emerges as the best validated therapeutic approach for children and adolescents who experienced trauma-related symptoms, particularly symptoms associated with anxiety or mood disorders. The best approach to the injured child requires injury and pain assessment followed by specific interventions, such as pain management, brief consultation, and crisis intervention immediately after the specific traumatic event. Family support also may be necessary to help the family through this difficult period. The main conclusion that arises from the research on resilience in development is that extraordinary resilience and recovery power of children depend on basic human protective systems operating in their favor. This finding has produced a fundamental change in the framework for understanding and helping children at high risk or already in trouble. This shift is evident in a changing conceptualization of the goals of prevention and intervention that currently address competence and problems. Strategies for fostering resilience described in this article should be tested in future controlled psychotherapy trials to verify their efficacy on children's protective factors.

Pathways to adolescent health: early intervention

OBJECTIVES

The wisdom of early intervention is one of the most strongly held beliefs in health care. However, although the intention to intervene early is generally believed to be a good one, too often we don't know when to do it, on whom to do it, and how to do it. Furthermore, if we consider the effectiveness of the interventions that have been used widely over the last 20 years we would have to conclude that although we have had some modest gains with issues such as teenage pregnancy, we have not been successful with most early intervention efforts. The development of more effective early interventions in adolescent populations requires a thorough appreciation and application of the theoretical and developmental bases of health behaviors and behavioral change.

METHODS

These analyses were achieved through a review of the literature relevant to interventions in a variety of problem behaviors in adolescents.

RESULTS/CONCLUSIONS

This review has demonstrated that although we don't have all of the answers we have the technological means to achieve greater success from early intervention. However, these benefits to our youth cannot be realized unless policies are developed that support the utilization and implementation of the most effective theory-based methodologies. Furthermore, these policies must be supported by research that enhances the translation of these effective interventions into broad national applications.

Risk factors associated with non-fatal adolescent firearm injuries

STUDY OBJECTIVES

To identify behavioral, environmental, and sociodemographic risk factors associated with non-fatal firearm injuries among inner city adolescents in the United States.

DESIGN

A case-control study in which patients with firearm injury serve as cases and those with medical conditions serve as controls.

SETTING

A level I trauma center in a metropolitan area serving a predominately lower socioeconomic status population.

PARTICIPANTS

Cases were 45 consecutive patients 11-18 years presenting to the emergency department with non-fatal firearm injury; controls were 50 age and gender matched patients presenting with acute medical problems.

OUTCOME MEASURE

Odds ratios (OR) and associated 95% confidence interval (CI) as estimates of the magnitude of association between risk factors and non-fatal firearm injury.

RESULTS

After adjusting for age, gender and socioeconomic status, multivariate analysis identified four risk factors independently associated with firearm injury: living with less than two parents (OR 3.8, 95% CI 1.2 to 12.2), skipping class (OR 7.1, 95% CI 1.7 to 28.9), previous arrest (OR 6.2, 95% CI 1.9 to 20.7), and being African-American (OR 4.2; 95%CI 1.4 to 14.9).

CONCLUSION

Risk factors for adolescents sustaining a non-fatal firearm injury are sociodemographic and environmental, not just behavioral. Thus interventions that foster protective and supportive environments may help prevent firearm injuries.

Ten-year research review of physical injuries

OBJECTIVE

To review the past 10 years of research relevant to psychiatry on injuries in children and adolescents.

METHOD

A literature search of databases for "wounds and injuries, excluding head injuries," was done with Medline and PsycINFO, yielding 589 and 299 citations, respectively. Further searching identified additional studies.

RESULTS

Progress is occurring in prevention, pain management, acute care, psychiatric treatment, and outcomes. The emotional and behavioral effects of injuries contribute to morbidity and mortality. Psychiatric assessment, crisis intervention, psychotherapy, psychopharmacological treatment, and interventions for families are now priorities. Research offers new interventions for pain, delirium, posttraumatic stress disorder, depression, prior maltreatment, substance abuse, disruptive behavior, and end-of-life care. High-risk subgroups are infants, adolescents, maltreated children, suicide attempters, and substance abusers. Staff training improves quality of care and reduces staff stress.

CONCLUSIONS

Despite the high priority that injuries receive in pediatric research and treatment, psychiatric aspects are neglected. There is a need for assessment and for planning of psychotherapeutic, psychopharmacological, and multimodal treatments, based on severity of injury, comorbid psychopathology, bodily location(s), and prognosis. Psychiatric collaboration with emergency, trauma, and rehabilitation teams enhances medical care. Research should focus on alleviating pain, early psychiatric case identification, and treatment of children, adolescents, and their families, to prevent further injuries and reduce disability.

Firearm-related injuries affecting the pediatric population. Committee on Injury and Poison Prevention. American Academy of Pediatrics

This statement reaffirms the 1992 position of the American Academy of Pediatrics that the absence of guns from children's homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. A number of specific measures are supported to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on handguns and semiautomatic assault weapons; and expanded regulations of handguns for civilian use. In addition, this statement reviews recent data, trends, prevention, and intervention strategies of the past 5 years.

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.

Epidemiology and prevention of traffic injuries to urban children and adolescents

OBJECTIVES

To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community.

MATERIALS AND METHODS

Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983-1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community.

PRIMARY RESULTS

Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983-1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for >/=1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness >/=1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; chi2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio:.64; 95% CI:.58,.72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio:.55; 95% CI:.38,.79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio:.89; 95% CI:.72, 1.09) or in traffic injuries among younger children who

Gunshot wounds: bullet caliber is increasing

BACKGROUND

The incidence of gunshot wounds has increased over the past two decades. In the past several years at our Level I trauma center in Newark NJ, we perceived that the size of ammunition involved in these wounds has been increasing as well. We sought to document this trend by using autopsy data as well as bullets received by surgical pathology.

METHODS

Measurements of bullets stored in surgical pathology were taken from alternate years between 1981 and 1993, then every year through 1997. A total of 745 bullets were studied in this 16-year period. Bullets deformed beyond measurability and shotgun pellets were excluded from the study (approximately 20%). Linear regression of mean bullet caliber over time was performed, and analysis of variance was used to assess statistical significance of apparent differences. In addition, autopsy reports from the regional medical examiner's office were surveyed for description of bullet size. Bullet caliber, in these reports, is described as "small," "medium," or "large." A total of 397 reports were studied from 1981 to 1997. Once again, shotgun wounds (<5%) were excluded. The percentage of large-caliber projectiles was plotted against time, and chi2 for trend was used to determine statistical significance.

RESULTS

Results are tabulated as mean +/- standard error bullet caliber (millimeters) over time. Linear regression reveals r = 0.944, p<0.0001. Data obtained from autopsy reports are not tabulated here, but chi2 for trend reveals a statistically significant increase in the proportion of large caliber and decrease in proportion of small-caliber bullets (p<0.001).

CONCLUSION

These data unveil an ominous trend toward the use of larger-caliber firearms in accidents, homicides, and suicides.

What pediatricians can do to further youth violence prevention--a qualitative study

OBJECTIVE

Youth violence is a public health problem world wide. However, the United States has the worst rate of youth violence among industralized countries. This study was conducted to learn what pediatricians, community leaders, and parents think the doctor's role is in youth violence prevention during the well-child examination for children.

METHODS

Interviews were conducted with pediatricians, community leaders, and parents living or working in Los Angeles, California.

RESULTS

All three groups interviewed believed that the physician should incorporate violence prevention counseling as part of the well-child examination. The mechanism of action differed for the three groups. Almost half of pediatricians' statements focused on their role as prevention counselor, with respect to such issues as appropriate discipline and gun safety. One third of community leaders' statements, however, related to physician referral to existing community resources. More than half of parents' statements referred to the pediatrician as someone who can directly educate their child about making positive choices.

CONCLUSIONS

Although pediatricians cannot solve the problem of youth violence alone, findings from this study suggest that they should address this issue with their patients and should work in tandem with existing community resources to further a solution to this growing epidemic.

Spinal cord injuries in adolescents after gunshot wounds: an increasing phenomenon in urban North America

While much attention is focused on firearm fatalities, the purpose of this study was to determine the expense of acute medical care and the rehabilitation experience of surviving adolescent patients in the USA with spinal cord injury secondary to gunshot wounds. We analyzed a cohort of 19 patients, 18 of whom survived 12 months after spinal cord injury. The need for primary medical care related to the injury, current work and scholastic status, and satisfaction with the quality of rehabilitation were determined. Ten were not involved in any type of academic or meaningful activity, five had returned to school, three were undergoing rehabilitation, and one patient died. Major complications were present in 14 of the 18 patients. Thus, despite a high survival rate after spinal cord injury in this USA population, considerable long-term disability persists, and survivors report a low level of satisfaction with life.

Successful approaches to community violence intervention and prevention

The field of injury prevention and control is diverse, cross-cutting, and has attracted the efforts of individuals from multiple disciplines. Many types of interventions have been applied in the area on intentional injury, specifically interpersonal violence. The results have been variable with few projects demonstrating scientific efficacy. Among the acknowledged stumbling blocks have been issues of project design, and deficiencies in the incorporation of communities into project development and implementation. This article discusses those elements that are critical to the creation of any community-based violence prevention intervention and offers guidelines for establishing a project's community context.