Family Firearm Ownership and Firearm-Related Mortality Among Young Children: 1976-2016

Adverse Childhood Experiences and Trajectories of Firearm Exposure in Childhood

OBJECTIVE

To examine the longitudinal relationship between exposure to adverse childhood experiences (ACEs) in early life and trajectories of firearm exposure from early to middle childhood (ages 5-9 years old).

STUDY DESIGN

Data from the Longitudinal Studies of Child Abuse and Neglect (LOGSCAN) study were used. The LONGSCAN study was a prospective study in the United States and contained data from 1354 children from age 4 to age 18 years old. Exposure to ACEs was measured through the wave 1 interview (age 5 years old) and trajectories of firearm exposure were created using data from waves 1 (age 5 years old) and two (age 9 years old).

RESULTS

Two trajectories of firearm exposure in childhood were identified: a low exposure group and a group with persistently-high firearm exposure from ages 5 to 9 years old. ACEs were associated with membership in the high exposure group and children with four or more ACEs had over twice the odds of membership in the high exposure group compared with children with zero ACEs.

CONCLUSION

ACEs exposure in early childhood is associated with persistently-high exposure to firearms from early to middle childhood. This finding highlights the need for pediatricians to consider screening for both ACEs and firearm exposure in routine examinations, as well as the need for future research to identify and evaluate interventions intended to address exposure to adversity and firearms.

Retrospective evidence for pediatric benefit of U.S. assault weapons ban as rationale for implementing an even more effective ban

BACKGROUND

With data available since 1981, firearm death rates in American children and adolescents can be evaluated for trends during the 13 years before, the decade of, and during 16 years since the United States (U.S.) 1994-2004 Federal Assault Weapons Ban (FAWB).

METHODS

National and regional firearm mortality trends in the U.S. during 1981-2020 were assessed with joinpoint regression applied to Centers for Disease Control and Prevention data.

RESULTS

After increasing exponentially before the FAWB, the national firearm death rate in 0-14 year-olds promptly reversed course and declined throughout the FAWB and then reversed again after the FAWB and resumed an exponential increase (all phases p<0.001). The reduction in firearm death rate occurred within 1-3 years of the start of the FAWB, in both sexes, in all four census regions of the U.S., and in all four major race/ethnicity subgroups, especially non-Hispanic blacks. No other form of violence in 0-14 year-olds had this temporal relationship with the FAWB. The firearm mortality reduction during the FAWB is strongly-highly correlated with the concomitant reduction in handgun manufacturing in 91 % of 24 sex, race/ethnicity and region subsets analyzed, These FAWB-related trends were also apparent in older adolescents and young adults and less so in older persons.

CONCLUSIONS

Firearm death rates in 0-14 year-olds before, during, and after the FAWB, and no other type of injury, implicate the FAWB as having had a beneficial effect. Legislation to mitigate firearm mortality and injury inclusive of a FAWB should be especially beneficial to children and young adolescents, and regardless of sex, race/ethnicity or region in the U.S.

Violent Experiences and Patterns of Firearm Ownership From Childhood to Young Adulthood

Importance

Young adults in their 20s are at high relative risk for self- and other-directed firearm injury, but little is known about gun access patterns for this group.

Objective

To describe the longitudinal patterns of firearm access from childhood to young adulthood and to estimate whether violence experienced as a child or as an adult is associated with gun ownership in young adulthood.

Design, Setting, and Participants

The Great Smoky Mountains Study included participants from 11 contiguous, mostly rural counties in the Southeastern US. The first wave was completed in 1993 and the most recent in 2019. Periodic survey data were gathered in adolescence through participants' late 20s. In 2023, adjusted Poisson regression with incident rate ratios (IRRs) and 95% CIs were used to estimate associations between violence and gun ownership in young adulthood in 3 age cohorts from the original sample.

Exposures

Violent experiences in childhood (bullying, sexual and physical abuse, violent events, witnessing trauma, physical violence between parents, and school/neighborhood dangerousness) or adulthood (physical and sexual assault).

Main Outcomes and Measures

Initiating gun ownership was defined as no gun access or ownership in childhood followed by gun ownership at age 25 or 30 years. Maintaining gun ownership was defined as reporting gun access or ownership in at least 1 survey in childhood and ownership at age 25 or 30 years.

Results

Among 1260 participants (679 [54%] male; ages 9, 11, and 13 years), gun access or ownership was more common in childhood (women: 366 [63%]; men: 517 [76%]) than in adulthood (women: 207 [36%]; men: 370 [54%]). The most common longitudinal pattern was consistent access or ownership from childhood to adulthood (373 [35%]) followed by having access or ownership in childhood only (408 [32%]). Most of the violent exposures evaluated were not significantly associated with the outcomes. Being bullied at school was common and was associated with reduced ownership initiation (IRR, 0.76; 95% CI, 0.61-0.94). Witnessing a violent event was significantly associated with increased probability of becoming a gun owner in adulthood (IRR, 1.24; 95% CI, 1.03-1.49).

Conclusions and Relevance

In this cohort study, gun ownership and access were transitory, even in a geographic area where gun culture is strong. Early adulthood-when the prevalence of gun ownership was relatively low-may represent an opportune time for clinicians and communities to provide education on the risks associated with firearm access, as well as strategies for risk mitigation.

Trends in paediatric firearm-related encounters during the COVID-19 pandemic by age group, race/ethnicity and schooling mode in Tennessee

BACKGROUND

Increases in paediatric firearm-related injuries during the COVID-19 pandemic may be due to changes in where children and adolescents spent their time. This study examines changes in the frequency of paediatric firearm-related encounters as a function of schooling mode overall and by race/ethnicity and age group at a large trauma centre through 2021.

METHODS

We use data from a large paediatric and adult trauma centre in Tennessee from January 2018 to December 2021 (N=211 encounters) and geographically linked schooling mode data. We use Poisson regressions to estimate smoothed monthly paediatric firearm-related encounters as a function of schooling mode overall and stratified by race and age.

RESULTS

Compared with pre pandemic, we find a 42% increase in paediatric encounters per month during March 2020 to August 2020, when schools were closed, no significant increase during virtual/hybrid instruction, and a 23% increase in encounters after schools returned to in-person instruction. The effects of schooling mode are heterogeneous by patient race/ethnicity and age. Encounters increased among non-Hispanic black children across all periods relative to pre pandemic. Among non-Hispanic white children, encounters increased during the closure period and decreased on return to in-person instruction. Compared with pre pandemic, paediatric firearm-related encounters increased 205% for children aged 5-11 and 69% for adolescents aged 12-15 during the school closure period.

CONCLUSION

COVID-19-related changes to school instruction mode in 2020 and 2021 are associated with changes in the frequency and composition of paediatric firearm-related encounters at a major trauma centre in Tennessee.

Examining risky firearm behaviors among high-risk gun carriers in New York City

Precarious firearm conduct among inexperienced gun possessors has the potential to intensify firearm-related fatalities and injuries. The current study involves face-to-face interviews with 51 high-risk (and prohibited) residents of Brooklyn and the Bronx, NY, each of whom have either been shot or shot at. We analyze study participants' lived experiences regarding urban gun violence (including as victims and perpetrators), firearm handling, sharing, and improper storage. Despite claiming to be knowledgeable about firearm fundamentals, the vast majority of respondents acknowledged never having received professional instruction, but rather "figured it out" by "playing around" with available guns. These informal methods were shaped by respondents' desire to arm themselves despite inadequate access to firearm training. Study participants also described routinely stashing firearms in unsecure, easily accessible locations. Our study findings have important implications for informing community-based harm reduction and safety strategies among persons within high-risk networks.

Child Access Prevention Laws and Non-Hispanic Black Youth Firearm Mortality

Firearm injuries are the leading cause of death for youths 19 and younger in general and the third leading cause of death for non-Hispanic Black youths. Child Access Prevention (CAP) laws have been explored concerning their impact on firearm mortality reduction among heterogenous groups of youth, but not specifically among non-Hispanic Black youths. We analyzed data related to non-Hispanic Black youth firearm mortality, non-Hispanic Black poverty rates, firearm dealer density, and CAP laws for each state to ascertain the impact of CAP laws from 2015 to 2019. During the study period, a total of 6778 non-Hispanic Black youths died due to firearm trauma with the leading causes of death being homicides (85.8%); mostly seen among males (96%), and in the South (53.2%). When compared by CAP laws, the states with the strongest laws had statistically significantly lower rates of firearm mortality than states with the weakest laws. After adjusting for state poverty and firearm dealer density, the differences were not statistically significant but still, stronger CAP laws were associated with lower rates of firearm mortality among non-Hispanic Black youth. CAP laws alone can have a modest impact on non-Hispanic Black youth firearm mortality. To adequately reduce firearm mortality among non-Hispanic Black youths, the state and local governments should, along with CAP laws, enact policies to reduce poverty, crime, access to firearms by criminals, and neighborhood dysfunction among non-Hispanic Black communities.

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.

Pediatric firearm injury trends in the United States: A national trauma data bank (NTDB) analysis

AIM OF STUDY

Firearm injuries are the second leading cause of injury-related death in the USA in children less than 18. We compared overall and intent-specific firearm hospitalizations across age group and race to understand recent trends.

METHODS

A retrospective cohort of 20,083 children from the national trauma data bank involved in incidences of firearm discharges from 2013 to 2017 was divided by race, discharge intent, gun type, and four age groups: infants (ages 0-2), toddlers (3-6), children (7-12), and adolescents (13-18). Discharge intent and gun type were determined by ICD-9-CM and ICD-10-CM External Causes of Injury codes. Injury severity score (ISS), hospital discharge disposition, and length of stay (LOS) were used as predictors for morbidity and mortality.

RESULTS

From 2013 to 2017, there were on an average 4016 firearm injuries reported to the NTDB (n = 20,083). 71% (n = 14,313) of the incidents were assaults. Victims who identified as African American and Caucasian made up 60% (n = 11,890) and 26% (n = 5162) of the total victims, respectively, and were predominantly male (86%, n = 17,202). Victims who identified as Caucasian made up 70% of suicides (n = 819), while African Americans made up 70% of assaults (n = 9733). 87% (n = 17,525) of the patient population were adolescents. The number of accidental firearm discharges compared to firearm assaults was greater for toddlers, while the opposite was true for infants, children, and adolescents. Average LOS by age group varied each year, though children had the highest total average LOS.  Average ISS was highest for infants and adolescents (11.5 and 10.4) and American Indians and Caucasians (10.1 and 11.1). Overall mortality rate was 6% (n = 1220) and had no significant differences between years. Mortality rate was highest for infants (7%, n = 25).

CONCLUSIONS

Adolescent males and African Americans were disproportionately affected by overall and assault-specific firearm discharges. Firearm injury prevention legislation is critical to prevent these injures.

A Preclinical Medical School Curriculum on Firearm Violence to Develop Patient Counseling and Foundational Health Policy Skills

BACKGROUND

Firearm violence is a unique public health crisis in the USA (US). A majority of U.S. physicians believe they should discuss firearm safety with patients. However, little education on firearm injury prevention and counseling exists in medical school. We sought to address this gap by creating a curriculum on firearm violence as a part of a required preclinical medical school course focused on health policy issues.

METHODS

The Kerns 6-step model for curriculum development was used to define the problem and assess learner needs. The two-hour small group session was co-authored by a student and faculty member to address the course theme of health policy as applied to firearm violence. The Issue-Attention Cycle, history of firearm policy, and US politics were incorporated from published literature, with a patient counseling role-play added in 2019.

RESULTS

The 'Current Case in Health Policy - Firearm Violence' small group was implemented in 2018 and 2019 for all first-year medical students. Of the 2018 student evaluations, 57% selected this small group as the most valuable in the course. In a follow-up survey in 2020, 78% of the respondents agreed that they felt more confident counseling patients on firearm safety following the role-play.

CONCLUSION

Students broadly endorsed the incorporation of firearm policy and counseling skills into medical education. This curriculum can be adapted for learners at all stages of training, especially given the limited exposure to this topic in medical education.

Age at first alcohol use and weapon carrying among adolescents: Findings from the 2019 Youth Risk Behavior Survey

BACKGROUND

Although studies have investigated the association between alcohol use and violent behaviors such as weapon carrying, few studies have examined the association between age at first alcohol use and weapon-carrying among adolescents. The objective of this study was to investigate the association between age at first alcohol use and weapon carrying among adolescents.

METHODS

Data for this study came from the 2019 Youth Risk Behavior Survey. An analytic sample of 13,442 adolescents aged 14-18 years old (51% female) was analyzed using binary logistic regression. The outcome variable investigated in this study was weapon carrying during the past 30 days, and the main explanatory variable investigated was age at first alcohol use.

RESULTS

Of the 13,442 adolescents, 13.5% carried a weapon during the past 30 days, and 15.4% reported having their first alcoholic drink before age 13. In the multivariable logistic regression, adolescents who reported having alcohol before age 13 had more than double the odds of carrying a weapon when compared to those who never had alcohol before age 13 (AOR = 2.32, p < .001, 95% CI = 1.87-2.89). Other significant factors associated with weapon carrying include male gender, victim of bullying, teen dating violence, sexual violence, suicidal ideation, and history of substance use. Adolescents who self-identified as Black/African American or Hispanic were significantly less likely to carry a weapon when compared to adolescents who self-identified as non-Hispanic White.

CONCLUSION

The findings of this study underscore the importance of developing age appropriate intervention strategies to curb early initiation of alcohol use and weapon carrying among adolescents.

When the kids get guns - The effects of lowering the minimum age of firearm possession in Alabama

At this time, the relationship between firearm minimum age laws and pediatric injury rates remains unclear. In September 2015, Alabama implemented Act 2015-341 (Act 341) which allowed minors to carry guns with parental permission. The purpose of this study was to evaluate the effect that Act 341 had on firearm injury rates. We created a database of all pediatric patients who presented to the Children's of Alabama's (CoA) emergency department and the Jefferson County Coroner's Office (JCCO) with a gunshot wound injury between May 2011 to December 2019. Wilcoxon ranked sum test analysis were used to contrast the average number of monthly patients arriving before and after implementation of Act 341 and Wilcoxon ranked sum test and Fisher Exact were used to evaluate differences in demographic and outcome data. A total of 316 patients presented within the specified time period with 116 arriving prior to Act 341 and 200 arriving after; an average of 2.21 and 3.85 patients per month respectively. We found an increase of 1.63 patients per month (p < 0.001). There was also significant increases in the proportion of patients who died or had a long-term disability following the event as well as the number of days of admission. Our study is suggestive that lowering the minimum age can lead to increased pediatric injury and indicates that further research is needed to fully elucidate the relationship.

Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

OBJECTIVE

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury.

METHODS

This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury (excluding nonpowder) in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included: (1) difference in health care encounters for 1 year before and 1 year after injury, (2) difference in health care expenditures, and (3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests.

RESULTS

Among 1,821 children, there were 22,398 health care encounters before the injury and 28,069 after. Concomitantly, there was an overall increase of $16.5 million in health expenditures ($9,084 per patient). There was a 50% increase in children qualifying for complex chronic condition status after firearm injury.

CONCLUSIONS

Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Firearm Storage Practices of US Members of the American College of Surgeons

BACKGROUND

As a part of its firearm injury prevention action plan, the American College of Surgeons (ACS) surveyed the entire US ACS membership regarding individual members' knowledge, experience, attitudes, degree of support for ACS Committee on Trauma (COT) firearm programs, and degree of support for a range of firearm injury prevention policies. This survey included questions regarding members' prevalence of firearm ownership, type of firearm(s) owned, type of firearm(s) in the home, personal reasons for firearm ownership, and methods of firearm/ammunition storage.

STUDY DESIGN

An email invitation to participate in an anonymous, 23-item survey on firearms was sent to all US ACS members (n = 54,761) by a contracted survey research firm. Cross tabulation of questionnaire items by demographic characteristics and chi-square analyses were performed with statistical significance p < 0.05.

RESULTS

The overall response rate was 20.4% (11,147/54,761). Forty-two percent of respondents keep firearms in their home (82% long guns, 82% handguns; 32% high-capacity magazine fed, semi-automatic rifles); 75% keep guns for self-defense/protection, 73% for target shooting; 39% store firearms unlocked, and 32% store guns unlocked and loaded. Results vary by practice/training location, practice type, military experience, sex, age, presence of children in the home, level of training, and race/ethnicity.

CONCLUSIONS

A significant percentage of ACS members keep firearms in their home, and nearly one-third store firearms in an unlocked and loaded fashion. Safe storage is a basic tenet of responsible firearm ownership. These data present opportunities for engaging surgeons in efforts to improve safe firearm storage.

Parents' Perspectives on Safe Storage of Firearms

Firearms contribute substantially to leading causes of death among US children ages 10-19 (suicide and homicide). Safe storage of guns is important but poorly adopted. This study sought to understand knowledge, attitudes, beliefs, and firearm storage practices among parents living in households with firearms. Focus groups (FG) were conducted with gun-owning parents/guardians in three US states with high firearm ownership. Participants also completed an anonymous survey which included demographic characteristics, previous gun education, purpose of gun ownership, and storage practices. Eight FG were conducted with 57 parents. 74% of participants stored at least one firearm unlocked, with many loaded. Overall risk perception for firearm injury was low. Many participants believed modeling responsible use within the family would demystify the presence of a firearm and decrease accidental shootings. There was strong perception that safe storage interferes with personal protection needs, especially for handguns. Trigger locks were considered a nuisance and rarely used. Parents were confident in their youth's ability to handle guns safely and did not believe that safe storage would deter suicide. Preferred messengers for safe storage education were military or law enforcement rather than physicians. Participants advocated for safe storage education paired with hands-on use education. Gun-owning parents supported safety education and endorsed education from nonmedical sources. Education about suicide prevention may improve adoption of safe storage by parents. These results will inform the development of a firearm safe storage campaign with improved acceptability for communities with high firearms use and ownership.

Sociodemographic Factors and Outcomes by Intent of Firearm Injury

BACKGROUND AND OBJECTIVES

Firearm injuries are a leading and preventable cause of morbidity and mortality among youth. We sought to explore differences in sociodemographic factors and youth firearm injury outcomes by injury intent (unintentional, assault, and self-harm).

METHODS

We conducted a repeated cross-sectional analysis of emergency department (ED) visits among youth aged 21 and younger presenting to an ED with a firearm injury between 2009 and 2016 using the Nationwide Emergency Department Sample. We performed multivariable logistic regression to measure the strength of association between (1) patient-level factors, (2) visit-level characteristics, and (3) clinical outcomes and intent of firearm injury.

RESULTS

We identified 178 299 weighted visits for firearm injuries. The mean age was 17.9 (95% confidence interval 17.8-18.0) years; 89.0% of patients were male, 43.0% were publicly insured, 28.8% were admitted, and 6.0% died. Approximately one-third of the injuries were categorized as unintentional (39.4%), another third as assault (37.7%), and a small proportion as self-harm (1.7%). Unintentional firearm injuries were associated with younger age, rural hospital location, Southern region, ED discharge, and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back, or spinal cord injury. Firearm injuries by assault were associated with lower socioeconomic status, urban hospital location, and requiring admission.

CONCLUSIONS

We identified distinct risk profiles for youth with unintentional, self-harm-, and assault-related firearm injuries. Sociodemographic factors related to intent may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

Retracted Nonfatal firearm injuries: Utilization and expenditures for children pre- and postinjury

Firearm injuries are one of the leading preventable causes of morbidity and mortality among children. Limited information exists about the impact of nonfatal firearm injuries on utilization and expenditures. Our objective was to compare health care encounters and expenditures 1 year before and 1 year following a nonfatal firearm injury. This was a retrospective cohort study of children 0 to 18 years with ICD-9/ICD-10 diagnosis codes for firearm injury in the emergency department or inpatient setting from 2010 to 2016 in the Medicaid MarketScan claims database. Outcomes included 1) difference in health care encounters for 1 year before and 1 year after injury, 2) difference in health care expenditures, and 3) difference in complex chronic disease status. Descriptive statistics characterized patient demographics and health care utilization. Health expenditures were evaluated with Wilcoxon signed-rank tests. Among 3,296 children, there were 47,660 health care encounters before the injury and 61,660 after. Concomitantly, there was an overall increase of $18.5 million in health expenditures ($5,612 per patient). There was a 40% increase in children qualifying for complex chronic condition status after firearm injury. Children who experience nonfatal firearm injury have increased number of health care encounters, chronic disease classification, and health care expenditures in the year following the injury. Prevention of firearm injuries in this vulnerable age group may result in considerable reductions in morbidity and health care costs.

Increasing Rate of Unintentional Firearm Deaths in Youngest Americans: Firearm Prevalence and Covid-19 Pandemic Implication

BACKGROUND

The United States has had, by far, the world's greatest civilian ownership of firearms. An even greater ownership occurred during the Covd-19 pandemic, mostly of handguns and including many new owners. The U.S. has also had the least progress of the 41 highest sociodemographic countries ranked by the Institute for Health Metrics and Evaluation in reducing the unintentional firearm mortality rate in young children. This study characterized the unintentional firearm mortality trends in American 1-4 year-olds by sex and race/ethnicity and evaluated the trends in the context of firearm prevalence in the U.S.

METHODS

Mortality data for 1999-2018 were obtained from the U.S. Centers for Disease Control and Prevention and the Institute for Health Metrics and Evaluation, firearm injury and mortality data for 2016-2020 from Everytown for Gun Safety #NotAnAccident database, firearm background check data for 1999-2020 from the National Instant Criminal Background Check System, and civilian firearm prevalence for 2017 from the Small Arms Survey.

RESULTS

In American 1-4 year-olds, the rate of unintentional firearm deaths during 1999-2018 increased exponentially at an average annual percent rate of 4.9 (p < 0.001) and was greatest in non-Hispanic black children. Unintentional firearm deaths had the most rapid increase of all evaluable causes of death in the age group. The unintentional firearm death rate increase was correlated with the concurrent rate of firearm background checks and handgun permits issued (each p < 0.001) and in non-Hispanic white children with handgun prevalence in their families (p = 0.03). Globally, the unintentional firearm death rate was also correlated with firearm prevalence (p = 0.02).

CONCLUSIONS

An increase in fatal firearm accidents in the United States death rate among 1-4 year-olds is directly associated with the steadily increasing prevalence of firearms. The acceleration of firearm deaths and injuries among young Americans, especially among non-Hispanic black children, requires urgent solutions to address firearm prevalence and access. The problem is expected to become even more urgent as a result of the record high firearm sales that occurred in the United States during the 2020 coronavirus pandemic.

Critical care resource use, cost, and mortality associated with firearm-related injuries in US children's hospitals

BACKGROUND/PURPOSE

To assess trends and resource use attributable to firearm-related injuries in US pediatric intensive care units (PICUs).

METHODS

Retrospective data from Pediatric Health Information Systems (PHIS) database from 2004 to 2017.

RESULTS

Of 5,984,938 admissions to 28 children's hospitals, 3707 were for firearm injuries. A total of 1088 of 3707 hospitalizations (29.9%) required PICU admission. Median PICU length of stay was 2 days (IQR, 1-6 days), and the median cost for PICU patients was $37,569.31 (IQR, $19,243.83-$77,856.32). Use of mechanical ventilation (674/1088 admissions [61.9%]), surgical procedures (744/1088 admissions [68.3%]), blood transfusions (429/1088 admissions [39.9%]), and intracranial pressure monitoring devices (30/1088 admissions [2.8%]) increased in PICU patients. Computed tomography showed an overall increase (197/287 [68.6%] to 138/177 [78%], P = .037) from 2004 to 2007 to 2016-2017. Mortality among PICU patients (140/1058 [13.23%]) attributable to firearm-related injuries increased insignificantly (34/285 (11.93%] to 25/172 [14.53%], P = .746).

CONCLUSIONS

Using PHIS data, we found a significant increase in median cost per hospitalization and an increase in critical care resource use, including the frequency of invasive mechanical ventilatory assistance, neuromonitoring, operations performed, and transfusion of blood products. Further research is needed to continue to characterize the burden of pediatric critical firearm injury.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

Gunshot wound incidence as a persistent, tragic symptom of area deprivation

BACKGROUND

More than 30,000 Americans die every year of firearm-related injuries. Gun violence is frequently addressed by law enforcement and policing, as opposed to public health interventions that might address poverty or deprivation. Our goal was to evaluate the past 20 years of gunshot wound injury demographics seen at our level I academic trauma center and create a risk map model correlating gunshot wound incidence with area deprivation.

METHODS

Patients admitted for gunshot wound-related injuries between 1996 and 2017 were identified using our trauma registry. Demographic and injury data were extracted and analyzed. Multivariable logistic regression models were created to identify predictors of mortality. Geographic information system mapping of incident location and home address was completed to identify zip code hot spots of high gunshot wound incidence. Area Deprivation Indices, which reflect local income or poverty, housing, education, and employment were used as a marker of relative economic disadvantage. Spearman rank correlation was used to determine the relationship between Area Deprivation Indices score and gunshot wound rate.

RESULTS

A total of 2,413 patients with gunshot wounds were evaluated. The cohort had a mean age of 28.8 ± 11.5 and was 89.6% male. Mean Injury Severity Score was 11 ± 12.5. gunshot wounds were most frequently a result of assault (91.1%), followed by unintentional injury (3.4%). Geographic information systems mapping revealed significant clustering of gunshot wounds. The areas with highest per capita incidence of gunshot wounds was strongly correlated with Area Deprivation Indices (0.594, P < .001).

CONCLUSION

Geographic regions of known lower socioeconomic resources have higher incidence of gunshot wounds in our community. Both Area Deprivation Indices and gunshot wound incidents in these distressed communities remained unchanged throughout the past 20 years, despite law enforcement crime suppression efforts. Gunshot wounds appear to be a symptom of area deprivation, similar to failing schools and poor health outcomes. Efforts to decrease poverty and community capacity-building may help alleviate this area deprivation.

Homicidal Ideation among Children and Adolescents: Evidence from the 2012-2016 Nationwide Emergency Department Sample

OBJECTIVE

To assess the prevalence and behavioral, sociodemographic, and psychiatric/psychological correlates of homicidal ideation among a sample of children and adolescents.

STUDY DESIGN

We employed descriptive and multivariate logit models of homicidal ideation using data from the 2012-2016 Nationwide Emergency Department Sample from the Healthcare Cost and Utilization Project. This study was conducted with data from emergency departments in the US, and we used a sample of (N = 17 041 346) children and adolescents between the ages of 5 and 17 years.

RESULTS

Pediatric homicidal ideation is rare with a prevalence estimate of 0.09%; however, its prevalence increases substantially from age 5 years to age 15 years when it peaks, and then declines through the end of adolescence. Conduct disorders conferred 1483% increased odds, attention deficit hyperactivity disorder conferred 616% increased odds, and other behavioral and emotional disorders increased a 2-fold to nearly 4-fold increased liability for homicidal ideation net the effects of sex, age, urban residence, insurance status, and zip code median household income.

CONCLUSION

In the wake of homicide tragedies, it is often the case that numerous behavioral and clinical red flags were present in the developmental history of the perpetrator, but these were overlooked. Identifying children and adolescents who present with homicidal ideation is a crucial pediatric and public health matter that can inform prevention and behavioral interventions that forestall lethal violence.

Characteristics of Gun Advertisements on Social Media: Systematic Search and Content Analysis of Twitter and YouTube Posts

Background

Although gun violence has been identified as a major public health concern, the scope and significance of internet gun advertising is not known.

Objective

This study aimed to quantify the characteristics of gun advertising on social media and to compare the reach of posts by manufacturers with those of influencers.

Methods

Using a systematic search, we created a database of recent and popular Twitter and YouTube posts made public by major firearm manufacturers and influencers. From our sample of social media posts, we reviewed the content of the posts on the basis of 19 different characteristics, such as type of gun, presence of women, and military or police references. Our content analysis summarized statistical differences in the information conveyed in posts to compare advertising approaches across social media platforms.

Results

Sample posts revealed that firearm manufacturers use social media to attract audiences to websites that sell firearms: 14.1% (131/928; ±2.9) of Twitter posts, 53.6% (228/425; ±6.2) of YouTube videos, and 89.5% (214/239; ±5.1) of YouTube influencer videos link to websites that facilitate sales. Advertisements included women in efforts to market handguns and pistols for the purpose of protection: videos with women included protection themes 2.5 times more often than videos without women. Top manufacturers of domestic firearms received 98 million channel views, compared with 6.1 billion channel views received by the top 12 YouTube influencers.

Conclusions

Firearm companies use social media as an advertising platform to connect viewers to websites that sell guns. Gun manufacturers appropriate YouTube servers, video streaming services, and the work of YouTube influencers to reach large audiences to promote the widespread sale of consumer firearms. YouTube and Twitter subsidize gun advertising by offering server and streaming services at no cost to gun manufacturers, to the commercial benefit of Google and Twitter’s corporate ownership.

A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting

PURPOSE

Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting.

METHODS

A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety.

RESULTS

The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home.

CONCLUSION

Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home.

LEVEL OF EVIDENCE

Level III.