Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic

BACKGROUND

Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic.

METHOD

The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic.

RESULTS

Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic.

DISCUSSION

Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

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.

Threats, Violence, and Weapon Use Against Children in Domestic Violence Protection Orders

BACKGROUND AND OBJECTIVES

Childhood exposure to domestic violence is common, but the overlap between threats and violence against children and weapon/firearm use has not been well studied. The objectives of this study were to: assess differences in respondent firearm access and the use of weapons in granted domestic violence protection orders (DVPOs) with and without minors (individuals <18 years of age); and characterize the frequency and characteristics of threats and acts of violence against minors.

METHODS

We conducted a cross-sectional study of a random sample of granted DVPOs from 2014-2020 in King County, Washington. We examined the use of threats, violence, and weapons by restrained individuals (ie, respondents) by reviewing and abstracting information from DVPO case files.

RESULTS

Respondent weapon use and firearm possession were more common among DVPOs including minors than DVPOs not including minors (weapon use: 38.2% and 33.0%; firearm possession: 23.1% and 19.1%, respectively). Almost 2 in 3 DVPOs including minors (1338 of 2029) involved threats or violence directed at a minor perpetrated by the DVPO respondent. About 1 in 3 (32.5%) DVPOs documented explicit threats, and 1 in 2 (48.9%) documented violence. Over two-thirds (680 of 993, 68.5%) of acts of violence directed at minors included a weapon.

CONCLUSIONS

We found higher lethality risk (weapon use and respondent firearm access/ownership) among DVPOs including minors. Many minors experienced threats and acts of violence involving weapons and firearms by DVPO respondents. Evidence-based safety planning strategies and training of judicial officers are needed.

Lessons Learned From Integrating Anti-Oppression Pedagogy in a Graduate-Level Course in Epidemiology

Despite the high burden of injury and violence globally and disproportionate burden on marginalized communities, few US schools of public health and departments of epidemiology offer classes focused on injury and violence, and even fewer are taught with an antiracist or anti-oppression framework. Recent years have brought renewed focus to incorporating antiracist and anti-oppression principles to pedagogy. Public health professionals have increasingly grappled with how we teach, conduct research, and advocate for just policies, which are shaped by interlocking systems of oppression. Although all areas of epidemiology are shaped by these structures, motivations for those who study injury and violence ought to be especially keen. In this commentary, we illustrate how anti-oppression can be integrated into course development and delivery with a case study of a graduate-level course at the University of Washington School of Public Health on injury and violence epidemiology. We include feedback from an epidemiology faculty reviewer, as well as narratives from students describing what worked and what did not. We offer our reflections and lessons learned, hoping to encourage others within public health and epidemiology to adopt an anti-oppression framework in developing classes and programs, particularly those related to injury and violence.

Race, structural racism and racial disparities in firearm homicide victimisation

OBJECTIVES

To identify an approach in measuring the association between structural racism and racial disparities in firearm homicide victimisation focusing on racism, rather than race.

METHODS

We examined associations of six measures of structural racism (Black/white disparity ratios in poverty, education, labour force participation, rental housing, single-parent households and index crime arrests) with state-level Black-white disparities in US age-adjusted firearm homicide victimisation rates 2010-2019. We regressed firearm homicide victimisation disparities on four specifications of independent variables: (1) absolute measure only; (2) absolute measure and per cent Black; (3) absolute measure and Black-white disparity ratio and (4) absolute measure, per cent Black and disparity ratio.

RESULTS

For all six measures of structural racism the optimal specification included the absolute measure and Black-white disparity ratio and did not include per cent Black. Coefficients for the Black-white disparity were statistically significant, while per cent Black was not.

CONCLUSIONS

In the presence of structural racism measures, the inclusion of per cent Black did not contribute to the explanation of firearm homicide disparities in this study. Findings provide empiric evidence for the preferred use of structural racism measures instead of race.

School Handgun Carrying Among Youth Growing Up in Rural Communities

PURPOSE

To characterize school handgun carrying and violence risk factors among rural youth.

METHODS

Using a sample of rural youth (n = 1995), we quantified the proportion who carried a handgun to school, carried but not to school, and did not carry across grades 7-12 and endorsed risk factors for violence in individual, peer, school, and community domains.

RESULTS

Overall, 3% (95% confidence interval [CI]: 2%-4%) of youth ever carried to school; 15% (95% CI: 14%-16%) carried but not to school; and 82% (95% CI: 80%-84%) never carried. Violence risk factors (e.g., attacking someone) were more commonly endorsed by youth who carried to school (84%; 95% CI: 73%-95%) than those who carried but not to school (51%; 95% CI: 44%-58%) and did not carry (23%; 95% CI: 20%-26%).

DISCUSSION

Carrying a handgun to school in rural areas is not common; however, it is associated with risk factors for violence. Understanding violence risk factors among youth who carry handguns to school could inform violence prevention programs in rural areas.

Bullying and physical violence and their association with handgun carrying among youth growing up in rural areas

OBJECTIVES

This study builds on prior research showing a strong relationship between handgun carrying and delinquent behaviors among urban youth by examining the association between handgun carrying trajectories and various types of violence in a rural sample.

METHODS

This study uses data from a longitudinal cohort study of 2002 public school students in the United States from 12 rural communities across 7 states from ages 12-26 (2005-2019). We used logistic regressions to assess associations of various bullying and physical violence behaviors with latent trajectories of handgun carrying from adolescence through young adulthood.

RESULTS

Compared to youth with very low probabilities of carrying a handgun in adolescence and young adulthood, trajectories with high probabilities of handgun carrying during adolescence or young adulthood were associated with greater odds of using bullying (odds ratios (ORs) ranging from 1.9 to 11.2) and higher odds of using physical violence during adolescence (ORs ranging from 1.5 to 15.9) and young adulthood (ORs ranging from 1.9 to 4.7). These trajectories with higher probabilities of handgun carrying were also associated with greater odds of experiencing physical violence like parental physical abuse and intimate partner violence, but not bullying.

CONCLUSION AND IMPLICATION

Experiencing and using bullying and physical violence were associated with specific patterns of handgun carrying among youth growing up in rural areas. Handgun carrying could be an important focus of violence prevention programs among those youth.

Suicide, Firearms, and Terminal Illness: A Latent Class Analysis Using Data From the National Violent Death Reporting System

OBJECTIVE

Firearms are highly lethal when used for suicide and are used more frequently as a suicide method by persons of older age. Individuals with terminal illness are at high risk for suicide, yet little research has explored how firearms may be used for self-harm in this population. The authors sought to understand the patterns of psychiatric diagnoses, substance use disorders diagnoses, and suicide mechanisms for individuals with terminal illness who died by suicide as well as their demographic and circumstantial characteristics.

METHODS

A latent class analysis using data from the National Violent Death Reporting System was undertaken to better understand typologies of individuals with terminal illness who died by suicide in 2003-2018 (N=3,072). To develop the classes, the authors considered diagnoses of mental illness and of alcohol or substance use disorders, suicidal thoughts and behaviors, and mechanism of suicide (firearm or no firearm). Demographic and circumstantial variables were examined across classes.

RESULTS

The analysis revealed four classes of persons with terminal illness who died from suicide: depression and nonfirearm methods (N=375, 12%), suicidal intent and firearm use (N=922, 30%), alcohol or substance use disorder and nonfirearm methods (N=70, 2%), and firearm use only (N=1,705, 56%).

CONCLUSIONS

Firearm access is an important consideration for terminally ill persons at risk for suicide. Screening for psychiatric and substance use disorders may not identify terminally ill persons who are at increased suicide risk because of the presence of a firearm in the home. This population may benefit from tailored interventions in specialty care settings to address firearm safety.

Analysis of Daily Ambient Temperature and Firearm Violence in 100 US Cities

IMPORTANCE

Firearm violence is a leading public health crisis in the US. Understanding whether and how ambient temperature is associated with firearm violence may identify new avenues for prevention and intervention.

OBJECTIVE

To estimate the overall and regional association between hotter temperatures and higher risk of firearm violence in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used distributed lag nonlinear models, controlling for seasonality and long-term time trends by city and pooled results overall and by climate region. The most populous cities in the US with the highest number of assault-related firearm incidence (ie, shootings) from 2015 to 2020 were analyzed. Data analysis was performed from October 2021 to June 2022.

EXPOSURES

Maximum daily temperature by city.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of assault-related firearm shootings by city.

RESULTS

A total of 116 511 shootings in 100 cities were included in this analysis. The pooled analysis estimated that 6.85% (95% CI, 6.09%-7.46%) of all shootings were attributable to days hotter than city-specific median temperatures. This equates to 7973 total shootings (95% CI, 7092-8688 total shootings) across the 100 cities over the 6-year study period, although the number of total persons injured or killed would be higher. Estimated risk of firearm incidents increased almost monotonically with higher temperatures, with a local peak at the 84th percentile of the temperature range corresponding to a relative risk of 1.17 (95% CI, 1.12-1.21) compared with the median temperature. However, even moderately hot temperatures were associated with higher risk of shootings. Although significant, there was low heterogeneity between cities (I2 = 11.7%; Cochran Q test, P = .02), indicating regional or climate-specific variation in the daily temperature and incident shootings relationship.

CONCLUSIONS AND RELEVANCE

These findings underscore the importance of heat adaptation strategies broadly throughout the year to reduce shootings, rather than focusing on only the hottest days.

Neighborhood segregation, tree cover and firearm violence in 6 U.S. cities, 2015-2020

Neighborhood segregation by race and income is a structural determinant of firearm violence. Addressing green space deficits in segregated neighborhoods is a promising prevention strategy. This study assessed the potential for reducing firearm violence disparities by increasing access to tree cover. Units of analysis were census tracts in six U.S. cities (Baltimore, MD; Philadelphia, PA; Richmond, VA; Syracuse, NY; Washington, DC; Wilmington, DE). We measured segregation using the index of concentration at the extremes (ICE) for race-income. We calculated proportion tree cover based on 2013-2014 imagery. Outcomes were 2015-2020 fatal and non-fatal shootings from the Gun Violence Archive. We modeled firearm violence as a function of ICE, tree cover, and covariates representing the social and built environment. Next, we simulated possible effects of "tree equity" programs, i.e., raising tract-level tree cover to a specified baseline level. In our fully-adjusted model, higher privilege on the ICE measure (1 standard deviation, SD) was associated with a 42% reduction in shootings (incidence rate ratio (IRR) = 0.58, 95% CI [0.54 0.62], p < 0.001). A 1-SD increase in tree cover was associated with a 9% reduction (IRR = 0.91, 95% CI [0.86, 0.97], p < 0.01). Simulated achievement of 40% baseline tree cover was associated with reductions in firearm violence, with the largest reductions in highly-deprived neighborhoods. Advancing tree equity would not disrupt the fundamental causes of racial disparities in firearm violence exposure, but may have the potential to help mitigate those disparities.

A Clinician's Guide to Conducting Research on Causal Effects

Surgeons are uniquely poised to conduct research to improve patient care, yet a gap often exists between the clinician's desire to guide patient care with causal evidence and having adequate training necessary to produce causal evidence. This guide aims to address this gap by providing clinically relevant examples to illustrate necessary assumptions required for clinical research to produce causal estimates.

Prevalence of a loaded firearm in the home among birth parents experiencing symptoms of postpartum depression

Firearm access increases the risk of suicide among all household members. The prevalence of loaded firearms in the home among those experiencing symptoms of postpartum depression (PPD) is unknown. We conducted a cross-sectional study using Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2019. We included participants from the nine jurisdictions that asked about loaded firearms in the home and who screened positive for PPD. We excluded participants whose infants were not alive at time of survey completion and who did not respond to the firearm question, resulting in an analytic sample of 4986 participants. Using PRAMS analytic weights, we estimated the prevalence of a loaded firearm in the home and the prevalence of screening for PPD based on having a loaded firearm in the home. Among PRAMS participants experiencing symptoms of PPD, 8.8% (95% CI: 7.6%, 10.1%) reported there was a loaded firearm in their home. Participants with a loaded firearm in their home were more likely to be White (81.3% vs. 60.6%) and live in a rural area (57.9% vs. 27.5%) than those without. Among participants who reported attending a postpartum checkup, 78.6% (95% CI: 67.0%, 90.2%) of those with a loaded firearm in their home reported having been asked by a provider if they were feeling depressed, compared to 88.7% (95% CI: 85.3%, 92.0%) of those without. About 1 in 11 birth parents experiencing symptoms of PPD report a loaded firearm in their home. Further screening for firearm access in this population may need to be considered.

Long-Term Prescription Opioid Use After Injury in Washington State 2015-2018

BACKGROUND

Patients with injury may be at high risk of long-term opioid use due to the specific features of injury (e.g., injury severity), as well as patient, treatment, and provider characteristics that may influence their injury-related pain management.

OBJECTIVES

Inform prescribing practices and identify high-risk populations through studying chronic prescription opioid use in the trauma population.

METHODS

Using the Washington State All-Payer Claims Database (WA-APCD) data, we included adults aged 18-65 years with an incident injury from October 1, 2015-December 31, 2017. We compared patient, injury, treatment, and provider characteristics by whether or not the patients had long-term (≥ 90 days continuous prescription opioid use), or no opioid use after injury.

RESULTS

We identified 191,130 patients who met eligibility criteria and were included in our cohort; 5822 met criteria for long-term use. Most had minor injuries, with a median Injury Severity Score = 1, with no difference between groups. Almost all patients with long-term opioid use had filled an opioid prescription in the year prior to their injury (95.3%), vs. 31.3% in the no-use group (p < 0.001). Comorbidities associated with chronic pain, mental health, and substance use conditions were more common in the long-term than the no-use group.

CONCLUSION

Across this large cohort of multiple, mostly minor, injury types, long-term opioid use was relatively uncommon, but almost all patients with chronic use post injury had preinjury opioid use. Long-term opioid use after injury may be more closely tied to preinjury chronic pain and pain management than acute care pain management.

Assault-related injuries reported to police and treated by healthcare providers in the United States

Research suggests that assault-related injuries known by the police significantly differ from those known by healthcare providers, but the magnitude and nature of these differences are poorly understood. To address this gap, our study examined the empirical differences between assault-related injuries reported to police and treated by healthcare providers. In June of 2021, we analyzed the National Crime Victimization Survey (1993-2019) to estimate the prevalence of police reporting and healthcare use among 5093 nonfatal victimizations that caused injury and were either reported to the police or treated by healthcare in the United States. Quasi-Poisson models identified the factors associated with whether people who sustained the injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare). Among victimizations that caused only minor injuries, 43% involved only a police report, 11% involved only healthcare, and 46% involved both services. Among victimizations that caused serious injuries, 14% involved only a police report, 13% involved only healthcare, and 73% involved both services. Whether people with violent injuries used healthcare (v. only reported to police) and reported to police (v. only used healthcare) was significantly associated with 13 different person- and incident-level factors. The number and nature of assault-related injuries reported to law enforcement significantly differ from those treated by healthcare providers. Therefore, public health efforts to link police and healthcare data are warranted and recommended.

Trajectories of Handgun Carrying in Rural Communities From Early Adolescence to Young Adulthood

IMPORTANCE

Characterizing patterns of handgun carrying among adolescents and young adults can inform programs to reduce firearm-related harm. Longitudinal patterns of handgun carrying among rural adolescents have not been identified.

OBJECTIVES

To assess specific points of intervention by characterizing patterns of handgun carrying by youths in rural communities from early adolescence to young adulthood and to quantify how age at initiation, duration, and frequency of carrying differ across identified patterns.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses the control group of the community-randomized trial of the Communities That Care prevention system, conducted among public school students in 12 rural communities across 7 states. Participants self-reported their handgun carrying at 10 data collection points from 12 to 26 years of age (2005-2019). Data were analyzed from January to July 2021.

MAIN OUTCOMES AND MEASURES

Handgun carrying in the past 12 months. Latent class growth analysis was used to estimate handgun carrying trajectories.

RESULTS

In this longitudinal rural sample of 2002 students, 1040 (51.9%) were male; 532 (26.6%) were Hispanic, Latino, Latina, or Latinx; 1310 (65.4%) were White; and the highest level of educational attainment of either parent was a high school degree or less for 649 students (32.4%). The prevalence of handgun carrying in the last 12 months ranged from 5.3% (95 of 1795) to 7.4% (146 of 1969) in adolescence and increased during the mid-20s (range, 8.9% [154 of 1722] to 10.9% [185 of 1704] from 23 to 26 years of age). Among the participants who reported handgun carrying at least once between 12 and 26 years of age (n = 601 [30.0%]), 320 (53.2%) reported carrying a handgun in only 1 wave. Latent class growth analysis indicated 6 longitudinal trajectories: never or low probability of carrying (1590 [79.4%]), emerging adulthood carrying (166 [8.3%]), steadily increasing carrying (163 [8.1%]), adolescent carrying (53 [2.6%]), declining carrying (24 [1.2%]), and high probability and persistent carrying (6 [0.3%]). The earliest mean (SD) age at initiation of handgun carrying occurred in both the adolescent and declining carrying groups at the ages of 12.6 (0.9) and 12.5 (0.7) years, respectively. More than 20% of some groups (emerging adulthood [age 26 years: 49 of 154 (31.8%)], steadily increasing [age 26 years: 37 of 131 (28.2%)], declining [age 13 years: 7 of 23 (30.4%)], and high probability and persistent carrying [age 15 years: 3 of 6 (50.0%)]) reported carrying 40 times or more in the past year by the age of 26 years.

CONCLUSIONS AND RELEVANCE

This study found distinct patterns of handgun carrying from adolescence to young adulthood in rural settings. Findings suggest that promoting handgun safety in rural areas should start early. Potential high-risk trajectories, including carrying at high frequencies, should be the focus of future work to explore the antecedents and consequences of handgun carrying in rural areas.

Domestic Violence Alleged in California Child Maltreatment Reports During the COVID-19 Pandemic

During the COVID-19 pandemic, reports to child abuse and neglect hotlines have dropped significantly across the United States. Yet, during this same period, calls to domestic violence hotlines have increased. The purpose of this study was to examine if there have been measurable changes in domestic violence-related reports to child abuse and neglect hotlines. Using administrative child protection records from California, we plotted counts and proportions of child maltreatment reports with and without domestic violence allegations before and through the onset of school closures associated with the COVID-19 pandemic. We used an interrupted time series analysis to evaluate whether or not there was a change in domestic violence allegations in child protection reports corresponding to the COVID-19 pandemic. We document that during the first two quarters of 2020 there was a 14.3% drop in the overall number of child protection reports. Despite a decline in maltreatment reporting overall, there was a 25% increase in the proportion of reports with allegations of domestic violence. Our findings suggest both the count and composition of reports to child protection agencies were affected by the COVID-19 pandemic. The current analyses also showcase the seasonality of CPS reports generally, and reports with DV allegations, specifically.

Risk Factors for Child Death During an Intimate Partner Homicide: A Case-Control Study

Corollary victims represent approximately 20% of all intimate partner homicides (IPH), and many are children. We used National Violent Death Reporting System (NVDRS) data (2003-2017) to compare all IPH incidents with a child corollary victim (n = 227) to all IPH incidents where a child was present but not killed (n = 350). We examined risk factors for child fatality during an IPH. For each risk factor, we calculated the odds ratio for child death during the IPH, adjusting for multiple comparisons. Perpetrator history of suicidal behavior, rape of the intimate partner victim, a non-biological child of the perpetrator living in the home, and perpetrator job stressors increased odds while prior separation of the IPV victim from the perpetrator decreased the odds of a child death during an IPH incident. To our knowledge, this is the first case-control study using live-controls within NVDRS and can help direct prevention efforts for child death during IPH.

Life experiences preceding high lethality suicide attempts in adolescents at a level I regional trauma center

OBJECTIVE

To describe life experiences associated with patterns of medically treated and documented self-directed violence among youth who attempted suicide using highly lethal means to understand precipitating factors among youth using such lethal means.

METHOD

Using data from a regional, level 1 Trauma center, we identified all youth suicide attempt survivors who received treatment from 2010 to 2018 for a suicide attempt with a firearm, hanging, or jump from height injury (n = 42). We described differences in patient demographics and life experiences associated with patterns of self-directed violence by suicide attempt mechanism. We additionally assessed mechanisms used in any prior suicide attempts to identify potential increasing lethality of mechanism selection.

RESULTS

There were 42 eligible patients included, of whom 40.5% attempted suicide with a firearm, 26.2% with hanging, 33.3% with jumping injury. A greater proportion of patients with firearm injuries endorsed social support and had fewer preparatory acts, history of self-harming behavior, prior suicide behaviors, and fewer prior attempts compared to patients who attempted suicide with other mechanisms.

CONCLUSIONS

Given our findings, means safety should remain a key strategy to prevent highly lethal suicidal behavior among adolescents, especially with firearms, given that such attempts may occur prior to formal contact with mental health services.

Barriers to recruitment, retention and intervention delivery in a randomized trial among patients with firearm injuries

BACKGROUND

We discuss barriers to recruitment, retention, and intervention delivery in a randomized controlled trial (RCT) of patients presenting with firearm injuries to a Level 1 trauma center. The intervention was adapted from the Critical Time Intervention and included a six-month period of support in the community after hospital discharge to address recovery goals. This study was one of the first RCTs of a hospital- and community-based intervention provided solely among patients with firearm injuries.

MAIN TEXT

Barriers to recruitment included limited staffing, coupled with wide variability in length of stay and admission times, which made it difficult to predict the best time to recruit. At the same time, more acutely affected patients needed more time to stabilize in order to determine whether eligibility criteria were met. Barriers to retention included insufficient patient resources for stable housing, communication and transportation, as well as limited time for patients to meet with study staff to respond to follow-up surveys. These barriers similarly affected intervention delivery as patients who were recruited, but had fewer resources to help with recovery, had lower intervention engagement. These barriers fall within the broader context of system avoidance (e.g., avoiding institutions that keep formal records). Since the patient sample was racially diverse with the majority of patients having prior criminal justice system involvement, this may have precluded active participation from some patients, especially those from communities that have been subject to long and sustained history of trauma and racism. We discuss approaches to overcoming these barriers and the importance of such efforts to further implement and evaluate hospital-based violence intervention programs in the future.

CONCLUSION

Developing strategies to overcome barriers to data collection and ongoing participant contact are essential to gathering robust information to understand how well violence prevention programs work and providing the best care possible for people recovering from injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02630225 . Registered 12/15/2015.

Nonfatal use of firearms in intimate partner violence: Results of a national survey

Research on intimate partner violence (IPV) and firearms has typically focused on homicide, so there is limited information on how firearms are used in nonfatal ways, particularly in community samples. We sought to estimate the prevalence of nonfatal firearm abuse in the context of IPV, understand how and against whom firearms are used, and examine consequences of this abuse. Using a national web-based survey of US adults who experienced IPV (n = 958), we asked respondents about experiences with nonfatal firearm abuse, including the frequency of firearm behaviors and consequences. Based on screening data weighted to be nationally representative, we estimated that 9.8% (95% CI: 9.0%, 10.6%) of US adults - or nearly 25 million - have experienced nonfatal firearm abuse by an intimate partner (i.e., were threatened with a firearm, had a firearm used on them, or were threatened by a partner who possessed or had easy access to a firearm). IPV victims who experienced nonfatal firearm abuse commonly reported experiencing other forms of IPV. The most common behaviors included the partner displaying a firearm (67.5%) and threatening to shoot the victim (63.0%). The majority (80.5%) of perpetrators were male, and 49.2% of respondents had a child at home at the time of abuse. The most common consequences of nonfatal firearm abuse were concerns for safety (86.2%) and feeling fearful (82.7%). Additionally, 43.1% of respondents reported physical injury, and 37.4% missed days of work or school. Practice and policy around firearm access for IPV perpetrators should attend to nonfatal firearm use against intimate partners.

Within- and between-person associations with drug use disorder among adolescents and emerging adults presenting to an urban emergency department

BACKGROUND

The distinction between within- and between-person associations with drug use disorder (DUD) has implications for intervention targets and content. We used longitudinal data from youth entering an urban emergency department (ED) to identify factors related to changes in DUD diagnosis, with particular emphasis on alcohol use.

METHODS

Research staff recruited youth age 14-24 (n = 599) reporting any past six-month drug use from a Level-1 ED; participants were assessed at baseline and four biannual follow-ups. Participants self-reported validated measurements of peer/parental behaviors, violence/crime exposure, drug use self-efficacy, and alcohol use. Research staff performed diagnostic interviews for DUD with nine substances, post-traumatic stress disorder (PTSD), and major depressive disorder (MDD). We used repeated measures logistic regression models with person-level covariate means, and person-mean-centered covariates, as separate variables, to separate within- and between-person covariate effects.

RESULTS

Among 2,630 assessments, 1,128 (42.9 %) were DUD diagnoses; 21.7 % were co-diagnoses with multiple drugs. Positive (aOR = 0.81, 95 %CI:[0.70, 0.94]) and negative (aOR = 1.73, 95 %CI:[1.45, 2.07]) peer behaviors related to DUD, primarily through between-person effects. Parental support (aOR = 0.92, 95 %CI:[0.83, 0.99]), community violence/crime (aOR = 1.28, 95 %CI:[1.14, 1.44]), PTSD/MDD diagnosis (aOR = 1.36, 95 %CI:[1.04, 1.79]), and alcohol use quantity (aOR = 1.06, 95 %CI:[1.02, 1.11]) were associated with DUD, showing primarily within-person effects. Other factors, such as interpersonal violence involvement (aOR = 1.47, 95 %CI:[1.21, 1.78]), showed both within- and between-person effects.

CONCLUSIONS

DUD is prevalent in this population, and within-person changes in DUD are predictable. Within-person effects suggest the importance of addressing escalating alcohol use, enhancing parental support, crime/violence exposure, and other mental health diagnoses as part of DUD intervention.

Helping individuals with firearm injuries: A cluster randomized trial

BACKGROUND

Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries.

METHODS

We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization.

RESULTS

Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury.

CONCLUSIONS

This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program.

LEVEL OF EVIDENCE

Care management, level II.

Prevalence, age of initiation, and patterns of co-occurrence of digital dating abuse behaviors nationwide

INTRODUCTION

Little is known about the patterns of adolescent and young adult digital dating abuse (DDA) nationwide. This study characterizes (1) the lifetime prevalence, (2) the age of initiation, and (3) the patterns of co-occurrence of both using and experiencing DDA behaviors in dating relationships.

METHODS

A cross-sectional online survey was conducted among a sample of 696 U.S. young adults recruited from Prolific, an online research platform. The sample was 50.7% female, 43.7% male, and 5.6% gender non-binary or transgender. The average age was 18.7 years (SD = 0.63, range: 16-22).

RESULTS & CONCLUSIONS

Among those with dating experience, 76.1% (n = 530) reported either using or experiencing at least one DDA behavior in their lifetime. Overall, 42.9% of respondents reported using and 58.3% experiencing digital monitoring and control behaviors, 25.0% reported using and 49.2% experiencing digital direct aggression, and 12.4% reported using and 36.4% experiencing digital sexual coercion. The average age of initiation for most DDA behaviors was 16 years with respondents reporting experiencing these behaviors at 11 years of age at the earliest. Of those with any involvement with DDA, 59.2% report both using at least one DDA behavior and experiencing at least one DDA behavior (n = 314), 32.5% report experiencing at least one DDA behavior but not using any (n = 172), and 8.3% report using at least one DDA behavior but not experiencing any (n = 44). DDA behaviors are common, can occur at young ages. Our findings highlight crossover between those who use and those who experience DDA behaviors and suggest prevention should focus on underlying issues that drive both the use and experience of these behaviors.

Firearms and protective orders in intimate partner homicides

PURPOSE

To determine differences among intimate partner homicides (IPH) by whether or not a firearm was used in and whether a protective order (PO) was filed prior to IPH.

METHOD

We identified all incidents of IPH recorded in the National Violent Death Reporting System from 2003-2018, based on the relationship between victim and perpetrator. We characterized incidents, perpetrators and victims in IPH cases by whether or not a firearm was used, and whether a PO had been sought or issued prior to the IPH.

RESULTS

We identified 8,375 IPH incidents with a total of 9,130 victims. Overall 306 (3.3%) victims were killed in a firearm IPH with PO, 4,519 (53.9%) in a firearm IPH without PO, 176 (2.1%) in a non-firearm IPH with PO and 3,416 (40.7%) in a non-firearm IPH without PO. Based on review of incident narratives, 5.4% (n=451) of incidents involved a previously-granted or sought PO, and none of which had explicitly mentioned firearm removal as a part of the PO.

CONCLUSIONS

The majority of victims were killed with a firearm. Prior literature suggests that POs with firearm removal may be effective strategies for reducing risk of IPH, but we found no documentation in the narratives that firearm removal was a condition in the POs identified. As very few IPH narratives included documentation of a PO, it is likely that ascertainment of PO status is incomplete and could be an area for improvement in NVDRS data collection efforts.

Firearm purchasing and storage during the COVID-19 pandemic

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

Fidelity Assessment of a Social Work-Led Intervention Among Patients with Firearm Injuries

PURPOSE

To support future development and refinement of social work-led intervention programs among patients with firearm injuries and to demonstrate how a fidelity assessment can be used to adjust and refine intervention delivery in an ongoing trial.

METHODS

We conducted a fidelity assessment of a randomized controlled trial of a social work-led intervention among patients with a firearm injury.

RESULTS

We found that our study intervention was well implemented, meeting 70% of the fidelity assessment score items, however noted lower fidelity with client-based items.

DISCUSSION

As a result of fidelity assessment findings, we refined intervention delivery to improve implementation fidelity including beginning to review cases of all patients each month, rather than focusing on patients in crisis. Our fidelity assessment process and findings offer insight into the challenges of implementing an intervention among patients with firearm injuries and highlights the value of monitoring intervention fidelity during an ongoing trial.

Selection bias and misclassification in case-control studies conducted using the National Violent Death Reporting System

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

Life experiences associated with change in perpetration of domestic violence

BACKGROUND

This study assessed whether several adult life experiences, including loss of support, loss of food security, loss of housing, and substance use cessation, are associated with change in domestic violence (DV) perpetration from early to later adulthood. Using 2015 to 2016 cross-sectional, self-report survey data from Medicaid enrollees in Oregon (N = 1620), we assessed change in DV perpetration from early adulthood (19-30 years) to later adulthood (≥ 31 years of age), cut points determined by existing survey questions. Multinomial logistic regression models were constructed to estimate the association between life experiences and physical DV perpetration using odds ratios (OR), adjusting for sociodemographic characteristics, DV victimization, and childhood abuse, bullying, and social support.

FINDINGS

Of the 20% of participants who perpetrated DV, 36% perpetrated DV in both early and later adulthood (persisters), 42% discontinued (desisters) and 22% began (late-onsetters) perpetration in later adulthood. Loss of support and loss of food security were both associated with change in DV perpetration (i.e., desistance or late onset of perpetration or both). Loss of support was associated with 9.5 times higher odds of being a desister (OR = 9.5, 95% CI = 1.1, 84.1) and 54.2 times higher odds of being a late-onsetter (OR = 54.2, 95% CI = 6.5, 450.8) of DV perpetration compared to persisters. Loss of food security was associated with 10.3 times higher odds of being a late-onsetter (OR = 10.3, 95% CI = 1.9, 55.4) of DV perpetration compared to persisters. In addition, substance use cessation was associated with 10.3 times higher odds of being a desister (OR = 10.3, 95% CI = 1.9, 56.2) compared to persisters.

CONCLUSIONS

Findings suggest that specific life experiences in adulthood, including loss of support, loss of food security, and substance use cessation, are associated with changes in DV perpetration.

Use of multiple failure models in injury epidemiology: a case study of arrest and intimate partner violence recidivism in Seattle, WA

Background

Single-failure survival models are commonly used in injury research. We aimed to demonstrate the application of multiple failure survival models in injury research by measuring the association between arrest and IPV recidivism.

Methods

We used data from a population-based cohort of 5466 male-female couples with a police-reported, male-perpetrated incident of IPV against their female partners that occurred in Seattle, WA during 1999–2001. We estimated the risk of physical and psychological IPV recidivism (separately) for the 12 months following the index event, according to perpetrator arrest or non-arrest for the index event. We used time-dependent extended Cox regression analyses for time-to-first IPV event and Prentice, Williams and Peterson model-based analyses for time-to-multiple IPV events.

Results

Arrest was associated with a reduction in time-to-first physical IPV recurrence but was not associated with time-to-first psychological IPV recurrence during the 12-month follow-up. Arrest was associated with a significantly decreased risk of physical and psychological IPV during the 12-month follow-up in the multiple failure models. The association between arrest and lower risk of physical IPV recidivism increased with increasing number of follow-up IPV events.

Conclusions

We found arrest to be a plausible deterrent for recurrent IPV reduction. Our study also illustrates the use of multiple failure survival analyses in injury research. Such techniques facilitate inference about estimands that may have greater public health relevance and properly account for injury recurrence. By using multiple failure models, we were able to more deeply understand the relationship between arrest and IPV over time.

Firearm-related behaviors following firearm injury: changes in ownership, carrying and storage

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

Feasibility and indicator outcomes using computerized clinical decision support in pediatric traumatic brain injury anesthesia care

BACKGROUND

Traumatic brain injury anesthesia care is complex. The use of clinical decision support to improve pediatric trauma care has not been examined.

AIMS

The aim of this study was to examine feasibility, reliability, and key performance indicators for traumatic brain injury anesthesia care using clinical decision support.

METHODS

Clinical decision support was activated for patients under 19 years undergoing craniotomy for suspected traumatic brain injury. Anesthesia providers were prompted to adhere to process measures via on-screen alerts and notified in real time of abnormal monitor data or laboratory results (unwanted key performance indicator events). Process measures pertained to arterial line placement and blood gas draws, neuromuscular blockade, hypotension, anemia, coagulopathy, hyperglycemia, and intracranial hypertension. Unwanted key performance indicators were: hypotension, hypoxia, hypocarbia, hypercarbia, hypothermia, hyperthermia, anesthetic agent overdose; hypoxemia, coagulopathy, anemia, and hyperglycemia. Anesthesia records, vital signs, and alert logs were reviewed for 39 anesthetic cases (19 without clinical decision support and 20 with clinical decision support).

RESULTS

Data from 35 patients aged 11 months to 17 years and 77% males were examined. Clinical decision support reliably identified 39/46 eligible anesthetic cases, with 85% sensitivity and 100% specificity, and was highly sensitive, detecting 89% of monitor key performance indicator events and 100% of reported lab key performance indicator events. There were no false positive alerts. Median event duration was lower in the "with clinical decision support" group for 4/7 key performance indicators. Second insult duration was lower for duration of hypocarbia (by 44%), hypotension (29%), hypothermia (12%), and hyperthermia (15%).

CONCLUSION

Use of clinical decision support in pediatric traumatic brain injury anesthesia care is feasible, reliable, and may have the potential to improve key performance indicator outcomes. This observational study suggests the possibility of clinical decision support as a strategy to reduce second insults and improve traumatic brain injury guideline adherence during pediatric anesthesia care.

Validating the National Violent Death Reporting System as a Source of Data on Fatal Shootings of Civilians by Law Enforcement Officers

OBJECTIVES

To evaluate the National Violent Death Reporting System (NVDRS) as a surveillance system for fatal shootings of civilians by law enforcement in the United States.

METHODS

We cross-linked individual-level mortality data from the 2015 NVDRS and 5 open-source data sets ( FatalEncounters.org , Mapping Police Violence, the Guardian's "The Counted," Gun Violence Archive, and The Washington Post's "Fatal Force Database"). Using the comprehensive cross-linked data set, we assessed the proportion of study-identified fatal police shootings that were captured by NVDRS, overall and by state, and by each open-source data set.

RESULTS

There were 404 unique study-identified fatal shootings by law enforcement in the 27 states for which data were available from NVDRS, 393 (97%) of which were captured in NVDRS. The proportion of shootings captured by NVDRS varied only slightly by state.

CONCLUSIONS

The NVDRS provides a comprehensive count of fatal police shootings. Public Health Implications. Expanding NVDRS to all 50 states would provide comprehensive counts of fatal police shootings and detailed circumstantial information about these deaths at the national level. Open-source data can continue to provide real-time data collection as well as more complete information about nonfirearm officer-involved deaths.

Concomitant Upper Extremity Fracture Worsens Outcomes in Elderly Patients With Hip Fracture

Background

Elderly patients with low-energy hip fractures have high rates of morbidity and mortality, but it is not well known how often concurrent upper extremity fractures occur and how this impacts outcomes. We used the National Trauma Databank (NTDB), the largest aggregation of US trauma registry data available, to determine whether patients with concurrent upper extremity and hip fractures have worse outcomes than patients with hip fractures alone.

Methods

We accessed the NTDB to identify patients aged 65 to 100 who sustained a hip fracture. The cohort was then narrowed to include only patients who sustained their injury in a fall and had an injury severity score indicating hip fracture as the most severe injury. We then analyzed this group to assess the impact of a simultaneous upper extremity fracture on length of stay, in-hospital mortality, and discharge disposition.

Results

From 2007 to 2014, a total of 231,299 patients aged 65 to 100 were identified as having a hip fracture. The narrowed cohort with fall as the mechanism and hip fracture as the most severe injury included 193,862 patients. Of these, 12,618 patients sustained a concomitant upper extremity fracture (6.5%). Compared to isolated hip fractures, patients with a concomitant upper extremity fracture had higher odds of death in the hospital (odds ratio [OR] = 1.3; 95% confidence interval = 1.2-1.4), were less likely to be discharged to home as compared to a skilled facility (OR = 0.73; 95% confidence interval = 0.68-0.78), and had a significantly longer average length of stay (7.1 vs 6.4 days, P < .001).

Conclusions

We found a 6.5% prevalence of concomitant upper extremity fractures in patients aged 65 to 100 with a hip fracture sustained after a fall where the hip fracture was the most severe injury. These patients had a higher risk of in-hospital mortality, were less likely to be discharged to home, and had longer average length of stay.

Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients

BACKGROUND

Current guidelines recommend routine clamping of external ventricular drains (EVD) for intrahospital transport (IHT). The aim of this project was to describe intracranial hemodynamic complications associated with routine EVD clamping for IHT in neurocritically ill cerebrovascular patients.

METHODS

We conducted a retrospective review of cerebrovascular adult patients with indwelling EVD admitted to the neurocritical care unit (NICU) during the months of September to December 2015 at a tertiary care center. All IHTs from the NICU of the included patients were examined. Main outcomes were incidence and risk factors for an alteration in intracranial pressure (ICP) and cerebral perfusion pressure after IHT.

RESULTS

Nineteen cerebrovascular patients underwent 178 IHTs (79.8 % diagnostic and 20.2 % therapeutic) with clamped EVD. Twenty-one IHTs (11.8 %) were associated with post-IHT ICP ≥ 20 mmHg, and 33 IHTs (18.5 %) were associated with escalation of ICP category. Forty IHTs (26.7 %) in patients with open EVD status in the NICU prior to IHT were associated with IHT complications, whereas no IHT complications occurred in IHTs with clamped EVD status in the NICU. Risk factors for post-IHT ICP ≥ 20 mmHg were IHT for therapeutic procedures (adjusted relative risk [aRR] 5.82; 95 % CI, 1.76-19.19), pre-IHT ICP 15-19 mmHg (aRR 3.40; 95 % CI, 1.08-10.76), pre-IHT ICP ≥ 20 mmHg (aRR 12.94; 95 % CI, 4.08-41.01), and each 1 mL of hourly cerebrospinal fluid (CSF) drained prior to IHT (aRR 1.11; 95 % CI, 1.01-1.23).

CONCLUSIONS

Routine clamping of EVD for IHT in cerebrovascular patients is associated with post-IHT ICP complications. Pre-IHT ICP ≥ 15 mmHg, increasing hourly CSF output, and IHT for therapeutic procedures are risk factors.

Loaded Handgun Carrying Among US Adults, 2015

OBJECTIVES

To determine the frequency of loaded handgun carrying among US adult handgun owners, characterize those who carry, and examine concealed carrying by state concealed carry laws.

METHODS

Using a nationally representative survey of US adults in 2015, we asked handgun owners (n = 1444) about their past-30-day carrying behavior.

RESULTS

Among surveyed handgun owners, 24% (95% confidence interval[CI] = 21%, 26%) carried loaded handguns monthly, of whom 35% (95% CI = 29%, 41%) did so daily; 82% (95% CI = 77%, 86%) carried primarily for protection. The proportion of handgun owners who carried concealed loaded handguns in the past 30 days was 21% (95% CI = 12%, 35%) in unrestricted states, 25% (95% CI = 21%, 29%) in shall issue-no discretion states, 20% (95% CI = 16%, 24%) in shall issue-limited discretion states, and 9% (95% CI = 6%, 15%) in may-issue states.

CONCLUSIONS

We estimate that 9 million US adult handgun owners carry loaded handguns monthly, 3 million do so every day, and most report protection as the main carrying reason. Proportionally fewer handgun owners carry concealed loaded handguns in states that allow issuing authorities substantial discretion in granting carrying permits.

Formal firearm training among adults in the USA: results of a national survey

Despite broad support for policies requiring that prospective firearm owners receive training before acquiring a firearm, little is known about the scope and content of firearm training in the USA. Nationally representative surveys conducted in 1994 estimated that 56%-58% of the US firearm owners had received formal firearm training. We conducted a nationally representative survey in 2015 (n=3932; completion proportion=55%) to update those estimates and characterise training contents. 61% of firearm owners and 14% of non-owners living with a firearm owner reported having received formal firearm training. The most commonly reported combination of training topics was safe handling, safe storage and preventing accidents. 15% of firearm owners reported that their training included information about suicide prevention. The proportion of the US firearm owners with formal firearm training has not meaningfully changed since two decades ago. Training programme contents vary widely. Efforts to standardise and evaluate the effectiveness of firearm training are warranted.

Strategies to Address Unmet Needs and Facilitate Return to Learn Guideline Adoption Following Concussion

BACKGROUND

Many students do not receive return to learn (RTL) services upon return to academics following a concussion.

METHODS

Using a mixed-methods approach, we conducted a survey of RTL practices and experiences in Washington State schools between January 2015 and June 2015. We then held a statewide summit of RTL stakeholders and used a modified Delphi process to develop a consensus-based RTL implementation model and process.

RESULTS

Survey participants included 83 educators, 57 school nurses, 14 administrators, and 30 parents, representing 144 schools in rural and urban areas. Unmet need domains and recommendations identified were (1) a current lack of school policies; (2) barriers to providing or receiving accommodations; (3) wide variability in communication patterns; and (4) recommendations shared by all stakeholder groups (including desire for readily available best practices, development of a formal school RTL policy for easy adoption and more training). Using stakeholder input from RTL summit participants and survey responses, we developed an RTL implementation model and checklist for RTL guideline adoption.

CONCLUSIONS

Washington State children have unmet needs upon returning to public schools after concussion. The student-centered RTL model and checklist for implementing RTL guidelines can help schools provide timely RTL services following concussion.

Proposed variations of the stepped-wedge design can be used to accommodate multiple interventions

OBJECTIVES

Stepped-wedge design (SWD) cluster-randomized trials have traditionally been used for evaluating a single intervention. We aimed to explore design variants suitable for evaluating multiple interventions in an SWD trial.

STUDY DESIGN AND SETTING

We identified four specific variants of the traditional SWD that would allow two interventions to be conducted within a single cluster-randomized trial: concurrent, replacement, supplementation, and factorial SWDs. These variants were chosen to flexibly accommodate study characteristics that limit a one-size-fits-all approach for multiple interventions.

RESULTS

In the concurrent SWD, each cluster receives only one intervention, unlike the other variants. The replacement SWD supports two interventions that will not or cannot be used at the same time. The supplementation SWD is appropriate when the second intervention requires the presence of the first intervention, and the factorial SWD supports the evaluation of intervention interactions. The precision for estimating intervention effects varies across the four variants.

CONCLUSION

Selection of the appropriate design variant should be driven by the research question while considering the trade-off between the number of steps, number of clusters, restrictions for concurrent implementation of the interventions, lingering effects of each intervention, and precision of the intervention effect estimates.

Development and Feasibility of a Real-Time Clinical Decision Support System for Traumatic Brain Injury Anesthesia Care

BACKGROUND

Real-time clinical decision support (CDS) integrated with anesthesia information management systems (AIMS) can generate point of care reminders to improve quality of care.

OBJECTIVE

To develop, implement and evaluate a real-time clinical decision support system for anesthetic management of pediatric traumatic brain injury (TBI) patients undergoing urgent neurosurgery.

METHODS

We iteratively developed a CDS system for pediatric TBI patients undergoing urgent neurosurgery. The system automatically detects eligible cases and evidence-based key performance indicators (KPIs). Unwanted clinical events trigger and display real-time messages on the AIMS computer screen. Main outcomes were feasibility of detecting eligible cases and KPIs, and user acceptance.

RESULTS

The CDS system was triggered in 22 out of 28 (79%) patients. The sensitivity of detecting continuously sampled KPIs reached 93.8%. For intermittently sampled KPIs, sensitivity and specificity reached 90.9% and 100%, respectively. 88% of providers reported that CDS helped with TBI anesthesia care.

CONCLUSIONS

CDS implementation is feasible and acceptable with a high rate of case capture and appropriate generation of alert and guidance messages for TBI anesthesia care.

Violence Perpetration Among Patients Hospitalized for Unintentional and Assault-Related Firearm Injury: A Case-Control Study and a Cohort Study

BACKGROUND

Hospital-based violence intervention programs typically focus on patients whose firearm injury occurred through interpersonal violence (assault). Knowledge of violence perpetration by victims of unintentional (accidental) firearm injury is limited.

OBJECTIVE

To examine violence perpetration before and after a patient becomes hospitalized for firearm injury according to injury intent (intentional [assault] or unintentional [accidental]).

DESIGN

A case-control study and a retrospective cohort study.

SETTING

Hospitals in Washington.

PATIENTS

Persons aged 15 years or older hospitalized for a firearm injury, other injuries, or a noninjury reason from 2006 to 2007.

MEASUREMENTS

In the case-control study, the odds of violence-related arrest from 2001 through hospitalization by injury intent among 3 groups were compared. In the cohort study, the rates of violence-related arrest from hospitalization through 2011 by injury intent among 3 groups were compared.

RESULTS

Patients with unintentional firearm injuries (n = 180) were more likely than those with other unintentional injuries (n = 62 795; odds ratio [OR], 2.01 [95% CI, 1.31 to 3.09]) and no injuries (n = 172 830; OR, 3.43 [CI, 2.22 to 5.32]) to have been arrested for a violent crime before hospitalization. Prior violence-related arrest did not differ between patients with assault-related firearm injuries (n = 339) and those with other assault-related injuries (n = 2342; OR, 1.10 [CI, 0.84 to 1.46]). During follow-up, the cumulative incidence of violence-related arrest for patients with unintentional and assault-related firearm injuries was 10% and 15% (subhazard ratio, 1.88 [CI, 1.11 to 3.17] and 1.61 [CI, 1.08 to 2.44]), respectively, compared with 1% for those without injuries.

LIMITATION

Exclusion of self-inflicted injuries, misclassification of intent, and ascertainment bias.

CONCLUSION

Some firearm injuries classified as accidental may indicate involvement in the cycle of violence and present an opportunity for intervention.

PRIMARY FUNDING SOURCE

City of Seattle and the University of Washington Royalty Research Fund.

Variations in State Laws Governing School Reintegration Following Concussion

OBJECTIVE

We sought to examine the prevalence, scope, and specificity of provisions governing school reintegration in current state concussion laws.

METHODS

State concussion laws as of May 2016 were independently assessed and classified by 2 trained coders. Statutes were classified as "Return-to-Learn" (RTL) laws if they contained language mandating institutional action at the state, district, or school level related to academic reintegration of youth who have sustained a concussion. All statutes classified as RTL laws were further analyzed to determine scope, required actions, and delineation of responsibility.

RESULTS

RTL laws were uncommon, present in only 8 states. Most (75%) of these laws held schools responsible for RTL management but mandated RTL education for school personnel was less frequent, present in only one-quarter of the laws. None of the RTL laws provided guidance on support of students with persistent postconcussive symptoms, and only 1 recommended an evidence-based standard for RTL guidelines.

CONCLUSIONS

Our review of state concussion laws indicates scant and vague legal guidance regarding RTL. These findings suggest an opportunity for legislative action on the issue of RTL, and reveal the need for better integration of laws and research, so that laws reflect existing best-practice recommendations and remain current as the evidence base develops.

Proceedings of the First International Conference on Stepped Wedge Trial Design

I1 Introduction

Mona Kanaan, Noreen Dadirai Mdege, Ada Keding

O1 The HiSTORIC trial: a hybrid before-and-after and stepped wedge design

RA Parker, N Mills, A Shah, F Strachan, C Keerie, CJ Weir

O2 Stepped wedge trials with non-uniform correlation structure

Andrew Forbes, Karla Hemming

O3 Challenges and solutions for the operationalisation of the ENHANCE study: a pilot stepped wedge trial within a general practice setting

Sarah A Lawton, Emma Healey, Martyn Lewis, Elaine Nicholls, Clare Jinks, Valerie Tan, Andrew Finney, Christian D Mallen, on behalf of the ENHANCE Study Team

O4 Early lessons from the implementation of a stepped wedge trial design investigating the effectiveness of a training intervention in busy health care settings: the Thistle study

Erik Lenguerrand, Graeme MacLennan, John Norrie, Siladitya Bhattacharya, Tim Draycott, on behalf of the Thistle group

O5 Sample size calculation for longitudinal cluster randomised trials: a unified framework for closed cohort and repeated cross-section designs

Richard Hooper, Steven Teerenstra, Esther de Hoop, Sandra Eldridge

O6 Restricted randomisation schemes for stepped-wedge studies with a cluster-level covariate

Alan Girling, Monica Taljaard

O7 A flexible modelling of the time trend for the analysis of stepped wedge trials: results of a simulation study

Gian Luca Di Tanna, Antonio Gasparrini

P1 Tackling acute kidney injury – a UK stepped wedge clinical trial of hospital-level quality improvement interventions

Anna Casula, Fergus Caskey, Erik Lenguerrand, Shona Methven, Stephanie MacNeill, Margaret May, Nicholas Selby

P2 Sample size considerations for quantifying secondary bacterial transmission in a stepped wedge trial of influenza vaccine

Leon Danon, Hannah Christensen, Adam Finn, Margaret May

P3 Sample size calculation for time-to-event data in stepped wedge cluster randomised trials

Fumihito Takanashi, Ada Keding, Simon Crouch, Mona Kanaan

P4 Sample size calculations for stepped-wedge cluster randomised trials with unequal cluster sizes

Caroline A. Kristunas, Karen L. Smith, Laura J. Gray

P5 The design of stepped wedge trials with unequal cluster sizes

John N.S. Matthews

P6 Promoting Recruitment using Information Management Efficiently (PRIME): a stepped wedge SWAT (study-within-a-trial)

R Al-Shahi Salman, RA Parker, A Maxwell, M Dennis, A Rudd, CJ Weir

P7 Implications of misspecified mixed effect models in stepped wedge trial analysis: how wrong can it be?

Jennifer A Thompson, Katherine L Fielding, Calum Davey, Alexander M Aiken, James R Hargreaves, Richard J Hayes

S1 Stepped Wedge Designs with Multiple Interventions

Vivian H Lyons, Lingyu Li, James Hughes, Ali Rowhani-Rahbar

S2 Analysis of the cross-sectional stepped wedge cluster randomised trial

Karla Hemming, Monica Taljaard, Andrew Forbes

Ornithine transcarbamylase deficiency: enzyme studies on a further case and a method of diagnosis using plasma enzyme ratios

The activities of the urea cycle enzymes in the liver of a female patient with hyperammonemia were determined (Table 1). Ornithine transcarbamylase (OTC, EC. 2.1.3.3) was reduced to 5-10% of normal and the residual enzyme showed an apparent Kmorn of 0.69 (normal 0.37 +/- 0.10) mmol liter. The pH dependence was normal. The patient's mother also showed hyperammonemia but was not clinically affected. Consideration of the genetics of the disease suggested that many female patients should have a mixture of normal and mutant enzymes. Electrophoresis of the patient's liver extract showed an additional band of OTC activity probably due to this mutant enzyme. The ratio of plasma glutamate-pyruvate transaminase to OTC was abnormal in four clinically affected patients with OTC deficiency (Fig. 4B) but not in two of their mothers without clinical signs.