Factors Associated With Recurrent Pediatric Firearm Injury : A 10-Year Retrospective Cohort Analysis.

BACKGROUND: Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. OBJECTIVE: To examine the factors associated with recurrent firearm injury among children who presented with acute (index) nonfatal firearm injury in the St. Louis region. DESIGN: Multicenter, observational, cohort study. SETTING: 2 adult and 2 pediatric level I trauma hospitals in St. Louis, Missouri. PARTICIPANTS: Pediatric patients aged 0 to 17 years presenting with an index firearm injury between 2010 and 2019. MEASUREMENTS: From the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, we collected data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and mortality. The Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the cumulative incidence of experiencing a recurrent firearm injury. RESULTS: During the 10-year study period, 1340 children presented with an index firearm injury. Most patients were Black (87%), non-Hispanic (99%), male (84%), and between the ages of 15 and 17 years (67%). The estimated risk for firearm reinjury was 6% at 1 year and 14% at 5 years after initial injury. Male children and those seen at an adult hospital were at increased risk for reinjury. LIMITATION: Our data set does not account for injuries occurring outside of the study period and for reinjuries presenting to nonstudy hospitals. CONCLUSION: Children who experience an initial firearm injury are at high risk for experiencing a recurrent firearm injury. Interventions are needed to reduce reinjury and address inequities in the demographic and clinical profiles within this cohort of children. PRIMARY FUNDING SOURCE: National Institutes of Health.

Personal goals of young survivors of violent injury: implications for practice.

INTRODUCTION: Firearm injuries are the leading cause of death among young people in the USA and disproportionately impact communities of colour and those experiencing socioeconomic distress. Understanding the personal goals of violently injured patients is essential to identifying protective factors and developing interventions that promote them. However, limited research characterising these personal goals exists. OBJECTIVE: The objective of this study was to use qualitative thematic analysis to analyse and describe the personal goals of young people who enrolled in a region-wide hospital-based violence intervention programme after surviving a violent injury. METHODS: A qualitative coding framework was developed, evaluated, and implemented using data from Life Outside of Violence, the St. Louis Area Hospital-Based Violence Intervention Programme. Chart abstraction procedures were used to compile qualitative data on Life Outside of Violence participants' personal goals documented by clinical case managers during individual treatment planning sessions with participants (n=168). Descriptive analyses are reported and implications for practice are discussed. RESULTS: Key findings reveal that (1) violent injury survivors have unmet therapeutic and resource needs, indicating the importance of having service providers with both clinical and case management skills, (2) anger management is a common clinical goal, and (3) employment opportunities are a common resource need. CONCLUSIONS: Findings from this study inform the implementation of the Life Outside of Violence programme and offer a roadmap to other hospital-based violence intervention programmes operating nation-wide. Our results provide insight into participants' needs, desires, and motivations, allowing unique opportunities for improved participant engagement and service delivery.

Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study.

BACKGROUND: Firearm injuries are a public health crisis in the United States. OBJECTIVE: To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury. DESIGN: Multicenter, observational, cohort study. SETTING: Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019. PARTICIPANTS: Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury. MEASUREMENTS: Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury. RESULTS: We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years. LIMITATIONS: Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals. CONCLUSION: Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence. PRIMARY FUNDING SOURCE: Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.

A systematic review of recurrent firearm injury rates in the United States.

OBJECTIVES: To conduct a systematic review of methodologies, data sources, and best practices for identifying, calculating, and reporting recurrent firearm injury rates in the United States. METHODS: In accordance with PRISMA guidelines, we searched seven electronic databases on December 16, 2021, for peer-reviewed articles that calculated recurrent firearm injury in generalizable populations. Two reviewers independently assessed the risk of bias, screened the studies, extracted data, and a third resolved conflicts. FINDINGS: Of the 918 unique articles identified, 14 met our inclusion criteria and reported recurrent firearm injury rates from 1% to 9.5%. We observed heterogeneity in study methodologies, including data sources utilized, identification of subsequent injury, follow-up times, and the types of firearm injuries studied. Data sources ranged from single-site hospital medical records to comprehensive statewide records comprising medical, law enforcement, and social security death index data. Some studies applied machine learning to electronic health records to differentiate subsequent new firearm injuries from the index injury, while others classified all repeat firearm-related hospital admissions after variably defined cut-off times as a new injury. Some studies required a minimum follow-up observation period after the index injury while others did not. Four studies conducted survival analyses, albeit using different methodologies. CONCLUSIONS: Variability in both the data sources and methods used to evaluate and report recurrent firearm injury limits individual study generalizability of individual and societal factors that influence recurrent firearm injury. Our systematic review highlights the need for development, dissemination, and implementation of standard practices for calculating and reporting recurrent firearm injury.

A Regional Approach to Hospital-Based Violence Intervention Programs Through LOV.

CONTEXT: Community violence is an underaddressed public health threat. Hospital-based violence intervention programs (HVIPs) have been used to address the root causes of violence and prevent reinjury. OBJECTIVE: In this article, we describe the methodology of the St Louis Region-wide HVIP, Life Outside Violence (LOV) program, and provide preliminary process outcomes. DESIGN: Life Outside Violence mentors intervene following a violent injury to decrease risk of subsequent victimization and achieve goals unique to each participant by providing therapeutic counseling and case management services to patients and their families. PARTICIPANTS AND SETTING: Eligible patients are victims of violent injury between the ages of 8 and 24 years, who are residents of St Louis, Missouri, and present for care at a LOV partner adult or pediatric level I trauma hospital. INTERVENTION: Enrolled participants receive program services for 6 to 12 months and complete an individual treatment plan. MAIN OUTCOME MEASURES: In this article, we report LOV operational methodology, as well as process metrics, including program enrollment, graduation, and qualitative data on program implementation. RESULTS: From August 15, 2018, through April 30, 2022, 1750 LOV-eligible violently injured patients presented to a partner hospital, 349 were approached for program enrollment, and 206 consented to enroll in the program. During this pilot phase, 91 participants graduated from the LOV program and have process output data available for analysis. CONCLUSIONS: Life Outside Violence has been implemented into clinical practice as the first HVIP to influence across an entire region through partnership with multiple university and hospital systems. It is our hope that methods shared in this article will serve as a primer for organizations hoping to implement and expand HVIPs to interrupt community violence at the regional level.

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

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

Linking out-of-hospital deaths with a regional hospital-based firearm injury database: a clinical researcher's guide to accessing data from the National Death Index.

IntroductionFirearm injuries are a public health crisis in the US. The National Death Index (NDI) is a well-established, comprehensive database managed by the National Center for Health Statistics at the CDC. In this methodology paper we describe our experience accessing and linking data from the NDI to our regional, hospital-based violent injury database to identify out-of-hospital deaths from firearms. METHODS: We outline the key steps of our submission to the NDI. Data were collected from research team meeting notes, team member emails with NDI staff, and information provided from the NDI website and supplementary guides. Few of our collaborators or university partner investigators had accessed or used data from the NDI. We discuss the online NDI Processing Portal data request, data preparation and receipt from the NDI, troubleshooting tips, and a timeline of events. RESULTS: Our query to the NDI returned 12 034 records of 12 219 firearm-injured patient records from 2010 and 2019. The record match rate was 98.5%. DISCUSSION: Linking hospital-based data sets with NDI data can provide valuable information on out-of-hospital deaths. This has the potential to improve the quality of longitudinal morbidity and mortality calculations in hospital-based patient cohorts. We encountered logistic and administrative challenges in completing the online NDI Processing Portal and in preparing and receiving data from the NDI. It is our hope that the lessons learnt presented herein will help facilitate easy and streamlined acquisition of valuable NDI data for other clinical researchers. WHAT THIS STUDY ADDS: - A step-by-step guide for clinical researchers of how to apply to access data from the National Death Index (NDI).- Advice and lessons learned on how to efficiently and effectively access data from the NDI.- A well-described methodology to improve the quality of longitudinal morbdity and mortality calculations in hospital-based cohorts of firearm injured patients.What is already known on this subject:- There is a need for robust, longitudinal data sources that reliably track morbidity and mortality among firearm injured patients in the United States.- The NDI is a well-established, comprehensive database that holds death records for all 50 states, which provides valuable mortality data to the public health and medical research community.

Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients.

Background: Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives: To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods: Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results: Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion: Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients. How to cite this article: Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.

Counseling on Access to Lethal Means in the Emergency Department: A Script for Improved Comfort.

Individuals with suicidal ideation (SI) frequently present to the emergency department (ED). We hypothesized that CALM: Counseling on Access to Lethal Means training improves non-physician provider comfort with delivering an ED-based counseling intervention on lethal means restriction. Ten non-physician intervention counselors who currently provide CALM to ED patients presenting with SI were surveyed for demographics, prior experience caring for patients with SI, prior CALM experience, comfort providing CALM, and which method of training most improved comfort with CALM. Survey response rate was 100%. Following CALM training, 80% of respondents expressed confidence in their ability to counsel patients on safe storage of lethal means, although 50% felt that a script most improved comfort. Most survey respondents reported feeling comfortable counseling suicidal patients on safe storage of lethal means, but that the addition of a script for the counseling session improved comfort more than the online CALM training.

A Cross-Sectional Study of Firearm Injuries in Emergency Department Patients.

This is a single-center cross-sectional study of consecutive patients who presented to an urban emergency department (ED) with firearm injuries between July 1, 2014 and June 30, 2016. The objective of this study was to describe the characteristics of patients in this cohort and identify those at risk of firearm re-injury to inform future interventions. Patients in this cohort with both initial and recidivistic firearm injures were found to be predominately young, African American men. OBJECTIVE: To describe the characteristics of patients who present to the emergency department (ED) with firearm injuries and identify those at risk of firearm re-injury. METHODS: This is a single-center cross-sectional study of consecutive patients who presented to the ED with firearm injuries between July 1, 2014 and June 30, 2016. We collected data on patient demographics, history of previous traumatic injury including firearm injury, and whether the firearm injury was self-inflicted. We also evaluated characteristics of patients in this cohort who returned to the ED with firearm re-injury within a one year follow-up period. RESULTS: This study included 1226 unique patients. Our data demonstrate that patients presenting to the ED for firearm injury were predominately young, African American males. Fourteen percent had a history of a previous firearm injury and 20% had a history of other non-firearm assault. Patients who had been shot previously were more likely to be African American, male, uninsured, unemployed, and have a history of other non-accidental trauma. Eight percent of firearm injuries were self-inflicted. All 35 patients who sustained a new firearm injury within 1 year of the index injury were African American males with a median age of 23. CONCLUSIONS: Among patients treated in the ED for firearm injuries, young, African American males are disproportionately at risk of firearm injury and re-injury. ED visits for traumatic injury represent an opportunity to provide social work, case work, and counseling-based interventions to help disrupt the cycle of violence in high-risk individuals.

Medroxyprogesterone Acetate Regulates HIV-1 Uptake and Transcytosis but Not Replication in Primary Genital Epithelial Cells, Resulting in Enhanced T-Cell Infection.

Although clinical and experimental evidence indicates that female sex hormones and hormonal contraceptives regulate susceptibility to human immunodeficiency virus type 1 (HIV-1) infection, the underlying mechanism remains unknown. Genital epithelial cells (GECs) are the first cells to encounter HIV during sexual transmission and their interaction with HIV may determine the outcome of exposure. This is the first report that HIV uptake by GECs increased significantly in the presence of the hormonal contraceptive medroxyprogesterone acetate (MPA) and progesterone and that uptake occurred primarily via endocytosis. No productive infection was detected, but endocytosed virus was released into apical and basolateral compartments. Significantly higher viral transcytosis was observed in the presence of MPA. In GEC and T-cell cocultures, maximum viral replication in T cells was observed in the presence of MPA, which also broadly upregulated chemokine production by GECs. These results suggest that MPA may play a significant role in regulating susceptibility to HIV.

HIV-1 gp120 induces TLR2- and TLR4-mediated innate immune activation in human female genital epithelium.

Although women constitute half of all HIV-1-infected people worldwide (UNAIDS World AIDS Day Report, 2011), the earliest events in the female reproductive tract (FRT) during heterosexual HIV-1 transmission are poorly understood. Recently, we demonstrated that HIV-1 could directly impair the mucosal epithelial barrier in the FRT. This suggested that the HIV-1 envelope glycoprotein gp120 was being recognized by a membrane receptor on genital epithelial cells, leading to innate immune activation. In this study, we report that pattern-recognition receptors TLR2 and -4 bind to HIV-1 gp120 and trigger proinflammatory cytokine production via activation of NF-κB. The gp120-TLR interaction also required the presence of heparan sulfate (HS). Bead-binding assays showed that gp120 can bind to HS, TLR2, and TLR4, and studies in transfected HEK293 cells demonstrated that HS and TLR2 and -4 were necessary to mediate downstream signaling. Exposure to seminal plasma from HIV-1-infected and uninfected men with gp120 added to it induced a significant proinflammatory cytokine response from genital epithelial cells and disruption of tight junctions, indicating a role for gp120 in mucosal barrier disruption during HIV-1 heterosexual transmission. These studies provide, for the first time to our knowledge, a possible mechanism by which HIV-1 gp120 could directly initiate innate immune activation in the FRT during heterosexual transmission.

Development of promyelocytic leukemia zinc finger-expressing innate CD4 T cells requires stronger T-cell receptor signals than conventional CD4 T cells.

MHC class II-expressing thymocytes and thymic epithelial cells can mediate CD4 T-cell selection resulting in functionally distinct thymocyte-selected CD4 (T-CD4) and epithelial-selected CD4 (E-CD4) T cells, respectively. However, little is known about how T-cell receptor (TCR) signaling influences the development of these two CD4 T-cell subsets. To study TCR signaling for T-CD4 T-cell development, we used a GFP reporter system of Nur77 in which GFP intensity directly correlates with TCR signaling strength. T-CD4 T cells expressed higher levels of GFP than E-CD4 T cells, suggesting that T-CD4 T cells received stronger TCR signaling than E-CD4 T cells during selection. Elimination of Ras GTPase-activating protein enhanced E-CD4 but decreased T-CD4 T-cell selection efficiency, suggesting a shift to negative selection. Conversely, the absence of IL-2-inducible T-cell kinase that causes poor E-CD4 T-cell selection due to insufficient TCR signaling improved T-CD4 T-cell generation, consistent with rescue from negative selection. Strong TCR signaling during T-CD4 T-cell development correlates with the expression of the transcription factor promyelocytic leukemia zinc finger protein. However, although modulation of the signaling strength affected the efficiency of T-CD4 T-cell development during positive and negative selection, the signaling strength is not as important for the effector function of T-CD4 T cells. These findings indicate that innate T-CD4 T cells, together with invariant natural killer T cells and γδ T cells, receive strong TCR signals during their development and that signaling requirements for the development and the effector functions are distinct.

Vancomycin Use in Patients Discharged From the Emergency Department: A Retrospective Observational Cohort Study.

BACKGROUND: Infections due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with significant morbidity and mortality and are typically treated with intravenous vancomycin. Given vancomycin's time-dependent mechanism of action, it is unlikely that vancomycin administration in the emergency department (ED) prior to disposition home could be beneficial. STUDY OBJECTIVES: To characterize the indications, dosing, and appropriateness of vancomycin use in patients discharged from the ED. METHODS: This is a single-center retrospective observational cohort study of patients who received vancomycin in an urban, academic, tertiary care ED. The subjects were consecutive adult patients administered intravenous vancomycin in the ED and then discharged home over an 18-month period. Outcomes were measured 1) to characterize patients receiving vancomycin prior to discharge home from the ED; and 2) to identify patients that did not meet indications for appropriate use based on the 2011 Infectious Diseases Society of America guidelines for treating MRSA infections. RESULTS: There were 526 patients that received vancomycin in the ED prior to discharge during the study period. In this cohort, 368 (70%) patients were diagnosed with skin and soft tissue infections. A MRSA risk factor was present in 396 (75%) patients. Prior to discharge, one dose of vancomycin was administered to 357 (68%) patients. Underdosing of vancomycin occurred in 239 (73%) patients. CONCLUSIONS: Vancomycin was given frequently to patients discharged home from the ED, most commonly for conditions where vancomycin was not indicated, such as skin and soft tissue infections. The majority of these patients received a vancomycin dosing strategy that is not only unlikely to lead to clinical improvement, but also has the potential to contribute adversely to the development of antibiotic resistance. Further investigation is needed into the impact of vancomycin use, the emergence of vancomycin resistance, and the role of ED-based antibiotic stewardship.

Machine learning classification of new firearm injury encounters in the St Louis region: 2010-2020.

OBJECTIVES: To improve firearm injury encounter classification (new vs follow-up) using machine learning (ML) and compare our ML model to other common approaches. MATERIALS AND METHODS: This retrospective study used data from the St Louis region-wide hospital-based violence intervention program data repository (2010-2020). We randomly selected 500 patients with a firearm injury diagnosis for inclusion, with 808 total firearm injury encounters split (70/30) for training and testing. We trained a least absolute shrinkage and selection operator (LASSO) regression model with the following predictors: admission type, time between firearm injury visits, number of prior firearm injury emergency department (ED) visits, encounter type (ED or other), and diagnostic codes. Our gold standard for new firearm injury encounter classification was manual chart review. We then used our test data to compare the performance of our ML model to other commonly used approaches (proxy measures of ED visits and time between firearm injury encounters, and diagnostic code encounter type designation [initial vs subsequent or sequela]). Performance metrics included area under the curve (AUC), sensitivity, and specificity with 95% confidence intervals (CIs). RESULTS: The ML model had excellent discrimination (0.92, 0.88-0.96) with high sensitivity (0.95, 0.90-0.98) and specificity (0.89, 0.81-0.95). AUC was significantly higher than time-based outcomes, sensitivity was slightly (but not significantly) lower than other approaches, and specificity was higher than all other methods. DISCUSSION: ML successfully delineated new firearm injury encounters, outperforming other approaches in ruling out encounters for follow-up. CONCLUSION: ML can be used to identify new firearm injury encounters and may be particularly useful in studies assessing re-injuries.

Emergency Department vancomycin use: dosing practices and associated outcomes.

BACKGROUND: Emergency Department (ED) dosing of vancomycin and its effect on outcomes has not been examined. STUDY OBJECTIVE: To describe current vancomycin dosing practices for ED patients, focusing on patient factors associated with administration, dosing accuracy based on patient body weight, and clinical outcomes. METHODS: Single-center, retrospective cohort study of vancomycin administered in the ED over 18 months in an academic, tertiary care ED. Data were collected on 4656 patients. Data were analyzed using a generalized estimating equations model to account for multiple doses being administered to the same patient. RESULTS: The ED dose was continued, unchanged, in 2560 admitted patients (83.8%). The correct dose was given 980 times (22.1%), 3143 doses (70.7%) were underdosed, and 318 were overdosed (7.2%). Increasing weight was associated with underdosing (adjusted odds ratio 1.52 per 10 kg body weight, p < 0.001). Patients who received doses of vancomycin > 20 mg/kg had longer hospital length of stay (p = 0.005); were more likely to spend ≥ 3 days in the hospital (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.12-1.98, p = 0.006); and more likely to die (OR 1.88; 95% CI 1.22-2.90, p = 0.004). CONCLUSION: In this largest study to date examining ED vancomycin dosing, vancomycin was commonly given. Dosing outside the recommended range was frequent, and especially prevalent in patients with a higher body weight. The ED dose of vancomycin was frequently continued as an inpatient, regardless of dosing accuracy. There is significant room for improvement in dosing accuracy and indication. Vancomycin dosing in the ED may also affect clinical outcomes.

Tec kinases regulate T-lymphocyte development and function: new insights into the roles of Itk and Rlk/Txk.

The Tec (tyrosine kinase expressed in hepatocellular carcinoma) family of non-receptor tyrosine kinases consists of five members: Tec, Bruton's tyrosine kinase (Btk), inducible T-cell kinase (Itk), resting lymphocyte kinase (Rlk/Txk), and bone marrow-expressed kinase (Bmx/Etk). Although their functions are probably best understood in antigen receptor signaling, where they participate in the phosphorylation and regulation of phospholipase C-gamma (PLC-gamma), it is now appreciated that these kinases contribute to signaling from many receptors and that they participate in multiple downstream pathways, including regulation of the actin cytoskeleton. In T cells, three Tec kinases are expressed, Itk, Rlk/Txk, and Tec. Itk is expressed at highest amounts and plays the major role in regulating signaling from the T-cell receptor. Recent studies provide evidence that these kinases contribute to multiple aspects of T-cell biology and have unique roles in T-cell development that have revealed new insight into the regulation of conventional and innate T-cell development. We review new findings on the Tec kinases with a focus on their roles in T-cell development and mature T-cell differentiation.

Care of Bullet-related Injuries: A Cross-sectional Study of Instructions and Prescriptions Provided on Discharge from the Emergency Department.

INTRODUCTION: There are more than 80,000 emergency department (ED) visits for non-fatal bullet-related injuries (BRI) per year in the United States. Approximately half of these patients are discharged home from the ED. Our objective in this study was to characterize the discharge instructions, prescriptions, and follow-up plans provided to patients discharged from the ED after BRI. METHODS: This was a single-center, cross-sectional study of the first 100 consecutive patients who presented to an urban, academic, Level I trauma center ED with an acute BRI beginning on January 1, 2020. We queried the electronic health record for patient demographics, insurance status, cause of injury, hospital arrival and discharge timestamps, discharge prescriptions, and documented instructions regarding wound care, pain management, and follow-up plans. We analyzed data using descriptive statistics and chi-square tests. RESULTS: During the study period, 100 patients presented to the ED with an acute firearm injury. Patients were predominantly young (median age 29, interquartile range 23-38 years), male (86%), Black (85%), non-Hispanic (98%), and uninsured (70%). We found that 12% of patients did not receive any type of written wound care instruction, while 37% received discharge paperwork that included instructions to take both an NSAID and acetaminophen. Fifty-one percent of patients received an opioid prescription, with a range from 3-42 tablets (median 10 tablets). The proportion of patients receiving an opioid prescription was significantly higher among White patients (77%) than among Black patients (47%). CONCLUSION: There is variability in prescriptions and instructions provided to survivors of bullet injuries upon ED discharge at our institution. Our data indicates that standardized discharge protocols could improve quality of care and equity in the treatment of patients who have survived a BRI. Current variable quality in discharge planning is an entry point for structural racism and disparity.

Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury.

The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes.