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.

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.

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.

An exploration of factors impacting implementation of a multisystem hospital-based violence intervention program.

Community violence, particularly gun violence, is a leading cause of morbidity and mortality in young people in the United States. Because persons experiencing violence-related injuries are likely to receive medical care through emergency departments, hospitals are increasingly seen as primary locations for violence intervention services. Currently, there is little research on how best to implement hospital-based violence intervention programs (HVIPs) across large hospital systems. This study explored the factors influencing the implementation of a multi-site HVIP using qualitative interviews with a purposive sample of 20 multidisciplinary stakeholders. Thematic analysis was used to generate several themes that included: (1) reframing gun violence as a public health issue; (2) developing networks of community-hospital-university partners; (3) demonstrating effectiveness and community benefit; and (4) establishing patient engagement pathways. Effective implementation and sustainment of HVIPs requires robust and sustained multidisciplinary partnerships within and across hospital systems and the establishment of HVIPs as a standard of care.

Positioning public health surveillance for observational studies and clinical trials: The St. Louis region-wide hospital-based violence intervention program data repository.

INTRODUCTION: Firearm injuries are a public health epidemic in the United States, yet a comprehensive national database for patients with firearm injuries does not exist. Here we describe the methods for a study to develop and query a new regional database of all patients who present to a St. Louis level I trauma hospital with a violent injury, the St. Louis Hospital-Based Violence Intervention Program Data Repository (STL-HVIP-DR). We hypothesize that the STL-HVIP-DR will facilitate identification of patients at risk for violent injury and serve as a comparison population for participants enrolled in clinical trials. METHODS: The STL-HVIP-DR includes all visits made for violent injury to four level I trauma hospitals in St. Louis, Missouri between January 1, 2010 and December 31, 2019. Two health systems representing the four participating hospitals executed a data sharing agreement to aggregate clinical data on firearm injuries, stabbings, and blunt assaults. Dataset variables include demographic hospital and timestamp, medical, and insurance information. RESULTS: A preliminary cross-sectional query of the STL-HVIP-DR reveals 121,955 patient visits among the four partner level I trauma hospitals for a violent injury between 2010 and 2019. This includes over 18,000 patient visits for firearm injury. DISCUSSION: The STL-HVIP-DR repository fills a critical gap regarding identification and outcomes among individuals who are violently injured, especially those with non-lethal firearm injuries. It is our hope that the methods presented in this paper will serve as a primer to develop repositories to help target violence prevention services in other regions.

Neoadjuvant Therapy for Melanoma: A U.S. Food and Drug Administration-Melanoma Research Alliance Public Workshop.

Tremendous progress has been made in treating patients with metastatic melanoma over the past decade. In that timeframe, the FDA has approved 12 novel treatments for patients with advanced unresectable melanoma, comprising both kinase-targeted therapies and immune checkpoint inhibitors (ICI), and five treatments for adjuvant (postoperative) use in patients with high-risk resectable stage III melanoma. It is not known whether outcomes can be further improved by administering kinase inhibitors or ICI in the neoadjuvant (presurgical) setting in patients with high-risk resectable melanomas. Noting research community interest in exploring the neoadjuvant approach for treating melanoma and recognizing that early harmonization of methodologies may expedite the development of therapeutics in this space, the FDA and Melanoma Research Alliance convened a public workshop on November 6, 2019, in National Harbor, Maryland, to discuss key issues. The workshop consisted of 23 faculty and included more than 250 live participants. Topics discussed included opportunities for advancing novel endpoints for regulatory purposes as well as translational research, clinical trial design considerations, and strategies for optimizing patient selection while mitigating risk.

Melanoma models for the next generation of therapies.

There is a lack of appropriate melanoma models that can be used to evaluate the efficacy of novel therapeutic modalities. Here, we discuss the current state of the art of melanoma models including genetically engineered mouse, patient-derived xenograft, zebrafish, and ex vivo and in vitro models. We also identify five major challenges that can be addressed using such models, including metastasis and tumor dormancy, drug resistance, the melanoma immune response, and the impact of aging and environmental exposures on melanoma progression and drug resistance. Additionally, we discuss the opportunity for building models for rare subtypes of melanomas, which represent an unmet critical need. Finally, we identify key recommendations for melanoma models that may improve accuracy of preclinical testing and predict efficacy in clinical trials, to help usher in the next generation of melanoma therapies.

Counseling on Access to Lethal Means-Emergency Department (CALM-ED): A Quality Improvement Program for Firearm Injury Prevention.

INTRODUCTION: Suicide is the 10th leading cause of death in the United States, with firearms reported as the cause of death in up to 50% of these cases. Our goal was to evaluate the feasibility of the Counseling on Access to Lethal Means intervention in the Emergency Department (CALM-ED) by non-physician personnel. METHODS: We conducted this single-center, prospective, quality improvement study (QI) in an urban, academic ED with over 90,000 annual patient visits. The study looked at adult patients who were discharged after presenting to the ED with suicidal crisis. Assessment of access to lethal means was conducted at the bedside, followed by a counseling session regarding safe storage of lethal means and follow-up via telephone call 48-72 hours after ED discharge. We collected data on patient's sociodemographics, psychiatric history, access to lethal means, lethal means storage methods, the patient's specific plans for lethal means storage after discharge, and post-discharge follow-up care. RESULTS: Of 215 eligible patients, 166 voluntarily agreed to participate in CALM-ED, of whom 84 (51%) reported access to lethal means. Following the intervention, 75% of patients described a specific storage plan for their lethal means. Patients with and without access to firearms were equally likely to participate in the follow-up telephone call. CONCLUSION: An ED-based CALM QI intervention is feasible for implementation by non-physician personnel and is well received by patients and families. This intervention has the potential to help saves lives at times of suicide crisis.

Physician Documentation of Access to Firearms in Suicidal Patients in the Emergency Department.

INTRODUCTION: Suicide is the 10th leading cause of death in the United States. An estimated 50% of these deaths are due to firearms. Suicidal ideation (SI) is a common complaint presenting to the emergency department (ED). Despite these facts, provider documentation on access to lethal means is lacking. Our primary aim was to quantify documentation of access to firearms in patients presenting to the ED with a chief complaint of SI. METHODS: This was a cross-sectional study of consecutive patients, nearly all of whom presented to an academic, urban ED with SI during July 2014. We collected data from all provider documentation in the electronic health record. Primary outcome assessed was whether the emergency physician (EP) team documented access to firearms. Secondary outcomes included demographic information, preexisting psychiatric diagnoses, and disposition. RESULTS: We reviewed 100 patient charts. The median age of patients was 38 years. The majority of patients had a psychiatric condition. EPs documented access to firearms in only 3% of patient charts. CONCLUSION: EPs do not adequately document access to firearms in patients with SI. There is a clear need for educational initiatives regarding risk-factor assessment and counseling against lethal means in this patient cohort.

Fibroblast growth factor signaling regulates pillar cell development in the organ of corti.

One of the most striking aspects of the cellular pattern within the sensory epithelium of the mammalian cochlea is the presence of two rows of pillar cells in the region between the single row of inner hair cells and the first row of outer hair cells. The factors that regulate pillar cell development have not been determined; however, previous results suggested a key role for fibroblast growth factor receptor 3 (FGFR3). To examine the specific effects of FGFR3 on pillar cell development, we inhibited receptor activation in embryonic cochlear explant cultures. Results indicated that differentiation of pillar cells is dependent on continuous activation of FGFR3. Moreover, transient inhibition of FGFR3 did not inhibit the pillar cell fate permanently, because reactivation of FGFR3 resulted in the resumption of pillar cell differentiation. The effects of increased FGFR3 activation were determined by exposing cochlear explants to FGF2, a strong ligand for several FGF receptors. Treatment with FGF2 led to a significant increase in the number of pillar cells and to a small increase in the number of inner hair cells. These effects were not dependent on cellular proliferation, suggesting that additional pillar cells and inner hair cells were a result of increased recruitment into the prosensory domain. These results indicate that FGF signaling plays a critical role in the commitment and differentiation of pillar cells. Moreover, the position of the pillar cells appears to be determined by the activation of FGFR3 in a subset of the progenitor cells that initially express this receptor.