Association of 7 million+ tweets featuring suicide-related content with daily calls to the Suicide Prevention Lifeline and with suicides, United States, 2016-2018.

OBJECTIVE: The aim of this study was to assess associations of various content areas of Twitter posts with help-seeking from the US National Suicide Prevention Lifeline (Lifeline) and with suicides. METHODS: We retrieved 7,150,610 suicide-related tweets geolocated to the United States and posted between 1 January 2016 and 31 December 2018. Using a specially devised machine-learning approach, we categorized posts into content about prevention, suicide awareness, personal suicidal ideation without coping, personal coping and recovery, suicide cases and other. We then applied seasonal autoregressive integrated moving average analyses to assess associations of tweet categories with daily calls to the US National Suicide Prevention Lifeline (Lifeline) and suicides on the same day. We hypothesized that coping-related and prevention-related tweets are associated with greater help-seeking and potentially fewer suicides. RESULTS: The percentage of posts per category was 15.4% (standard deviation: 7.6%) for awareness, 13.8% (standard deviation: 9.4%) for prevention, 12.3% (standard deviation: 9.1%) for suicide cases, 2.4% (standard deviation: 2.1%) for suicidal ideation without coping and 0.8% (standard deviation: 1.7%) for coping posts. Tweets about prevention were positively associated with Lifeline calls (B = 1.94, SE = 0.73, p = 0.008) and negatively associated with suicides (B = -0.11, standard error = 0.05, p = 0.038). Total number of tweets were negatively associated with calls (B = -0.01, standard error = 0.0003, p = 0.007) and positively associated with suicide, (B = 6.4 × 10-5, standard error = 2.6 × 10-5, p = 0.015). CONCLUSION: This is the first large-scale study to suggest that daily volume of specific suicide-prevention-related social media content on Twitter corresponds to higher daily levels of help-seeking behaviour and lower daily number of suicide deaths. PREREGISTRATION: As Predicted, #66922, 26 May 2021.

Adherence to suicide reporting guidelines by news shared on a social networking platform.

Rates of suicide in the United States are at a more than 20-y high. Suicide contagion, or spread of suicide-related thoughts and behaviors through exposure to sensationalized and harmful content is a well-recognized phenomenon. Health authorities have published guidelines for news media reporting on suicide to help prevent contagion; however, uptake of recommendations remains limited. A key barrier to widespread voluntary uptake of suicide-reporting guidelines is that more sensational content is perceived to be more engaging to readers and thus enhances publisher visibility and engagement; however, no empirical information exists on the actual influence of adherence to safe-reporting practices on reader engagement. Hence, we conducted a study to analyze adherence to suicide-reporting guidelines on news shared on social media and to assess how adherence affects reader engagement. Our analysis of Facebook data revealed that harmful elements were prevalent in news articles about suicide shared on social media while the presence of protective elements was generally rare. Contrary to popular perception, closer adherence to safe-reporting practices was associated with a greater likelihood of an article being reshared (adjusted odds ratio [AOR] = 1.19, 95% confidence interval [CI] = 1.10 to 1.27) and receiving positive engagement ("love" reactions) (AOR = 1.20, 95% CI = 1.13 to 1.26). Mean safe-reporting scores were lower in the US than other English-speaking nations and variation existed by publisher characteristics. Our results provide empirical evidence that improved adherence to suicide-reporting guidelines may benefit not only the health of individuals, but also support publisher goals of reach and engagement.

Web-Based Social Networks of Individuals With Adverse Childhood Experiences: Quantitative Study.

BACKGROUND: Adverse childhood experiences (ACEs), which include abuse and neglect and various household challenges such as exposure to intimate partner violence and substance use in the home, can have negative impacts on the lifelong health of affected individuals. Among various strategies for mitigating the adverse effects of ACEs is to enhance connectedness and social support for those who have experienced them. However, how the social networks of those who experienced ACEs differ from the social networks of those who did not is poorly understood. OBJECTIVE: In this study, we used Reddit and Twitter data to investigate and compare social networks between individuals with and without ACE exposure. METHODS: We first used a neural network classifier to identify the presence or absence of public ACE disclosures in social media posts. We then analyzed egocentric social networks comparing individuals with self-reported ACEs with those with no reported history. RESULTS: We found that, although individuals reporting ACEs had fewer total followers in web-based social networks, they had higher reciprocity in following behavior (ie, mutual following with other users), a higher tendency to follow and be followed by other individuals with ACEs, and a higher tendency to follow back individuals with ACEs rather than individuals without ACEs. CONCLUSIONS: These results imply that individuals with ACEs may try to actively connect with others who have similar previous traumatic experiences as a positive connection and coping strategy. Supportive interpersonal connections on the web for individuals with ACEs appear to be a prevalent behavior and may be a way to enhance social connectedness and resilience in those who have experienced ACEs.

Using Transformer-Based Topic Modeling to Examine Discussions of Delta-8 Tetrahydrocannabinol: Content Analysis.

BACKGROUND: Delta-8 tetrahydrocannabinol (THC) is a psychoactive cannabinoid found in small amounts naturally in the cannabis plant; it can also be synthetically produced in larger quantities from hemp-derived cannabidiol. Most states permit the sale of hemp and hemp-derived cannabidiol products; thus, hemp-derived delta-8 THC products have become widely available in many state hemp marketplaces, even where delta-9 THC, the most prominently occurring THC isomer in cannabis, is not currently legal. Health concerns related to the processing of delta-8 THC products and their psychoactive effects remain understudied. OBJECTIVE: The goal of this study is to implement a novel topic modeling approach based on transformers, a state-of-the-art natural language processing architecture, to identify and describe emerging trends and topics of discussion about delta-8 THC from social media discourse, including potential symptoms and adverse health outcomes experienced by people using delta-8 THC products. METHODS: Posts from January 2008 to December 2021 discussing delta-8 THC were isolated from cannabis-related drug forums on Reddit (Reddit Inc), a social media platform that hosts the largest web-based drug forums worldwide. Unsupervised topic modeling with state-of-the-art transformer-based models was used to cluster posts into topics and assign labels describing the kinds of issues being discussed with respect to delta-8 THC. Results were then validated by human subject matter experts. RESULTS: There were 41,191 delta-8 THC posts identified and 81 topics isolated, the most prevalent being (1) discussion of specific brands or products, (2) comparison of delta-8 THC to other hemp-derived cannabinoids, and (3) safety warnings. About 5% (n=1220) of posts from the resulting topics included content discussing health-related symptoms such as anxiety, sleep disturbance, and breathing problems. Until 2020, Reddit posts contained fewer than 10 mentions of delta-8-THC for every 100,000 cannabis posts annually. However, in 2020, these rates increased by 13 times the 2019 rate (to 99.2 mentions per 100,000 cannabis posts) and continued to increase into 2021 (349.5 mentions per 100,000 cannabis posts). CONCLUSIONS: Our study provides insights into emerging public health concerns around delta-8 THC, a novel substance about which little is known. Furthermore, we demonstrate the use of transformer-based unsupervised learning approaches to derive intelligible topics from highly unstructured discussions of delta-8 THC, which may help improve the timeliness of identification of emerging health concerns related to new substances.

Evidence of the emergence of illicit benzodiazepines from online drug forums.

Illicit or 'designer' benzodiazepines are a growing contributor to overdose deaths. We employed natural language processing (NLP) to study benzodiazepine mentions over 10 years on 270 online drug forums (subreddits) on Reddit. Using NLP, we automatically detected mentions of illicit and prescription benzodiazepines, including their misspellings and non-standard names, grouping relative mentions by quarter. On a collection of 17 861 755 posts between 2012 and 2021, we searched for 26 benzodiazepines (8 prescription; 18 illicit), detecting 173 275 mentions. The rate of posts about both prescription and illicit benzodiazepines increased consistently with increases in deaths involving both drug classes, illustrating the utility of surveillance via Reddit.

Signals of increasing co-use of stimulants and opioids from online drug forum data.

BACKGROUND: Despite recent rises in fatal overdoses involving multiple substances, there is a paucity of knowledge about stimulant co-use patterns among people who use opioids (PWUO) or people being treated with medications for opioid use disorder (PTMOUD). A better understanding of the timing and patterns in stimulant co-use among PWUO based on mentions of these substances on social media can help inform prevention programs, policy, and future research directions. This study examines stimulant co-mention trends among PWUO/PTMOUD on social media over multiple years. METHODS: We collected publicly available data from 14 forums on Reddit (subreddits) that focused on prescription and illicit opioids, and medications for opioid use disorder (MOUD). Collected data ranged from 2011 to 2020, and we also collected timelines comprising past posts from a sample of Reddit users (Redditors) on these forums. We applied natural language processing to generate lexical variants of all included prescription and illicit opioids and stimulants and detect mentions of them on the chosen subreddits. Finally, we analyzed and described trends and patterns in co-mentions. RESULTS: Posts collected for 13,812 Redditors showed that 12,306 (89.1%) mentioned at least 1 opioid, opioid-related medication, or stimulant. Analyses revealed that the number and proportion of Redditors mentioning both opioids and/or opioid-related medications and stimulants steadily increased over time. Relative rates of co-mentions by the same Redditor of heroin and methamphetamine, the substances most commonly co-mentioned, decreased in recent years, while co-mentions of both fentanyl and MOUD with methamphetamine increased. CONCLUSION: Our analyses reflect increasing mentions of stimulants, particularly methamphetamine, among PWUO/PTMOUD, which closely resembles the growth in overdose deaths involving both opioids and stimulants. These findings are consistent with recent reports suggesting increasing stimulant use among people receiving treatment for opioid use disorder. These data offer insights on emerging trends in the overdose epidemic and underscore the importance of scaling efforts to address co-occurring opioid and stimulant use including harm reduction and comprehensive healthcare access spanning mental-health services and substance use disorder treatment.

Detection of emerging drugs involved in overdose via diachronic word embeddings of substances discussed on social media.

Substances involved in overdose deaths have shifted over time and continue to undergo transition. Early detection of emerging drugs involved in overdose is a major challenge for traditional public health data systems. While novel social media data have shown promise, there is a continued need for robust natural language processing approaches that can identify emerging substances. Consequently, we developed a new metric, the relative similarity ratio, based on diachronic word embeddings to measure movement in the semantic proximity of individual substance words to 'overdose' over time. Our analysis of 64,420,376 drug-related posts made between January 2011 and December 2018 on Reddit, the largest online forum site, reveals that this approach successfully identified fentanyl, the most significant emerging substance in the overdose epidemic, >1 year earlier than traditional public health data systems. Use of diachronic word embeddings may enable improved identification of emerging substances involved in drug overdose, thereby improving the timeliness of prevention and treatment activities.

Characterizing and Identifying the Prevalence of Web-Based Misinformation Relating to Medication for Opioid Use Disorder: Machine Learning Approach.

BACKGROUND: Expanding access to and use of medication for opioid use disorder (MOUD) is a key component of overdose prevention. An important barrier to the uptake of MOUD is exposure to inaccurate and potentially harmful health misinformation on social media or web-based forums where individuals commonly seek information. There is a significant need to devise computational techniques to describe the prevalence of web-based health misinformation related to MOUD to facilitate mitigation efforts. OBJECTIVE: By adopting a multidisciplinary, mixed methods strategy, this paper aims to present machine learning and natural language analysis approaches to identify the characteristics and prevalence of web-based misinformation related to MOUD to inform future prevention, treatment, and response efforts. METHODS: The team harnessed public social media posts and comments in the English language from Twitter (6,365,245 posts), YouTube (99,386 posts), Reddit (13,483,419 posts), and Drugs-Forum (5549 posts). Leveraging public health expert annotations on a sample of 2400 of these social media posts that were found to be semantically most similar to a variety of prevailing opioid use disorder-related myths based on representational learning, the team developed a supervised machine learning classifier. This classifier identified whether a post's language promoted one of the leading myths challenging addiction treatment: that the use of agonist therapy for MOUD is simply replacing one drug with another. Platform-level prevalence was calculated thereafter by machine labeling all unannotated posts with the classifier and noting the proportion of myth-indicative posts over all posts. RESULTS: Our results demonstrate promise in identifying social media postings that center on treatment myths about opioid use disorder with an accuracy of 91% and an area under the curve of 0.9, including how these discussions vary across platforms in terms of prevalence and linguistic characteristics, with the lowest prevalence on web-based health communities such as Reddit and Drugs-Forum and the highest on Twitter. Specifically, the prevalence of the stated MOUD myth ranged from 0.4% on web-based health communities to 0.9% on Twitter. CONCLUSIONS: This work provides one of the first large-scale assessments of a key MOUD-related myth across multiple social media platforms and highlights the feasibility and importance of ongoing assessment of health misinformation related to addiction treatment.

Adolescent Opioid Misuse Attributable to Adverse Childhood Experiences.

OBJECTIVES: To estimate the proportion of opioid misuse attributable to adverse childhood experiences (ACEs) among adolescents. STUDY DESIGN: A cross-sectional survey was administered to 10 546 seventh-to twelfth-grade students in northeastern Ohio in Spring 2018. Study measures included self-reported lifetime exposure to 10 ACEs and past 30-day use of nonmedical prescription opioid or heroin. Using generalized estimating equations, we evaluated associations between recent opioid misuse, individual ACEs, and cumulative number of ACEs. We calculated population attributable fractions to determine the proportion of adolescents' recent opioid misuse attributable to ACEs. RESULTS: Nearly 1 in 50 adolescents reported opioid misuse within 30 days (1.9%); approximately 60% of youth experienced ≥1 ACE; 10.2% experienced ≥5 ACEs. Cumulative ACE exposure demonstrated a significant graded relationship with opioid misuse. Compared with youth with zero ACEs, youth with 1 ACE (aOR 1.9, 95% CI, 0.9-3.9), 2 ACEs (aOR, 3.8; 95% CI, 1.9-7.9), 3 ACEs (aOR, 3.7; 95% CI, 2.2-6.5), 4 ACEs (aOR, 5.8; 95% CI, 3.1-11.2), and ≥5 ACEs (aOR, 15.3; 95% CI, 8.8-26.6) had higher odds of recent opioid misuse. The population attributable fraction of recent opioid misuse associated with experiencing ≥1 ACE was 71.6% (95% CI, 59.8-83.5). CONCLUSIONS: There was a significant graded relationship between number of ACEs and recent opioid misuse among adolescents. More than 70% of recent adolescent opioid misuse in our study population was attributable to ACEs. Efforts to decrease opioid misuse could include programmatic, policy, and clinical practice interventions to prevent and mitigate the negative effects of ACEs.

Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence - United States, January 2017-December 2018.

Suicide is a growing public health problem in the United States, claiming approximately 47,000 lives in 2017 (1). However, deaths from suicide represent only a small part of a larger problem because each year millions of persons experience suicidal ideation and engage in suicidal and nonsuicidal self-directed violence, both risk factors for suicide (2). Emergency departments (EDs) are an important setting for monitoring these events in near real time (3-5). From 2001 to 2016, ED visit rates for nonfatal self-harm increased 42% among persons aged ≥10 years (1). Using data from CDC's National Syndromic Surveillance Program (NSSP), ED visits for suicidal ideation, self-directed violence, or both among persons aged ≥10 years during January 2017-December 2018 were examined by sex, age group, and U.S. region. During the 24-month period, the rate of ED visits for suicidal ideation, self-directed violence, or both increased 25.5% overall, with an average increase of 1.2% per month. Suicide prevention requires comprehensive and multisectoral approaches to addressing risk at personal, relationship, community, and societal levels. ED syndromic surveillance data can provide timely trend information and can support more targeted and prompt public health investigation and response. CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices includes tailored suicide prevention strategies for health care settings (6).

National Trends in hospitalizations for self-directed violence related to opioids and/or depression - United States, 2000-2015.

This study examined national trends in self-directed violence in the context of changes in opioid use and depression to better inform prevention measures. Using 2000-2015 National Inpatient Sample (NIS) data, we identified 625,064 hospitalizations for self-directed violence among persons aged ≥10 years in the United States. Based on whether co-listing opioid related diagnosis and depression, we categorized hospitalizations for self-directed violence into four comorbid categories as 1) related to opioids alone; 2) related to depression alone; 3) related to both opioids and depression; and 4) related to neither opioids nor depression. Census population estimates served as the denominator for calculating hospitalization rates for self-directed violence. Hospitalization rates for self-directed violence related to opioids doubled from 5.1 per 100,000 persons in 2000 to 11.0 in 2015. The rate of increase was highest for self-directed violence related to both opioids and depression, which increased 9.4% annually during 2000-2011 and then decreased 4.3% annually during 2011-2015. Hospitalizations for self-directed violence related to depression alone remained the predominant category, accounting for approximately 60% of hospitalizations for self-directed violence; the rates among females aged 10-24 years were the highest among all subgroups, and rose 7.8% annually since 2011 reaching 93.2 per 100,000 persons in 2015. These findings highlight the importance of assessing the risk for self-directed violence among patients misusing opioids and the importance of treating opioid use disorder and depression, particularly when they co-occur. Prevention and treatment of depression is especially important for young females.

Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USA.

OBJECTIVES: Violence is a major public health problem in the USA. In 2016, more than 1.6 million assault-related injuries were treated in US emergency departments (EDs). Unfortunately, information about the magnitude and patterns of violent incidents is often incomplete and underreported to law enforcement (LE). In an effort to identify more complete information on violence for the development of prevention programme, a cross-sectoral Cardiff Violence Prevention Programme (Cardiff Model) partnership was established at a large, urban ED with a level I trauma designation and local metropolitan LE agency in the Atlanta, Georgia metropolitan area. The Cardiff Model is a promising violence prevention approach that promotes combining injury data from hospitals and LE. The objective was to describe the Cardiff Model implementation and collaboration between hospital and LE partners. METHODS: The Cardiff Model was replicated in the USA. A process evaluation was conducted by reviewing project materials, nurse surveys and interviews and ED-LE records. RESULTS: Cardiff Model replication centred around four activities: (1) collaboration between the hospital and LE to form a community safety partnership locally called the US Injury Prevention Partnership; (2) building hospital capacity for data collection; (3) data aggregation and analysis and (4) developing and implementing violence prevention interventions based on the data. CONCLUSIONS: The Cardiff Model can be implemented in the USA for sustainable violent injury data surveillance and sharing. Key components include building a strong ED-LE partnership, communicating with each other and hospital staff, engaging in capacity building and sustainability planning.

Conversational topics of social media messages associated with state-level mental distress rates.

Background: Upstream public health indicators of poor mental health in the United States (U.S.) are currently measured by national telephone-based surveys; however, results are delayed by 1-2 years, limiting real-time assessment of trends.Aim: The aim of this study was to evaluate associations between conversational topics on Twitter from 2018 to 2019 and mental distress rates from 2017 to 2018 for the 50 U.S. states and capital.Method: We used a novel lexicon, Empath, to examine conversational topics from aggregate social media messages from Twitter that correlated most strongly with official U.S. state-level rates of mental distress from the Behavioral Risk Factor Surveillance System.Results: The ten lexical categories most positively correlated with rates of frequent mental distress at the state-level included categories about death, illness, or injury. Lexical categories most inversely correlated with mental distress included categories that serve as proxies for economic prosperity and industry. Using the prevalence of the 10 most positively and 10 most negatively correlated lexical categories to predict state-level rates of mental distress via a linear regression model on an independent sample of data yielded estimates that were moderately similar to actual rates (mean difference = 0.52%; Pearson correlation = 0.45, p < 0.001).Conclusion: This work informs efforts to use social media to measure population-level trends in mental health.

Childhood Violence Is Associated with Forced Sexual Initiation Among Girls and Young Women in Malawi: A Cross-Sectional Survey.

OBJECTIVE: To describe associations between childhood violence and forced sexual initiation in young Malawian females. STUDY DESIGN: We analyzed data from 595 women and girls who were 13-24 years old who ever had sex and participated in Malawi's 2013 Violence Against Children Survey, a nationally representative household survey. We estimated the overall prevalence of forced sexual initiation and identified subgroups with highest prevalences. Using logistic regression, we examined childhood violence and other independent predictors of forced sexual initiation. RESULTS: The overall prevalence of forced sexual initiation was 38.9% among Malawian girls and young women who ever had sex. More than one-half of those aged 13-17 years at time of survey (52.0%), unmarried (64.6%), or experiencing emotional violence in childhood (56.9%) reported forced sexual initiation. After adjustment, independent predictors of forced sexual initiation included being unmarried (aOR, 3.54; 95% CI, 1.22-10.27) and any emotional violence (aOR, 2.47; 95% CI, 1.45-4.24). Those experiencing emotional violence alone (aOR, 3.04; 95% CI: 1.01-9.12), emotional violence in combination with physical or nonpenetrative sexual violence (aOR, 2.50; 95% CI, 1.23-5.09), and emotional violence in combination with physical and nonpenetrative sexual violence (aOR, 2.61; 95% CI, 1.20-5.67) had an increased independent odds of forced sexual initiation. CONCLUSIONS: Experiences of forced sexual initiation are common among Malawian females. Emotional violence is strongly associated with forced sexual initiation, alone and in combination with other forms of childhood violence. The relationship between emotional violence and forced sexual initiation highlights the importance of comprehensive strategies to prevent childhood violence.

Prevalence of Violence Victimization and Perpetration Among Persons Aged 13-24 Years - Four Sub-Saharan African Countries, 2013-2015.

Violence is a major public health and human rights concern, claiming over 1.3 million lives globally each year (1). Despite the scope of this problem, population-based data on physical and sexual violence perpetration are scarce, particularly in low-income and middle-income countries (2,3). To better understand factors driving both children becoming victims of physical or sexual violence and subsequently (as adults) becoming perpetrators, CDC collaborated with four countries in sub-Saharan Africa (Malawi, Nigeria, Uganda, and Zambia) to conduct national household surveys of persons aged 13-24 years to measure experiences of violence victimization in childhood and subsequent perpetration of physical or sexual violence. Perpetration of physical or sexual violence was prevalent among both males and females, ranging among males from 29.5% in Nigeria to 51.5% in Malawi and among females from 15.3% in Zambia to 28.4% in Uganda. Experiencing physical, sexual, or emotional violence in childhood was the strongest predictor for perpetrating violence; a graded dose-response relationship emerged between the number of types of childhood violence experienced (i.e., physical, sexual, and emotional) and perpetration of violence. Efforts to prevent violence victimization need to begin early, requiring investment in the prevention of childhood violence and interventions to mitigate the negative effects of violence experienced by children.

Increase in Drug Overdose Deaths Involving Fentanyl-Rhode Island, January 2012-March 2014.

Objective: This study identified sociodemographic, substance use, and multiple opioid prescriber and dispenser risk factors among drug overdose decedents in Rhode Island, in response to an increase in overdose deaths (ODs) involving fentanyl. Methods: This cross-sectional investigation comprised all ODs reviewed by Rhode Island's Office of the State Medical Examiners (OSME) during January 2012 to March 2014. Data for 536 decedents were abstracted from OSME's charts, death certificates, toxicology reports, and Prescription Monitoring Program (PMP) databases. Decedents whose cause of death involved illicit fentanyl (N = 69) were compared with decedents whose causes of death did not involve fentanyl (other drug decedents; N = 467). Results: Illicit-fentanyl decedents were younger than other drug decedents (P = 0.005). While more other-drug decedents than illicit fentanyl decedents had postmortem toxicological evidence of consuming heroin (31.9% vs 19.8%, P < 0.001) and various pharmaceutical substances (P = 0.002-0.027), third party reports indicated more recent heroin use among illicit fentanyl decedents (62.3% vs 45.6%, P = 0.002). Approximately 35% of decedents filled an opioid prescription within 90 days of death; of these, one-third had a mean daily dosage greater than 100 morphine milligram equivalents (MME/day). Most decedents' opioid prescriptions were filled at one to two dispensers (83.9%) and written by one to two prescribers (75.8%). Notably, 29.2% of illicit fentanyl and 10.5% of other drug decedents filled prescriptions for buprenorphine, which is used to treat opioid use disorders. Conclusions: Illicit-fentanyl deaths frequently involved other illicit drugs (e.g., cocaine, heroin). The proportion of all decedents acquiring greater than 100 MME/day prescription dosages written and/or filled by few prescribers and dispensers is concerning. To protect patients, prescribers and dispensers should review PMP records and substance abuse history prior to providing opioids.

Health system and law enforcement synergies for injury surveillance, control and prevention: a scoping review.

BACKGROUND: Healthcare providers and law enforcement (LE) officers are among the most common first responders to injuring events. Despite frequent interface between the health system (HS) and LE sectors, the published evidence that supports their collaboration in injury surveillance, control and prevention has not been comprehensively reviewed. METHODS: We conducted a scoping review of literature published from 1990 to 2016 that focused on local and regional HS and LE collaborations in injury surveillance, control and prevention. Our aim was to describe what is known and what remains unexplored about these cross-sector efforts. RESULTS: 128 articles were included in the final review. These were categorised by their focus on either surveillance activities or partnerships in injury control and prevention programmes. The majority of surveillance articles focused on road traffic injuries. Conversely, articles describing partnerships and programme evaluations primarily targeted the prevention of interpersonal violence. DISCUSSION: This review yielded two major findings: overall, the combination of HS and LE injury data added value to surveillance systems, especially as HS data augmented LE data; and HS and LE partnerships have been developed to improve injury control and prevention. However, there are few studies that have evaluated the impact and sustainability of these partnerships. CONCLUSIONS: The current evidence to support HS and LE collaboration in injury surveillance and control and prevention programmes is heterogeneous. Notable gaps suggest ample opportunity for further research and programme evaluation across all types of injury.

Development of the SaFETy Score: A Clinical Screening Tool for Predicting Future Firearm Violence Risk.

BACKGROUND: Interpersonal firearm violence among youth is a substantial public health problem, and emergency department (ED) physicians require a clinical screening tool to identify high-risk youth. OBJECTIVE: To derive a clinically feasible risk index for firearm violence. DESIGN: 24-month prospective cohort study. SETTING: Urban, level 1 ED. PARTICIPANTS: Substance-using youths, aged 14 to 24 years, seeking ED care for an assault-related injury and a proportionately sampled group of non-assault-injured youth enrolled from September 2009 through December 2011. MEASUREMENTS: Firearm violence (victimization/perpetration) and validated questionnaire items. RESULTS: A total of 599 youths were enrolled, and presence/absence of future firearm violence during follow-up could be ascertained in 483 (52.2% were positive). The sample was randomly split into training (75%) and post-score-construction validation (25%) sets. Using elastic-net penalized logistic regression, 118 baseline predictors were jointly analyzed; the most predictive variables fell predominantly into 4 domains: violence victimization, community exposure, peer influences, and fighting. By selection of 1 item from each domain, the 10-point SaFETy (Serious fighting, Friend weapon carrying, community Environment, and firearm Threats) score was derived. SaFETy was associated with firearm violence in the validation set (odds ratio [OR], 1.47 [95% CI, 1.23 to 1.79]); this association remained (OR, 1.44 [CI, 1.20 to 1.76]) after adjustment for reason for ED visit. In 5 risk strata observed in the training data, firearm violence rates in the validation set were 18.2% (2 of 11), 40.0% (18 of 45), 55.8% (24 of 43), 81.3% (13 of 16), and 100.0% (6 of 6), respectively. LIMITATIONS: The study was conducted in a single ED and involved substance-using youths. SaFETy was not externally validated. CONCLUSION: The SaFETy score is a 4-item score based on clinically feasible questionnaire items and is associated with firearm violence. Although broader validation is required, SaFETy shows potential to guide resource allocation for prevention of firearm violence. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse R01024646.