Temporal trends in female firearm homicides across states in the Northeast of Brazil during the period 2000-2019. / Tendência temporal da mortalidade por homicídios femininos por arma de fogo nos estados da região Nordeste do Brasil no período 2000-2019.

This article aims to analyze temporal trends in female firearm homicides in the Northeast of Brazil during the period 2000-2019. We conducted an ecological study using data on firearm homicides of women aged 10 years and over obtained from the Mortality Information System. The population data were taken from the 2010 Census. Homicide rates were calculated after correcting the data to account for differences in the quality and coverage of death records. Trends were assessed using negative binomial regression and described using relative risk and p values. Average annual percentage changes in homicide rates were also calculated. The regional firearm homicide rate during the study period was 4.40 per 100,000 women. Rates were highest in the state of Alagoas (5.40), the 15-19 age group (5.84) and in public thoroughfares (1.58). Trends were upward across all states except Pernambuco, where they were downward, and Alagoas, where rates were stationary. The place of occurrence with the highest percentage increase in firearm homicides over the study period was public thoroughfares. Female firearm homicides showed an upward trend across most northeastern states.

O objetivo deste artigo é analisar a tendência temporal dos homicídios femininos perpetrados por arma de fogo nos estados nordestinos, no período de 2000 a 2019. Estudo ecológico, com dados de homicídios por arma de fogo em mulheres com 10 ou mais anos, registrados no Sistema de Informação Sobre Mortalidade. Os dados de mortalidade e os dados populacionais foram obtidos junto ao Departamento de Informática do Sistema Único de Saúde. Após a correção dos registros de óbito para qualidade e cobertura dos óbitos, as taxas de mortalidade foram calculadas Tendências foram avaliadas por regressão binomial negativa, classificadas de acordo com o valor do risco relativo e valor de p. Calculou-se a variação percentual anual média das taxas de mortalidade. A região apresentou 4,40 homicídios por arma de fogo por 100 mil mulheres no período do estudo, maiores coeficientes em Alagoas (5,40), na faixa etária de 15-19 anos (5,84), e via pública (1,58). As tendências foram ascendentes, com exceção de Pernambuco em que foi descendente, e estacionárias em Alagoas. Os homicídios por arma de fogo em via pública apresentaram maior percentual de aumento no período estudado. Observou-se tendência ascendente nos homicídios femininos perpetrados por arma de fogo na maioria dos estados nordestinos.

Active shooter in emergency departments in Guanajuato State, Mexico.

Mass violence events, especially in healthcare settings, have devastating consequences and long-lasting effects on the victims and the community. The rate of violent events in Mexico, especially in hospital settings, has increased since 2006, but has become more evident in 2018. Guanajuato State, located in central Mexico, is among the states most affected by the wave of violence, especially active shooter events. The year 2019 had the highest number of incidents. Therefore, the Silver Code and the components of Safe Hospitals, in accordance with the Hartford consensus and PAHO guidelines, were implemented in the hospitals of the Institute of Public Health of the State of Guanajuato, with a focus on the actions of healthcare personnel to prevent collateral damage. Although subsequently there were still fatalities and injuries in the events involving active shooters in the hospitals, there were no casualties among healthcare personnel, according to data from the Institute of Public Health, Guanajuato State. This paper presents information from the data from General Directorate of Epidemiology to describe the hospital mass violence situation in the State of Guanajuato, Mexico and recounts the step taken to effectively manage and prevent these situations moving forward. Specific recommendations based on international consensus and our experience provided include increasing the level of security checks for people entering the hospital premises, training healthcare personnel on violence-related preparedness and improving management of active shooter events consistent with published evidence, to reduce the possibility of casualties.

Epidemiologic analysis and mortality outcome of firearm injuries in French Guiana (2016-2019).

BACKGROUND: French Guiana (FG) is a French territory located in South America with the highest rate of armed assaults. FG presents a poorly developed road system and a young and precarious population that makes the geographical and socio-demographic characteristics specific. No data concerning the firearm injury management are available in this country. Studying thesis trauma could permit to improve the management of victims. The objective of this study is to investigate the epidemiology of firearm injuries in FG, to define characteristics of the victims, and to assess factors associated with death. These identified factors could enable target primary prevention and intensification of medical management. METHODS: From January 2016 to December 2019, we conducted a retrospective study at the Cayenne General Hospital (CGH), including all patients admitted for firearm injuries in the emergency department, the medical emergency and resuscitation service, and the forensic service. A bivariate analysis was performed to assess relevant clinical data that were entered into a logistic regression model to assess factors associated with death. RESULTS: A total of 871 files were analyzed concerning 340 patients included after cross-checking. Victims were mainly males (90%) and young (30 ± 11 years old). The injury occurred mainly at night (60%), in a context of assaults (83%) and with long-barreled guns (82%). Among the 290 patients managed at the CGH, 60% were hospitalized including 12% that were in the intensive care unit, 41% that required surgical treatment, and 7% that died in hospital. The overall average length of stay was 10 ± 18 days. Overall mortality (n = 71, 21%) is statistically associated with male gender (p = 0.007) and suicide context (p < 0.001). In multivariate analysis, the sites of wounds (head and neck, thorax; p < 0.001) as well as induced organ injuries (neurological, respiratory, and vascular; p < 0.005) were independent factors associated to mortality. CONCLUSIONS: This work underlines the high incidence of ballistic trauma in FG. This mainly involves a young and male population linked to the use of long arms and assaults. Despite the geographical difficulties of the territory and the technical platform deficits (no neurosurgery, no cardiothoracic surgery, no interventional radiology), the mortality is comparable to other studies, but remains more than twice as high as in mainland France. Finally, despite a change in legislation restricting access to firearms, our results show that gunshot firearm injuries remain a major public health concern requiring greater political actions.

Firearm manufacturing and imports in the USA and their association to firearm homicides in Central America and the Caribbean, 1991-2019.

BACKGROUND: Firearm manufacturing and imports grew in the US during the mid-2000s. We hypothesise those increases corresponded to increased international firearms trafficking and in turn were associated with increases in firearm homicides abroad. METHODS: We used the Global Burden of Disease database to quantify annual firearm and non-firearm homicide rates in Central American and Caribbean countries, 1991-2019. We obtained US firearm manufacturing and import data from the Bureau of Alcohol, Tobacco, Firearms and Explosives. We used two-way fixed effects regressions to estimate within-country associations between homicide rates (firearm and non-firearm) and US firearm manufacturing and imports. FINDINGS: Firearm homicide rates in Central American and Caribbean countries increased from 8.38/100K population in 2004 to 17.55/100 K in 2012 and remained steady thereafter. Those surges coincided with increases in US firearm manufacturing/imports (from 4.99 million in 2004 to 13.12 million in 2012). Non-firearm homicides remained roughly constant from 1991 to 2019. Adjusted analysis showed that an annual increase of one million firearms manufactured/imported in the US corresponded to an annual increase of 1.42 (95% CI 0.62 to 2.21) firearm homicides per 100 K in Central American and Caribbean countries. The corresponding change for non-firearm homicides was -0.18 (95% CI -1.46 to 1.11). We found country-to-country variability in these effects. INTERPRETATION: Increases in US firearm manufacturing/imports were associated with increases in firearm homicide rates in Central American and Caribbean countries but not associated with non-firearm homicides. The specificity to firearm homicides suggests possible international repercussions of increased firearm manufacturing and imports in the US implications are discussed.

A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014.

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.

Epidemiological profile of female firearm-related mortality.

ABSTRACT: The mortality rate of women due to firearms increases every day in Brazil and globally. This study aimed to evaluate the trends of firearm-related mortality in women from the years 2007 to 2016 in order to determine their profile and to associate these indicators with public policy and strategies to reduce mortality.This is an ecological time-series study using secondary data of women aged 10 to 49 years old collected through the mortality information system (SIM) in Brazil. Furthermore, independent characteristics such as education, color, race and civil status were also collected from SIM. Data was analyzed using the Join Point open source software version.There was an increase in the mortality rate of women who received 4 to the 7 years of education, were single, and brown-skinned. There was a significantly increased rate of mortality in women whose ages ranged from 20 to 29 years followed by 30 to 39 years; the rate was also significantly higher in the northeast region followed by the southeast region.There is a need for professional training to assist women in vulnerable situations.

Shotgun injuries. Need for a special point of view.

BACKGROUND: Shotgun injuries (SGI) are infrequent, but due its special ballistics, are related to adverse outcomes. OBJECTIVE: To analyze operative and administrative variables, critical for the institution. METHOD: Demographics and health-care related variables from SGI patients admitted to Military Central Hospital (Mexico City) between July 2006 and August 2019, were retrospectively studied. Statistics methods used were dispersion measures and relative occurrence frequency. RESULTS: Over a 15 months-span, 21 SGI patients were admitted. Mean age was 36.9 ± 13.6 years (range: 14-61) and male gender was dominant (n = 20; 95%). Type II SGI were the most common injuries (62%; 13/21). Mean hospital length of stay was 37.1 ± 28.7 days (range: 3-109) while stay at ICU was 20.3 ± 22.5 days (range: 3-99). Global rate of morbidity was 82% (17/21) and most frequent complications were infective. Global mortality rate was 24% (5/21). CONCLUSIONS: Once SGI cause prolonged length of stay, high rate of morbidity and of enormous consuming of material and human resources, primary prevention strategies are convenient for health-care systems compromised to the care of these cases.

ANTECEDENTES: Las lesiones por disparo de escopeta (LE) son infrecuentes, pero debido a su balística especial se relacionan con un pronóstico adverso. OBJETIVO: Analizar variables operativas y administrativas de los pacientes con LE, de interés para la institución. MÉTODO: Se estudiaron retrospectivamente variables demográficas y asistenciales de pacientes con LE admitidos al Hospital Central Militar (Ciudad de México) entre julio de 2006 y agosto de 2019. Los métodos estadísticos usados fueron medidas de dispersión y frecuencia relativa de ocurrencia. RESULTADOS: En 158 meses se admitieron 21 pacientes con LE. La edad media fue de 36.9 ± 13.6 años (rango: 14-61) y predominó el sexo masculino (n = 20; 95%). La LE tipo II fue la más frecuente (62%; 13/21). La estancia hospitalaria media fue de 37.1 ± 28.7 días (rango: 3-109) y en cuidados intensivos fue de 20.3 ± 22.5 días (rango: 3-99). La tasa global de morbilidad fue del 82% (17/21) y las complicaciones más frecuentes fueron infecciosas. La tasa gobal de mortalidad fue del 24% (5/21). CONCLUSIONES: Las LE son causa de estancia hospitalaria prolongada, alta tasa de morbilidad y un enorme consumo de recursos humanos y materiales, por lo que las estrategias de prevención primaria son convenientes para los sistemas de salud comprometidos con el cuidado de estos casos.

Undeclared civil war? Urban violence in major city in Brazil. / Guerra civil não-declarada? Um recorte do status da violência urbana em uma capital no Brasil.

PURPOSE: Civil violence is responsible for 2.5% of deaths worldwide; it killed more people in the 21st century than the sum of all wars. This study describes violence victims treated at a trauma reference hospital in Salvador, Brazil and analyzes the impact of different types of interpersonal violence. METHODS: Interpersonal violence victims admitted between July 2015 and July 2017 were included. The 1,296 patients (mean age: 30.3 years; 90% male) were divided into three groups according to the mechanism of interpersonal violence: 1) beating, 2) firearm injury and 3) stab wound (STW) injury. The groups were compared for the following variables: age, gender, trauma mechanism, Revised Trauma Score (RTS) at admission, need for intensive care unit (ICU) attention, length of hospital stay, need for transfusion of blood products and death. RESULTS: Gunshot wounds (GSW) were the primary mechanism of injury (59%), followed by beating (24%) and STW (17%). Gunshot wound victims had a lower mean RTS upon admission, increased need for blood products and more Intensive Care Unit (ICU) admissions. Beating victims had the longest mean hospital stay (11.6 ± 19.6 days). The GSW group accounted for 77.4% of all deaths. The in-hospital mortality rate was significantly higher in the GSW group (12.7%) than in the beating group (5.4%) and in the STW group (4.9%). CONCLUSIONS: Gunshot wound victims are more critical: they require longer ICU stays, more transfusions of blood products and exhibit increased mortality compared with STW and beating victims.

OBJETIVO: a violência civil é responsável por 2,5% da mortalidade mundial, matou mais pessoas no século XXI do que o somatório de todas as guerras deste período. Este estudo descreve as vítimas de violência admitidas em um hospital de referência em trauma em Salvador - Bahia, Brasil e analisa o impacto dos diferentes tipos de violência interpessoal. MÉTODOS: foram incluídos vítimas de violência interpessoal admitidas entre julho de 2015 e julho de 2017. 1296 pacientes (média de idade foi 30,3 anos, 90% do sexo masculino) foram divididos em três grupos de acordo com o mecanismo de violência interpessoal: espancamento, ferimentos por projétil de arma de fogo (FPAF), ferimentos por arma branca (FAB). Os grupos foram comparados de acordo com as seguintes variáveis: idade, sexo, mecanismo de trauma, Revised Trauma Score (RTS) na admissão, necessidade de internamento em unidade de tratamento intensivo (UTI), tempo de internamento, necessidade de transfusão de hemocomponentes e morte. RESULTADOS: FPAF foram o principal mecanismo de injúria (59%), seguido por agressão (24%) e FAB (17%). As vítimas de FPAF apresentaram a menor média de RTS na admissão, maior necessidade de uso de hemocomponentes e de internamento em UTI. Vítimas de espancamento tiveram a maior média de duração de internação hospitalar (11,6±19,6 dias). Os FPAF causaram 77,4% das mortes. CONCLUSÃO: vítimas de FPAF são mais críticas, requerendo maior tempo de tratamento em UTI, mais hemocomponentes e maior mortalidade comparativamente às vítimas de FAB e espancamento.

Gun-carrying restrictions and gun-related mortality, Colombia: a difference-in-difference design with fixed effects.

OBJECTIVE: To assess the effect of a permanent gun-carrying restriction on gun-related mortality in Colombia between 2008 and 2014, and determine differences in the effect of the restriction by place of death and sex. METHODS: In 2012, Bogotá and Medellín introduced a permanent gun-carrying restriction. We compared gun-related mortality rates in these cities (intervention cities) with the rates in all other Colombian cities with more than 500 000 inhabitants (control cities). We used data from the Colombian National Department of Statistics to calculate monthly gun-related mortality rates between 2008 and 2014 for intervention and control cities. We used a differences-in-differences method with fixed effects to assess differences in gun-related mortality in intervention and control cities before and after the introduction of the gun-carrying restriction. We stratified effects by place of death (public area or residence) and sex. We made robustness checks to test the assumptions of the models. FINDINGS: Gun-related deaths in the control and intervention cities decreased between 2008 and 2014; however, the decrease was greater in the intervention cities (from 20.29 to 14.93 per 100 000 population; 26.4%) than in the control cities (from 37.88 to 34.56 per 100 000 population; 8.8%). The restriction led to a 22.3% reduction in the monthly gun-related mortality rate in Bogotá and Medellín. The reduction was greater in public areas and for males. Robustness checks supported the assumptions of the models. CONCLUSION: The permanent restriction on carrying guns reduced gun-related deaths. This policy could be used to reduce gun-related injuries in urban centres of other countries with large numbers of gun-related deaths.

Craniofacial injuries by firearms projectiles: An analysis of 868 deaths in the five regions of Brazil.

Firearms injuries have a legal and medico-legal importance, and are especially lethal when they reach the craniofacial regions of the victim. The present study aims to identify the characteristics of craniofacial lesions resulting from firearm projectiles, to register the most affected craniofacial regions by this type of injury and to verify the demographic profile of the victims. A retrospective study was carried out on the autopsy records produced in the first semester of 2015, in five Institutes of Legal Medicine in Porto Velho, situated in the cities of João Pessoa, Vitória, Porto Alegre and Brasília. Data extracted included sex, skin color and age of the victim, craniofacial region reached, shooting distance, shape and size of the injuries and manner of death (homicide, suicide or accident). Based on the 868 reports analyzed, it was possible to observe 1700 entrance lesions of firearm projectiles in craniofacial regions. Among cases of known manner of death, homicides were the most frequent (97.0%). It was observed a higher frequency of male victims (93.3%), mixed race (62.0%), between the ages of 12 and 29 years (59.4%). In all cases considered as suicide or accident there was only one entrance wound, but in 82.8% of the homicides there were multiple gunshot wounds. The craniofacial most affected regions were temporal (25.2%) and occipital (19.8%). The most common sites of projectiles exit were the temporal (25.3%) and parietal (16.1%). All cases of suicide were related to contact shot (69.2%) or close-range shot (30.8%), and among the homicides the distant range shots were more frequent (54.0%). The shape of entrance wounds was mostly circular (56.8%) and oval (31.3%), and among the exit injuries, the lesions were irregular (43.3%) and starry (24.1%). The entrance wounds showed smaller sizes than the exit lesions (p < 0.0001). The data obtained are useful for guiding research that takes into account craniofacial trauma caused by firearm projectiles, makes it possible to compare this data with those of other countries and can base investigative conclusions based on the analyzes discussed in the present work.

Fatores associados a óbitos por ferimentos por arma de fogo: em atendimentos móveis pré-hospitalares de um samu regional do Paraná / Factores asociados con muertes por lesiones causadas por armas de fuego: en servicios móviles prehospitalarios de un samu regional de Paraná / Factors associated with deaths from firearm injuries: in pre-hospital mobile care at a regional samu in Paraná

RESUMO Objetivo: analisar perfil sociodemográfico, morbimortalidade e distribuição espacial de vítimas de ferimentos por armas de fogo atendidas pelo serviço de atendimento móvel de urgência. Métodos: estudo transversal dos registros de atendimento de 603 vítimas de ferimento por arma de fogo atendidas pelo Serviço de Atendimento Móvel de Urgência. Utilizaram-se estatística descritiva, análise de associação univariada e mapa de Kernel para distribuição espacial. Resultados: a maioria das vítimas era do sexo masculino (94%), com idade entre 21 e 30 anos (61,5%). A maioria dos óbitos (73,7%) ocorreu nessa mesma faixa etária. A distribuição espacial demonstrou a maior parte das vítimas em municípios conurbados da região metropolitana, com elevada morbimortalidade. Conclusão: houve maior prevalência de vítimas e óbitos em homens, na faixa dos 21 aos 30 anos, com ferimento em cabeça e pescoço e múltiplos sítios. Nesta amostra não foi possível estabelecer relação estatística significativa entre as cidades das ocorrências, porém se notam focos bem expressivos nas cidades de Sarandi e Paiçandu. Os resultados podem fornecer subsídios para formular políticas públicas para prevenção da violência e preparo para atenção às emergências.

RESUMEN Objetivo: analizar el perfil sociodemográfico, la morbimortalidad y la distribución espacial de las víctimas de lesiones causadas por armas de fuego atendidas por el servicio móvil de urgencias. Métodos: estudio transversal de los registros de atención de 603 víctimas de lesiones por armas de fuego atendidas por el servicio móvil de urgencias. Se utilizó estadística descriptiva, análisis de asociación univariante y el mapa de Kernel para la distribución espacial. Resultados: la mayoría de las víctimas eran hombres (94%), entre 21 y 30 años de edad (61,5%). La mayoría de las muertes (73,7%) ocurrió en este mismo grupo de edad. La distribución espacial mostró la mayoría de víctimas en los municipios conurbados de la región metropolitana, con alta morbilidad y mortalidad. Conclusión: hubo mayor prevalencia de víctimas y muertes en hombres, entre 21 y 30 años, con lesiones de cabeza y cuello y múltiples lugares. A pesar de haberse observado focos bastante expresivos en las ciudades de Sarandí y Paiçandu, en esta muestra no se ha logrado establecer una relación estadísticamente significativa entre las ciudades de los incidentes. Los resultados podrían proporcionar información relevante para formular políticas públicas de prevención de la violencia y preparación para la atención de emergencias.

ABSTRACT Objective: to analyze the sociodemographic profile, morbidity and mortality and spatial distribution of victims of firearms injuries attended by the mobile emergency care service. Methods: cross-sectional study of the care records of 603 firearm injury victims attended by the Mobile Emergency Care Service. Descriptive statistics, univariate association analysis and Kernel map were used for spatial distribution. Results: most of the victims were male (94%), aged between 21 and 30 years (61.5%). Most deaths (73.7%) occurred in this same age group. The spatial distribution showed the majority of victims in conurbated municipalities in the metropolitan region, with high morbidity and mortality. Conclusion: there was a higher prevalence of victims and deaths in men, aged 21 to 30 years, with head and neck injuries and multiple sites. In this sample it was not possible to establish a statistically significant relationship between the cities of the occurrences, but there are quite expressive focuses in the cities of Sarandi and Paiçandu. The results can provide input to formulate public policies for preventing violence and preparing for emergency care.

Prognosis of mortality and evolution in pancreatoduodenal trauma in patients with wound by projectile of firearm.

BACKGROUND: The wounds caused by the firearm projectile are published to date in a public health problem in the world. As an example, we mentioned the injuries caused by firearms are the first cause of death in the age group between 1 to 19 years in the United States, as in Mexico. OBJECTIVE: Analysis of the prognostic factors of mortality and evaluation of the evolution in patients with TPD due to abdominal HPPAF. METHOD: Retrospective, observational, descriptive study. Helped by 49 clinical files of patients who were admitted to the department of surgery of the University Hospital José Eleuterio González, between 2011 to 2015 and whose diagnosis was due to pancreatic trauma (TP), duodenal trauma (TD) or pancreatoduodenal trauma (TPD) by wounds caused by the firearm projectile. RESULTS: During a collection period of 5 years, a total of 49 clinical records applicable to the study were obtained according to the inclusion criteria, of which 36 (73%) suffered only from TD, 37 (75%) from TP and 24 (49%) about TPD. Significant differences were obtained for mortality associated with TD and TPD, but not for TP. The most affected organ as a lesion associated with a TPD was the liver, followed by thoracic structures and the stomach. The most significant risk factor for mortality was a prolonged stay in the intensive care unit. CONCLUSIONS: Data obtained are consistent with those consulted, providing new reproducible statistics for future studies regarding the increasing violence in our country and around the world.

ANTECEDENTES: Las heridas por proyectil de arma de fuego constituyen un problema de salud pública en el mundo. Como ejemplo mencionamos que este tipo de lesiones son la primera causa de muerte en el grupo de edad de 1 a 19 años en los EE.UU., al igual que en México. OBJETIVO: Análisis de los factores pronósticos de mortalidad y evaluación de la evolución en pacientes con TPD por HPPAF abdominal. MÉTODO: Estudio retrospectivo, observacional y descriptivo, realizado con 49 expedientes clínicos de pacientes que fueron admitidos en el departamento de cirugía del Hospital Universitario José Eleuterio González entre los años 2011 y 2015, cuyo diagnostico fue herida por proyectil de arma de fuego con trauma pancreático (TP), duodenal (TD) o pancreatoduodenal (TPD). RESULTADOS: Durante un periodo de recolección de 5 años se obtuvieron 49 expedientes clínicos aplicables al estudio según los criterios de inclusión, de los cuales 36 pacientes (73%) sufrieron únicamente TD, 37 (75%) TP y 24 (49%) TPD. Se obtuvieron diferencias significativas para la mortalidad asociada a TD y TPD, pero no para TP. El órgano más afectado como lesión asociada a un TPD fue el hígado, seguido de las estructuras torácicas y el estómago. El factor de riesgo para mortalidad más significativo fue una estancia prolongada en la unidad de cuidados intensivos. CONCLUSIONES: Los datos conseguidos concuerdan con los consultados, otorgando nueva estadística reproducible para futuros estudios respecto a la violencia creciente en nuestro país y alrededor del mundo.

Guerra civil não-declarada? Um recorte do status da violência urbana em uma capital no Brasil / Undeclared civil war? Urban violence in major city in Brazil

RESUMO Objetivo: a violência civil é responsável por 2,5% da mortalidade mundial, matou mais pessoas no século XXI do que o somatório de todas as guerras deste período. Este estudo descreve as vítimas de violência admitidas em um hospital de referência em trauma em Salvador - Bahia, Brasil e analisa o impacto dos diferentes tipos de violência interpessoal. Métodos: foram incluídos vítimas de violência interpessoal admitidas entre julho de 2015 e julho de 2017. 1296 pacientes (média de idade foi 30,3 anos, 90% do sexo masculino) foram divididos em três grupos de acordo com o mecanismo de violência interpessoal: espancamento, ferimentos por projétil de arma de fogo (FPAF), ferimentos por arma branca (FAB). Os grupos foram comparados de acordo com as seguintes variáveis: idade, sexo, mecanismo de trauma, Revised Trauma Score (RTS) na admissão, necessidade de internamento em unidade de tratamento intensivo (UTI), tempo de internamento, necessidade de transfusão de hemocomponentes e morte. Resultados: FPAF foram o principal mecanismo de injúria (59%), seguido por agressão (24%) e FAB (17%). As vítimas de FPAF apresentaram a menor média de RTS na admissão, maior necessidade de uso de hemocomponentes e de internamento em UTI. Vítimas de espancamento tiveram a maior média de duração de internação hospitalar (11,6±19,6 dias). Os FPAF causaram 77,4% das mortes. Conclusão: vítimas de FPAF são mais críticas, requerendo maior tempo de tratamento em UTI, mais hemocomponentes e maior mortalidade comparativamente às vítimas de FAB e espancamento.

ABSTRACT Purpose: Civil violence is responsible for 2.5% of deaths worldwide; it killed more people in the 21st century than the sum of all wars. This study describes violence victims treated at a trauma reference hospital in Salvador, Brazil and analyzes the impact of different types of interpersonal violence. Methods: Interpersonal violence victims admitted between July 2015 and July 2017 were included. The 1,296 patients (mean age: 30.3 years; 90% male) were divided into three groups according to the mechanism of interpersonal violence: 1) beating, 2) firearm injury and 3) stab wound (STW) injury. The groups were compared for the following variables: age, gender, trauma mechanism, Revised Trauma Score (RTS) at admission, need for intensive care unit (ICU) attention, length of hospital stay, need for transfusion of blood products and death. Results: Gunshot wounds (GSW) were the primary mechanism of injury (59%), followed by beating (24%) and STW (17%). Gunshot wound victims had a lower mean RTS upon admission, increased need for blood products and more Intensive Care Unit (ICU) admissions. Beating victims had the longest mean hospital stay (11.6 ± 19.6 days). The GSW group accounted for 77.4% of all deaths. The in-hospital mortality rate was significantly higher in the GSW group (12.7%) than in the beating group (5.4%) and in the STW group (4.9%). Conclusions: Gunshot wound victims are more critical: they require longer ICU stays, more transfusions of blood products and exhibit increased mortality compared with STW and beating victims.

Geospatial, racial, and educational variation in firearm mortality in the USA, Mexico, Brazil, and Colombia, 1990-2015: a comparative analysis of vital statistics data.

BACKGROUND: Firearm mortality is a leading, and largely avoidable, cause of death in the USA, Mexico, Brazil, and Colombia. We aimed to assess the changes over time and demographic determinants of firearm deaths in these four countries between 1990 and 2015. METHODS: In this comparative analysis of firearm mortality, we examined national vital statistics data from 1990-2015 from four publicly available data repositories in the USA, Mexico, Brazil, and Colombia. We extracted medically-certified deaths and underlying population denominators to calculate the age-specific and sex-specific firearm deaths and the risk of firearm mortality at the national and subnational level, by education for all four countries, and by race or ethnicity for the USA and Brazil. Analyses were stratified by intent (homicide, suicide, unintentional, or undetermined). We quantified avoidable mortality for each country using the lowest number of subnational age-specific and period-specific death rates. FINDINGS: Between 1990 and 2015, 106·3 million medically-certified deaths were recorded, including 2 472 000 firearm deaths, of which 851 000 occurred in the USA, 272 000 in Mexico, 855 000 in Brazil, and 494 000 in Colombia. Homicides accounted for most of the firearm deaths in Mexico (225 000 [82·7%]), Colombia (463 000 [93·8%]), and Brazil (766 000 [89·5%]). Suicide accounted for more than half of all firearm deaths in the USA (479 000 [56·3%]). In each country, firearm mortality was highest among men aged 15-34 years, accounting for up to half of the total risk of death in that age group. During the study period, firearm mortality risks increased in Mexico and Brazil but decreased in the USA and Colombia, with marked national and subnational geographical variation. Young men with low educational attainment were at increased risk of firearm homicide in all four countries, and in the USA and Brazil, black and brown men, respectively, were at the highest risk. The risk of firearm homicide was 14 times higher in black men in the USA aged 25-34 years with low educational attainment than comparably-educated white men (1·52% [99% CI 1·50-1·54] vs 0·11% [0·10-0·12]), and up to four times higher than in comparably-educated men in Brazil, Colombia, and Mexico. In the USA, the risk of firearm homicide was more than 30 times higher in black men with post-secondary education than comparably educated white men. If countries could achieve the same firearm mortality rates nationally as in their lowest-burden states, 1 777 800 firearm deaths at all ages and in both sexes could be avoided, including 1 028 000 deaths in men aged 15-34 years. INTERPRETATION: Firearm mortality in the USA, Mexico, Brazil, and Colombia is highest among young adult men, and is strongly associated with race and ethnicity, and low education levels. Reductions in firearm deaths would improve life expectancy, particularly for black men in the USA, and would reduce racial and educational disparities in mortality. FUNDING: Canadian Institutes of Health Research and the University of Toronto Connaught Global Challenge.

Epidemiological and toxicological profile of homicide victims in a legal medicine unit in Brazil.

OBJECTIVES: The use of illicit drugs is considered a risk factor for victimization by lethal violence and is frequently found in necropsies of homicide victims. This study aimed to evaluate the profile of these victims. METHODS AND MATERIAL: A cross-sectional retrospective study was performed on homicide victims in 2014 with a sample composed of all homicide cases in 2014 for which toxicology had been performed in an Official Forensic Laboratory (Minas Gerais- Brazil). RESULTS: 1382 homicide victims composed the sample. The group with a positive toxicology test (N = 943) presented higher proportions of men (p = 0.003), black/brown skin (p < 0.001), firearm history (p = 0.007) and a lower mean age (p < 0.001). In 72.2% of the positive tests, cocaine and benzoylecgonine were found; in 67.7%, THC and/or its metabolite was found; and in 43.1%, both illicit drugs were found. CONCLUSIONS: The role of illicit drugs in early death goes far beyond intoxication as they are directly associated with age, skin color and gender. Young black/mixed men have an increased risk of homicide. Our findings point to the importance of investing in social actions, public safety and efforts to reduce drug use in this at-risk population.

["Armed juvenicide": youth homicides and firearms in Latin America]. / "Juvenicidio armado": homicidios de jóvenes y armas de fuego en América Latina.

This article analyzes the impact of firearms in the homicides of young people in Latin America today. A cross-sectional descriptive epidemiological study was carried out based on data from the Pan American Health Organization. There were 14,427 deaths due to assaults with firearms in young people, that is, a rate of 14.3 per 100,000 young people for the year 2014 in Latin America. Thus, 80% of all homicides in young people between 10 to 19 years of age in the region were committed with firearms. This especially affects young males, with a rate of 26.5 per 100,000 deaths due to assault with firearms, although it should not be overlooked that the deaths among women are largely femicides. In addition, 1,828 deaths of undetermined intent with firearms (especially in Argentina and Venezuela) and 284 deaths with firearms in legal interventions (showing higher policy lethality among young people) were registered. The corrected rate is therefore 16.4 young people killed by others with firearms per 100,000 youth in Latin America. The need for gun control and disarmament policies, de-stigmatization campaigns and youth development programs is discussed, in order to reduce the current conditions that foster and invisibilize the so-called "armed juvenicide" in Latin America.

​Este artículo analiza el impacto de las armas de fuego en los homicidios de jóvenes en América Latina en la actualidad. Para ello, se realizó un estudio epidemiológico descriptivo transversal a partir de los datos de la Organización Panamericana de la Salud. Se encontraron 14.427 muertes por agresiones con armas de fuego de jóvenes, con una tasa de 14,3 por 100.000 jóvenes para el año 2014 en América Latina. Así, el 80% de todos los homicidios de jóvenes de entre 10 a 19 años de la región fueron cometidos con armas de fuego. Esto afecta especialmente a los varones, cuya tasa asciende a 26,5 por 100.000 muertes por agresiones con armas de fuego, aunque en el caso de las mujeres no se descarta que, en su mayoría, se trate de feminicidios. Además, se registraron 1.828 muertes con armas de fuego de intención no determinada (especialmente provenientes de Venezuela y Argentina) y 284 muertes con armas de fuego en intervenciones legales (mostrando la mayor letalidad policial hacia los jóvenes). La tasa corregida pasa a ser de 16,4 por 100.000 jóvenes muertos por terceros con armas de fuego en América Latina. Se plantea la necesidad de políticas de control de armas y desarme, de campañas de desestigmatización y de programas de desarrollo de la juventud, que reduzcan las actuales condiciones que propician e invisibilizan el llamado "juvenicidio armado" en América Latina.

Abdominal trauma: experience of 4961 cases in Western Mexico.

INTRODUCTION: Trauma is a leading cause of morbimortality in the world. Intraabdominal compartment is the third most affected anatomical region and bleeding from this origin is difficult to identify, therefore the importance to predict possible lesions to the abdominal cavity. OBJECTIVE: To describe and analyze the sociodemographic profile and injuries found in patients with abdominal trauma in a western hospital in Mexico. METHOD: Consecutive patients included in the local registry GDL-SHOT were analyzed. RESULTS: From 4961 patients, 91.4% were men, with a mean age of 28.7 years. Regarding the mechanism of trauma, 39.7% were stab wounds, 33% blunt abdominal trauma and 27.3% gunshots. The most affected organs were: small bowel (20.9%), liver (18.2%), and colon (14.2%). The mean hospital stay was 6.95 days with a mortality of 6.74%. CONCLUSION: In Mexico, abdominal trauma represents an important cause of morbidity and mortality, especially in young patients. We found an important amount of penetrating trauma.

INTRODUCCIÓN: El trauma es una de las principales causas de morbimortalidad en el mundo. El abdomen es, en frecuencia, la tercera región anatómica más afectada, y el compartimento intraabdominal es un sitio de hemorragia difícil de identificar, por lo que cobra importancia el conocimiento de las posibles lesiones tras un traumatismo. OBJETIVOS: Describir y analizar el perfil sociodemográfico y las lesiones encontradas en pacientes con trauma abdominal en un hospital de referencia del occidente de México. MÉTODO: Se seleccionaron para su análisis los pacientes incluidos en el registro hospitalario local GDL-SHOT. RESULTADOS: De 4961 pacientes, el 91.4% fueron hombres, con un promedio de edad de 28.7 años. Respecto al mecanismo, el 39.7% correspondió a arma blanca, el 33% a trauma cerrado y el 27.3% a arma de fuego. Los órganos más afectados fueron el intestino delgado (20.9%), el hígado (18.2%) y el colon (14.2%). La estancia hospitalaria promedio fue de 6.95 días, con una mortalidad del 6.74%. CONCLUSIONES: En México, el trauma abdominal representa una causa importante de morbimortalidad, en especial en pacientes jóvenes, y predomina el mecanismo penetrante; el manejo más común es no conservador. La frecuencia de lesiones encontradas es discordante con la literatura de otros países y predominan las de vísceras huecas, probablemente por la diferencia en los mecanismos implicados.

Juvenicidio armado: homicidios de jóvenes y armas de fuego en América Latina / Armed juvenicide: youth homicides and firearms in Latin America

RESUMEN ​Este artículo analiza el impacto de las armas de fuego en los homicidios de jóvenes en América Latina en la actualidad. Para ello, se realizó un estudio epidemiológico descriptivo transversal a partir de los datos de la Organización Panamericana de la Salud. Se encontraron 14.427 muertes por agresiones con armas de fuego de jóvenes, con una tasa de 14,3 por 100.000 jóvenes para el año 2014 en América Latina. Así, el 80% de todos los homicidios de jóvenes de entre 10 a 19 años de la región fueron cometidos con armas de fuego. Esto afecta especialmente a los varones, cuya tasa asciende a 26,5 por 100.000 muertes por agresiones con armas de fuego, aunque en el caso de las mujeres no se descarta que, en su mayoría, se trate de feminicidios. Además, se registraron 1.828 muertes con armas de fuego de intención no determinada (especialmente provenientes de Venezuela y Argentina) y 284 muertes con armas de fuego en intervenciones legales (mostrando la mayor letalidad policial hacia los jóvenes). La tasa corregida pasa a ser de 16,4 por 100.000 jóvenes muertos por terceros con armas de fuego en América Latina. Se plantea la necesidad de políticas de control de armas y desarme, de campañas de desestigmatización y de programas de desarrollo de la juventud, que reduzcan las actuales condiciones que propician e invisibilizan el llamado "juvenicidio armado" en América Latina.

ABSTRACT This article analyzes the impact of firearms in the homicides of young people in Latin America today. A cross-sectional descriptive epidemiological study was carried out based on data from the Pan American Health Organization. There were 14,427 deaths due to assaults with firearms in young people, that is, a rate of 14.3 per 100,000 young people for the year 2014 in Latin America. Thus, 80% of all homicides in young people between 10 to 19 years of age in the region were committed with firearms. This especially affects young males, with a rate of 26.5 per 100,000 deaths due to assault with firearms, although it should not be overlooked that the deaths among women are largely femicides. In addition, 1,828 deaths of undetermined intent with firearms (especially in Argentina and Venezuela) and 284 deaths with firearms in legal interventions (showing higher policy lethality among young people) were registered. The corrected rate is therefore 16.4 young people killed by others with firearms per 100,000 youth in Latin America. The need for gun control and disarmament policies, de-stigmatization campaigns and youth development programs is discussed, in order to reduce the current conditions that foster and invisibilize the so-called "armed juvenicide" in Latin America.

"Juvenicidio armado": homicidios de jóvenes y armas de fuego en América Latina / "Armed juvenicide": youth homicides and firearms in Latin America

RESUMEN ​Este artículo analiza el impacto de las armas de fuego en los homicidios de jóvenes en América Latina en la actualidad. Para ello, se realizó un estudio epidemiológico descriptivo transversal a partir de los datos de la Organización Panamericana de la Salud. Se encontraron 14.427 muertes por agresiones con armas de fuego de jóvenes, con una tasa de 14,3 por 100.000 jóvenes para el año 2014 en América Latina. Así, el 80% de todos los homicidios de jóvenes de entre 10 a 19 años de la región fueron cometidos con armas de fuego. Esto afecta especialmente a los varones, cuya tasa asciende a 26,5 por 100.000 muertes por agresiones con armas de fuego, aunque en el caso de las mujeres no se descarta que, en su mayoría, se trate de feminicidios. Además, se registraron 1.828 muertes con armas de fuego de intención no determinada (especialmente provenientes de Venezuela y Argentina) y 284 muertes con armas de fuego en intervenciones legales (mostrando la mayor letalidad policial hacia los jóvenes). La tasa corregida pasa a ser de 16,4 por 100.000 jóvenes muertos por terceros con armas de fuego en América Latina. Se plantea la necesidad de políticas de control de armas y desarme, de campañas de desestigmatización y de programas de desarrollo de la juventud, que reduzcan las actuales condiciones que propician e invisibilizan el llamado "juvenicidio armado" en América Latina.

ABSTRACT This article analyzes the impact of firearms in the homicides of young people in Latin America today. A cross-sectional descriptive epidemiological study was carried out based on data from the Pan American Health Organization. There were 14,427 deaths due to assaults with firearms in young people, that is, a rate of 14.3 per 100,000 young people for the year 2014 in Latin America. Thus, 80% of all homicides in young people between 10 to 19 years of age in the region were committed with firearms. This especially affects young males, with a rate of 26.5 per 100,000 deaths due to assault with firearms, although it should not be overlooked that the deaths among women are largely femicides. In addition, 1,828 deaths of undetermined intent with firearms (especially in Argentina and Venezuela) and 284 deaths with firearms in legal interventions (showing higher policy lethality among young people) were registered. The corrected rate is therefore 16.4 young people killed by others with firearms per 100,000 youth in Latin America. The need for gun control and disarmament policies, de-stigmatization campaigns and youth development programs is discussed, in order to reduce the current conditions that foster and invisibilize the so-called "armed juvenicide" in Latin America.

Fatal cardiac trauma in the city of Manaus, Amazonas state, Brazil. / Trauma cardíaco fatal na cidade de Manaus/AM, Brasil.

OBJECTIVE: to determine the frequency of fatal cardiac trauma in the city of Manaus, Brazil, between November 2015 and October 2016, and to clarify the mechanisms of trauma and death, previous hospital treatment, as well as the injuries associated with cardiac trauma. METHODS: retrospective, observational, and cross-sectional study, which reviewed the necropsy reports of individuals whose cause of death was cardiac injury. RESULTS: the cardiac trauma rate was of 5.98% (138 cases) out of 2,306 necropsies performed in the study period by Instituto Médico Legal (IML) de Manaus (IML is a Brazilian institute responsible for necropsies and cadaveric reports). Males accounted for 92% of the cases. The median age was 27 years (14-83). Gunshot wounds (GSW) was the trauma mechanism in 62.3% and stab wound (SW) in 29.7%. Exsanguination was responsible for most of the deaths and cardiac tamponade was present in second place. On-site death occurred in 86.2% of the cases. The ventricles were the most common site of cardiac injury. Hemothorax was identified in 90.6% of the individuals. Only 23 patients (16.7%) were taken to the hospital (Emergency Room), but six (26.2%) were submitted only to chest drainage, not to thoracotomy. The lung was unilaterally affected in 57% of the cases and bilaterally in 43%. CONCLUSION: fatal cardiac trauma represented an index of 5.98% in the city of Manaus. Most patients die at the scene of the trauma, usually due to exsanguination caused by gunshot wound. About a quarter of patients who reached the hospital and died were not diagnosed with cardiac trauma in time.

OBJETIVO: determinar o índice de trauma cardíaco fatal na cidade de Manaus e esclarecer os mecanismos de trauma e de morte, o tratamento hospitalar prévio, assim como as lesões associadas ao trauma cardíaco. MÉTODOS: estudo retrospectivo, observacional, transversal, que revisou os laudos de necropsias do Instituto Médico Legal de Manaus entre novembro de 2015 e outubro de 2016, cuja causa mortis foi lesão cardíaca. RESULTADOS: o índice de trauma cardíaco foi de 5,98% (138 casos) dentre 2306 necropsias realizadas no período do estudo. Homens foram afetados em 92%. A mediana de idade foi de 27 anos (14 a 83). A arma de fogo foi o mecanismo de trauma em 62,3% e a arma branca em 29,7%. A exsanguinação foi responsável pela maioria das mortes e o tamponamento cardíaco esteve presente em segundo lugar. Óbito no local ocorreu em 86,2%. Os ventrículos foram as câmaras mais lesionadas. O hemotórax foi descrito em 90,6%. Apenas 23 (16,7%) doentes foram removidos até o pronto socorro, porém seis deles (26,2%) não foram submetidos à toracotomia, apenas à drenagem de tórax. O pulmão foi acometido em 57% unilateralmente e 43% bilateralmente. CONCLUSÃO: o trauma cardíaco fatal representou um índice de 5,98% na cidade de Manaus. A maioria dos doentes morre na cena do trauma, geralmente devido à exsanguinação causada por ferimento de arma de fogo. Cerca de um quarto dos pacientes que chegaram ao pronto socorro e morreram, não foram diagnosticados com trauma cardíaco em tempo hábil.